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Based on review of facility policies, review of digital video recordings, review of the facility's Central Emergency Department (ED) Log, review of a security report, review of medical records, and interviews, the facility failed to provide a Medical Screening Examination (MSE) to one patient (Patient #3) of 45 patients reviewed. This failure resulted in Patient #3 traveling 2.5 miles to Hospital B where he was provided a MSE and treatment. The facility also failed to complete a Physician's Certification documenting the risk and benefits of transferring one patient (#33) of 45 reviewed.

The findings included:

Patient #3 presented to the ED at Hospital A on 12/20/2021 at 7:14 PM for complaint of high blood sugar. Patient #3 was verbally abusive, cursing, and threatening to staff resulting in ED staff calling the local police department. Patient #3 left the ED with police officers on 12/20/2021 at 7:34 PM without having been provided a Medical Screening Exam or Stabilizing Treatment. Hospital B is 2.5 miles away from Hospital A and Patient #3 arrived at Hospital B's ED on 12/21/2021 at 5:28 AM. Patient #3 was provided an MSE at 5:30 AM and was diagnosed with Hyperglycemia (high blood sugar level). At 5:37 AM, Patient #3's blood sugar level was 275 (normal is 90-120), and he was treated with a dose of insulin (medication used to treat high blood sugar/diabetes). Patient #3 was discharged home from Hospital B's ED on 12/21/2021 at 7:03 AM.

Patient #33 presented to Hospital A's ED on 6/5/2022 at 3:09 AM by Emergency Medical Services (EMS) for complaint of gunshot wound to left lower leg. Patient #33 was transferred to Hospital B on 6/5/2022 at 4:05 AM by EMS without the Certificate of Transfer form being completed and signed by a physician. There was no written certification by a physician of the benefits and risks of Patient #33's transfer to Hospital B on 6/5/2022.

Refer to:
A-2406
A-2409

Based on review of facility policies, review of digital video recordings, review of the facility's Central Emergency Department (ED) Log, review of a security report, review of medical records, and interviews, the failed to provide a Medical Screening Examination (MSE) to one patient (Patient #3) of 45 patients reviewed.

The findings included:

Review of facility policy titled "EMTALA [Emergency Medical Treatment and Active Labor Act] GUIDELINES - TREATMENT OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES" dated May 2021 revealed, "...The Hospital's EMTALA obligations are triggered when there has been...A request for examination and/or treatment of a medical condition by an individual...The Hospital will provide to any individual, including an infant who is Born Alive at any stage of development, who comes to the Emergency Department an appropriate Medical Screening Examination...The Hospital will provide a Medical Screening Examination (MSE) for an individual who...Comes to an on-campus DED [designated emergency department], requesting examination or treatment...If the Hospital offers examination and treatment and informs the individual or the person acting on the individual's behalf of the risks and benefits to the individual receiving the examination and treatment, but the individual or person acting on the individual's behalf does not consent to the examination and treatment, the Hospital shall take all reasonable steps to have the individual or the person acting on the individual's behalf sign form...Refusal to Permit Medical Examination...Exhibit B...Leaving the Facility Against Medical Advice, Treatment, or Transfer...In the case of an individual who departs the DED prior to triage (leaves without being seen), who does not yet have a medical record opened, reasonable efforts will be made to have the individual provide basic information for purposes of documenting his/her ED presentation. If such individual refuses to sign Exhibit B [Refusal to Permit Medical Examination], Hospital staff will document the steps taken to secure the individual's written informed refusal..."

Review of the facility's policy titled "SCREENING/TRIAGE PROCESS - EMERGENCY CARE CENTER - ECC" dated April 2022 revealed, "...The patient reserves the right to refuse the medical screening exam. In such cases, the Registered Nurse [RN] functioning in the triage capacity will explain the right to and the risks of refusing the medical screening exam and will encourage the patient to allow for the medical screening exam process. Should the patient continue to refuse the medical screening exam after being informed of these rights and risks, the Registered Nurse will then document the above observations..."

