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Based on policy review, ambulance run report review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided for 2 patients who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 03/02/2022 and 02/14/2022.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for 2 patients (Patients #2 and #1) who presented to the hospital's DED for psychiatric evaluation on 03/02/2022 and 02/14/2022.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy review, ambulance run report review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided for 2 patients (Patients #2 and #1) who presented to the hospital's Dedicated Emergency Department (DED) for psychiatric evaluation on 03/02/2022 and 02/14/2022.

The findings included:

Review of facility policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) Policy" last revised 09/2021 revealed, "... Patient refusing examination, treatment, or Transfer to another facility shall be documented in the medical record. Staff will take all reasonable steps to obtain a written informed refusal of examination, treatment or Appropriate Transfer to another facility signed by the patient. Staff will document whether they were able to advise the patient of the risks and benefits of examination, treatment, or Transfer to another facility..."

Medical Record (Patient #2):

Review of a prehospital care report written on 03/02/2022 at 1838 by Emergency Medical Technician (EMT) #1 revealed, "...dispatched to a 66-year-old male psychiatric call. On arrival, all units were staged in the area due to the patient stating he wanted to blow the building up. When scene was secured by [Named Police Department], Ems [Emergency Medical Services] and Squad went inside of the building and found the patient sitting in a chair. Ems 5 crew went and grabbed the stretcher while the Squad crew assessed the patient and checked vitals. The patient stated to the effect that he just wanted to leave the assisted living facility. Ems and Squad assisted the patient onto a stretcher. During transport, Ems 5 crew re-assessed the patient. All vitals stayed in the normal range. Ems crew arrived at [Hospital A] and assisted the patient into a wheelchair. Ems crew transferred care over to [Hospital A] ER [Emergency Room] staff ... Medical History: Behavior - Dementia (with behavioral disturbance), Behavior - Major Depression; Behavior - Manic Episodes Medical History Obtained From: Patient ... Complaint Psychiatric ... Primary Symptom: Behavior, Strange and inexplicable ... Type of Person Signing: Healthcare Provider ... I have assumed authority and responsibility for the medical care and patient management for the patient named in the Patient Care Report ... [ Pivot Registered Nurse {RN} #2 Signature]..."

Closed medical record review conducted on 04/26/2022 revealed Patient #2 was a 66-year-old male who presented via ambulance to Hospital A's DED on 03/02/2022 at 1835. Review revealed at 1840, his triage was initiated by RN #3. Patient #2 was triaged as a Level 3. Patient #2's Medical History was reviewed by RN #3 as Alcohol Abuse. Review of a note written by RN #3 on 03/02/2022 at 1843 revealed, "Arrives via wheelchair from [Named Assisted Living Facility{ALF}] for being violent with staff." Review of a note written by RN #4 on 03/02/2022 at 2016 revealed, "Pt [patient] up to hospitality telling them 'I am leaving now. I can walk myself back.' Hospitality to pivot desk to notify RN of pts leaving. Pt did not have an IV [Intravenous Access] and left in NAD [No Apparent Distress]." Patient #2 was documented as LWOT [Left Without Treatment] on 03/02/2022 at 2019.

Telephone interview was conducted with the Senior Administrator for Risk Management (SARM) on 04/26/2022 at 1337. Interview revealed Patient #2's sister called the facility on 03/14/2022 because he was missing. She advised Risk Management he had been brought to the ED by ambulance from his ALF, and never returned. Interview confirmed Patient #2 was triaged as a level 3 and after a couple of hours he walked up to the Hospitality Associate [non-clinical personnel] and stated he was going back to the ALF. Risk Management was not made aware of the situation until Patient #2's sister called the facility. Interview revealed "we" recommended the sister issue a Silver Alert and offered Hospital Police assistance. The SARM advised to her knowledge, the sister did not utilize Hospital Police. Facility representatives additionally "reached out" to Patient #2's son, however he deferred to Patient #2's sister. Interview revealed "To my knowledge at that time he [Patient #2] was his own guardian." Interview revealed the DED received no hand-off report regarding Patient #2 from the ALF prior to his arrival.

