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Based on review of medical records, ambulance run reports, policies and procedures and interviews the facility failed to ensure that an appropriate medical screening examination was provided, that was within the capability of the hospital's emergency department including ancillary services routinely available to determine whether or not a emergency medical emergency exists for an individual presenting to the hospital's emergency department bay via ambulance with presenting signs and symptoms of psychiatric disturbances for 1 (#19) of 20 sampled patients. Refer to findings in Tag A-2406.

Based on review of medical records, ambulance run reports, policies and procedures and interviews the facility failed to ensure that an appropriate medical screening examination was provided, that was within the capability of the hospital's emergency department including ancillary services routinely available to determine whether or not an emergency medical condition exists for an individual presenting to the hospital's emergency department bay via ambulance with presenting signs and symptoms of psychiatric disturbances for 1 (#19) of 20 sampled patients.

Findings include:

Ambulance Run Report

The Pre-hospital care report (ambulance run report) dated 3/14/2017 for patient #19 was reviewed. The provider impression was listed as, Behavioral/Psychiatric disorder." The narrative of the report revealed in part, " ...a 59 y/o (year /old) ... standing on the side of the road attended by (Name of) County Sheriff Officers. Pt (Patient) appears atraumatic and in no apparent distress per (Name of) County Sheriff Office. They were called out by neighbors that STD (stated) that pt. was going from house to house arguing with the neighbor saying that she wanted to slip and fall on their property. Pt also witnessed trying to walk out into oncoming traffic".
H (history) - HTN (Hypertension), Diabetes.
A (Assessment) A&O (awake and alert) x 4, ABCs (airway, breathing, circulation) intact, skin w/d (warm/dry)/normal color: Head to toe neg (negative) abnormalities noted VS (vital signs) taken as noted. Pt was found to be incoherent and making statements about wanting to shoot herself and shoot EMS (emergency medical services). VS taken as noted.
R (Re-assessment): Pt ambulated to unit and secured in pilot chair, ongoing assessment performed. Pt began to unbuckle her seatbelt while en route accusing me of raping her. Pt's condition unchanged while en route. Upon arrival at hospital refused to go in. Pt refused to be triaged by hospital staff. EMS contacted the on-call supervisor and received orders for four point restraint by (physician name) for transport to (another acute care hospital). Med 2 dispatched to (name of 2 streets) to meet with (Name of ) County Sheriff Officers for a Psych (psychiatric) eval (evaluation). Upon arrival 2 Deputies were on road side with patient and a third showed up after EMS, patient ...had been in a verbal altercation with her neighbors threatening to fall down the hill in the neighbors front yard and injure herself. Deputies found patient walking on the edge of side walk and patient informed them that she was trying to fall off sidewalk and hoped to break her leg, she was very abusive to law enforcement and EMS crew, contradicting almost every statement that she made, i.e., my vital signs are fine I just checked my blood pressure and blood sugar it ' s 124/76 and my bgl (blood glucose level) is 122. Crew and law enforcement made many attempts to go to the ambulance to have vital signs taken. Patient accused law enforcement and EMS crew of raping her and (expletive word "F") her, throwing her personal effects at crew member multiple times, attempting to hit officers, asking which one of us is single and which one is married....the patient finally went to unit for vital signs and sat in the captain's chair for vitals, BP (blood pressure) -197/111 (normal BP-90/60-120/80), Pulse =124 (normal pulse 60-100), Resp (respiration)20, BGL 285 (normal blood glucose level 60-100). Advised patient of risks with HTN and BGL being high. The patient stated that she was a Registered Nurse and knows all about it. While in unit the patient made statement about I wish I had been hit by a car, I should just go and shoot myself while holding hand in symbol of a gun to her head, rambling on ...and does not own a gun, she stated many times that she wished she were dead...men are rapists..., I am gonna kill yall, I called dispatch to be patched thru the (name of acute care hospital ) Med control for orders to restrain patient if needed after providing patients vitals and current actions to Dr. White (is a coded name in hospital to announce and alert staff of onsite emergencies, i.e., Psychiatric emergency) verified orders to restrain patient against her will and to transport for evaluation, and informed patient of the orders, patient secured with seat belts in captains chair, patient asking for something to drink like a sprite or coke to lower her BP advised her that it would only cause her blood sugar to go even higher, partner provided patient with a diet coke to attempt to calm patient down from screaming that she was thirsty and was not going anywhere without something to drink, while en-route to University Hospital ER (emergency room) since crew was advised that (name of another acute care hospital) was on total Psych diversion, Partner (name of partner) was in back talking with patient