The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Intake: TN 647

Based on policy review, personnel file review, inservice training records, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital DED to determine if an emergency medical condition existed in order to provide appropriate treatment for such conditions and ensure the patient was stabilized prior to leaving the DED for 1 of 22 (Patient #2) sampled patients.

The findings included:

1. Review of the facility's policy, "Emergency Medical Treatment and Labor Act (EMTALA)" revealed, "POLICY: A. Medical Screening Exam (MSE): 1. When an individual comes to [Name of facility], and request is made for emergency care, [Name of facility] must provide an appropriate Medical Screening Examination within the capability* of the facility emergency department*, including ancillary services routinely available to determine whether an emergency medical condition exists... B. In the absence of a request for services, EMTALA applies if a prudent layperson observer would believe, based on the individuals' appearance or behavior, that the individual needs examination or treatment for an emergent medical condition. 2. The Medical Screening Examination is to be provided by Qualified Medical Personnel. Individuals coming to the emergency department must be provided an MSE beyond initial triage."

Review of the facility's policy, "DISRUPTIVE BEHAVIOR " revealed, "POLICY: Disruptive behavior in the workplace will be reported and address ....DEFINITIONS: Disruptive behavior is defined as any action, statement or other conduct which is reasonably likely to impair the efficiency, safety or tranquility of the work environment. Examples of disruptive behavior include but are not limited to: striking another person, yelling, throwing objects, abusive or foul language, physical or verbal threats to inflict harm, discriminatory conduct, non-constructive derogatory comments about the facility or other employees, sexual, emotional or physical harassment, physical or verbal intimidation, retaliation, refusal to perform job duties, impairment by drugs or alcohol, and inappropriate comments on the medical record ...Patient Disruptive Behavior 1. Employees are educated at orientation and annual inservice regarding management of disruptive behavior. 2. Disruptive behavior by a patient must be reported by calling a supervisor, the Administrator on Duty, the compliance hotline (#4555) or by entering an electronic incident report. 3. Employees will attempt to manage disruptive behavior and minimize risk by using the following techniques/actions when appropriate: remain calm, maintain eye contact (to the extent it seems safe (noting that to some people appear aggressive), maintain a safe distance, remove audiences, encourage the patient to relocate to a more appropriate/safe environment, allow the patient to vent, listening empathetically, exhibit a willingness to help, set limits and calmly convey the expectation that the patient will control his/her own behavior, and calling in assistance if unable to de-escalate the situation. 4. Employees should not: become defensive, threatening, sarcastic, judgmental, condescending, raise his/her voice, invade personal space, debate, ridicule, patronize, engage in a power struggle or attempt to physically subdue the disruptive patient (unless physically threatened with imminent bodily injury and in self-defense or defense of another). 5. Disruptive behavior that rises to the level in which an employee feels that he/she or other persons are in danger of harm should be reported to Security immediately by calling [listed phone numbers] and calling "Code 10 " ...7. Once any immediate danger or threat is under control, security will contact the house supervisor, facilities director, or administrator on duty to communicate the circumstances of the situation ...Repetitive Disruptive Patient Behavior [NAME OF FACILITY] WILL AT ALL TIMES ABIDE BY ITS EMTALA OBLIGATIONS TO PROVIDE TRIAGE AND STABILIZATION TO PATIENTS PRESENT TO THE EMERGENCY DEPARTMENT OR IN NEED OF EMERGENCY CARE.

2. Review of the facility's in-service training (Rapid Regulatory Compliance: Non-clinical: Part 1) which is provided to the facility's Patient Access Service Representatives revealed, "Corporate Compliance: Applicable Laws and Regulations Finally, let's look at: EMTALA The Emergency Medical Treatment and Active Labor Act (EMTALA) is also called the Patient Anti-Dumping Statute. This statute requires Medicare hospitals to provide emergency services to all patients, whether or not the patient can pay. Hospitals are required to: Screen patients, who may have an emergency condition, Stabilize patients who have an emergency condition."

There was no additional EMTALA related information included in the Rapid Regulatory Compliance: Non-Clinical training.

3. Medical record review for Patient #2 revealed the patient arrived at the DED on 10/6/12 at 19:31 with a chief complaint of nose bleed and coughing blood. The "LEAVING AGAINST MEDICAL ADVICE (AMA) OR WITHOUT A MEDICAL SCREEN" form documented, "Patient left without notice .....Time 1941 ...Staff Comments: Pt had spit on floor & cursing at Reg. Staff. Pt called @ 1941 No answer, pt left prior to triage. Unable to encourage pt to stay or inform pt risk of leaving." It was signed by RN #1 at 19:41 on 10/6/12.

