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Based on a review of the facility's Emergency Department (ED) central logs, medical records, policies and procedures, interviews with staff, and a review of the facility's huddle meeting minutes, it was determined the facility failed to provide an appropriate and continuous Medical Screening Examination (MSE) for one (P#1) out of 20 patients sampled.

Findings were:

Cross-reference A2406 as it relates to the facility's failure to provide an appropriate and continuous Medical Screening Examination (MSE)

Based on a review of the facility's Emergency Department (ED) central logs, medical records, policies and procedures, interviews with staff, Emergency Medical Services report, video review, Medical Staff Bylaws and Rules and Regulations, and a review of the facility's huddle meeting minutes, it was determined the facility failed to provide an appropriate and continuous Medical Screening Examination (MSE) for one (P#1) out of 20 patients sampled.

Findings were:

A review of the facility's Central Log revealed that Patient (P) #1 presented to the Emergency Department (ED) and was registered as a patient on 1/10/22 at 7:00 p.m. and given a disposition of Left Without Being Seen (LWBS). P#1 was registered as a patient on 1/11/22 at 1:37 a.m. with LWBS disposition. Continued review revealed that P#1 was registered as a patient on 1/11/22 at 9:47 p.m. and was discharged.

A review of a Pre-Hospital Report revealed that Emergency Medical Services (EMS) responded to a non-emergent call to a Long-Term Care (LTC) facility on 1/10/22. P#1 was transported to the Emergency Department (ED) non-emergently at 6:35 p.m. P#1 arrived at the ED at 6:53 p.m. ED Notes by Registered Nurse (RN) BB on 1/10/22 at 8:43 p.m. revealed no answer when P#1 was called for triage. ED Notes revealed that procedures and treatment were not carried out due to P#1 leaving prior to seeing a health care provider. P#1's discharge disposition was set to Left Without Being Seen (LWBS) on 1/10/22 at 11:42 p.m.

A review of the ED Notes revealed that P#1 arrived in ED on 1/11/22 at 1:37 a.m. The arrival complaint was right knee pain after being shot in the knee two weeks prior. P#1 was placed in a triage room at 1:41 a.m., and triage started at 1:59 a.m. The chief complaint was updated on 1/11/22 at 1:59 a.m. to Annual Wellness Visit. P#1 had been sent to the ED by a personal care home. P#1 had no complaints and did not know why he was at the ED.

A chest x-ray was ordered by Medical Doctor (MD) HH on 1/11/22 at 2:03 a.m., and the chest x-ray began at 2:23 a.m. ED Notes by Registered Nurse (RN) DD on 1/11/21 at 7:54 a.m. revealed that P#1 was called to a room with no answer. The results of the chest x-ray were obtained on 1/11/22 at 8:10 a.m. ED Notes by RN DD on 1/11/22 at 8:14 a.m. revealed that P#1 was called for a room two times with no answer. P#1's disposition was set to LWBS on 1/11/22 at 8:42 a.m.

A review of the ED Notes by Registered Nurse (RN) EE dated 1/11/22 at 8:30 p.m. revealed that P#1 was pulled from the lobby to be assessed. P#1 reported that he had been in the hospital all day, denied leaving the area, and was able to ambulate without assistance. P#1 had a plastic bag over his left foot. P#1 denied falling, and there were no signs of trauma. P#1 was confused regarding the year and events surrounding being sent to the hospital. RN EE spoke with P#1's family to inform the family member that P#1 was safe, and that the ED staff were beginning the examination process. The family member confirmed that P#1 had a past medical history of seizures with multiple head injuries due to falling with seizure activity. The family member reported that P#1 lived with a different family member until he was shot on 12/1/21. The family member denied that P#1 had been homeless or incarcerated. The case was discussed with Medical Doctor (MD) II. A review of ED Notes on 1/11/22 at 9:34 p.m. revealed that P#1 did not have any obvious deformity to his legs. P#1's baseline mental state was unclear.

A review of the ED Notes revealed that MD II conducted a Medical Screening Examination (MSE) on 1/11/22 at 10:08 p.m. The MD Provider Notes revealed that the patient and the LTC facility provided limited patient history. P#1 presented to the ED for evaluation of a positive PPD (tuberculosis skin test). P#1 stated he had a history of diabetes and was sent to the ED for elevated blood sugar. P#1 said he was not on any medications. P#1 also stated he was shot three weeks ago in his right lower extremity, requiring surgery. P#1 said his leg was fine with no complaints near the surgical site. P#1 also said he lived with his mom but was currently living at a LTC facility. P#1 was alert to person but not time or situation. P#1 did not have a cough, fever, or acute distress. P#1's HR and rhythm were normal. P#1's skin exam showed a 20mm x 15mm round erythematous (abnormal redness) patch with slight induration (inflammation) on the left arm that was presumed to be the site of the PPD injection. MD II said he would communicate with the LTC facility that an appointment was needed with infectious disease.

