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Based on interview, record review, policy review, and review of video surveillance, the hospital failed to provide a complete Medical Screening Examination (MSE) to one patient (#14), within the hospital's capability to determine if an Emergency Medical Condition (EMC) for one of two Emergency Department (ED) visits. The hospital also failed to enter one patient (#14) into the ED log, when the patient presented to the ED a third time. There were 23 patients' medical records reviewed who presented to the hospital's ED seeking care, out of sample selected from October 2019 to March 2020. The hospital's failure to provide patients with a MSE, places them at risk for undetected emergencies and delays in receiving treatment to stabilize an emergency. These failures had the potential to affect all patients who presented to the ED. The ED had an average of 6,000 emergency visits per month.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and on-call Roster," dated 07/21/17, showed the following directives for staff:
- A central log shall be maintained of all individuals who come to the Emergency Department seeking assistance, and whether such individuals refused treatment or were refused treatment, or were transferred admitted or discharged.
- All individuals who come to the ED shall receive a MSE by qualified medical personnel.
- A MSE will include a history of the individuals presenting condition, a physical exam, use of ancillary services routinely available to the ED for example radiology, laboratory, and Behavioral Health Advisory Committee (BHAC) for individuals with psychiatric symptoms, an assessment of suicide or homicide (HI, thoughts to harm another person) attempt or risk, disorientation or assaultive behavior that indicates danger to self or others.
- Under no circumstances shall ED staff suggest or coerce individuals to leave the ED.

Review of the hospital's undated document titled, "EMTALA [Emergency Medical Treatment and Labor Act] Training," showed the following directives for staff:
- The law separates payment considerations from emergency care, and assures that all patients with emergencies will be cared for in the ED, regardless of their ability to pay.
- EMTALA applies to any patient that had "come to the ED." It applied to any individual on the hospital campus, including individuals on the grounds and in the parking garages.
- Patients have the right to receive a MSE, to receive stabilizing treatment and when necessary, the right to receive an appropriate transfer.
- The screening exam was performed by qualified individuals such as ED physicians, nurse practitioners under physician supervision and BHAC.
- The purpose of the MSE was to determine whether the patient had an emergency medical condition, which means either labor or a medical condition with acute (sudden onset) symptoms of sufficient severity (including pain, psychiatric disturbances or substance abuse) such that the absence of immediate medical attention could result in placing the health of the individual in serious jeopardy.

Review of the hospital's undated document titled, "Emergency Medical Screening, Treatment, Transfer and on-call Roster," showed that a MSE will include a history of the individuals presenting condition, a physical exam, use of ancillary services routinely available to the ED for example radiology, laboratory, BHAC and for individuals with psychiatric symptoms, an assessment of suicide or homicide (HI, thoughts to harm another person) attempt or risk, disorientation or assaultive behavior that indicates danger to self or others.

Review of Patient #14's medical records showed that he did present to the ED on three occasions, once on 03/02/20 and two times 03/03/20. Patient #14 was seen by a physician on only one of those visits (visit #2).

Visit #1
Record review, interviews and review of video surveillance showed that Patient #14 presented to the ED on 03/02/20 at 3:35 PM, was triaged (process of determining the priority of a patient's treatment based on the severity of their condition) and answered yes to one of two triage questions used to screen for suicidal ideation (SI, evaluation used to determine the potential risk for a person's desire to kill themselves). The ED's triage computer system automatically placed the patient on suicide precautions (SP, interventions put into place to prevent self-harm or death). SP interventions were never implemented, and the patient was placed in the ED waiting room where he remained (at times not observed) for approximately six hours. The patient began to pace and became disruptive. He was escorted off the property by security, under the direction of the ED's nursing staff, and without an appropriate MSE.

During an interview on 03/11/20 at 9:05 AM, Staff S, Medical Director of the ED, stated that a patient should not be escorted off of the property without a MSE.

Visit #2
Record review and interviews showed that Patient #14 presented to the ED on 03/03/20 at 6:30 AM, and had requested a mental health evaluation for auditory and visual hallucinations (seeing and hearing things which were not there). During the triage process the patient again answered yes to one of the triage questions used to screen patients for SI. The ED physician examined the patient and discharged the patient to home at 10:25 AM.

During an interview on 03/10/20 at 10:40 AM, Staff H, ED Supervisor, stated that the hospital had a contract with a Psychiatric Hospital that provided staff for consultations for behavioral health patients, available 24 hours a day, seven days a week.

