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

The findings included:

Based on policy review, medical record review and staff and physician interviews, the hospital failed to perform a timely and complete medical screening exam including explaining the risks of refusals of exam or treatment when patients left AMA (against medical advice) for 3 of 29 sampled Dedicated Emergency Department (DED) patients reviewed (Patient #1, #7, and #19)

~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406.

Based on policy review, medical record review and staff and physician interviews, the hospital failed to perform a timely and complete medical screening exam including explaining the risks of refusals of exam or treatment when patients left AMA (against medical advice) for 3 of 29 sampled Dedicated Emergency Department (DED) patients reviewed (Patients #1, #7, and #19)

The findings included:

1. Review of the Emergency Medical Treatment and Labor Act (EMTALA) policy, effective 11/2022, revealed "...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who comes to the emergency department an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer..."

The "Refusal of Care Leaving the Hospital AMA Leaving the Hospital ED WOT [Without Treatment]...", effective 10/2022, revealed "...Definitions...B. AMA....1. Patient who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure prior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ..."



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2. DED medical record review revealed Patient #19 arrived to the emergency department on 05/07/2024 at 0003. Review revealed an arrival complaint of "possible miscarriage." Vital signs at 0008 were abdominal pain score of 8 - severe pain. Review of the ED Triage Note at 0009 revealed "Pt c/o abd pain, cramping, and vaginal bleeding. Pt had OB urine confirmed pregancy (sic) ....EDD 1/3/25 ....Pt states bleeding started today but states abd pain and cramping started after she was hit in the stomach yesterday around 1330." Review of the ED Provider Note, service time 0157, revealed " ...HPI [space] 27-year-old female with no medical history presents to the ED with a chief complaint of threatened labor and vaginal bleeding that started at 11PM on 5/6/2024. Patient reports that she was assaulted yesterday and points to her belly. She reports that her ex-boyfriend assaulted her and he is now along. She denies any dizziness chest pain shortness of breath but reports abdominal cramping and vaginal bleeding. She has tissue noted in his (sic) lower back and it shows some moderate amount of blood. Patient is gravida 3 para 2 no abortions ....Physical Exam .... Constitutional: She is not in acute distress. Appearance: She is not ill-appearing, toxic-appearing or diaphoretic ....Abdominal ....Palpations: Abdomen is soft. Tenderness: There is abdominal tenderness .....CBC WITH DIFFERENTIAL ....WBC ....11.83 (H) .... MPV ....11.5 (H) ....Absolute Neutrophils .... 8.29 (H).... Absolute Immature Granulocytes.... 0.03 (H) .... URINALYSIS ....Color ....Amber (A) .... Clarity .... Turbid (A) ....Hemoglobin ....3+ (A) .... Ketones .... 1+ (A) .... Protein ....1+ (A) .... RBC .... >182 (H) .... WBC ....85 (H) ....Squamous Epithelial Cells ....Few (A) ....Medications Ordered/Administered .... Acetaminophen ....650 mg .... Oral . ..." Further review of the ED Provider Note revealed "....ASSESSMENT / MEDICAL DECISION MAKING .... ED COURSE ....1527: Patient informed the nurse that she is not waiting until the morning for her ultrasound. She reports that she is going. Patient left AMA. [space] DIAGNOSIS 1. Left against medical advice ...." Review of an ED RN Note, at 0328, revealed "Patient states that she does not want to stay for the U/S in the morning. Patient states that she will follow up with her OBGYN today." Timeline review at 0329 revealed "Patient discharged." Review did not reveal an AMA form or evidence of explaining the risks of leaving to Patient #19.

Telephone interview on 10/01/2024 at 1029 with NP #26 revealed the NP did not recall Patient #19. Interview revealed the statement that the ex-boyfriend was "now along" was a typo. NP #26 stated "100% the ex-boyfriend was not there....would have called hospital police. ..." Interview revealed no recollection of the "tissue" documented and indicated a "moderate" amount of bleeding was more than scant/small but not saturating multiple pads and no clots. Interview revealed Hospital A did not have ultrasound 24/7 and the NP explained to patients they would there between 7:00 and 8:00 am. NP #26 stated the majority of times patients did not wait, they had already left by the time the NP got notified. NP #26 indicated "If I saw her before she left I would have documented ....I go over risks of leaving and benefits of staying."