A review of ED Notes by RN EE dated 1/11/21 at 10:22 p.m. revealed that RN EE spoke to the LTC facility. P#1 was sent to the ED after a positive PPD, and no symptoms of tuberculosis (TB) were reported. P#1 was COVID positive. The baseline mental state was unknown per the LTC facility, and the LTC facility denied a past medical history of TB or increased risk factors.

A review of a Progress Note by MD II dated 1/11/22 at 11:05 p.m. revealed that a chief concern for P#1 was an Altered Mental Status (AMS). Laboratory tests and a Computed Tomography (CT) (x-ray to give multiple pictures) of the head were ordered. A chest x-ray was normal. P#1 did not have a fever, cough, blood when coughing, or weight loss. P#1 had not been in jail or a homeless shelter. P#1 admitted a prior history of alcoholism but no Intravenous (IV) drug use. MD II consulted with Infectious Disease. Infectious Disease said P#1 could follow up in the clinic to treat latent TB or receive yearly chest x-rays. MD II noted that P#1 would be discharged to the LTC facility in stable condition. P#1's diagnosis was a Positive PPD.

A review of an ED Note by Registered Nurse (RN) JJ dated 1/12/22 at 12:10 a.m. revealed that transport would pick up P#1 in the morning, at approximately 9:30 a.m. P#1 would reside in DH-1 (a room with a stretcher near triage) until picked up by transport. A review of ED Notes dated 1/12/21 10:04 a.m. revealed the new estimated time of arrival for transport was 10:30 a.m.

A review of an Ancillary Note by Registered Nurse (RN) KK dated 1/12/22 at 10:58 a.m. revealed that Case Management was consulted by Unit Secretary (LL). The LTC facility refused to take P#1 back, stating P#1 had TB. Case Management spoke with the LTC facility's Director of Nursing (DON), who insisted P#1 could not come back to the nursing home, as P#1 had active TB and required a negative pressure room. The DON was aware that a positive TB was nowhere in the P#1's chart. The DON maintained that P#1 could not return to the LTC facility. Case Management spoke to the LTC facility Administrator, who wanted P#1's chest x-ray faxed to the TLC facility before P#1 could return. Transport was to pick up P#1. P#1 was discharged from the ED on 1/12/22 at 11:36 a.m. with transport to the LTC facility.

Review of surveillance video for the ED from 1/10/22 at 6:52 p.m. until 1/11/22 at 8:34 p.m. revealed the following with an added 3-minute time discrepancy:

1/10/22 - 6:52:49 p.m.: EMS arrived at the drop-off area in front of the ED.

1/10/22 - 6:54:42 p.m. P#1 was removed from the ambulance and entered the ED vestibule on a stretcher wearing a red plaid shirt and a ball cap. P#1 and EMS waited near the nurse's station.

1/10/22 - 7:01:46 p.m. EMS talked to the registrar and returned to P#1 with an identification bracelet.

1/10/22 - 7:15:25 p.m. EMS assisted P#1 to a wheelchair.

1/10/22 - 7:16:44 p.m. P#1 was taken to the ED waiting area by EMS.

1/10/22 - 7:18:00 p.m. EMS pushed P#1 into the triage area.

1/10/22 - 7:19:52 p.m. EMS was observed leaving the ED.

1/10/22 - 7:21:21 p.m. P#1 was pushed in a wheelchair out of the triage area to a section in the waiting room where there was no camera surveillance (to the right of the nurse's station, near the inside exit to the east wing of the hospital).

1/11/22 - 1:48:49 a.m. P#1 re-entered camera surveillance from the direction of vending machines located near the inside exit of the east wing of the hospital. P#1 was pushed into the triage area by facility staff.

1/11/22 - 1:56:55 a.m. P#1 was pushed into the waiting room and left in front of the triage area in a wheelchair.

1/11/22 - 2:09:19 a.m. P#1 was taken by wheelchair to the registrar's desk at the nurse's station inside the ED.

1/11/22 - 2:25:08 a.m. P#1 was pushed down the hallway in the direction of the radiology department.

1/11/22 - 2:33:26 a.m. P#1 was returned to the waiting room and seated in the wheelchair close to the triage area. P#1 remained in the waiting room, occasionally ambulating to the bathroom or changing chairs. P#1's gait appeared unsteady at times.

