HospitalInspections.org

Based on record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity a complete medical screening examination (MSE) for three patients, (#1, #11 and #24), and ensure that an emergency medical condition (EMC) was stabilized when one patient, (#1) of 36 sampled cases from 01/02/23 through 10/02/23, was discharged with an unstable medical condition. The hospital's average monthly Emergency Department (ED) census over the past six months was 2,469.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 03/08/23, showed that any person presenting to the ED would receive an appropriate MSE beyond triage (process of determining the priority of a patient's treatment based on the severity of their condition), sufficient enough to indicate the presence or absence of an EMC. A person determined to have an EMC should be provided a necessary examination, treatment to stabilize them and an appropriate transfer to another medical facility as indicated. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists. To stabilize an EMC means to provide such medical treatment of the condition as may be necessary to assure that no deterioration of the condition is likely to result from discharge or transfer.

Review of the hospital's document titled, "Parkland Health Center Medical Staff Bylaws, and Rules and Regulations," dated 01/27/21, showed all patients presenting to the ED will be provided with a MSE.

Review of the hospital's policy titled, "Medical Screening Exam," dated 08/29/23, showed all patients presenting to the ED will receive a MSE in order to determine whether an EMC exists. Patient care will be provided in an appropriate setting and promote continuity of care. The medical condition with be evaluated and medical emergencies will be identified to prevent further worsening of the condition. The MSE is initiated with triage, but is on-going throughout the continuum of patient care. An MSE should include but is not limited to the assessment of the chief complaint, information as appropriate to the chief complaint, assessments of affected body systems, vital signs, a primary assessment, and any indicated diagnostic testing. Appropriate stabilizing treatment will be rendered prior to admission or transfer of the patient.

Patient #1 presented to the ED twice on 01/02/23, once on 01/04/23 and again on 01/05/23. All of the ED visits were similar in complaint. On the first visit Patient #1 presented with swelling in his legs, abdominal pain, wheezing and shortness of breath, but no chest x-ray was obtained and no medications were administered. He presented for the second time, 45 minutes after his previous discharge, with similar complaints, but left the ED two hours and 15 minutes after presentation, prior to being evaluated by a Physician. The third ED visit, occurring on 01/04/23, revealed a diagnosis of congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), and pneumonia (infection in the lungs), he was given antibiotics and medications to reduce his swelling and assist with his fluid retention. The Physician wanted to admit the patient but he refused. The final ED visit occurred on 01/05/23, where testing revealed he required a hospital admission. Two hours and 40 minutes after the decision to admit him he was changed to a discharge status. There was no documentation in the medical record to show why the Physician changed his need for hospitalization. The following day, Patient #1 presented to Hospital E with similar complaints to his previous ED visits at Parkland Medical Center, and he was admitted to the hospital and required treatment for CHF for seven days.

Patient #11 presented to the ED on 04/17/23 with a chief complaint of a mental health problem. Patient #11 initially denied hallucinations (seeing or hearing things which are not there) or delusions (false ideas about what is taking place or who one is), but did admit to hearing voices that were very vague and muffled and visual hallucinations that were not well formed. It was discovered that her blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) was 517. The ED Physician, Patient and family agreed to stabilize her medical condition prior to seeking admission in a psychiatric (relating to mental illness) unit. Patient #11 became uncooperative with staff, and accused her nurse of placing toxic substances into her intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and was allowed to leave against medical advice (AMA) and left without signing papers. She did not receive a mental health examination (MHE). She was found in her apartment, by police on 04/20/23, hiding in the corner, afraid that others were out to harm her. She was taken back to the ED and evaluated by a Qualified Mental Health Professional (QMHP). It was determined at that time that she had an EMC and required an admission to an inpatient psychiatric unit.

