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Based on review of hospital documents, policies, medical records, and staff interviews, the hospital failed to enforce its EMTALA policy to ensure staff provided an appropriate medical screening examination for 1 of 30 sampled patients who presented to the Emergency Department (ED) of the hospital from March 2015 - September 2015. (Patient #1)

Failure to ensure the ED staff provided an appropriate medical screening examination for each of the patients requesting medical care in the ED in accordance with the hospital's EMTALA policy could potentially result in patient harm and/or poor outcomes for patients.

Findings include:

1. Review of the hospital policy titled "EMTALA" updated 6/15, revealed in part, "...all individuals who present to the medical center requesting an unscheduled examination...will have an appropriate medical screening examination performed within the normal capability of the medical center's available staff and facilities in order to determine if an emergency medical condition exists..."

Review of hospital policy titled, "Behavioral Health Admissions and Management" updated 6/15, revealed the following in part, "...The established process and procedures are applicable to patients admitted with a primary Behavioral Health diagnosis and/or...patients with suicidal ideation in the Emergency Department (ED)...patient is escorted to bathroom, given hospital provided clothing and asked to remove all personal clothing...nurse and other staff personnel do a complete search of body/skin assessment, visualizing all areas of the body...all patients belongings will be...secured"

Review of the hospital policy titled "Court Orders, Subpoenas and Investigative Demands" updated 1/12, revealed in part, "...Court orders have the force and effect of law...They prescribe an action to be taken or not taken by Broadlawns Medical Center (BMC) as an institution or by the BMC employee described in the order...failure to comply with a court order may result in a contempt of court citation...court order for Psychiatric examination, evaluation or admission..."



Refer to A 2406 for additional information concerning the medical screening examination of Patient #1.

Based on review of hospital documents, policies, medical records, video footage and staff interview, the hospital failed to ensure Patient #1 received an appropriate medical screening examination. The investigation involved review of the Emergency Department (ED) medical records for 30 sampled patients who presented to the ED seeking care from March 2015 to September 2015.

Failure to ensure Patient #1 received an appropriate medical emergency examination could potentially result in patient harm and/or poor patient outcomes.

Findings include:

1. Review of documents titled, "In The District Court For Polk County" dated September 3 2015, included in part, "...[Patient #1] Alleged to be mentally impaired...is seriously mentally impaired, needing medical care and treatment...Alleged to be a person with substance-related disorder...depression and suicide thoughts..."

2. Review of the closed medical record showed on 9/4/15 at 7:19 PM, Patient #1 presented to the ED accompanied by two sheriff deputies under a District Court Order for seriously mentally impaired. The medical record did not contain evidence the Emergency Department (ED) staff followed the hospital policies to provide an emergency screening examination for Patient #1's emergency medical/psychiatric condition.

a. A document titled, "ED Note" included in part, "...Condition...Not evaluated by provider...Code Visit ED...Not Evaluated by Provider..."

b. At 7:41 PM, ED Registered Nurse (RN) E documented the sheriff deputies refused to stay with patient until a locked facility or 1:1 sitter was available. Patient #1 unattended agreed to stay in the ED room. ED RN E informed Patient #1 the area was not a locked unit but told the patient to stay.

c. At 7:42 PM, ED RN K documented patient brought in by sheriff deputies. Patient #1 changed into hospital attire, body searched and staff secured the patient belongings. ED RN K escorted Patient #1 to the ED room, obtained the patient's blood pressure, heart rate, pulse, temperature.

d. At 8:39 PM, House Supervisor G documented Patient #1 eloped.

e. At 8:43 PM, ED Physician A documented patient eloped without my knowledge prior to exam. Disposition: AMA (Against Medical Advice). Not evaluated by provider.

3. During a interview on 9/16/15 at 3:20 PM, the CNO acknowledged ED staff failed to follow the hospital's EMTALA policy to ensure Patient #1 received a medical screening examination. The CNO said potential outcomes for the patient in her opinion could include anything because the patient was not able to judge risks or solutions for herself, and they didn't know the patient's mental abilities which placed him/her at a greater risk for harm or injury. She said the court order obligated their hospital to have a physician examine the patient and report the results to the court. She said the patient's history of depression and suicidal ideation placed the patient at a greater risk for harm or injury. The Chief Nursing Officer (CNO) said the hospital's policy states when patients are brought to their ED unit accompanied by law enforcement, when the law enforcement officers leave, ultimately it is the ED staff's responsibility to stay with the patient. The CNO reported all ED staff received annual training on the hospital policies for EMTALA Behavioral Health Admissions and Management, and received additional training in Managing Aggressive Behaviors (MAB). The CNO stated the ED staff are trained to deal with patients that have psychiatric or chemical dependency problems.