1/11/22 - 7:54:46 a.m. The patient advocate (PA) MM was observed speaking to P#1 in the waiting area. P#1 had been observed leaving the waiting area since being returned at 2:33 a.m. from the triage area.

1/11/22 - 2:01:06 p.m. P#1 walked toward the bathroom.

1/11/22 - 2:10:13 p.m. P#1 was observed exiting the restroom and sitting in a chair close to the restroom to the left of the triage area.

1/11/22 - 2:35:12 p.m. P#1 walked back to the section of the waiting room near the triage area and sat in a chair near a window.

1/11/22 - 3:25:09 p.m. P#1 walked toward the right of the triage station with a plastic bag covering his left foot. P#1 walked out of view of the surveillance camera in the direction of a bathroom, the exit of the ED, and the entrance into the east wing of the hospital.

1/11/22 - 3:37:30 p.m. P#1 returned to a chair across from the triage area.

Surveillance footage of P#1 was observed at various intervals. P#1 remained seated in the waiting room, observed walking toward the restroom or changing chairs from 1/11/22 - 2:33:26 a.m. until 1/11/22 - 8:09:42 p.m. There was no indication that P#1 left the waiting room during the hours observed.

1/11/22 - 8:09:42 p.m. Patient Advocate (PA) GG is observed talking to P#1.

1/11/22 - 8:18:25 p.m. Registration was observed, bringing out papers from the triage area and handing them to P#1.

1/11/22 - 8:19:49 p.m. PA GG was observed leaving the ED and returned with a paper bag at 8:24:10 p.m. PA GG gave what appeared to be a bag of food to P#1.

1/11/22 - 8:34:12 p.m. P#1 was taken back into the triage area.

A review of the Medical Staff Bylaws and Rules and Regulations approved 3/11/19, Article XI, 11B, Emergency Services, Medical Screening Examinations (MSE), revealed that an MSE, within the capability of the facility, would be performed on all individuals who came to the facility requesting examination or treatment to determine the presence of an Emergency Medical Condition. Qualified medical personnel (QMP) who could perform MSEs included medical staff members with clinical privileges in Emergency Medicine, other active staff members, and appropriately credentialed Advanced Practice Professionals. In addition, MSEs in obstetrics could be conducted by members of the Medical Staff with Obstetrics and Gynecological (OB/GYN) privileges, certified Nurse-Midwives with OB/GYN privileges, and RNs who had education and training in the care of pregnant/laboring patients.

The policy further revealed that the facility would provide an appropriate medical screening examination (MSE) for all patients presenting to the facility seeking emergency treatment. An individual would be on hospital property when the individual was at or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways. An Emergency Medical Condition (EMC) would be a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy. The facility would provide necessary stabilizing treatment for EMCs and an appropriate transfer if the facility did not have the capacity or capability to provide treatment necessary to stabilize the emergency medical condition. The facility would not delay an examination to inquire about insurance or payment status. The facility would accept appropriate transfers if the facility had specialized capabilities not available at the transferring hospital. The facility would obtain or attempt to obtain written informed refusal of examination, treatment, or appropriate transfer when/if the patient refused such action.

A review of a policy titled "Leaving Against Medical Advice" Policy #7810732, last revised 4/2/20, revealed that if a patient wished to leave from the triage area prior to receiving a medical screening, the triage/treatment nurse would notify the charge nurse and try to encourage the patient to stay and be seen. The patient would be advised of the risks involved in leaving without having a medical screening performed. The conversation would be documented in the medical record if a record had been made. The policy further revealed that if an adult patient with altered mental status, a patient on an involuntary hold, or a patient who lacked decision-making capacity eloped, additional procedures would be implemented. Nursing staff would notify the nursing supervisor and initiate a low-key rapid search of the unit, searching room to room, utility rooms, exam rooms, lounges, waiting areas, and adjacent stairwells. The nursing supervisor would notify the local law enforcement and security that the patient was missing. The nursing supervisor would provide a detailed description of the patient and explain safety-related concerns. If the patient returned to the unit, the patient's condition would be assessed and documented. The time the patient was noted to be missing, response to all search efforts, notifications, and times would be documented in the medical record.

During a telephone interview with the complainant on 1/14/22 at 1:54 p.m., the complainant stated that P#1 was transferred from a Long-Term Care (LTC) facility to the Emergency Department (ED) by ambulance because of a positive tuberculosis screening and dropped off at Facility A's ED on 1/11/22 at 6:53 p.m. The next day, 1/12/22, the complainant called Facility A to check the status of P#1 and was told that P#1 had been transferred to Facility B. When the complainant called Facility B, the complainant was informed that P#1 had been transferred back to Facility A. When the complainant called Facility A, the complainant was told that P#1 had left the ED with a family member without being seen. The complainant said that the family of P#1 was contacted and denied picking up P#1 from the ED. The complainant said the police department was contacted, and a missing person report was filed. The complainant said P#1 was located at Facility A's ED on 1/12/22 at 10:22 p.m. in the waiting room, eating food from a fast-food restaurant located within the facility. The complainant did not know how P#1 could have gotten money for food.