Patient #24 presented to the ED twice, on 08/22/23 and on 08/23/23. She had exhibited similar behaviors on both visits. She had been wandering in and out of traffic, refusing to move for oncoming vehicles, and exhibiting bizarre behavior. She would refuse to answer any questions for Emergency Medical Services (EMS, emergency response personnel, such as paramedic, first responders, etc.) personnel or triage personnel. On the first visit, the provider ordered a MHE, but discharged the patient prior to the completion of the evaluation. On the second visit, Patient #24 arrived via EMS accompanied by law enforcement. Three separate law enforcement officers completed affidavits (a written statement confirmed by oath, for use as evidence in court) related to Patient #24's behavior. She had exhibited the same behaviors on the previous visit. The provider that had discharged her on 08/22/23, also completed an affidavit related to Patient #24's behaviors. During the second visit on 08/23/23, a MHE was completed by a QMHP. She was determined to be at risk for injury or death to herself or others, placed on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others), and required admission to an inpatient psychiatric unit.


41474

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity a complete medical screening examination (MSE) for three patients (#1, #11, and #24) of 36 Emergency Department (ED) records reviewed from 01/04/23 to 10/02/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 2,469, with an average of 191 transfers a month.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 03/08/23, showed that any person presenting to the ED would receive an appropriate MSE beyond triage (process of determining the priority of a patient's treatment based on the severity of their condition), sufficient enough to indicate the presence or absence of an EMC. A person determined to have an EMC should be provided a necessary examination, treatment to stabilize them and an appropriate transfer to another medical facility as indicated. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists. To stabilize an EMC means to provide such medical treatment of the condition as may be necessary to assure that no deterioration of the condition is likely to result from discharge or transfer.

Review of the hospital's document titled, "Parkland Health Center Medical Staff Bylaws, and Rules and Regulations," dated 01/27/21, showed all patients presenting to the ED will be provided with a MSE.

Review of the hospital's policy titled, "Medical Screening Exam," dated 08/29/23, showed all patients presenting to the ED will receive a MSE in order to determine whether an EMC exists. Patient care will be provided in an appropriate setting and promote continuity of care. The medical condition with be evaluated and medical emergencies will be identified to prevent further worsening of the condition. The MSE is initiated with triage, but is on-going throughout the continuum of patient care. An MSE should include but is not limited to the assessment of the chief complaint, information as appropriate to the chief complaint, assessments of affected body systems, vital signs, a primary assessment, and any indicated diagnostic testing. Appropriate stabilizing treatment will be rendered prior to admission or transfer of the patient.

Review of Patient #1's medical record dated 01/02/23 showed the following:
- He was a 62-year-old male who presented to the ED, via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.), at 3:42 AM, for a chief complaint of abdominal pain, chronic congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues) and swelling to both lower legs.
- Nursing documentation showed that upon triaging Patient #1 he reported that he had walked from a nearby town, and was by the police department asking for an ambulance. Patient #1 had alcohol. He requested medication for his swelling and pain medications.
- Past medical history included alcohol abuse, anxiety (a feeling of fear or worry experienced intermittently), high blood pressure and drug abuse.
- A review of systems showed that Patient #1 had shortness of breath and wheezes (a high-pitched whistling sound made while breathing) were noted, leg swelling, and umbilical hernia (when part of the intestine bulges through the opening of abdominal muscles near the bellybutton), and pain that he rated at a seven out of ten. Initial vital signs (VS) were blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 119/88, pulse (the number of heart beats per minute) of 101, temperature of 97.6, oxygen saturation (measure of how much oxygen is in blood) of 98%, respiratory rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) of 18 and a weight of 160 pounds.
- Blood work was obtained and had several values out of range, with the most significant being a Pro B-type Natriuretic peptide (NT-proBNP, a blood test useful for diagnosing acute heart failure, normal range is less than 300) of 10,866 and a Troponin (Trop T hs, a blood test used to diagnose a heart attack, normal range was less than 22) of 47. A urine drug screen was positive for marijuana.
- An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed no significant change compared with an EKG performed on 12/13/22.
- Nursing documentation showed that Patient #1 discharged from the ED at 6:34 AM, still requesting pain medications and was told that he was not getting any.
- No medications were administered during the ED visit.

