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Based on interview and record review, the facility failed to ensure three (3) of 24 sampled patients (7, 10, and 24) received a medical screening examination, to determine whether or not an emergency medical condition existed. Patient 7 and 24 were physically removed from the triage area of the hospital's emergency department (ED) by staff. Patient 10 was told by the charge to leave the hospital's ED.

This deficient practice resulted in patients not being medically screened to determine whether or not an emergency condition existed which had the potential to be a danger to self or others.

Findings:

1. A review of Patient 7's medical record indicated that Patient 7 arrived to the emergency department on 9/22/19 at 10:29 PM and left at 11:03 PM without receiving medical screening examination. The medical record indicated Patient 7 visited the emergency department for psychotic symptoms. The "ED-Note-Nursing," dated 9/22/19 and timed at 11:03 PM, written by the charge nurse, indicated that Patient 7 was called three times, no answer. Patient 7 left from ED lobby without being triaged.

On 11/5/19, at 2:55 PM, during an interview, the security manager stated he became aware of an incident that occurred on 9/22/19, regarding the physical removal of Patient 7, by emergency room (ER) staff, on the morning of 9/23/19. The security manager stated that security guard 1 reported the incident because she refused to follow the order from the charge nurse, to remove Patient 7 from the ER. The security manager reviewed the video footage and interviewed security guard 1. The security manager reported the incident to the ER supervisor and risk management execute director (RMD).

On 11/6/19, at 7:22 AM, during an interview, the emergency room technician (ERT) stated he took Patient 7's vital signs in the triage area, while Patient 7 sat on the bed. ERT stated he was asking Patient 7 basic questions, but Patient 7 was difficult, and was not very nice or polite. ERT stated when he asked Patient 7's reason for coming to the ER, Patient 7 replied that nothing was wrong with him and stated he wanted to smoke. ERT stated that the charge nurse came to triage Patient 7, and Patient 7 became agitated and confrontational with the charge nurse. The ERT stated that Patient 7 stated he wanted to smoke, and the charge nurse replied "there's the door". The ERT stated he was instructed by the charge nurse to remove Patient 7 from ER. The ERT stated he assisted Patient 7 off the bed, and walked him outside. The ERT stated Patient 7 sat just outside the entrance, to the right of the sliding door near the ambulance area. ERT told the patient he could not sit there and tried to pick him up by his hands, but Patient 7 locked his legs and would not get up. ERT stated he and a security guard grabbed the patient's arms and pulled the patient, in a sitting position. Patient 7 was gliding on the floor as they pulled him to the curb, and onto the grass. ERT stated Patient 7 wanting to fight with the security, the police were called, they spoke to Patient 7, then Patient 7 got up and left.

On 11/6/19, at 8:11 AM, during an interview, security guard 1 stated that on the night of 9/22/19, she was working at metal detector entrance in the ER. Security guard 1 stated Patient 7 was observed asking staff for a lighter. Security guard 1 stated Patient 7 entered the ER and went to the lobby and stated he was going to register. Security guard 1 stated Patient 7 was rallying other patients in the lobby and flirting with female patients. Security guard 1 stated Patient 7 was called to the triage hallway bed, and the ERT started doing vital signs. Patient 7 stated "nothing" was wrong when he was asked for his reason coming to the ER. Security guard 1 stated that Patient 7 stated he wanted to a cigarette and the charge nurse told Patient 7 that if he wanted to smoke he had to go across the street. Security guard 1 stated that the charge nurse instructed her to take him out of the ER. The security guard 1 stated she refused to take Patient 7 out because the patient was not combative or aggressive. Security guard 1 stated that the charge nurse instructed the ERT to take the patient out. Security guard 1 stated that the ERT took Patient 7 by the arm, while he was sitting on the bed, and nudged him, so Patient 7 got up and they started walking out. Security guard 1 stated that Patient 7 was very verbal and sat down on the floor next to the ER entrance. Security guard 1 stated she was in the process of calling the police, when she observed ERT and security guard 4 grab Patient 7. The patient's whole body became stiff, then ERT and security guard 4 dragged Patient 7 to the grass, and onto the curb. Security guard 1 stated Patient 7 was following staff around asking for a cigarette. The police came and talked to Patient 7 and the patient left on his own accord.