Repeat telephone interview was conducted with the SARM on 04/26/2022 at 1546. Interview revealed on 03/24/2022 Patient #2's sister informed Hospital A was found passed away in the community, around a pond on the property of a local rehabilitation facility. Patient #2 was not a patient of the facility. Interview revealed Patient #2's death is a Medical Examiner's case, however the report has not been finalized.

Staff interview with RN #3 was conducted on 04/27/2022 at 0925. Interview confirmed RN #3 assigned to triage on 03/02/2022 however she did not recall Patient #2. Interview revealed typically when EMS brings a patient to triage they will hand off the patient to a RN assigned to the pivot position. The pivot nurse gets the report from EMS and accepts the patient. Interview revealed if a patient comes from a facility without a chart, RN #3 reviews their history with the patient. Interview revealed if Patient #2's EMR has his history as Alcohol Abuse, that was what he stated his history was. Interview revealed, "if someone is admitting suicidal or homicidal ideation, definitely triaged Level 2. If I don't have a clear report of what type of psych exam he would need I don't know if he would need enough resources to justify triage at Level 2." Interview revealed if a patient is waiting for a room in the lobby and wants to leave, facility staff would attempt to persuade them to stay, but if they were adamant about leaving staff would ask how they were getting home, or who is coming to get them. Staff would additionally ensure the patient did not have an IV in place. If a patient was acting "strange" lobby staff would contact the charge nurse and possibly hospital police to see if "there was anything to warrant making them stay."

Staff interview with Pivot RN #2 was conducted on 04/27/2022 at 1022. Interview confirmed RN #2 was the pivot nurse on 03/02/2022 and she recalled Patient #2. Interview revealed Patient #2 at the time of EMS handoff was sitting calmly in a wheelchair, and he did not speak to RN #2. RN #2 did not recall exactly what was stated in the EMS handoff report, however "probably all they told me was he was agitated with staff; he was from a facility. The report is usually brief and did not get into his medical history."

RN #4 [the nurse who documented Patient #4 was leaving] was a travel nurse who was no longer under contract with the facility, and unavailable for interview.

Medical Record (Patient #1):

Closed medical record review on 04/27/2022 revealed Patient #1 was a 24-year-old male who presented to Hospital A's DED on 02/14/202 at 1108 for "Psych Exam." Patient #1 was triaged at 1145 and chief complaint updated at 1146 which revealed "Pt (patient) states 'I just want to talk to my doctor about my mental health, I don't want to say anything to anyone else.' " Patient #1 had a Glasgow Coma Scale of 15 (15 is normal, alert, and oriented) at 1148. Review of the "Triage Screening" at 1148 revealed "Suicide Assessment-Is patient presenting with a primary Behavioral Health Condition?: No." Review of the ED triage Note at 1148 revealed "Pt A&Ox4 (alert and oriented), waiting in lobby comfortably. Pt instructed to notify PIVOT RN (nurse in lobby) or CP (care partner) if condition changes." Patient #1 was assigned as an ESI 3 at 1148. Review of ED note by PIVOT RN #5 at 1201 revealed "Px (patient) seen walking out of the lobby going to the parking area. GTL (gold side team leader) saw the patient drove (sic) his car out from the parking area." Patient #1's disposition was changed to LWOT (Left Without Treatment) at 1203. Review of ED note by RN #5 at 1204 revealed "PIVOT RN/GTL RN witnessed the patient walked out of the ED lobby and drove his car out of the ED parking area." Review of RN #4's note at 1247 revealed "Px had been out of the ED lobby for >40 mins since he left and drove away from the parking area." Patient #1 was discharged out of the system at 1249.

Interview on 04/28/2022 at 1121 with RN #6 revealed she vaguely recalled Patient #1. RN #6 stated he presented for a psych exam and was placed in the lobby until a bed was available. RN #6 stated she witnessed him exit the lobby, go to his car, and leave. RN #6 stated her, nor RN #5 (the pivot nurse) attempted to stop Patient #1 from leaving or inquire where or what he was doing. RN #6 stated they can't make a patient stay unless they were IVC'd. RN #6 stated if a patient was endorsing suicidal or homicidal ideation, she would attempt to get them to a room immediately and if they attempted to leave, she would call security. RN #6 stated patients "come and go to their cars all the time." Interview revealed there was no attempt to intervene in patient #1 leaving.

Request for interview with PIVOT RN #5 revealed she was unavailable.