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Based on document review and staff interviews, the hospital failed to ensure the medical staff followed hospital policies, ensuring 1 of 19 patients selected for review, received an appropriate medical examination (Patient #9). Failure of the hospital's emergency department (ED) staff to provide an appropriate medical screening examination (MSE) within the hospital's capabilities, resulting in Patient #9 leaving the hospital's ED without receiving an appropriate medical examination to determine if Patient #9 had an emergency medical condition and Patient #9 needing to return to the hospital's ED to receive an MSE 7 hours later. The hospital's administrative staff identified an average of 5,355 patients per month who presented to the hospital's dedicated emergency department (DED) and requested emergency medical care.

Findings included:


1. Review of the policy "Emergency Medical Treatment and Labor Act," reviewed/Revised 3/22 , revealed in part, "...All individuals who come to [hospitals name] DED for examination or treatment shall receive an appropriate MSE...DED will provide an appropriate level of medical screening in a uniform manner to all patients who present...with substantially the same or similar complaints...MSE can involve...a brief history and physical examination,...diagnostic procedures...MSE to be provided within the capabilities of [hospital name]..."

2. Review of the "Medical Staff Rules and Regulations" approved 7/13/17, revealed in part, "...All patients requesting emergency treatment shall be examined by a practitioner prior to discharge...Emergency Department Physicians will Routinely Treat any patient who presents to the Emergency Department for treatment..."

3. Review of Patient #9's medical record revealed Patient #9 presented to the Emergency Department (ED) on 5/28/22 at 2:57 AM. Patient #9 complained of right foot and ankle pain.

4 During an interview on 7/18/2022 at 10:38 AM, ED Physician A revealed with the presenting complaint of foot and ankle pain, ED Physician A would typically obtain a patient history, perform a focused exam to the right foot and ankle, and obtain x-rays of the foot and ankle if needed. ED Physician A reported a heated verbal altercation with Patient #9 prior to exam being performed. Patient #9 was transported to jail and had not received an examination, care or treatment for his right foot and ankle pain prior to transport.

5. During an interview on 7/12/2022 at 8:40 AM, ED Physician B reported Patient #9 returned by ambulance to the ED on 5/28/22 at 9:51 AM. ED Physician B reported they performed a history, focused exam, and ordered x-rays. Patient #9 was diagnosed with a right foot and ankle sprain, provided with crutches, discharge care and follow up instructions.



Please see A-2406 for additional information.

Based on document review and staff interviews, the acute care hospital's (ACH) emergency department (ED) staff failed to provide an adequate medical screening examination for 1 of 19 patients (Patient #9) that presented to the ACH's ED. Failure to provide an appropriate medical screening exam resulted when ED Physician A failed to attempt de-escalation techniques with Patient #9's agitation and yelling, and instead, engaged in a heated verbal altercation that ended with Patient #9's arrest and transport to jail prior to receiving an appropriate medical screening examination (MSE) to determin if Patient #9 had an emergency medical condition (EMC) and the subsequent return of Patient #9 to the ED by ambulance approximately 7 hours later for an appropriate MSE of right foot and ankle pain. The hospital's administrative staff identified an average of 5,355 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings included:

1. Review of Patient #9's closed medical record revealed Patient #9 presented to the ACH ED on 5/28/22 at 2:57 AM via private car with 2 friends appearing intoxicated, was loud, and belligerent from the moment of arrival. Patient # 9 has medical history of memory issues related to past traumatic brain injury and antisocial personality disorder in adult.

2. At 3:08 AM, Physician A documented, in part, "Patient brought back to the emergency room 8 for treatment cursing and screaming ...even though [they] were brought back immediately... screaming out from room cursing and yelling. Completely belligerent and uncooperative and I am unable to do an exam...however. [Patient #9] is awake and alert ambulatory although limping and does not have a life-threatening medical condition...has been cleared from a medical clearance exam although I am unable to evaluate [Patient #9's] foot/ankle injury. My intent was to evaluate this but [Patient #9] is so belligerent and smells heavily of alcohol...patient poses a threat to myself and staff...unable to calm down to allow me to examine [them] and at this point I refused to examine the injury as this is not the only Emergency Department the cities area and [Patient # 9] has been threatening to me both verbally and physically. A medical screening exam has been done." The patient was "free to go to another emergency department as this is not a life or limb threatening injury." Discharged at 3:08 AM in police custody without further examination, x-ray, or treatment for his foot/ankle injury. An Addendum added to the chart by ED Physician A states, "Patient never placed hands on me and I never placed hands on the patient."

