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Based on medical record reviews, Staff interviews, review of the surveillance camera video dated 12/15/2020, review of the emergency department's policies and procedures, review of Narrative Statement, and review of personnel files, the hospital failed ensure that when an individual comes to the emergency department the hospital must provide an appropriate medical screening examination within the capability of the hospital's department, including ancillary services routinely available to the emergency department to determine whether or not an an emergency medical condition exists for 1 (Patient #1) of 20 sampled patients presenting to the hospital's emergency department requesting medical assistance, but was escorted off the property by a security officer without receiving a medical screening examination.
Cross Reference to tag A 2406.

Based on medical record reviews, Staff interviews, review of the surveillance camera video dated 12/15/2020, review of the emergency department's policies and procedures, review of Narrative Statement, and review of personnel files, the hospital failed ensure that when an individual comes to the emergency department the hospital must provide an appropriate medical screening examination within the capability of the hospital's department, including ancillary services routinely available to the emergency department to determine whether or not an an emergency medical condition exists for 1 (Patient #1) of 20 sampled patients presenting to the hospital's emergency department requesting medical assistance, but was escorted off the property by a security officer without receiving a medical screening examination.

The findings are:

Patient #1
On 2/2/21 at 8:28 AM, review of Patient #1's emergency department chart revealed the patient was presented to the emergency department on 12/15/20 at 19:10 (7:10 PM), and was triaged on 12/15/20 at 19:19(7:19 PM) by Registered Nurse (RN) 1. Review of the triage note dated 12/15/2020 at 19:19(7:19 PM) revealed "Pt(Patient) is very loud and uncooperative, cursing at staff and security. Unsure of total complaint. Reports "I want help". States "lungs are weak" also reports he had the "virus" Pt. reports he was "recently released for having the virus". Documentation showed the ESI level 4 (Emergency Severity Index is a five (5) level emergency department algorithm that provides clinically relevant stratification of patients into 5 groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs.) Documentation revealed the patient's vital signs at 19:12 (7:12 PM ) were Blood Pressure: 117/76; MAP (Mean arterial pressure is defined as the average pressure in a patient's arteries during 1 cardiac cycle) 88, Pulse 53, Respirations 19, Temperature 95.4 (Fahrenheit), O2 sat (Oxygen saturation) 97%(percent) on room air. Review of the patient's Medical History revealed "history of gastrointestinal disease including pancreatitis. Chronic neck/back/right foot pain. Asthma. Bleeding on my brain". Review of the patient's surgical history revealed "history of orthopedic surgery. Right foot. "in my head". Documentation showed "Psychiatric history: no previous psychiatric history." Review of the documentation titled, "Social history", revealed "Patient currently uses tobacco, patient smokes cigarettes, Patient smokes 1 pack per day, Patient drinks every day, less than 5 drinks per day, Patient currently uses drugs, abuses marijuana." Review of the discharge note reads, "Pt was escorted off the property by security at 19:49 (7:49 PM). The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide an appropriate medical screening examination for Patient #1 on 12/15/2020 when he/she requested emergency medical care on hospital property.

Video Surveillance Review
On 2/2/21 from 2:03 PM until 2:47 PM, the hospital's surveillance video was reviewed with the Director of Patient Safety & Risk Management and the Director of Nursing for the Emergency Department and Women & Children.


Timeline of Video (12/15/2020) No Audio
18:58(6:58 PM) Patient enters the emergency department (ED) wearing a camouflage coat and hat with ear flaps, carrying a white bag. Takes off his mask. Walks over to waiting room.

8:59(6:59 PM) Patient walks towards the desk. Security #2 enters the area and motions toward face. Patient is holding a mask. He walks toward an employee and the employee is helping patient with his mask. Visitor Service Representative enters the ED and walks to the desk. Patient slides the mask down. Placed the white bag in a chair at the desk. Patient tries to pull his mask up. And the mask apparently breaks, and employee gets another mask. There is a male and female in waiting room and the male is in a wheelchair. Another male sits further back in the waiting room.

19:01 (7:01 PM) The patient walks to the back of the wheelchair. Security #2 and Visitor Service Representative enter the ED. Security# 2 approaches patient and walks back to the desk. Security #2 motions for the patient to go with him. The Visitor Service Representative leaves the ED.