During an interview on 10/04/23 at 12:20 PM, Staff T, Registered Nurse (RN), stated that she cared for Patient #1 during his first ED visit on 01/02/23. She requested pain medication for Patient #1, but Staff W, Physician, never responded to her requests. It was not typical for Physicians to just not respond to any request from a nurse. Staff W was usually very good to get back to her.

During a telephone interview on 10/04/23 at 2:15 PM, Staff W, Physician, stated that he had no idea why he never responded to Staff T's request for pain medication for Patient #1. Typically he got right back to nurses for any request. He did not remember why no pain medications were given to Patient #1 and the medical record did not indicate any type of response to the request.

Review of Patient #11's medical record dated 04/17/23, showed the following:
- She was a 42-year-old female who presented to the ED with family, at 8:16 AM, with a chief complaint of a mental health problem.
- Past medical history included bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), anxiety, drug abuse, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), and diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing).
- Staff R, ED Physician, documented in the initial assessment that Patient #11's brother brought her to the ED and reported she had been acting bizarrely and acting as though others were out to get her. Patient #11 initially denied hallucinations (seeing or hearing things which are not there) or delusions (false ideas about what is taking place or who one is), but did admit to hearing voices that were very vague and muffled and visual hallucinations that were not well formed. She reported burning sensations in her arms and legs, using methamphetamine about one week prior to her ED visit, and not taking her diabetic medications for two weeks. The psychiatric portion of the evaluation stated that she was anxious with poor insight, mild paranoia, admitted to hallucinations and denied suicidal ideation (SI, thoughts of causing one's own death).
- Blood work was obtained and showed a blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) of 517. It was explained to the patient and her family that they would try to stabilize her blood glucose before they could seek admission in a psychiatric facility.
- A urine sample was obtained and showed ketones (when a type of sugar is present in the urine, may indicate high blood sugar levels in the body) were present in her urine.
- Initial VS were obtained and showed a BP of 109/73, pulse rate of 103, RR of 17 and oxygen saturation of 97%.
- At 2:10 PM, nursing documentation showed that Patient #11 believed her primary nurse was placing something toxic in her intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and fired her as a nurse. She was very hostile, screamed profanities and ripped out her IVC. Security was present as well as Staff R, Physician, who stated that the patient was not on a psychiatric hold. Patient #11 was escorted to the restroom by security, she changed into her belongings, then asked for a cab voucher to which she was denied.
- Physician documentation showed that after intravenous (IV, in the vein) fluids and insulin (medication that regulates the amount of sugar in the blood) were started the patient became argumentative with staff. Patient #11 stated she would not stay any longer in the ED and left without signing papers.
- Staff BB, RN, documented in the medical record that Patient #11 flipped out, pulled her IVC out and tried to take off. Staff R, Physician, let her go against medical advice (AMA) because she brought herself in.
-There was no assessment completed by a Qualified Mental Health Professional (QMHP).

Review of Patient #11's medical record dated 04/20/23 showed the following:
- She presented to the ED via police at 1:26 PM, with a chief complaint of mental health problems.
- Blood work was obtained and showed a blood glucose of 447.
- A history and physical assessment showed that Patient #11 had been demonstrating unusual behavior with paranoia (excessive suspiciousness without adequate cause), and was found in her apartment with no lights on hiding in a corner, as she believed that others in the apartment complex were out to get her.
- A QMHP evaluated Patient #11 and recommended inpatient treatment for psychosis.

During an interview on 10/04/23 at 12:33 PM, Staff S, RN, stated that while she did not remember Patient #11 specifically, it did not sound like she should have been allowed to leave the hospital AMA. If the patient was a danger to themselves or others they were not allowed to leave the ED AMA. Lots of patients presented to the ED and denied thoughts of hurting themselves or others, but ED staff would still hold them to make sure they were safe. It did not make a difference how the patient presented to the ED, they had to be safe and able to make good decisions to be able to leave.

