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Based on interview and documentation review, it was determined the Hospital failed to ensure that all individuals presenting to the emergency department seeking treatment were provided with an appropriate medical screening examination in five (Patient #1, Patient #5, Patient #9, Patient #10 and Patient #13, ) of 21 medical records reviewed.

Findings included:

I. Clinical Record review indicated Patient #1 presented to the ED and during triage (the process of determining the order in which individuals will be seen by a medical care provider based on their need for immediate medical treatment.), at 6:30 PM, reported experiencing a bad reaction to medication that had been taken three months prior to the visit. Patient #1 reported it felt like his/her heart was going to burst since taking the medication and was in need of medication to calm down. Patient #1's heart rate upon initial assessment was 137 (normal range 60-90) and at the end of the triage process had decreased to between 109-119. The Triage Nurse noted Patient #1 was manic with pinpoint pupils and was out of control while in the triage area. Patient #1 was assigned a triage Priority Level of III (Triage Priority Levels include Levels I to V; with I being the most acute/urgent.), and sent to the waiting area. Patient #1, while in the waiting area made rude hand gestures and used foul language toward nursing staff members. At 7:48 PM the Nursing Supervisor was notified of the behavior Patient #1 was exhibiting in the waiting room and Hospital security staff escorted Patient #1 off of Hospital Property. Documentation indicated Patient #1's had left without being seen.

Security Officer #1 was interviewed in person on 2/7/2011 at 3:35 PM with the Director of Quality and Safety present. Security Officer #1 said a call was received from the Charge Nurse,at 7:20 PM , who reported Patient #1 was yelling, swearing and making a scene in the ED waiting room. The Charge Nurse instructions were to escort Patient #1 off of the property.

Security Officer #2 was interviewed in person on 2/7/11 at 7:15 AM with the Director of Quality and Safety present. Security Officer #2 said the Security officers had talked with the Charge Nurse and the Charge Nurse had stated that during a conversation with the Nursing Supervisor it was determined it was okay to ask Patient #1 to leave.

Security Officer #3 was interviewed in person on 2/7/11 at 3:10 PM with the Director of Quality and Safety present. Security Officer #3 said Security Officer #1 had reported the Charge Nurse wanted Patient #1 to leave if he/she could not be cooperative.

Review of 1/19/11 security documentation indicated a call was received, at 7:20 PM from the Charge Nurse regarding Patient #1 yelling, swearing and making a scene if front of small children in the ED waiting room. The Charge Nurse informed security Patient #1 needed to be escorted off Hospital property due to this behavior. Patient #1 was brought from the ED waiting room through the side door and escorted off the property via the ambulance bay.

II. The Hospital policy that addressed evaluation of crisis patients was reviewed. The policy stated a patient presenting in need of crisis evaluation represents a potentially unstable and fatal condition. Crisis patients are classified as Priority II (urgent) and will be evaluated by an Emergency Department attending physician to determine suicide risk, as soon as possible after all Priority I (emergency) patients are stable.


Review of Patient #5's medical record documentation indicated Patient #5 presented to the Hospital ED with a chief complaint of severe depression, suicidal ideation and uncontrollable temper rage. Patient #5 was classified as a crisis patient in need of a crisis evaluation. Patient #5 at triage was classified as a Priority III. Patient #5 left without being seen after waiting room for one hour.

Review of Patient #9's medical record documentation indicate Patient #9 presented to the ED with the chief complaint of alcohol withdrawal and was classified as a crisis patient in need of a crisis evaluation. Patient #9 left without being seen after waiting over 2 hours.

Review of Patient #10's medical record documentation indicated Patient #10, who had a history of attention deficit disorder and bi-polar/mood disorder, presented to the Hospital ED and reported increased aggression, that they had been off medication to treat the bi-polar/mood disorder for a year and had requested to be started back on the medications. Patient #10 reported feeling the desire to act out. Patient #10 was assessed as needing a crisis evaluation, classified as a Priority III and sent to the waiting room. When Patient #10's name was called over two hours later it was determined Patient #10 had left without being seen.

Review of Patient #13 medical record documentation indicated Patient #13, who had been diagnosed as bi-polar and a post traumatic stress disorder and who had a long history cutting, presented to the Hospital's ED with healing lacerations on the left forearm and reported he/she felt suicidal. When triaged Patient #13 was classified as a crisis patient in need of a crisis evaluation. Patient #13 was evaluated and classified as a Priority III by the triage nurse. Patient #13 left the ED without being seen after waiting 2 hours.

Also refer to The Conditions of Participation deficiency Tag A-1104

Based on documentation review it was determined Pateint #1's received no stabilizing treatment for an emergency medical condition prior to being escorted off Hospital property.

Findings included:

Clinical Record review indicated Patient #1 presented to the ED and during triage reported experiencing a bad reaction to medication that had been taken three months prior to the visit; feeling like his/her heart was going to burst since taking the medication and being in need of medication to calm down. Patient #1's heart rate upon initial assessment was 137 (normal range 60-90) and at the end of the triage process had decreased to between 109-119. The Triage Nurse noted Patient #1 was manic with pinpoint pupils and was out of control while in the triage area. While in the waiting area Pateint #1's was disruptive, making rude hand gestures and using foul language. The Nursing Supervisor was notified of Patient #1 behavior and Hospital security staff escorted Patient #1 off of Hospital Property.

Documentation did not indicate an appropriate medical screening and behavioral health assessment were provided and that Patient #1's emergency medical condition was stabilized before being escorted off of the Hospital Property.

