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Based on review of hospital policies, documents, medical records, and staff interviews, the hospital failed to enforce its policies and provide Patient #6, who staff observed as behaving erratically outside the Emergency Department (ED) and dressed inappropriately for the severe cold; with an appropriate medical screening examination out of 30 cases selected for review from December 29, 2015 to February 5, 2016.

Failure to ensure staff follow their policies and provide an appropriate medical screening examination to any individual presenting to the ED requesting care, or to any individual on hospital property who a prudent layperson observer would conclude from the individual's appearance or behavior, that the individual needs emergency examination or treatment, could potentially delay the individual's treatment and/or result in harm to the individual.

Findings include:

1. Review of the hospital policy titled "EMTALA: Medical Screening and Stabilizing Treatment", dated 4/14 included in part..."Procedure: Any patient who comes to the Hospital's dedicated emergency department and requests or has a request made on his or her behalf for emergency medical examination and treatment or who a prudent layperson would believe, on the basis of the individual's appearance or behavior, requires examination or treatment for a medical condition, will be provided an appropriate medical screening examination within the capabilities of the dedicated emergency department....Definitions: Comes to the Emergency Department...an individual is considered to have "come to the emergency department if the individual has...a request made on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition."

Review of the hospital policy titled, "Unit Structure and Practice Model", dated 1/14 revealed, in part..."Description: The Emergency Department is a 24 bed unit...any individual seeking emergent/non-emergent care will be properly assessed, given an appropriate medical screening examination, and appropriate services/referrals rendered..."

Review of the hospital policy titled, "Care Of Patients Presenting With Psychiatric Complaints In The Emergency Department" with a revision date of 5/15, included in part, "...Regarding care of patients who present with psychiatric complaints in the Emergency Department...charge nurse will be notified immediately of all patients who present to the Emergency Department with a psychiatric complaint...patient will be immediately roomed...nurse...will assess the patient for the presence of...Imminently Dangerous to Self/Others/Property...unable to care for self...inability to keep self safe from harm...Delusions or paranoid thoughts...Gross Psychotic Presentation...Disorientation to person/place/time...Fixed delusions...If the patient is positive for any of the above symptoms, they will be placed in a behavioral health room, they will be changed into paper scrubs...Direct observation of the patient will be performed by Security personnel...Any patient who displays any of the behaviors listed above...will not be allowed to leave the Department...If a patient attempts to elope...a Code Strong will be called and the patient will be detained within the Department for his or her own safety..."

2. Review of a document titled, "Quality, Patient Safety and Compliance Education" dated 2015 provided to all physicians annually included in part..."EMTALA...Wheaton Franciscan Healthcare... must provide a medical screening exam to individuals (including visitors) presenting themselves an any area of the hospital main campus if the individuals require or has a request made on their behalf, for examination or treatment for what may be an emergency medical condition. A request will be considered to have been made if a prudent layperson observer would conclude, based on the person's appearance or behavior, that the person needs emergency examination or treatment..."

Review of a document titled, "Covenant Medical Center Medical Staff Rules and Regulations", dated 12/3/15, included in part, "...Emergency Department...EMTALA Compliance: All members of the Medical Staff are expected to abide by the requirements of...EMTALA...an emergency medical condition is a medical condition manifesting itself by acute symptoms of severity including...psychiatric disturbances, and/or substance abuse such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy...an individual is considered to have "come to the emergency department" if the individual has presented at the hospital's dedicated emergency department or on hospital property...for a potential emergency medical condition, or has such a request made on his or her behalf..."

3. The the ED staff reported, on the evening of 2/4/16 at approximately 9:30 PM, the outside temperature was 25 degrees Fahrenheit when Patient #6 approached the ED entrance wearing only a sleeveless T-shirt, jeans and carrying a snow covered coat. The ED staff reported Patient #6 appeared erratic, bizarre, and suspicious. The ED staff brought the patient into the ED.