During an interview on 10/04/23 at 1:30 PM, Staff R, Physician, stated that only patients that were able to make decisions for themselves were allowed to leave the hospital AMA. Patient #11 never stated that she wanted to kill herself or someone else so she was able to leave AMA. Nothing that Patient #11 did while she was in the ED constituted holding her against her will.

Review of Patient #24's ambulance report titled, "EMS C-Patient Care Record," dated 08/22/23, showed the following:
- An ambulance was dispatched to pick up Patient #24 on 8/22/23 at 8:12 AM.
- The initial call indicated that a sick person was standing in the roadway, not moving for oncoming traffic, and vehicles were forced to go around her.
- Patient #24's behavior was described as calm, with exaggerated and repetitive movements of her face and arms. When questioned, she would stare straight ahead and mumble to herself. She complied with the request to stand and ambulate to the ambulance, but she did so in an altered state.
- Patient #24 was unable to sign EMS documentation due to her mental and/or physical impairment.
- At 8:37 AM, care was transferred to the nursing staff of the hospital.

Review of Patient #24's first ED visit, dated 08/22/23, showed the following:
- At 8:31 AM, she presented to the ED via EMS, with the chief complaint of bizarre behavior. She had been found standing in the middle of the road, not moving for oncoming traffic, forcing vehicles to move around her. Her past medical history included benzodiazepine (a class of psychoactive drugs that act as tranquilizers and are commonly used to treat a range of conditions, including anxiety and insomnia) abuse, methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) use, Cluster B Personality Disorder (patients have difficulty regulating their emotions and behaviors, they are dramatic, emotional, and often unpredictable), and homelessness.
- At 8:40 AM, Patient #24 refused to answer triage questions. She indicated that she was not suicidal/suicidal ideation (SI, thoughts of causing one's own death) or homicidal ideation (HI, thoughts or attempts to cause another's death). She was mumbling to herself, but speech was clear when she did answer questions. She provided her name, date of birth, and social security number to the EMS staff, but would not provide additional information to nursing staff. She requested something to eat.
- At 10:03 AM, Patient #24 received IV fluids.
- At 10:58 AM, Staff AA, ED Physician, documented that the patient's disposition was pending a urine sample.
- At 10:59 AM, Staff AA, documented that Patient #24 was medically cleared for QMHP evaluation.
- At 11:00 AM, Staff AA, entered an order for a Behavioral Health consult to be completed by a QMHP.
- At 12:21 PM, Staff AA, documented that the patient was awake and ready to leave. That Patient #24 had stated, "It was just the pill that I took. I am fine."
- At 12:22 PM, Staff AA, documented that Patient #24 was more alert, she had eaten, and was refusing to provide a urine sample. Patient #24 was leaving the department, declined any further treatment. There was no affidavit or 96 hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) in place. No reason to hold Patient #24, she was not SI or HI.
- At 12:23 PM, Patient #24's disposition was set to discharge.
- At 12:26 PM, Staff Z, Master Social Worker (MSW), QMHP, documented that she had been preparing to complete Patient #24's psychiatric evaluation when she was informed by Staff AA, that the patient had left the ED.
- At 12:58 PM, Staff U, RN, documented that Patient #24 was asked to provide a urine specimen and she stated that she would not. Her issues were from taking an Adderall (a stimulant that when abused may impact the brain and the regulation of emotions; may cause hallucinations, impaired or delusional thinking, agitation and/or aggressive behavior) pill. Patient #24 seemed reasonable, but after she changed into her clothes and was walking down the hall, out the door, she exhibited bizarre behavior. She began talking to someone, but no one was there. Staff U called local law enforcement and spoke with an officer that was familiar with Patient #24. The officer informed Staff U that he would make contact with the patient to check on her and to escort her to a cooling center.
- At 1:12 PM, Patient #24's departure condition was listed as ambulatory, her discharge instructions had been reviewed, and she was unaccompanied.

Although requested, there were no security incident reports related to Patient #24 or the contacting of local law enforcement related to her.

