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Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures, interviews and review of video recording dated 4/28/2021, it was determined the facility failed to provide an appropriate medical screening examination within its capability and capacity for one of 20 sampled patients (P) #1 when P#1 presented to the Emergency Department (ED) on 4/28/2021 with a complaint of diarrhea. Specifically, after arrival to the facility ED ambulance triage area, P#1 directed verbally abusive behavior toward the facility staff. Facility staff failed to attempt a triage assessment, failed to notify the physician or other qualified medical personnel, and failed to attempt to obtain an informed refusal for treatment from P#1. P#1 was escorted from the facility's ED by the facility's security.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate Medical Screening Examination.

Cross refer A-2407, as it relates to the facility's failure to ensure that the physician was informed that P#1 refused treatment, failed to obtain or attempt to obtain an informed refusal of care from P#1 that resulted in P#1 not receiving a medical screening examination.

Based on review of medical records, Medical Staff Rules and Regulations, policy and procedures, interviews, and review of video recording dated 4/28/2021, it was determined the facility failed to provide an appropriate medical screening exam within the capabilities of the facility including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one of 20 patients (P#1) when (P) #11 presented to the Emergency Department for a complaint of diarrhea.

Findings included:

A review of EMS (Emergency Medical Service) #1 Patient Care Report for P#1 revealed on 4/28/2021 at 9:50 p.m., EMS responded to a 911 call fromPt #1 for complaints of nausea ,vomiting, and diarrhea. Continued review of the report revealed that P#1 appeared to be agitated requested to be transported to the facility. P#1's blood pressure at 10:31 p.m. was 132/82 (normal was 120/80). P#1 arrived at the facility at 10:33 p.m. Review of the report narrative revealed that P#1 was abruptly removed from the facility due to being verbally abusive to the facility staff.

A review of P#1's medical record documented P#1 arrived at the facility's emergency department (ED) via EMS (ambulance) on 4/28/21 at 10:39 p.m. with a complaint of nausea, vomiting, and diarrhea. Documentation in the record revealed triage was started at 10:42 p.m. and completed at 10:44 p.m. A note written at 10:48 p.m. by Registered Nurse (RN) FF revealed P#1 was verbally aggressive with staff and escorted out by security. At 10:51 p.m., P#1's disposition was entered as eloped by RN FF. Review of P#1 record failed to reveal vital signs and a triage level assessment.

A review of EMS #2 Prehospital Care Report dated 4/29/2021 at 5:47 a.m., EMS was dispatched as a result of a 911 call to pick up P#1 with complaints of diarrhea and difficulty breathing. Based on the address documented on the Prehospital Care Report, P#1 was not on the facility's property or within 250 yards of the property.

A review of the "Medical Staff Rules and Regulations", dated 02/2016 revealed the following:
Medical screening (EMTALA): All patients presenting to the Emergency Department (ED) will receive a medical screening exam. Medical screening exams must be performed by a physician or physician extender (Physician assistant or nurse practitioner). The screening may be done by either the emergency department physician or a designated physician extender.

A review of facility's policy titled "Medical Screening Examination, Central Log, On-call Coverage, and Signage", last reviewed 1/2021. The policy applied to anyone who requested or a request via representative presented to the facility's main ED or other areas including but not limited to the Family Birth Center, Sickle Cell Acute Care Center, all on and off-campus clinics operating under the facility's Medicare Provider Number as well as sidewalks, parking lots and driveways within 250 yards of the facility's main campus.

Medical Screening Examination and Stabilization policy: It was the policy of the facility to provide an appropriate Medical Screening Examination (MSE) when the individual comes to its Dedicated Emergency Department (DED) and:
1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or
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: When an MSE was Required:
The facility provided an appropriate MSE within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether an EMC exist:

A. Determine if an EMC existed. The facility performed an MSE to determine if an EMC existed. It was not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE. Triage was not equivalent to an MSE. Triage entailed the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital to prioritize when the individual will be screened by a physician or other QMP.
B. Definition of MSE: An MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It was not an isolated event. The MSE was appropriate to the individual's presenting signs and symptoms and the capability and capacity of the facility.
C. An ongoing process. The individual was continuously monitored according to the individual's needs until it was determined whether the individual has an EMC, and if so, until he or she was stabilized or appropriately admitted or transferred. The medical record reflected the amount and extent of monitoring that was provided prior to completion of the MSE and until discharge or transfer.
D. Judgement of Physician or QMP. The extent of the necessary examination to determine whether an EMC existed was generally within the judgement and discretion of the physician or other QMP that performed the examination function.
E. Extent of MSE varied by presenting symptoms. The MSE varied depending on the individual's signs and symptoms:
i. Depending on the individual's presenting symptoms, an appropriate MSE involved a wide spectrum of actions, ranging from a simple process involved only a brief history and physical examination to a complex process that involved performing ancillary studies and procedures.