Visit #3
Review of the ED log, interviews, and video surveillance, showed that on 03/03/20, some time around 7:00 PM, security officers responded to Patient #14, who was smoking on the hospital grounds. Patient #14 told security that he was going to register in the ED as soon as he finished smoking. Security officers agreed, left Patient #14, and drove away. Patient #14 then approached a woman who was located outside of the ED entrance, cursed at her and stated to her that he was mad at his mother and that he was going to go in and "hit everyone that was in a (healthcare) mask." The woman signaled to security for assistance, and when security responded, Patient #14 was directed to the check in at the ED's registration desk. Patient #14 presented to ED registration on 03/03/20 at 7:16 PM, spoke with the registration personnel, and then left the ED with security at approximately 7:18 PM. The patient was not placed on the registration log, nor provided with information related to the risks of leaving without being seen.

Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and on-call Roster," dated 07/21/17, showed that a central log shall be maintained of all individuals who come to the ED seeking assistance, and whether such individuals refused treatment, or were refused treatment, or were transferred, admitted, or discharged.

Review of the video recording dated 03/03/20 at 7:16 PM, showed that Patient #14 entered the ED and waited his turn to speak with the ED's registration personnel. The patient appeared to speak with staff sitting at the registration desk. At approximately 7:18 PM, along with security, the patient left the ED.

Review of the ED log, dated 03/03/20 showed no evidence of Patient #14's arrival to the ED, that he requested care or that he left the ED without receiving an examination for the 03/03/20 at 7:16 PM visit.

During an interview on 03/10/20 at 2:45 PM, Staff D, Chief Operating Officer (COO), stated that on the third visit, Patient #14 was never placed on the ED log, and the patient should have been.

On 03/09/20, at surveyor entrance, the hospital had recognized on 03/05/20 the noncompliance and immediately put into place corrective action to prevent reoccurrence. The hospital's corrective actions included education and monitoring procedures to prevent reoccurrence, and identified staff ultimately responsible for oversight of the plan of correction as evidenced by:
- On 03/05/20 education was distributed by the Vice President of General Council, Director of the ED and the Director of Security and Safety, to the ED, security, and safety staff, , that no patient who presented to the ED and requested an examination or treatment would be escorted off the hospital property without the approval of an on duty Director of Clinical Operations (DCO). The DCO would ensure that the patient received an MSE prior to departure, and if necessary, appropriate stabilizing treatment.
- On 03/05/20 the Director of Case Management/Services line implemented a new procedure for ED case management and social work staff to expedite mental health evaluation by the contracted psychiatric hospital staff for patients identified as needing direct observation, and to wait with the patient while the evaluation was pending. This was completed by 03/05/20.
- On 03/06/20 the Vice President/Chief Nursing officer began implementing a huddle that would include the DCO, Triage RN and Charge RN, to determine a plan for patient throughput when the ED waiting room was nearing capacity, which would ensure patients receive a MSE consistent with EMTALA requirements. These huddles were to continue daily, on every shift.
- On 03/06/20 the Vice President/Chief Nursing Officer began development of a plan to permit the Admission Assessment Unit to be open 24 hours on Mondays and Tuesdays to correlate with the ED's busiest days.
- On 03/08/20 the Director of the Emergency Services and the ED Educator began distributing EMTALA education as a required on line module for ED staff, Director of Clinical Operations, labor and delivery, critical care float pool, and circulated education to the ED Physicians. Compliance would be tracked daily, with a completion deadline of one week.
- On 03/08/20 the Chief Medical Officer distributed EMTALA education to the ED Physicians.
- On 03/09/20 the Director of Emergency Services began conducting audits and reviews on 100 percent of the LWBS patients from the ED, by the ED director and his/her team. Any cases of concern identified would be forwarded to the Senior Director of Critical Care, the Vice President/Chief Nursing Officer and Compliance for additional review. These audits were to continue daily.
- On 03/09/20 education was provided to the ED staff by the Director of the ED, that all patients who presented to the Emergency Department, (ED) would be screened for SI with current screening questions. Education was provided to the ED staff that all patients presenting with SI would be assessed an Emergency Severity Index (ESI, a numerical value one (most urgent) to five (least urgent), that shows priority of medical evaluations, as well as resources needed to treat patients) level 2. Suicidal and Homicidal patients were not to be placed in the waiting room, and would be promptly bedded in the ED with direct observation for patient safety. The education was to be completed by 03/11/20.
- The Vice President and General Council, and the Compliance director of the hospital began providing EMTALA education to Security and Safety and reinforced that any individual requesting assistance on the entire hospital campus fell under EMTALA policy. Every effort should be taken to make sure that the patient is taken to the ED for a MSE, with a completion date of 03/20/20.
- The Vice President and Chief Operation Officer of the Hospital would implement assessors from the contracted psychiatric hospital in the ED 24 hours a day seven days a week by 04/10/20.
- The Director of Emergency Services would evaluate software capabilities for the CSSR tool results to flow to the ED summary to facilitate physician access to information by 04/10/20.