Review of Patient #24's ambulance report titled, "EMS C-Patient Care Record," dated 08/23/23, showed the following:
- At 10:02 AM, an ambulance was dispatched to pick up Patient #24.
- Local law enforcement informed EMS staff that they had received multiple calls for a woman "jumping in front of traffic and laying in front of trucks." Law enforcement requested that Patient #24 be taken to the hospital for a 96-hour hold /psychiatric evaluation.
- Patient #24 was uncooperative with EMS staff, refused to answer assessment questions or basic information, such as her name, age, and date of birth.
- Upon arrival at the hospital, Patient #24 began to wander around, but was able to follow commands for where she was to wait for treatment.
- Patient #24 was unable to sign EMS documentation due to her mental and/or physical impairment.
- At 10:16 AM, care was transferred to the nursing staff of the hospital.

Review of Patient #24's second ED visit, dated 08/23/23, showed the following:
- At 10:25 AM, she presented to the ED via EMS and law enforcement to be evaluated for unsafe behavior. She reportedly was high on methamphetamine and was running into traffic. She had been seen the previous day for similar behaviors.
- Her past medical history included benzodiazepine abuse, methamphetamine use, Cluster B Personality Disorder, and homelessness.
- At 10:29 AM, documentation indicated that Patient #24 refused to speak with nursing staff. She refused to answer triage questions.
- At 10:36 AM, multiple laboratory tests were ordered, including a urine drug screen.
- At 10:44 AM, documentation indicated that Patient #24 continued to refuse to speak with staff. She had a blank stare on her face and was mouthing words.
- At 11:15 AM, the urine drug screen test indicated that she was positive for amphetamines.
- At 12:35 PM, Patient #24's disposition was set to Transfer to Another Facility.
- At 3:05 PM, an order was entered for a Behavioral Health consult to be completed by a QMHP.
- At 4:35 PM, Patient #24 was placed in Boarder status.
- At 5:03 PM, the QMHP evaluation was completed. Documentation showed that based on clinical presentation of patient engaging in high risk behaviors (jumping into traffic) that could cause harm or death to herself, Patient #24 met criteria for an inpatient psychiatric admission.
- At 9:04 PM, the transfer form was completed.
- At 12:21 AM, Patient #24 was discharged. Transferred to Hospital D (Psychiatric Hospital).

Review of an affidavit completed by Staff X, Emergency Nurse Practitioner (ENP)/Family Nurse Practitioner (FNP), dated 08/23/23, showed Patient #24 had presented to the hospital's ED two days in a row for running into traffic while under the influence of methamphetamine. Indicating that she was a threat to herself and others with this behavior.

Review of an affidavit completed by Staff AA, DO, dated 08/23/23 showed that Staff AA had observed Patient #24 on 08/21/23, dance in front of her vehicle, cross the road, stumble into Police Department B's parking lot, and pass out. Staff AA contacted 911 for Patient #24. On 08/22/23, Patient #24 arrived for assessment at the hospital's ED. Staff AA was the provider assigned to assess her. She appeared manic (elevated or excited mood or behavior) and psychotic (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature). Staff AA ordered a mental health evaluation (MHE), but the Licensed Clinical Social Worker (LCSW) would not evaluate the patient because her urine had not been sent for testing. Patient #24 refused to urinate. Since Patient #24 was not SI or HI and not a threat to herself, Staff AA discharged her. On 08/23/23, Patient #24 returned to the ED, wearing the same clothes. She remained psychotic and was refusing to cooperate with completing her examination. She was paranoid (excessive suspiciousness without adequate cause), manic, and chronically intoxicated with poly-substances. Without help, she could walk in front of a vehicle and kill herself.

Review of three affidavits completed by Police Department B officers, dated 08/23/23, showed they had responded to multiple calls from individuals concerned about Patient #24's behavior. She had been observed bending over in the middle of a street, banging her head on the ground, doing cartwheels in the middle of a busy street, running in front of traffic, dancing with a pole, laying down on the ground like she had collapsed, and laying on the ground in front of a dump truck refusing to move. During conversations with the officers, Patient #24 had appeared to be listening to someone else. She stated she was hearing voices, but would not tell the officers what the voices were saying. She was unable to concentrate and at times was confused. Due to the numerous calls from concerned individuals, her mental state, and her behaviors, the officers believed that she was a danger to herself.

