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Based on policy and procedure review, medical record review, staff and physician interviews the hospital failed to ensure a timely medical screening examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 3 DED elopement patients (Patient #22 and Patient #32).

The findings include:

The hospital failed to ensure a timely medical screening examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 2 DED elopement patients (Patient #22 and Patient #32).

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

Based on policy and procedure review, medical record review, and staff and physician interviews the hospital failed to ensure a timely medical screening examination (MSE) was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 3 elopement patients (Patient #22 and Patient #32).

The findings include:

Review of the policy and procedure titled "Treatment of Patients with Emergency Medical Conditions (EMTALA)" Effective 04/2019 revealed " ...C. Medical Screening Examination 1. All individuals who are considered to have 'come to (Named Hospital) emergency department' for examination or treatment ...shall be given an appropriate medical screening examination by a qualified medical personnel to determine if an emergency medical condition exists ...Triaging a patient does not constitute a medical screening examination ..."

Review of the medical record revealed Patient #22 was an 85-year-old male who presented to the emergency department (ED) via ambulance on 04/12/2022 at 1508 following a fall at his residence. Review revealed Patient #22's triage started at 1509 by CN (charge nurse) #34. Review of the ED triage note entered by CN #34 on 04/12/2022 at 1510 revealed "Pt (patient) had witnessed fall. Pt denies LOC (loss of consciousness) and is not on thinners (blood thinners)." Review of the ED triage note entered by Registered Nurse (RN) #35 (triage nurse) on 04/12/2022 at 1515 revealed "Pt presents to ED via EMS (emergency medical services) with unwitnessed fall at SNF (skilled nursing facility). Pt c/o (complains of) pain to R (right) side of forehead that has small laceration. Denies any other injuries. Denies LOC. Not on blood thinners." Review revealed RN #35 performed "Focused Assessment" at 1515 of Patient #22's "Airway, Breathing, Circulation, and Disability" all of which were "Within Defined Limits." At 1516 Patient #22's vital signs were as follows BP (blood pressure)-151/64, HR (heart rate)-59, Resp (respirations)-18, Sp02 (oxygen saturation)- 95% room air, and T (temperature)-98.2. At 1519 orders were placed by MD (medical doctor) #36 for "Imaging-CT (cat scan) Head Wo (without) Contrast; CT Cervical Spine Wo Contrast." At 1624 MD #37 reviewed Patient #22's History. Review of the ED timeline revealed on 04/12/2022 at 2140 (6 hours and 32 minutes after arrival to the ED) Patient #22's ED disposition was set to "LWBS (left without being seen) after triage." Review failed to reveal an MSE was initiated during Patient #22's time waiting in the ED lobby.

Review revealed Patient #22 was transported back to Hospital A DED on 04/13/2022 at 0854 and admitted at 1750. Review of the History and Physical (H&P) dated 04/13/2022 at 1759 revealed "Assessment /Plan: NSTEMI (non-ST-elevation myocardial infarction is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle) ...HPI: (history of present illness) Patient #22 is a 85 y.o male with PMHx (past medical history) HTN (hypertension-high blood pressure) ...cognitive impairment ...Patient #22 represented (sic) to ED s/p (status post) fall on 4/12 and wondering out of the hospital same day and was unable to be located until today at (named location). He was brought back to the ED in stable condition. Patient with severe cognitive impairment and unable to get a clear history of events ..." Review revealed Patient #22 was discharged back to the SNF on 04/15/2022.

Review of the elopement incident report for Patient #22 revealed "Pt arrived via EMS and was triaged at 1510. At 1910 CT tech attempted to locate patient for exam, unable to locate patient. Triage made 3 attempts to locate patient with no response. As we were unable to locate patient, he was discharged as left without being seen after triage following the 3 attempts. At 0101 received a call from the patient's son requesting update. Advised son that patient was not present in department. Pt's son advised he would call SNF to check with them. At 0106 (named) SNF called and advised that patient was not there and should be here in the ED. They advised that patient has hx of dementia. Description obtained from SNF. Hospital Police notified at 0115. House Supervisor notified at 0120."

