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Based on medical record review, policy review, hospital record review, review of the facility emergency department (ED) log, review of facility grievances, review of facility surveillance video, facility law enforcement investigative reports, staff interview, patient interview, and review of facility policy, the facility failed to correctly reflect the disposition of patients on the central emergency department log, failed to ensure a complete medical screening exam was completed for all individuals who presented to the emergency department, and failed to provide appropriate transfer following receipt of the medical screening examinations. This affected three (Patient #1, Patient, #3, and Patient #11) of six patients reviewed and had the ability to affect all patients who presented to the ED for treatment. The cumulative effect of these deficiencies affects the ability of the ED to provide appropriate care and treatment of patients in the ED as defined in §489.24.

See citations at A2405, A2406, and A2409.

Based on review of the facility emergency department (ED) log, staff interview, review of the facility protective service investigation, and review of facility policy, the facility failed to correctly reflect the disposition of patients on the central emergency department log. This affected one patient (Patient #1) of 2,220 individuals who presented at the facility's Barberton, Ohio campus during the month of July 2023. This had the potential to affect all patients who presented at the ED.

Findings include:

Review of the facility's Barberton ED's central ED log revealed Patient #1 presented at the ED on 07/19/23 at 9:34 AM. The disposition was marked as eloped on 07/19/23 at 11:03 PM.

Review of the facility's ED surveillance video revealed Patient #1 was physically escorted by two facility protective service staff, one under each arm of the patient, to the parking lot and to the patient's private automobile on 07/19/23 at approximately 9:57 PM.

Review of the facility protective services investigative documentation revealed the facility's protective service department staff who responded to the 07/19/23 incident documented the Patient #1 was removed from the facility's ED on 07/19/23 at 9:57 PM.

Interview with Staff F and Officer G on 08/21/23 at 12:53 PM confirmed Patient #1 was physically escorted by the facility's security officers out of the ED department and into the parking lot.

Review of the facility's policy titled "Elopement from the Emergency Department," reviewed 05/10/22, defined an elopement as patients who leave unexpectedly during their emergency department visit. The policy directed staff to do the following: A reasonable effort is made by hospital personnel to prevent and/or respond to a patient's elopement. Attempt to locate the patient in and around the department. Notify emergency department provider of patient elopement.

This was an example of non-compliance discovered during the investigation of Substantial Allegation #OH00144939.

Based on medical record review, hospital record review, review of facility grievances, review of facility surveillance video, facility law enforcement investigative reports, staff interview, patient interview, and review of facility policy, the facility failed to ensure a complete medical screening exam was completed for all individuals who presented to the emergency department. This affected one patient (Patient #1) of twenty patients reviewed and had the potential to affect all individuals who presented to the facility's emergency departments and requested a medical screening examination.

Findings include:

Review of the medical record for Patient #1 from the facility's Barberton, Ohio ED campus (ED A), where the patient first presented on 07/19/23, revealed the patient was registered on the ED log at 9:34 PM. The patient's chief complaint was abdominal pain and vomiting. The nursing triage note of 07/19/23 at 9:40 PM documented the patient with severe abdominal pain.

Patient #1 was seen in triage at 9:34 PM by both the nurse and the ED physician on duty. The physician documented the patient presented with acute severe epigastric abdominal pain with nausea, vomiting. The patient reports a history of gastric ulcer The patient arrives afebrile, mildly hypertensive but otherwise reassuring vitals. The presentation was concerning for gastric ulcer, gastritis, pancreatitis, acute biliary process, acute intra-abdominal process which was discussed with the patient. The physician was recommending to obtain a work-up to evaluate including computerized tomography (CT) scan of the abdomen pelvis, laboratory evaluation, and electrocardiogram (EKG). The plan was to treat with the pain medication morphine, antinausea medication Zofran, and intravenous (IV) fluids.

Review of the physician's orders revealed the ED physician, Physician C, had placed orders for IV injection of morphine sulfate, an injection of Zofran 4 milligrams (mg), and fluid bolus of normal sterile saline. Laboratory tests ordered included a comprehensive metabolic panel, complete blood count, lipase, and complete urinalysis. A CT of the pelvis and abdomen was ordered. The medical record revealed no laboratory or radiological tests were completed during this visit.

