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Based on interview, record review, and review of facility policies, it was determined the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) provisions related to medical screening exams (MSE), that was within the hospital's capability and capacity. The deficient practice affected Patient #1 (P1), who became aggressive and threatened violence when staff attempted to place an IV. P1 was escorted out of facility by hospital security prior to completion of the MSE.

Facility provided evidence of investigation and staff education following incident.

The findings include:

The facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital's emergency department (ED) for one (1) of twenty-four (24) sampled patients. Patient (P) 1 presented to the ED on 01/11/2025 with complaints of shortness of air and chest pain.

Cross Refer to A2406.

Based on interview, record review, and review of facility policies, it was determined the facility failed to provide a Medical Screening Examination (MSE) within the capability of the hospital's emergency department (ED) for one (1) of twenty-four (24) sampled patients. Patient (P) 1 presented to the ED on 01/11/2025 with complaints of shortness of air and chest pain. While present, P1 became aggressive and threatened violence when staff attempted to place an IV. P1 was escorted out of facility by security prior to completion of an MSE.

Facility provided evidence of investigation and staff education following incident.

The findings include:

Review of the facility policy EMTALA: Treatment and Transfer of Individuals in Need of Emergency Medical Services, last reviewed 11/02/2022, revealed all facilities with a dedicated ED must provide individuals who need or seek care with an MSE within the capability of the ED to determine whether an emergency medical condition exists.

Review of System Workplace Violence Prevention Committee policy, last reviewed 06/26/2023, revealed patients that are causing an unsafe/disruptive environment for staff/visitors/other patients may be discharged. Policy goes on to state all steps in outline must be met prior to discharging patient. The policy goes on to outline, for patients presenting to ED, EMTALA guidelines were to be followed, to include ensuring patient received an MSE to determine if a medical emergency existed.

Review of Current Summary Aggressive Patient Event entered 01/11/2025 revealed Patient (P) 1 was known to facility. Report states P1 came by EMS and when staff attempted to insert an IV patient began cussing and drew fist back to punch staff. Staff member stopped and walked away when charge nurse came in and told patient he needed to leave. Security escorted patient out and police were notified.

Email with local police dated 02/27/2025 revealed no police report was filed regarding P1 on 01/11/2025.

Review of P1's medical record revealed P1 presented to facility via EMS on 01/11/2025 at 12:22 AM with chief complaint shortness of air and chest pain on inhalation x2 years. Medical Doctor (MD) 1 put in orders at 12:40 AM for a DuoNeb (combination of bronchodilators to open airways in lungs) inhaler, a saline bolus, a COVID/Flu/RSV PCR (nasal swab) test, troponin (test for heart attack), lactic acid, CMP, CBC, an EKG, and a portable chest x-ray. EKG was completed at 12:49 AM and results were communicated to MD1 at 12:55 AM. Chest x-ray obtained at12:57 AM, compared to results of chest x-ray in system on 12/23/2024. Chest x-ray noted no pleural effusions, no pneumothorax, and no acute osseous process. Medical record notes RN1 and Paramedic (PM)1 were in P1 room at 1:19 AM discontinuing breathing treatment and attempting to start IV access (P1 had removed IV placed by EMS) when P1 became verbally aggressive and physically threatening (making a fist, attempting to strike PM1). Note states security was notified and P1 was escorted out of the ED. Medical record completed by Charge Nurse (CN) 1 goes on to reveal P1 was provided an MSE, left facility AMA after risk vs benefits were explained, and declined to sign AMA form at 1:32 AM. No documentation from MD1 in record.

Interview with PM1 on 03/04/2025 at 9:00 AM stated he worked with P1 on the night of 01/11/2025. PM1 stated they got P1 back to a room, triaged him, and orders started coming in. He stated P1 was not aggressive initially, but when he went in with RN1 to get an IV line started, P1 jerked his arm away. PM1 stated he told P1 he knew an IV wouldn't feel comfortable, but he needed to have one. PM1 stated P1 jerked his arm away again, started swearing, and drew his fist back like he was going to strike PM1. PM1 stated he asked P1 not to do that, but P1 continued to swear and act like he was going to strike him. PM1 stated at that point he left the room. PM1 stated he had seen MD1 poke his head in the room, and assumed MD1 had seen P1, as there were multiple orders in system that were more in depth than typical triage orders.

Interview with RN1 on 03/04/2025 at 10:20 AM stated she was working on 01/11/2025 and was assigned to P1. She stated there were just a few patients in the department that night, and MD1 was working. She stated they did an EKG on P1, who was there maybe an hour and MD1 had put in close to 20 orders on patient. RN1 stated when she entered the room, P1 had already pulled the IV out that EMS had put in. She stated she was in the room with PM1 trying to start a new IV line and P1 was yelling, grumbling, and cursing her. She stated P1 came off the bed yelling, drew back his fist and swung at she and PM1. She stated they tried to calm him down, explaining what they were doing but he just got angrier. RN1 stated she yelled for help. Security was just outside the door, and the patient's room was right across from the nurse's station where Charge Nurse (CN) 1 was. RN1 stated she removed herself from the room, thinking P1 was upset with her or that she was triggering his anger, and she didn't know what happened after that. RN1 stated she thought MD1 had been in there to see P1, as P1 had very specific orders. RN1 stated she wasn't aware P1 had not completed a medical screening until she spoke with the Medical Director Southwest (MD SW) days later.