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3. DED review on 09/25/2024 of Patient #7 revealed a 70-year-old-male that presented to the emergency department on 03/29/2024 at 1747 with a chief complaint of suicide intentions. Review of a triage note at 1757 recorded vital signs that included a pain level of 6, moderate pain. Review of the triage note revealed the patient reported suicide ideations with a plan of walking out in front of oncoming traffic and abdominal pain that started around one hour ago. The patient denied nausea, vomiting or diarrhea. Review revealed the patient was triaged with an Emergency Severity Index (ESI) level of 2 (scale of 1 - 5 with 1 the most emergent). Review of the record revealed the patient was roomed at 1809 with a patient safety observer in place for safety monitoring beginning at 1810. Review revealed laboratory studies were ordered and completed. At 1847 a Columbia Suicide Severity Rating Suicide Risk Assessment was completed with a total score of 7 or moderate risk identified. Review of nursing notes recorded at 1936 stated the patient endorsed suicide ideations but denied homicidal ideations or audio or visual hallucinations. Review revealed the patient had a plan to walk out in front of traffic. The patient stated he had some stomach pain on the right side and reported he was hungry. Review of a medical screening examination initiated on 03/29/2024 at 1947 revealed the patient presented to the DED with complaints of suicide ideations and abdominal pain. Review revealed the patient had a past medical history of depression, substance abuse, and suicide ideations. Review of the note stated that the patient had a plan to walk into traffic due to his depression. Review revealed the patient reported a momentary abdominal pain which he believed was due to being hungry. A review of systems was done and positive for suicide ideations. A physical exam was completed showing the patient was alert and oriented with no acute distress. The patient's attention and perception were recorded as normal, mood and speech were normal, with cooperative behavior. "... Medical Decision Making 70-year-old M (male) with significant psychiatric history presenting for SI (suicide ideations) with plan. Labs ordered and reviewed, unremarkable. Patient medically cleared for tele psych consultation for further evaluation and treatment of psychiatric problems. ED COURSE Clinical Impressions as of 03/30/2024 at 0029 Suicidal ideation, Depression, unspecified depression type, Cannabis use disorder." A tele psych consult was requested at 1950. Record review revealed hourly rounding by nursing staff was documented beginning on 03/30/2024 at 0121 showing the patient was resting at that time. Review of the DED record revealed ongoing safety monitoring and review of vital signs. A Suicide Assessment was recorded by nursing at 0719 that documented a low suicide risk level. Review of a tele psych consult electronically signed on 03/30/2024 at 1421 revealed, "... RECOMMENDATIONS Assessment and Plan 70 yo (year old) male with SI and plan to walk into traffic. Lives with his son and states they were arguing yesterday and this made him have thoughts of killing himself. He states he gets lonely and depressed at his son's house. He has been to the ED several times recently for the same complaint. He was recently at (name of outpatient facility) for the same complaint. He continues to state that if he is discharged he will hurt himself. Currently calm and cooperative, no psychomotor agitation or retardation, speech wnl (within normal limits), good eye contact. Thoughts appear linear and directable. Mood and affect appropriate. Insight and judgement appear fair, and age-appropriate. Recommend IVC (involuntary commitment) be continued and inpatient hospitalization ... IVC Status Recommended Initiate IVC ... ADDENDA Mr. (patient name) was reporting SI. In the note, it says that he was reporting SI but at the end of the note it says No SI/HI noted. The note should have read No HI noted but reporting SI." Review of a nursing note dated 03/31/2024 at 1406 revealed, "Patient stated that he was no longer suicidal and no longer wanted to be at the hospital. Patient asking to leave AMA (against medical advice). (Emergency department physician MD #6) notified and patient signed AMA form. Review of the "Notice of Treatment and Implications for Care Eligibility Act (NOTICE Act) Leaving Against Medical Advice (AMA)" form revised 10-22 revealed, "As a result of being notified of my rights under the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) I, _______________, a patient at (name of hospital system), at my own insistence and without the authority of and against advice of my personal physician(s) am informing you that I am refusing to be admitted as an observed patient. I have been fully counseled of the risks to my health due to my refusal of examination and/or treatment and unadvised discharge. ... I hereby release (hospital system name), its officers, agents, employees, and my personal physician(s) from any responsibility for all consequences caused as a result of me leaving the hospital." Review of the form revealed it was signed by Patient #7 on 03/31/2024 at 1400 and signed by a nurse as the witness. There was no signature of a provider on the form. Review of a nursing note recorded the patient left ambulatory by himself on 03/31/2024 at 1413. Review of the DED record revealed no discharge instructions were documented in the medical record. Review of the DED record revealed no documentation of a discussion of the risks of leaving or the benefits of staying. Review of the record revealed the only provider notes were documented on 03/29/2024 at 1947 when the medical screening examination was initiated and on 03/30/2024 at 1421 when the tele psych evaluation was completed. Review revealed no provider documentation of a reassessment of the patient's condition and no documentation of risks and benefits.

