HospitalInspections.org

Based on record review, policy review, document review, interview, and video surveillance review, the hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 2 of 29 patients (Patient 1 and Patient 22) who presented to the emergency department (ED) seeking emergency medical care.

The hospital's failure to perform an appropriate MSE has the potential for all patients to be discharged with an unidentified Emergency Medical Condition (EMC) which has the potential to delay necessary stabilizing treatment and may lead to deterioration of the patient's condition, including harm and death.

Based on record review, policy review, document review, interview, and video surveillance review, the hospital failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 2 of 29 patients (Patient 1 and Patient 22) who presented to the emergency department (ED) seeking emergency medical care.

The hospital's failure to perform an appropriate MSE has the potential for all patients to be discharged with an unidentified Emergency Medical Condition (EMC) which has the potential to delay necessary stabilizing treatment and may lead to deterioration of the patient's condition, including harm and death.


Findings Include:

Review of "Medical Staff Bylaws: Governance and Credentialing Manual" Approved 04/18/24 showed, " ...IV.8. Emergency Clinical Privileges. For the purpose of this Section, an "emergency" is defined as a condition in which serious or permanent harm would result to a patient or bystander or in which the life of a patient or bystander is in immediate danger and any delay in administering treatment would add to that danger. In the case of an emergency, any Practitioner shall be permitted and assisted to do everything possible (within the scope of the Practitioner's license) to save the life of a patient or prevent serious harm, using every facility of the Hospital necessary, including the calling of any consultation necessary or desirable, regardless of his or her Department, Section, Medical Staff status, or Clinical Privileges. The Practitioner shall make every reasonable effort to communicate promptly with the appropriate individuals concerning the need for emergency care and assistance by Members of the Medical Staff with appropriate Clinical Privileges, shall promptly yield such care to qualified Members of the Medical Staff when it becomes reasonably available, and once the emergency has passed or assistance has been made available, shall defer to the appropriate Department Chairperson and/or Section Chairperson (as applicable) with respect to further care of the patient ..."


Review of a document titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)" revised on 04/17/23 showed, "The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care of the patient ...


Standards for Medical Screening Examinations

1. Patients who come to a Dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP [Qualified Medical Professional].

2. The Medical Screening Examination extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred.

3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition [EMC].

4. If the Medical Screening Examination [MSE] does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital's facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures ....


"Qualified Medical Person or Personnel" (QMP) refers to physician and non-physician individuals defined by the medical staff's bylaws, rules, and regulations or other document approved by the Hospital's governing body to perform the medical screening examinations for those individuals that present to a Dedicated Emergency Department and request examination and treatment ..."


"Comes to the Emergency Department" means an individual:

1. Has presented at a Hospital's Dedicated Emergency Department and requests examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition;

2. Has presented on Hospital property, other than the Dedicated Emergency Department, and requests examination or treatment for what may be an Emergency Medical Condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment;

"Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, 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 (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;
Serious impairment to any bodily functions;
Serious dysfunction of any bodily organ or part ...
Some intoxicated individuals may meet the definition of "emergency medical condition" because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ.
Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or to others, would be considered to have an emergency medical condition ..."

"Hospital Property" means the entire main campus of the Hospital, including the sidewalks, parking lots and driveways or hospital departments, including any building owned by the hospital that are within 250 yards of the hospital. The term "Hospital Property" does not include other areas or structures that are not part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately under Medicare, or restaurants, shops, or other non-medical facilities. Ministry-specific details may be attached to this policy. If you have questions about whether your location meets this definition, please contact the Compliance or Legal Department.

"Medical screening examination" is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. Depending on the patient's presenting symptoms, the medical screening examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that involves ancillary studies and/or diagnostic tests and procedures. A medical screening examination is not an isolated event, but an ongoing process. The medical record shall include continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be documentation in the medical record of an evaluation prior to discharge or transfer.

