HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

A-2406: Medical Screening Examination:
The hospital failed to provide a Medical Screening Examination (MSE) to a patient who was taken to the Emergency Department by ambulance (Patient #1). Seven (7) patients out of 19 patients were identified with a delay in a medical screening or no medical screening being performed before leaving the ED (Patients #7, #8, #9, #11, #12, #16, #19).

A-2408: Delay in Examination or Treatment:
The hospital failed to provide a Medical Screening Examination (MSE) to a patient who was taken to the Emergency Department by ambulance (Patient #1). Seven (7) patients out of 19 patients were identified with a delay in a medical screening or no medical screening being performed before leaving the ED (Patients #7, #8, #9, #11, #12, #16, #19).

Employee #1 confirmed during an interview on 03/12/2023 that a medical screening examination was not performed on Patient #1. Employee #1 confirmed that seven (7) patients did not have a MSE before they left the ED or that the patient's MSE was delayed. Employee #1 confirmed hospital security did not follow AMA/LWOT protocol when one (1) patient (Patient #1) was escorted off hospital property to a bus stop. Employee #1 confirmed a comprehensive assessment was not performed on one (1) patient (Patient #1).

Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination (MSE) to a patient who was taken to the Emergency Department by ambulance (Patient #1).

Findings include:

Patient #1 presented to the Emergency Department (ED) via ambulance for altered mental status on 01/02/2024 at 1850. At 1905 Patient #1 was triaged in the ED and placed in the lobby to await a medical screening examination. At approximately 1950 Hospital security escorted the patient off the hospital premises to a bus stop without notifying the ED staff and getting a medical screening examination. Patient #1 returned to the ED via ambulance again on 01/03/2024 at 0602 after being found unresponsive at a bus stop. Patient #1 was found to have a subarachnoid hemorrhage, was placed on life support and transferred to the Intensive Care Unit (ICU).

Policy titled, "Emergency Department Patient Care", revealed: "...Purpose: Emergency Department (ED) patients at Banner Health can expect that patient care will be provided according to established practice guidelines as outlined below, and that additional interventions will be implemented based upon patient assessment and the prescribed medical regime...ESI - Emergency Severity Index: ESI is a five-level triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resources needed...Against Medical Advice (AMA): refers to patients who request to be discharged from the hospital before completion of treatment or contrary to the advice of the attending physician...Comprehensive Assessment: this assessment cannot be performed by an LPN. This includes the Triage Physical Assessment, the first physical assessment of the encounter for the patient, & the initial post-procedure physical assessment...Left Without Treatment (LWOT): refers to patients who leave the hospital after requesting to be seen in the Emergency Department / OB department, but prior to receiving a medical screening exam...Triage Assessment: 1. Completed by a RN and/or QMP. If a Paramedic is used to expedite the triage to assist with high patient volume, the RN oversees the ESI scoring, care plan of the patient and utilizes standing orders when needed. 2. An Emergency Severity Index (ESI) score is assigned when the triage
assessment is completed.
ESI 1 = Requires immediate life-saving interventions
ESI 2 = High risk situation or confused/lethargic/disoriented or severe pain
distress
ESI 3 = Two or more resources may be needed
ESI 4 = One resource may be needed
ESI 5 = No resources needed...
3. ED triage documentation may include, but is not limited to:
Chief complaint, vital signs, pain, and oxygenation
Mode arrival and mechanism of injury
Triage assessment and ESI scoring
Infectious Disease Screening
Suicide Screening...
Medical Screening Examination: 1. A medical screening exam (MSE) is completed by an Emergency Physician or QMP.
When applicable, the ED Medical Provider and/or QMP will complete the MSE in conjunction with an RN or Paramedic as a joint assessment.
Both the ED Medical Provider and/or QMP and RN or Paramedic perform a complaint specific assessment to prioritize, treat and evaluate for emergent, urgent, and non-urgent patients...
Assessment/Reassessment: Occurs according to the patient ' s clinical presentation or any significant clinical event with the minimum requirements as follows:
ESI 1 = Continuous observation and monitoring, with documented reassessments at a minimum of every 1 hour until hemodynamically stable, then minimally every 2 hours or per admitting unit guidelines of care.
ESI 2 = Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care
ESI 3 = Documented reassessments every 4 hours
ESI 4 = Documented reassessments every 6 hours
ESI 5 = Documented reassessments every 6 hours..
General Nursing Care:
1. Patients arriving from all portals of entry into the ED will receive a baseline assessment of their chief complaint by a registered nurse, physician or designee.
An ESI score will be assigned based upon acuity and resources needed.
Patients assigned ESI level 1& 2 to be given placement priority.
These priorities may be modified throughout the patient encounter as diagnostic testing/findings are made available and intervention/treatments are evaluated for effectiveness...."