4. Review of the facility's self reported incident for the 10/6/12 issue involving Patient #2 revealed, "Patient arrived at the emergency room seeking treatment for hemoptysis. He was disruptive and cursing the registration staff and security was asked to intervene and monitor. The patient was given an emesis bag but continued to spit blood on the floor and call registration staff names. The registration clerk lost his temper and had security remove the patient from the facility prior to medical screening. When the patient asked for the registration clerk's name, the clerk held up a sign that said, "F... you." This incident is being reported as verbal abuse of a patient and will be reported to the State/CMS as an EMTALA violation. The facility found the incident to be substantiated as reported ...."

5. Review of the personnel file for Staff #1, a Patient Access Services Representative, revealed a statement that was not dated or timed, regarding Patient #2. In the document, Staff #1 stated, "During the brief time he was here, [Patient #2] returned to the window several times telling us to kick out the patient ahead of him so that he could be seen and making racial statements to [Staff #2] and I, such as "cracker," honky mother-f ....r," and "bambie bitch." Security was notified and asked to handle the situation. However, after several times of being addressed by security to not spit on the floor, the patient still had not complied and continued to make racial statements. By then, [named Patient #2] paperwork had been completed and handed over to the triage nurse. During this time, there was also a discharged patient in the waiting room that was loud, disruptive and possibly drunk. This had also been addressed by security, which had also been met with noncompliance. This created a hostile environment for the registration and nursing staff ... I asked security to escort the man off the premises, which they did. As he left he asked my name, once again calling me a "bambie bitch." I reacted by writing "F... you" on a sheet of paper and showing it to him ...."

Reviews of Staff #1's personnel file reveal he had completed the Rapid Regulatory Compliance: Non-clinical: Part 1 training on EMTALA on 4/27/12.

6. Review of an e-mail dated 10/9/12 at 12:39 PM from the Captain of the Security Division revealed, "Here is [Security Officer #1] report on the incident we spoke about. On October 6, 2012, I [Security Officer #1] was asked by registration employee [Staff #1] at 19:45 hrs to escort a verbally disruptive patient out of [name of facility] and off the property. (Note) The patient was also spitting blood on the floor after being told several times to use the vomit bag he had been given. The patient agreed to leave but wanted to get the names of those working the registration desk to file a complaint for refusing to treat him. At the time employee "[Staff #1]" wrote vulgar expletives on a note pad and pressed it to the glass and said that's my name. I then told the patient again that it's time to leave. He again agreed and left the property. No further information is available."

7. During a telephone interview on 11/5/12 at 1:24 PM Staff #2 stated, "[Staff #1] was at the station, I walked up front to check on him to see if he needed any help. [Patient #2] was at the window and there were 2-3 behind him. [Patient #2] was upset said he needed to be seen. I got him registered in a matter of seconds and he was very angry when asked to have a seat. Then he signed his paper work and started spitting on the floor with 3 patients standing at the window behind him. We did not say anything because the triage nurse saw the spit and she asked environmental services to clean up the spit. [Staff #1] explained to him that the nurse would get to him as soon as she could. The patient responded with a racial comment and kept returning to the window with more racial and vulgar comments and saying them to me too. Security came to the waiting room after [Staff #1] alerted them after the first racial comment and vulgarity. Security then talked to the gentleman and went back to their office ...he [Patient #2] was asked to leave because he was using racist's comments and vulgarity to his fullest. [Staff #1] asked security to please ask the gentleman to leave again. Security asked the gentleman to leave and the gentleman again came back to [Staff #1's] window and said, 'Give me your name you f..king cracker' and that's when [Staff #1] responded with the note."

During this telephone interview with Staff #2 on 11/5/12 at 1:24 PM, she was asked by the surveyors if she had been trained on EMTALA and she stated, "Am now." She further stated that she did not know about EMTALA regulations prior to this incident.

8. During a telephone interview on 11/5/12 at 3:00 PM, RN #1 stated, "Did not go out into the waiting room, I had a patient in triage. If the patient had been in distress, for example, wheezing or chest pain, I would have called him right back. There were a couple of disruptive patients in the waiting room ...that's not unusual. I heard Security being paged. I didn't realize what had happened until I triaged the next man ...he told me. The patient [Patient #2] was already gone. I did not report the incident with [Staff #1]. I have been trained on EMTALA policy."

9. During a telephone interview on 11/5/12 at 4:18 PM, RN #2 stated, "I got a call from [name of physician] who said there had been an altercation with Security. [Per her written statement, the physician told her the patient had left the hospital approximately 2 hours prior.] I went to Security and asked about a patient being escorted off the property. They said it was not them but [Staff #1]. I spoke to [Staff #1] who stated, 'I did it.'

11. During an interview in the conference room on 11/5/12 at 2:48 PM, the Patient Registration Manager stated he had no formal training in EMTALA. He further stated that he knew that you could not turn a patient away and could not ask for money up front.
Based on policy review, personnel file review, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital DED to determine if an emergency medical condition existed in order to provide appropriate treatment for such conditions and ensure the patient was stabilized prior to leaving the DED for 1 of 22 (Patient #2) sampled patients.
Refer to findings in deficiency A-2406.