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SSM HEALTH ST. MARY'S HOSPITAL - JEFFERSON CITY 2505 MISSION DRIVE JEFFERSON CITY, MO 65109 May 14, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on a review of Emergency Medical Services Documents, Emergency Department (ED) Logs, Medical Records, Medical Staff Bylaws, Medical Staff Rules and Regulations and staff interviews, it was determined the facility failed to ensure a Medical Screening Examination was received for one patient (#1) of 30 patients who presented to the ED. Please refer to A2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to provide a Medical Screening Examination (MSE) within the facility's capacity and capability to determine if an Emergency Medical Condition (EMC) existed for one patient (#1) out of 30 Emergency patients who presented to the Emergency Department (ED). The ED average daily census was 93, the average monthly census was 2806 and the total transfers from November 1, 2014 through April 30, 2015 were 370. The facility census at the time of entrance was 117.

Findings included:

1. Record review of the facility's policy titled, "Emtala-Medical-Screening Examination/Treatment and Transfer/Acceptance of Patients with Emergency Medical Conditions," revision date 11/2014, showed any individual who requests treatment for a potential EMC regardless of his/her ability to pay for services, will receive a MSE to determine whether he/she has an EMC. Hospital will provide care, within the extent of its Capabilities and Capacity, to patients suffering from an EMC.
-Examination on every patient presenting to the Emergency Department or on Hospital Property requesting emergency medical treatment in a uniform manner to determine if an EMC exists regardless of the individual's ability to pay for medical care. Triage is not equivalent to a medical screening exam.
-A Medical Screening Examination is a process designed to reach reasonable clinical confidence as to whether an emergency condition exists for the patient.

2. Review of the undated Emergency Medical Service (EMS) Prehospital Care Radio Report showed that the [AGE] year old male patient was in no medical distress and was sleeping in a park. He was discharged from Hospital B on 05/10/15 at 12:38 AM. He was picked up by Highway Patrol, and taken to EMS due to bizarre behavior.

3. Review of the 05/10/15 ambulance trip report showed the ambulance arrived at patient # 1's location at 10:50 AM. Documentation showed that the highway patrol contacted the ambulance because they found patient # 1 alongside the highway. Further documentation showed the officer stated that patient #1 had bizarre behavior and was unable to answer questions appropriately and that during the officer ' s interview, he repeatedly had to take patient # 1 out of oncoming traffic to avoid being hit. The ambulance crew documented they obtained patient # 1 ' s vital signs, that the patient was speaking in broken sentences and when asked his current location, stated he (patient # 1) thinks he is in the state of Maine. Further documentation showed approximately 15 minutes prior to arrival, St. Mary ' s Health Center was contacted to provide patient report. The ambulance arrived at the hospital at 11:31 AM and moved patient # 1 to room number FastTrack one and repeated report at the bedside.

4. Review of Patient #1's "Emergency Record," dated 05/10/15, showed the following:
-Patient #1 arrived at the ED by ambulance at 11:39 AM. The patient was found asleep by the side of the road by the Highway Patrol who took patient to EMS who then brought patient to this facility (Hospital A).

-The patient was triaged by Staff R, Charge Nurse, at 11:39 AM. Vital Signs, height and weight, Oxygen saturation and pain rating were taken. Abuse and a suicide screening were completed with all questions in the negative. The patient was placed in the waiting area where he slept until a room was available.
-The patient was "roomed in" (taken to room #21 by Staff W, Registered Nurse) at 11:59 AM.
- He stated that he was here because he was "losing his mind", "whatever it is called when your father rapes you", "poison in heart and mind", and "for the same reason that I always have the same reasons that I always have the same problems that I have."
-Documentation showed that at 12:16 PM, Staff W informed the patient that she was going to take his blood pressure. He stated that "you quite (sp) acting fucking stupid and treat me and God with respect." She called security and the charge nurse and the patient was escorted off of hospital property by security.
-The record showed the patient Left without Being Seen (LWBS) at 12:23 PM. The reason for leaving was that the patient was threatening to staff. The medical record did not contain evidence that patient # 1 signed a refusal to consent to examination or treatment or that staff explained the risks of refusal.

Documentation of an entry by the charge nurse provided by the facility and dated 05/10/15 at 12:26 PM was marked as draft and was not part of the medical record because it was not signed by Staff R, Charge Nurse. This draft stated that the patient was verbally abusive to staff and he didn't want treatment.

During an interview on 05/13/15 at 2:16 PM, Staff W, Registered Nurse, stated that she had come on shift at noon and was assigned the patient by the charge nurse.
-She stated that she went to the waiting room and brought the patient into Room #21. He was lying on the bed with the head of the bed up.
-He was difficult to understand because he kept his arm in front of his mouth and mumbled.
-The statements are in quotes because it is exactly what he said.
-She walked to the other side of the bed and told him she was going to take his blood pressure and his tone changed and she felt threatened because the statement he made came out of the blue.
-She didn't think he was delusional. Her feeling was that he wanted a bed to sleep in and for her to leave him alone.
-He stayed on the bed. He didn't act like he was going to hit her but she felt threatened and called security and the charge nurse. She didn't know what was said after that because she wasn't in the room.

During an interview on 05/14/15 at 10:30 AM, Staff D, ED Manager, stated that Staff W's charting did not specify behaviors, actions or words which would indicate threatening behavior.

During a telephone interview on 05/13/15 at 4:40 PM, Staff R, Charge Nurse, stated that the patient was brought in by the EMS after the Highway Patrol found him asleep by the road.
-He triaged the patient who was reluctant to give information but said he had been seen at another hospital (Hospital B) earlier in the evening (discharged [DATE] at 12:38 AM.) He stated that when the patient was asked if he wanted treatment, he shrugged his shoulders.
-He took the patient back to the waiting area and the patient went to sleep.
-He stated that he was called by Staff W who said she felt threatened and had called Security.
-He stated he went to Room #21 and talked with the patient who stated that he didn't want treatment.
-The patient was escorted to the waiting room doors.

During an interview on 05/13/15 at 3:30 PM, Staff S, Security, stated that he had been called to the ED for the patient in Room #21 who was being disruptive.
-He stated the patient was lying in bed with the head of the bed up. He said the nurse was telling the patient he needed to calm down.
-The patient was waving his arms around but he wasn't threatening with words or gestures.
-The charge nurse came into the room and said that the patient needed to leave and they would escort him out.
-They followed him to the door and Security watched him walk down to the parking lot and down the trails toward a residential neighborhood. It concerned him that the patient was headed for houses so he called law enforcement.

During a telephone interview on 05/13/15 at 4:10 PM, Staff Q, ED Physician, stated that he had signed into the computer to see Patient #1. He stated that in the 15 minutes or so it took him to get to the room, the patient was gone and he was told the patient LWBS.

During an interview on 05/13/15 at 4:00 PM, Staff P, ED Medical Director, stated that ideally the patient should be seen for a Medical Screening Examination. He stated that upon review of the patient's medical record, the statement that the patient was "losing his mind" was concerning because the patient might have underlying mental illness.

During an interview on 05/14/15 at 10:00 PM, Staff V, Chief Executive Officer, stated that patients who leave without being seen do not come to his attention unless it rises to an unusual level. He stated that all patients should have a medical screening examination but if the patient refused to be treated, the EMTALA obligation is fulfilled. He stated that he would like to have seen that the physician had been consulted before the patient left.

Review of patient # 1s' 05/11/15 medical record from Hospital C (the patient was seen at this third hospital after he did not receive a MSE at SSM Health St. Mary's) showed the patient presented to their ED requesting care.