19:02(7:02 PM) Patient is talking and gesturing to staff behind the desk. Patient sits down in the waiting room. Security goes to him and is apparently talking to the patient.

19:03(7:03 PM) The Visitor Service Representative enters the ED. Patient gets up. Security #2 taps the patient on the patient's right arm and gestures for the patient to go outside.

19:04(7:04 PM) Patient pulls mask down. Visitor Service Representative and Security #2 motion for patient to go outside. Patient appears to shake his head.

19:05(7:05 PM) Security #3 enters the ED. Approaches the patient and gestures to go outside. They exit the ED.

19:07(7:07 PM) Security #3 enters the ED and approached the desk. Patient re-enters the ED.

19:08(7:08 PM) Patient pulled mask down. Talking and gesturing with staff and Security #3

19:12(7:19 PM) Given paper by Clerical Associate. Patient signed the form. Arm band placed on patient.

19:13(7:13 PM) Patient sat in chair for vital signs. Security #3 is standing with him.

19:20 (7:20 PM) The patient gets up and walks to bench out of view of the video.

19:21 (7:21 PM) Registered Nurse #1 leaves the desk. Security #3 walks out of the ED.

19:22(7:22 PM) RN #1 returns to ED.

19:23(7:23 PM) RN #1 walks out of ED.

19:24(7:24 PM) Security #2 walked in ED and gestured to patient. Appeared to be talking on radio on jacket.

19:25(7:25 PM) Security #2 walked out of the ED. Patient stood up and walked out of view. Security #2 comes back in ED and out again, comes back in and gestured to patient. Visitor Service Representative comes in.

19:27(7:27 PM) Security #3 comes in and gestures to patient.

19:28(7:28 PM) Security #3 and patient walked out of the ED door. Security #3 had hand on the patient's right arm.

19:32 (7:32 PM) The outside ED view showed Security #3 and patient outside walking away from the ED. They are in the road talking and gesturing.

19:34(7:34 PM) Patient walked toward ED entrance. Security #3 appeared to take his arm and lead him away. They walked across the street.

19:35(7:35 PM) They reached the end of the parking lot and out of view.

19:36(7:36 PM) Security #3 walked toward ED, stopped, and patient walked toward Security #3.

19:40(7:40 PM) Security #3 walked to the ED in a hurry and patient not seen.

Narrative Statement for Security #3
"At approximately 6:57 PM on December 15, 2020, Mr. ..... (Patient #1) came into the emergency room. At 7:01 PM, Mr. .....(Patient #1) was asked to leave if he was not going to sign in. Mr. .....(Patient #1) continued to walk around the ER waiting room ignoring Officer (#2). Once Mr. .....(Patient #1) got louder, Officer (#2) called me for Assistance. I arrived at 7:05 PM and asked Mr. .....(Patient #1) to walk outside and talk to me about what was going on. Mr. ..... (Patient #1) would not walk outside at first and was calling Officer (#2) racist names such as "cracker" and the "KKK". Once outside I asked Mr. .....(Patient #1) what the issue was and why he was being loud. I asked if Mr. .....(Patient #1) wanted to be seen and then walked inside at 7:07 PM to see if he had already been checked in. At 7:08 PM, I walked Mr. .....(Patient #1) inside to sign in. I stood with Mr. .....(Patient #1) to keep him from being loud and yelling. At 7:14 PM, Mr. .....(Patient #1) was triaged in the ER waiting area where I remained next to him to keep him from acting out. Mr. .....(Patient #1) had to be repeatedly told to keep his mask on and to stop moving during the triage process. Nurse .....(RN #1) informed Mr. .....(Patient #1) that if he did not cooperate that he would not be able to be seen. At 7:21 PM, Mr. .....(Patient #1) was asked to sit on the bench closer to the restrooms and nurse .....(RN #1) also informed him that he needed to keep his mask on and remain quiet or he would be asked to leave. I walked Mr. .....(Patient #1) over to the bench and let him know that he needed to stay quiet and remain seated and listen out for his name to be called. I also informed Mr. .....(Patient #1) that if he began to act up again and staff requested for him to leave that I would be back to escort him off the property. I then went to finish locking up day surgery. Before I walked out of the door, I told Officer .....(#2) that Mr. .....(Patient #1) could stay on the bench inside of the ER and wait to be seen and if he had any issues to call me back over. At 7:24 PM. Mr. .....(Patient #1) was up walking around cursing at Officer (#2) and other patients in the waiting room. Nurse (RN #1) stated that Mr. .....(Patient #1) needed to leave. Officer (#2) called me to come back to the ER and assist with Mr. .....(Patient #1). Once I arrived back in the ER waiting room, I told Mr. .....(Patient #1) to come outside with me. Once outside, I told him that he could wait outside to be seen but he would not be inside cursing and using racist remarks toward my officer. Mr. .....(Patient #1) said he would not wait outside and continued to call Officer (#2) a "cracker" and cursing at him. I told Officer (#2) he could go inside and I would talk to Mr. .....(Patient #1) to deescalate the tension between the two of them. I began to walk Mr. .....(Patient #1) toward the ER parking lot and told him that he could be seen by a doctor but he would not be waiting inside. Mr. .....(Patient #1) begin to yell "call the police, I don't care". I told Mr. .....(Patient #1) that he did not want me to call the police and that he now needed to leave the property. Mr. ....(Patient #1) asked if he could come back to be seen and I informed him, yes, he could come back and be seen. Mr. .....(Patient #1) stated that he would be back the next day. I stood outside with Mr. ....(Patient #1) until I heard another call for assistance come over the radio at 7:36 PM. At that time, I went inside to assist and Mr. .....(Patient #1) walked off the property.