In regards to Patient #14's third visit the hospital recognized on 03/05/20 the failure to place Patient #14 on the ED log and put into place the following corrective action to prevent reoccurrence:
- The Director of the ED provided education to ED staff, for patients that presented to the ED and chose not to be seen. Staff were to request that the patient sign the ED log before leaving. If the patient declined to sign, staff were to ask the patient to provide a name verbally and staff were to record that name if provided. This had a completion date of 04/10/20.
- On 03/08/20 the Director of the ED, and the ED Educator began distributing EMTALA education as a required on line module for Emergency Department, (ED) staff, Director of Clinical Operations, labor and delivery, critical care float pool, and circulated education to the ED Physicians. Compliance would be tracked daily, with a completion deadline of one week.
- On 03/08/20 the Chief Medical Officer distributed EMTALA education to the ED Physicians.

During the course of the survey, and based on interviews and record reviews the Hospital was found to have no violations or similar problems as related to EMTALA, for at least the past six months.

Please refer to 2405 and 2406 for further details.

Based on interview, record review, policy review, and review of video surveillance, the hospital failed to enter into the Emergency Department (ED) log, one patient (#14) of 23 patients' medical records reviewed who presented to the hospital's ED seeking care, out of sample selected from October 2019 to March 2020. This failure had the potential to affect all patients who presented to the ED.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and on-call Roster," dated 07/21/17, showed the following directives for staff that a central log shall be maintained of all individuals who come to the ED seeking assistance, and whether such individuals refused treatment, or were refused treatment, or were transferred admitted or discharged.

During an interview of 03/10/20 at 3:56 PM, Staff F, Security Officer, stated the following:
- On 03/03/20 around 7:00 PM, she found Patient #14 smoking in the parking lot.
- She asked Patient #14 what he was doing and he indicated to her that he was going to finish smoking and then go check in to the ED.
- She continued to observe the patient in the parking lot from a distance, and saw him approach a woman who stood outside of the ED entrance.
- She observed him interact with the woman, and the woman began to back away from the patient and signaled to her for assistance.
- She asked the woman what happened, and upon interview, the woman reported that the patient had approached her, cursed her out, stated that he was mad at his mother, and that he was going to go in and "hit everyone that was in a (healthcare) mask."
- She followed the patient into the ED registration area, and informed the patient that he could not curse, threaten or hit people, and the patient agreed.
- Patient #14 went to the registration desk to be checked in.
- A patient care technician began to check Patient #14 into the ED, when Patient #14 told the patient care technician that the hospital staff could not help him, and Patient #14 left the ED registration area.
- She observed and followed the patient to his vehicle, and he drove away.

Review of the video surveillance on 03/03/20 at 7:16 PM, showed that Patient #14 entered the ED and waited his turn to speak with the ED's registration personnel. The patient appeared to speak with staff sitting at the registration desk. At approximately 7:18 PM, along with security, the patient left the ED.

Review of the hospital's undated policy titled, "ED - Triage (process of determining the priority of a patient's treatment based on the severity of their condition)," showed that the ED technician (also known as a patient care technician) will greet patients entering the emergency ambulatory entrance, and will complete the mini registration to register the patient into the ED log. Patients who decide not to be evaluated will be asked to sign the "Patient Request to Decline Medical Screening Examination" form (also known as a left without being seen [LWBS] form).

During an interview on 03/11/20 at 9:45 AM, Staff E, Patient Care Technician, stated the following:
- Patient #14 approached the registration desk.
- She did not obtain the patient's name or information related to why the patient was there.
- Patient #14 left the ED.
- If a patient wanted to leave the ED without being seen, staff were supposed to provide patients with the LWBS form, but she did not offer one to Patient #14.

