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Based on review of facility policies, review of facility digital video recordings, review of the facility's Emergency Department (ED) Central Log, review of medical records, and interviews, the facility failed to ensure one patient (Patient #4) with an infection was listed on the Emergency Department (ED) Central Log and failed to provide an appropriate Medical Screening Examination (MSE) for one patient (Patient #4) of 33 ED patients reviewed.

The findings included:

Refer to A-2406 for Medical Screening Exam

Based on review of facility policies, review of facility digital video recordings, review of the facility's Emergency Department (ED) Central Log, review of medical records, and interviews, the facility failed to ensure one patient (Patient #4) with an infection was listed on the Emergency Department (ED) Central Log of 33 ED patients reviewed.

The findings included:

Review of Hospital A's policy titled "EMTALA [Emergency Medical Treatment and Active Labor Act] GUIDELINES - TREATMENT OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES" dated May 2021 revealed "...The Hospital's EMTALA obligations are triggered when there has been...A request for examination and/or treatment of a medical condition by an individual...Central Log or EMTALA Log means the log the hospital is required to maintain. A log containing information regarding each individual who comes to the emergency department and that documents whether the individual refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, stabilized and/or transferred, discharged or expired...The Emergency Department will maintain copies of the Central Logs...

Review of a digital security video recording (without audio) at Hospital A dated 11/21/2021 and identified by the Quality Director as a video from a security camera located in the waiting room at Hospital A showed the following:
11/21/2021 at 11:56 AM - Patient #4 presented to the ED walked to a table with 5 clipboards laying on it (the clipboards contain Triage Forms, which patients write their name, address, and complaints on and then give to registration staff or triage nurse). There was no facility staff present at the registration desk.
11/21/2021 at 11:57 AM - Patient #4 reached onto the registration desk and got some cleaning wipes and wiped off the table where the clipboards were.
11/21/2021 at 11:58 AM - Patient #4 took a clipboard to a seat in the waiting room and began to fill it out
11/21/2021 at 12:01 PM - Patient #4 took the form to the registration desk, placed it on the end of the counter in front of the triage room, picked up a different clipboard containing forms and took it back to his seat in the waiting room. Continued review revealed the patient was writing on more than one form on the clipboard.
11/21/2021 at 12:06 PM - the triage nurse picked up Patient #4's form off the counter and took it back into the triage room with him.
11/21/2021 12:18 PM - Patient #4 got up and walked out of site of the camera
11/21/2021 12:19 PM - Patient #4 re-appeared on the video recording
11/21/2021 at 12:21 PM - Patient #4 appeared restless and appeared to be recording himself and the ED waiting room with his telephone
11/21/2021 at 12:22 PM - Patient #4 walked to the table of clipboards and purposefully wiped his hands over each form, the table surface, and the registration counter. The patient then opened the door to the triage room was talking to the triage nurse, who then comes to the door. A security officer comes up to the patient and triage nurse and the patient can be seen talking excitedly and waving his arms/phone around. The security officer and the triage nurse talk to the patient without touching him.
11/21/2021 at 12:23 PM - Patient #4 walked back to his seat in the waiting room, he is talking and appears agitated, and he is followed by the security officer. The patient picks up his belongings, which included what appeared to be a large coffee cup. The video recording then switched to a camera by the ED exit/entrance doors. Patient #4 can be seen talking excitedly to the security officer just inside the doors.
11/21/2021 from 12:23 PM to 12:24 PM - Patient #4 appeared to be waving his arms and phone around while yelling at the security officer. The security officer appeared to be talking to patient but did not touched him.
11/21/2021 at 12:24 PM - Patient #4 pushes his face up into the security officer's face and appears to be pushing his chest against the security officer while yelling. The security officer grips the patient's arms and pushes him out the ED door and out of sight of the camera.
11/21/2021 12:24 PM - a large spray of fluid comes forcefully through the door and goes all over the floor and onto staff and patients.
Review of video recording revealed Patient #4 was in the ED for 27 minutes.