Interview with Charge Nurse (CN) 1 on 03/04/2025 at 2:07 PM stated he was sitting at the nurse's station on the night of 01/11/2025 when RN1 and PM1 called for security. He stated he responded with security and told P1 he had to leave. He stated P1 had orders in system, so he believed MD1 had seen P1. CN1 went on to state the facility has a zero-tolerance policy for aggression, and he was following policy when he made the judgement call and trying to keep his staff safe. CN1 stated there was no option in the system for patients escorted out by security, so he put P1's disposition as left AMA (against medical advice).

Interview with Security (S) 1 on 03/03/2025 at 3:30 PM stated he was working the night of 01/11/2025 and remembered receiving a call about a patient being aggressive. He stated he was told P1 had made a fist when staff went to stick him with an IV. S1 and S2 escorted P1 out of the ED without incident. P1 didn't want to go to a shelter, and refused to leave, so eventually the local police were called. S1 stated when police told P1 to leave, he did. S1 stated he did not threaten or act aggressively towards security staff.

Interview with S2 on 03/04/2025 at 3:46 PM stated he was working the night of 01/11/2025 and remembered the incident with P1. He stated he was in the ED talking to staff when RN1 screamed his name. S2 stated RN1 told him P1 drew a fist and acted like he was going to hit staff. S2 stated CN1 instructed him to remove the patient, and he and S1 escorted P1 out. S2 stated P1 appeared irritated at the medical staff but was cooperative with security. S2 stated they spoke with P1 for a bit, and eventually had to call local police as P1 refused to leave. He stated after police arrived they were able to convince P1 to leave.

Interview on 03/05/2025 at 12:16 PM with the Emergency Department Director (ED Director) stated she reviewed the incident with P1. She stated P1 came into the ED just after midnight on Saturday 01/11/2025 by EMS with complaints of shortness of breath and chest pain x3 years. ED Director stated MD saw problems P1 presented with and started placing orders based on that, as well as likely reviewed documentation from a previous visit to a sister facility on 01/07/2025. While staff were working on following MD orders, P1 became upset when staff attempted to place an IV, started cursing at staff and posturing as if to strike staff. Staff called out for help, security and CN1 responded, with CN1 asking security to escort P1 out. ED Director stated she was reviewing incident reports the following Monday when she received a call from the Director of Compliance and Privacy (DCP) to ask if she could confirm there was a MSE on P1. She stated she reached out to the Nurse Manager (NM) and asked if she was aware if MSE had been completed on P1. ED Director stated she and NM researched the chart and interviewed staff that worked that night about the incident and MSE. ED Director stated when MD notes aren't signed, they don't see them in system. ED Director stated MD1 was contacted, and it was determined an MSE was not completed. Both RN1 and PM1 thought MD1 had seen P1, and CN1 wasn't certain. ED Director stated they followed back up with DCP to let her know, and she conducted her portion of the investigation. ED Director stated all staff involved were night shift workers who had worked the weekend, which played a significant role in the investigation timeline. After determining on 01/15/2025 an MSE had not been completed, facility self-reported to state survey agency.

ED Director went on to state CN1 was trained on EMTALA and CPI and sent P1 out without knowing for certain that MD had provided P1 an MSE. ED Director stated DCP did education sessions with all ED staff via Teams, providing an opportunity for staff to ask questions. ED Director shared EMTALA training had also recently (prior to incident) been assigned in computer-based learning. If an incident were to occur in future, staff know to ask provider if MSE has been completed, with security also educated to ask that question prior to escorting a patient from the ED.

ED Director concluded there is no disposition on ED documentation for patients escorted out by security without receiving a MSE - it should not happen. If a patient chose to leave before receiving a MSE, it would be documented as LWBS (Left Without Being Seen). If a patient left after receiving a MSE, disposition would be eloped (if not seen by staff) or AMA (Against Medical Advice) if seen by staff and educated on risk vs benefits of leaving. ED Director stated CN1 falsified documentation by documenting P1 left AMA, and did not attempt to contact his supervisor for guidance at the time of the incident. If staff have an incident they aren't sure how to handle, they are to contact their supervisor, ED Director, or an administrator on call. Staff could have left the room, informed MD1 P1 refused IV. ED Director stated CN1 (who worked Fridays through Sundays) was placed on administrative time off beginning Wednesday 01/15/2025 and was terminated the following week on 01/23/2025. ED Director shared MD1 was in Cambodia, as he split his time between facility and a clinic in Cambodia and was out of reach. Also, shared DCP was in Washington.