Review of the hospital's document titled, "Order for 96 Hour Detention, Evaluation and Treatment and Warrant (Mental Health)," dated 08/23/23, showed based on affidavits and evidence submitted, there was probable cause to believe Patient #24 had a mental disorder and there was likelihood of serious harm to herself or others. The court ordered her to be transported to Hospital D for detention, evaluation, and treatment for a period not to exceed 96 hours.

Review of Patient #24's medical record from Hospital D, dated 08/24/23, showed that Patient #24 was transferred and admitted for concerns related to her running in/out of traffic while under the influence of methamphetamine. Her prior history included multiple psychiatric admissions, intentional overdose and SI, with a plan to walk into traffic. She has been violent with staff on previous admissions. During her ED stay, she was noted to be responding to internal stimuli and refused make eye contact or answer questions. She denied SI or HI. She stated she receives messages from God, has had visual hallucinations of animals and God, and auditory hallucinations. She can hear God through everyday objects. She presented to the ED two days in a row with the same presenting problems and behaviors. She continued to be disorganized and psychotic.

During a telephone interview on 10/05/23 at 4:50 PM, Staff AA, ED Physician, stated that Patient #24 had been in the ED two to three days in a row and had been wearing the same clothes each visit. She had seen Patient #24 on 08/21/23, when she walked in front of her vehicle while she was taking her child to school. She then saw Patient #24 on 08/22/23 when she presented to the ED for assessment. She had ordered a MHE for Patient #24 and a urine drug screen. The mental health intake personnel were very insistent that drug screens and alcohol levels were obtained prior to their evaluation of patients. Patient #24 had refused to give a urine sample. She appeared to be "clinically sober". Staff AA stated that walking in and out of traffic was not normal behavior. Patient #24 had become more alert after eating and receiving IV fluids. She did not observe any further strange behaviors. She did not discuss Patient #24 with the nursing staff prior to discharging her. She would have re-assessed the patient if nursing staff had voiced any concerns. She would not have been concerned that Patient #24 was observed by staff talking to herself upon exiting the ED. Staff AA had also been working on 08/23/23, the second day that Patient #24 presented to the ED. She completed an affidavit that listed all of the facts pertaining to Patient #24's behaviors. She thought that Patient #24 had voiced that she was suicidal on her second visit. She had been more confrontational and was refusing to answer any questions. Staff had to hold her down to obtain her bloodwork. She was still in the same clothes from two days prior. Her behaviors placed her at risk and she was admitted to a psychiatric unit.

During an interview on 10/04/23 at 12:00 PM, Staff U, RN, stated that she had been taking care of Patient #24 on 08/22/23. Patients that have a MSE to be medically cleared prior to a MHE. Clearance would generally include basic laboratory work, urine drug screen, possibly an EKG or chest x-ray. She had never experienced a QMHP refuse to evaluate a patient. The laboratory work and urine drug screen would not delay the evaluation. She did not recall making a phone call to law enforcement about Patient #24. Staff would notify security if law enforcement needed to be contacted. She did observe Patient #24 exit the hospital having a conversation with herself. She was worried about her safety. She was positive she had voiced her concerns to the provider, most likely via a secure chat message.

