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Based on interview, record review and policy review, the facility failed to provide a medical screening examination (MSE) sufficient to determine if the presence of an Emergency Medical Condition (EMC) existed for one patient (#20) of 27 patients reviewed, who presented to the Emergency Department (ED) seeking care on 09/08/18 (two visits) and on 09/10/18 with the following:
- The patient presented to the ED by Emergency Medical Services (EMS, ambulance) on 09/08/18 at 9:38 PM, with complaints of chest pain. There were no vital signs performed, no examination completed and the patient was allowed to exit the ED and smoke, and did not return for greater than 30 minutes, without further evaluation.
- The patient was arrested on hospital property near Medical Building One and returned to the ED by law enforcement at 10:51 PM, with complaints of chest pain and agitation. He was belligerent with law enforcement and staff, vital signs were not obtained, and the patient refused laboratory studies. The police brought the patient to the ED to determine fit for confinement. The ED Physician documented that the patient was agitated, and reported he was not taking his bipolar medications. The patient was released into police custody in "stable" condition without further evaluation.
- The patient presented to the ED by EMS on 09/10/18, with complaints of chest pain. He was belligerent with, and threatened, hospital staff. The patient had two knives removed from his possession, then refused further treatment and was escorted by security out of the ED prior to completion of the MSE. He was met by law enforcement on hospital grounds, and transported by law enforcement to Facility B (nearby facility), where he was later transported to Facility C (hospital with psychiatric capability and capacity) and admitted for inpatient psychiatric care.
The ED saw an average of 2100 patients per month.

Refer to A-2406 for additional information.

















40189

Based on interview, record review and policy review, the facility failed to provide a medical screening examination (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#20) of 27 patients reviewed, who presented to the Emergency Department (ED) seeking care on 09/08/18 (two visits) and on 09/10/18 with the following:
- The patient presented to the ED by Emergency Medical Services (EMS, ambulance) on 09/08/18 at 9:38 PM, with complaints of chest pain. There were no vital signs performed, no examination completed and the patient was allowed to exit the ED and smoke, and did not return for greater than 30 minutes, without further evaluation.
- The patient was arrested on hospital property near Medical Building One and returned to the ED by law enforcement at 10:51 PM, with complaints of chest pain and agitation. He was belligerent with law enforcement and staff, vital signs were not obtained, and the patient refused laboratory studies. The police brought the patient to the ED to determine whether the patient was fit for confinement. The ED Physician documented that the patient was agitated and had reported that he was not taking his bipolar medications. The patient was released into police custody in "stable" condition and determined "fit for confinement" without further evaluation by the ED.
- The patient presented to the ED by EMS on 09/10/18, with complaints of chest pain and in a manic (elevated or excited mood or behavior) state. He was belligerent with, and threatened hospital staff. The patient had two knives removed from his possession by the police before EMS arrived and transported him to the ED and were given to hospital security. Patient #20 then refused further treatment and exited the ED prior to completion of the MSE. He was met by law enforcement on hospital grounds, and transported by law enforcement to Facility B (nearby facility), where he was later transported to Facility C (hospital with psychiatric capability and capacity) and admitted for inpatient psychiatric care.
The ED saw an average of 2100 patients per month.

Findings included:

1. Record review of the facility's undated policy titled, "Emergency Medical Treatment and Active Labor Act," showed:
- Individuals who come to the ED and request examination or treatment will receive an appropriate MSE beyond medical triage (assigned degree of urgency to decide the order of treatment) provided by qualified medical personnel.
- The MSE must be within the capacity of the ED department and include ancillary services to determine whether or not an EMC exists.
- Necessary examination and treatment to stabilize the patient will be provided.
- If the individual refuses to consent to examination and treatment the hospital shall take all reasonable steps to secure written informed refusal, including sections in the AMA form and document the circumstances surrounding a refusal to sign if applicable.
- Hospital staff will communicate to the patient the continuing offer to provide evaluation, care and treatment to the patient, even if it is refused.

