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Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

A-2406 / 489.24(a): Provide an appropriate medical screening examination within the capability of the hospital's emergency department. The hospital failed to educate Patient #31 on the risks of leaving the hospital without a medical screening examination. Patient #31 presented to the hospital's Emergency Department (ED) with a chief complaint of shortness of breath related to asthma. The patient was given a breathing treatment in the triage area and sent back to the full lobby to wait because there were no ED beds available. The patient told the RN she was going to leave because she was still short of breath. The RN told the patient she had anxiety and not asthma and that it was okay for her to leave. There was no documentation that the patient was educated on the risks of leaving without a medical screening examination. The patient went to another hospital shortly after that and was admitted to the ICU. Hospital staff reported during interviews that their policies and procedures do not require staff to educate and document the risks of leaving without receiving a medical screen examination.

Based on review of clinical records, hospital policies and procedures and documents, and staff interviews, it was determined the hospital failed to educate Patient #31 on the risks of leaving the hospital without a medical screening examination. Patient #31 presented to the hospital's Emergency Department (ED) with a chief complaint of shortness of breath related to asthma. The patient was given a breathing treatment in the triage area and sent back to the full lobby to wait because there were no ED beds available. The patient told the RN she was leaving, and there was no documentation that the patient was educated on the risks of leaving without a medical screening examination. The patient went to another hospital shortly after that and was admitted to the ICU. This deficient practice poses the risk of patient harm if the patient is not educated on the risks of leaving without being evaluated by a qualified medical provider.

Findings include:

The hospital's policy and procedure titled, "Leaving Without Treatment / Being Seen, Against Medical Advice, and Elopement" included: "DEFINITIONS...'LWBS' means leaving without being seen (without triage)...'LWOT' means leaving without treatment (without medical screen)...'AMA' means leaving against medical advice...PROCEDURE...If a patient is triaged and registered (LWOT), the nurse should complete the EMR as completely as possible. Documentation and (sic) should include: a. Date/time left, if known...b. Any other pertinent information...If a patient request to leave AMA follow the procedures outlined below...A registered nurse will determine the patient's reasons for the request...Reasonable attempts will be made to discourage patient from leaving and correcting the reason for the patient's desires to leave...If the patient insists, the nurse will inform the patient's attending physician...An AMA form will be signed by the patient and placed in the permanent chart...The patient will be informed of the possible risks and benefits involved with leaving AMA preferably by the attending physician or the RN witnessing the signature of the patient...."

The hospital's EMTALA policy included: "The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department...The medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist...Refusal of Treatment...If the Hospital offers further examination and treatment and informs the individual or the person acting on the individual's behalf of the risks and benefits of the examination and treatment, but the individual or person acting on the individual's behalf does no consent to the examination and treatment, the Hospital must take all reasonable steps to have the individual or the person acting on the individual's behalf acknowledge their refusal of further examination and treatment in wiring. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual's; the risks/benefits of the examination and/or treatment; the reasons for refusal; and if the individual's refused to acknowledge their refusal in writing, the steps taken to secure the written informed refusal. Hospital personnel involved with the individual's care or witnessing the individual's refusing consent must document the patient's refusal in the medical record."

Patient #31 went to Abrazo West Campus on 03/12/2020 at 6:39 p.m. with a chief complaint of shortness of breath. The patient was triaged at 6:39 p.m. and was assigned an Emergency Severity Index (ESI) acuity score of "2" (emergent). The patient was evaluated by an ED physician at 7:10 p.m. who documented the patient's past medical history included asthma and that the patient had been seen by his/her Pulmonologist the prior day. The patient reported being intubated in the past due to asthma exacerbations. The physician ordered BiPap (BiLevel Positive Airway Pressure) at 7:20 p.m. which was placed by a Respiratory Therapist at 7:26 p.m. The Respiratory Therapist's description of the patient's respiratory status included, "diminished... labored... irregular...wheezes... gasping." Respiratory Therapy documentation at 9:09 p.m. revealed the patient was receiving oxygen via nasal cannula. There was no documentation as to when Bipap was discontinued. The last documentation by the Respiratory Therapist was at 9:52 p.m. There were no nursing assessments of the patient's respiratory status after the initial assessment at 6:39 p.m. except the following note at 7:33 p.m.: "SOB (shortness of breath) at rest." The ED physician documented at 11 p.m. that the patient was to be admitted with "Acute respiratory failure" and Acute Asthma Exacerbation. The physician also documented: "...Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Patient indicated understanding of instructions." The RN documented at 11:20 p.m. that the patient eloped with the intravenous line.

Patient #31 presented to the ED again on 03/13/2020 at 11:54 a.m. with a chief complaint of shortness of breath. The patient was triaged at 12:45 p.m. The patient's vital signs were: Blood Pressure: 134/74; Heart Rate: 113 (high) and assigned an acuity of "3" (urgent). The RN (Staff#6) documented at 1:08 p.m., "RN spoke to Dr. (name) regarding pt. pt c/o (complained of) short of breath. VSS (vital signs stable). O2 sat 98% on RA (room air). no wheezing noted. pt is anxious. breathing Tx (treatment) ordered and given in triage. pt to be placed back in lobby. pt refused and states that she is going home." There was no documentation that the patient was encouraged to stay and educated on the risks of leaving without a medical screening examination by a medical provider.

The Medication Administration record revealed the ED RN administered a breathing treatment by nebulizer at 12:56 p.m. There was no documentation that the RN performed a respiratory assessment prior to and after the breathing treatment.

