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Based on policy and procedure review, medical record review, hospital document 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 and failed to explain risk and benefits to a patient that left against medical advice (AMA) for 1 of 3 sampled AMA patients (Patient #3).

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 and failed to explain risk and benefits to a patient that left AMA for 1 of 3 sampled AMA patients (Patient #3).

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

Based on policy and procedure review, medical record review, hospital document 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 and failed to explain risk and benefits to a patient that left against medical advice (AMA) for 1 of 3 sampled AMA patients (Patient #3).

The findings include:

A) Review of the policy and procedure titled "EMTALA Policy" last revised 04/2021 revealed "General (Named hospital) is committed to complying with the Emergency Medical Treatment and Labor Act ...Nursing Procedures 1. Any individuals who 'comes (sic) to the Emergency Department' will be offered a Medical Screening Examination by this Hospital ...3. All patients shall receive a Medical Screening Examination, based on patient acuity, the overall demands of the emergency department and the capabilities of the institution ...4. Patients refusing examination, treatment ...shall be documented in the medical record. Staff will take all reasonable steps to obtain a written informed refusal of examination, treatment .... signed by the patient. Staff will document whether they were able to advise the patient of the risks and benefits of examination, treatment ...Qualified Medical Personnel Procedures 1. A Qualified Medical Person shall provide a Medical Screening Examination to all patients who come to the Emergency Department. Except in the case of a documented refusal, AMA, or instance of a patient leaving without being seen ..."

Review of the policy and procedure titled "Triage/Assessment" last revised 02/2020 revealed " ...PROCEDURE: ...XI. Patients who are triaged but leave before receiving any treatment are classed as left without treatment. Patients who have diagnostics or treatment started and leave (sic) being placed in a room will be classed as leaving against medical advice ..."

Review of the policy and procedure titled "Informed Consent" last revised 02/2020 revealed Consent for Treatment for Adults ...3. The patient should sign a release form, "Leaving Hospital Against Medical Advice," before a witness, stating that he is leaving the hospital against medical advice, specifying the refusal of treatment involved, and the effect that the refusal has upon the patient's treatment. a. The statement should include that the patient has been fully counseled by his/her physician ...c. In the event patient refuses to sign the form, attach the form to progress notes and document that patient refused to sign ..."

1. Closed medical record review on 07/26/2021 revealed Patient #3 was a 74-year-old female who presented to the DED on 07/02/2021 at 1719 for vomiting, fever, and dizziness x 7 days. Patient #3's vital signs at 1746 were: pulse (P) 74, respirations (R) 22, and temperature (T) 98.2, blood pressure (BP) 133/69, and SP02 100% room air. Review revealed Patient #3 was triaged at 1740. Review of Registered Nurse (RN) #1's triage note dated 07/02/2021 at 1748 revealed "Patient #3 is 74 yrs Female and has a c/o (complaint of) ...Fever ...subjective, x last 24 hrs. Afebrile at triage. Vomiting x 2 today. No active vomiting on arrival ...Pt is alert, oriented to person, place and time, and pleasant at time of triage ...Orders placed/Interventions performed in triage- none at this time. Pt had nausea medication PTA (prior to arrival). Will hold meds for now. Post Triage dispo: to lobby to await bed placement." Review revealed Physician Assistant (PA) #1 ordered Zofran-ODT (medication for nausea) 4mg (milligrams) at 1821 and it was administered to Patient #3 at 1826. Review of vital signs at 2030 revealed P 58, R 16, T (not documented), BP 125/68, SP02 97% room air. Review of RN #2's ED note dated 07/02/2021 at 2150 (4 hours and 31 minutes after arrival to the ED) revealed "Pt leaving our facility, states she can be 'seen quicker in (Named City).'" Review revealed at 2148 Patient #3's ED disposition was set to AMA and discharged in the system at 2151. Review failed to reveal a MSE was initiated during Patient #3's time waiting in the ED lobby. Review failed to reveal risk and benefits were discussed or an AMA form signed prior to Patient #3 leaving the hospital.

Review of the ED dashboard dated 07/02/2021 revealed 16 patients arrived at the ED between 1600-1959 (Patient #3 arrived at 1719) and 13 between 2000-2359 hours. Review revealed a total census for 07/02/2021 was 69 patients.

Review revealed Patient #3 presented to Hospital B DED on 07/02/2021 at 2340 with complaints of "Dental Pain (Had top teeth pulled approx a week ago. Having difficulty eating, having N/V (nausea and vomiting). Daughter states she is having decrease in mentation. Dentist prescribed ATB (antibiotics) this past Monday, but patient unable to take due to N/V." Review revealed Patient #3 was admitted on 07/03/2021 for "acute kidney injury (kidneys suddenly can't filter waste from the body), Metabolic encephalopathy (condition which brain function is disturbed due to different diseases or toxins in the body), Nausea vomiting diarrhea-after taking antibiotics, and Hyperkalemia (high potassium)." Review of the H&P (history and physical) dated 07/03/2021 at 0036 revealed "Chief Complaint: Altered mental status HPI: This 74 y.o. female with a history of hypertension (high blood pressure), CKD (chronic kidney disease), dyslipidemia (high cholesterol) presents with altered mental status. Patient was brought in by family ...Patient recently had dental procedure and was on antibiotics. She has been having nausea vomiting diarrhea. She was taken to a different hospital and was not acting right so brought to this hospital ...She is seen in (Named Town) North Carolina. In emergency room patient underwent lab work and chest x-ray and CT (cat scan-a type of imaging) head and hospitalist was called for further management ..."

Interview on 07/27/2021 at 1002 with PA #1 revealed he ordered Zofran for Patient #3 due to the nurse reporting that Patient #3 was nauseous. Interview revealed Patient #3 was triaged and placed in the waiting room. Interview revealed a MSE was not started on Patient #3. PA #1 stated when an ED room was available, the provider saw the patient and started the MSE. Interview revealed patient volume and acuity played a role in being able to room and start the MSE for the patient.

Interview on 07/27/2021 at 1041 with RN #1 revealed he triaged Patient #3 per record review however he did not recall her. Interview revealed once they were roomed the provider evaluated the patient started the MSE.

Interview on 07/27/2021 at 1045 with RN #2 revealed she made a note in Patient #3's chart about her leaving. RN #2 stated she didn't talk with Patient #3 before she left, the message that Patient #3 was leaving was relayed by the front desk secretary after Patient #3 left. RN #2 stated Patient #3 was dispositioned as an AMA because she received treatment. RN #2 stated it was their process to disposition a patient as an AMA if they received any form of treatment while they waited to be seen by a provider. RN #2 stated if a patient had not received any type of treatment before leaving, they would select left without treatment as their disposition. RN #2 stated if staff saw a patient leaving, they would get them to sign the AMA after explaining the risk and benefits. Interview revealed if secretaries were busy they might not have time to notify the nurse prior to a patient leaving the ED waiting room.

Interview on 07/27/2021 at 1057 with the Medical Director of Emergency Services revealed when patients present to the ED, they get registered then get triaged. Interview revealed standard order sets could be used to get care going. Interview revealed if there was no room available then the patient waited in the ED waiting room until a room came available. Interview revealed once a patient was in a room the provider started the MSE. Interview revealed the ED was staffed with a MD 24 hours a day and mid-level coverage from 8 am until 3 am. Interview revealed if a patient received any type of treatment and left before the MSE was started, they considered them to have left AMA even if there was no discussion with the patient about the risk and benefits.