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Based on staff interview and facility document review, it was determined that the facility failed to comply with §489.24 by conducting an inappropriate medical screening exam for a patient presenting to the emergency department with an emergency medical condition (A-2406).

The findings include:

See Tag A-2406
Based on staff interview and document review, it was determined hospital staff failed to conduct an appropriate medical screening exam on each individual that presented to the emergency department (ED) in one (1) of twenty (20) medical records reviewed in the survey sample (Medical Record (MR)6).

Based on staff interview and document review, it was determined hospital staff failed to conduct an appropriate medical screening exam on each individual that presented to the emergency department (ED) in one (1) of twenty (20) medical records reviewed in the survey sample (Medical Record (MR)6).

Findings:

The facility's policy, "EMTALA Policy: Emergency Medical Screening, Treatment, and Transfer Policy" last revised March 2024 was reviewed and reads in part, " ...It is the policy of Virginia Hospital Center Arlington Health System and its subsidiaries (collectively, 'VHC Health') to provide an appropriate medical screening to any individual who comes to a VHC Health Dedicated Emergency Department ...An emergency medical condition is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child ...Any individual who comes to the Dedicated Emergency Department, either by ambulance or walk-in, requesting examination or treatment shall be provided with an appropriate medical screening examination (MSE). A. The purpose of an MSE is to determine if an individual is experiencing an Emergency Medical Condition ...A patient experiencing an Emergency Medical Condition must be stabilized prior to being discharged or transferred ...A patient may be discharged after the Emergency Medical Condition has been addressed or after a determination has been made that the patient is sufficiently stable for discharge ...the patient must be provided with a plan for appropriate follow-up care with discharge instructions."

The medical record for MR6 contained documentation that the patient first presented to the ED on January 26, 2025, at 7:47 AM for complaints of suicidal ideation and leg pain. The patient was medically cleared. The patient was seen by psychiatry in the ED and cleared to be discharged to outpatient treatment. The patient was discharged and taxicab transportation arranged to outpatient facility.

MR6 returned to the ED at 7:04 AM on January 28, 2025. The patient was brought in by Emergency Medical Services (EMS) with a chief complaint of suicidal ideation and plan. OTHMD1 (contracted physician) documented at 7:04 AM, " ...41-year-old male with history of suicidal ideation with previous psychiatric admission and malingering who presents to the ED with laceration to the left thumb and same complaints of previous ED visit after being seen yesterday for leg pain and suicidal ideations. The patient was seen by psychiatry yesterday who told him to follow up with Fairfax CSB and was sent via cab. Patient was able to ambulate with steady gait. Patient was escorted by security after being verbally abusive towards staff. "

The provider's physical exam indicated the patient was not in acute distress and was not ill appearing. The following systems were indicated as reviewed on physical exam and were normal: head, ear, nose, throat; eyes; cardiovascular; pulmonary; abdominal; musculoskeletal; skin; neurological. The psychiatric component had the following comment documented, "Unable to assess secondary to patient agitation."

The provider (OTHMD1) documented the following at 07:22 AM on January 28, 2025, "Patient became verbally aggressive towards nursing staff. Ambulating around ED and then was attempted to be redirected back to room by nursing staff ...patient started yelling, 'you all are racist.' Patient escorted out by security. Department of Human Services to be informed as patient was reporting suicidal ideation and is familiar to the Department of Human Services system to determine if patient needs a welfare check by police."

Documentation in the medical record indicated the hospital called Department of Human Services to make aware that the patient had left the ED.

Nursing documentation at 7:09 AM indicated the patient was suicidal and homicidal and presently had thoughts of harming others. Nursing also documented the patient suicidal intent with a specific plan. At 7:22 AM RN2 (Registered Nurse) documented, " ...This RN asked patient about treatment plan from yesterday and if he followed through. Patient became irate. This RN attempted to walk patient back to room as he is ambulatory and walked independently multiple times. Patient screamed that he is unable to walk. Patient continued to become irate. Patient then placed into wheelchair and [staff member] placed in hallway bed. Patient now calling this RN, 'racist white [expletive]' and verbally threatening this RN. Patient informed that there is a zero-tolerance policy against violence. Patient stated, 'I don't give a [expletive] about that call the [expletive] cops and I'll get a felony.' OTHMD1 witnessed behaviors and stated that patient can be escorted off of property by security due to high risk of patient causing harm to staff. Department of Human Services being called by scribe to inform them of patient and behaviors along with treatment plan that was set up yesterday."

Documentation indicated that MR6 was escorted off hospital property by security staff at 7:32 AM on January 28, 2025. The medical record contained no documentation that an emergency medical exam to include a psychiatric component was conducted to determine whether or not an emergency medical condition existed prior to hospital staff ordering security to escort MR6 off hospital property. There was no documentation in the record that interventions of any kind were ordered or offered to facilitate the exam or treatment of the patient.

The patient returned to the ED via EMS at 7:58 AM on January 28, 2025 (less than 30 minutes after being escorted out by security previously). The patient continued to express suicidal ideation with plan. The patient was placed on the waiting list for the behavioral health unit at the facility at 10:40 AM. No male beds were available at that time. Referrals were sent to nine (9) other inpatient behavioral health facilities. The patient was transferred to an outside hospital for behavioral health services at 3:29 PM on January 28, 2025.

An interview was conducted with RN2 (the charge nurse interacting with MR6 on January 28, 2025) on March 10, 2025, at 3:15 PM. RN2 indicated that MR6 came in with suicidal ideation and was verbally aggressive toward the nursing staff. RN2 indicated that OTHMD1 requested that security escort the patient from the building due to aggressive behavior and the patient left with security. RN2 stated that hospital staff called the Department of Human Services to notify that the patient was in the ED with suicidal ideation and to see if the police should be contacted to bring the patient back to the hospital in police custody.

An interview was conducted with the emergency department's medical director (OTHMD3) on March 10, 2025, at 3:20 PM. (OTHMD1 was unavailable for interview). OTHMD3 indicated that MR6 had been to the ED multiple times with the same complaint of suicidal ideation. MR6 was verbally aggressive and escalating and the physician (OTHMD1) had to compare the risk of harm to hospital staff to the risk of the patient's self-harming behavior in a very short window of time. There was a real threat to hospital staff by the patient and security was called to escort the patient off the property. OTHMD3 indicated that there was usually a police officer on the unit, but no officer was present at this time. Calling the police would not have resulted in a timely response. OTHMD3 indicated that a medical screening exam should still be completed in the ED whether or not the patient was agitated or aggressive and that OTHMD3 appeared to be in stable condition to leave the ED. OTHMD3 indicated the Department of Human Services was immediately contacted to inform of the patient's condition and to assess whether the patient should be brought back to the emergency department in police custody.


MR6 came to the ED on January 28, 2025, at 7:04 AM with complaints of suicidal ideation and plan. There was no documentation in the medical record that a medical screening exam to include a psychiatric component to assess whether or not an emergency medical condition existed was conducted. There were no documented interventions in the medical record to facilitate the exam or treatment of the patient. MR6 became verbally aggressive and was escorted out of the hospital by security at the direction of the ED provider. The patient returned to the ED via EMS approximately a half an hour later with the same complaint (suicidal ideation and plan), was evaluated and transferred to an outside facility for inpatient psychiatric care.