HospitalInspections.org

Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 2 of 26 sampled emergency department patients (Patients #3, #4).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on policy reviews, medical record reviews, police report, and interviews, the hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 2 of 26 sampled emergency department patients (Patients #3, #4).

The findings included:

Review of the policy titled "...EMTALA - Medical Screening and Treatment of Emergency Medical Conditions", effective 01/2024, revealed "PURPOSE: To ensure that individuals coming to an affiliated hospital's Dedicated Emergency Department seeking assessment and treatment for a medical condition, or coming to Hospital Property requesting....treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required.... Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. ..."

1. Review of "Emergency Documentation" by an ED Provider (NP#1), dated 05/31/2024 at 2029, revealed Patient #3 had "...History of Present Illness 63-year-old.... with past medical history of coronary disease (disease of the heart's major blood vessels), pacemaker (implantable device to help regulate the heart's rhythm), congestive heart failure (chronic condition where the heart does not pump blood like it should), hypertension (high blood pressure).... Patient was brought in by EMS (Emergency Medical Services) for intoxication complaint of chest pain. Had 12 lead EKG per EMS showed no signs of STEMI (ST segment elevation myocardial infarction- serious heart attack). Patient was placed in waiting room. I was standing in the hallway doing him (sic) SCDs and he walked back into the ED department and walked proximally 50 ft without any difficulty and then laid down on the floor yelling that he was having chest pain and he needed to be seen immediately. Patient was offered wheelchair he was asked repeatedly to get up into the wheelchair so I can take him to triage and check his EKG and start lab work on him he states he refused that he was not going back out to the waiting room. I tried informed (sic) that he was taking him to triage so he could be evaluated and get his EKG and get his workup started patient keeps screaming that he was having chest pain and he needed a room immediately. He repeatedly refused to get up off the floor and get into the wheelchair he refused to let us assist him into the wheelchair. When myself and where the nurses attempted to pick him up off the floor and put him in the wheelchair he started to get aggressive and threatened as in informed this (sic) to take his hands off of him. He was asked numerous times to get in the wheelchair and then we can get him treatment but want to lay on the floor could not treat him. He refused to get up off the floor laid on the floor. (City name) police department was called and patient was taken away in handcuffs by the police. Again he repeatedly refused to get up off the floor and get into the wheelchair so he could receive treatment he was in no apparent distress. ..." The provider note further revealed "...Assessment/ Plan 1. Left against medical advice." Review of an ED Nursing Note, dated 05/31/2024 at 2037, revealed "...Patient continued to refuse assistance. Patient given AMA (against medical advice) paperwork; patient refused to sign. (City) PD notified that patient was uncooperative and refusing to participate in care. Patient escorted off of hospital property in custody of .... PD. An "Addendum" to the Emergency Documentation provider note was made 06/03/2024 at 0520 which noted "...Patient was able to tell me his name, where he was and why he was at hospital. He again repeatedly refused to get up of the floor and refused assistance into wheelchair or to let us do any assessment on him. He was told I would take him to stretcher in Triage but was told repeatedly that I did not have a room with stretcher available at the time and he needed to be triaged. He again repeatedly refused to get off hte (sic) floor or let us start any kind of assessment on him. he was told that by refusing to be assessed or let us move him off the floor that he was refusing treatment and ....PD would be called to get him off the floor. He told us to go ahead and call them."

Review of a security report, dated 05/31/2024 at 2049, revealed "...Called to triage... to watch patient (Pt #3) throw a temper tantrum on the floor. He would not comply with doctor's orders. Charge nurse.... called police to have patient removed. Police arrived and took patient away. ..."

Review of a police report, "INCIDENT/INVESTIGATION REPORT" dated 05/31/2024 revealed "Suspect Actions/ TRESPASS..." The Narrative noted "SUBJECT TRESPASSED" and "SUBJECT WAS ARRESTED WITHOUT INCIDENT."

Review of the Hospital B medical record, on 01/16/2025, revealed an ED Triage Assessment on 05/31/2024 at 2249 that documented a stated complaint of chest pain times 3 days. Review of the Emergency Department Provider Note at 2355 revealed "... presents with chest pain for 3 days. He was seen at (Hospital A) immediately prior to being seen here.... Medical Decision Making....The patient does appear to have acute coronary syndrome in the context of his positive troponin (lab test).... I am concerned he is having NSTEMI with this positive troponin and his chest pain.... he does not meet.... criteria for STEMI.... He does have critically low potassium and required both IV and oral potassium.... Patient admitted. ..." Review revealed Patient #3 was discharged home on 06/06/2024.