On 11/6/19, at 10:20 AM, video footage involving Patient 7 on 9/22/19 was viewed with the RMD. The following was observed. At 10:34 PM, Patient 7 arrived to the hallway bed. Patient 7 sat on the bed and ERT started taking his vital signs, security guards were present in the area. The charge nurse came to see Patient 7, there was an interaction. ERT picked up Patient 7 by the arm and walked him outside the ER. Patient 7 sat on the floor, to the right of the ER entrance, near the ambulance parking. The ERT and security guard 4 took Patient 7 by the arms and dragged him, in a sitting position, to the grass by the curb.

Concurrently, the RMD stated that Patient 7 was already in triage, but the staff shoved him out. The RMD stated that they believed that the charge nurse had been doing this for a long time.

On 11/7/19, at 8:25 AM, during an interview, the ER supervisor stated she learned from the security manager of an incident that occurred on 9/22/19, involving Patient 7. The ER supervisor stated, according to the video, Patient 7 went to the ER, sat in the hallway bed while ERT took his vital signs. The charge nurse had an interaction with Patient 7. The charge nurse spoke with security guard 1, the security guard refused to take out the patient. The ER supervisor stated that the ERT took the patient out, on the charge nurses's authority. The ER supervisor stated the incident was clearly an EMTALA violation, so she reported the incident to RMD.

The ER Director was interviewed on 11/7/19, at 8:25 AM, and stated that she was made aware of the incidents on 9/23/19, by the Security Manager. The ER Director stated that she alerted the RMD, and began an investigation of the incidents the occurred on 9/17/19 and 9/22/19. The ER Director stated that she had reviewed the video of the incidents and observed that on 9/17/19, the ERT grabbed Patient 7 and escorted him from the triage area, then ERT dragged Patient 7 away from the building. She stated Patient 7 should have been triaged and seen by a physician.

2. A review of Patient 10's medical record indicated Patient 10 arrived to the emergency department by ambulance on 5/3/19 at 2:36 AM. Patient 10 complained of anxiety and needed a medication refill. Patient 10 had a history of bipolar disorder (a psychiatric illness characterized by both manic and depressive episodes) and schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to a faulty perceptions, inappropriate actions and feeding). Patient 10 was triaged by charge nurse at 3:24 AM.

Patient 10's "Clinical Discharge Summary," dated 5/3/19, and timed at 5:37 AM, written by charge nurse, indicated Patient 10 eloped.

Patient 10's nursing note titled, "ED-Note-Nursing," dated 5/3/19 and timed at 5:36 AM, indicated Patient 10 left from the emergency room lobby after triage without been seen by medical doctor.

On 11/6/19 at 8:45 AM, during an interview, security guard 1 stated that on 5/3/19, Patient 10 was waiting in the lobby of the emergency department. Security guard 1 stated Patient 10 had been verbally aggressive towards staff. According to Patient 10, he needed medication refills. At one point, Patient 10 stated he was going to throw himself into traffic and become a 72-hour hold. There was a verbal escalation between the charge nurse and Patient 10. Patient 10 stated to the charge nurse that he wanted to leave. The charge nurse responded by waving his hand and stating "bye" and "get out of here". Patient 10 exited the building, then climbed to the roof to the medical record trailer. Patient 10 was crying and threatening to jump off the roof. Eventually, after talking with security guards, Patient 10 came down, and left the premises.

3. On 11/5/19, at 2:55 PM, during an interview, the security manager stated he became aware of an incident that occurred on 9/17/19, regarding the physical removal of Patient 24, by emergency room staff on the morning of 9/23/19. The security manager stated he reviewed the footage without audio. The security manager stated there was a female (Patient 24), at the registration desk, talking bizarre, and Patient 24 never have enough information to be registered. The security guard stated the patient was incoherent, and in obvious distress. The security manager stated the Patient 24 was carried out by the EDT and two security guards.

On 11/05/19 at 3:30 PM, the RMD stated during an interview, that on 9/17/19, Patient 24 was escorted out of the facility by three staff. The RMD stated that there was no documentation of Patient 24 being in the facility, and the facility did not have any documentation of Patient 24's name or other personal information. During the interview, the RMD stated the the staff was asked if they had thought about making the patient a "Jane Doe," and admitting the patient as the patient was in obvious distress.

On 11/6/19, at 7:22 AM, during an interview, the emergency department technician (ED tech) stated he was working in emergency room, when he heard screaming coming from the lobby. ED tech came to the lobby and saw a female (Patient 24) standing at the registration window and other patients were in the area. Patient 24 was making erratic gestures to people in the lobby. The ED tech stated he tried to help Patient 24 with the registration process. Patient 24 did not give a name. Patient 24 cursed at him and was dancing. The ED tech stated that the charge nurse instructed him to remove the patient. The ED tech and two security guard approached the patient, while she sat in the lobby. The ED tech stated Patient 24 swung her arms up in the air, so he grabbed her left wrist and right hand, then the situation got out of control because two security guards grabbed her feet and arms and they carried her out the lobby and onto the grass. Patient 24 ran off.