Record review of Barnes-Jewish St. Peters Hospital ED medical records, between 09/01/18 and 09/10/18 showed Patient #20 was a 57 year old male who presented multiple times to the ED:

1. On 09/08/18, between 9:38 PM-10:19 PM (first visit on this date), Patient #20 arrived, via EMS, with complaints of chest pain. He then left the ED to smoke and didn't return for greater than 30 minutes. No Vital Signs (VS) were obtained and there was no documentation that the patient was competent to leave against medical advice (AMA).

Review of the ambulance report dated 09/08/2018 showed that Patient #20 had called complaining of chest pain. When they arrived the patient stated he had been having chest pain for approximately 20 minutes and was still experiencing sharp anterior chest pain. The patient stated he had no history of cardiac issues, but that he did suffer from anxiety. Patient #20 stated that he had gotten stressed over personal issues and started feeling anxious. He stated that he had taken four baby aspirins before they arrived. The patient walked to the ambulance showing no signs of distress and breathing normal. His VS and 4-lead monitor (showing electrical activity of the heart) showed no changes in route to Barnes-Jewish St. Peter's Hospital ED. Upon arrival to the hospital report was given and he was left in the ED with a nurse and hospital staff.

Record review of Patient #20's ED record dated 09/08/18 (first visit on this date), showed that Patient #20 arrived via EMS at 9:38 PM complaining of chest pain. An emergency electrocardiogram (ECG, test of the heart's electrical activity) was performed immediately upon his arrival due to his complaints of active chest pain. At 9:53 PM immediately following the ECG, Patient #20 went outside to smoke. At 10:11 PM the patient had still not returned and the room was cleaned for a new patient. The staff was told if the patient returned he would be informed to go through registration and start over. At 10:17 PM the patient was unavailable to sign AMA and at 10:19 PM the patient was discharged.

2. On 09/08/18, between 10:51 PM-11:35 PM (second visit on this date), Patient #20 was arrested on hospital property near Medical Building One and returned to the ED in police custody with a request for an examination to ensure the patient was fit for confinement. During this time the patient was non-cooperative, argued with law enforcement and the medical provider.

Record review of Patient #20's ED record dated 09/08/18 (second visit on this date) showed that Patient #20 arrived in police custody with a request for "fit for confinement." The diagnosis code for this visit was FIT, admission type and source was documented as, "emergency by court." Patient #20 stated that he refused to be examined at that time. He was noted as positive for agitation, nervous, anxious, and hyperactive. At 10:59 PM showed that nursing was unable to obtain VS due to patient's behavior and his loud cursing. At 23:26 Patient #20 refused blood draw as ordered by physician. At 23:35 Patient #20 was discharged with Clinical Impression: Refusal of Care and the Disposition: Condition Stable. He was discharged in police custody with a fit for confinement.

Review of physician documentation on 09/08/18 showed that Patient #20 was a 57 year old male with multiple examinations in the past nine days with complaints of peripheral edema, chest pain, and various complaints on multiple occasions. He had presented earlier in the evening with complaints of chest pain, an ECG had been performed, not felt to be representative of any changes, and patient left the ED with no further examination. The patient is now actively arguing with police and actively arguing with the examiner. Patient #20 had a history of bipolar disorder and admitted he is currently not taking his medications. He had multiple physical and laboratory examinations in recent weeks with no negative findings. He refused blood draws on this visit. Order was written for discharge with a fit for confinement.

