HospitalInspections.org

Based on record review, observation and interview facility staff failed to ensure all patients who present on hospital property with an emergent medical condition were documented on the Emergency Department (ED) central log for 1 of 20 patients (Patient #1), and failed to complete a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the Emergency Department in a total sample of 20 medical records reviewed.

Findings include:

The facility staff failed to ensure a patient who presented on hospital property with an emergent medical condition was documented on the ED central log. See Tag A-2405.

The facility staff failed to provide a Medical Screening Exam for a patient who presented to the Emergency Department. See Tag A-2406.

Based on record review and interview, facility staff failed to ensure all patients who presented on hospital property with an emergent medical condition are documented on an Emergency Department (ED) central log for 1 of 1 patients (Patient #1) in a total of 20 medical records reviewed.

Findings Include:

A review of the facility's policy titled, ""ABMC EMTALA (Emergency Medical Treatment and Labor Act)" last reviewed 01/27/2025 revealed, "... Record-Keeping... b) A recording of everyone who came to the hospital's Dedicated Emergency Department seeking screening or treatment... The log will include the patient's name and medical record number (if available) and indicate whether he/she (a) was refused treatment..."

Review of the facility's video recording (no audio) from 12/18/2024 revealed Patient #1's mother presented back Hospital A's ED (Emergency Department) registration desk on 12/18/2024 at 7:26 PM. Patient #1's Mother B exited Hospital A on 12/18/2024 at 7:28 PM.

Review of the facility's ED log for 12/18/2024 revealed Patient #1 presented to the ED on 12/18/2024 at 4:14 PM. There was no documentation on the log indicating Patient #1 re-entered the ED or that Patient #1's Mother B requested Patient #1 wanted to be seen again at 7:26 PM.

An interview was conducted on 01/28/2025 at 11:06 AM with CMO (Chief Medical Officer) E. When asked Patient #1, CMO E stated, "We have already established through video footage that [Patient #1's Mother B] came back into the ER requesting her daughter be seen again."

Based on record review, observation and interview the facility staff failed to complete a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the Emergency Department in a total sample of 20 medical records reviewed.

Findings Include:

A review of the facility's policy titled, "ABMC EMTALA (Emergency Medical Treatment and Labor Act)" last reviewed 01/27/2025 revealed, " ... Comes to the Dedicated Emergency Department; when an individual, who is not a hospital patient, does one of the following: 1. Presents to a hospital's Dedicated Emergency Department and requests, or has a request made on his/her behalf, an examination or treatment for a medication condition ... Policy: A. Hospital staff will provide an appropriate Medical Screening Examination for all individuals who present to the DED (Dedicated Emergency Department) with a medical condition ..."

A review of Patient #1's medical record revealed that Patient #1 was a 34-year-old female with a medical history of bipolar disorder who presented to Hospital A on 12/18/2024 at 4:14 PM via ambulance and in police custody under an EM-1 hold (Emergency detention) for medical clearance and anxiety for involuntary admission to an inpatient behavioral health facility. Patient #1 was discharged in stable condition into the custody of her parents for a safety plan to home on 12/18/2024 at 7:15 PM, after police lifted the EM-1 hold. Patient #1's mother presented back Hospital A's ED registration area on 12/18/2024 at 7:26 PM, requesting Patient #1 be evaluated again. Patient #1's Mother B exited Hospital A on 12/18/2024 at 7:28 PM. Patient #1 presented to Hospital C on 12/18/2024 at 9:10 PM where she was admitted for suicidal ideation.

A review of Facility A's adverse event filed on 12/19/2024, "SE-24-035296" revealed that Risk Manager F spoke with Patient #1's Mother B on 12/20/2024 who stated that Patient #1 froze on the sidewalk and wanted to come back into the ER. Review of the event revealed that security footage was reviewed on 01/03/2025 confirming that Patient #1's Mother B spoke with registration.

Observation of the security footage in the ED on 12/18/2024 revealed:
12/18/2024 at 7:15 PM: Patient #1, Patient #1's Mother B, and Patient #1's father walk out of the ED. Patient #1 and Patient #1's Mother B are standing outside of the ED. Patient #1 and Patient #1's mother enter the vestibule area of the ED.
12/18/2024 at 7:26 PM: Patient #1's Mother B comes back into the ED and has a conversation with registration (PSR H). No audio.
12/18/2024 at 7:28 PM: Patient #1's Mother B leaves the ED.

During an interview on 01/28/2025 at 10:11 AM with PSR H (PSR who had contact with Patient #1 on 12/18/2024), when asked about Patient #1, PSR H stated, "[Patient #1] and her family were discharged and walked past the desk and then a bit later the patient was upset and crying. [Patient #1's Mother B] came back to the desk and said that [Patient #1] didn't want to leave. The mom said she didn't know what the patient wanted to do. I know the police spent some time talking with the patient and then she left with her parents." When asked about the situation with Patient #1, PSR H stated, "I should have ensured that the patient either wanted to be checked back into the ER or not."

An interview was conducted on 01/28/2025 at 11:06 AM with CMO (Chief Medical Officer) E. When asked about the incident with Patient #1, CMO E stated, "We have already established through video footage that [Patient #1's Mother B] came back into the ER requesting her daughter be seen again."

During an interview on 01/28/2025 on 2:53 PM with Patient #1, when asked about her ED visit at Hospital A on 12/18/2024, Patient #1 stated, "I wanted to be seen again. They told my mom that I was already discharged. They told me to go to another hospital."

During an interview on 01/28/2025 at 3:16 PM with Patient #1's Mother B, when asked about Patient #1's ED visit at Hospital A on 12/18/2024, Patient #1's Mother B stated, "I told the registration desk that my daughter wanted to come back in, and they told me that she was already discharged."