The medical record reviewed Patient #1 received no medications during his ED visit at ED A.

The physician documented "I was notified by ED nursing staff that patient suddenly became angry, aggressive, hostile towards ED staff, hospital security was involved, and patient was removed from hospital premises. I was notified of this after patient had been removed from premises, prior to my ability to intervene or verbally de-escalation." The physician diagnosis was documented as: abdominal pain. The disposition documented as eloped, removed by hospital security.

Review of the facility's grievance documentation revealed the facility had received a grievance on 07/20/23 regarding Patient #1. The documentation revealed Patient #1 presented to ED A on 07/19/23. The patient arrived for an evaluation of severe abdominal pain, was rocking back and forth, and was unable to sit or lie down. Patient #1 stated he was a disabled vet and struggled with post traumatic stress disorder (PTSD). He was taken back to triage the doctor let him know it was probably his gallbladder or his appendix. The doctor said they would get him some morphine and get some testing done. Next a nurse came in and wanted to take his vital signs. She was getting frustrated with him because she could not get his vital signs. She told him to stop it and to calm down. He told her that he couldn't and she walked away. Patient #1 stated at this point he felt abandoned. He was still in pain and he was left alone. He yelled out to a nurse walking by and said "I'm in trouble, please get me some help." This nurse got the first nurse to come back and see him. She still wanted his vitals and could not get them so she brought a group of officers to him. He stated part of his PTSD is that he does not like being around people with guns and these officers were all standing there with their hands on their guns. He stated "I had already gone through a metal detector, why did they think they might need to use their guns?" The officers told him to calm down and he couldn't because he was shaking in pain. He was hurting so much that he told them "You guys just shoot me right now." Then they questioned him about being suicidal. One of the officers had a mustache and was about six feet two inches. Instead of deescalating the situation this officer was swearing at him. He was instigating the situation and making it worse. Patient #1 stated he recorded part of this interaction with the officers. He recorded this officer saying he could not come back to ED A for treatment because"You don't act right." The officers grabbed him by the arms to walk him out. He was in so much pain he fell to his knees and the officers mocked him for this. Then they dragged him out while he was on his knees. Patient #1 stated "It felt like I was ignored and since I did not agree with being ignored they sent the Gestapo after me." He added "I live a very clean lifestyle. I don't even eat McDonalds and they treated me like a drug addict." He sat in his car and called his friend to help him calm down. Then he went to the Wadsworth ED (ED B). He presented in the same condition and they "Treated me great, over the top great." He was transferred to the hospital's Akron campus and had surgery to remove his appendix. Then he was discharged home.

Review of the facility protective services investigative documentation revealed the facility's protective service department staff who responded to the 07/19/23 incident documented the Patient #1 was removed from the facility's ED on 07/19/23 at 9:57 PM. The facility's protective service department initiated an investigation on 07/21/23 and obtained statements from the responding officers.

Review of Officer G's written response revealed staff recognized the patient was in pain. The patient was just being irate. Officer G affirmed he had cussed at Patient #1 and told the patient he was removed from the ED because he wasn't acting right. The officer stated they had held Patient #1 under the arms and escorted him out of the ED.

Review of Officer H's written responses revealed Officer H affirmed Patient #1 told officers to shoot him, but stated they thought that was the pain talking. Officer H stated the patient did appear to be in a lot of pain. Officer H stated Officer G informed Patient #1 they wouldn't see him since he was acting this way, which is why they had the police remove him. Officer H verbalized officers grabbed Patient #1's arms to walk the patient out. Patient #1 walked out while each officer had an arm in escort position. The officers took him outside and let him go. The patient was screaming in the lobby and officers just wanted to get him away from everyone and outside. The officer was stated the patient wasn't dragged out but he went limp in legs and officers held him up. The patient walked out while each officer had an arm.