Review of a document titled "EMTALA Training" undated showed, " ...Providing the MSE. When an individual "Comes to the Emergency Department" and EMTALA applies, the hospital must:
"Conduct a MSE to determine if an EMC exists; and
"Provide stabilizing treatment, or an appropriate transfer if the hospital lacks the capability and capacity to provide stabilizing treatment.
A MSE must be provided for any patient who comes to the Emergency Department, or other applicable hospital property, and requests or appears to need emergency care.
Even if it appears that the medical condition is not an emergency, the hospital must still conduct a MSE to verify that an EMC does not exist ...
When is an MSE Provided?
A MSE should be provided as soon as possible when:
"An individual presents to a hospital DED and requests or appears to need examination or treatment for a medical condition.
"An individual presents elsewhere on Hospital Property (not a DED) and requests or appears to need examination or treatment for what may be an EMC ...
How is an MSE Conducted?
The MSE should be specific to the type of services needed by the individual. Documentation in the medical record must reflect the type and scope of exam performed:
For Medical Conditions:
o History and physical exam, treatments, and medications.
o Medically indicated screenings, diagnostic tests or procedures.
o Physician impressions, diagnoses, and outcomes.
o Mental status evaluation.
o Vital signs and oral medical history and mental status evaluation ...
Psychiatric/Substance Related Conditions:
o Assessment of suicidal or homicidal attempt and/or risk.
o Assessment of orientation or assault behavior that poses a risk to the patient or others ...
Hospital Property Examples
So how does "Hospital Property" affect the hospital's EMTALA obligation? Click on each example below to see the different requirements:
An individual presents to a location on "Hospital Property" other than a Dedicated Emergency Department
When an individual presents at a location on Hospital Property that is not a Dedicated Emergency Department and requests an examination or treatment for what may be an Emergency Medical Condition, EMTALA apples (sic). The hospital must have policies and procedures for the screening and necessary stabilizing treatment required by EMTALA ..."


Review of a policy titled, "ED Dismissal Process-Work Instruction" Revised 4/7/2023 showed, "PURPOSE:
A. To outline the RN role in dismissal of the Emergency Department (ED) patient.
PATIENT POPULATION: ED patients triaged with the Emergency Severity Index (ESI) level of 1, 2 or 3. ESI level 4 and 5 ED patients per RN judgment.
H. Patient or guardian acknowledges understanding by signing dismissal paperwork.
I. Copy of instructions given to patient or guardian.
J. RN or designee provides assistance needed to facilitate patient dismissal from ED.
K. RN will document the process to include patient condition on dismissal, interventions and
dismissal disposition ..."


Review of a policy titled, "Discharge Dispositions" Revised 2/14/2022 showed, " POLICY To define and standardize inpatient and emergency department patient discharge dispositions; including Against Medical Advice (AMA), Eloped, and Left Without Being Seen (LWBS); for use in related policies and procedures.
PROCEDURE

Against Medical Advice (AMA) - An adult or emancipated minor who has been seen by a physician or licensed practitioner (LP) and chooses to terminate treatment and leave the facility against the advice of the physician or LP. To leave AMA requires decision-making capacity, which includes the ability to understand the nature and consequences of a decision about treatment options and the ability to make and communicate a decision based on that understanding.

Applicability - Inpatient and Emergency Department

Eloped - A patient who leaves or attempts to leave the hospital when doing so may present an imminent threat to the patient's health or safety because (1) the patient has been deemed too ill or impaired to make a reasoned decision to leave, (2) the patient is under orders by a physician or court to receive mandatory treatment, or (3) the patient has a court-appointed guardian for health care decisions. Applicability - Inpatient and Emergency Department
Eloped incidents do not include events involving competent adults or emancipated minors with decision-making capacity who leave against medical advice (AMA) or left without being seen (LWBS).
Left Without Being Seen (LWBS) - A patient who leaves before a triage assessment is complete. Applicability - Emergency Department.


Patient 1

Review of video surveillance, involving Patient 1, dated 06/03/24 showed:
08:11:24 PM - Patient 1 exiting main lobby of the hospital via wheelchair.
From 08:34:07 PM through approximately 11:03:00 PM - Patient 1 remained in a transportation vehicle (van) in front of the hospitals main entrance.
11:03:12 PM - The van was seen pulling up to ED sidewalk.
From 11:03:12 PM - 11:59:59 PM - Patient 1 remained in vehicle.

Review of video surveillance, involving Patient 1, dated 06/04/24 showed:
From 12:00:00 AM - 12:08:30 AM - Five security officers and one associate in ceil blue scrubs were seen removing Patient 1 by the arms from the vehicle (Patient 1 had remained in the transportation vehicle for approximately 4 hours).
12:12:16 AM- The van pulls away leaving Patient 1 face down on the curb.
From 12:12:16 AM - 12:24:50 AM - Patient 1 remained face down on the curb.
12:24:54 AM - Five security officers, five mental health safety associates (MHSAs) staff, three in ceil blue scrubs, two in navy blue scrubs were noted to assist Patient 1 into a wheelchair.
12:41:00 AM- Patient 1 was seen entering the ED entrance via wheelchair with three security and one staff in ceil blue scrubs.