Policy titled, "EMTALA-Medical Screening Examination and Stabilization Treatment", revealed: "...Banner Health provides care for individuals presenting to its hospitals (and Dedicated Emergency Departments, as defined below) with emergency medical conditions without discrimination and regardless of their payor status or eligibility for financial
assistance...Medical Screening Examination ( " MSE " ):
1. An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need emergency examination or treatment...
2. An appropriate MSE will be offered to individuals in the Hospital ' s Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance behavior would cause a prudent layperson observer to believe that such individuals need examination or treatment for a medical condition. Where the individual requires obstetrical or psychiatric services, the MSE may be rendered in OB Triage or the psychiatric crisis center...
3. When an EMS provider brings an individual to the Hospital with a Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms. Hospital should assess whether the EMS can appropriately monitor the individual ' s condition...
4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE...
5. An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ' s needs and must continue until the EMC is stabilized or the
Patient is admitted or appropriately transferred...
6. An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay...
13. A Physician or Qualified Medical Personnel (QMP), as determined by the Board, will medically screen Patients. Where a QMP performs the screening exam, such QMP will consult with the Patient ' s physician during or at an appropriate time after the medical screening examination as necessary...."

Document titled, "Security Report", revealed: "...01/02/2024 1914 hrs {sic}. Security made aware someone laying in ED lobby on floor asleep. I attempted several times to talk to patient and get [him] up off the floor. Patient refused. Security called for back up. Patient began exposing [himself] to lobby. Patient asked again by security to get off floor and complied getting into wheelchair. Patient escorted from lobby to outside in wheelchair by security due to behaviors. Patient given 2 blankets...1950 hrs{sic} Patient observed to be smoking outside ED lobby in smoke free zone. Security instructed patient to stop smoking. Patient refused. Patient told security that [he] no longer wanted treatment from the ED and was requesting to leave AMA. Patient was escorted off hospital property to bus stop via wheelchair and patient was left sitting on bus stop bench with 2 blankets...."

Review of the Hospital Quality Committee Meeting Minutes for February 2024 revealed LWOTs were at 9.23%. Further review revealed the average ED lobby wait time before being treated was 107 minutes, with a goal of 30 minutes. Further review revealed the ED was focusing on treating and discharging ESI 3 and 4's. Further review of minutes revealed a safety report involving Patient #1. The ED Safety Event report revealed: "..Poor pre-hospital?EMT handoff...Triaged as ESI 3...In lobby, patient was not cooperative and inappropriate...Security unsuccessful with getting patient to comply...Patient requested to leave before treatment, so security assisted to bus stop...Minimal communication between security and ED staff...Patient did not follow typical porcess for leaving without treatment (strict process that we do have to follow to remain complaint with EMTALA regulations)...Miscommunication and not taking patient out of system as refusal of treatment, patient did come back next day via ambulance...Patient found to have head bleed, did not improve, patient succumbed to injury...Advanced to full RCA due to breech of EMTALA regulations...RCA closed and all education completed...."

Review of Patient #1's medical record dated 01/02/2024 revealed Patient #1 arrived by ambulance to the ED at 1850.