During an interview on 2/9/16 at 5:10 PM, ED Physician B reported, on the evening of 2/4/16, [Registration Clerk] called [RN F] about a patient. ED Physician B stated, "I overheard the conversation and directed them to call security and get the patient to come inside to warm up." ED Physician B stated, "I was waiting to see him as a patient after staff got him registered." ED Physician D reported, at some point he heard the patient had left the ED. ED Physician B stated, "The hospital Security Officers and the Waterloo Police Department attempted to locate him and bring him back to the hospital. It was very cold that night and the patient wasn't dressed appropriately." ED Physician stated, "The patient was behaving erratically outside."

Refer to A2406 for further details.

Based on review of hospital policies, documents, medical records, and staff interviews, the hospital failed to provide Patient #6, who staff observed as behaving erratically outside the Emergency Department (ED) and dressed in appropriately for the severe cold; with an appropriate medical screening examination out of 30 cases selected for review from December 29, 2015 to February 5, 2016.

Failure to ensure staff provide an appropriate medical screening examination to any individual presenting to the ED requesting care, or to any individual on hospital property who a prudent layperson observer would conclude from the individual's appearance or behavior, that the individual needs emergency examination or treatment, could potentially delay the individual's treatment and/or result in harm to the individual.


Findings include:

1. During the course of an unrelated complaint investigation at Covenant Medical Center, the VP (Vice President) of Medical Affairs reported the following:

a. During an interview on 2/5/16 at 10:47 AM, the VP of Medical Affairs reported on 2/4/16 at 9:48 PM an "event" occurred. The VP of Medical Affairs stated, "One of the hospital security officers and registration clerk brought a man into the ED after they observed a man with bizarre behaviors. The VP of Medical Affairs reported he was still gathering information and the specific details of the event would forward the information to the Iowa Department of Inspections and Appeals.

b. During an interview on 2/9/16 at 12:45 PM, when asked for the information from the event on 2/4/15, the Risk Manager stated, "We are still completing interviews and completing the report of the event." The Risk Manager identified the man as [Patient #6].


2. Review of the hospital document titled "Security Department Confidential Incident Report" dated 2/4/16 at 9:50 PM, completed by Security Officer H, stated in part, "...Individual: confused, suspicious... Action Taken: observation...Narrative: On...2/4/16...officers were notified by ED admissions of a suspicious individual outside the ED entrance. Upon arrival, officers observed a male who was acting in a suspicious manner...walking along the circle drive in front of the ED...hitting the protective posts. Officers made contact with him... the man stated he wanted to speak with [Psychiatrist E]...he told the security officer he had been released from [Behavior Health Unit] in the recent past...Officers advised that the doctor was not in the building but instead offered to come sit in the ED lobby to warm up...he was dressed in a cut off T-shirt and was covered in snow...he was in the ED lobby for a few minutes and then left the building...he ran across the circle drive and ran back and forth through the snow, even jumping at times for no apparent reason...Officers followed the subject...made contact with him...the man spoke as if he had no recollection of speaking with us just five minutes prior. The subject began speaking of father's affiliation with the...Indian Tribe...his conversation was extremely hard to follow...the conversation ended...officers followed him...the man jumped over the fence at the apartment property. Officers followed the man's footprints and eventually the security officers lost him...Officers made contact with Waterloo Police Department...stated they would check the area for the man..."

Review of a document titled, "Call For Service Record" with a date/time of 2/4/16 at 9:55 PM, provided by the Waterloo Police Department, stated in part, "The police officers responded to a call from the hospital ED staff, [RN F (Registered Nurse] for a "mental person". At 9:56 PM, upon arrival to the ED premises the police officers observed a male subject outside of the hospital visitors entrance, running through the snow. The male subject was dressed in a black sleeveless shirt and blue jeans. The hospital security staff told the police officer they followed the "psych patient" until the patient jumped a fence behind the high school (approximately 2 blocks from the hospital)..."