Further review of video showed the following:
12:41:46 AM- Patient 1 was seen entering Zone 2 (locked psychiatric area) of the ED.
12:51:35 AM - Patient 1 was seen being pushed via wheelchair into Room 5 of Zone 2.
12:51:35 AM - 04:39:35 AM - Patient 1 remained in Room 5.
04:21:19 AM - Multiple staff were observed entering Room 5 with a gurney.
04:39:35 AM to 04:39:44 AM - Patient 1 exited Room 5 and exited Zone 2 via a gurney.
Patient 1 had remained in Zone 2/Room 5 for approximately 4 hours.

H2 Staff failed to perform an appropriate MSE for Patient 1 even though his behaviors changed prior to discharge from the hospital and during an attempt to transfer him to H3 (state psychiatric hospital).

Review of Patient 1's H3 medical record showed Patient 1 was admitted on 06/04/24 at 7:20 AM.

During an interview on 06/12/24 at 3:30 PM with Staff H, Manager of Transportation Company stated that our company received a call to transport Patient 1 to Hospital 3 (H3 - a state psychiatric institution) with restraints. The hospital reported that Patient 1 was non-violent and would be transported in clothing. We accepted the transfer and sent our two drivers to pick up the patient. The drivers arrived around 8:00 PM on 06/03/24 to H2. About 8:30 PM one driver called for advice. The driver said that Patient 1 did not have pants on and that he was just in a gown. It took the drivers and hospital security about 30 minutes to get the patient downstairs to the van because of the patient's behavior and once they finally got him loaded into the vehicle the patient refused to sit in the seat and so he'd been kneeling on the floor of the vehicle for about 30-45 minutes. Patient 1 was screaming and wasn't coherent at all. The driver said that the patient was about 500 lbs. and the restraints didn't fit Patient 1 properly. The drivers didn't even get out of the parking lot and the patient had broken his restraints. The driver called for advice again, " ...you need to go back immediately to the hospital, make sure you're safe and go to security see if they can help you and you need to contact the police ..." As the transportation company we decided that we could not transport this patient safely. transport was unsafe and the hospital needed to obtain other transportation.

Staff I, RN came outside and stated that H2 was refusing to take Patient 1 back stating, " ...we aren't taking him back ..." The driver reminded Staff I that H2 was a public service and can't refuse care to a patient. Staff I stated, " ...well he's discharged we don't have to take him ..." The driver told Staff I we needed to drop Patient 1 back off into the emergency department so he can go back through the process. Staff I stated, " ...no we have 100 rooms upstairs for psych and they're full there's no there's no room for him and we have 28 patients waiting in the emergency department to go up to psych we don't have room for him we aren't taking him ...Staff O stated, " ...our computer systems are down so we aren't doing the best of job of caring for the patient ..."

During an interview on 06/12/24 at 3:15 PM, Staff Z, Security Officer, stated that on one of his rotations there was a lady walking out of the ED and a van sitting right there with Staff U, Security Officer and Staff I, RN. They told me the story briefly and went back to my post. Eventually before the shift was over, they pulled the van around to the ER so they could readmit the patient. They couldn't transport the patient because of his size and not being able to transport him in the van safely.

During an interview on 06/11/24 at 11:09 AM Staff J, Assistant Manager of Behavioral Health stated that she told the House Supervisor, that you know the process once a patient is discharged, if they need to be seen again then they need to go through the ED.

During an interview on 06/11/24 at 11:57 AM Staff K, Director of Behavioral Health stated, " ...It was my understanding that the patient was going to go back to the emergency department ..."

During an interview on 06/12/24 at 2:17 PM, Staff BB, Registered Nurse, stated that, she had noticed that there were security personnel out in front of the ED and then noticed that there was a patient lying face down on the concrete right next to the curb and kind of hanging off the curb and into the street of the EMS driveway. The patient had pulled up his gown and his rear end was showing.. The patient would intermittently arch his back and put his arms out in front of him and raise his legs behind him. He was looking around and he was just kind of mumbling and making just kind of weird noise. They said well because he refused to transport we are trying to figure out how we are going to get the patient to a H3. I asked why don't we take him upstairs until we can figure out what we are doing for him and not out here mooning everyone. They [Staff I and Staff CC] said that they couldn't take him back upstairs because he was a discharged patient ...I'm not quite sure exactly how long the patient was outside before being brought into the zone 2 the locked unit of the ED, he was outside a significant amount of time. The floor nurse said that they couldn't accept him back because they had discharged the patient and it was the ED personnel's responsibility to essentially figure out what else to do for the patient.

