HospitalInspections.org

Based on policy review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination was provided for a patient who presented to the hospital's Dedicated Emergency Department (DED) for evaluation on 11/11/2021.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's DED for psychiatric evaluation on 11/11/2021.

~cross refer to Tag A2406.

Based on policy review, medical record review, police report, and interviews the hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #2) who presented to the hospital's Dedicated Emergency Department (DED) for psychiatric evaluation on 11/11/2021.

The findings included:

Review of facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA)" effective 1997 revealed, "...Anyone who comes to the emergency department in need of emergency care or requesting exam or treatment will receive medical screening exam and stabilizing treatment in accordance with EMTALA ... Qualified medical personnel will, within the hospital's capability and capacity, conduct and document an appropriate medical screening examination (MSE). A. An appropriate medical screening examination should address the presenting symptoms and an assessment of those presenting symptoms ... B. Emergency medical condition is a condition manifesting itself by acute and severe symptoms of sufficient severity (including ... psychiatric disturbances and/or symptoms of substance abuse)..."

Closed medical record review conducted on 12/07/2021 revealed Patient #2 was a 27-year-old female who presented to Hospital A's DED by ambulance on 11/11/2021 at 2140 with a chief complaint documented as suicidal. Review of a note written by Registered Nurse (RN) #1 on 11/11/2021 at 2145 revealed, "Vital Signs Temp: (refused)." Review of a Triage Note written by RN #1 on 11/11/2021 at 2145 revealed, "Patient was picked up by EMS from home patient was sternum rubbed due to slumbered (sic) activity. Patient was covered in vomited (sic) per EMS. Patient will not let anyone get vitals (sic) signs on patient. EMS states that patient admitted to using alcohol. Upon arriver (sic) patient was trying to roll off of the stretched (sic). Patient moved to bed. Patient the (sic) punched this nurse with right hand and then kicked myself in the face and grabbed my arm. Patient the (sic) therapeutically held by security. Providers at bedside. (Local Police Department) called and patient taken out in police custody." Review of a Provider Note written by Doctor of Osteopathy (DO) #2 on 11/11/2021 at 2202 revealed, "...Immediately upon arrival patient became agitated, combative and required restraints. Patient did pick (sic) one of the nurses attempting to help her right in the face. We were unable to fully examine the patient due to her uncooperation (sic) and violent behavior. (Local Police Department) was called and patient was arrested. Nurse plans on pressing charges. Patient left in police custody. Unable to perform review of systems, appropriate physical exam." At 2202 DO #2 set the ED Disposition to Discharge. Review of a note written by Charge Nurse (CN) #3 on 11/11/2021 at 2328 revealed, "Departure Condition Departure Condition: Stable Mobility at Departure: Restrained."

Review of a report written by Security Officer (SO) #6 on 11/12/2021 at 0241 revealed, "...ON 11/11/2021 AT 21:40 HOURS, SECURITY WAS CALLED TO GO TO THE EMERGENCY SERVICES AMBULANCE BAY DUE TO A COMBATIVE PATIENT BEING BROUGHT IN BY EMS. WHEN SECURITY ARRIVED AT THE AMBULANCE BAY, SECURITY WAS INFORMED THAT THE PATIENT WAS TAKEN TO BED 36. AS SECURITY WAS APPROACHING ROOM 36, THE PATIENT, (Patient #2 Named), HAD JUST BEEN MOVED TO THE BED. ONCE (Patient #2 Named) WAS MOVED TO THE BED, SHE BEGAN SWINGINGS AT THE EMS AND NURSING STAFF. DURING THIS VIOLENT OUTBURST, (Patient #2 Named) WAS OBSERVED BY SECURITY STAFF STRIKING EMERGENCY SERVICES NURSE, (RN #5 Named), WITH HER FIST. AS SECURITY WAS ENTERING THE ROOM, (Patient #2 Named) NURSE (RN #5) IN HER FACE. SECURITY THEN TOOK HOLD OF (Patient #2 Named) AND HELD HER TO THE BED. AS WE WERE HOLDING (Patient #2) TO THE BED TO PREVENT HER FROM ASSAULTING ANYONE ELSE, (Patient #2) BEGAN USING PROFANITY AND RACIST REMARKS TOWARD SECURITY AND NURSING STAFF. (Patient #2 Named) CONTINUED TO STRUGGLE TO GET LOOSE AND AT ONE TIME EVEN ATTEMPTED TO BITE ONE OF THE MEDICAL STAFF THAT WAS ASSISTING IN HOLDING HER DOWN. AS SECURITY WAS HOLDING (Patient #2) DOWN, SECURITY WAS INFORMED THAT (Local Police Department) WERE CALLED AND ARE ENROUTE. WHEN (Local Police Department) ARRIVED, (Patient #2) WAS PLACED IN HANDCUFFS AND TRANSPORTED TO THE (Named) COUNTY JAIL. NURSE (RN #5) DID FILE CHARGES AGAINST (Patient #2) FOR ASSAULT."