Review of the Emergency Medical Services (EMS) runsheet dated 01/02/2024 revealed: "...Narrative: Dispatch-PM45 was dispatched to a medical emergency with TPD (Tucson Police Department)...Arrival: Upon arrival pt was laying on ground naked in a blanket in front of [his] apartment...Chief Complaint: Pt had a CC of vomiting and diarrhea with the onset of this morning. Pt also told case manager that someone drugged [him] and assaulted [him]. History: Pt said [he] was assaulted at an unknown time and that [he] had been drugged by said person. Pt also said [he] has been vomiting and having diarrhea all day. Case worker came to check on pt and [he] was laying on [his] floor naked with feces and blood all around the house...Assessment: Pt assessment revealed pt to have bruising to head and abrasions on back. Pt had a low fever. Additional assessment was unremarkable...Rx Treatment: none required...Transport: Pt was transported to Banner Main by MEDS848...."

Review of Patient #1 ED Nursing Triage note dated 01/02/2024 at 1905 revealed: "...ED Triage Chief Complaint: When asked what brings patient in to the ED, [he] states, "I don't know", states [he] drank "a lot" of alcohol today, also reports drug use but doesn't know what kind, not answering any further questions, moaning in triage...Pain present: no actual or suspected pain...Tracking Acuity: 3...Triage Assessment: Work of breathing: unlabored, Respiratory Pattern: Regular, Skin Color General: Usual for ethnicity, Skin Temperature: Warm, Skin Description: Dry, AVPU: alert and responsive...Glasgow Coma Scale: Eye Opening response: Spontaneously, Best verbal response: Confused, Best motor response: obeys commands; Glasgow Coma Scale 14...."

Further review of the triage note revealed no documentation of a comprehensive triage assessment for Patient #1.

Review of Patient #1 ED medical record revealed an ED Discharge/Admit note dated 01/02/2024 at 2357 which revealed: "...ED Disposition: Left without treatment (LWOT)...."

Review of Patient #1 ED medical record revealed a Refusal of Examination/Left Without Treatment/Elopement form dated 01/02/2024 which revealed: "...The patient left without informing staff of his/her withdrawal of a request for examination and/or prior to completion of care. At 2200 an attempt was made to locate the patient without success. At 2220 and attempt was made to locate the patient without success. At 2245 an attempt was made to locate the patient without success...."

Further review of Patient #1 ED medical record dated 01/02/2024 revealed no documentation of a medical screening examination being performed prior to Patient #1 leaving the ED. Further review of Patient #1 ED medical record dated 01/02/2024 revealed no documentation of communication between security and ED staff regarding Patient #1 requesting to leave the ED.

Review of the ED log for January 2024 revealed Patient #1 returned to the ED on 01/03/2024 at 0602 via ambulance.

Review of the EMS Runsheet for Patient #1 dated 01/03/2024 at 0527 revealed: "...Narrative: Dispatch- En03 responded to report of a [male] pt that was found lying on the ground outside with unknown complaint...Arrival-Found a staff member from the church on scene with the pt. The pt was found lying on the sidewalk outside the church wearing only half of a Tyvek suit and no shirt...Chief Complaint- The pt is moaning in apparent discomfort and has trouble verbalizing a CC. Cold exposure is suspected...History: The pt is a regular visitor in the area. [He] is wearing a hospital bracelet from the day before from Banner UMC which is across the street...Assessment: The pt is able to answer questions such as person and place. [He] follows commands after being prompted but will not verbalize a CC. [He] says that [he] has been sleeping on the sidewalk all night. It is 39 degrees F and the pt is not wearing a shirt. [He] has a small blanket on the ground that [he] is lying on. [He] has not {sic} obvious injuries but is moaning loudly in apparent discomfort. Secondary physical exam is unremarkable...Rx Treatment: The pt is given a blanket and appears to have relief and falls asleep...Transport- The pt agrees to transport to BUMC for treatment. [He] is assisted to the gurney and care is transferred to AMR 894 with pt in stable condition...."

Review of Patient #1 ED record dated 01/03/2024 revealed Patient #1 arrived via EMS to the ED at 0602.