During an interview on 06/11/24 at 1:38 PM Staff I, RN stated, "we're taking the patient over to the ER [Emergency Room] and getting him readmitted to the hospital, the Emergency Room staff had already listed the patient on the board, produced a FIN [encounter number] number so we were in action with admission process for him. Leadership had also spoken with bed placement to secure his previous bed upstairs ... the patient exited the van and we brought him into the ER [Emergency Room] zone two ...he wasn't under any physician's care.

During an interview on 6/11/24 at 2:08 PM, Staff M, Director of Nursing of H2 stated that if a patient comes to be seen or to receive any treatment, we have to provide initial screening and make sure that they are stable. It's not just if they come to be seen but also if they are within 200 yards. If an average person looks at a person and thinks they need help or medical attention we are to check on the patient. Obviously, Patient 1 met these criteria because his mind was not right.

During an interview on 06/12/24 at 1:36 PM, Staff A, Registered Nurse (RN) ED Director of H2 stated that if we reprocessed them through the emergency department, he would lose his bed at H3. The patient was being non-compliant with a lot of things because he's sick. He needs help so we were trying to work through all of the pieces.

During an interview on 06/12/24 at 2:40 PM, Staff AA, Medical Doctor (MD), overheard the staff talking about the condition and the situation. I was available if the patient needed anything, but it sounded like it was an inpatient going to an inpatient situation not an ED patient. I was available to be to be there to help out, but it didn't sound like there was an emergent condition. I know that the patient had been registered. I did not know I needed to see him. He didn't show up on the tracking board because we didn't have a tracking board at the time.

During an interview on 06/12/24 at 5:20 PM Staff CC, Charge RN stated that Staff I, RN stated that they were going to drop Patient 1 off to be admitted through the ED. Staff I went on to state that Patient 1's just going to be held in Zone 2; we are not seeing him as a patient. Staff CC stated that the ED staff were told Patient 1 was eating the bars on the bed but didn't do anything directly to harm himself or others.

During an interview on 6/13/24 at 9:00 AM Staff GG and HH, Transportation Company Drivers stated that we were told to take the patient to the ED entrance. We drove to the entrance and security was there waiting they attempted to get Patient 1 out of the van but were unsuccessful. A police officer showed up and they were able to pull Patient 1 out of the van by his arms where he then was laid face down on the curb. Staff HH went on to state that they spoke with Staff I about Patient 1 being readmitted to the emergency department and Staff I stated that [H2] couldn't do that because he's been discharged, and he has to be brought in by law enforcement.

During an interview on 06/13/24 at 1:52 PM, Staff JJ, MD ED Medical Director, stated that, if a patient presented to the emergency department and was on our grounds or in our emergency department we would certainly comply with EMTALA. If the patient shows up to be seen it would require registration and a medical screening exam documentation and then stability to the best of our capability.

During an interview on 06/13/24 at 2:30 PM, Staff LL, stated that he registered Patient 1 on 06/04/24 however unable to remember the exact time. The patient was discharged from 6 West and was supposed to be transported to another facility out of town. Staff LL went on to state that he didn't remember exactly what time the incident happened but the transport service that was there to pick up Patient 1 did not have the correct equipment to safely transport the patient and the transport staff refused to transport Patient 1. So [The Hospital] had to maintain custody of the patient until another transport company could come and take the patient. Staff CC, Registered Nurse (RN), instructed Staff LL to re-admit them through the Emergency Room (ER) so that the patient could be taken back to the 6th floor and the patient room was still available.

During an interview on 06/13/24 at 2:41 PM, Staff MM, RN Zone 2, stated that Patient 1 was brought back to zone 2 on the night of the 06/03/24 into 06/04/24 and no nurse was assigned to his care. No one was assigned to monitor him. We were told that he was there awaiting transport, so nobody was really watching him. We were only watching him because we have cameras in the room that he was in, but we weren't doing 15-minute checks, assessments, or medications.

During an interview on 06/14/24 at 8:00 PM, Staff NN, MHSA, stated that: "We got called that secure transport was there for [Patient 1], so we showed up on 6 West, and we helped get him transferred over to a wheelchair, which was an ordeal on itself. [Patient 1] was very sick this is the worst I've seen him. It was almost to the point where he's non-verbal he was mobile while he was staying at the hospital."

During an interview on 06/14/24 at 8:13 AM, Staff CCC, Behavioral Health Technician (BHT), stated that we were just doing some visual checks here and there but not like the documentation that we would normally..