Review of the ED A's surveillance video, dated 07/19/23 at 9:52 PM, revealed three facility protective services officers approach the facility's ED triage area. The video time at 9:55 PM depicted two officers escorting Patient #1 out the ED's main lobby front doors. The video depicted an officer on each side of patient and each officer held one of the patient's arms up closer to the armpit and escorted the patient from the facility into the parking lot and to his truck parked in the lot.

Review of the medical record from ED B's campus, about 15-20 minutes from the ED A campus, revealed Patient #1 presented at ED B on 07/19/23 at 11:04 PM. The patient was examined by the ED provider on 07/19/23 at 11:21 PM. The provider's documentation revealed Patient #1 was in acute distress and had decreased bowel sounds with abdominal tenderness in the epigastric area. The medical decision making documented acute appendicitis with laboratory tests and radiology ordered. Results of the CT of abdomen and pelvis with contrast were compatible with acute appendicitis. The results were discussed with the main campus physician on 07/20/23 at 2:31 AM. The patient received IV antibiotics and anti-emetics. The narcotic pain mediation Fentanyl was administered on 07/19/23 at 11:37 PM and on 07/202/23 at 12:50 AM and 3:27 AM. The ED physician's note documented the patient was accepted at the facility's main campus in Akron, Ohio (ED C) on 07/20/23 at 3:13 AM.

Review of the 07/20/23 ambulance transport record revealed Patient #1 was picked up at 3:57 AM from ED B and transported to the facility's main campus, ED C. Care was transferred to staff at ED C on 07/20/23 at 4:42 AM.

Review of the medical record at ED C revealed Patient #1 was seen by the ED provider and a request for an operating room was made on 07/20/23 at 5:05 AM with a surgeon assigned. Patient #1 underwent a laparoscopic appendectomy on 07/20/23 at 9:50 AM. The brief operative note documented the appendix found to be acutely inflamed with no signs of necrosis. The patient was stabilized and there were no complications. The patient was discharged home on 07/20/23 at 10:31 AM.

Interview with facility registered nurse, Staff F, on 08/22/23 at 9:03 AM revealed she was on duty and assigned to triage on the evening of 07/19/23. She stated Patient #1 arrived in the ED, appeared in pain and had difficulty standing related to the pain. The security officer assigned to the metal detector obtained a wheelchair for the patient and wheeled him back to triage for Staff F. The patient was seen in triage right away by both nursing and the provider. Orders were placed. Staff F stated the ED was busy and they hadn't gotten to Patient #1's pain medication. The patient was yelling and irate. He was informed he had to be patient. The patient yelled "If you're not going to treat me, I'll leave." He was informed he could leave if he wanted. Staff F stated she stepped away from the patient to call protective services. Staff F stated protective services was summoned to remove the patient from the triage area and the ED. Security picked up the patient by the arms, held him, and escorted him out of the ED. Staff F denied the patient had tried to physically touch or accost her. She stated he was gripping the arms of the chair, cussing and yelling "You're not (expletive) helping me."

Interview with Patient #1 on 08/23/23 at 9:29 AM revealed he presented at the facility's ED A campus on 07/19/23 at approximately 9:30 PM. The patient verbalized he was doubled over with pain, could barely walk, and had nausea and vomiting. He was seen in the ED right away and the physician saw him immediately as well. Patient #1 verbalized he was shaking and gripping the arms of the chair because the pain was so severe. He begged the nurse for anything to help with the pain. Patient #1 stated he sat there in the triage area and staff continually walked by him. He stated he was begging for help and no one responded. Patient #1 stated security was called. He was grabbed by security and escorted to the parking lot. The patient verbalized he called a friend for help. The patient verbalized he drove himself to the facility ED B campus about 20 minutes away, was seen immediately, and transferred via ambulance to ED C for surgery for appendicitis..

Interview with Officer I on 08/23/23 at 3:57 PM revealed he came to the ED triage area and could hear yelling and cussing. Patient #1 was seated in a chair in the triage area grunting and making noises. The triage nurse came into the triage area and instructed security to take him out of the area stating she couldn't treat him like this. Officer I stated the nurse wanted the patient escorted out. The patient was told he needed to exit the premises. The security staff used an escort position with two officers on either side and hands under the patients' arms. They walked him out to his car. Officer I stated Patient #1 appeared to be in pain.