Personnel File Review
On 2/2/2021 at 12:00 PM, review of the personnel file for Security Officer #3 verified Security Officer #3 was terminated on 02/01/2021.

Interviews
RN #1
On 2/2/2021 at 11:28 AM and 11:44 AM, in an interview with Registered Nurse (RN) #1, RN #1 verified that he/she worked the night shift on 12/15/2020 as the triage nurse. RN #1 reported "We had patients in the waiting room waiting to be seen ...(Patient #1) came in ...his clothes were dirty. He had 3 coats on and a Piggly Wiggly bag of food. He was cussing and loud and requested to be seen." RN #1 reported that Patient #1 said "I have COVID" and was not keeping his mask on and the greeter asked twice for him to keep his mask on. He had zoomed through screening and the security guard followed him in." RN #1 said he/she was unable to recall who the security guard was. RN #1 reported the patient said "I need help. I'll give you money. Don't have anywhere to go. I need help." RN #1 reported the patient was loudly saying obscenities, and called the white cop a "N". RN #1 reported "I finished triage. All the other patients in the waiting room wanted to leave because he said he had COVID and was cussing and loud." RN #1 reported "His blood pressure was good. Heart rate was perfect. He couldn't tell me his pain on a scale. He was bouncing around. Appeared stable. He could talk like you and me. He said his lungs were weak. Sometimes patients express things the best they can. I told him to slow down that he was talking too fast. He sat away from the other patients. I told him to keep his mask on and don't eat. He said okay, I got you." RN #1 reported "I sat him down away from the other patients where I could watch him. I went in the back from the waiting room to the ED to see if there was a room for him. The charge nurse (ED Charge Nurse 1)said there were no rooms. I'm working on it." RN #1 reported "When I came back from the ED into the waiting area, he was gone. I was gone like 4-5 minutes. The Clerical Associate for the ED told me he was escorted out by security. Escorted off the property." When RN #1 was asked what a "No Trespassing" designation meant in the patient's chart, RN #1 reported "Security calls that. They have to be off the property after discharge. It is assigned by security because they have caused a scene. It sticks with them and not assigned each visit."

Security #1
During an interview on 2/2/2021 at 11:46 AM to 12:02 PM, Security #1 verified that he/she worked on 12/15/2020 until 6:00 PM. When Security #1 was asked how and why patients are escorted off the hospital's property, Security #1 replied "Depends on the mannerisms. Get triaged in. After triage, they get rowdy, disrespectful, or violent, and they are ejected. Local police are called. Hospital staff makes the decision. We (security) try to de-escalate the situation. Use verbal judo to talk them down. Need confirmation from the nursing staff." Security #1 was asked who makes the decision to escort a patient off the premises, and Security #1 reported "Should be nursing staff."