During an interview on 10/04/23 at 3:30 PM, Staff Y, Associate Director of Behavioral Health Services, stated that patients should have a MSE prior to participating in a MHE. Behavioral Health Navigators obtain the orders for the MHE. They review the reason for the exam, where the patient is located, ensure that consents have been obtained, and they look for pertinent laboratory testing. Generally, the QMHP's prefer to know what if any substances the patient has been taking, and/or their blood alcohol level. They utilize that information to determine whether or not the patient is under the influence or intoxicated. Their status can impact the participation in the evaluation. Patients should not be impaired during the assessment. All of the QMHP's have a minimum of two years of experience. They are allowed to utilize their judgement as to whether or not a patient is sober enough to be evaluated. Laboratory values do not have to be available upon evaluation. A QMHP can begin an evaluation, then pause if the patient cannot participate. They would then ask for an additional waiting period, or possibly laboratory results, prior to resuming the evaluation. The QMHP never refuse to see a patient. The evaluation of the patient should be based on their presentation. The QMHP staff have access to every visit that a patient makes throughout the hospital system. They are able to review histories of drug usage, behaviors, previous evaluations, and any notes entered. QMHP will communicate with providers through secure chat messaging, but those messages do not save. She was not able to find any communication about Patient #24 between the QMHP and the provider on the 08/22/23 visit.

During an interview on 10/04/23 at 4:45 PM, Staff Z, QMHP, stated that she had been assigned to assess Patient #24 on 08/22/23. She did not refuse to evaluate the patient. She would have communicated with the provider through the secure chat messages. Those messages do not save. QMHP staff always follow a flowsheet in their system when they are assigned a patient evaluation. On 08/22/23 at 12:00 PM, she started a flowsheet for Patient #24. As part of the evaluation, the patient's history would be reviewed, along with current notes and laboratory results. She always notates the time that a patient was discharged on the flowsheet. She annotated that Patient #24 had "left prior to evaluation," at 12:27 PM. She had not been able to speak with Patient #24. All providers are medical professionals and are capable of writing affidavits if there are any concerns about patient behaviors. Any MHE can be started without laboratory results. If a patient was lucid and can have a conversation, they can be evaluated. All QMHP staff have access to a patient's previous visits and evaluations. Typically, if they were positive for one substance on a previous visit, they would likely be under the influence of the same substance on subsequent visits. Any provider can contact the QMHP to evaluate a patient, without a urine drug screen.

During an interview on 10/04/23 at 2:40 PM, Staff X, ED Nurse Practitioner, stated that she was assigned to care for Patient #24 on 08/23/23, her second visit to the ED. Patient #24 had exhibited the same behaviors on her previous visit. She had been in and out of traffic and was a danger to herself. Law enforcement had picked her up. She was able to review the provider notes from Patient #24's previous visit. She would not comment on the reason Patient #24 was discharged on the first visit. The behavioral health intake staff could be rigid at times with respect to laboratory testing. She had never had a QMHP staff member refuse to evaluate a patient. That type of refusal would require escalation to a supervisor or Risk Management. The provider and the hospital would be liable if a patient was discharged while impaired and suffered any type of injury or injured someone else. She completed an affidavit on Patient #24 due to danger to herself and others.

Although requested, secure chat messages between hospital staff were not available for communications related to Patient #24.





41474

Based on interview, record review and policy review, the hospital failed to ensure an emergency medical condition (EMC) was stabilized when one patient (#1) of 36 sampled cases from 01/04/23 through 10/02/23, was discharged with an unstable medical condition. The hospital's average monthly Emergency Department (ED) census over the past six months was 2,469.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy," dated 03/08/23, showed that any person presenting to the ED would receive an appropriate medical screening exam (MSE) beyond triage (process of determining the priority of a patient's treatment based on the severity of their condition), sufficient enough to indicate the presence or absence of an EMC. A person determined to have an EMC should be provided a necessary examination, treatment to stabilize them and an appropriate transfer to another medical facility as indicated. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists. To stabilize an EMC means to provide such medical treatment of the condition as may be necessary to assure that no deterioration of the condition is likely to result from discharge or transfer.