During an interview on 9/17/15 at 7:30 AM, ED Physician A reported she was the ED physician on 9/4/15 when Patient #1 was admitted to the ED. Physician A said once court ordered patients are in the ED they are to be evaluated by a physician and then a bed is secured in the Sands unit (behavioral unit) Physician A said at no time was she approached by ED Paramedic A, ED RN E, or ED RN K to inform her of Patient #1 being in the ED or what was going on with Patient #1, and they should have. Physician A reported the nurses should have communicated the patient's status with her and she would have assisted them to protect or secure the patient. Physician A said this was a terrible situation and avoidable. Physician A reported ED Paramedic A and ED RN E are frustrated with the "system" and that night they both made a poor decision with this patient. Physician A reported she had no idea what was going on with Patient #1. Physician A said she would expect nursing staff to monitor a court ordered patient until a physician can evaluate them and sheriff's deputies are not responsible for patients in their ED.

During an interview on 9/15/15 at 1:00 PM, ED Paramedic A reported although he wasn't assigned to care for Patient #1 on 9/4/15 he was aware the patient was court ordered and there was no staff available in the ED to sit with the patient. ED Paramedic A said he didn't check to see if security was available to sit with the patient because the patient wasn't his. He said the patient wasn't combative or resistive with the ED staff. He reported the patient asked him what to do. ED Paramedic A reported he told the patient she was free to go because staff couldn't physically hold the patient against their will. ED Paramedic A said in his opinion the two deputies "should have done their job" and "stayed in the ED with the patient".

During an interview on 9/15/15 at 1:47 PM, ED Nursing Director reported on 9/4/15 when Patient #1 presented to the ED there were 12 patients in the ED. The ED Nursing Director stated the minute Patient #1 arrived in the ED staff were responsible to provide care and monitor the patient and ensure a physician's medical screening examination was completed. The Nursing Director acknowledged the ED nursing staff failed to follow the hospital's EMTALA policies and procedures. The ED Nursing Director said Health Care Technician (HCT) D and HCT H were available and should have provided 1:1 care until the physician performed the medical screening examination and transferred Patient #1 to the Sands unit (Behavioral Unit).

During an interview on 9/15/15 at 2:00 PM, Security Officer M reported ED RN K and Health Care Technician (HCT) H had the patient change into scrubs before both of them escorted Patient #1 to a ED room. Security Officer M said Patient #1 was cooperative, crying and stated she wanted to go home. He said he was called away to assist with patients in the ED behavioral unit. Security Officer M reported the sheriff deputies are not expected to stay in the ED with patients, unless the patient is in police custody and handcuffed.

During an interview on 9/15/15 at 3:20 PM, Health Care Tech (HCT) D said on the night of 9/4/15 ED Paramedic A told Patient #1 she could either stay or leave the hospital once the sheriff's deputies left. HCT D reported the patient cried and at that point, ED Paramedic A returned the patient's clothing, the patient got dressed and left the ED. HCT D said the patient cried as she left the ED and HCT D was concerned for the patient's safety because this is a "rough" neighborhood.

During an interview on 9/16/15 at 10:00 AM, House Supervisor G said on 9/4/15 after Patient #1 eloped, she heard Physician A tell ED RN E that it was their responsibility to take care of the patient and they didn't. House Supervisor acknowledged everyone involved failed to follow the hospital's EMTALA policy that night and reported once a patient is in their hospital they are obligated to provide care and treatment to them. She said the nurses let Patient #1 leave and they shouldn't have. The House Supervisor stated, "In a "perfect" world everything that happened that night would have gone differently."

During an interview on 9/16/15 at 1:05 PM, HCT H said ED Paramedic A and ED RN E were arguing with the sheriff's deputies, Nurse E told the sheriff deputies they needed to stay with the patient and if the patient left it wouldn't be their fault. HCT H said the patient could hear everything and was crying and saying "I don't know what to do", "Will I be in trouble if I leave?" HCT H said ED RN E was "dead set" that it was not their responsibility to monitor the patient.