Interview with the ED physician, Staff C, on 08/28/23 at 1:00 PM revealed he was on duty the evening and night of 07/19/23. Staff C stated Patient #1 was seen immediately in triage, with laboratory studies and radiological studies ordered as well as medications to control the symptoms. The patient was in severe pain and yelling but was not threatening. Staff C performed his physical examination, history and physical, placed orders, then went to see other patients while awaiting results. Staff C assumed the patient would be medicated and the tests completed. Staff C stated he was in the back area of the main ED and did not hear any loud or argumentative voices or he would have intervened. Staff C stated he was not informed the patient was removed by security until well after he had left the premises. If he had been notified he could have intervened to deescalate the situation. Staff C verbalized ED providers were all trained in deescalation techniques and how to deal with difficult patients.

Interview with administrative staff, Staff A, on 08/23/23 at 4:03 PM confirmed Patient #1 presented for treatment on 07/19/23 at 9:34 PM to the facility's ED A location. The facility was unable to provide documentation Patient #1 was provided a medical screening exam for determination of an emergency medical condition. Staff A confirmed Patient #1 was escorted out of the ED and off the premises by the facility's protective services staff on 07/19/23 prior to the completion of the medical screening exam.

Review of the facility's policy titled "Medical Screening (EMTALA)," revised 08/21, directed any individual who comes to Summa Health System Property or Premises requesting an emergency examination or treat or a request made on the individual's behalf is entitled and shall be provided an appropriate Medical Screening Examination. Individuals who present to Summa Health System shall receive an appropriate medical screening examination regardless of their ability to pay.

This was an example of non-compliance discovered during the investigation of Substantial Allegation #OH00144939.

Based on medical record review, staff interview, and review of facility policy, the facility failed to provide appropriate transfer following receipt of the medical screening examinations for two (Patient #3 and Patient #11) of six patients reviewed for transfer. A total of 20 records were reviewed.

Findings include:

1) The medical record revealed Patient #3 was a 2-year-old female who arrived by private auto to the facility's Barberton, Ohio campus Emergency Department (ED) on 02/08/23 at 2:05 AM with chief complaints of fever and wheezing. The patient was seen by the ED provider on 02/08/23 at 2:51 AM and was documented as having tachypnea (rapid breathing) and tachycardia (fast heart rate). The patient received anti-fever medications, breathing treatments, and oral intake was encouraged. The patient was diagnosed as COVID 19 positive with the results of the tests and findings discussed with the patient's mother. Patient #3 remained tachypneic and tachycardiac and transfer to Akron Children Hospital for further evaluation was discussed with the patient's mother. The note documented the mother understands and was comfortable with this plan preferring transfer by private vehicle. Patient #3 was discussed with physician at Akron Children's Hospital ED who accepted the transfer. The medical record documented the patient was transferred to another facility on 02/08/23 at 4:59 AM via private vehicle to the receiving facility.

2) Review of the medical record Patient #11 was a 16-year-old patient who was seen at the facility's ED department on 08/21/23 with chief complaint of pelvic pain. The patient was seen by the ED provider on 08/21/23 at 8:23 PM. and recommended to have a pelvic examination and transvaginal ultrasound. The medical record documented the provider discussed with the patient's mother the need to obtain these tests. The mother agreed with an interfacility transfer to Akron Children's Hospital ED. The medical record documented the receiving hospital accepted the patient. The patient was transferred on 08/21/23 at 9:53 PM with the mother providing transportation to Akron Children's ED.

Review of the facility policy titled "Patient Transfer," revised 08/21, directed where patient transfer was necessary the transfer/transport must occur according to federal law.

The federal law directed that transfers were effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.

Interview with Nursing Staff A on 08/23/23 at 1:30 PM confirmed the facility failed to arrange for medical transport for two pediatric patients (Patient #3 and Patient #11).

This was an example of non-compliance discovered during the investigation of Substantial Allegation #OH00144939.