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Based on findings at A2406 and A2407, the facility failed to ensure compliance with Code of Federal Regulation (CFR) 489.24.

Based on record review, interview and policy review, the facility failed to provide a medical screening exam and treatment for 2 of 32 patients (Patient #32 and #1). The failure to provide a medical screening exam and treatment for the patients had the potential to place the patient at increased risk of harm or illness.

Findings include:

Patient #32

On 9/11/2022 at 11:03 PM, Patient #32 presented in the facility's lobby. According to the facility's self-report, the patient remained at the registration desk until 11:06 PM. The patient appeared hyperactive, gesticulating with upper extremities, and not making eye contact with the Patient Access Specialist on duty. A physician was observed seated in the provider area.

According to the report at 11:06 PM, an emergency department registered nurse entered the area observing the patient returning to the lobby seated with registration paperwork and unable to focus.

From 11:06 PM to 11:09 PM, the patient was observed responding to unseen stimuli, not making eye contact and unable to focus.

At 11:10 PM, the aforementioned registered nurse speaks to a security guard.

At 11:12 PM, the police show up and briefly encounter the patient before escorting the patient outside at 11:14 PM. The registered nurse appeared to be speaking with the physician initially referred to in the provider area.

At 11:13 PM, the registered nurse and physician watched the cameras as police escort the patient off the premises.

At 11:14 PM, the physician sits back down at the provider desk.

The self-report documented interviews were conducted with all the principal witnesses during the 11-minute episode and the facility interviews were reviewed. Individual interviews were conducted on site with the same individuals.

On 10/6/2022 at 9:35 AM, an In-Patient Registered Nurse verbalized hearing yelling in the lobby. The patient was yelling and conversing with self. The emergency department registered nurse went out to talk to the patient. The patient continued talking to self. Security called police.

On 10/6/2022 at 9:40 AM, an Emergency Department Technician verbalized upon arrival in the lobby, the patient was yelling and talking to self. The registered nurse told the tech the police were coming. The police came and told the patient to "shut up" and escorted the patient out.

On 10/6/2022 at 10:00 AM, the Patient Access Specialist indicated trying to get the patient to register, but the patient just kept yelling. Security showed up and asked if it was a police call. The registered nurse briefly spoke to the patient and then told the security guard to call police. Police arrived and escorted the patient out.

On 10/6/2022 at 10:30 AM, a Security Guard verbalized entering the lobby and watching the patient get loud with the nurse. The patient was loud and did not want to leave. The registered nurse told the security guard to go ahead and call police. The security guard was trained to make police calls based on the requests of the providers and nurses.

On 10/6/2022 at 10:47 AM, the Registered Nurse verbalized the patient was difficult to understand, talking to self out loud and responding to external stimuli. The patient access specialist tried to help to find out the patient's complaint, but the patient did not respond. The registered nurse did not want to touch the patient for risk of violence. The facility had only hands-off security guards. The registered nurse acknowledged having de-escalation training but told the security guard to contact police. The registered nurse confirmed there was no attempt to coax the patient into triage or summon the provider or other techs or employees to assist. The registered nurse indicated the police came and escorted the patient outside, and the nurse did not attempt to talk with the patient outside or attempt to utilize the police to convince the patient to be assessed. The registered nurse would do things differently in retrospect. The registered nurse did not recall indicating not wanting to take the patient because of a lengthy hold time before a mental health transfer could occur.

On 10/6/2022 at 12:15 PM, the Chief Nursing Officer indicated the emergency department registered nurse did not want to take the patient because of the potential for a lengthy hold time before a mental health transfer, and the registered nurse received written disciplinary action as a result, dated 10/4/2022, referencing this case as an EMTALA violation. The physician provider who appeared in the self-report was no longer utilized by the hospital.

On 10/7/2022 at 3:30 PM, the Chief Nursing Officer indicated there was no situation where patients would not be assessed.

The Emergency Medical Treatment and Labor Act Compliance policy #7082 revealed any individual who comes to this hospital seeking an examination and treatment of a potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition, necessary stabilizing treatment for any emergency medical condition, and if necessary, an appropriate transfer to another medical facility, without regard to the individual's ability to pay or method of payment.

Definition D. Emergency Medical Condition:

1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. placing the health of the individual in serious jeopardy.

The Professional Services Agreement with the physician group revealed the following:

Under exhibit 1.1, page 18, section D, Patient Admissions and Referrals:

1. All patients who present in the Department for care will receive a medical examination by a qualified medical provider.

The registered nurse's Emergency Room Registered Nurse job description revealed under essential job functions: plan, prioritize, and provide proficient, age-specific and developmentally/specialty appropriate nursing care by applying advanced specialty clinical nursing knowledge and skills and for ensuring the comfort and safety of patients/families.


Complaint #NV00067054



22489

Patient #1 (P1)

A review of the Emergency Department (ED) Central Log for the month of July 2022, documented P1 entered the ED on 07/29/2022 at 1859 (6:59 PM) for right knee pain.