Review of the Hospital A's ED Central Log dated 11/21/2021 revealed Patient #4 was not listed on the log.

Review of Hospital B's medical records revealed Patient #4 presented there on 11/21/2021 at 12:35 PM (12 minutes after last seen on video at hospital A).

During a telephone interview on 11/30/2021 at 9:15 AM, RN #2 at Hospital A stated she saw Patient #4 in the Triage Room screaming at the Triage Nurse (Registered Nurse - RN #1). RN #2 stated she saw Patient #4 "...right up in the face of [RN #1] screaming at him..." Continued interview revealed RN #2 did not see the patient again.

During a telephone interview on 11/30/2021 at 9:30 AM, Emergency Room Technician (ER Tech) #1 at Hospital A stated she was transporting a patient out of the ED when Security Officer (SO) #1 and Patient #4 went past her. She stated the patient was very loud and was verbally threatening the SO. She stated she saw SO #1 push Patient #4 out the ED exit doors and the patient hit the SO in his face with a cup of coffee. Continued interview revealed the coffee sprayed all over her and the patient she was escorting out of the ED. Further interview revealed the SO did not touch the patient before or after pushing him out of the exit door. ER Tech #1 stated the patient continued to yell, curse, and threaten the SO as he walked to his car.

During an interview on 11/30/2021 at 9:55 AM RN #1 at Hospital A stated he was the triage nurse on duty on 11/21/2021. RN #1 stated Patient #4 came to the triage room doorway and stated he had signed in with Methicillin Resistant Staphylococcus Aureus (MRSA/bacterial infection) and had been in the waiting room and had not been quarantined immediately. RN #1 stated the patient was very agitated, was yelling and loud, and stated he was going to leave and get treatment somewhere else. Continued interview revealed the RN #1 told the patient "if you want to leave that is your right." RN #1 stated the patient was escorted by the security officer to gather his belongings and leave the ED. RN #1 stated the patient was very loud, threatening, and disruptive while he was preparing to leave, and threw hot coffee on the security guard when he left. Continued interview revealed the hospital administrator was notified of the incident and the police were called.

During a telephone interview on 12/2/2021 at 8:48 AM, Security Officer (SO) #1 at Hospital A stated he observed Patient #4 enter the ED on 11/21/2021, pickup one of the clipboards, and then sit down to fill out the triage form. Continued interview revealed SO #1 had seen the patient in the ED before and had never observed any problems or conflicts with him in the past. SO #1 stated the patient walked to the registration desk after completing the triage form and instead of placing the triage form in the designated basket the patient placed the form on the registration counter. Further interview revealed the patient then picked up another clipboard of triage forms and carried them back to his seat in the waiting room where he began writing on the forms. SO #1 stated the triage nurse came out of triage, picked up the patient's triage form, and took it into the triage room. Continued interview revealed the patient began to behave odd, appeared restless, and was seen waving his telephone around as if he was recording himself. SO #1 stated Patient #4 then went to the registration desk and wiped his hands on environmental surfaces including the other clipboards containing triage forms that were lying on the table. SO #1 stated as he began to approach Patient #4, the patient opened the triage room door and began talking aggressively with the triage nurse. Continued interview revealed SO #1 heard the patient say that he "needed to be quarantined because he had an infection." SO #1 stated he asked the patient if he knew he had an infection then why was he touching all the clipboards, forms, and countertops and the patient replied, "because I can." SO #1 stated he told the patient that there was an isolated area in the waiting room where he could sit while he waited to be seen, but the patient stated that he wanted to leave and go to another facility. SO #1 stated he stayed with the patient because the patient was cursing, talking loudly, and appeared very agitated. Continued interview revealed SO #1 told the patient again that he could wait in the isolated area of the waiting room, but the patient again stated he was going to leave and go to another facility. SO #1 stated Patient #4 continued to be loud and disruptive in the waiting room and was telling at other patients saying, "they don't care about you here, you don't want to be seen here, I don't want to be here." Continued interview revealed SO #1 tried to talk to the patient and deescalate his anger but the patient began to curse loudly and was making threats. SO #1 stated the patient picked up his belongings in the waiting room and took all the triage forms off the clipboard he had been writing on and put them in his bag. SO #1 stated he asked the patient why he was taking the forms and the patient stated, "because I can." SO #1 stated the patient then walked toward the exit doors, stopped, and then became aggressive with the SO. Continued interview revealed the patient crowded the security officer and leaned his face in the SO's face. SO #1 stated he told the patient "it is time to leave" and pointed the patient out the door. Continued interview revealed the patient leaned into the SO's chest and told him "you will have to push me out." SO #1 stated he felt the patient was getting "dangerously aggressive" and there were other patient's near, so he gripped the patient's arms and used his chest to push the patient out the exit doors. Continued interview revealed the patient hit the SO in the face with his cup of hot coffee, crushing the cup, and spraying coffee all over the SO and the ED entrance area. SO #1 stated he released the patient as soon as he was out the exit doors, instructed the patient to leave, and then called the local police as the patient walked to his car. Continued interview revealed the SO had to move to prevent being ran over by the patient in his car as he left the ED parking lot. SO #1 stated Patient #4 had repeatedly stated he wanted to leave the ED, but if he had ever said he wanted to stay and be seen the SO would have escorted him to the isolated portion of the waiting room and stayed with him until he saw the doctor and was treated. SO #1 stated no patient wanting to be seen would be forced to leave the ED.