A review of the facility's policy titled " General EMTALA Definitions and Requirements", last reviewed 11/2019 revealed that the facility's EMTALA obligations were triggered when a request for medical care by an individual within a Dedicated Emergency Department ("DED"), when an individual requests emergency medical care on hospital property.

Emergency Medical Condition ("EMC") means:
1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual in serious jeopardy.
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part


During an interview with the Clinical Assistant (CA) LL on 7/14/21 at 8:44 a.m., in the conference room, he stated he had worked as a Clinical Assistant for over 21 years and worked at the facility as a Clinical Assistant for 11 years. CA LL said he worked the night shift in the ED from 7:00 p.m. until 7:00 a.m. He explained his responsibilities included obtaining patient vital signs, drawing blood, 1013 sitter, and assisted the MDs or RNs as needed. In addition, CA LL said he ensured that stretchers were available and sanitized for patient use when he worked in the ambulance triage area. CA LL indicated he remembered P#1 because he had encountered him 1-2 days prior in the ED. CA LL stated he worked the 7:00 p.m. to 7:00 a.m. shift on 4/28/21, and he reencountered P#1 in the ED. He added he worked with RN FF in the ambulance triage bay. He recalled hearing yelling and screaming in the ambulance bay and responded to the area. When he arrived, P#1 was yelling and screaming as he had when he saw him a day or two before. CA LL indicated P#1 was cursing and threatening to hit the EMS and ED staff in the triage area. Per CA LL, the EMS staff had reported that P#1 tried to hit them when they transported him to the ED. CA LL explained that RN FF asked P#1 why he was in the ED and what his complaint was, and P#1 cursed and stated he wanted to leave. CA LL stated that he, the EMS staff, and RN FF tried to calm P#1 down, but he continued to curse and scream at them. P#1 continued to say he wanted to leave, and he did not want the staff to treat or touch him. CA LL stated that he would have typically taken a patient's vital signs, but he stated that P#1 was too agitated to approach. CA LL stated that staff had not paged security because security was already in the ambulance bay. He indicated that security would escort a patient out if they wanted to leave. He added the MD, NP, or PA would often respond to the ambulance bay to assess a patient if needed. He added that P#1 did not receive a medical screening from an MD, PA, or NP during his visit. RN FF did not call an MD to assess P#1. CA LL recalled that P#1 did leave the ED, but he did not recall who took P#1 out of the ED or where P#1 had gone.

CA LL explained he received de-escalation training, but added it often did not work. He stated that if he could not get the patient to calm down, the RN typically took over. Per CA LL, patients are allowed to leave the ED if they want to unless they are a 1013. He stated that patients leaving the ED before discharge is commonplace in the ED. He explained he tried to get all the patients to sign an AMA form, but added that many patients refuse to sign the form. CA LL believed P#1 was asked about signing an AMA form, but he was not sure. He stated EMATALA is part of the annual training he receive each year.

During an interview with the Registered Nurse (RN) FF on 7/14/21 at 9:00 a.m. in the facility conference room, RN FF stated she had been a nurse for seven years and had worked at the facility in the emergency department (ED) for four years. RN FF recalled P#1 arrived at the ED by ambulance and entered the ambulance triage area via stretcher. RN FF received report from the emergency medical technician (EMT) that P#1 was stable. The EMT informed her that P#1 had been verbally abusive and attempted to hit one of the EMTs while en route. She did not review the EMS report. RN FF recalled that P#1 became verbally abusive while in the triage area and security attempted to calm him down. P#1 told RN FF that (P#1) did not wish to be seen in the ED, did not want treatment and wanted to leave the ED. RN FF explained that she was unable to do an assessment because of the aggressive verbal abuse and did not assign an acuity level. RN FF acknowledged that the medical record showed that triage had been completed and that P#1 had eloped, but triage never occurred, and P#1 left without being seen. RN FF explained that she had been unable to have P#1 sign an informed refusal form because he left so quickly after arriving to the ED. AMA forms were not kept in the triage areas.