Interview with a Nurse Practitioner (NP #1), on 01/07/2025 at 1700, revealed when Pt #3 arrived to the DED it was a "very busy night." There were multiple patients in the department, including the waiting room. EMS had reported the EKG on Patient (Pt) #3 did not show a STEMI so the patient was placed in the waiting room and would have been the next back to be seen. All the treatment rooms were full, per interview, and the patient was to go to triage to assess vital signs and get another EKG. Interview revealed there was a locked door between the waiting room and the ED treatment area. Pt #3 followed someone through the doors, then laid down on the floor and refused to get up. NP #1 stated Pt #3 screamed that he needed to be seen immediately but would not get off the floor into the wheelchair to be evaluated. Interview revealed NP #1 talked with the patient, told him there were no rooms/stretchers available in the "back" and they would get care started in triage. Pt #3, per interview, had an extensive cardiac history and the workup needed to be started, which would have begun during triage but the patient would not let staff touch him and was extremely disruptive. They tried to help the patient off the floor but he screamed not to touch him and physically stopped them from helping him up or touching him. Interview revealed the police was called due to Pt #3's behaviors, which included screaming, refusing to be touched or assisted up and threatening, disruptive behaviors.

Interview with RN #4, on 01/09/2025 at 0840, revealed the RN was the triage nurse when Patient #3 arrived. RN #4 stated EMS put Pt #3 in a wheelchair in the waiting area near triage. RN #4 was in process of triaging another patient when Pt #3 arrived, the RN stated, and Pt #3 was told by EMS that triage would get to him in a minute. The patient, per interview, demanded a bed but there were no beds available at the time. RN #4 stated Pt #3 ran through the ED door from the lobby waiting area into the ED, yelling "I'm in pain...stuck me in waiting room....need help... ." Interview revealed Patient #3 laid in the floor, would not get up and started acting like a "lunatic". Interview revealed it was a "massive scene." RN #4 stated the patient would not get up and then started refusing care. RN #4 stated when staff tried to help lift him off the floor, the patient started swatting at people, refused to be touched or moved and began demanding another hospital. Interview revealed security was involved, then the local police were called and the patient "...was arrested, it became a police issue" and Patient #3 was handcuffed and taken away.

In summary, Pt #3 arrived to the hospital complaining of chest pain. There were no beds available and the patient was placed in a wheelchair in the waiting room. Pt #3 got out of the wheelchair, entered the ED treatment area, laid down on the floor and refused to get up, screaming and demanding immediate bedding in the ED. Staff attempted to talk with the patient, but the patient continued to disrupt the department. Security and police were called. Per security and police documents, police was called to have the patient removed. No medical screening was performed. EMS was called later that night from the police department and the patient was transported to Hospital B and admitted.


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2. Medical record review on 01/08/2025 for Pt #4 revealed the 41-year-old presented to the DED on 05/05/2024 at 1218 with complaints of "feeling suicidal like jumping in front of car". Review of the Past Medical History (PMH) revealed ..." Schizoaffective behavior (chronic mental health disorder), history of substance abuse, Hepatitis C (an infection caused by a virus that attacks the liver), Seizures ..." Suicidal precautions were initiated. Labs were ordered for medical screening, but the phlebotomist was unable to draw the labs due to "patient refusal". Record review revealed Pt #4 became belligerent with medical staff and stated, "don't want to go to (name of Hospital A Campus 2). Review revealed a drug screen, COVID, RSV, and Flu swabs were able to be completed, and the results were negative. Pt #4 was discharged home to follow up with behavioral health within 1 week or sooner. Medical record review failed to reveal the stability of the patient. Pt #4 was discharged at 1320 (62 minutes after arrival to the ED). Further review of the medical record failed to reveal evidence of a safety contract, any documentation of a Psychiatric Nurse Liaison note or a Psychiatrist consult completed for Pt #4.

Interview on 01/09/2025 at 0838 with RN #2 revealed RN #2 did not recall Pt #4. The interview revealed the RN was doing triage the day Pt #4 came into the ED. Interview revealed RN #2 reviewed the record and based on the record a suicide screening was done and Pt #4 would have been "high risk" due to the thoughts and plan regarding suicide. RN #2 indicated the patient would then have changed into paper scrubs to ensure safety and security called to escort the patient back to a dedicated place in the ED for behavioral patients who are being held for disposition. The interview revealed RN #2 would have expected Pt #4 to be admitted based on the "high risk" screening result.

Telephone interview on 01/09/2025 at 0910 with RN #3 (a Psychiatric Nurse Liaison) revealed RN #3 remembered Pt #4. Interview revealed RN#3 was on shift the day Pt #4 came in. "Pt#4 came in here a lot and had been admitted numerous times before". The interview revealed the RN #3 saw Pt #4 on the day in question and discharged the patient. RN #3 indicated that if there was not a note then "that was on me- my fault that I didn't remember to document a note". The interview revealed that normally Psychiatrists would clear the patients. The interview revealed a referral was not made to the psychiatrist for this visit. Safety contracts were made on all patients not being admitted and they were supposed to be scanned into the medical record. The interview revealed a safety contract would have been done by this RN and the RN remembered one. RN #3 indicated a safety contract had been made but the nurse could not explain why it wasn't in the medical record. Further interview revealed Pt #4 was a current patient at Campus B at the time of the interview.

Request to interview the Emergency Department Physician who saw Pt #4 revealed the MD was unavailable for interview.