During an interview with the ED Clinical Nurse Manager (RN) AA, on 1/19/2022 at 9:32 a.m. in the conference room, RN AA stated the ED nurse received a report from EMS and P#1 was stable enough to go to the lobby. P#1 did not answer when he was called for triage. The nurse called again, and P#1 did not respond. P#1 was taken out of the system as Left Without Being Seen (LWBS) because P#1 was not answering when called. RN AA said later that night, when the lobby was starting to clear; someone noticed there was a patient who had not been called. P#1 was re-registered, vital signs were obtained, and a chest x-ray was ordered along with triage. P#1 was placed back into the waiting room to wait for the chest x-ray, and after the chest x-ray, P#1 returned to the lobby. RN AA said that sometime in the morning, P#1 was called three times. When P#1 did not answer, P#1 was taken out of the system. The nurse contacted the long-term care (LTC) facility to tell them P#1 was not at the ED. RN AA stated the ED staff tried to figure out where P#1 was by searching the lobby, the restrooms, and other areas and then went about the day. RN AA said that around 9:00 p.m. to 10:00 p.m., the ED staff received word that P#1 was in the lobby, so P#1 was re-registered. The LTC facility was contacted to find out why P#1 was at the ED and was told P#1 had a positive PPD and was positive for COVID. When the LTC facility called to ask about P#1, the unit secretary misspoke and told the LTC facility supervisor that P#1 was positive for tuberculosis. The LTC facility refused to take P#1 back, so Case Management became involved. The LTC facility wanted the police to go to the ED to identify P#1 since a missing person report had been filed. RN AA said P#1 never left the ED, and the police never came to the ED. The ED staff was able to identify P#1 with the wrist bracelet, and P#1 was the only patient with a gunshot wound to the leg. RN AA said the negative chest x-ray was faxed to the LTC facility and transport took P#1 back to the LTC facility. RN AA explained that a positive PPD was not considered an emergency medical condition. The protocol for a patient with a positive PPD was to separate from other patients and wear a mask. When P#1 arrived at the ED, the ED was on high-level diversion, and there were close to fifty people in the lobby. Every ED room was filled, and patients were in the hallways. The only place P#1 could be isolated was outside, and the ED was not going to put P#1 outside the ED. RN AA said that as far as he was aware, P#1 was not able to walk and would not have walked away from the ED with the gunshot wound to his leg. RN AA further stated that he did not recall anyone saying P#1 was sent to a different facility. The only way P#1 could have gone to another facility was with family or EMS. RN AA said that EMS was notified of the ED's diversion status. The coordinating center would not divert patients but would inform patients of the diversion status, and patients would be taken to the ED the patient chose. It would not make a difference why a patient came to the ED; the ED would not turn people away, regardless of diversion. RN AA stated that when the ED was full, a patient sitting in front of the door where patients were called may not hear their name being called because of the number of people.

During an interview with Registered Nurse (RN) CC on 1/19/22 at 11:35 a.m., RN CC said she came to the ED on 1/11/22 at 7:00 a.m. to begin her shift. When there was an open room, and it was P#1's turn to come back, P#1 was called three times and did not answer. RN CC said she went to the lobby to do the last call, and nobody answered. P#1 was taken out of the computer. RN CC said a call was transferred to the Charge Desk saying P#1 had not made it back to the LTC facility, and the LTC facility was looking for P#1. RN CC said she told the LTC facility that P#1 was not at the ED, and P#1 did not answer when the nurse called. RN CC said somebody on the night shift was still at the ED and said P#1 might have left with a family member. When the LTC facility called back, RN CC asked if the LTC facility had tried calling the family. RN CC said the ED could not get in touch with the family and did not know if the LTC facility reached the family. RN CC said she was at the ED until 7:00 p.m. The ED staff went to the lobby, called for P#1, checked the bathroom and the restaurant next to the ED.