to obtain her information and to monitor her, she began cursing him out and making a multitude of racial remarks, as he attempted to get the radio mic to call in report patient attempted to strike him and screaming that he raped her, I had the camera screen pulled up on radio screen to observe as needed, I called in radio report for (name of EMS Control) to advise University to request security to meet unit upon arrival. Upon arrival at ED patient refused to cooperate with EMS and exit unit from captains seat, security and on duty _____ County Deputy/Guard was at ER entrance and also tried to get patient to exit unit peacefully I advised patient that we have asked you nicely to come out of the truck and that ' s 1, now we are telling you, that ' s 2, patient got up from seat and held her hand out for me to help her and I reminded her she told me not to touch her or rape her ever again, with that patient exited the unit and proceeded to try and go anywhere else other than the ER patient finally corralled into the first set of ER doors where patient continued to vocal and verbally abusive to guards, EMS crew and threatened to kick me and punch us in the face, ER staff and family members of patients in the ER were gathering around ER desk to watch the commotion, several nurses came out to attempt to get patient to come in and be checked out while patient refusing to cooperate, ED (physician name) came out of the ER and spoke with patient, patient being rude and verbally abusive to him while at the same time was asking for something to drink, ED physician (name) got patient something to drink, Dr. ED physician (name) got patient a cup of water and asked her for her name which she gave reluctantly to him. He then asked patient what month it was and she told him March, at which point ED physician (name) told everybody that she is conscious and alert, to have her sign the refusal/release for (sic form) without eval, (evaluation) exam(examination) of attempting to treat her hyperglycemia or HTN, an ER nurse brought out the form and the patient finally signed it. All staff members walked back into the ER without registering or obtaining, vitals from patient, crew member (EMS person ' s name) went to obtain signatures from staff and was refused by staff member to sign for turnover of patient care, I asked for the computer with run report and went to ED doctor (name) and asked him if he would sign for patient ' s acceptance since he "Did his exam and decided that patient was CAOx4 and was mentally sound to sign for herself and refuse care and treatment, ED doctor (Name) sign our paperwork for patient. Patient e patient finally walked out of outside ER doors and stated: "I hope you are happy I just pissed in my pants and now I am a man, my balls are bigger than yours, how does that feel." I walked outside to calm down and gather thoughts, was concerned for patients wellbeing and mental state, morally and ethically I could not with good conscious let patient be abandoned at this time, after keeping an eye on the patient , while she walked in and out of traffic contacted our dispatcher and asked or the on duty supervisor to meet us at University ED, _____ (name) Supervisor arrived and was informed of the situation and of my concerns for the patient wellbeing and the actions of the staff and Doctor at University. He too observed the patient and her actions and asked me if I really wanted to continue with this patient ' s care, I felt that it was my responsibility to be the patient advocate and to seek care for her both morally and ethically, so I contacted ______ _____(name )of another EMS dispatch and requested to be patched thru to (name) of another acute care hospital Med Control Dr. White once again, advised white what had happened upon arrival at University ER, Her advise to bring her to another acute care hospital for evaluation. I informed him that It would take restraints, he asked what we had available to sedate patient and advised him of valium (medication used as a sedative) and versed (med used for sever agitation), he gave orders for physical restraints and 5 mg versed if need to restrain patient to bring to (name of ) another acute care hospital ED, Supervisor (name) and I walked into the ER and requested the _____ County Deputy on duty to come out to aid and to watch the restraint of patient, crew prepped restraints and stretcher for patient , Guard finally come out to observed, I asked him to record this on body cam which he finally turned on. Patient was 3 man lifted and carried to stretcher kicking and screaming and secured with ankle restraints and wrist, seat belts secured to keep patient safely secured to stretcher to prevent falling, loaded to unit and transported to (name) of acute care hospital ED for treatment and evaluation, upon arrival patient taken to acute medical side, staff advised of situation further and they witnessed the level of mental distress the patient was expressing, several threats where (sic were) made to the staff and EMS crew while waiting for room 12 to be made ready for the patient. ER staff placed the patient in room and transferred restraint to hospital leather and transferred patient to ED bed and secured her to prevent injuries, further reports were given to MD ' s on duty, the nursing staff and security, care turned over to doctor." Further review revealed the patient condition type was listed as, "weird behavior. The primary symptom was listed as Behavior strange an inexplicable.


