HospitalInspections.org

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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients seeking or requiring emergency medical care while on hospital property in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure that individuals who request or require emergency medical treatment while on hospital property receive a comprehensive medical screening examination and stabilizing treatment prior to transfer or discharge risks poor patient care outcomes, injury, and death.

Findings included:

1. The hospital failed to ensure that 2 of 26 patients requesting medical treatment (Patients #1 and #2) received a medical screening exam before they left the emergency department (ED).

2. The hospital failed to implement policies and procedures that ensure staff obtain emergency medical assistance for individuals experiencing medical emergencies while on hospital property.

3. The hospital failed to ensure that any individual experiencing an emergency medical condition while on hospital property receives a comprehensive medical screening exam and stabilizing treatment prior to transfer to another facility.

Cross reference: Tags A2406, A2409
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DEDICATED EMERGENCY DEPARTMENT

Based on interview, document review, and review of hospital policies and procedures, the hospital failed to provide an appropriate medical screening exam (MSE) for 2 of 26 patients (Patient #1 and Patient #2) seeking treatment in the emergency department (ED).

Failure to provide appropriate medical screening examinations by qualified medical professionals with stabilizing medical treatment prior to ED discharge or transfer risks poor health outcomes, injury, and death.

Findings included:

1. Review of the hospital's policy titled "EMTALA - Examination, Treatment and Transfer of Individuals in Need of Emergency Services," policy number 345.00, last approved 11/20, showed that the policy applied to all individuals who come to the hospital's emergency room seeking an examination, all individuals who request an examination or treatment for an emergency condition while on hospital property other than the emergency department, and all individuals on hospital property whom a prudent layperson would recognize would require an examination or treatment although no request for treatment is made.

2. Review of hospital documents showed that Patient #1 contacted the hospital to report concerns about his treatment in the emergency department. Document review showed that Patient #1 presented to the ED on 12/18/20 with a complaint of abdominal pain. He was discharged on 12/19/20 and had expressed his unhappiness with the care he had received in the ED. He was escorted out of the ED through the ambulance bay doors by a hospital security guard, and when he asked to use the phone to call for a ride, he was told no. Patient #1 complained that when he attempted to reenter the facility, the security staff member picked him up and slammed his body against the floor. When he got up, he complained of back pain and told the security officer he wanted to be seen again in the ED. The security guard told him, "the emergency department is closed." Patient #1 did not return to the ED, and document review showed that the hospital confirmed Patient #1's complaint with video review and staff interview.

3. Review of hospital documents showed that on 02/19/21 at 7:08 PM, Patient #2 was brought to the hospital by ambulance for a mental health evaluation at the request of law enforcement. Document review showed that:

a. Patient #2 was recently diagnosed with COVID-19. He had a history of sickle cell disease (a blood disorder) with frequent acute chest syndrome and pain crisis, anemia, blood clots in his lungs, anxiety, cluster B personality disorder, and substance abuse disorder. During his most recent visit, his temperature, pulse, and blood pressure were elevated at 99.3°F, 140 beats per minute, and 136/96, respectively. Patient #2 was cleared medically. He denied suicidal or homicidal ideation and did not meet criteria for designated crisis responder referral. He declined offers for transportation or housing assistance and was discharged.

b. At 8:28 PM, Patient #2 was observed leaving the hospital through the decontamination room exit door, accompanied by an emergency services technician (EST) (Staff #15). Patient #2 was then observed pacing back and forth on the walkway in front of the ambulance bay doors. He attempted to enter through the sliding glass doors, but they would not open. At 8:34 PM, Patient #2 pried open the sliding glass doors and entered doorway to the emergency department. An EST (Staff #16) guided Patient #2 back out onto the walkway and away from the ED. Two EST staff (Staff #15 and Staff #16) and three hospital security staff (Staff #17, #19, and #20) were blocking Patient #2's pathway to the ambulance bay entrance. They guided him to the sidewalk where he was met by two Tacoma police officers at 8:50 PM.

c. At 9:07 PM, the police officers drove away, and Patient #2 resumed his attempts to reenter the ED through the ambulance doors. At 9:09 PM, Patient #2 stood in the doorway of the main ED, but two security officers (Staff #14 and Staff #18) prevented him from advancing further. At 9:12 PM, four security staff and two ESTs work to remove Patient #2 from the ED doorway. Staff #19 and #14 pushed Patient #2's chest, causing him to lose his balance and pull one of the glass doors open as he tried to keep from falling. As Patient #2 lost his balance and stumbled backward onto the sidewalk, three security officers (Staff #14, #17, and #19) formed a 3-man barrier between him and the sliding glass doors. Staff #14, #17, and #19 guided Patient #2 in the direction of the bus stop, and Patient #2 made no further attempt to reenter the ED.