Review of a Police Report written by Police Officer #4 on 11/12/2021 at 0111 confirmed Patient #2 was arrested for assault and transported to the local county jail.

Telephone interview was conducted with RN #1 on 12/07/2021 at 1320. Interview revealed RN #1 was not Patient #2's nurse. Interview revealed RN #1 did witness RN #5 attempting to begin Patient #2's triage on 11/11/2021 and get punched and kicked in the face. RN #1 left her computer where she was documenting on her own patient to assist with a "hectic situation." Interview revealed Patient #2 was "brawling out and taken out in custody." Interview revealed RN #5 must have returned to the computer RN #1 was originally signed in on and documented the incident under RN #1's name.

Telephone interview was conducted with RN #5 on 12/07/2021. Interview revealed Patient #2 came in by EMS and was attempting to jump off their stretcher. Facility staff moved Patient #2 over to the ED stretcher, and RN #5 put the bed in its lowest position and when attempting to put up the second stretcher rail Patient #2 punched and kicked RN #5 in the face. Facility staff then placed Patient #2 in a therapeutic hold. Interview revealed DO #2 came to the room immediately after RN #5 was assaulted. After enough staff and security had arrived in the room, RN #5 removed herself from the room, and documented the incident. RN #5 had no further contact or interaction with Patient #2. Interview revealed RN #5 then went to the county magistrate's office.

Telephone interview was conducted with CN #3 on 12/07/2021 at 1604. CN #3 recalled Patient #2 being moved from the EMS stretcher to the ED stretcher and RN #5 was beginning to gown the patient. CN #3 recalled RN #5 may have reached down to remove a cell phone from the patient's shirt and Patient #2 punched RN #5 and staff started to initiate a therapeutic hold, then Patient #2 was able to kick RN #5. CN #3 recalled the incident happen "very fast." CN #3 stated DO #2 was originally in the nurse's station and came to the open door of the room when Patient #2 started hitting staff. CN #3 didn't recall DO #2 being able to enter the room as the room wasn't very big and it had multiple staff and EMS in it. DO #2 asked staff opinion on sedation and calling the local police department. CN #3 did not recall any other statements. Interview revealed when Patient left the ED, she was handcuffed in police custody, ambulation was steady. Patient #2 was belligerent and yelling, and her words were clear and coherent. Interview revealed CN #3 couldn't recall exactly what time Patient #2 left the department, but she was not in the ED long. Interview revealed CN #3 was not able to document the discharge until 2328 because the ED was very busy that night and she had to catch up on documentation later in the shift.

Telephone interview was conducted with DO #2 on 12/08/2021 at 1000. Interview revealed DO #2 went to Patient #2's room when she heard screaming. Interview revealed when she arrived, Patient #2 was being physically restrained, and hospital staff reported the patient had struck RN #5. DO #2 was also told the local police department was on the way to get the patient. Interview revealed Patient #2 was not cooperating with an assessment or examination attempts. Interview revealed, "She received as much eval that was safe for me and my staff." DO #2 did not recall ever stating Patient #2 was safe for discharge. Interview revealed Patient #2 was drunk and assaulting staff and DO #2 was trying to make it safe for us and her.