RN FF recalled that P#1 was taken via stretcher to the waiting room doors where he got into his own wheelchair and exited. RN FF stated there had not been a physician or other provider present when P#1 was in the ED. RN FF did not call a physician or the charge nurse regarding P#1. RN FF explained if a patient did not want treatment or did not want to stay, the usual process was to notify the physician. The physician informed the patient of the risks and benefits of leaving and had the patient sign the appropriate form. The nurse witnessed the signatures. RN FF explained the typical triage process for patients that arrived via EMS checked in with the registrar. The patient was placed in the triage area and the nurse received report from the EMS staff. A nurse completed the triage assessment and assigned a triage level. The nurse determined which area of the ED was appropriate and the EMS staff transferred the patient there. RN FF stated that a physician completed an assessment of a patient after the triage process.


During an interview with the Security Officer (SO) MM on 7/14/21 at 3:45 p.m. in the conference room, he revealed worked as a security officer since 1988 and worked at the facility for the past two years. SO MM explained that he had training in weapons, tactical response, HIPPA ( Health Insurance Portability and Accountability Act), de-escalation and EMTALA. He added that he worked the 7:00 p.m. to 7:00 a.m. shift and floated to different areas at the hospital. SO MM recalled P#1 because he encountered him before, during previous ED visits. SO MM explained that P#1 was wheelchair bound and typically loud and belligerent when he spoke to staff. SO MM indicated that on 4/28/21 he worked the 7:00 p.m. to 7:00 a.m. shift in the facility's ambulance triage area. He heard P#1 screaming and cursing. He added that P#1 used racial slurs and was verbally abusive to the EMS and facility staff. P#1 yelled and stated he did not want to be treated at the facility. P#1 was taken out of the facility by EMS. He said he did not recall if P#1 was seen at the facility before he left the facility triage area. SO, MM stated that his understanding of EMTALA was that if a patient presented to the facility, they were supposed to be evaluated by an MD and receive treatment.

A review of the video tape recording from the facility's ED took place on 7/13/2021 at 2:30 p.m. in the conference room. The video tape recording was dated 4/27/2021 with a timestamp of 10:40 p.m. There was no audio available for the recording. The video revealed that at 10:41 p.m. P#1 was brought into the ED ambulance triage area by EMS via stretcher. RN FF was observed sitting at a nurse's station speaking with another staff member. At 10:46:20 p.m., SO MM was observed approaching the nurse's station. SO MM appeared to be speaking to P#1. At 10:48 p.m. the EMT's were observed lifting P#1 from the stretcher and placed him in his personal wheelchair. As the EMT pushed P#1 toward the exit, the EMT dropped some of P#1's belongings. A staff member assisted the EMT by picking up P#1's belongings and resumed pushing P#1's wheelchair. Video Recording #2 revealed the EMT and an unidentified staff member pushed P#1 out the ambulance entrance toward the street. At 10:50:24 p.m., the EMT and an unidentified staff member were observed pushing P#1 they turned right on Jesse Hill Jr. Dr. and out of view. At 10:51:44, the EMT and unidentified staff member were observed walking back toward the ambulance entrance from Jesse Hill Jr. Dr.

The facility failed to ensure that an appropriate medical screening examination within the capability of the hospital's ED was provided to determine whether or not an emergency medical condition existed for Patient #1 on 4/28/2021.

Based on medical records review of facility policy and procedure, Medical Staff Bylaws review, staff interviews, and review of video recording it was determined the facility failed to ensure that the ED physician was informed that an individual (Pt. #1) refused examination and treatment; failed to obtain or attempt to obtain an informed refusal of form which explains the risks and benefits of the examination and treatment for 1 (#1) of 20 sampled patients medical records reviewed.

A review of P#1's medical record from the facility revealed that he arrived at the facility's emergency department (ED) via EMS (ambulance) on 4/28/21 at 10:39 p.m. with a complaint of vomiting and diarrhea. Documentation in the record revealed that triage was started at 10:42 p.m. and completed at 10:44 p.m. A note written at 10:48 p.m. by Registered Nurse (RN) FF revealed that P#1 became verbally aggressive with staff and was escorted out by security. At 10:51 p.m. P#1's disposition was entered as eloped by RN FF. Review of the record failed to reveal that an informed refusal of care form had been explained to or signed by P#1.