4. On 04/15/21 the investigator reviewed hospital documents with the Human Resources Business Partner (Staff #5). Document review showed that hospital staff (Staff #17) stated that on the night of 02/19/21, during his interactions with Patient #2, "his eyes were staring at you, but his mind was somewhere else." Staff #3 stated that on the night of 02/19/21, Patient #2's "only complaint was that his leg hurt."

5. On 03/11/21 at 3:55 PM, the investigator interviewed the Security Supervisor (Staff #10). Staff #10 stated that on 02/19/21 he was called by the supervisor of the Physical Security Support Center (camera operators) about an incident that was occurring on his campus. Staff #17 stated that he called his lead security officer (Staff #17), who told him that Patient #2 was discharged from the ED but was refusing to leave the property. Patient #2 had broken a door off its hinge, and the police were not responding to their calls. Staff #10 stated that he instructed Staff #17 to contact the hospital supervisor to see if they could offer Patient #2 a bus ticket to "convince him to leave."

Staff #10 stated that he called back after shift change and spoke with the new lead, Staff #17. When he asked Staff #17 if Patient #2 was trespassed yet, Staff #17 did not know. Staff #10 told Staff #17 to do so if that had not already been done. Staff #10 stated that he asked Staff #17, "What does he want?" Staff #17 told Staff #10 that he wanted his brother to come get him, but when they were calling his brother, Patient #2 just "stopped giving them the number and began trying to get into the property again."

6. On 04/06/21 at 2:05 PM the investigator interviewed the hospital social worker who provided the mental health assessment for Patient #2 on 02/19/21 (Staff #21). Staff #21 stated that she did not know that staff were having issues getting Patient #2 to leave the ED that night. Staff #21 stated that she did not know that Patient #2 was initially escorted out of the hospital by security upon discharge and stated that the tech told her he left through the ambulance bay. Staff stated that nobody told her that Patient #2 wanted to come back in, but if they had she would have reassessed him.

7. On 04/05/21 at 5:01 PM, the investigator interviewed an EST (Staff #15) working the night of 02/19/21. Staff #15 stated that he tried to walk Patient #2 to the bus stop after he was discharged, but then Patient #2 decided he wanted to walk the other way. Staff #15 stated that Patient #2 tried to reenter the ED through the decontamination exit, but "I told him, "it's locked. I told him he can go back through the front if he needed to be seen again. I told him, we can still see you, you just need to go through the other doors." Staff #15 stated that Patient #2 was acting erratically, pacing in the front of the ED, and that "everyone knew he was out there." Staff #15 stated that he was told because Patient #2 had COVID, used meth, and would not follow instructions, there was nothing that they could do for him.

8. On 04/07/21 at 4:20 PM the investigator interviewed the security officer assigned to work the evening shift on 02/19/21 (Staff #14). Staff #14 stated that Patient #2 was COVID positive and would not stay in his room. The doctor discharged patient #2 and said, "we need to get him out." Staff #14 stated that following his discharge, Patient #2 made multiple attempts to get in the ED through the ambulance bay doors. Staff #14 stated that they tried to direct Patient #2 to the bus stop, and "we gave him directions to Tacoma General," but he would not leave. When asked if he said why he wanted to go to the ED, Staff #14 stated that during his struggles to reenter the facility, Patient #2 said that his chest was hurting and that he wanted to get more drugs.

9. On 04/20/21 at 1:06 PM, the Risk Manager (Staff #7) confirmed that it is the hospital's expectation for staff to escort or assist any person seeking emergency care on hospital property to the ED admitting area if they are unable to understand or follow instructions. During the investigation, the Risk Managers (Staff #7 and Staff #8) confirmed that hospital staff should not tell patients that the emergency department is closed.

MEDICAL EMERGENCIES ON HOSPITAL PROPERTY

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to offer or provide medical assistance to who experienced a medical emergency on hospital property.

Failure to offer or administer medical assistance to individuals with medical emergencies risks poor health outcomes, injury, and death.

Findings included:

1. Review of the hospital's policy titled "EMTALA - Examination, Treatment and Transfer of Individuals in Need of Emergency Services," policy number 345.00, last approved 11/20, showed that the hospital's obligation to perform a medical screening examination as required by the Emergency Medical Treatment and Labor Act (EMTALA) exists when an individual (or someone on their behalf) requests treatment of a medical condition within the hospital's dedicated emergency department (ED), when and individual (or someone on their behalf) requests examination or treatment for an emergency medical condition on hospital property other than the dedicated ED, or when a prudent layperson would recognize that an individual on hospital property, other than the dedicated ED, requires examination or treatment for an emergency medical condition, even without a request.