3. At 3:12 AM, RN C documented, "called SC jail and updated on patient coming to jail."

4. Further review of Patient #9's medical record revealed Patient #9 returned to the ACH ED by ambulance on 5/28/22 at 9:51 AM with complaints of right foot and ankle pain from unknown mechanism.

5. At 10:05 AM, X-ray performed on Patient #9's right ankle/foot with findings, "No evidence of fracture."

6. At 10:34 AM, ED Physician B documented in part, "...states [they] were drinking last night...developed some right ankle and foot pain...Patient was extremely intoxicated last night came to the ED got into a shouting match with the ED provider [ED Physician A] that was working overnight...[Patient #9] was threatening to "beat that physician's [expletive]"...This resulted in the patient being escorted off the premises by police and spending the night in jail...now returns for re-evaluation of said ankle injury...Patient neurovascularly intact to foot and ankle. X-rays are negative for any fracture. Patient will be made non-weight bearing...Ace wrap applied. Will be discharged to follow-up with primary care provider...Diagnosis suspected foot and ankle sprain...Condition: improved, Stable..."
Patient #9 was discharged from the ED at 11:22 AM to home to self medicate with Tylenol and Motrin.

7. During an interview on 7/18/22 at 10:38 AM, ED Physician A revealed they had seen Patient #9, on ED video camera, lying face down on the hospital vestibule floor. Two other individuals had dumped Patient #9 off. Patient #9 was complaining about their ankle, yelling and cursing loudly, and would not get up. The ED staff wheeled Patient #9 straight back to a room and Patient #9 continued cursing. Everybody could hear the patient in the ED. We had other patients back here that didn't need to hear Patient #9's belligerent cursing. The nurses tried to get Patient #9 settled in and taken care of. ED Physician A reported thinking it might be a situation that they could de-escalate Patient #9 or use a chemical restraint (use of medications to subdue, sedate, or restrain a patient). ED Physician A went to Patient #9's room and asked Patient #9 why they were there. Patient #9 wouldn't give an answer and got right in ED Physician A's face and started to curse. ED Physician A reported it became clear that Patient #9's ankle was the problem. ED Physician A disclosed they argued with Patient #9 and ED Physician A had Patient #9 taken off the premises. ED Physician A assessed Patient #9 was not in a life-threatening situation. Patient #9's airway was clear, was not having a heart attack or a stroke, was awake and alert, neurologically fine. ED Physician A described Patient #9's behavior as being an "[ expletive], a belligerent drunk", but Patient #9 was "not psychotic". Intermittently, Patient #9 would say they wanted to leave and then screamed "get the [expletive] off me". ED Physician A verbalized they didn't know if Patient #9 wanted to be there or not. ED Physician A reported Patient #9 was abusing myself and the ED staff. ED Physician A acknowledged it was a heated argument. The cursing in ED Physician A's face, set ED Physician A off. Typically, when a patient presents with complaints of foot and ankle pain, ED Physician A would see the patient, take a medical history, look at the foot and ankle, and get x-rays. It involves an isolated, focused exam of the foot/ankle. ED Physician A stated the problem with Patient #9 and me in the ER had nothing to do with the ankle. ED Physician A described Patient #9 as a "belligerent drunk" and ED Physician A did not know why they responded like that to Patient #9.

8. During an interview on 7/12/22 at 8:40 AM, ED Physician B reported they took care of Patient #9 when Patient #9 returned to the ED on 5/28/22 at 9:51 AM. ED Physician B had already been notified that Patient #9 had presented to the ED early in the morning, got into an altercation with ED Physician A, and had viewed and listened to the audio video recording of the incident. ED Physician B reported the security camera didn't show the incident but could clearly hear the audio portion. ED Physician B provided the following analysis: ED Physician A's response wasn't professional. People need to always see you in control. Patient # 9 was combative and violent. ED Physician A's behavior was very out of control, unprofessional. They goaded (provoked) each other, both saying you hit me first. ED Physician A "snapped". ED Physician B disclosed this ED campus is a safety net for this community that sees a lot of crime. Patient #9 sought care for a lower extremity injury. The airway was intact, the primary survey intact. Patient #9 was able to interact, coherent enough to give a history. Alcohol intoxication was apparent but Patient #9 was not in immediate danger. ED Physician B was the provider that treated Patient #9 on the return ED visit. ED Physician B acknowledged Patient #9 talked about their previous visit and took issue with how they were treated by ED Physician A. ED Physician B reported Patient #9 remained combative and very "in your face". ED Physician B verbalized feeling threatened by Patient #9. Patient #9 questioned everything that ED Physician B or the ED staff did and remained pretty difficult. Patient #9 stated to ED Physician B something about the prior injury, used a very descriptive word like "crushed" but there was no physical evidence of that. Patient #9 had normal pulses in the affected extremity, nothing significant noted. Patient #9 couldn't put much weight on the right foot so crutches were provided. ED Physician B diagnosed a soft tissue injury, a sprain. There were no fractures seen on x-ray. Patient #9 was diagnosed with a right foot and ankle sprain, provided with crutches, discharge care and follow up instructions.