Telephone interview on 09/26/2024 at 1450 with the DED physician (MD #6) that was notified of Patient #7's request to leave AMA on 03/31/2024 revealed he remembered this patient as Patient #7 was in the emergency department frequently. He stated if he sent a patient out AMA he usually included the risks and benefits in the discharge instructions.

Interview on 09/27/2024 at 0850 with RN #7 revealed there were no discharge instructions or after visit summary found in Patient #7's DED record for the visit on 03/29/2024. Interview revealed there was no documentation of a discussion with Patient #7 of the risks of leaving AMA.



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4. Review of the medical record for Patient#1 (Pt) revealed a 29 year old female that presented to the DED (Dedicated Emergency Department) on 09/24/2024 at 1532 by private vehicle for a chief complaint of vaginal bleeding. The nursing triage assessment was initiated at 1558. Pt#1 indicated that the onset of symptoms began at 0700 on 09/23/2024. Triage vital signs, completed at 1600, revealed Pt#1 reported a pain level of 6/10 on a numerical pain scale. The triage notes at 1602 revealed Pt#1 came to the DED complaining of vaginal spotting associated with lower abdominal cramping that started the day prior. Pt#1 reported no bleeding on 09/24/2024. The triage note revealed Pt#1 was "Gravida 5, Para 2, Miscarriage 1, Abortion 1." Pt#1 was triaged at an acuity level "3" (scale of 1 - 5 with 1 the most emergent). Pt#1 was placed in an ED room at 1641. A urine pregnancy screen, urinalysis, and chlamydia/gonorrhea microbiology labs were ordered at 1708. Review of the DED Provider Note dated 09/24/2024 at 1738 revealed, " ... Patient came to the ED complaining of vaginal spotting associated with lower abdominal cramping that started yesterday. No vaginal bleeding today as claimed ... Vaginal Bleeding ... Pain quality: Aching ... Pain Severity: Mild ... Onset quality: Sudden ... Duration: 1 day ... Timing: Intermittent ... Progression: Resolved ... Chronicity: New ... Worsened by: Nothing ... Review of Systems ... Genitourinary: Positive for vaginal bleeding. Negative for flank pain and vaginal discharge... Results: ... Pregnancy Screen, Urine ... HCG (human chorionic gonadotropin) Positive ... Urinalysis, Complete (notable for the following components) ... Leukocyte Esterase, Urine: 3+, Protein, Urine: Trace, RBC (Red Blood Cells), Urine: 6, WBC (White Blood Cells), Urine: 21, and Squamous Epithelial Cells, Urine: Few ... Medical Decision Making ... 29-year-old female currently pregnant did not want to wait for full evaluation and lab work as well as ultrasound she left AMA (against medical advice). Urinalysis positive for WBCs, RBCs, leukocytes. Pregnancy positive. Patient was clinically stable prior to leaving AMA ... Clinical Impressions ... Threatened Abortion ..." Review of the AMA form revealed two sections of the form "To be completed by a physician:" were not completed by the provider. The sections were as follows: "A. The examination and/or treatment recommended and refused:" and "B. The likely dangers of refusal of such examination and/or treatment may include, but are not limited to the following:" Review revealed the AMA form was signed by the patient, by a nurse as a witness, and by the provider at 1742 on 09/24/2024. Review of the ED Notes at 1756 revealed, "Patient refused treatment and signed AMA form. Patient ambulated to the ed lobby with family and left via private vehicle." Pt#1 was discharged at 1759. Review of the medical record failed to reveal evidence that the risks of leaving AMA were discussed with Pt#1.

Interview on 09/27/24 at 0925 with the ED Manager (Manager#3) revealed the ED provider should discuss the risks of leaving AMA with patients. Interview revealed the ED provider was responsible for documenting the discussion.

Telephone interview on 09/27/2024 at 1101 with the ED Medical Director (MD#1) revealed the risks of leaving should be discussed with patients that request to leave AMA. Interview revealed providers were expected to document the conversation in a provider note or in the history and physical examination note.