During a telephone interview completed on 12/2/2021 at 11:56 AM, Patient #4 stated he presented to the ED at Hospital A on 11/21/2021 at around 1:00 or 2:00 PM. The patient stated he went to the ED because he believed he had an infection on his face. The patient stated there was no facility staff at the registration desk so he checked himself in and sat down in the waiting room. Patient #4 stated he felt he should have been quarantined because he has Human Immunodeficiency Virus (HIV/virus that attacks the body's immune system) and MRSA. The patient stated he waited 45 minutes in the waiting room and then he went to the desk and touched everything there and then went to the triage room, spoke to the nurse, and told the nurse that he should have been placed in quarantine because he had MRSA and he had touched everything on the registration desk. The patient stated the nurse asked the patient why he touched everything and he stated, "because I can." Patient #4 stated a security officer came over and told him to leave the ED. The patient stated the security officer forced him to leave the ED and the nurse just stood there. Patient #4 stated he was pushed out of the ED by the security guard and he spilled his coffee on himself during the struggle. The patient stated he did not want to leave Hospital A but had been forced to leave by the security guard. The patient stated his vital signs had not been taken and he had not been examined by a doctor. Patient #4 stated he left Hospital A and drove directly to Hospital B where he was seen right away.

During an interview on 12/1/2021 at 9:10 AM, the ED Director at Hospital A confirmed Patient #4 was not listed on the ED Central Log for his visit to the ED on 11/21/2021.

During a video conference on 12/1/2021 at 11:10 AM, the Quality Director confirmed Patient #4's visit to the ED on 11/21/2021 was not documented on the ED Central Log.

Based on review of facility policies, review of facility digital video recordings, review of the facility's Emergency Department (ED) Central Log, review of medical records, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for one patient (Patient #4) with an infection of 33 ED patients reviewed.

The findings included:

Review of Hospital A's policy titled "EMTALA [Emergency Medical Treatment and Active Labor Act] GUIDELINES - TREATMENT OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES" dated May 2021 revealed "...The Hospital's EMTALA obligations are triggered when there has been...A request for examination and/or treatment of a medical condition by an individual...The Hospital will provide to any individual...who comes to the Emergency Department an appropriate Medical Screening Examination...The Hospital will provide a Medical Screening Examination (MSE) for an individual who...Comes to an on-campus DED [designated emergency department], requesting examination or treatment...If the Hospital offers examination and treatment and informs the individual or the person acting on the individual's behalf of the risks and benefits to the individual receiving the examination and treatment, but the individual or person acting on the individual's behalf does not consent to the examination and treatment, the Hospital shall take all reasonable steps to have the individual or the person acting on the individual's behalf sign form...Refusal to Permit Medical Examination...Exhibit B...Leaving the Facility Against Medical Advice, Treatment, or Transfer...In the case of an individual who departs the DED prior to triage (leaves without being seen), who does not yet have a medical record opened, reasonable efforts will be made to have the individual provide basic information for purposes of documenting his/her ED presentation. If such individual refuses to sign Exhibit B [Refusal to Permit Medical Examination], Hospital staff will document the steps taken to secure the individual's written informed refusal..."