3. The surveyor, along with the Security Manager viewed the video footage recorded on the hospital security cameras on the night Patient #6 presented to the ED on 2/4/16 at 9:47 PM. Patient #6 wearing only a sleeveless T-shirt, jeans, and carrying a coat, was walking outside of the ED entrance. As the patient approached closer to the ED entrance doors he stopped, kicked a cement pole, and then began swinging his coat at the same cement pole. At 9:48 PM, the Registration Clerk along with, Security Officer D, and Security Officer H exited the ED entrance and approached the patient. At 9:49 PM, Patient #6 entered the ED lobby accompanied by the Registration Clerk, Security Officer D and Security Officer H. At 9:50 PM, the video footage showed Patient #6 sitting in a chair, unattended in the ED lobby. After approximately 2 minutes of being left unattended in the ED lobby, Patient #6 stood up, wearing only a sleeveless T-shirt, jeans, and carrying a coat, exited the ED through the main entrance doors to the outside elements. At 9:53 PM, Patient #6 is seen approximately 25 feet from the ED entrance, running back and forth. The patient stopped, turned and walked down the sidewalk towards West 9th Street. (A busy intersection running parallel to the hospital.)

4. Review of State Climatologist report revealed the following frigid weather conditions at the Waterloo airport on 2/4/16 at 8:54 PM the actual temperature was 25 degrees. The winds were from the the northwest at 15 mph (miles per hour) creating a wind chill of 13 degrees. At 10:54 PM the actual temperature was 18 degrees. The winds were from the west at 10 mph creating a wind chill of 6 degrees. There was 1/2 inch of new snow accumulation earlier in the evening. There was 6 inches of snow on the ground left over from snow events earlier in the month.

5. During the course of the investigation, the surveyor identified through interviews and review of documents, on the evening of 2/4/16 at approximately 9:30 PM, the ED staff reported Patient #6's behavior was erratic, bizarre, and suspicious as the patient approached the ED entrance. The ED staff brought the patient into the ED.

a. During an interview on 2/9/16 at 2:10 PM, Security Officer D stated, "On 2/4/16 at approximately 9:45 PM, [Security Officer H], paged me to assist them with a male with suspicious and bizarre behaviors in the ED lobby." Security Officer D stated, "When I arrived to the ED lobby, I saw a man sitting in the ED lobby. He was seemingly calm, but he was mumbling to himself. The man was wearing a cut off T-shirt, jeans, and carrying a coat covered in snow." Staff D stated, "The patient asked to talk with one of the psychiatric doctors (Psychiatrist E)." Security Officer D stated, "After approximately 3-5 minutes, he just got up and started walking out of the ED lobby." Security Officer D stated, "Security Officer G followed the patient out of the ED lobby." Security Officer D stated, "He never said he wanted help, but I knew he had told us earlier in the ED lobby that he wanted to talk to one of the psych doctors."

Security Officer D stated, "Once the patient was outside he walked approximately 25 feet from the ED entrance, he started sprinting back and forth in the snow. It was very cold outside. It was just below freezing, and there was snow on the ground. I was concerned for the patient's well being." Staff D stated, "At that point my gut told me the patient should not be left alone and a doctor needed to see the patient now."

Security Officer D stated, "The patient walked approximately 300 feet from the ED entrance down the sidewalk towards West 9th Street." Security Officer D stated, "The patient approached the security van, appeared confused and answered the our questions inappropriately and then he walked away from the security van." Security Officer D stated, "We continued to follow him because we were in fear for the patient's safety. The patient was not dressed for the winter weather conditions." Security Officer D reported, the Security Officers lost sight of the patient.