Review of the ED log, dated 03/03/20, showed no evidence of Patient #14's presentation to the ED on 03/03/20 at 7:16 PM.

During an interview on 03/10/20 at 2:45 PM, Staff D, Chief Operating Officer (COO), stated that on the third visit, Patient #14 was never placed on the ED log, and the patient should have been.

The patient presented to the hospital ED, but was not placed in the ED log, and was not informed of the risks of leaving without being seen.

Review of Patient #14's medical record from Hospital B, dated 03/04/2020 at 5:17 PM, showed that he jumped off of an overpass, landed on cement below, and sustained life threatening injuries. The patient was stabilized and transferred to Hospital C for specialized services where he remained in the Intensive Care Unit (ICU, special unit of hospital that have specially trained staff to perform intensive treatment).


41474

Based on interview, record review, policy review, and review of video surveillance, the hospital failed to provide a Medical Screening Examination (MSE) within its capability to determine if an Emergency Medical Condition (EMC) existed during one of two separate Emergency Department (ED) visits for one patient (#14) of 23 patients who presented to the hospital ED seeking care, out of a sample selected from October 2019 to March 2020. The ED had an average of 6,000 visits per month.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Screening, Treatment, Transfer and on-call Roster," dated 07/21/17, showed the following directives for staff:
- All individuals who come to the ED shall receive a MSE by qualified medical personnel.
- A MSE will include a history of the individuals presenting condition, a physical exam, use of ancillary services routinely available to the ED for example radiology, laboratory, Behavioral Health Advisory Committee (BHAC) and for individuals with psychiatric symptoms, an assessment of suicide (SI, to cause one's own death) or homicide (HI, thoughts to harm another person) attempt or risk, disorientation or assaultive behavior that indicates danger to self or others.
- ED staff shall attempt interventions with any individual indicating a desire to leave the ED prior to receiving a MSE.
- ED staff shall take reasonable steps to advise an individual indicating a desire to leave of the risks of refusing a MSE, and assess the individual's capacity to understand those risks.
- ED staff may request assistance from security and safety staff where indicated and all such interventions shall be documented.
- Under no circumstances shall ED staff suggest or coerce individuals to leave the ED.

Review of the hospital's undated document titled, "EMTALA Training," showed the following directives for staff:
- The law separates payment considerations from emergency care, and assures that all patients with emergencies will be cared for in the ED, regardless of their ability to pay.
- EMTALA applies to any patient that had "come to the ED." It applied to any individual on the hospital campus, including individuals on the grounds and in the parking garages.
- Patients have the right to receive a MSE, to receive stabilizing treatment and when necessary, the right to receive an appropriate transfer.
- The screening exam was performed by qualified individuals such as ED physicians, nurse practitioners under physician supervision and BHAC.
- The purpose of the MSE was to determine whether the patient had an emergency medical condition, which means either labor, or a medical condition with acute (sudden onset) symptoms of sufficient severity (including pain, psychiatric disturbances or substance abuse), such that the absence of immediate medical attention could result in placing the health of the individual in serious jeopardy.
- ED physicians will determine what specialists from the on-call list need to be involved in the patients care.
- If the individual leaves without a MSE, all reasonable steps shall be taken to have the patient sign the patient declination of medical screening exam form.

Review of Patient #14's ED record, and ED video review showed that the patient presented to the ED once on 03/02/20, and two times 03/03/20.

Visit #1
Review of Patient #14's medical record showed on 03/02/20 at 3:35 PM, the patient presented to the ED by ambulance, complaining of ingesting methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant), feeling very shaky, and feeling like his body was locked. He answered yes to wishing he were dead/or not wake up from sleep (part of the suicide risk assessment completed in triage), which directed staff to initiate suicidal precautions (SP, interventions put into place to prevent self-harm or death). He was given an acuity level of three by the triage nurse and placed in the waiting room. At 6:10 PM, Patient #14's reassessment acuity level was four - five (with no exam by a physician and/or mental health exam). Vital signs were documented at 4:07 PM and 7:40 PM. Patient #14's record indicated that he left both against medical advice (AMA) and left without being seen (LWBS) at 9:57 PM. Review of "Patient Request to Decline Medical Screening Examination" dated 03/02/20, showed Staff O, ED charge nurse, documented that Patient #14 had become a nuisance in the waiting room. At one point Patient #14 was found in the triage room, sitting in the nurse's chair, drinking the nurse's drink. He was asked several times to have a seat and not be disruptive, but he continued to be disruptive and was escorted off the property. The documentation showed no signature by the patient understanding the risk of leaving AMA or LWBS.

