HospitalInspections.org

Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by failing to provide an appropriate medical screening exam for 1 (#2) of 20 (#1 - #20) patients who presented to the emergency department. (See findings tag A-2406).

Based on record reviews and interviews, the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice was evidenced by failing to provide an appropriate medical screening exam for 1 (#2) of 20 (#1 - #20) patients who presented to the emergency department.

Findings:

Review of the hospital's policy titled "Emergency Department: Medical Screening Exam" reviewed 05/2017, revealed in part, any individual who comes on hospital property requesting examination or treatment is entitled to and shall be provided an appropriate medical screening examination by a physician to determine whether or not an emergency medical condition exists. The medical screening examination shall be the same medical screening examination that the hospital would perform on any individual coming to the hospital's emergency department with those signs and symptoms regardless of the individual's ability to pay for medical care.

Review of Patient #2's medical record revealed Patient #2 presented to the emergency department on 07/25/2024 at 10:45 a.m. Review of the ED summary report revealed in part, Patient #2's chief complaint was hallucinations and was given a triage level 5 - Non Urgent. Triage note revealed in part, 10:50 a.m. Patient #2 ripped blood pressure cuff off and took off on foot beating ER doors and ran outside where she met officers who took her into custody. Further review revealed a nursing note dated 07/25/2024 at 11:11 a.m. Patient #2 was brought to the ED by local police department with c/o hallucinations. Patient #2 was escorted to bed ER3 by police officers. While obtaining vital signs, S6CP stated he and officer had to return to road as only two officers were working. As soon as police left the ED, Patient #2 became belligerent, yelling and attempted to get out of the bed by climbing over bed rails. Patient #2 was prevented from climbing over rail to prevent injury; Patient #2 then exited bed at foot of bed and began to walk out of the ED in aggressive manner. As Patient #2 was walking out, Patient #2 began yelling and striking at floor scale, striking the ED doors to the exit of ED. ED door was opened and Patient #2 exited the ED into parking lot. Review of Patient #2's medical record failed to reveal a medical screening examination performed by a physician.

Review of the Police Department Offense Report presented by S1Adm revealed in part, on the above date I, S6CP responded to Barousse St to assist S7PO on a call of a female running down the road with no clothes on. Upon my arrival S7PO had located the female and convinced her to go into her residence and put clothing on. As I was talking with S7PO and the female who overdose herself to S7PO as Patient #2 I could see she was seriously under the influence of some type of narcotics. I asked Patient #2 what she was on and she advised Xanax and jiggers. Patient #2 advised she had taken 7 Xanax and 2 1/5 jiggers which is street terms for ecstasy. Patient #2 had sweat pouring from her and her eyes were huge and it was obvious that she was having a severe medical issues and mental issues. We requested an ambulance which we tried waiting for which was taking quite a while as usual here in town. It appeared that Patient #2 reactions and the drugs were getting worse and I was in fear for her medical well-being and advised S7PO that we could no longer wait for an ambulance we would transport before she went onto severe medical conditions. I radioed the dispatcher and advised to cancel the ambulance that we were transporting to the hospital. Upon arrival at the hospital we walked Patient #2 in and I informed the ER nurse S4LPN what the situation was and how we found her naked and also what I observed and that she was heavily under the influence of some type of drugs. I also stated to him that she appears to be in medical distress from the narcotics taken. We walked her to station three where 2 nurses began to get her vitals and start to exam her. I asked S4LPN if we could go because S7PO was the only unit on the road and he responded yes. Myself and S7PO walked out the hospital and stopped outside the ER door to speak with one of the maintenance guys. While speaking with the maintenance guy, the ER doors come flying open and Patient #2 comes out the ER and lets herself fall down to the concrete. Right behind her is the ER doctor screaming and hollering at us and says S6CP you can take her to jail. I advised him I was not taking her to jail that she needs medical and mental treatment and did nothing to go to jail for. He then advised me that he was not treating her and that she was not coming back in his hospital and hollering at me. I asked him if he was refusing medical treatment and he advised she is not coming back in the hospital. He then advised she was cutting up so I asked him why did someone not come get us we were at the back door which has cameras and they can see we were there. The ER doctor continued to scream and insist we take her to jail, I advised him that in her medical condition I was not taking her to jail and the ER doctor screamed I am medically clearing her right now for jail. I advised him I was not taking her to jail, she needs medical help and he refused again and closed the ER door on us. We tried calling an ambulance to transport her to another hospital but was refused as we were stated that they could not pick her up on hospital property without hospital request. At that time for her safety and her getting more and more needing what I appeared to be medical treatment and with the ER doctor refusing medical treatment I made the decision where we would transport her to the Police Department and have an ambulance pick her up there. Upon arrival at the Police Department, ambulance personnel transported Patient #2 to another hospital for medical treatment.