Interview on 06/10/2022 at 1500 with MD #37 revealed he reviewed Patient #22's history in the computer system but did not initiate an MSE. MD #37 stated MD #36 placed CT orders in the system but unsure if she physically evaluated him. MD #37 stated his goal was to initiate an MSE as soon as possible. MD #37 stated he started MSEs based on patient acuity and which patient required a bed sooner than the others.

Interview on 06/13/2022 at 1334 with RN #35 revealed she was the triage nurse on 04/12/2022 when Patient #22 presented to the ED. RN #35 stated she obtained Patient #22's vital signs then placed him in the waiting room. RN #35 stated the ED was busy that day and with only two triage nurses on duty, they were not able to reassess Patient #22.

Interview requested with MD #36 revealed she was unavailable.

(Patient #32):

Review of the medical record revealed Patient #32 was a 51-year-old female who presented to the emergency department (ED) on 06/14/2022 at 1948 for "Back pain." Review revealed vital signs at 2000 were as follows: BP-108/86, HR-99, Resp-18, Sp02-100% room air, and T-98.6. Patient #32's triage started at 2003 and was assigned as an ESI level 5 at 2004. Review of RN #40's triage note dated 06/14/2022 at 2003 revealed "Patient states that she was kicked out of group home because she wouldn't stay in the building and they were disrespectful to her. She states she was released from the hospital without medications." Review of the ED timeline revealed at 2004 Patient #32's chief complaint was updated to "Homeless." Review revealed Patient #32 was moved from the waiting room to PT (treatment area located behind the triage rooms) at 0555 and the MSE (medical screening exam) started at 0556 (9 hours and 8 minutes after arrival to the ED). Review of the ED MD #39 provider note dated 06/15/2022 at 0622 revealed "Final diagnoses: Homeless ...Impression: 51 year-old female with schizoaffective disorder (mental health condition including schizophrenia and mood disorder symptoms) ...who was recently at (named) emergency department 9 April to 14th June he (sic) was ultimately sent to a group home who left the group home yesterday because of an altercation who came to the emergency department initially for group home placement and medication refills 2 on my examination stated she would (sic) just wanted to get a bus to (named town) to stay with a friend (named) where her family from (named town) would then be coming to pick her up. Physical examination showed normal vital signs. ANO x3 (alert and oriented to person, place, and time). No SI (suicidal ideation) or HI (homicidal ideation) or hallucinations ...0627 Attempted to call guardian at number listed in chart. No answer. Left message for return call. 6:31 AM at this time, plan for case management evaluation at 0800. She has a guardian listed in the chart that I was unable to contact. Right now she has the capacity to leave if she chooses but we will provide her with more resources via case management if she chooses to stay. 0700 signed out to incoming provider. Case management consult pending at this time ..." Review of MD #38 ED provider note dated 06/15/2022 at 0902 revealed "I received care of this patient at 7 AM. During signout, my colleague, (named MD) received a call from patient's guardian. Per reports, guardian states that patient is not medically stabilized and is to be admitted for medication adjustment. She thinks that she is unsafe and unable to care for herself ...Upon receiving this collateral information, both (named MD) and MD #39 went to discuss need for placement and further evaluation with psychiatry with the patient; however the patient was not found to be in her room. The ED and surrounding areas were searched and patient was not found. Hospital police and security was notified ...I filled out an IVC (involuntary commit) form ..." Patient #32 eloped (exact time unknown) and was "discharged" off the board on 06/15/2022 at 0956.

Interview on 06/17/2022 at 1000 with MD #38 revealed she received report from the off-going provider and did not physically evaluate Patient #38. Interview revealed she was not sure why Patient #38's MSE was delayed. MD #38 stated there were concerns shared in collateral information that Patient #32 was not capable of caring for herself so she initiated the IVC process so when Patient #32 was located, she could be evaluated for her safety.

Interview on 06/17/2022 at 1121 with MD #39 revealed when he evaluated Patient #32, she and no complaints and was requesting a bus ticket to another town where family was located. Interview revealed due to "several ED boarders" (patients awaiting an admission bed) there was limited capacity in the ED and delayed the initiation of the MSE for Patient #32. Patient #32 was an ESI 5 therefore more emergent patients received an MSE prior to her.

Request for interview RN #40 (triage nurse) revealed she was unavailable.