Review of the hospital's untitled video recording, dated 03/02/20 from 3:33 PM to 8:42 PM, showed the following:
- Patient #14 was in the waiting room for several hours pacing and becoming increasingly active. At one point he entered the empty triage room, drank from the nurse's cup, and put his feet up on the desk.
- Security officers spoke with him twice.
- Patient #14 was then escorted out of the ED by security officers.

During an interview on 03/11/20 at 10:36 AM, Staff T, Board Certified Psychiatrist, stated that he was on call 24 hours a day, seven days a week by phone for any psychiatric related issue that would come up, and that patients could be admitted to the hospital for stabilization of psychiatric related issues.

During an interview on 03/10/20 at 11:00 AM, Staff I, ED Director stated the following:
- The first two questions in triage (related to suicide risk) would have indicated the patient needed the full Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) in collaboration with their contracted psychiatric hospital.
- Patient #14 was not brought back and given the full C-SSRS screening.
- Staff should not have escorted Patient #14 off the property without a MSE by a physician.
- Nursing staff had the ability to recognize and de-escalate a mental health patient who was escalating out of control.

During an interview on 03/10/20 at 1:00 PM, Staff L, ED Physician stated the following:
- If a patient answered "yes" to either of the questions regarding SI, then the patient should not have been allowed to leave without a MSE by a physician.
- All psychiatric patients with SI were given an acuity level of two.
- He would not expect a patient with SI to wait in the waiting room for six hours.
- A patient with SI should have been on a one to one observation.

During an interview on 03/10/20 at 3:25 PM, Staff O, ED Charge Nurse, stated the following:
- He did not observe or interact with Patient #14.
- He had written a request for Patient #14 to be escorted out because he had become a nuisance.
- He knew a physician had not evaluated Patient #14.
- A patient was not supposed to be escorted off of hospital property without a MSE.

During an interview on 03/10/20 at 2:25 PM, Staff N, RN, stated the following:
- Patients on methamphetamine were often suicidal.
- SI patients were not allowed to leave without a MSE by a physician.
- Patients who went to the waiting room were watched as well as they could be watched, while in the waiting room.
- Patient #14 had escalated to the point that she needed to call security.

During an interview on 03/10/20 at 4:10 PM, Staff R, RN, stated that she requested that Patient #14 be escorted off the hospital property on 03/02/20, without a MSE.

During an interview on 03/11/20 at 9:05 AM, Staff S, Medical Director of the ED, stated that a patient should not have been escorted off of the hospital property without a MSE.

Visit #2
Record review and interviews showed that Patient #14 presented to the ED on 03/03/20 at 6:30 AM, and had requested a mental health evaluation for auditory and visual hallucinations (seeing and hearing things which were not there). The ED physician examined the patient and discharged the patient to home at 10:25 AM.

Visit #3
Review of the ED log, interviews, and video surveillance review, showed that on 03/03/20, some time around 7:00 PM, security officers responded to Patient #14 who was smoking on the hospital grounds. Patient #14 told security that he was going to register in the ED as soon as he finished smoking. Security officers agreed, left Patient #14, and drove away. Patient #14 then approached a woman who was located outside of the ED entrance, cursed at her and stated to her that he was mad at his mother and that he was going to go in and "hit everyone that was in a (healthcare) mask." The woman signaled to security for assistance, and when security responded, Patient #14 was directed to the check in at the ED's registration desk. Patient #14 presented to ED registration on 03/03/20 at 7:16 PM, spoke with the registration personnel, and then left the ED with security at approximately 7:18 PM. The patient was not placed on the registration log, nor provided with information related to the risks of leaving without being seen.

Review of Hospital B's medical record dated 03/04/20 at 5:17 PM showed that Patient #14 jumped off of an overpass, landed on cement below, and sustained life threatening injuries. The patient was stabilized and transferred to Hospital C for specialized services where he remained in the Intensive Care Unit (ICU, special unit of hospital that have specially trained staff to perform intensive treatment).