Patient #31 presented to Hospital #2 on 03/13/2020 on or around 6 p.m. with a chief complaint of, "shortness of breath since yesterday...has been using her inhalers and nebulizer. pt with increased work of breathing." The patient was triaged by an RN who documented the patient's breathing was "labored" and "Use of accessory muscles." The patient's blood pressure at that time was 141/98 and heart rate 113 beats per minute. The RN assigned the patient an ESI score of "2" (emergent). The patient was evaluated by an ED physician at 6:13 p.m. whose documentation included: "The patient presents with wheezing and asthma...diffuse wheezing throughout, speaking in 1-2 word sentences, tachypnea, increased working of breathing, sitting in tripod position. A chest x-ray performed revealed: "Component of pulmonary edema with bilateral pleural effusions and associated compressive atelectasis." The ED physician's reassessment of the patient included: "Patient with history of asthma, started prednisone 60 mg orally yesterday as ordered by her pulmonologist. Today she presents with increased work of breathing wheezing and fatigue. Patient currently initiated on Bipap therapy. Patient having difficult time with Bipap secondary to claustrophobia...At the present time I would recommend continuing Bipap therapy with the aid of 0.5 mg of IV Ativan for sedation...Venous blood gas does no show acidosis but patient is clearly fatigued. Patient is comfortable with plan. Patient will require careful and close observation, admission to ICU."

Patient #31 was interviewed by telephone on 11/07/2020 regarding her ED visits on 03/12/2020 and 03/13/2020. Patient #31 reported that when she presented on 03/12/2020 she was placed on Bipap for a period of time, however, it was discontinued and placed on oxygen by nasal cannula. The patient reported the Respiratory Therapist came in frequently, however, the physician did not return even after repeated requests by the patient. The patient was concerned that she was not getting better with the oxygen by nasal cannula only, and "there was no known plan of care." She reported that she told the Respiratory Therapist that she was leaving and then "disconnected" her intravenous line and left. Patient #31 was told during the interview that the ED physician documented in her medical records that she was told she was being admitted The patient denied being told that and stated: "I would never have left if I had been told I was being admitted." The patient stated that she went to her Pulmonologist mid-morning on 03/13/2020. The Pulmonologist told her to go back to Abrazo West Campus ED for admission and that he would call the hospital and notify them so that she would not have to wait. The patient reported that when she got to the ED, she was not able to speak in full sentences, and the registration clerk had to take information off of her driver's license. The patient stated the ED lobby was "packed," and she waited in the lobby for over 30-minutes before triage. She added that a person near her in the lobby went up to the window to tell them there was someone in the lobby having problems breathing and pointed Patient #31 out. The patient's vital signs were taken and an EKG performed after being called to the triage area. The RN told the patient there were no rooms available but would give her a breathing treatment in the triage area. The RN told the patient to go back to the lobby after the treatment. The patient told the RN she was still having trouble breathing and asked how long she would have to wait. The patient's perception was that the RN was "annoyed" with her and told the patient she had "anxiety" and not asthma and that she was treated for her anxiety the prior evening.. The patient told her it was asthma, and the RN argued that she was not in any distress but rather anxious. The patient was concerned that she would have to wait an unknown amount of time in the lobby without care and asked the nurse if she was free to go. The nurse told her she could go whenever she wanted. Patient #31 was asked during the interview if the RN listened to her lungs at any time, and the patient responded, no. Patient #31 was asked if the RN explained the risks of leaving without being evaluated by a medical provider, and the patient responded, no. The patient reported she then called a family member who picked her up and took her to Hospital #2 where she was seen right away and admitted to the ICU.

Patient #31's ED records were reviewed with Staff #1, #2 and #3 on 12/1/2020. It was pointed out that there was no documentation in the 3/13/2020 record that the patient was educated on the risks of leaving without being evaluated by a physician. Staff #2 reported the RN documented the patient's vital signs were stable and she was no no distress and that the hospital's policies and procedures did not require the RN's to explain the risks of leaving to patients prior to receiving a medical screening examination. They acknowledged Patient #31 was in their ED the evening of 3/12/2020, was placed on Bipap, and was pending admission for respiratory distress prior to eloping. Staff #2 stated staff encourage patients to stay if they want to leave prior to being seen, however they were not expected to document that conversation in the medical record.

In summary, Patient #31 had a documented past medical history of respiratory stress which required intubation and mechanical ventilation support at Abrazo West Campus. The patient presented to the ED on 03/12/2020 in respiratory distress and was placed on Bipap in the ED with the plan to admit. Although the physician documented the patient was told about the planned admission, the patient claimed to be unaware of that and left the ED. The patient went to her Pulmonologist the following morning and was directed to return to the ED for admission. The patient was told during triage that there were no beds available in the ED and that she would have to wait in the lobby after receiving a breathing treatment in the triage area. The RN documented the patient's vital signs were stable with no wheezing and that the patient was "anxious." There was no documentation of a respiratory assessment including lung sounds prior to or after the breathing treatment. The patient felt she was in respiratory distress and voiced her concern to the RN. The patient told the RN she was going to leave. There was no documentation that the patient was educated on the risks of leaving without being seen by a medical provider. The patient went to Hospital #2 a short time after leaving and was admitted to the ICU. The hospital staff interviewed reported their policies and procedures did not require staff to educate patients on the risks of leaving without a medical screening examination or to document the education provided.