Based on interview and documentation review, it was determined the Hospital failed to ensure that all individuals presenting to the emergency department seeking treatment were provided with an appropriate medical screening examination in five (Patient #1, Patient #5, Patient #9, Patient #10 and Patient #13, ) of 21 medical records reviewed.

Findings included:

I. Clinical Record review indicated Patient #1 presented to the ED and during triage (the process of determining the order in which individuals will be seen by a medical care provider based on their need for immediate medical treatment.), at 6:30 PM, reported experiencing a bad reaction to medication that had been taken three months prior to the visit. Patient #1 reported it felt like his/her heart was going to burst since taking the medication and was in need of medication to calm down. Patient #1's heart rate upon initial assessment was 137 (normal range 60-90) and at the end of the triage process had decreased to between 109-119. The Triage Nurse noted Patient #1 was manic with pinpoint pupils and was out of control while in the triage area. Patient #1 was assigned a triage Priority Level of III (Triage Priority Levels include Levels I to V; with I being the most acute/urgent.), and sent to the waiting area. Patient #1, while in the waiting area made rude hand gestures and used foul language toward nursing staff members. At 7:48 PM the Nursing Supervisor was notified of the behavior Patient #1 was exhibiting in the waiting room and Hospital security staff escorted Patient #1 off of Hospital Property. Documentation indicated Patient #1's had left without being seen.

Security Officer #1 was interviewed in person on 2/7/2011 at 3:35 PM with the Director of Quality and Safety present. Security Officer #1 said a call was received from the Charge Nurse,at 7:20 PM , who reported Patient #1 was yelling, swearing and making a scene in the ED waiting room. The Charge Nurse instructions were to escort Patient #1 off of the property.

Security Officer #2 was interviewed in person on 2/7/11 at 7:15 AM with the Director of Quality and Safety present. Security Officer #2 said the Security officers had talked with the Charge Nurse and the Charge Nurse had stated that during a conversation with the Nursing Supervisor it was determined it was okay to ask Patient #1 to leave.

Security Officer #3 was interviewed in person on 2/7/11 at 3:10 PM with the Director of Quality and Safety present. Security Officer #3 said Security Officer #1 had reported the Charge Nurse wanted Patient #1 to leave if he/she could not be cooperative.

Review of 1/19/11 security documentation indicated a call was received, at 7:20 PM from the Charge Nurse regarding Patient #1 yelling, swearing and making a scene if front of small children in the ED waiting room. The Charge Nurse informed security Patient #1 needed to be escorted off Hospital property due to this behavior. Patient #1 was brought from the ED waiting room through the side door and escorted off the property via the ambulance bay.

II. The Hospital policy that addressed evaluation of crisis patients was reviewed. The policy stated a patient presenting in need of crisis evaluation represents a potentially unstable and fatal condition. Crisis patients are classified as Priority II (urgent) and will be evaluated by an Emergency Department attending physician to determine suicide risk, as soon as possible after all Priority I (emergency) patients are stable.


Review of Patient #5's medical record documentation indicated Patient #5 presented to the Hospital ED with a chief complaint of severe depression, suicidal ideation and uncontrollable temper rage. Patient #5 was classified as a crisis patient in need of a crisis evaluation. Patient #5 at triage was classified as a Priority III. Patient #5 left without being seen after waiting room for one hour.

Review of Patient #9's medical record documentation indicate Patient #9 presented to the ED with the chief complaint of alcohol withdrawal and was classified as a crisis patient in need of a crisis evaluation. Patient #9 left without being seen after waiting over 2 hours.

Review of Patient #10's medical record documentation indicated Patient #10, who had a history of attention deficit disorder and bi-polar/mood disorder, presented to the Hospital ED and reported increased aggression, that they had been off medication to treat the bi-polar/mood disorder for a year and had requested to be started back on the medications. Patient #10 reported feeling the desire to act out. Patient #10 was assessed as needing a crisis evaluation, classified as a Priority III and sent to the waiting room. When Patient #10's name was called over two hours later it was determined Patient #10 had left without being seen.

Review of Patient #13 medical record documentation indicated Patient #13, who had been diagnosed as bi-polar and a post traumatic stress disorder and who had a long history cutting, presented to the Hospital's ED with healing lacerations on the left forearm and reported he/she felt suicidal. When triaged Patient #13 was classified as a crisis patient in need of a crisis evaluation. Patient #13 was evaluated and classified as a Priority III by the triage nurse. Patient #13 left the ED without being seen after waiting 2 hours.

Also refer to The Conditions of Participation deficiency Tag A-1104

Based on documentation review it was determined Pateint #1's received no stabilizing treatment for an emergency medical condition prior to being escorted off Hospital property.

Findings included:

Clinical Record review indicated Patient #1 presented to the ED and during triage reported experiencing a bad reaction to medication that had been taken three months prior to the visit; feeling like his/her heart was going to burst since taking the medication and being in need of medication to calm down. Patient #1's heart rate upon initial assessment was 137 (normal range 60-90) and at the end of the triage process had decreased to between 109-119. The Triage Nurse noted Patient #1 was manic with pinpoint pupils and was out of control while in the triage area. While in the waiting area Pateint #1's was disruptive, making rude hand gestures and using foul language. The Nursing Supervisor was notified of Patient #1 behavior and Hospital security staff escorted Patient #1 off of Hospital Property.

Documentation did not indicate an appropriate medical screening and behavioral health assessment were provided and that Patient #1's emergency medical condition was stabilized before being escorted off of the Hospital Property.