In a phone interview on 08/14/2024 at 12:45 p.m. S3RN stated shortly after the police left, Patient #2 ripped off the blood pressure cuff and scooted down to the foot of the bed. She stated Patient #2 stormed to the ED doors. She stated Patient #2 started banging on the ED doors and S5MD went to meet Patient #2. She stated she heard S5MD say "get her out of here, I don't want her in my ER". She stated she didn't see the police officers but that's who she assumed S5MD was talking to.

In a phone interview on 08/14/2024 at 1:09 p.m. S5MD stated he was at the desk observing when Patient #2 came in. He stated Patient #2 was a little agitated when the police walked Patient #2 to the ED bed. S5MD stated Patient #2 was cooperative at this point. He stated the staff began taking vital signs. S5MD stated he overheard bits and pieces that Patient #2 was upset about a death in her family. He stated S6CP had left when the triage nurse was taking their report. He stated Patient #2 never stated she wanted to harm herself or anyone else. S5MD stated when the triage nurse walked away to get something, Patient #2 became belligerent, trying to get out the stretcher. He stated he was concerned for her safety. He stated Patient #2 got out the bed before he could get to her. S5MD stated as Patient #2 ran down the hall she was yelling saying she didn't want to be here. He stated Patient #2 threatened the staff's safety in general. S5MD stated Patient #2 was yelling, "If yall try to stop me, I will hurt yall". He stated within 30-40 seconds from S6CP leaving is when Patient #2 became belligerent. S5MD stated Patient #2's presentation was of stimulant intoxication rather than psychosis. S5MD stated he had not examined Patient #2 but determined that from what he had observed. He stated Patient #2 picked up the floor scale and attempted to throw it but couldn't. He stated Patient #2 then ran into the ED doors. S5MD stated he pressed the button to open the ED doors because those doors cost $700 to repair if broken. S5MD stated when the doors opened Patient #2 walked in the waiting area, turned right, and pressed the button and the ED entrance door opened. S5MD stated he followed Patient #2 into the parking lot. He then stated he stood in the ED door entrance. S5MD stated S6CP was standing on the grass near the entrance and Patient #2 sat down in front of him. He stated he addressed S6CP, not in an angry or disrespectful but was forceful with S6CP. S5MD stated he told S6CP that Patient #2 is threatening him and his staff, destroying the ER, and he couldn't have her here in this condition. S5MD stated he told S6CP that he would be happy to medically clear her. S5MD stated they needed some help from the police to secure Patient #2 to be able to give medication to calm Patient #2 down. S5MD stated triage was initiated, he had observed Patient #2 calmly answering questions when S6CP was present. He stated as soon as S6CP left, Patient #2 became violent and wanted to leave. S5MD stated in the state Patient #2 was in, there was no way to evaluate the patient until they could get her to calm down and that was not the case.

In an interview on 08/15/2024 at 8:48 a.m. S1Adm stated it did not appear that a medical screening exam was performed by the physician for Patient #2. S1Adm verified there was no physician documentation included in the medical record for Patient #2. He verified the only documentation from the physician was on the Alternate Discharge Status Form where the physician signed acknowledging Patient #2 eloped from the ED.

In an interview on 08/15/2024 at 2:10 p.m. while reviewing the hospital's policy titled "Emergency Department: Medical Screening Exam", S1Adm stated once a patient reaches the outside of the hospital, the hospital staff will not go outside. He stated at that point the hospital staff calls the police department for the patient. He stated the police would bring the patient back inside the emergency department.

In a phone interview on 08/19/2024 at 10:07 a.m. S2DON stated hospital "a" has 10 psychiatric beds. He stated on 07/25/2024 the psychiatric unit had 6 patients. He verified there was a bed available in the psychiatric unit on 07/25/2024.

Review of Patient #2's medical record from hospital "b" revealed in part, Patient #2 was brought in by ambulance on 07/25/2024 at 12:04 p.m. with a chief complaint of psychiatric evaluation and was given a triage level 2- Emergent high risk. Review of the ED notes by provider revealed in part, 30-year-old black female to the emergency department via EMS for evaluation of bizarre behavior. Patient #2 was found outside running around naked yelling. Patient #2 appears to be acutely psychotic and is agitated yelling at staff. She is having flight of ideas and is very pressured speech. Unable to get history of previous psychiatric illness. Is able to state she has no physical complaints. No chest pain or shortness of breath. Patient #2 required chemical sedation. Further review of Patient #2's medical record from hospital "b" revealed in part, Patient #2 was placed on PEC on 07/25/2024 at 12:28 p.m. Patient #2 was transferred to hospital "c" on 07/25/2024 at 5:44 p.m. with a diagnosis of bizarre behavior; psychosis, unspecified psychosis type.