The Emergency Documentation form signed by the physician on 08/20/2022 for the ED visit for P1 on 07/29/2022, indicated P1 presented to the ED for left knee pain from a fall four days ago.

P1 was recognized by the staff as previously trespassing on the property, being threatening to staff, and destruction of property. P1 was observed to be weight bearing on the affected leg and had been walking on it since the incident. The physician indicated P1 had no medical emergency. The physician indicated the patient then complained of chest pain, the staff attempted to obtain vitals and an electrocardiogram, but the patient had refused, walked out to the parking lot, and called 911.

There was no documented evidence P1 was brought back from the ED waiting area for a medical screening evaluation (MSE).

On 10/06/2022 at 12:20 PM, the Chief Compliance Officer (CCO) indicated P1 was not taken back for an MSE and stayed in the waiting room. The CCO confirmed the physician did not conduct an MSE on P1.

On 10/06/2022 at 9:14 AM, the ED Technician indicated P1 never received an MSE from the physician on 07/29/2022. The ED Technician indicated P1s medical record was flagged regarding the patient being verbally aggressive from previous ED visits. The ED Technician indicated going out to the waiting room with the Registered Nurse (RN) and the RN informed P1 that P1 would not be treated in the ED. P1 became angry, then complained of chest pain and called 911 from the waiting room. The ED Technician indicated informing P1 to come back into the ED to be assessed for the chest pain. The patient refused to go back to be assessed for chest pain and waited for the ambulance to arrive. Within a minute the ambulance arrived and the P1 was taken to another ED.

On 10/06/2022 at 9:30 AM, the Laboratory Technician indicated on 07/29/2022, P1 was calm, not irritated when waiting in the waiting room in the ED. The Laboratory Technician indicated the ED Technician and the RN went to the waiting area and informed P1 they were "eighty sixed (86'd) (or trespassed from the facility and not to be seen) because of being hostile in the past ED visits. The Laboratory Technician indicated the ED Technician and the RN informed the patient, P1 was not allowed on the property. After P1 was informed could not be seen in the ED, P1 complained of chest pain, called 911 and left the ED by ambulance to another ED. The Laboratory Technician indicated when P1 entered the ED for knee pain, P1 was not taken to the back for an MSE.

On 10/06/2022 at 9:45 AM, the RN indicated P1 initially came in for knee pain on 07/29/2022. The RN indicated going to P1 with the ED Technician and the ED technician informed P1 would be "86d". The RN indicated P1 was aware "86" meant P1 could not be seen in the ED. After being told of being "86d", P1 became angry, complained of chest pain, and called 911. The RN indicated informing P1 to come to the back to be assessed for the chest pain but P1 refused and was taken to another ED by the ambulance. The RN indicated P1 did not receive an MSE for the initial complaint of knee pain.

On 10/06/2022 at 9:58 AM, the Patient Access Specialist (PAS) indicated on 07/29/2022, P1 entered the ED for back pain or knee pain. The PAS indicated P1 entered the ED and checked in at the front desk. The PAS indicated there had been a sticky note posted on the front desk for several months. The note documented P1s name and the car P1 was driving, to check P1 in the system, to have P1 wait in the waiting room and call 411 (non-emergency police) due to P1 trespassed from the facility. The PAS indicated the ED Technician and RN went out to the lobby and informed P1 of being "86d". The PAS indicated P1 sat back down in the waiting area and complained of chest pain. The RN and ED Technician came back out to have the patient come back to be assessed for the chest pain. The patient refused and called 911. The ambulance arrived and took the patient to another ED. The PAS indicated P1 was not taken to the back for a MSE for their initial complaints of back pain or knee pain.

The facility's EMTALA (Emergency Medical Treatment and Labor Act) Findings/Corrective Action Summary investigation report on P1's incident on 07/29/2022 indicated no MSE was performed on P1. The facility self-reported the incident to the State Agency on 09/07/2022.

Complaint #NV00067045

Based on record review, interview and policy review, the facility failed to ensure it took reasonable steps to secure an individual's written informed refusal of care, treatment, or transfer for 2 of 32 patients (Patient #10 and #18). The failure to obtain informed consent for refusal of care, treatment or transfers had the potential to place the patient at increased risk of harm or illness if appropriate services or resources are not available.


Findings include:

Patient #10

On 7/25/2022, the emergency department triaged Patient #10 with a chief complaint of worsening right eye pain, headache, and photosensitivity of 3 days duration.

Nursing assessed the patient as non-urgent with acuity of "4", less urgent.

The physician saw the patient, ordered, and administered ibuprofen 800 milligrams. The physician administered Tetracaine eye drops and performed Fluorescein, demonstrating no ulcerations or lesions. No foreign body was identified upon exam. Tonometry could not be performed due to equipment failure, and the physician recommended an emergent transfer due to potential for vision loss. The physician documented the physician refused the transfer and wanted to be discharged but would travel directly to the recommended facility.