On 6/14/2022 at 10:10 AM, in the Administration Conference Room, a digital security video was provided on a computer disc and identified by the Security Manager as being a video recording of Patient #3 in the ED waiting room on 12/20/2021. Observations of the video recording revealed Patient #3 walked into the ED on 12/20/2021 at 7:14 PM and immediately began to complete paperwork while sitting in a waiting room chair. ED staff placed a wristband on Patient #3 at 7:22 PM. ED staff (identified by Security manager as Registered Nurse [RN] #1) spoke with the patient at 7:23 PM for 32 seconds and then walked away. At 7:24 PM, the patient was approached by a security guard and after speaking, the patient and security officer walked out of sight of the camera view toward the exit. At 7:25 PM, the patient and officer returned to the ED waiting room and the patient sat down in a chair. At 7:27 PM, the patient appeared to be yelling at staff in the lobby. At 7:28 PM, RN #1 and the security officer were talking with the patient and can be seen pointing towards the exit doors and the patient laid down in the floor in front of RN #1 and the security officer. At 7:30 PM, two police officers arrived and talked to the patient and RN #1. At 7:34 PM, the patient walked out of the ED with the two police officers.

Review of Hospital A's Central ED Log revealed Patient #3 presented to the ED on 12/20/2021 at 7:20 PM for complaint of high blood sugar.

Review of Security Report #CSH2006 dated 12/20/2021 at 7:20 PM revealed, "...On 12/20/21 at approx. [approximately] 1920 [7:20 PM] EMS [Emergency Medical Services] brought out [Patient #3] to the lobby...[Patient #3] then asked [ED staff named] for some food she told him she would not be able to get him food tell [until] after he had been seen at which time he accused [ED Staff] of calling him a 'nigger' at which time I [Officer's name] told [Patient #3] that he does [not] need to talk like that to any of the staff...he started to call me a 'Fat mother fucker' and a 'Stupid piece of shit'...[RN #1/Charge Nurse] came out to lobby and told him if he wanted to be seen that he would have to sit down and stop acting up he then proceeded to call [RN #1] a 'White Bitch' a 'Ho' a 'Slut' and told her to 'suck his dick'. [RN #1] then told him that he is no longer welcome here and that he needed to leave...called for [Security] Supervisor...to come to the ED...[Patient #3] gather his things and walked him out he then came back in...[RN #1] called [Police Department]...[Police Department] arrived at 1930 [7:30 PM]...and escorted [Patient #3] off the property..."

Review of Patient #3's ED record from Hospital A dated 12/20/2021 revealed the patient arrived there on 12/20/2021 at 7:20 PM for complaint of "...high blood sugar...". Review of an ED Note dated 12/20/2021 at 7:28 PM written by RN #1 revealed, "...Patient verbally abusive in the lobby to staff and visitor, stating 'fat bitch, suck my dick', threatening harm, that he would beat my ass, stating he is not leaving. Scaring all visitors and Patients..." Review of an ED Note dated 12/20/2021 at 7:35 PM written by RN #2 revealed, "...Pt [patient] verbally abusive, cussing at charge RN, security, pt [patient] advocate, and every patient in the lobby. Security asked pt to leave due to violent nature of pt. Unable to triage pt due to pt continual yelling and uncooperativeness..." Patient #3 was discharged from the ED at Hospital A on 12/20/2021 at 7:35 PM with a comment stating, "...ED Disposition set to LWBS [left without being seen] before triage..." Continued review of the medical record revealed no documentation of Patient #3 being triaged or provided a Medical Screening Exam. Continued review revealed no documentation of the patient refusing an MSE or leaving Against Medical Advice (AMA).