Review of Hospital A's policy titled "SCREENING/TRIAGE PROCESS - EMERGENCY CARE CENTER - ECC" dated February 2020 revealed "...The patient reserves the right to refuse the medical screening exam. In such cases, the Registered Nurse [RN] functioning in the triage capacity will explain the right to and the risks of refusing the medical screening exam and will encourage the patient to allow for the medical screening exam process. Should the patient continue to refuse the medical screening exam after being informed of these rights and risks, the Registered Nurse will then document the above observations..."

Review of a digital security video recording (without audio) at Hospital A dated 11/21/2021 and identified by the Quality Director as a video from a security camera located in the waiting room at Hospital A showed the following:
11/21/2021 at 11:56 AM - Patient #4 presented to the ED walked to a table with 5 clipboards laying on it (the clipboards contain Triage Forms, which patients write their name, address, and complaints on and then give to registration staff or triage nurse). There was no facility staff present at the registration desk.
11/21/2021 at 11:57 AM - Patient #4 reached onto the registration desk and got some cleaning wipes and wiped off the table where the clipboards were.
11/21/2021 at 11:58 AM - Patient #4 took a clipboard to a seat in the waiting room and began to fill it out
11/21/2021 at 12:01 PM - Patient #4 took the form to the registration desk, placed it on the end of the counter in front of the triage room, picked up a different clipboard containing forms and took it back to his seat in the waiting room. Continued review revealed the patient was writing on more than one form on the clipboard.
11/21/2021 at 12:06 PM - the triage nurse picked up Patient #4's form off the counter and took it back into the triage room with him.
11/21/2021 12:18 PM - Patient #4 got up and walked out of site of the camera
11/21/2021 12:19 PM - Patient #4 re-appeared on the video recording
11/21/2021 at 12:21 PM - Patient #4 appeared restless and appeared to be recording himself and the ED waiting room with his telephone
11/21/2021 at 12:22 PM - Patient #4 walked to the table of clipboards and purposefully wiped his hands over each form, the table surface, and the registration counter. The patient then opened the door to the triage room was talking to the triage nurse, who then comes to the door. A security officer comes up to the patient and triage nurse and the patient can be seen talking excitedly and waving his arms/phone around. The security officer and the triage nurse talk to the patient without touching him.
11/21/2021 at 12:23 PM - Patient #4 walked back to his seat in the waiting room, he is talking and appears agitated, and he is followed by the security officer. The patient picks up his belongings, which included what appeared to be a large coffee cup. The video recording then switched to a camera by the ED exit/entrance doors. Patient #4 can be seen talking excitedly to the security officer just inside the doors.
11/21/2021 from 12:23 PM to 12:24 PM - Patient #4 appeared to be waving his arms and phone around while yelling at the security officer. The security officer appeared to be talking to patient but did not touched him.
11/21/2021 at 12:24 PM - Patient #4 pushes his face up into the security officer's face and appears to be pushing his chest against the security officer while yelling. The security officer grips the patient's arms and pushes him out the ED door and out of sight of the camera.
11/21/2021 12:24 PM - a large spray of fluid comes forcefully through the door and goes all over the floor and onto staff and patients.
Review of video recording revealed Patient #4 was in the ED for 27 minutes.

Review of the Hospital A's ED Central Log dated 11/21/2021 revealed Patient #4 was not listed on the log.