b. During an interview on 2/9/16 at 3:10 PM, Staff E, Registration Clerk, reported on 2/4/16, at approximately 9:30 PM, she observed a man outside by the ambulance bay doors who was stumbling, and wearing only a sleeveless shirt, jeans, and carrying a coat. Staff E stated, "It was cold outside and I was concerned." Staff E reported she went outside to help the patient when he started hitting the cement blocks in front of the ED entrance doors with his coat. Staff E stated, "I went outside and asked him if I could help him." Staff E stated, "He said he was a psych patient and he wanted to say hello to [Psychiatrist B]". Staff E said, "I knew at that point something wasn't right." Staff E reported, the patient's behavior was abnormal. Staff E stated, "I was thinking he was a psych patient, he had fallen and hit his head, or was on something." Staff E stated, "I was in fear for his safety and well being." Staff E stated, "I got him to come in to be seen by a nurse or doctor." Staff E stated, "I went back to the ED nursing unit and told [RN F (Registered Nurse)] about the patient. I think she said something about a medical screen." Staff E stated, "By the time [RN F] and I came back to the ED lobby the patient had taken off." Staff E reported she went outside to see if she could get the patient to return but the patient was walking down the sidewalk towards the hospital chapel entrance.

c. During an interview on 2/9/16 at 5:10 PM, ED Physician B reported, on the evening of 2/4/16, [Registration Clerk] called [RN F] about a patient. ED Physician B stated, "I overheard the conversation and directed them to call security and get the patient to come inside to warm up." ED Physician B stated, "I was waiting to see him as a patient after staff got him registered." ED Physician D reported, at some point he heard the patient had left the ED. ED Physician B stated, "The hospital Security Officers and the Waterloo Police Department attempted to locate him and bring him back to the hospital. It was very cold that night and the patient wasn't dressed appropriately." ED Physician stated, "The patient was behaving erratically outside."

d. During an interview on 2/10/16 at 4:00 PM, RN F stated, "[Registration Clerk] came back to the nurses station and reported she seen a man dressed in a sleeveless shirt and jeans, wandering around outside of the ED. She said the man was hitting the cement posts with a coat." RN F stated, "[Registration Clerk] told me the patient stopped by to say hello to [Psychiatrist E] and she brought him into the ED lobby." RN F stated, "I had never dealt with something like this before so I spoke with [ED Physician B] and he told me to call security and the Waterloo Police Department." RN F stated, "By the time I went out to the lobby no one was there." RN F reported she went outside and saw the patient pacing back and forth in the snow approximately 25 feet from the ED entrance. RN F stated, "I came back inside and told the security staff to watch him." RN F reported she called the Waterloo Police Department.

e. During an interview on 2/15/16 at 2:50 PM, Security Officer G reported on 2/4/16 at 9:20 PM he received a call from [Security Officer H] to come out front of the ED. Security Officer G stated, "[Security Officer H] told me there was a man wearing a tank top, that was covered in snow, and he was acting erratically." Security Officer G stated, "When I got outside [Security Officer H and Registration Clerk] were talking with the individual." Security Officer G stated, "I reached out to shake his hand and his hands were as cold as ice." Security Officer G stated, "I asked the patient if he would come inside to warm up and he agreed. The patient followed [Registration Clerk] into the ED lobby and I returned to the ED to watch 3 patients." Security Officer G stated, "Approximately 5 minutes later, I received a call from [Security Officer H] and he told me the patient had left the ED lobby."

Security Officer G stated, "[Security Officer H] told me the patient started acting erratic outside of the ED." Security Officer G reported by the time he got to the opposite end of the parking lot in front of the ED, [Security Officer H and Security Officer D] were in the van talking with [Patient #6]. Security Officer G reported the patient appeared agitated and tense. Security Officer G stated, "At approximately 9:45 PM the patient walked away from the security staff." Security Officer G reported the security staff continued to follow the patient until they lost sight of the patient, approximately 2 blocks away from the hospital.

f. During an interview on 2/15/16 at 4:05 PM, Staff H, Security Officer stated, "[Registration Clerk] asked me to watch a guy out front of the ED, who was acting suspicious." Security Officer H stated, "At that point I observed a man walking towards the circular drive in front of the ED entrance. He started hitting the concrete pylons (post or tower) with his sweatshirt." Security Officer H stated, "[Registration Clerk] and I went outside to talk with the patient and he told us he wanted to speak with [Psychiatrist E]." Security Officer H stated, "The patient said he had been released from the psychiatric floor not that long ago." Security Officer H stated, "I told the patient [Psychiatrist E] was not at the hospital."