Review of Hospital B medical records revealed Patient #3 arrived there on 12/21/2022 at 5:28 AM. Review of an ED Triage Note dated 12/21/2022 at 5:33 AM revealed, "...Patient arrives to triage with c/o [complaint of] hyperglycemia [high blood sugar level]. Patient states he was seen at the health clinic and was unable to get insulin [medication used to treat diabetes/high blood sugar]. Patient states he had his glucometer [device for measuring blood sugar level] and it was high..." The patient's blood pressure at 5:33 AM was 171/104 (normal is below 120/80). The patient's blood sugar level at 5:37 AM was 275 (normal is below 100).

RN #1 was interviewed by telephone on 6/14/2022 at 9:37 AM. RN #1 stated she remembered Patient #3's visit to Hospital A's ED on 12/20/2021. RN #1 stated the patient was yelling and threatening staff, patients, and visitors in the ED waiting room. RN #1 stated she spoke with the patient and tried to calm him down, but he continued to yell, curse, and make threatening statements toward her and others in the waiting room. RN #1 stated she explained the ED was very busy and he would need to wait until staff could evaluate him, but the patient insisted on being seen immediately. RN #1 stated she told the patient if he did not calm down, she would have to call the police. RN #1 stated the patient was a large man and very threatening and he was frightening staff as well as patients and family in the waiting room. RN #1 stated the police came and took him out of the ED. RN #1 stated the patient would not calm down enough to be triaged and he was not triaged or provided a Medical Screening Exam (MSE) before leaving. RN #1 stated the patient did not sign a Refusal of MSE or an AMA form.

RN #2 was interviewed by telephone on 6/14/2022 at 4:20 PM. RN #2 stated she remembered Patient #3's ED visit on 12/20/2021. RN #2 stated she was unable to triage the patient because he was screaming, cursing, and threatening staff. RN #2 stated she called the patient for triage, but he would not come to the triage room and stood in the lobby screaming and cursing. RN #2 stated everyone in the lobby was afraid of him. RN #2 stated someone called the police and when the police came, the patient left with them. RN #2 stated the patient was not triaged and was not provided a Medical Screening Exam.

Interview with the Quality Director in the Administrative Conference Room on 6/15/2022 revealed there was no documentation of Patient #3 being provided an MSE on his 12/20/2021 ED visit.

Based on policy review, medical record review, and interview, the facility failed to complete a Physician's Certification of the need, benefits, and risks regarding the transfer of one patient (#33) of 45 reviewed.

The findings included:

Review of facility policy titled "EMTALA [Emergency Medical Treatment and Active Labor Act] GUIDELINES - TREATMENT OF INDIVIDUALS IN NEED OF EMERGENCY MEDICAL SERVICES" dated May 2021 revealed, "...If an individual has an EMC [Emergency Medical Condition]...With Certification. The individual may be transferred if the individual is informed of the risks...a physician has signed the Certification on the "Physician's Certification" section of Exhibit A [facility's Transfer Form] that the benefits of the transfer to another facility outweighs the risks..."

Medical record review revealed Patient #33 presented to the Emergency Department (ED) at Hospital A on 6/5/2022 at 3:09 AM for complaint of gunshot wound to left lower leg. The patient was provided an MSE by a physician at 3:10 AM and was diagnosed with Gunshot Wound and Type III Open Displaced Fracture of Left Tibia. Patient #33 was transferred to Hospital B on 6/5/2022 at 4:05 AM. Continued review revealed there was no Physician Certification documenting the need, benefits, and risks of the transfer to Hospital B.

Review of Hospital B medical records revealed Patient #33 arrived there on 6/5/2022 at 3:57 AM. Review of the Discharge Summary dated 6/11/2022 revealed, "...Patient is a 28-year-old female who was injured on 6/5/2022 during a mastiff [mass] shoot out downtown. She was initially taken to [Hospital A] and transferred to [Hospital B] emergency department.

Interview with the Quality Director in the Administrative Conference Room on 6/15/2022, revealed there was not a completed Physician's Certification documenting the need, benefits, and risks of Patient #33's transfer in the medical record.