Licensed Practical Nurse(LPN) #1
During an interview on 2/2/2021 between 12:13 PM and 12:21 PM, Licensed Practical Nurse (LPN) #1 verified working in the ED on 12/15/2020. LPN #1 reported "I don't remember much. We called the patient three times to come back to the room. The Tech called the patient 2 times. When I went to call the third time, I was told to take the patient off as he was escorted off the property." LPN #1 reported "I documented in the patient's chart about the discharge and time and escorted off." When asked who makes the decision to escort a patient off the property, LPN #1 reported "Charge nurse makes the decision." When asked if security ever makes the decision to escort a patient off the property, LPN #1 reported "Not that I've ever witnessed. We have to go to the charge nurse first. Have to be seen by the provider before escorted off." LPN #1 reported last EMTALA training was"after this incident. The training was done on line on MYPAL under Learning."

Quality Lead
During an interview on 2/2/2021 at 2:32 PM, the Quality Lead revealed Security #3 was no longer employed by the hospital. Quality Lead reported, "Security #3 was terminated effective 02/01/2021".

Security #2
During an interview on 2/2/2021 between 3:43 PM and 4:06 PM, Security #2 verified he/she worked as a security guard in the ED foyer/screening area starting 6:00 PM on 12/15/2020. Security 2 reported "We call him ..... He was in the ED lobby to be screened. He was cussing and causing a disturbance. He said "F... you to me. He went up to the registration desk and was getting loud with them. I think the nurse was .....(RN #1) and the Tech. He told me "get away from me you nigger. Don't touch me." Security #2 reported "We told him he needed to calm down or he won't be seen. Haven't seen him since that day. I called over the walkie talkie for some assistance. They sent ..... (Security #3) the Sergeant." Security #2 reported "Security #3 was no longer employed by the hospital. Security #3 got into a fight with another security guard." Security #2 reported "..... (Security #3) told me he(Patient #1) doesn't like white people. While she was dealing with him, I went back to my post." Security #2 reported "Registration called me in again to the ED lobby from the screening area. I called ..... (Security #3) again. The nurses told him(Patient #1) that if he didn't behave, he needed to be escorted out. He(Patient #1) was not following instructions, and wouldn't keep his mask up. .....(Security #3 told him(Patient #1) to stand up and come on outside with me (Security 3). He(Patient #1) went outbound and off the premises." When asked who makes the decision for the patient to be escorted out, Security #2 replied "It's ....(Security #3 and the nurses decision that he(Patient #1) had to leave. He (Patient #1)wouldn't calm down and smelled like alcohol. I called .....(Security #3) to come back because he's/she's (Security #3) my supervisor. (Security #3) .... said he's (Patient #1) going outbound now. I saw him heading to the courthouse." When Security #2 was asked to define outbound, Security #2 said "Off the premises". When Security #2 was asked to explain training he/she had received concerning escorting patients off the premises, Security #2 replied "Let them know you need them to calm down. Ask them do you need help. Take them to the nurse desk. Tell them if you don't calm down I'm going to call backup. Nurses make the decision."

ED Charge RN
During an interview on 2/3/2021 between 7:55 AM and 8:04 AM, Emergency Department (ED) Charge RN verified he/she worked as the ED charge nurse on 12/15/2020 when Patient #1 was in the ED. ED Charge RN reported "I know the name. He's in the ED often enough to remember that." When the ED Charge RN was asked if he/she remembers anything about that night, the ED Charge Nurse replied "No". ED Charge RN defined his/her role as "be between security, the patient, and the doctor." When the ED Charge Nurse was asked who makes the decision to have a patient leave or be escorted off the hospital's premises, the ED Charge Nurse reported "Security, but they should consult us." The ED Charge RN reported he/she had EMTALA training in January 2021.

Director of Patient Safety and Risk Management (DPSRM)
During an interview on 2/3/2021 between 8:05 AM and 8:09 AM with the Director of Patient Safety and Risk Management (DPSRM), he/she reported the hospital has one statement from Security #3 related to the hospital's investigation for the potential EMTALA incident. When asked when the hospital was first aware of the incident, the DPSRM reported, "The DON(Director of Nurses)/ED Director/ Director of Women and Children said he/she first heard about it at the morning huddle on 12/16/2020."