A review of the facility's "Medical Staff Rules and Regulations", dated 02/2016 revealed the following:

Discharge contrary to medical advice: Cases occasionally arise wherein the patient or his family insist upon the patient being discharged contrary to the advice of the medical staff. In such instances, the house staff physician in charge of the patient will observe the following procedure:
1. If the patient is "Limited English Proficient" contact Language Interpreter Services.
2. Attempt to dissuade the patient, making clear the danger inherent in such action.
3. When the patient cannot be dissuaded, have his sign the facility's form or electronic equivalent "Authorization of Release," copies of which are available at the nursing stations or clinic areas.
4. Fully note the circumstances of the incident in the patient's medical record.
Note: The same form or electronic equivalent is to be used for emergency patients who present to the hospital, but who refuse treatment or who accept treatment on an outpatient basis but refuse to be admitted.

A review of the facility's policy titled "Medical Screening Examination, Central Log, On-call Coverage, and Signage", last reviewed 1/2021 included but was not limited to:

Refusal to Consent to Treatment
a. Written refusal - refusal of care or leave against medical advice. If a physician or QMP began the MSE or any stabilizing treatment and an individual refused to consent to a test ,examination or treatment or refused any further care and was determined to leave against medical advice, after being informed of the risks and benefits and the hospital's obligations under EMTALA, reasonable attempts were made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Against Medical Advice Form. The medical record must contain a description of the screening and the examination, treatment or both if applicable that was refused by or on behalf of the individual.
b. Documentation of information. If an individual refused to sign a consent form, the physician or nurse documented that the individual had been informed of the risks and benefits of the examination and/or treatment but refused to sign the form.

During an interview with the Registered Nurse (RN) FF on 7/14/21 at 9:00 a.m. in the facility conference room, RN FF stated that she had been a nurse for seven years and had worked at the facility in the emergency department (ED) for four years. RN FF recalled that P#1 arrived at the ED by ambulance and entered the ambulance triage area via stretcher. RN FF received report from the emergency medical technician (EMT) that P#1 was stable. The EMT informed her that P#1 had been verbally abusive and attempted to hit one of the EMTs while en route. She did not review the EMS report. RN FF recalled that P#1 became verbally abusive while in the triage area and security attempted to calm him down. P#1 told RN FF that he (P#1) did not wish to be seen in the ED, did not want treatment and wanted to leave the ED. RN FF explained that she was unable to do an assessment because of the aggressive verbal abuse and did not assign an acuity level. RN FF acknowledged that the medical record showed that triage had been completed and that P#1 had eloped, but triage never occurred, and P#1 left without being seen. RN FF explained that she had been unable to have P#1 sign an informed refusal form because he left so quickly after arriving to the ED. AMA forms were not kept in the triage areas. RN FF recalled that P#1 was taken via stretcher to the waiting room doors where he got into his own wheelchair and exited. RN FF stated that there had not been a physician or other provider present when P#1 was in the ED. RN FF did not call a physician or the charge nurse regarding P#1. RN FF explained if a patient did not want treatment or did not want to stay, the usual process was to notify the physician. The physician informed the patient of the risks and benefits of leaving and had the patient sign the appropriate form. The nurse witnessed the signatures. RN FF explained that the typical triage process for patients that arrived via EMS checked in with the registrar. The patient was placed in the triage area and the nurse received report from the EMS staff. A nurse completed the triage assessment and assigned a triage level. The nurse determined which area of the ED was appropriate and the EMS staff transferred the patient there. RN FF stated that a physician completed an assessment of a patient after the triage process.