Interview on 03/04/2025 at 9:15 AM with the Nurse Manager (NM) shared she saw the incident report involving P1 on Monday 01/13/2025 in the afternoon and received an email from CN1 regarding the incident with P1 and was contacted by DCP that day as well asking questions about the incident involving P1. She stated she had to reach out to CN1 as she did not see documentation that a MSE had been completed for P1. She stated, in interview with CN1, he stated he did not believe a MSE had been completed, and although he did not see what transpired involving P1, he went off report from PM1 and RN1. NM stated for almost any aggressive patient, staff are to send someone else in to try to deescalate the patient, and security can attempt to deescalate as well while staff continue to try to treat the patient. NM stated she could not recall a time since she had been NM (since 2013) that a patient had been removed prior to receiving an MSE. NM stated CN1 made a judgement call to have P1 escorted out.

Continued interview with NM stated all staff know the importance of the MSE, and all staff are trained on EMTALA. She stated EMTALA education is received quarterly. NM stated in latest training (following incident) the importance of the MSE was stressed. NM stated all staff also receive non-violent crisis intervention training on hire and receive yearly refresher training, which covers de-escalation.

Review of transcript EMTALA Training Session, from a TEAMS (Microsoft TEAMS, video conferencing software) meeting recorded on 01/17/2025 from 1 PM until 1:40 PM revealed Director of Compliance and Privacy (DCP) trained ED staff on EMTALA, with focus on ensuring patients receive an MSE. DCP discussed incident that occurred on 01/11/2025 with P1, noting leadership - the provider (MD1) never had an opportunity to go in and try to calm P1. Training encouraged staff to use skills learned in nonviolent crisis training, such as de-escalation or removing oneself from the situation. Also calling for help, to include security. Staff are then encouraged to talk to their lead person, charge nurse or supervisor to get them involved, as well as getting the provider involved. Emphasis of training is ensuring provider can screen patient to determine whether a medical emergency exists. In cases of extreme violence, security can call police, and police can escort patients off property AFTER an MSE has been completed.

Review of email from Nurse Manager Medical Center Southwest ED (NM) to ED Director for Southwest and East (ED Director) dated 02/28/2025 titled Training, revealed all ED nurses, technicians, and paramedics had received the TEAMS training above, with completion dates ranging from 01/16/2025 to 01/31/2025, with most staff having completed training on 01/16/2025 or 01/17/2025.

Interview with RN2 on 03/03/3035 at 2:54 PM stated staff were trained on how to deal with patients that present with aggressive behavior, to include verbal de-escalation and removing oneself from a situation and allowing another staff to attempt to deescalate. RN2 further shared staff received EMTALA training, and that they are required to see all patients that present to the ED regardless of what situation they may be having. RN2 shared on more recent EMTALA training, the focus was on ensuring patients receive an MSE.

Interview with ER Tech on 03/03/2025 at 3:09 PM stated she had received training on de-escalation and has had to de-escalate aggressive patients in the past. She stated if not able to deescalate, she would get her charge nurse and go on up the chain from there to include security and potentially police. ER Tech stated she had also had EMTALA training, with most recent training emphasizing that all patients must receive an MSE from a provider. ER Tech stated she had been on two TEAMS meetings for education following incident involving P1.

Interview with PM1 on 03/04/2025 at 9:00 AM stated he had received training on de-escalation. He stated he received EMTALA training and had a recent class that covered more specifics as it related to their facility. When asked to elaborate, PM1 stated there was no easy way to tell in the medical record if an MSE had been completed by a provider, and the MSE had to be completed when a patient presented to the ED.

Interview with NM on 03/04/2025 at 9:15 AM stated everyone is trained on de-escalation, with training on hire and yearly refresher training. NM stated staff receive EMTALA training quarterly and have had a recent training emphasizing the importance of an MSE.

Interview with RN1 on 03/04/2025 at 10:20 AM stated she received training on nonviolent crisis intervention every year, and EMTALA training every quarter. She stated following the incident with P1, she received additional training, a group call with more in-depth discussion on EMTALA, to include policies and procedures for dealing with aggressive patients.

Interview with S2 on 03/04/2025 at 3:46 PM stated he had received nonviolent crisis intervention training. Following the incident with P1, S2 stated he met with his supervisor and was informed to ask staff in the future for any patient incident in the ED if the patient had been medically screened.

Interview with the ED Director on 03/05/2025 at 12:16 PM stated staff were educated following the incident with P1, with focus on what constitutes an MSE and the importance of the MSE. ED Director stated staff were given time to ask questions during the training. If staff aren't certain a patient has had an MSE, they are to talk to the provider. ED Director also shared security leadership was asked to train security staff to so they could ask if a patient had a medical screening exam prior to escorting a patient out of the ED.