9. During an interview on 7/13/22 at 7:12 AM, RN C reported there are security cameras on the hospital entrance vestibule. RN C, RN E, and RN F viewed three people come in the door, stumbling. RN C, RN E, and RN F grabbed a wheelchair and went to the vestibule. Patient #9 had fallen and was lying face down on the floor. Patient #9 was asked to roll over as they couldn't assist Patient #9 up in that position. Patient #9 responded to Patient #9's friends, take me some place else they are not going to help me. RN C clarified the ED staff's intent to help. RN C observed all three were drunk and stumbling around. RN C recalled a friend helped Patient #9 into the wheel chair and the ED RNs took Patient #9 back to room 8, passing by Police Officer (PO) D on the way back. RN C helped Patient #9 get up on the bed and took off Patient # 9's right shoe. RN C tried to put Patient #9's feet up in bed, assess injury, take vital signs, and complete general admission procedures. Patient #9 refused to allow RN C to do these. RN C reported leaving the room to allow Patient #9 to settle a bit as sometimes this helps. Patient #9's friend remained in room 8. RN C revealed continued yelling and cussing could be heard coming from room 8. By then the PO D, (had been at desk inside the door and heard all the commotion) and 2 security officers (SO) arrived in the ED. Patient #9 is observed laying on the floor on their back in the door way filming with their phone. ED Physician A had told Patient #9 to stop cussing. Patient #9 said these "[expletive]" aren't going to help me, take me somewhere else. RN C verbalized the first time the ED Physician A said stop swearing, and walked away. Patient #9 stood back up, standing on left leg, tippy toes of right foot. RN C reported ED Physician A intended to get an x-ray and thought the ankle might be sprained or broken. Patient #9 didn't put full weight on it, but was putting some weight on that foot. Patient #9 continued to yell and curse. ED Physician A returned. PO D decided to call the local police department. Patient #9 stood in the door way with Patient #9's friend, PO D was two or 3 feet away. RN C was right behind PO D, between ED Physician A and PO D. RN C reported she was trying to get ED Physician A to not go around RN C and hit the patient, as RN C was concerned it might happen. RN C described trying to hold ED Physician A off with both arms/hands, pushing ED Physician A back and telling them to go sit down and cool down. RN C reported ED Physician A did go back to the nurses' station and sit down. When police arrived RN C asked ED Physician A to go to the break room but ED Physician A remained at nurses' desk. RN C acknowledged ED Physician A was the only scheduled provider in the ED that night. When police officers(PO) arrived, they were just going to escort the patient out. Patient #9 said to the PO's, no you need to arrest ED Physician A. RN C divulged at one point, when ED Physician A was yelling at the patient, spit flew out of ED Physician A's mouth and hit Patient #9. Patient # 9 identified that as one of the reasons Patient #9 felt ED Physician A should be arrested, ED Physician A yelled and spit on Patient #9 and Patient #9's friends. RN C revealed Patient #9 was not originally going to jail. Security/police obtained a wheel chair to escort Patient #9 off the property. As the police officers wheeled Patient #9 out, Patient #9 threw themselves out of the chair and onto the floor. That was when the police decided to arrest Patient #9. RN C verbalized Patient #9 and their friends were both so intoxicated, there was no reasoning with them. ED Physician A said Patient #9 hit a switch and said to RN C something about these "entitled [expletive]", they just hit a switch. RN C talked to PO D after the incident and they said "what was that?" RN C reported they have never had to get between a doctor and a patient before and clarified this was all verbal aggression. RN C acknowledged when RN C was between ED Physician A and Patient #9 was concerned about them becoming physical but that never happened.