4. Review of video footage on 9/16/15 at 2:00 PM with Manager of Public Safety Officer L revealed:

a. At 7:19 PM, Patient #1 entered the ED through the ambulance garage doors accompanied by two sheriff deputies and approached the nurse's station.

b. At 7:22 PM, The patient appeared to be crying, stood at the nurse's station for approximately 4 minutes before ED RN K and HCT H walked from behind the nurse's station and escorted the patient to the decontamination room in the ED.

c. At 7:28 PM, HCT H, ED RN K, with Patient #1 dressed in scrubs left the decontamination room walked down the hallway and entered the ED room with ED RN K, HCT H and the 2 sheriff deputies.

Approximately 54 seconds later ED RN K and HCT H walked out of the patient's ED room.

d. At 7:29 PM, ED RN K removed the patient's belongings from the decontamination room and placed them in a blue bin under a counter behind the nurse's station.

e. At 7:31 PM, ED RN K walked into Patient #1's ED room. Approximately 10 seconds later, ED RN K walked out of the patient's ED room and returned to the nurse's station.

f. At 7:34 PM, ED RN K walked into the patient's ED room. After 1 minute and 30 seconds ED RN K and 2 sheriff's deputies walked out of the patient's ED room.

g. At 7:36 PM, ED RN E stood in the doorway of the patient's ED room and appeared to be talking with the patient for approximately 5 seconds then ED RN E walked back to the nurse's station.

h. At 7:36 PM and 13 seconds, ED RN K stood up at the nurse's station, the patient walked out of the patient's ED room. ED Paramedic A picked up the bin from under the nurses counter, opened the lid, and placed it on the nurses' station (accessible to the patient.) The patient walked towards the bin and removed the clothing and belongings. The 2 sheriff's deputies walked out of the ED through the ambulance garage. ED RN E present, made a gesture to the patient to go down toward the decontamination room. HCT H followed the patient.

i. At 7:37 PM and 50 seconds, ED RN K entered the decontamination room and approximately 3 minutes later walked out of the decontamination room and returned to the nurse's station.

j. At 7:40 PM, House Supervisor G walked into the decontamination room and approximately 2 minutes later walked out of the decontamination room and stood outside the door talking with Crisis Team, Social Worker I. (The Crisis Team consisted of a Registered Nurse and a Social Worker assigned to the specialized 4 bed, locked mental health unit, in the ED. The Crisis Team provided specialized care to patients with a mental health crisis.)

k. At 7:43 PM, ED Paramedic A approached House Supervisor G and Crisis Team member, Social Worker I and stood outside of the decontamination room for about 10 seconds. Approximately 31 seconds later House Supervisor G and Social Worker I left the hallway and entered the nurse's station. ED Paramedic A stood outside of the decontamination room for approximately 20 additional seconds then returned to the nurse's station.

l. At 7:44 PM, House Supervisor G walked back to the decontamination room and stood at entrance. Approximately 22 seconds later, House Supervisor G left the area.

m. At 7:45 PM, the patient accompanied by HCT H, left the decontamination room dressed in street clothes, walked back into ED patient's room. HCT H returned to the nurse's station.

n. At 7:47 PM, HCT H walked into ED patient's room (for approximately 2.5 minutes), walked out, and returned to the nurses station. At that time Patient #1 dressed in street clothing, walked out of ED patient's room, walked down the hallway, and walked out of the ED through the ambulance garage.

o. The video footage failed to show the ED physician entered Patient #1's ED room to perform a medical screening examination at any time throughout the time Patient #1 was a patient in the ED. The patient without receiving a medical screening examination by a physician exited the ED to the outside at 7:49 PM. (approximately 30 minutes after the patient arrived in the ED.)

5. During an interview on 9/16/15 at 4:35 PM, ED RN K said she was Patient #1's primary nurse. ED RN K reported she did not look at Patient #1's court order paper work because she "didn't have enough time to do it." She said even if she were knowledgeable about the patient's history of depression and suicidal ideation prior to the patient leaving she still would have allowed the patient to leave because she was told that they couldn't force patients to stay if they didn't want to. ED RN K reported the patient was cooperative with the staff. ED RN K said she didn't recall seeing Patient #1 leave and did not know what happened to the patient.

During an interview on 9/17/15 at 2:15 PM, Sheriff's Deputies Q and R said ED RN E walked into Patient #1's room and said, "If they are not going to stay, you don't have to stay." The patient got up and went out of the room. The sheriff deputies reported ED Paramedic A took the patient's property and put it on the desk and said, "Here you go." The patient took her property.

Refer to A 2400 for additional information