Medical Record review University Hospital
Review of Patient #19's medical record revealed that the fifty-nine (59) year old patient presented to the facility's emergency room on 3/14/2017 at 11:50 PM for medical screening. Review of RN #8's notes on 3/14/2017 at 11:52 PM revealed that patient #19 was in the ambulance bay with EMS, refusing to go into the ER. The patient was cursing loudly, stating that he/she did not want to be there. MD #7 performed a medical screening examination and stated the patient was free to sign out against medical advice (AMA). The patient was alert and oriented to person, place, time, and situation. Respirations were even and unlabored; ambulating in a steady gait. The patient refused to be touched, or have vital signs taken. The patient was triaged on 3/14/2017 at 11:57 PM, and assigned a level 3.
Triage notes revealed that the patient had been walking up and down the street cursing, mad at a neighbor. A medical screening examination was performed by the physician. The patient refused to be touched and for vital signs to be taken.

Documentation by the ED physician revealed that MD #7 interviewed the patient on 3/14/17 at 11:58 PM, noting that the patient was brought in by EMS and was refusing medical care. The patient was appropriately dressed for the weather. The patient was walking down the street to the store to get a Sprite and was stopped by police. EMS was called, and the patient was brought to ER for a psychiatric evaluation. The patient was alert and oriented to person, place and time; no hallucinations/delusions, no suicidal/homicidal ideations or evidence of psychosis. The patient did not have pressured speech, a flight of ideas, or tangential (wandering) thoughts. Patient #19 had stated that she left/her house unlocked, had animals there, and, wanted to go home. He further documented the patient had pressured speech and no delusions during an interview. She has no suicidal or homicidal ideation. She has no evidence of Psychosis. She has no evidence of flight of ideas or tangential thought. It was a Normal interview. MD #7 noted that he/she offered to examine the patient more completely, but the patient had refused.

Review of RN #8's notes on 3/15/2017 at 12:00 AM revealed patient #19 signed out AMA. The patient was encouraged to stay and be evaluated by the ER MD, and was informed of the risks of leaving without further evaluation. The patient had refused to stay and walked out of the ER in no apparent distress. The patient was alert and oriented to person, place, time, and situation. Respirations were even and unlabored; ambulated in a steady gait
The patient signed an AMA form on 3/15/2017 at 12:00 AM, and left the ER on 3/15/17 at 12:02 AM.


