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On the days of the EMTALA (Emergency Medical Treatment And Labor Act) investigation based on observations, interview, facility policy and procedures and facility camera surveillance video, emergency department security guard schedules, and personnel files, the hospital failed to ensure that a medical screening examination was provided to determine whether or not an emergency medical condition existed for an individual when a request was made on his/her behalf for 1 (Patient #1) of 21 sampled patients who presented to the emergency department.


The findings are:


Cross Reference to A 2406: On the days of the EMTALA investigation
survey based on interviews and reviews of facility surveillance camera video (12/31/2013), policy and procedures, medical records and security staffing schedules personnel files and interviews, the hospital failed to triage and failed to provide an appropriate medical screening examination to a patient presenting to the hospital's emergency department with a bleeding head wound and personality changes who left the hospital's emergency department when informed by the hospital's security guards that the hospital would call the police if the patient entered the hospital's emergency department. As this resulted in the patient leaving the hospital without receiving triage or a medical screening examination to determine whether or not an emergency medical condition existed for 1 (#1) of 21 sampled patients.

On the days of the EMTALA(Emergency Medical Treatment And Labor Act) investigation survey based on observations and interview, the hospital failed to post a sign specifying the rights of individuals with emergency medical conditions, women in labor, and whether or not the hospital participates in the Medicaid program under the state program.


The findings are:


On 01/13/14 at 10:15 a.m., observations of the emergency department entrance, emergency department lobby, and emergency department treatment rooms revealed no signs were posted identifying the rights of individuals with emergency medical conditions, women in labor, and whether or not the hospital participates in the Medicaid program under the state. On 1/13/14 at 10:15 a.m., the Administrative Vice President of Patient Services verified the finding and reported that he/she did not know where the signs were.

On the days of the EMTALA investigation survey based on interviews and
reviews of facility surveillance camera video (12/31/2013), policy and
procedures, medical records and security staffing schedules personnel
files and interviews, the hospital failed to triage, and failed to provide
an appropriate medical screening examination to a patient presenting to
the hospital's emergency department with a bleeding head wound and
personality changes who left the hospital's emergency department when
informed by the hospital's security guards that the hospital would call the
police if the patient entered the hospital's emergency department. As this
resulted in the patient leaving the hospital without receiving triage or a
medical screening examination to determine whether or not an emergency
medical condition existed for 1 (Patient #1) of 21 sampled patients.

The findings are:


1. Facility Surveillance Camera Video
On 01/16/14 from 9:35 a.m. to 10:25 a.m., review of McLeod Medical Center - Dillon (Hospital A) emergency department's surveillance camera video for the surveillance video captured on 12/31/2013 revealed a woman arrived at the emergency room entrance on 12/31/2014 at 7:44 p.m., and proceeded to assist the passenger (Patient #1) from the vehicle. The video showed Security Guard 2 approached the vehicle with a wheelchair, and then stood back while the woman went to the passenger side of the vehicle and tried to assist the passenger (Patient #1) out of the vehicle. The woman stops and turns toward Security Guard 2 and gestures with her hands. Then, the woman assisted the individual (Patient #1) on the passenger side back into the vehicle, closed the passenger door, and left the emergency department. Continuing review of the surveillance video on 12/31/2013 showed the woman came to the hospital's emergency department again on 12/31 2013 at 8:04 p.m., followed by another vehicle with a male driver. The male driver of the second vehicle proceeded into the entrance of the emergency room and retrieved a wheel chair while the woman walked to the passenger side of the car to remove the passenger (Patient #1). The woman assisted the passenger (Patient #1) from the passenger side of the vehicle
and placed the passenger (Patient #1) in the wheelchair. The video showed
the passenger (Patient #1) sat in the wheel chair, and then got out of the wheel chair and walked back towards the door of the vehicle. The man and woman were interfacing with the passenger (Patient #1) and appeared to try to get the passenger (Patient #1) back in the wheel chair. The video showed Security Guard 2 and Security Guard 1 traveled to the vehicle and appeared to engage the couple at the vehicle in conversation. The passenger (Patient #1) got back into the vehicle and the man and woman left with the passenger (Patient #1).