2. On 02/19/21 at 7:08 PM, Patient #2 was brought to the hospital by ambulance for a mental health evaluation at the request of law enforcement. Document review showed that:

a. Patient #2 was recently diagnosed with COVID-19. He had a history of sickle cell disease (a blood disorder) with frequent acute chest syndrome and pain crisis, anemia, blood clots in his lungs, anxiety, cluster B personality disorder, and substance abuse disorder. Patient #2 was cleared medically by the physician. His social work mental health assessment showed that he denied suicidal or homicidal ideation and did not meet criteria for designated crisis responder referral. He declined offers for transportation or housing assistance and was discharged from the ED at 8:28 PM.

b. Between 8:28 PM and 8:50 PM, and 9:07 PM and 9:15 PM Patient #2 made multiple attempts to enter the ED through the ambulance bay doors, but he was denied reentry. Security staff (Staff #14, #17, and #18) slowly directed Patient #2 toward the bus stop.

c. At 10:00 PM Patient #2 was already at the public bus stop when night shift security staff (Staff #1, #2, and #3) started their shift. Staff #2 and #3 followed Patient #2 and flashed strobing lights into his face. Patient #2 attempted to get away from them by crossing the street and walking north down J Street, but they continued to follow him.

d. At 10:47 PM, Patient #2, Staff #2 and Staff #3 stood at the southeast corner of 16th and J Streets. As Patient #2 sat down on the ground, Staff #2 approached him from behind, grabbed him under his arms, turned him face down, and forced him to the ground. Staff #2 knelt on the ground over Patient #2 and forced Patient #2's head and face down toward the ground. Staff #2's arms moved in a downward motion toward Patient #2. Staff #3 stood by and watched as the entire event occurred. Staff #1 arrived while Staff #2 was still on the ground with Patient #2. At 10:50 PM, Patient #2 stood up, swaying back and forth. Staff #1, #2, and #3 were facing him and could see him stumble as he tried to remain upright.

e. Staff #1, #2, and #3 turned and walked back to the hospital. Patient #2 followed from a distance. At 10:56 PM, Patient #2 collapsed face first next to a mailbox by the hospital main entrance. He remained motionless until 11:30 PM.

f. At 11:00 PM, Staff #17 walked several feet past Patient #2 as he lay motionless next to him on the sidewalk. He paused five seconds, turned around, and walked past him once more without stopping.

g. At 11:03 PM, Staff #1, #2, and #3 were observed standing in the window of hospital main lobby, facing in the direction of Patient #2 who remained motionless on the sidewalk.

h. On 02/20/21 at 2:44 AM, video monitoring showed Patient #2 laying on the sidewalk. Patient #2's head was hanging off the curb into the main street.

i. On 02/20/21 at 3:09 AM, Patient #2's body had fallen off the sidewalk and was entirely in the street.

j. On 02/20/21 at 3:29 AM, the camera operator zoomed a camera in on Patient #2. Patient #2 was laying face down, completely in the street.

k. On 02/20/21 at 4:03 AM, a passerby saw Patient #2 laying on the sidewalk and stopped. The person took out a cell phone and continued walking toward the crosswalk. Tacoma police and fire arrived 4:28 AM.

3. Document review showed that the hospital interviewed Staff #3 on 03/01/21. When asked if he should have checked on Patient #2 at some point during the shift, Staff #3 stated that not checking on him "was probably not the right thing to do."

4. Document review showed that the hospital interviewed Staff #1 on 03/05/21. When asked if he thought Patient #2 required medical attention during the shift, Staff #1 stated that Patient #2 appeared "pretty steady" and that "he did not mention anything about needing medical attention."

5. Document review showed that the hospital interviewed the night shift camera operator (Staff #22) on 03/11/21. Document review showed that Staff #22 stated that he was "concerned about the safety of staff, "since it was reported to him that Patient #2 had assaulted two staff members on evening shift. Staff #22 stated that he "assumed Patient #2 was wanting shelter" since he had "refused care and didn't want to leave the premises," and that was why he put up such a struggle earlier in the ED. Staff #22 stated that he "wasn't sure if Patient #2 was awake, but he "didn't pose a threat as long as he was laying down."

6. On 04/21/21 at 3:00 PM, the investigator interviewed the Interim Regional Security Director (Staff #13) and the Security Supervisor (Staff #10). Both staff stated that it was their expectation that security staff obtain assistance for any individual on hospital property who appears to require medical assistance. Staff #13 and Staff #10 confirmed the investigator's findings that security staff should have checked on Patient #2 and obtained medical assistance for him while he was laying on the sidewalk in front of the hospital.
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Based on interview, record review and review of hospital policies and procedures, the hospital failed to provide a medical screening exam (MSE) and stabilizing treatment prior to transferring a medically unstable patient to another hospital.