Review of the Police Report dated 09/08/18 showed that at 10:42 PM the police responded in reference to a peace disturbance and report of a violent unruly subject at Barnes-Jewish St. Peter's Hospital ED. It was reported to police that the patient had tried to re-enter the ED into the same room he had left earlier. The room was occupied by another patient and Patient #20 was told he would have to re-register and wait for another room. He became belligerent, loud and rude and demanded to talk with a doctor or a nurse. He then went outside to sit on a bench in front of the ED entrance. When the police arrived he was advised to leave the area due to his behavior and hospital security wanted him off the property. As the patient began walking away he told the officer that he would call for another ambulance. The police officer advised him that would be considered misuse of 911 calls and he would be arrested for false 911 calls. A few minutes later another officer called and said the patient had called 911 and said he was dying. The patient was located on hospital property near Medical Building One where he was arrested. Police escorted the patient back into the Barnes-Jewish St. Peter's Hospital ED to obtain a fit for confinement. Two doctors attempted to talk to and examine the patient, but he refused. The physician found the patient fit for confinement and he was taken to the police station. He was arrested at 10:47 PM and booked for peace disturbance and misuse of 911 calls at 10:49 PM.

3. On 09/10/18 at 2:12 PM, Patient #20 arrived at Barnes-Jewish St. Peter's Hospital ED seeking care for chest pain and in a manic (elevated or excited mood or behavior) state.

Review of an ambulance report dated 09/10/18, showed that Patient #20 reported he began to have chest pain after he ran across the street. He was very loud and appeared manic (elevated or excited mood or behavior). He had two knives on him that the police removed and took possession of. When the patient was asked to describe his pain he stated, "They took my knives or else I would show you what it feels like," then described the pain as a stabbing. The patient was transported to Barnes-Jewish St. Peter's Hospital. Patient #20 reported to the paramedic that the last time he was at Barnes-Jewish Hospital St. Peters security had him arrested.

Record review of Patient #20's ED record, showed that:
- He presented to the ED on 09/10/18 at 2:12 PM, seeking care for chest pain and in a manic (elevated or excited mood or behavior) state.
- He stated he came prepared to punch the security officer.
- The paramedic gave the hospital security officer two knives that had been removed from the patient by the police before he was transported by EMS and arrived in the ED.
- The patient had an ECG and an intravenous (IV, in the vein) catheter (small, plastic tube inserted into the body) in place, when he demanded he wanted everything removed and wanted to leave.
- Patient #20 left the treatment room and security followed him out of the ED where law enforcement had arrived outside.
- Patient #20 was immediately transported off of hospital property by law enforcement officers.

During an interview on 09/20/18 at 11:45 AM, Staff C, ED RN, stated that on 09/10/18:
- There was a picture of Patient #20 posted in the ED with instructions to notify security if he returned for treatment.
- The ambulance staff called the ED and reported that they were bringing Patient #20 in with chest pain, so staff notified security as instructed.
- Upon arrival, the patient was taken into an exam room and immediately began to tell staff members that "he had come prepared to take out security", and referred to the glove with the hard casing over the knuckle area.
- Patient #20 immediately wanted medical equipment removed from his body so he could go outside.
- He got off the stretcher, started walking around the perimeter of the ED, so security followed him and directed him to the exit.
- When he exited, law enforcement officers immediately took control of him.
- She was asked by a law enforcement officer to complete an affidavit related to the patients threats toward security and the knives that ambulance staff had removed.
- Staff C stated that she did not know about the knives until after he had left.
- She stated that she did not feel threatened by the patient, and felt the threats were directed toward the security officers, but she wrote out the affidavit as requested by law enforcement.

Interview with Staff C conflicted with her statement referenced in the law enforcement documentation.

During an interview on 09/20/18 at 11:45 AM, Staff E, ED Assistant Nurse Manager, stated that Patient #20 arrived in a manic state and unable to stop talking. While in the ED, he became agitated and verbalized that he did not want to stay, but refused to sign refusal of treatment paperwork and walked out of the ED treatment room, and to the facility parking lot.