2. Medical Records from Hospital B
A review of the medical record revealed that Patient #1 an 18 year old who
presented to the emergency department on 12/31/2013 and was triaged
(process of deciding which patients should be treated first based on how sick or seriously injured they are.) at 10:37 p.m. Under the HPI (History of
Present illness) HEAD INJURY, stated in part, "CHIEF COMPLAINT:
Patient presents for the evaluation of head injury, head contusion." ...
OCCURRED: onset was unknown, Injury occurred during altercation ... MECHANISM: Complaint occurred by blunt trauma, direct blow...
LOCATION: Posterior scalp. QUALITY: Unable to describe pain. Open wound is bleeding controlled. ASSOCIATED LOC (Level of
consciousness): Uncertain as to whether or not loss of consciousness occurred. GCS 10 (Glasgow Coma scale- a scale that measures level of consciousness, especially after head injury- Normal GCS is 15)" ... E/M CAVEAT: Emergency room caveat invoked due to patient with mental status changes. NOTES: patient confused, agitated does not provide any history per mom, patient dropped off at house at 9 pm, went to different hospital around 9:30 where she left and then brought him. . . CONSTITUTIONAL: ... agitated, uncooperative PHYSICAL EXAM ... Head ... Contusion (an injury-as from a blow with a blunt instrument) of: Left occipital (back of the skull) region, laceration of left occipital region ...NECK ... Tenderness present, diffusely. NEURO: The GCS total is 9. ... Radiology Interpretation: Preliminary review of CT(Computerized Tomography-use of computerized x-rays to make a detail picture of the inside of one's body to define normal or abnormal structures in the body) by radiologist (A medical doctor who specializes in diagnosing and treating diseases and injuries using imaging techniques such x-rays and CT).. HEAD: Interpretation of Head CT shows SDH (Subdural Hematoma-a collection of blood outside the brain), SAH (sub-arachnoid Hemorrhage- is bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space- SAH is considered a medical emergency). There is intracranial hemorrhage. Further review of the medical record revealed, Procedure: INTUBATION (a procedure in which a flexible plastic tube is placed, in the windpipe to maintain an open airway): ... 1/1/2014 Pre- intubation O2 amt (amount): 100%... The following medications were given to facilitate intubation ...Etomidate and Rocuronium. Patient #1 was intubated with an 8.0 endotracheal tube and placed on the ventilator (a method to mechanically assist or replace spontaneous breathing)" A gastric tube was also inserted through the mouth for airway maintenance. Intravenous therapy was also started for hydration and medication administration. Blood and urine was obtained and sent to the laboratory for analysis. The medical record also indicated, "Nursing Procedure: Transfer ... Patient transferred at 0105 (1/1/2014) ...Reason for transfer: Need for specialized care, Accepting institution:
(Hospital C), accepting physician (physician's name) ...DIAGNOSIS: Final: Primary: "Skull Fracture-closed, w/intracranial hemorrhage."
ADDITIONAL: Alteration of consciousness, Neck Injury [Unspecified],
subarachnoid hemorrhage-traumatic, Subdural hematoma -traumatic ...
Disposition type: Transfer, Disposition: Transfer -Trauma, Disposition
Transport: Air Transport, Condition Critical."


3. MEDICAL RECORD FROM HOSPITAL C
Review of the medical record revealed that Patient #1 arrived at the hospital
on 1/1/2014 at "approximately" 0130. The patient was listed as trauma
code 1 (hospitals that are equipped and staffed to provide comprehensive
emergency medical services to patients suffering traumatic injuries). Review
of the Emergency Department Documentation specified in part, History
of present illness: This is an 18 year old ...with no past medical history
who presents after he was discovered to have depressed skull fracture and
contusions. Reportedly... the patient returned home after being out with
his friends all day. His mother reported that he was altered so she took him
to the local emergency room. He came in that apparently threatened to call
911 so the mother took him in her car to Hospital B... He was intubated
due to combativeness and declining GCS. He was transferred to Hospital
C ... Physical Examination: Head palpable skull fractures. Right otorrhea
(discharge from the ear). ... Repeated the CT of the head and cervical
spine which revealed depressed left parietal skull fracture with associated
hemorrhagic contusions. He also has countercoup hemorrhagic contusions to the right subfrontal region. ...Impression: Acute respiratory failure related to status post RSI (Rapid sequence Intubation- intubation required to recognize signs of impending respiratory failure ICH trauma), PLAN: Condition : Critical ... Patient #1 was admitted to the surgical ICU (Intensive care Unit-specially equipped hospital area designed for the treatment of patients with sudden life threatening conditions). Neurosurgery was consulted to help with further management of the patient's care. On 1/1/2014 Patient #1 underwent a procedure where an intracranial bolt device was placed in his head to monitor intracranial pressures.


4. Policy and Procedure
Review of the facility's policy, titled, "Medical Screening Exams" M-9 specified in part, "I. Policy Person presenting to McLeod Health seeking emergency medical care should receive a medical screening exam to determine the presence of an emergency medical condition."


5. Security guards schedules
On 1/13/2014, based on information identified in the complaint allegation, the emergency department's security assignment schedule was reviewed for security personnel on duty on 12/31/2013, and validated that three security guards were on duty in the hospital on 12/31/2014.


6. Personnel Files
On 01/15/14 from 8:40 a.m. to 8:58 a.m., review of personnel files revealed annual EMTALA training for Security Guard 2 on 01/09/14 who had worked as a security guard for four years and had no prior disciplinary history. Review of Security Guard 1 had been employed as a security guard by the hospital for 8 months when the incident occurred on 12/31/2013 and had no prior disciplinary history. Security Guard 1 had received no EMTALA training per the personnel file. Security Guard 1 stated that he/she had been a former police officer.