Medical Record Review (Acute care hospital Patient #19 was transferred to by EMS)
Review of the record revealed that Patient #19 arrived in the ED on 3/15/2017 at 1:01 AM. The triage nurse documented the patient was triaged as a Level 2- Emergency. The patient ' s Vital Signs were: Blood pressure: 161/82 (H-High); Pulse: 113 (H); Oral Temperature: 36.7 Degrees Centigrade (98.1 Degree Fahrenheit); Respiratory Rate:22 . Documentation by the ED physician revealed in part, "Chief complaint: Pt bought in by ambulance for psych eval._____ County PD (Police Department) for AMS (altered mental status), +SI/HI w (with) plan. Pt intentionally ran into ...traffic x 2 today Combative with police and EMS. Pt. screaming, altered, hyperverbal and aggressive. History and Physical ...Upon arrival to ED, patient combative, aggressive. Placed in Leather restraints and given Haldol (anti-psychotic medication used to treat mental/mood disorders), Benadryl and Ativan (medication used to treat Anxiety). Patient calmed substantially. Patient states she is a diabetic, was minding her business, trying to check her blood sugar, and that potentially her ...neighbors called the police on her, and the police grabbed her despite her protests. Denies SI/HI. ..Pt agreed to cooperate with labs and head CT. Physical Exam ...Psychiatric: Appearance: Clean. Demeanor: moderately cooperative, Attire: appropriate. Mood: angry, combative. Affect: Congruent Speech: Loud, Thought process: Not goal directed. Thought content: Denies hallucinations, suicidal ideations, homicidal ideation. Cognitive function: Alert, Insight (poor), Judgment (poor) ...Medical Decision Making: ...Blood glucose elevated ...trace Ketones on urine ...BUN 14 ... Ammonia 25, ...no history of cirrhosis, No major electrolyte abnormalities ...Head CT: w/o (without) evidence of bleed, fracture, or mass. Patient's AMS likely secondary to psychiatric cause. Will plan for psych/eval." Documentation further revealed that the patients care was assumed by the Physician's Assistant (PA) on 3/15/2017, and that Psych had been called. Further documentation revealed the emergency department nurses notes and laboratory results, CT scan and x-ray results were reviewed by the PA. Documentation also revealed the patient ' s glucose level was 343, trace Ketones, plan was to provide intravenous fluids (IVF) but the patient refused and, fluid intake by mouth was encouraged. Patient finally agreed to IVF on repeat examination, and additional fluids and repeat blood glucose would be provided. Further documentation revealed that at 9:06 am psych intake notified the patient was medically cleared. Patient #19 was placed on a 1013 by psych. The Impression and Plan/Diagnosis was documented as Psychosis, atypical, Ketonuria (ketones in the urine, usually characteristic of diabetes mellitus) Hyperglycemia (elevated blood sugar levels) and bacteriuria (bacteria in the urine without accompanying symptoms). Review of the hospital ' s Authorization for transfer dated 3/17/2017 revealed the patient was accepted and transferred to a psychiatric hospital for further care.

The reason for the ED visit was listed in part, "ED Chief complaints: AMST Altered Mental Status ...Pt brought in by ambulance for psych eval ...County PD (police Department) called for AMS, +SI/HI w (with plan). Pt. intentionally ran into traffic ...x 2 today. Combative with police and EMS. Pt. screaming, altered, hyperverbal, and aggressive." The patient ' s Glucose level was 343, Trace ketones


Interviews
Telephone interview with MD #7 on 3/28/2017 at 2:30 PM revealed that he/she had worked various shifts at the facility since 1999, and had received EMTALA training last year. The MD recalled hearing voices in the ambulance bay and had gone out to see what was going on. He/she was informed by EMTs that patient #19 had been upset, and walking down a street cursing. MD #7 stated that he/she had not been informed that EMS were bringing the patient there, and had not received information regarding any previous history on the patient. The physician explained that he/she had spoken to the patient for approximately five (5) minutes in the ambulance bay, while the EMTs stood nearby, even providing the patient with water. He/she continued on stating that based on his/her interview with the patient, the patient was dressed appropriately for the weather; was alert and oriented to person, place, and time; had normal speech; was calm, and, had no signs of distress. No smell of alcohol was noted, and the MD did not have reason to believe the patient had been using drugs or alcohol. MD #7 also stated that the patient did not convey suicidal or homicidal behavior issues or signs of a mental imbalance which would justify strapping him/her down against his/her will for further examination. The physician explained that the EMTs had remained present during his/her assessment, and, had not provided any additional information, or objected to his/her decision to allow the patient to leave if he/she wished to do so. MD #7 stated that when he/she left the area, nurses were still speaking to the patient, and he/she believed the patient had agreed to stay, but later discovered the patient had left.
The facility failed to ensure that an appropriate medical screening examination was provided for patient #19 on 3/14/2017 related to her presenting signs and symptoms in the hospital 's e-bay of psychiatric disturbances/erratic behavior as evidenced by failing to ensure that a complete medical screening examination in the ED was provided to include services routinely available in the ED, as stated in the policy laboratory, CT scans and other diagnostic procedures to determine whether or not an emergency/psychiatric medical condition existed .