During an interview with the Patient Representative (PR) GG on 1/19/22 at 1:09 p.m. in the conference room, PR GG stated her job was to advocate for patients between patients and staff if anything needed to be resolved. PR GG explained what triggered her to check on P#1 was that a patient representative had told her that P#1 was at the ED the previous day. PR GG recalled seeing P#1 since arriving at work at 12:00 p.m. P#1 looked tired like he had been sitting there all day, and P#1 appeared to be by himself. P#1 was seen talking to other people. PR GG had not seen P#1 get out of his chair. PR GG went to the Charge Desk to find out why P#1 was back at the ED and asked if P#1 had been there since the previous day. The charge nurse said P#1 had been called a few times and got pulled out of the system. PR GG said she recalled seeing P#1 with a bag on his foot all day. PR GG stated she asked P#1 if he was still waiting to be seen and if he had eaten anything. PR GG said she could not get much information from P#1. PR GG went to the restaurant near the exit of the ED and entrance of the east wing of the hospital and brought P#1 some food. She said she brought the food close to 8:30 p.m. after the night shift arrived at the ED. After getting the food, P#1 was taken back to receive care.

During a telephone interview with Registered Nurse (RN) BB on 1/19/22 at 6:21 p.m., RN BB stated that P#1 did not answer when called on night shift. RN BB called a second time and did not see P#1. RN BB said the lobby was packed, and P#1 may not have heard his name being called. P#1 was sitting near the vending machines, and a patient access person told RN BB that P#1 was in the lobby. P#1 could not explain why he was in the ED during triage, and P#1 had no complaints. RN BB stated that P#1 had never been at the facility, and there was no paperwork on P#1. A chest x-ray was ordered based on why P#1 originally signed into the ED. RN BB said that when triage was finished, RN BB placed P#1 in the lobby in the direct sight of the triage nurse. When radiology personnel came to get P#1, RN BB pointed P#1 out to them. RN BB said P#1 was sitting in the lobby at shift change. RN BB said she did not see P#1 ambulate. P#1 was in a wheelchair.

An interview was conducted with the Director of Quality (DQ) NN on 1/20/22 at 9:15 a.m. in the conference room. DQ NN stated that from the time of the Medical Screening Exam (MSE) on 1/11/22 at 10:08 p.m. until 1/12/22 at 12:54 a.m., P#1 was in POD D, Hall One, which was an alcove with a stretcher bed for patients waiting on transport. P#1 was moved to an exam room for a more thorough assessment on 1/12/22 at 12:54 a.m. P#1 was moved back to the alcove (DH1) and the stretcher to wait for transport. DQ NN stated that P#1 was provided food, water, and assistance to the bathroom while waiting for transport.
DQ NN explained that the Patient Flow Committee, who reported to Quality, looked at the length of stay (LOS) in the ED and entered the times on a scorecard monthly which included the time it took to see a physician, time to discharge, and disposition, and the time from admission to a bed. In addition, there was a report that showed wait times each day, and metrics were reviewed monthly. If there were too many outliers, the scorecard would go to the Quality Oversight Committee. The week of the alleged incident, 1/10/22, the ED was on a high census Level III for days at a time. That high census level had not occurred since the start of the COVID pandemic. The ED was still having a lot of holds (patients waiting to be transferred or admitted), but the inpatient areas were starting to show more movement so that patients could be admitted. If inpatient units were at a stalemate, the patients would return to the ED. DQ NN stated the facility had opened alternate care areas so patients would not be stuck in the ED. She continued saying that January wait times had been discussed, and a high census level was instituted. In addition, the ED conducted a huddle every day at 11:30 a.m. to discuss how to move and discharge patients appropriately to reduce holds in the ED.

The Director of Quality further stated that snacks were available upon request in the ED waiting room, and patients would be offered nutrition when in a room.
DQ QQ said that Patient Advocates would round through the ED, link families together in the ED, and talk to patients about concerns patients may have. In addition, Patient Advocates would get patients blankets and try to make the patients comfortable, including getting patients snacks and/or water. The Patient Advocate would also help assess patients and alert the nurse if a patient seemed to be having issues. DQ NN stated a nurse remained out front in the registration area. In addition, a nurse and paramedic in the alcove out front would assist if someone needed help to the restroom.

A review of the ED Huddle Minutes dated September 2021 to December 2021 revealed the following discussion:
September 2021 - Assess and reassess the patient prior to transfer to the assigned room. Assess and reassess patients every two hours while in the lobby/waiting area. Repeat vital signs, blood sugar, pain level, and document.

Summary

The patient was not seen by a qualified medical provider during his first or second emergency department visits. The patient had altered mental status and the patient was lost between the second and third emergency department registrations. He was never stabilized before being listed as "Left without being seen." The patient's baseline mental status was never confirmed. The patient remained confused at the time of discharge. He was not alert to place or situation. The patient did not receive an appropriate continuing medical screening examination. The patient was not stabilized prior to discharge.