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Based on the record review and interview, the facility failed to complete an appropriate Medical Screening Exam within the capability of the Hospital Emergency Department for one of 21 patients (Patient #16). The Hospital did not provide a medical screening exam before the patient left the emergency department from Hospital A.

There is no evidence in the medical record to show that the medical screening examination addressed the potential overdose, self-harm, and vomiting. Additionally, there was no evidence that other labs or clinical tests had been completed to determine if an emergency medical condition existed. Facility A allowed Patient# 16 to leave against medical advice (AMA) while actively self-harming in the facility.

Based on the record review and interview, the facility failed to complete an appropriate Medical Screening Exam within the capability of the Hospital Emergency Department for one of 21 patients (Patient #16). The Hospital did not provide a medical screening exam before the patient left the emergency department from Hospital A.

Findings included:
Record Review:
A review of an Ambulance trip report on 03/16/2024 at 1747 PM revealed:

EMS arrived at the fire department, where Patient #16 was initially located, assessed the patient's condition, and transported her to Hospital A as per the patient's request.

The EMS documentation shows the following:
"Pt walks out to the ambulance and climbs into the patient compartment. She sits on a stretcher and has an episode of emesis. Offered pt nausea medication IV, and pt said she is a hard stick but allows 1 IV attempt. Unsuccessful IV attempt. Given 4mg of Zofran ODT, the pt has another episode of emesis shortly after."

A review of the emergency department medical record at facility A Chart #1 for patient#16 visit on 3/16/2024 The emergency department medical provider notes (doctor Staff #2) revealed the following:

The reevaluation section revealed the following:
" While in the waiting room lobby, the patient began to lie down on the floor, make.
"Backstroke swimming motions'' on the floor and banging head repeatedly on the floor."

"The Patient, at this point, began to slide down against a concrete pillar and then eventually ended up laying down on the floor with her head propped up against a concrete pillar, repeatedly attempting to bang the back of her head against the pillow. The security guard was very conscientious about placing his hand behind her head so that she would not injure/harm herself by banging her head against the concrete."

The Medical Decision-Making section revealed:
" Patient refused to be evaluated by me.
The patient refused any medical intervention.
The patient said she wanted to leave, so she got off the stretcher and left the emergency department.
At this point, the patient was classified as leaving AGAINST MEDICAL ADVICE."

Patient Discharge & Departure revealed the following:
"All vital signs available during this entry have been reviewed.
Clinical Impression:
Primary Impression: Left against medical advice.
Secondary Impressions: Aggression
Time of Impression 1920 PM
Disposition Decision: Other "

There is no evidence in the medical record to show that the medical screening examination addressed the potential risk of overdose, self-harm, and vomiting. Additionally, there was no evidence that other labs or clinical tests had been completed to determine if an emergency medical condition existed. Facility A allowed Patient# 16 to leave against medical advice (AMA) while actively self-harming in the facility.

A review of a Police report by Deputy #1 at 19:13:52 03/16/24 revealed:
Patient#16 called the police department asking for help and reported that she was in the ER, and a male doctor "grabbed her hair and yanked it."

"I spoke with hospital security and medical staff, who advised me that patient#16 refused treatment and began hitting her head on concrete pillars outside of the hospital. Patient#16 eventually worked her way down a pillar and began hitting her head on the brick portion, then got on the ground and hit her head on the ground."

"Based on patient#16 's reported actions to me, hitting her head against the wall multiple times due to frustration, I believed she was a danger to herself. I detained her on a detention warrant."

"While patient#16 was in the rear of my patrol vehicle, she advised me that she took approximately 30 pills of her anxiety medication earlier and was having chest pains."

A review of Chart #2 at Facility B Patient #16 revealed:
"Per EMS report, the patient was drowsy, with seizure-like activity, and was given 5 mg of Versed EN route. During the ED evaluation, the patient was alert, with purposeful jerking of her entire body, which was inconsistent with seizure activity. Per chart review, the patient has been seen at multiple facilities for similar behaviors and has previously been intubated for such presentation. Per chart review from Harris, the patient has been seen for psychogenic nonepileptic seizure-like activity and admitted to that facility on 02/12/2024. The patient has been extensively evaluated for seizures, undergone continuous EEG, MRI brain, and head CT, and seen by a neurologist and psychiatrist, all of whom have concluded that symptoms."

Medications given at facility B:
03/16/24 2100 - droperidol (INAPSINE) injection 2.5 mg
03/16/24 2106 - midazolam (PF) (VERSED) injection 5 mg
03/16/24 2108 - ondansetron (ZOFRAN) IV Push 4 mg
03/16/24 2108 - electrolyte-A (PLASMA-LYTE) bolus 1,000 mL
03/17/24 1100 - ENSURE Nutritional Supplement Bolus 1 cart

Final Diagnosis section at facility B:
F41.1 Generalized anxiety disorder.
R45.851 Suicidal ideations
Z91.51 Personal history of suicidal behavior
"The Medical ER Provider reports that Patient #16 needs psychiatric evaluation for Suicidal ideations and Other."

The patient was discharged home and given resources for outpatient behavioral assessment.

The EMTALA Policy at Medical City North Hills, named- Texas Medical Screening Examination and Stabilization Policy: [Last revised 04/2022], states that:
POLICY:
"An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and:
2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition."
Procedure:
"I. When an MSE is Required.
A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the OED, to determine whether or not an EMC exists: (i} to an individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when:
a.The individual comes to a DED of a hospital, and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where:
I.The individual requests medication to resolve or provide stabilizing treatment for a medical condition.
II.The individual arrives as a transfer from another hospital or health care facility. Upon the arrival of a transfer, a physician or qualified medical person ("QMP") must perform an appropriate MSE. The physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The individual's MSE must be documented; this type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under EMTALA ceases."

Interviews:
During an interview with Staff#1, the ER Medical Director, at 1005 AM, states the following:

Q: What prompted the involvement of the police?
A: The patient prompted the involvement of the police. She called the police after she ran to the parking lot and away from the hospital premises.

Q: Was the decision to discharge the patient and transfer her to Facility B based on medical necessity and evaluation of the patient's condition?
A: Facility A did not make the decision. We were unable to care for her, and triage MSE or Stabilizing treatment was not possible due to her uncooperative behavior. The patient called the police, according to our security. Police decided to take her to Facility B.

During an interview with facility B Director of Patient Safety, Risk, and Community Health Quality on 05/14/2024 at 0401 PM stated the following:

Q: Can you provide specific details regarding the nature of the complaint filed against Facility A?
A: The patient was brought to Facility A via EMS for a potential overdose. Per their documentation, the patient was uncooperative during triage. The patient went to a breezeway and began self-harm by hitting her head on the wall and floor. The patient then moved outside, where she continued to hit her head. The patient was placed under a detention warrant by North Richland Hills Police and brought to Facility B. The patient did not receive medical clearance before departing Facility A.

Q: What incidents or events prompted the filing of this complaint?
A: The patient caused self-harm by hitting her head on the wall and floor multiple times in front of medical staff at Facility A. The patient was not medically cleared before being taken to Facility B.

Q: Has the complaining facility identified any specific areas of concern or potential violations of EMTALA regulations that they believe need to be addressed?
A: When a patient requires transfer to a higher level of care, the patient should be medically cleared or stable depending on the transferring hospital's resources.

Q: Were there any witnesses or documentation supporting the allegations outlined in the complaint?
A: Medical records from Facility A support the patient's self-harm and lack of medical clearance before transfer.