Interview with the ER Medical Director on 3/28/2017 at 4:30 PM in the conference room revealed that he/she was familiar with patient #19's case because he/she had received a complaint from the ambulance company. The complaint stated that the EMTs had made contact with the patient, then had spoken to another facility's ER MD, who recommended the patient be brought to an ER, but, that they were on Behavioral Health diversion, so could not accept the patient themselves. The ER Medical Director believed that this may have contributed to the EMTs' confusion because their facility would usually have received a phone call directly from the EMTs, providing notification of a patient en route (which they had not). The Medical Director stated that based on a review of MD #7's note in the medical record, he/she believed the physician had assessed the patient for capacity to make their own decisions. He/she continued on stating that he/she believed that MD #7 felt the patient had demonstrated that he/she could make his/her own decisions, and therefore could not be held against his/her will. The Medical Director added that he felt the EMTs may have been a little agitated with the patient/situation.

Telephone interview with RN #8 on 3/28/2017 at 5:00 PM revealed that he/she had worked in the facility's emergency department for approximately seven years, and was also the assistant manager. The RN stated that he/she was trained in EMTALA annually. RN #8 recalled patient #19, explaining that when he/she went out to the ambulance bay, he/she found MD #7 speaking to patient #19, who was angry and refusing to be touched. The patient denied wanting to harm self, was loud, outlandish, and angry, but did not seem to be in acute psychosis. The RN explained that patient #19 was upset about being forced to go to the ER, but had calmed down when he/she had spoken to him/her. He/she stated that patient #19 had explained that he/she had gotten into an argument with his/her crazy Christian neighbors. The RN continued on stating that one (1) of the emergency medical technician's (EMT) verbal tone to the patient was condescending, which upset the patient. RN #8 stated that the EMTs had informed him/her that patient #19 had been involved in a verbal altercation with his/her neighbors, and, had been walking up and down the street cursing. A sheriff had been present on arrival, and had given the patient the option of going to the ER, or going to jail; the patient had chosen the ER. The RN did not recall EMS informing him/her of the patient having displayed any self-harming behavior. The RN also stated that the EMTs had remained with the patient, and, had followed him/her out of the area as the RN left to attend to other patients. RN #8 explained that he/she had received a telephone call later that night from a charge nurse at another hospital's emergency room, asking what had happened at this facility. The RN stated that he/she informed the charge nurse that patient #19 had been angry, but appropriate, and staff could not force/her (#19) to stay. The RN continued on stating that the charge nurse informed him/her that there might be a problem because EMS had brought the patient from this property to their property.

Policies and Procedures

Review of facility policy 301-38, EMTALA Signage/Medical Screening Exam, effective 1/98, revised 3/15, reviewed 1/17, revealed:

Definition: A. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual ... in serious jeopardy. 2 Serious impairment of bodily functions: 3 Serious dysfunction of any bodily organ part ...Medical Screening Evaluation: The process required to reach within reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists. Such screening must be done within the facility ' s capability and available personnel ...the medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient ' s needs and must continue until the patient is either stabilized or appropriately transferred.
POLICY: 1. University Hospital Emergency Department provides a medical screening examination and stabilization treatment to any individual regardless of diagnosis, financial status, race, color, national origin, or handicap. Care will be rendered in the same manner and with the same care given any other patient under similar circumstances, regardless of the patient ' s ability to pay.
PROCEDURE: ...Depending on the patient ' s presenting signs and symptoms, the medical screening exam may range from a simple process involving a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic procedures. . .5. If an individual refuses a medical screening exam, the RN or MD will inform the patient of the risk and benefits involved in refusal of the medical screening exam. If the patient refuses, he/ she will be asked to sign out AMA (Against Medical Advice) and a synopsis of the education given to the patient and family will be documented in the electronic medical record by nurse or physician. A concerted effort will be made to get the patient or responsible family member's signature.

The facility ' s Policy and procedure titled "Patients who leave Against Medical Advice (AMA)", Policy No. 302-8, last Revised 3/16, last Reviewed 3/16, revealed in part, "Procedure: 1. AMA ' s Definition: "AMA" refers to those patients who after having treatment initiated, decide to leave before treatment is completed and against medical advice. Review of the medical record revealed no documentation that treatment was initiated for patient #19 on 3/14/2017.