During an interview with the Clinical Assistant (CA) LL on 7/14/21 at 8:44 a.m., in the conference room, he stated he had worked as a Clinical Assistant for over 21 years and worked at the facility as a Clinical Assistant for 11 years. CA LL said he worked the night shift in the ED from 7:00 p.m. until 7:00 a.m. He explained his responsibilities included obtaining patient vital signs, drawing blood, 1013 sitter, and assisted the MDs or RNs as needed. In addition, CA LL said that he ensured that stretchers were available and sanitized for patient use when he worked in the ambulance triage area. CA LL indicated that he remembered P#1 because he had encountered him 1-2 days prior in the ED. CA LL stated he worked the 7:00 p.m. to 7:00 a.m. shift on 4/28/21, and he reencountered P#1 in the ED. He added that he worked with RN FF in the ambulance triage bay. He recalled hearing yelling and screaming in the ambulance bay and responded to the area. When he arrived, P#1 was yelling and screaming as he had when he saw him a day or two before. CA LL indicated P#1 was cursing and threatening to hit the EMS and ED staff in the triage area. Per CA LL, the EMS staff had reported that P#1 tried to hit them when they transported him to the ED. CA LL explained that RN FF asked P#1 why he was in the ED and what his complaint was, and P#1 cursed and stated he wanted to leave. CA LL stated that he, the EMS staff, and RN FF tried to calm P#1 down, but he continued to curse and scream at them. P#1 continued to say he wanted to leave, and he did not want the staff to treat or touch him. CA LL stated that he would have typically taken a patient's vital signs, but he stated that P#1 was too agitated to approach. CA LL stated that staff had not paged security because security was already in the ambulance bay. He indicated that security would escort a patient out if they want to leave. He added that the MD, NP, or PA would often respond to the ambulance bay to assess a patient if needed. He added that P#1 did not receive a medical screening from an MD, PA, or NP during his visit. RN FF did not call an MD to assess P#1. CA LL recalled that P#1 did leave the ED, but he did not recall who took P#1 out of the ED or where P#1 had gone. CA LL explained that he received de-escalation training, but he added that it often did not work. He stated that if he could not get the patient to calm down, the RN typically took over. Per CA LL, patients are allowed to leave the ED if they want to unless they are a 1013. He stated that patients leaving the ED before discharge is commonplace in the ED. He explained that he tried to get all the patients to sign an AMA form, but he added that many patients refuse to sign the form. CA LL believed P#1 was asked about signing an AMA form, but he was unsure. He stated that EMATALA is part of the annual training he received each year.

During an interview with the Emergency Department (ED) Chief Medical Director (MD) EE on 7/14/21 at 11:44 a.m., in the conference room, he stated that Med Control consisted of the MDs that worked each Zone in the ED. MD EE stated that if an EMT/EMS needed to reach a physician regarding a patient, they would call Med Control, and whichever MD was available would answer the call. Additionally, MD EE indicated that if EMS called and indicated a patient called from the facility and requested a transfer to another facility, the MD would evaluate the patient's capacity to make a competent decision and discuss the risks and benefits of the transfer. MD EE explained that if a patient presented to the ED and wanted to transfer before receiving a Medical Screening Exam (MSE), his expectation of the staff was to notify an MD. The MD would evaluate the patient before a transfer.

During an interview with the Security Officer (SO) MM on 7/14/21 at 3:45 p.m. in the conference room, he revealed worked as a security officer since 1988 and worked at the facility for the past two years. SO MM explained that he had training in weapons, tactical response, HIPPA, de-escalation and EMTALA. He added that he worked the 7:00 p.m. to 7:00 a.m. shift and floated to different areas at the hospital. SO MM recalled P#1 because he encountered him before, during previous ED visits. SO MM explained that P#1 was wheelchair bound and typically loud and belligerent when he spoke to staff. SO MM indicated that on 4/28/21 he worked the 7:00 p.m. to 7:00 a.m. shift in the facility's ambulance triage area. He heard P#1 screaming and cursing. He added that P#1 used racial slurs and was verbally abusive to the EMS and facility staff. P#1 yelled and stated he did not want to be treated at the facility. P#1 was taken out of the facility by EMS. He said he did not recall if P#1 was seen at the facility before he left the facility triage area. SO, MM stated that his understanding of EMTALA was that if a patient presented to the facility, they were supposed to be evaluated by an MD and receive treatment.

A review of the video tape recording from the facility's ED took place on 7/13/2021 at 2:30 p.m. in the conference room. The video tape recording was dated 4/27/2021 with a timestamp of 10:40 p.m. There was no audio available for the recording. The video revealed that at 10:41 p.m. P#1 was brought into the ED ambulance triage area by EMS via stretcher. RN FF was observed sitting at a nurse's station speaking with another staff member At 10:46:20 p.m., SO MM was observed approaching the nurse's station. SO MM appeared to be speaking to P#1. At 10:48 p.m. the EMT's were observed lifting P#1 from the stretcher and placed him in his personal wheelchair. As the EMT pushed P#1 toward the exit, the EMT dropped some of P#1's belongings. A staff member assisted the EMT by picking up P#1's belongings and resumed pushing P#1's wheelchair. Video Recording #2 revealed the EMT and an unidentified staff member pushed P#1 out the ambulance entrance toward the street. At 10:50:24 p.m., the EMT and an unidentified staff member were observed pushing P#1 they turned right on Jesse Hill Jr. Dr. and out of view. At 10:51:44, the EMT and unidentified staff member were observed walking back toward the ambulance entrance from Jesse Hill Jr. Dr.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 4/28/21 Patient #1 failed to obtain or documented attempts to obtain an informed refusal form which explains the risks and benefits of the examination and treatment.