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Based on a review of the facility's policy, medical records (MR), video recording of the incident, and interview with staff (EMP), it was determined that the Hospital of the University of Pennsylvania (HUP) failed to provide a timely medical screening examination for two of two patients presenting at the HUP Cedar Avenue Emergency Department (ED), (MR21 and MR22).

Findings include:

Review of facility policy "Evaluation, Treatment, and Transfer of Patients with Emergency Medical Condition to/from the Hospital (EMTALA)" last revised June 26, 2017, revealed: This policy applies to the Hospital of the University of Pennsylvania, ... . This policy also applies to (i) those practices and sites that are remote locations, or on-campus or off-campus facilities or departments of HUP and operating under its license, including e.g., HUP-Cedar Avenue...PROCEDURE, A. EVALUATION AND STABILIZATION. 1. Medical Screening Examination a. Presenting for a Medical Screening Examination. i. Dedicated Emergency Department. Any individual who comes to a Dedicated Emergency Department requesting examination or treatment for a medical condition must be given a medical screening examination is also required: (a) where a request is made on the individual's behalf; or (b) where, in the absence of any request, a prudent layperson would believe based on the individual's appearance or behavior that the individual needs examination or treatment for a medical condition...ii Hospital Property, other than a Dedicated Emergency Department. Any individual who comes to the Hospital...requesting examination or treatment for what may be an emergency medical condition must be given a medical screening examination by a physician (or other Qualified Medical Personnel) to see if he/she is in an emergency medical condition. A medical screening examination is also required; (a) where a request is made on the individual's behalf; or (b) where, in the absence of any request, a prudent layperson would believe based on the individual ' s appearance or behavior that the individual needs examination or treatment for what may be an emergency medical condition. For the purpose of this policy, an individual will have "come to the Hospital" if he/she is on Hospital property, which includes the Hospital's main campus..."

1). Review of MR21, revealed arrival date of March 3, 2022, at 3:07 AM to the HUP Cedar Avenue Emergency Department with complaint of "Psychiatric Evaluation". Further review revealed MR21 completed a quick registration and was assigned an attending physician at 3:08 AM. Further review revealed the ED Disposition for Discharge Information was documented at 3:28 AM on March 3, 2022, as "Left Without Being Seen Before Triage."

Review of the facility's video recording of an ED incident on March 3, 2022, video recording time stamped approximately 3:02 AM to 4:05 AM with EMP2, EMP4. EMP5, EMP6, EMP7, EMP8, EMP9 and EMP13 revealed MR21 was escorted by city police officers into the HUP- Cedar Avenue Campus Emergency Department. Further review of the video recording revealed MR21 completed the ED registration process and entered the ED waiting room area and was seated. MR21 then exited the ED waiting room area in what appeared to be a state of verbal distress, unescorted by staff and appeared to be walking toward the ED main hallway and was grabbed by EMP28 from the rear at the collar area of the her upper clothing garment. Continued review of the video coverage revealed MR21 returned to the waiting room and sat in a waiting room chair. EMP27, EMP28 and EMP29 entered the waiting room and removed MR21 from a sitting position in the waiting room area and physically carried MR21 by the upper and lower extremities toward the ED sliding glass doors exiting the ED, passing through the ED alcove which contains a metal detector to the outside of the ED. Continued review of the video coverage revealed MR21 appeared to be emotionally and physically distressed and resistant to the physical handling and removal from the ED. Further review of the video recording revealed EMP27, EMP28 and EMP29 purposely made forcible contact with the head and body of MR21 with the metal detector located in the ED alcove during the removal of MR21 from the ED with the assistance of EMP27, EMP28 and EMP29. Further review of the video recording shows EMP27, EMP29, EMP30 and EMP33 walking outside of the ED toward the parking garage and MR21 exiting the parking garage away from the ED. Further review of the video coverage revealed that MR21 did not receive a Medical Screening Examination.