Review of Hospital A's electronic medical records dated 11/21/2021 revealed there was no medical record for Patient #4's presentation to the ED on 11/21/2021.

Review of Hospital B's medical records revealed Patient #4 presented there on 11/21/2021 at 12:35 PM (12 minutes after last seen on video at hospital A). Continued review revealed the patient was provided a MSE at 1:04 PM and was diagnosed with Tinea Corporis (fungal skin infection also called ringworm) and Furuncle (red pus-filled bump) of the Face. Continued review revealed the patient was discharged home in stable condition on 11/21/2021 at 1:13 PM, with prescriptions for Diflucan (an oral anti-fungal medication) and Lotrimin (antifungal medication) topical cream.

During a telephone interview on 11/30/2021 at 9:15 AM, RN #2 at Hospital A stated she saw Patient #4 in the Triage Room screaming at the Triage Nurse (RN #1). RN #2 stated she saw Patient #4 "...right up in the face of [RN #1] screaming at him..." Continued interview revealed RN #2 did not see the patient again.

During a telephone interview on 11/30/2021 at 9:30 AM, Emergency Room Technician (ER Tech) #1 at Hospital A stated she was transporting a patient out of the ED when Security Officer (SO) #1 and Patient #4 went past her. She stated the patient was very loud and was verbally threatening the SO. She stated she saw SO #1 push Patient #4 out the ED exit doors and the patient hit the SO in his face with a cup of coffee. Continued interview revealed the coffee sprayed all over her and the patient she was escorting out of the ED. Further interview revealed the SO did not touch the patient before or after pushing him out of the exit door. ER Tech #1 stated the patient continued to yell, curse, and threaten the SO as he walked to his car.

During an interview on 11/30/2021 at 9:55 AM RN #1 at Hospital A stated he was the triage nurse on duty on 11/21/2021. RN #1 stated Patient #4 came to the triage room doorway and stated he had signed in with Methicillin Resistant Staphylococcus Aureus (MRSA/bacterial infection) and had been in the waiting room and had not been quarantined immediately. RN #1 stated the patient was very agitated, was yelling and loud, and stated he was going to leave and get treatment somewhere else. Continued interview revealed the RN #1 told the patient "if you want to leave that is your right." Continued interview revealed RN #1 did not advise the patient to stay for an MSE and did not advise the patient of the benefits of staying for an MSE or the risks of leaving without an MSE. Continued interview revealed Patient #4 did not have a medical record initiated. RN #1 stated the patient was escorted by the security officer to gather his belongings and leave the ED. RN #1 stated the patient was very loud, threatening, and disruptive while he was preparing to leave, and threw hot coffee on the security guard when he left. Continued interview revealed the hospital administrator was notified of the incident and the police were called.