Review of Patient #1 triage note dated 01/03/2024 at 0613 revealed: "...Chief Complaint: BIBA w/no report given by EMS. Pt only responsive top {sic} pain in triage and not answering triage questions. Patient breahting {sic} on own, VSS. Pt drooling in triage. Was here last night and very intoxicated ultimately LWOT, Unknown substance intake, Unknown hx {sic}...Pain Present: No actual or suspected pain...Tracking acuity 3...Triage assessment: Work of breathing: unlabored, quiet; Respiratory pattern: Regular; Skin Color General: usual for ethnicity; Skin temperature: warm; Skin description: dry; AVPU: Responds to painful stimuli...Glasgow Coma Score: Eye opening response: to pain; Best verbal response: Incomprehensible sounds; Best motor response: Localizes to noxious stimuli; Glasgow Coma Score: 9...."

Review of Patient #1 ED Provider note dated 01/03/2024 revealed: "...patient care initiated 01/03/2024 0748...ED admitted via ambulance 01/03/2024 0602...History of Present Illness: This is [52 year old male] presenting to the emergency department today with altered mental status. History obtained from chart review. [He] had checked into the ED last night at approximately 7 PM. At that time the triage note states: 'When asked what brings patient in to the ED, [he] states "I don't know" states [he] drank 'a lot' of alcohol today, also reports drug use but doesn't know what kind, not answering further questions, moaning in triage...[He] LWOT. [He] then came back to the ED by ambulance to the waiting room per triage, no report given by EMS. Difficult to obtain history at this time. When asked what brought [him] to the ED [he] states "Everything's all wrong." [He] reports pain everywhere and a few minutes later will deny pain...[He] reports then denies headache...[He] moans with any touch. [He] is A&O X 1...Differential diagnosis: ETOH intoxication, other substance intoxication, metabolic encephalopathy, sepsis, intracranial hemorrhage...I got a call from the attending neuroradiologist regarding this patient's head CT findings at 1234, immediately paged neurology stroke and neurosurgery...I spoke with (consulting neurosurgeon) recommendations and treatment decisions include: will come evaluate patient, concern for aneurysm, will admit patient...ED Course: ...[His] exam did not show any obvious evidence of trauma or focal tenderness to suggest an etiology for [his] symptoms. Labs ordered to evaluate for infection, status, antibiotics were ordered for potential sepsis, head CT ordered...When (labs) resulted in the ETOH was negative but became much more concern for potential intracranial source of [his] symptoms including meningitis versus bleed. Head CT obtained. I received a call from the neuroradiology attending reported subarachnoid hemorrhage and hydrocephalus...Nicardipine drip was started for blood pressure control. Neurosurgery came to evaluate this patient and admit to their service for likely drain placement...."

Further review of Patient #1 ED medical record dated 01/03/2024 revealed Patient #1 was admitted to the Intensive Care Unit (ICU) at 1419 on 01/03/2024.

An additional 19 ED records were randomly selected for review which included patients who were transferred, admitted, discharged, or left before Medical Screening Examinations. The following seven (7) patients were identified with a delay in a medical screening or no medical screening being performed before leaving the ED:
Patient #7: registered on 01/02/2024 at 1247, triaged at 1303 ESI 3, LWOT at 2015, elapsed time was approximately 7 hours and 28 minutes.
Patient #8: registered on 01/02/2024 at 1315, triaged at 1352 ESI 3, LWOT at 2015, elapsed time was approximately 7 hours.
Patient #9: registered on 01/02/2024 at 2128, triaged at 2308 ESI 4, MSE at 0047, elapsed time was approximately 3 hours 19 minutes.
Patient #11: registered on 01/02/2024 at 1437, triaged at 1510 ESI 2, MSE at 2241, elapsed time was approximately 8 hours.
Patient #12: registered on 01/09/2024 at 1805, triaged at 1849 ESI 3, LWOT at 0155, elapsed time was approximately 5 hours and 50 minutes.
Patient #16: registered on 02/15/2024 at 1223, triaged at 1237 ESI 3, MSE at 1543, elapsed time was approximately 3 hours and 20 minutes.
Patient #19: registered on 02/01/2024 at 1245, triaged at 1249 ESI 2, MSE at 1533, elapsed time was approximately 2 hours and 18 minutes.
Further review of the 19 additional records revealed there was no documentation that there were any delays in assessments and/or treatments based on patient ability to pay for medical services.