Security Officer H reported the patient walked into the ED lobby and sat down in a chair. Security Officer H stated, "I went back to the security office that overlooks the ED lobby. I could see him. He sat there a couple minutes. I did not see him leave. The next thing I knew [Registration Clerk] told me the patient was outside running through the snow by the ED visitors entrance." Security Officer H stated, "So, I got up and went outside because the patient's behavior was odd. The patient was jumping and stomping on the ground." Security Officer H stated, "[RN F] came outside and said she was calling the Waterloo Police Department. I told her we would keep an "eye" on the patient until the police department arrived."

Security Officer H stated, "The patient started walking down the sidewalk towards West 9th Street. I followed him because he acted strange. I did not want him to do anything until a nurse could check him out." Security Officer H stated, "I guess you could say I was worried for his safety or I would not have followed him." When asked if Security Officer H was told to keep the patient in the ED, Security Officer H stated, "Normally if someone is not free to go, the nurses will tell us the patient is not free to go. As far as I was concerned, he was free to go."

g. During an interview on 2/16/16 at 9:45 AM, Staff I, Registration Representative reported on 2/4/16 she observed a man dressed in a tank top and pants, walked aimlessly outside in front of the ED lobby. Staff I reported she remained at the registration desk in the ED Lobby when the two security officers and [Registration Clerk] went outside to get the patient. "It was "freezing" cold outside and the individual wasn't dressed for the weather." Staff I stated, "The patient came in willing. He sat down and was watching television. I did not know if he wanted to be seen by a doctor." Staff I stated, "[Registration Clerk] went back to get him a cup of coffee and to talk with [RN F]. The patient stood up and told me he was going to go that he was feeling warmer and just wanted to go home. He was fidgety. When asked who was watching the patient in the ED lobby, Staff I stated, "I was not told to watch him."

h. Review of a document titled, "ED Patient Log" dated 2/4/16, revealed the ED staff did not document information in the ED Patient Log that showed Patient #6 presented to the ED with erratic, bizarre, and suspicious behaviors and the disposition of the patient.

i. Review of the hospital document titled, "Monthly ED Physician Schedule" revealed, on 2/4/16, ED Physician B and ED Physician Assistant C were present in the ED, at the time Patient #6 presented to the ED.

j. Review of the hospital document titled, "Nursing Daily Roster" revealed, on 2/4/16, 5 RN's were present in the ED, at the time Patient #6 presented to the ED.

k. Review of the hospital document titled, "ED Census" dated 2/4/16 revealed 12 patients presented to the ED requesting treatment from 9:00 PM to midnight.

l. The Risk Manager reported, the Adult Behavioral Health Unit has a total of 16 patient beds and on 2/4/16 at 10:00 PM, the patient census was 12 patients. There were 4 Adult Behavioral Unit beds available for patient use, at the time Patient #6 presented to the ED.

6. Review of Patient #6's closed medical record showed on 2/5/16 at 6:34 PM, (approximately 21 hours after the patient presented to the ED on 2/4/16) Patient #6 presented to the ED, accompanied by Waterloo Police requesting a psychiatric evaluation and complaining of an alcohol problem.

Progress Note on 2/5/16 at 6:55 PM, completed by ED Physician F included in part, "...The patient states he does not feel safe at home... made suicidal comments...has a significant past medical history of Schizoaffective disorder, anxiety, and acute mania...Patient's case discussed with psychiatry...he can be admitted to the psychiatric floor..."