During an interview on 09/20/18 at 11:25 AM, Staff B, Lead Security Officer, stated that when Patient #20 arrived in the ED on 09/10/18 the paramedic told security they had removed two knives from the patient. The patient had reported that he planned to take out security or anyone else who got in his way. Staff B stated Patient #20 was very insulting and made verbal threats toward staff members. Two security officers were present when the patient attempted to leave, and although everyone encouraged him to remain in the treatment room, he insisted on going outside to smoke. Patient #20 was told multiple times about leaving against medical advice (AMA), but he refused to sign any papers. The nurse removed his IV and he walked around the perimeter of the ED and then exited out of the ED with the security officers. He was met outside by the local law enforcement. The officers asked him what was wrong and what he wanted, and Patient #20 asked to be transported to another facility (Facility B).

Review of the a law enforcement report dated 09/10/18, showed that at 2:26 PM, the officers were dispatched to Barnes-Jewish Hospital-St. Peters, in reference to a peace disturbance. On arrival, they made contact with Patient #20, who stood outside the ED entrance and made several inflammatory statements about hospital staff. When the officer asked the patient what the problem was, he stated there was no problem and that he wanted to be treated for a heart condition at another hospital. Staff C, ED Registered Nurse (RN) came to the ED entrance and reported that the patient had made threats to ED staff. The officer asked Staff C to complete an affidavit. Staff C documented that the patient wore a green glove on his right hand, with hard molded plastic casing around the knuckles, in order to punch the security officer. The police officer then advised the patient that he would take him to another hospital for an involuntary commitment. The patient stated that he needed a psychiatric evaluation, agreed to the transport, and the officer transported Patient #20 in his patrol car to Facility B.

Record review of Facility B's ED medical record dated 09/10/18, showed that Patient #20 arrived at 3:20 PM by law enforcement, due to manic behavior. His symptoms were auditory hallucinations (hearing things that are not there) and disorganized thoughts. He could not remember why he had been at Barnes-Jewish-St. Peters, was talking non-stop with flight of ideas (jumping from one thought to the next, common with mania) and refused to answer questions for the RN during the assessment. He made sexually inappropriate comments to the staff and continued to make comments after staff told him that he made them feel uncomfortable. Behavioral Health was notified to do an assessment, and it was recommended that a psychiatric bed be located for the patient's inpatient psychiatric treatment admission. At 10:42 PM the physician noted that the patient needed resources, (psychiatric bed), that was not available at Facility B, and made arrangements to transfer Patient #20 to the inpatient psychiatric unit at Facility C.

Record review of Facility C's ED medical record dated 09/11/18, showed that Patient #20 arrived by ambulance for voluntary (agreed to) psychiatric admission related to agitation and mania. While he awaited admission, the patient became agitated and required security assistance so that staff could administer medications to decrease the patient's agitation.

During an interview on 09/20/18 at 11:30 AM, Barnes-Jewish Hospital-St. Peters, Staff H, ED Nurse Manager stated that the patient had been to the ED may times during the month, and that when he arrived, he wanted to go outdoors or wander in the waiting area. He would make others in the waiting area uncomfortable, and he would be asked to leave the area. He was frequently not medication compliant, and was manic, and the hospital staff would get his medications for him at the pharmacy, as well as accommodate transportation for him to the emergent outpatient psychiatric clinic.

During an interview on 09/20/18 at 10:00 AM, Barnes-Jewish Hospital-St. Peters, Staff A, Risk Manager, stated that Patient #20 had a long history with this facility. She stated that he usually came to the ED by ambulance with a medical complaint, but it wasn't long before he would get up and decide he was leaving. Staff A stated that the ED staff knew Patient #20 well, that he was often in a manic state from not taking his medications, and the hospital staff would frequently go to the pharmacy at times to get his prescriptions, which the hospital paid for. The hospital also arranged transportation for his outpatient psychiatric treatment at times so he wouldn't miss appointments.

The patient's history included bipolar disorder, for which the patient reported he did not take his prescribed medications.

There was no documentation in Patient #20's Barnes-Jewish Hospital-St. Peters ED records, that showed the patient was provided with a prescription for psychiatric medications that he no longer had access to.

Although requested, Barnes-Jewish Hospital-St. Peters, failed to provide a list of Patient #20's prescribed home medications.