During a telephone interview on 12/2/2021 at 8:48 AM, Security Officer (SO) #1 at Hospital A stated he observed Patient #4 enter the ED on 11/21/2021, pickup one of the clipboards, and then sit down to fill out the triage form. Continued interview revealed SO #1 had seen the patient in the ED before and had never observed any problems or conflicts with him in the past. SO #1 stated the patient walked to the registration desk after completing the triage form and instead of placing the triage form in the designated basket the patient placed the form on the registration counter. Further interview revealed the patient then picked up another clipboard of triage forms and carried them back to his seat in the waiting room where he began writing on the forms. SO #1 stated the triage nurse came out of triage, picked up the patient's triage form, and took it into the triage room. Continued interview revealed the patient began to behave odd, appeared restless, and was seen waving his telephone around as if he was recording himself. SO #1 stated Patient #4 then went to the registration desk and wiped his hands on environmental surfaces including the other clipboards containing triage forms that were lying on the table. SO #1 stated as he began to approach Patient #4, the patient opened the triage room door and began talking aggressively with the triage nurse. Continued interview revealed SO #1 heard the patient say that he "needed to be quarantined because he had an infection." SO #1 stated he asked the patient if he knew he had an infection then why was he touching all the clipboards, forms, and countertops and the patient replied, "because I can." SO #1 stated he told the patient that there was an isolated area in the waiting room where he could sit while he waited to be seen, but the patient stated that he wanted to leave and go to another facility. SO #1 stated he stayed with the patient because the patient was cursing, talking loudly, and appeared very agitated. Continued interview revealed SO #1 told the patient again that he could wait in the isolated area of the waiting room, but the patient again stated he was going to leave and go to another facility. SO #1 stated Patient #4 continued to be loud and disruptive in the waiting room and was telling at other patients saying, "they don't care about you here, you don't want to be seen here, I don't want to be here." Continued interview revealed SO #1 tried to talk to the patient and deescalate his anger but the patient began to curse loudly and was making threats. SO #1 stated the patient picked up his belongings in the waiting room and took all the triage forms off the clipboard he had been writing on and put them in his bag. SO #1 stated he asked the patient why he was taking the forms and the patient stated, "because I can." SO #1 stated the patient then walked toward the exit doors, stopped, and then became aggressive with the SO. Continued interview revealed the patient crowded the security officer and leaned his face in the SO's face. SO #1 stated he told the patient "it is time to leave" and pointed the patient out the door. Continued interview revealed the patient leaned into the SO's chest and told him "you will have to push me out." SO #1 stated he felt the patient was getting "dangerously aggressive" and there were other patient's near, so he gripped the patient's arms and used his chest to push the patient out the exit doors. Continued interview revealed the patient hit the SO in the face with his cup of hot coffee, crushing the cup, and spraying coffee all over the SO and the ED entrance area. SO #1 stated he released the patient as soon as he was out the exit doors, instructed the patient to leave, and then called the local police as the patient walked to his car. Continued interview revealed the SO had to move to prevent being ran over by the patient in his car as he left the ED parking lot. SO #1 stated Patient #4 had repeatedly stated he wanted to leave the ED, but if he had ever said he wanted to stay and be seen the SO would have escorted him to the isolated portion of the waiting room and stayed with him until he saw the doctor and was treated. SO #1 stated no patient wanting to be seen would be forced to leave the ED.

During a telephone interview completed on 12/2/2021 at 11:56 AM, Patient #4 stated he presented to the ED at Hospital A on 11/21/2021 at around 1:00 or 2:00 PM. The patient stated he went to the ED because he believed he had an infection on his face. The patient stated there was no facility staff at the registration desk so he checked himself in and sat down in the waiting room. Patient #4 stated he felt he should have been quarantined because he has Human Immunodeficiency Virus (HIV/virus that attacks the body's immune system) and MRSA. The patient stated he waited 45 minutes in the waiting room and then he went to the desk and touched everything there and then went to the triage room, spoke to the nurse, and told the nurse that he should have been placed in quarantine because he had MRSA and he had touched everything on the registration desk. The patient stated the nurse asked the patient why he touched everything and he stated, "because I can." Patient #4 stated a security officer came over and told him to leave the ED. The patient stated the security officer forced him to leave the ED and the nurse just stood there. Patient #4 stated he was pushed out of the ED by the security guard and he spilled his coffee on himself during the struggle. The patient stated he did not want to leave Hospital A but had been forced to leave by the security guard. The patient stated his vital signs had not been taken and he had not been examined by a doctor. Patient #4 stated he left Hospital A and drove directly to Hospital B where he was seen right away.

During an interview on 12/1/2021 at 9:10 AM, the ED Director at Hospital A confirmed there was no medical record or other documentation of Patient #4's visit to the ED on 11/21/2021. Further interview confirmed there was no documentation Patient #4 was advised of the benefits of having an MSE or notified of the risks of leaving without an MSE.

During a video conference on 12/1/2021 at 11:10 AM, the Quality Director confirmed there was no medical record or other documentation of Patient #4's visit to the ED on 11/21/2021. Continued interview confirmed there was no documentation Patient #4 was provided a MSE on 11/21/2021 or advised of the benefits of having an MSE or the risks of leaving without an MSE.