Review of Patient #1's medical record dated 01/05/23 showed the following:
- Patient #1 presented to the ED at 4:04 PM, for shortness of breath.
- Physician documentation showed that Patient #1 reported not taking any medication for the past three days, and requested he be admitted to the hospital as his legs felt like they were balloons ready to pop. Patient #1 repeatedly requested pain medication, and had a history of doing so. Medical decision making showed he had worsening drug seeking behavior, worsening congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues) and shortness of breath. Patient #1 was to be admitted to the hospital.
- Blood work showed a Pro B-type Natriuretic peptide (NT-proBNP, a blood test useful for diagnosing acute heart failure, normal range is less than 300) of 19,022 and a Troponin (Trop T hs, a blood test used to diagnose a heart attack, normal range was less than 22) of 41.
- A urine drug screen was positive for marijuana.
- Triage vital signs (VS, body temperature, blood pressure, heart rate, and breathing rate) showed a blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 121/93, temperature of 97, pulse rate (the number of heart beats per minute) of 113, RR of 28, oxygen saturation (measure of how much oxygen is in blood) of 100%, and the patient reported to staff that his weight was 174 pounds. No current weight was obtained.
- On 01/06/23 at 2:28 AM, Patient #1 was set for an admission to the hospital with two or more nights anticipated for inpatient only procedures.
- At 5:13 AM, Patient #1 was set for discharge and his intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream)
was removed.
- At 5:53 AM, nurse documentation showed that when she entered Patient #1's room he yelled out that he was having a heat stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and dying, he cursed at staff and moaned and asked for pain medication. Patient #1 had requested dilaudid (medication used to treat severe pain) hourly throughout his ED visit. Patient #1 yelled at the nurse and security while he was being escorted out to the lobby. He was allowed to use the rest room and make a phone call for his ride then security escorted him off property due to his behavior toward staff.

Review of an incident report completed by security officers on 01/06/23 at 5:30 AM, showed that security was called to the ED for a verbally abusive patient. Nursing staff reported that Patient #1 had been medically cleared to be discharged from the ED, on his fourth visit, and had been verbally abusive to staff throughout his ED visit and needed to leave. Patient #1 took his time getting dressed so security officers had to assist him. Patient #1 walked to a wheelchair and requested to use the rest room. He attempted to find a ride, but was unable to, so he told security officers to just call the police. Police arrived and told Patient #1 that he needed to leave. Patient #1 informed police officers that he didn't have anyone to call, and requested he be taken to jail. Patient #1 was placed under arrest for trespassing and transported by police to jail.

Review of the arrest record for Patient #1, from Facility B, showed the following:
- On 01/06/23 at 6:26 AM, police officers were dispatched to Parkland Hospital in reference to Patient #1 refusing to leave the property.
- Patient #1 had been at the hospital all night and had become violent with medical staff by insulting the doctors and nurses and calling them vulgar names. Hospital security officers advised that medical staff discharge Patient #1 from the hospital and the patient refused to leave.
- Police officers advised Patient #1 to call someone to pick him up from the hospital, but were told that he had no one. They then offered to call a cab for him, but he refused. Patient #1 was told several times that he needed to leave the hospital. Patient #1 told officers that he was not leaving and they would have to take him to jail.
- At approximately 6:42 AM, Patient #1 was handcuffed and taken into custody for trespassing.

Review of Patient #1's medical record from Hospital E, dated 01/07/23 through 01/14/23, showed the following:
- Patient #1 presented to the ED on 01/07/23 at 8:15 PM, with a chief complaint of abdominal pain.
- VS were BP 121/89, pulse rate of 81, RR of 16, temperature of 97.4, oxygen saturation of 93% and weight of 180 pounds.
- Patient #1 was admitted to the hospital on 01/07/23, for CHF, where he remained until his discharge from the hospital on 01/14/23.

During an interview on 10/04/23, Staff P, RN, stated that she cared for Patient #1 in the ED on 01/05/23, during his fourth visit. When Patient #1 first presented to the ED he required oxygen, but after some time he did not need it anymore. She did not know why the Physician decided to discharge Patient #1 after things were in place for him to be admitted to the hospital. Patient #1 was belligerent from the time he arrived to the ED until the moment he was escorted out of the hospital.

During a telephone interview on 10/04/23 at 9:05 AM, Staff Q, Physician, stated that he did not remember why he decided to discharge Patient #1 on 01/05/23, his fourth visit, instead of admitting him. There was no documentation in the medical record indicating why the change was made.