An interview conducted on March 14, 2022, at 12:20 PM with EMP2, EMP5, EMP7, EMP8, EMP9 and EMP13 confirmed the events in the video recording of the HUP Cedar Avenue Emergency Department incident on March 3, 2022, video time stamped at approximately 3:02 AM-4:05AM , forcibly removing MR21 from the ED. Further interview confirmed the facility failed to provide MR21 with a Medical Screening Examination.

Review of the facility's video coverage of the ED incident on March 3, 2022, video recording time stamp at 4:01 AM with EMP2, EMP4. EMP5, EMP6, EMP7, EMP8, EMP9 and EMP13 revealed MR21 voluntarily reentered the ED alcove and sat down. Further review of the video recording revealed MR21 then proceeded to disrobe upper body clothes and shoes. The video coverage revealed EMP31 approaching MR21 in the ED alcove, resulting in a verbal exchange between MR21 and EMP31. Further review revealed MR21 redressing and EMP31 directing MR21 from the ED alcove to the outside of the ED. Further review of the video recording revealed MR21 did not receive a Medical Screening Examination prior to exiting the ED.

An interview conducted on March 14, 2022, at 12:20 PM with EMP2, EMP5, EMP7, EMP8, EMP9 and EMP13 confirmed the events in the video recording of MR21 entering the ED alcove at approximatley 4:01AM and exiting the ED alcove in the presence of EMP28 and EMP31 without receiving a Medical Screening Examination at HUP Cedar Avenue Emergency Department on March 3, 2022.

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2) Review of MR22, revealed MR22 presented to the HUP Cedar Avenue Emergency Department via emergency medical services transport on October 29, 2021, at 8:53 AM with complaint of "Rectal Bleeding" and was admitted to Room ED06. Further review revealed CF1, ED provider was assigned to MR22 on October 29, 2021, at 8:59 AM. In addition, MR22 was assigned an Emergency Severity Index (ESI) acuity score of Level 2 (emergent/urgent) at 9:19 AM by EMP34.

Review of MR22, progress note authored by CF1 dated October 29, 2021, at 8:53 AM and filed on October 29, 2021, at 9:22 AM, revealed " Patient arrived via Emergency Medical Services. The patient was noncompliant with Emergency Department staff., verbally abusive and threatening. I was attempted to de-escalate with patient and the patient was unable to de-escalate. The patient was asked to leave the Emergency Department and return when able to comply in a safe manner. Patient then went outside the ED and laid down on the sidewalk. Security brought patient back into the ED. The patient had another family member at bedside, and we gave the patient another 10 minutes without stimulation. Patient started yelling at family member, myself, and staff again. The patient denied alcohol and cocaine use, the patient was oriented. Decided to give patient another 10 minutes. In that time, patient eloped."

Review of MR22, progress note authored by EMP34 dated October 29, 2021, at 9:10AM revealed "Delayed note due direct patient care. Patient was removed by security initially for irate behavior, per the request of ED provider [name redacted]. Patient ambulated out of ED with security escort then returned."

Review of MR22, progress note authored by EMP34 dated October 29, 2021, at 9:20 AM revealed " Patient acting irate...Patient tried to throw a punch, and then was asked to leave by ED provider [name redacted] and security. Patient independently got up from bed and ambulated toward ED waiting area, while stating " I will walk back out there and pass back out again. Patient escorted to ED door by security."

A telephone conference call conducted on March 17, 2022, at 2PM with CF1,confirmed that MR22 was asked to leave the HUP Cedar Avenue Emergency Department due to behavior prior to the medical screening exam. CF1 stated "I remember this patient. The patient was very irate and disruptive. I was fearful for my myself and the staff. I did have the security staff escort the patient out of the emergency department because of behavior and informed the patient I could not wait (provide service) until the patient's behavior calmed down."

An interview conducted on March 28, 2022, at 3:15 PM with EMP9, confirmed that MR22 was escorted from the HUP Cedar Avenue Emergency Department twice by the hospital's security staff at the request of the ED provider due to behavior and prior to the completion of the medical screening examination. EMP9 confirmed that MR22 eloped from HUP Cedar Avenue Emergency Department after being escorted out of the ED by hospital security staff.