Failure to provide a medical screening exam and stabilizing medicaal treatment prior to transfer places individuals at risk for poor outcomes, harm, and death.

Reference: Emergency Treatment and Labor Act (EMTALA) Interpretive Guidelines§489.24(e)

"The Emergency Treatment and Labor Act (EMTALA) regulations at 42 CFR 489.24(b) define "transfer" as " ...the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by ...the hospital ..."

Findings included:

1. Review of the hospital's policy titled, "EMTALA - Examination, Treatment, and Transfer of Individuals in Need of Emergency Services," policy number 345.00, last approved 11/20, showed that if a person comes to the hospital emergency department (ED) and requests care, or is on hospital property and appears to need medical treatment, a qualified medical provider will conduct a medical screening exam (MSE) to determine if an emergency medical condition exists. If an emergency medical condition is determined to exist, the facility must provide stabilizing medical treatment and initiate transfer procedures.

2. Medical record review showed that on 02/20/21 at 4:30 AM Tacoma Fire Department requested an ambulance transport for an unresponsive male (Patient #2) who was reported "lying on the ground for at least one hour." Document review showed that hospital security (Staff #1) was present when the ambulance crew arrived at 4:33 AM. Staff #1 reported that Patient #2 had been kicked out of St Joes ED a couple of hours ago for being aggressive with staff, and they "won't accept him" as a patient. Document review showed that Patient #2 was lying face down, moaning, and was otherwise unresponsive. Document review showed that Patient #2 had a low heart rate of 32 beats per minute, and the paramedic was unable to obtain his blood pressure or start a line to administer intravenous fluids. He was placed on a gurney and transported emergently to Tacoma General Hospital at 4:49 AM.

3. Document review showed that on 02/19/21 at 10:56 PM, Patient #2 collapsed on hospital property following use of force application by hospital staff (Staff #1, Staff #2). Document review showed that following his collapse, hospital security staff remained aware of his presence on property and monitored him either in person, through windows, or via remote video monitoring until his departure on 02/20/21 at 4:49 AM.

4. On 03/18/21 at 2:28 PM, the investigator interviewed Staff #1. Staff #1 stated that on 02/19/21, he saw Patient #2 with two officers on J Street, and "he went to see if everything was okay." Afterwards, Patient #2 followed them back to the hospital, and he saw Patient #2 sit down by the mailbox. Staff #1 saw Patient #2 "a couple more times during the shift, still sitting there by the mailbox," and then between 3:00 and 4:00 AM, he got a call from the camera operator notifying him that Tacoma police and fire were on property, at the mailbox where Patient #2 was. When Staff #1 arrived on the scene, the police told him that Patient #2 was going to Tacoma General hospital, and the ambulance crew verified this information.

5. On 03/18/21 at 1:39 PM, the investigator interviewed the paramedic who transported Patient #2 to Tacoma General Hospital on 02/20/21 (Staff #11). Staff #11 stated that when he arrived, he spoke with Tacoma Police, Tacoma Fire, and hospital security staff (Staff #1). Staff #1 reported to the police, fire and ambulance response crew that Patient #2 was aggressive, security had just kicked him out of the hospital a couple of hours ago, and given his history of aggressive behavior toward staff, hospital security told Tacoma Police that he wanted the patient to go to Tacoma General Hospital.

6. On 03/18/21 at 1:46 PM, the investigator interviewed the emergency medical technician (EMT) who transported Patient #2 to Tacoma General Hospital on 02/20/21(Staff #12). Staff #12 stated that the security officer present at the scene (Staff #1) informed the ambulance team that Patient #2 had been kicked out of St Joeseph three times, and they "will not take him back." Staff #12 stated that she is aware that hospitals cannot refuse to take patients, and "security is not the right person to make that decision." Staff #12 stated that "we have had problems with them in the past, and we didn't feel like fighting with them." Staff #12 stated that "nobody knew why he was down," and Tacoma General was the trauma hospital that day, so we packed him up and took him to TG (Tacoma General)." Staff #12 stated that the patient was not stable and that he "coded as soon as we got him into the ambulance."

7. During the time of the document review, hospital Risk Management staff (Staff #7 and Staff #8) confirmed the investigator's finding that Patient #2 experienced an emergency medical condition while on hospital property, and the hospital failed to provide a medical screening examination and stabilizing treatment prior to Patient #2's transfer to another facility.