Patient 1 failed to have a medical record for this encounter in the emergency department. The hospital failed to conduct an appropriate MSE for Patient 1 to determine whether he had an emergency medical condition (EMC).


Patient 22

Review of Patient 22's medical record showed a 33-year-old-male who presented to the ED on 06/12/24 at 2:45 AM by EMS with a chief complaint of alcohol intoxication. Patient 22 had a past medical history of Traumatic Brain Injury, hypertension, obesity, major depressive disorder, bipolar disorder, borderline personality disorder and alcohol withdrawal seizures. Patient 22 had a pattern of being brought to the ED due to public intoxication.

Review of Patient 22's record dated 06/12/24 at 2:45 AM showed Staff RR, MD documented that he completed an MSE on 6/12/24 at 3:00 AM.

Further review of the medical record dated 06/12/24 at 3:00 AM, showed Staff RR, documented the following physical examination findings: Cardiovascular: Regular rate and rhythm, No murmur, No edema. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. Chest wall: No tenderness. Back: Nontender. Musculoskeletal: Normal ROM, normal strength, no tenderness. Gastrointestinal: Soft, Nontender, Non distended, Signs: McBurney's negative, Murphy's negative. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed, normal motor observed, normal speech observed.

Review of video surveillance dated 06/12/24 from 2:45 AM thru 06/12/24 at 09:56:50 AM failed to show Staff RR performing a physical exam on Patient 22 including listening to lung sounds, cardiac heart tones, or palpitating abdomen. Staff RR failed to complete a physical examination of Patient 22 even though it is documented in Patient 22's record.

The hospital discharged Patient 22 to home on 06/12/24 at 11:05 AM. The hospital failed to notify his guardian of this admission or his discharge.

During an interview on 06/18/24 at 7:18 AM with Staff RR, MD stated, " ...I'm extremely familiar with [Patient 22], he is one of our frequent flyers and goes through spurts we'll have him for a couple days or weeks ...for discharge if it's an adult male who is clinically sober and wishes to leave there is no indication for me to keep him so there's no reason to engage the guardian ...he's had a TBI so has that affected him ...it's hard to get a baseline ..."

During an interview on 06/20/24 at 3:07 PM, Staff XX, RN, stated that Patient 22 comes in drunk, they put him on the stretcher and let him sleep it off. When he gets to a point where he's sober and can walk, eat, and drink they discharge him.

During an interview on 06/17/24 at 5:57 PM with F1, Patient 22's Guardian stated, " ...problem is the legal guardianship, they never call me and tell me when he's in there ...I call when I don't hear from [Patient 22] and check to see if he has been admitted or is there, when I called to find out they had told me he had been there, they'll tell me that but they won't call me knowing I have guardianship ...[Patient 22] has a mental illness, traumatic brain injury and severe alcoholism because of being on the streets ...he needs treatment that's what they should be there to do that's their job ..."

During an interview on 06/20/24 at 12:07 PM, Staff UU, MD, stated that I think he's just an alcoholic typically just knowing [Patient 22] the way we know him we would just allow him time to sober up. I suppose if he's not sobering up as expected then I might add on some lab at that point but it's not standard to do a blood alcohol level. We should not be doing too many blood alcohol levels because that get you medical legal trouble if you discharge. We try to base discharge disposition on clinical sobriety so it's when they are no longer cognitively impaired or psychotic and the patient has no psychomotor impairment.

06/12/24 at 8:44 PM, when he arrived in the ED by EMS. The staff did not triage the patient. No provider saw this patient. The hospital did not get any lab studies, imaging, cardiovascular tests, and/or neurological testing. Patient 22 left the ED without being seen (LWBS) on 06/12/24 at 9:07 PM. Even though the hospital is aware the patient has a guardian, they failed to notify F1 of his admission or that he LWBS.

Patient 22 had a pattern of being brought to the ED due to public intoxication, the ED allowed him to sober up, and then dismiss the patient. Documentation failed to show hospital staff notified the guardian five out of five times of his admission or discharge disposition. The records showed that the hospital did not complete a community mental health screen on Patient 22 four of the five ED visits. Discharge documentation on all visits contained written information for community resources to help Patient 22 with his substance abuse disorder, however, it is not clear whether Patient 22 had any ability to read or understand written words secondary to his traumatic brain injury. Documentation showed lack of any social work involvement to assist Patient 22 in obtaining community resources regarding substance abuse disorder so the ED was not the place where he sought primary care.