Employee #1 confirmed during an interview conducted on 03/12/2024 that Patient #1 had been admitted to the ED on 01/02/2024 and left the ED prior to receiving a medical screening examination. Employee #1 confirmed that Patient #1 was escorted off the hospital property by hospital security without security notifying ED staff. Employee #1 confirmed Patient #1 was left at a bus stop by security. Employee #1 confirmed that Patient #1 returned to the ED via EMS the following morning after being found with an altered mental status at a bus stop. Employee #1 confirmed that Patient #1 was diagnosed with a subarachnoid hemorrhage during the ED admission on 01/03/2024.

Employee #13 confirmed in an interview conducted on 03/12/2024 that January 2024 was a busy month for the ED. Employee #13 stated that the ED saw 1603 more patients in January 2024 than in January 2023.

Provider #5 confirmed in an interview conducted on 03/12/2024 that Patient #1 was a patient in the ED on 01/02/2024. Provider #5 confirmed that Patient #1 was triaged and then placed in the lobby to await a medical screening examination. Provider #5 confirmed that there was an interaction between security and Patient #1 when Patient #1 was exhibiting some disruptive behavior. Provider #5 confirmed that security placed Patient #1 in a wheelchair and was escorted off the hospital property and left at a bus stop. Provider #5 confirmed that there was no communication regarding Patient #1 between security and ED personnel prior to escorting Patient #1 off the premises.

Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to provide a Medical Screening Examination (MSE) and treatment to a four (4) out of 20 patients who left without treatment (LWOT) (Patients #1, #7,#8, #12) and delayed a Medical Screening Examination and treatment for more than two (2) hours for four (4) out of 20 patients (Patients #9, #11, #16, #19).

Findings include:

Policy titled, "EMTALA-Medical Screening Examination and Stabilization Treatment", revealed: "...An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ' s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred...An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay...Where an individual comes to the Hospital ' s Dedicated Emergency Department and requests services for a medical condition that is not of an emergency nature, the Hospital will perform such screening as would be appropriate to determine that the individual does not have an EMC. After such determination is made, the person may be directed elsewhere for services...."

Review of medical records of twenty patient randomly selected from the ED logs for December 2023, January 2024 and February 2024 revealed the following:
The hospital failed to provide a Medical Screening Examination (MSE) and treatment to four (4) out of 20 patients before the patients left without treatment:
· Patient #1: registered on 01/02/2024 at 1850, triaged at 1905 ESI 3, LWOT at 2357, elapsed time was approximately 5 hours and 7 minutes.
· Patient #7: registered on 01/02/2024 at 1247, triaged at 1303 ESI 3, LWOT at 2015, elapsed time was approximately 7 hours and 28 minutes.
· Patient #8: registered on 01/02/2024 at 1315, triaged at 1352 ESI 3, LWOT at 2015, elapsed time was approximately 7 hours.
· Patient #12: registered on 01/09/2024 at 1805, triaged at 1849 ESI 3, LWOT at 0155, elapsed time was approximately 5 hours and 50 minutes.
Further review of the medical records revealed the hospital delayed a MSE and treatment on four (4) of 20 patients for more than two hours:
· Patient #9: registered on 01/02/2024 at 2128, triaged at 2308 ESI 4, MSE at 0047, elapsed time was approximately 3 hours 19 minutes.
· Patient #11: registered on 01/02/2024 at 1437, triaged at 1510 ESI 2, MSE at 2241, elapsed time was approximately 8 hours.
· Patient #16: registered on 02/15/2024 at 1223, triaged at 1237 ESI 3, MSE at 1543, elapsed time was approximately 3 hours and 20 minutes.
· Patient #19: registered on 02/01/2024 at 1245, triaged at 1249 ESI 2, MSE at 1533, elapsed time was approximately 2 hours and 18 minutes.

Employee #1 confirmed that the hospital did not perform MSE or treatment on four (4) patients prior to the patients leaving without treatment (Patients #1, #7, #8 # 12). Employee #1 confirmed that the MSE and treatment was delayed more than two (2) hours for four (4) patients (Patients #9, #11, #16, #19).