7. Interviews:
On 1/14/2014 at 1540 and on 1/15/2014 at 5:57 p.m., Security Guard 1 was
interviewed and verified that he/she was on duty on 12/31/2013 in the emergency department on the 3:00 p.m.(evening) shift. Security Guard 1 reported that his/her duties in the emergency department involved sitting at the receptionist desk and roaming the back of the emergency department. During the interview on 1/14/2014, Security Guard 1 reported the he/she had no recall of any incidents out of the ordinary occurring on the evening of 12/31/2013. During the interview on 1/15/2014, Security Guard 1, when asked about any incidents that may have occurred where a patient and family presented to the emergency department but left prior to entering the emergency department, Security Guard 1 reported that he/she vaguely remembered an incident like someone being under the breeze way and then
leaving. Security Guard 1 verified the emergency department has video surveillance, but it is video only with no audio.

On 1/14/2014 at 3:55 p.m. and 1/15/2014 at 5:50 p.m., Security Guard 2 verified that he/she was on duty on 12/31/2013 on the 3:00 p.m. shift in hospital's emergency department, and he was responsible for monitoring the grounds that shift. During both interviews, Security Guard 2 reported that the emergency department was busy that evening, and he/she could not recall off hand that someone had presented to the emergency department in a vehicle and then left. He verified that the emergency department has surveillance video but that it is video only with no audio.

On 1/15/14 from 11:19 a.m. to 11:30 a.m., a telephone interview with the father/mother of Patient #1 revealed that when they arrived to McLeod Dillon Medical Center that "a tall employee was outside with the wheelchairs. The Mother stated that she told him/her that her son (Patient #1) needed some help. The mother reported that the hospital employee informed her that if you pull up, I'll help you. The mother reported that she pulled up under the breezeway, but when the hospital employee saw how her son was acting; the hospital employee said to her, "if you bring your son in here, I'm going to have him locked up." The mother stated that
she said, "Sir, my son needs medical attention." The mother stated that the hospital employee stated, "if you bring him in here, I'm gonna have him locked up with him acting like that." The mother reported that she explained to the employee that he had been hit in the head and was bleeding real bad. The mother stated that the hospital employee told her, "Ma'am I'm telling you if you bring him in here like that all they will do is have him locked up." The mother stated that she took her son to Hospital B where he was placed on life support (ventilator) and shipped to Hospital C on the helicopter on the ventilator."

On 01/16/14 from 11:35 a.m. to 11:50 a.m., during a telephone interview with Security Guard 1, Security Guard 1 reported that he recalled that on 12/31/2013 during the evening shift that a woman in a vehicle arrived at the emergency room entrance for the second time, and "the woman was trying to get the passenger (Patient #1) in a wheelchair." Security Guard 1 reported the woman was kind of tussling with the passenger (Patient #1). Security Guard 1 stated, "we did tell her that we can't make the passenger come into the hospital to get treatment. So I told her that if they get any rowdier that we would have to call the police. I told them they couldn't bring that rowdiness into the waiting room because we had kids and women in the lobby- it was kind of busy. People in the lobby were looking so I didn't want to get them upset. The passenger (Patient #1) - looked like he was bleeding from the head. Both vehicles left and they never came back...."The facility failed to ensure that their hospital security guard was knowledgeable regarding when a request was made on Patient #1's behalf (his mother) seeking medical assistance on 12/31/2013 because the patient's mother concluded that a bleeding head wound (as also identified/verified by the hospital security guard interview), with personality changes, was a need for an examination and treatment of a medical condition. On 12/31/2013 Patient#1 needed/required a medical screening examination to determine whether or not an emergency condition existed. An emergency medical condition was identified on 12/31/13 and 1/1/2014 at hospital B and C.

On 01/16/14 at 12:00 p.m. from 12:08 p.m., during a telephone interview with Security Guard 2, Security Guard 2 revealed that he/she recalled an incident that occurred on 12/31/2013 on the evening shift when a woman made a second visit to the emergency room entrance. Security Guard 2 stated that there was another person in a separate vehicle, and the man in the other vehicle went to the emergency room entrance to obtain a wheelchair. Security Guard 2 reported, "Then we went outside. The passenger (Patient #1) wasn't pulling on the woman but was yanking away from the man.... The passenger (Patient #1) kept telling the woman that he wasn't going into the hospital. The passenger was getting aggressive, so we told them that we would have to call the police if it escalated. They never could get the passenger (Patient #1) to come in. Then, they got in the car and left". The facility also failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 12/31/2013 when Patient #1 presented to the hospital's emergency room seeking medical care, a medical screening examination should have been provided to determine the presence of an emergency medical condition.