On 11/6/19, at 9:23 AM, video footage involving Patient 24 on 9/17/19 was viewed with the RMD. The following was observed. At 11:39 PM, Patient 24 arrived at the lobby and attempted to register at the registration window. Patient 24 was moving erratically and dancing at times. Patient 24 tried to fill out the registration form, then dropped the clipboard on the floor. EDT and two security guards were in the area. The charge nurse came to the lobby and motioned with his arm "out to the EDT". At 11:52 PM, Patient 24 sat down on a chair in the lobby, at that time, the EDT and two security guards forcefully pulled Patient 24 off her seat and carried her out of the ER and onto the grass on the curb. Patient 24 ran off and was not seen.

Concurrently, RMD stated Patient 24 was clearly in crisis. The RMD stated that the charge nurse looked at Patient 24 and pointed to ERT to take her out. The RMD stated that a security guard was actually laughing, as two other security guards and the ERT carry Patient 24 out of the ER.

On 11/6/19, at 12:38 PM, the PET Clinician (Psychiatric Emergency Team), for the facility stated she observed Patient 24 in the ER and that Patient 24 should have been triaged, medically cleared and then admitted to a facility. She stated that she can not see a patient until they are admitted and medically cleared. The PET Clinician stated that she did not witness Patient 24 being carried out from the facility, she stated she was involved with another patient in the ER, she stated Patient 24 appeared "gravely disabled" and needed to be treated.

On 11/7/19, at 8:25 AM, during an interview, the ER supervisor stated she learned from the security manager of an incident that occurred on 9/17/9 involving a female patient (Patient 24) in the ER. The ER supervisor stated she watched the video and stated Patient 24 was at the window in the lobby attempting to full out sheet, she was clearly psychotic. The charge nurse interacted with ERT, the charge nurse motioned to ERT to take Patient 24 out. Then, Patient 24 went to the lobby and sat on the chair, the ERT and two security guards approached her, grabbed her and pulled her out. The ER supervisor stated the manner in which they took her out was uncalled for, and Patient 24 should have been taken in and treated as "Jane Doe".

The ER Director was interviewed on 11/7/19, at 8:25 AM, and stated that she was made aware of the incidents on 9/23/19, by the Security Manager. The ER Director stated that she alerted the RDM, and began an investigation of the incidents the occurred on 9/17/19 and 9/22/19. The ER Director stated that she watched the incident from 9/17/19 and Patient 24 appeared "psychotic", and was forcibly removed from the facility by the ERT and security and carried to the curb, outside the ER. She stated that it appeared that the Charge Nurse waved and indicated to remove the patient from the ER. The ER Director stated that Patient 24 should have been taken to the triage area,admitted and seen by a physician.

There was no record of Patient 24 in the emergency department's log.

An interview of the facilities Director of Human Resources was conducted on 11/7/19, at 9:15 AM. During the interview, the Director of Human Resources stated that all employees at the facility receive abuse training when they are hired and annually through the facilities "RED BOOK", computerized training. A printed copy of the facilities "RED BOOK was provided and no EMTALA was found. On 11/7/19, at 10:45 AM, the Director of Human Resources stated that he was unable to locate EMTALA Training in the "RED BOOK" computerized training provided to all facility staff.

The facility's policy and procedure titled, "Emergency Department," dated 7/2019, indicated all patients will be evaluated by the triage or primary nurse once they have had a quick registration by the emergency department registration clerk.

The facility's policy and procedure titled, "Triage," dated 6/2017, indicated all patients presenting to the emergency department (ED) will be triaged and categorized according to the Emergency Severity Index (ESI, a decision-making process based on the collection of date and information which is utilized to sort injured and ill patients into categories [acuity levels] based on the urgency of their medical condition). The Emergency Medical Treatment and Active Labor Act (EMTALA) requires medical screening of individuals seeking emergency care to determine whether an emergency medical condition exist. At the time of triage, basic medical information will be obtained by the licensed healthcare personnel, which will include a minimum of the patient's name, vital signs, pain, and chief complaint. Upon arrival to the ED, registration will do a quick registration for each patient that presents to the emergency department. Patients cannot be triaged until quick registration is complete.