On 10/5/2022 at 3:00 PM, Patient #10 indicated asking to stay at the hospital and did not verbalize wanting to be discharged. The patient verbalized, the physician said, "I'm going to discharge you, and you need to go to [other hospital emergency department]". The patient said the physician said to keep the hospital wrist band on to be seen quicker over there. The patient further indicated the physician did not use the word "transfer", but the physician told the patient to go directly to [other hospital emergency department]. The patient verbalized not being asked about taking an ambulance or signing a form to refuse an ambulance or being asked for a provider to be secured at the other facility ahead of time. The physician was unaware whether the patient had a ride or was driving self.

On 10/7/2022 at 10:45 AM, the physician was interviewed. The physician indicated the patient was seen in an exam room. The patient needed an ophthalmology consult. The facility always transferred patients for such consults, mostly to a specific facility. The physician recommended a transfer to the patient and the patient declined, saying patient wanted to take self. In general, patients would take an ambulance. If unwilling to go by ambulance, would set up an ophthalmology consult ahead of time generally. The patient adamantly refused transfer and adamantly refused setting up a receiving physician for transfer. The physician denied telling the patient to leave the emergency department wrist band on to expedite care at the recommended facility. The physician acknowledged awareness of the facility's ambulance transfer form and general refusal of care form. The physician did not contact the recommended facility because the patient refused transfer which the physician recommended. The physician acknowledged failing to consider whether or not the patient was driving self. The physician did not do an AMA (against medical advice) refusal because there were no more services the facility's emergency department could offer the patient.

The physician did not utilize the facility's ambulance refusal form.
The physician did not utilize the facility's Physician Record Of Refusal Of Care, which included "offering other physician evaluation / transfer, or offering to call patient's physician" and general refusal.

On 10/7/2022 at 3:30 PM, the Chief Nursing Officer indicated the Physician Record of Refusal of Care form should have been used for the transfer refusal and leaving against medical advice.

Patient #18

On 9/5/2022, the emergency department triaged Patient #18 with a chief complaint of appearing to be under the influence. Unable to express a chief complaint, moving erratically talking about shoes.

Nursing assessed the patient as emergent with acuity of "2", emergent.

The physician saw the patient and assessed as far as was able to with review of systems. The physician ruled out suicidal/homicidal ideations, the patient was not a legal hold candidate. The physician documented: Patient appears intoxicated on drugs, very tangential and hyperverbal. [Patient] makes many paranoid and delusional statements. When asked about recent meth use [patient] indicates that he's 'been cooking' and something about 'salts'. Patient was acting bizarrely but with effort is redirectable.

The physician ordered 10 milligrams of Valium and administered Valium 20 milligrams. Patient was making several allusions to drug use which the physician believed to be the reason for the behavior. Patient was given food and water. The physician ordered 10 milligrams of Olanzapine, but the patient refused it, saying "f___off." The physician documented the patient used other insulting language to the physician and other staff. The physician documented "AGAINST MEDICAL ADVICE" (AMA) the patient was not taking the psychiatric medication and was escorted off the property with a final diagnosis of substance abuse with psychosis.

On 10/7/2022 at 9:15 AM, the physician indicated the patient was wandering around and alluded to drug use. The patient was hyperverbal and acting strangely with the nurse. The physician verbalized the patient had a hostile vibe but hoped the patient would settle down. The difference in dosing the patient's Valium was probably due to dictation error.

The patient was declared as leaving AMA because of refusing the Olanzapine. The patient was not disagreeing with future plan for admission. The physician felt the patient was not a legal hold candidate and treatment could not be forced. When asked if there was any way the patient could have been stabilized, the physician responded, "you tell me." The patient did not verbalize a need for a drug test or shelter, or we would have made those calls." The physician felt the patient did not need a urine tox screen because the patient implied being on meth, and there was no screening for that. The patient became disruptive. The police were called and were a no-show, so the physician coaxed the patient for several minutes, and escorted the patient out of the building.

The patient's record lacked documented evidence the physician used a Physician Record of Refusal of Care form. The facility did not have a separate leaving against medical advice policy.

On 10/7/2022 at 3:30 PM, the Chief Nursing Officer indicated the Physician Record of Refusal of Care form should have been used for leaving against medical advice.

Facility policy EMTALA Compliance #7082, procedure #C3 Transfer documented:
Patient refusal to accept medical screening exam, treatment, or physician certified transfer.
Patient transfer against medical advice: If an individual refuses a MSE or treatment, refuses a physician certified transfer, or requests to be transferred against medical advice, explain the risks and benefits of the proposed services, and makes reasonable efforts to have the individual sign the Ambulance Refusal form. If the individual refuses to sign the form, document the risks and benefits explained to the individual, the efforts taken to have the individual sign the form, and the individual's refusal to do so.

Section III, A, 5. a. of the Rules and Regulations for the Hospital Medical Staff revealed Patient refusing to take medical advice: All patients leaving against medical advice must be asked to sign a special release form. In cases where patients cannot sign, the signature of the nearest relative or guardian must be obtained. Notation should also be made in the medical record. If the patient or family refuses to sign the form, then the physician must document the encounter and patients' refusal in the medical record.


Complaint #NV00067045