10. During an interview on 7/12/2022 at 2:38 PM, RN F reported they happened to look up at security cameras and saw a Patient #9 hobbling in with 2 other individuals. RN F, RN C, and RN E went to the vestibule and observed all of them on the ground in the vestibule. RN F reported all three appeared intoxicated. Patient #9 was face down and complained of foot or ankle pain. We asked Patient #9 to roll over so we could assist them up and into the wheel chair. Patient #9 responded with immediate agitation, swore and called us names. Patient #9 yelled we were racist and refusing them care. Patient #9 finally rolled over and we got them in the wheel chair and took them straight back to room 8. RN C thought they could handle Patient #9 themselves so RN F left and took the wheel chair from room 8. RN C came out a short time later and said Patient #9 was refusing vital signs and everything else RN C was trying to do. RN C left Patient # 9 alone, hoping Patient #9 would chill out. Sometimes that helped. ED Physician A was at the nurses' desk, which is across from room 8. RN C and ED Physician A walked back into room 8 to see Patient #9 after a few minutes had gone by. ED Physician A walked out in approximately 5 minutes yelling and screaming. ED Physician A dropped a lot of profanity and said to Patient #9, if you don't want to be treated ..., you are not allowing us to do our job .... then just "get the[expletive] out". RN F reported she heard most of the altercation but didn't actually see much. RN F acknowledged it was a little frightening and very unprofessional of ED Physician A.

11. During an interview on 7/13/2022 at 12:00 PM, RN E reported RN C, RN E, and RN F saw Patient #9 on the ED camera monitor. RN C, RN E, and RN F met the patient in the entrance vestibule. Patient #9 was found face down on the ground, two people with them trying to get Patient #9 up. RN E reported we asked Patient #9 to roll over so we could help them get up. Patient #9 became agitated, yelled profanity and claimed we were refusing to help. We explained we just wanted Patient #9 to roll over so we could assist them up into the wheel chair we brought. Patient #9's Friends rolled them over onto their back and assisted us in getting Patient #9 up and into the wheel chair. RN C wheeled Patient #9 straight back to the ED. On the way to the department, registration staff asked for Patient #9's name and date of birth. Patient #9 refused to give it to the registration staff but Patient #9's friends supplied Patient # 9's name. Patient #9 replied "Infinity" to their birthday. Patient #9 told RN C they were cold, demanded a blanket, and they had better turn up the heat and get them comfortable. RN E verbalized once they got Patient #9 in the room, RN C assisted Patient #9 into the bed. RN C asked Patient #9 to put their feet in the bed so they could get side rail up and take vital signs. Patient #9 refused all cares. Patient #9 said they needed a blanket and didn't need their feet up. Patient #9 demanded we take them straight back to x-ray. RN E recalled the interaction between ED Physician A and Patient #9 associated events as follows: The whole interaction lasted about 2-3 minutes, very quick. RN E noted during all this time Patient #9 swore, was very aggressive, and demanding. RN E stated ED Physician A had heard all this commotion. ED Physician A was behind the nurses but called into room 8 and told the Patient #9 that if they were going to continue to act like this they could leave the department. Patient #9 was angry, stated we refused to help them. ED Physician A told Patient #9 it was unacceptable to treat the nurses this way. They are trying to help you but you are acting irrational (or along those lines). Patient #9 yelled again and swore, again claimed were refusing them care. ED Physician A walked out of nurses' station to room 8. ED Physician A never actually went into the Patient #9's room, stood at the doorway. Patient #9 got up from the bed and walked to the door way and met ED Physician A. They yelled at each other back and forth. Someone called hospital security back. PO D showed up about the same time as security. RN C stayed with ED Physician A and Patient #9 through the entire event. RN E tried, at one time, to put hand on ED Physician A to gently push them back away from the patient but ED Physician A didn't respond. RN E reported they had never seen a provider act aggressively towards a patient like that. Typically, a provider would come in explain how things would go and try to de-escalate the situation. Instead of that happening, it just escalated to the point of no return.