Director of Security #1
During an interview on 2/3/2021 at 1:40 PM with Director of Security #1, he/she revealed "Security #3's last date of employment was 1/20/2021 at the end of the shift." Director of Security #1 reported "Security #3 was terminated from the hospital's contracted security services effective 02/01/2021 which was verified by review of Security #3's personal file. When Director of Security #1 was asked why the only witness statement from Security #3 was obtained for the investigation of the potential EMTALA incident when other witnesses were also involved, Director of Security #1 replied "I don't know. Hypothetically, Security #3 was the supervisor in charge." Director of Security #1 reported EMTALA training is done for security personnel by state law enforcement and the hospital.

Visitor Service Representative (VSR)
During an interview on 2/3/2021 between 2:05 PM and 2:19 PM with the Visitor Service Representative (VSR), he/she verified working on 12/15/2020 in the ED Screening area when .....(Patient #1) presented to the ED. The VSR stated "Yes. Acted like he was under the influence. Loud and would not wear his mask. Cussing and asked to tone it down. People at desk asked him to tone down. Security tried to talk to him. Get him to calm down. Everybody know him. Told him we're trying to get you in. He wouldn't listen to them. He said, 'I got something in my bag, a rat' and everybody bust out laughing. He went outside. Tried to spit on the security officer". When asked if the VSR saw the patient leaving the ED with a security officer, the VSR said "Yes. One of the security guards did go out there to talk some sense to him. You can tell the difference when he's under the influence or not. He's very funny and well known. More aggressive this night." VSR stated "Nurses asked security to come in and talk to him cause there were kids in there, and he was cussing and tried to get him to wear his mask."

Clerical Associate
During an interview on 2/4/2021 between 8:00 AM and 8:24 AM with the Clerical Associate in the ED, he/she verified working at the front desk for the ED as the Greeter on 12/15/2020 when Patient #1 was in the ED. The Clerical Associate said "Yes, I remember him (Patient #1). I registered him. He was coughing and said, 'I just got out of the hospital for COVID. Here for chest pain.' He did not want to keep his mask on. Did his vitals. He was sitting in the corner and cussing loud. He called the security guard a "N". He wouldn't keep his mask up. He was told to keep his mask on. He didn't want to hear that. I went to security. The nurse told him 'look, you need to sit or you're gonna be escorted out. .....(Security #3)said 'Come on, let's go outside and talk.' I heard something hit the door on their way out. He (Patient #1) threw something. He got mad and left. Every time he comes in, he give us a run for our money." The Clerical Associate reported, "I want to get this right. He got told 'if you don't sit down and keep your mask on, and stop using profanity, you're gonna be escorted out'. Security told him let's go outside and talk."

Hospital Policies
Policy: Medical Screening Examination
It is the policy of Palmetto Health Tuomey to provide an individual who comes to the emergency department an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an Emergency Medical Condition (EMC) exists, regardless of the individual ' s ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a Dedicated Emergency Department (DED) or when an individual request emergency medical care on hospital property, other than a DED.

Procedure: When a medical screening examination is required:
An individual must receive a MSE within the capabilities of the hospitals DED, to determine whether or not an EMC exist or with respect to a pregnant woman having contractions, whether the woman is in labor, and whether or not the treatment requested is explicitly for an emergency condition if:

1. The individual comes to a DED of a hospital and a request is made on his or her behalf for examination or treatment for a medical condition, including where:

a. The individual request medication for a medical condition

b. The individual arrives as a transfer from another hospital or healthcare facility. A physician or Qualified Medical Person (QMP) must perform a screening sufficient to determine whether or not there has been any change in the individual's condition from the time he or she left the transferring facility until the arrival at the accepting facility. The medical screening of the individual must be documented. The triage nurse cannot perform this type of screening. Triage is not a medical screening exam.

2. The individual arrives on the hospital property other than a DED and a request is made on the individual's behalf for examination or treatment for an EMC.

3. Prudently person observer. Although no request is made, the appearance or behavior of an individual who comes to the DED or any other location in the hospital would cause a prudent layperson observer to believe that the individual needed such examination or treatment.