12. During an interview on 7/13/22 at 2:15 AM, PO D reported it was roughly about 2:50 AM when they saw 2 nurses going to the front vestibule. There were 3 drunk people, one laid on the ground cursing. PO D reported they didn't go immediately as most people don't like to see the police. It can make things worse. We don't want to set the wrong tone right away or make them unnecessarily uncomfortable. PO D recalled when they went back into the ER PO D observed ED Physician A leaving room 8. PO D heard ED Physician A say Patient #9 could leave. Patient #9 looked at PO D and asked me if PO D was there to shoot them. PO D responded of course not. PO D verbalized ED Physician A returned to room 8 and said "get them out of here". ED Physician A and Patient #9 started yelling back and forth. ED Physician A asked Patient #9 what were they reaching for in their pocket. Patient #9 took out a phone and said they were going to film us. ED Physician A and Patient #9 were face to face. PO D relayed they got between the ED Physician and Patient #9 to separate them. PO D recalled they were trying to figure out how Patient #9 got to the ED as wasn't planning to arrest Patient #9. PO D reported they were looking for a safe way for Patient #9 to leave and go home. Patient #9 refused to provide information for safe way home. Patient #9 continued to be difficult, caused a scene, and ultimately ended up going to jail. PO D called the local police to come in as PO D to assist with transport. PO D reported the language that ED Physician A used was unacceptable and unprofessional. PO D noted there was no de-escalation attempted what so ever. ED Physician A and Patient #9 engaged in a "Hit me, no you hit me" dialog, each wanted the other to throw the first punch. From the time PO D got back there, ED Physician A said the patient needs to go. PO D witnessed no offer of medical treatment.

13. During an interview on 7/14/2022 at 7:00 AM, Security Officer (SO) G and SO H reported they were working together on May 28th and responded to the ED at the same time. SO G reported they were called and asked to come into the ED. SO G and SO H badged into the ED and immediately heard yelling, turned the corner and see the Patient #9 and ED Physician A about a foot apart, facing each other, screaming. PO D stood, sort of wedged between the two facing Patient # 9. PO D asked Patient #9 and ED Physician A to calm down. ED Physician A stood at PO D's shoulder yelling at Patient #9. SO G can't remember specific words being yelled but noted it was very inappropriate. SO G tapped the doctor on their shoulder and told them that's enough and asked ED Physician A to go back to the nurses' station. SO G reported there was no physical contact between ED Physician A and Patient #9. SO G and SO H noted Patient #9 was intoxicated and ED Physician A was egging Patient #9 on. SO G reported hearing both Patient #9 and ED Physician A repeatedly said "hit me" to each other.

14. During an interview on 7/18/22 at 12:22 PM Patient #9 reported they got kicked out of the ED on 5/28/22 around 3:00 AM. Patient #9 reported they had hurt the heel of their foot and went to the ED for care. Patient #9 recalled for some reason, ED Physician A called Patient #9 inappropriate names. Patient #9 verbalized ED Physician A is the one who is supposed to be the professional, went to all the years of school, yet Patient #9 is the one who went to jail?! Patient #9 said that isn't right. Patient #9 verbalized Patient #9 and ED Physician A "got into it". Patient #9 recalled their foot was hurting so bad and asked the nurses what was taking so long because Patient #9 was actually hurt. Patient # 9 acknowledged that the ED RNs took Patient #9 straight back to an ED room when they arrived and reportedly took Patient #9's blood pressure, but that's all they did. Patient #9 verbalized they didn't get to see a doctor, get an x-ray or nothing. Patient #9 insisted ED Physician A wanted to fight Patient #9 and voiced they didn't understand how a doctor can act like ED Physician A did. Patient #9 reported the police had to get between ED Physician A and Patient #9 as ED Physician A wanted to fight. Patient # 9 reported they felt very "disrespected" and that was when Patient #9 got up off the floor, stood up on one foot and faced ED Physician A. Patient #9 reiterated it was not fair that ED Physician A just left the room and Patient #9 went to jail. Patient #9 reported they returned to the ED and received treatment for the ankle injury when Patient #9 got released from jail about 7 hours later. Patient #9 reported upon return to the ED Patient #9 was examined by a doctor, had x-rays of the swollen right foot and ankle, was diagnosed.

15. During an interview on 7/13/22 at 2:37 PM, the Director of Critical Care and ED revealed that they were made aware of the incident by the Head of Security between 7:00 AM and 8:00 AM on 5/28/22. The Director of Critical Care and ED voiced concern with the verbal interactions from ED Physician A and Patient #9 after hearing the details and escalated these concerns to hospital administration, legal team, nursing, and physicians. Patient #9 was verbally abusive. ED Physician A reciprocated that, unfortunately. An MSE was done. The Director of Critical Care and ED acknowledged that Patient #9 presented with ankle and foot pain and ED Physician A did not provide an examination of the right foot/ankle or x-rays to determine the nature or severity of the injury as other patients who present to the ED with similar symptoms would have received.

The ACH ED failed to provide an appropriate medical screening examination within the hospitals capabilities to rule out an (EMC) before Patient #9 was discharged into police custody.