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Based on record review, interview, and observations the facility failed to meet the Condition of Participation to protect patients rights by not preventing patient abuse.

The findings are:

A. The facility failed to prevent abuse. Refer to Tag A-0145.



49835

Based on facility record review and staff interviews, the facility failed to to inform a patient of the risks of leaving the emergency room against medical advice for 2 (P (patient)13, and 28) out of 19 (P11-P29) patient charts reviewed for presenting to the emergency room. This deficient practice is likely to result in unsafe patient outcomes for all patients who leave the facility against medical advice.

The findings are:

A. Record review of the facility's policy titled, "Patient Discharge and Departure - Release of Patient from Hospital & [and] Leaving Against Medical Advice" dated, 05/12/2023, under, "Description/Overview" stated, ". . . Patients leaving the hospital AMA should have appropriate follow up appointments, medical equipment and supplies, discharge medications from the outpatient pharmacy of the patient's choice, home health care and other services needed by the patient at discharge." Under, "Procedure for departure against medical advice or away without notice" stated, "1. Discharging a patient (AMA)
1.1. Ask the patient to stay and talk with the physician or APP [Advanced Practice Provider].
1.2. Notify the physician or APP if he/she is unaware the patient wishes to leave against
medical advice.
1.3. The discharging clinician should make all reasonable efforts to accommodate the patients concerns, if possible so they can remain hospitalized.
1.4. Ask the patient to sign the Patient Departure/Discharge Against Medical Advice Form (form can be found under Clinical Forms> Discharge). If the patient refuses, all individuals who witnessed the situation should sign the form where it indicates that the patient refused to sign."

B. Record review of the facility's document titled, "Patient Departure/Discharge Against Medical Advice" dated 06/24/2015 there were four blank lines that indicated a place for, "Description of the Potential Risks/Complications of Refusal of Examination/Treatment (to be completed by health care professional)."

C. Record review of P13's medical record for the visit date 05/04/2024 revealed:

1. Emergency department note dated 05/04/2024 at 6:11 AM stated "[Patient] presents to [name of facility] as a transfer from [name of transferring facility] for evaluation of bilateral [both eyes] visual changes over the last 24 to 48 hours. Concern for possible retinal detachment [a serious condition that can cause vision loss if not treated] from sending facility and need for ophthalmology [eye doctor] evaluation. Per chart review patient has experienced waxing and waning symptoms of bilateral visual disturbance to include left-sided peripheral blurry vision and right central vision changes. VSS [vital signs stable]." The record did not contain any evidence of a plan or further orders in the providers note.

2. Emergency department nursing discharge summary dated 05/04/2024 at 10:06 AM stated "Left Against Medical Advice. . . Pt [patient] son had taken pt to their car. Pt son came to inform staff that they were not wanting to continue to be in the waiting room and that they could be reached by phone if they were needed. Notified MD [medical doctor] of this."

3. Orders for visit date 05/04/2024 did not reveal evidence of a request for ophthalmology consult.

4. The record did not contain any evidence of an AMA form signed or discussion of risks or benefits with the patient and/or family.

D. Records review of form for P28 labeled "Patient Departure/Discharge Against Medical Advice" (AMA form). The section with the header "Description of the Potential Risks/Complications of Regusal [SIC] of Examination/Treatment (to be completed by Healthcare professional)" was blank.

E. During an interview with Clinical Staff member Staff (S)16 on 08/15/2024 at 11:48 AM confirmed that an explanation regarding the potential risks and complications of leaving the emergency room without examination or treatment is documented on the AMA form. This is a requirement as an attestation that the patient had been advised and understands the potential risks and complications of leaving the emergency room without being fully examined and treated. When asked if this was a routine process for patients leaving AMA, S16 stated "Yes, I thoroughly explain the health risks of leaving AMA up to the possibility that they may die if that's the case." When asked if documentation of this patient education is required at the facility, S16 replied "Yes, it is. . . They should have a clear understanding of the risks before they leave AMA."

F. During an interview on 08/15/2024 at 2:45 PM with S12, non-clinical, it was explained that facility policy does not require staff to fill out the AMA form in its entirety.

Based on record review, interview, and observations the facility failed to prevent abuse of 2 (P[patient]6 and P30) out of 2 (P6 and P30) patients reviewed for patient rights. This deficient practice could lead to physical and mental harm to any patient that presents to the hospital.

The findings are:

A. Record review of the facility's policy titled, "Security Officers - Use of Physical Force" dated 08/30/2021, under "Guideline Steps" stated, "Security Officers may be called to protect patients, visitors, students and staff from a violent situation prior to Law Enforcement arrival. Security Officers may use force ONLY when absolutely necessary to protect themselves and others from immediately imminent bodily harm."

B. During an observation of the Emergency Room (ER) on 8/13/2024 at 4:15 PM, surveyor heard a commotion in the hallway in the ER and P30 sat in a chair when a security guard approached P30 and stated, "Do you want to be restrained?" A nurse outside of a room stated, "We got him calmed, please go."

C. During an interview on 08/15/2024 at 1:05 PM with Staff (S)13, non-clinical, when questioned regarding the observation noted above, S13 stated, "That was not the appropriate approach." S13 explained that security officers should always start with a calming approach.

D. Refer to Tag-2406 Finding B for P6 presenting to the emergency room for medical condition.

E. Record review of the security footage outside of the emergency room entrance for date 05/05/2024 at 11:45 PM, P6's belongings were on a bench outside of the emergency room entrance, S18, non-clinical goes to gather P6's belongings, P6 appeared to attempt to stop S18 from getting her belongings. As P6 grabbed at S18 to stop him, S9, non-clinical, grabbed P6 from behind around her trunk and pulled her back. P6 was released and appeared to stomp toward S18 foot but missed. S9 and S18 then grabbed P6 under the arms, P6 can be seen forcefully being removed from hospital premises. S7, non-clinical, followed behind with P6's belongings. S9 and S18 left P6 on a concrete foundation near a bus stop with her belongings.

F. During an interview on 08/13/2024 at 2:16 PM with P6 regarding the incident on 05/05/24, P6 explained that she was hurt by hospital staff, and she already had an injured knee and normally uses a cane.

G. During an interview on 08/13/2024 at 3:20 PM with S17, clinical, confirmed that force had been used by security to remove some patients from the emergency room.

H. During an interview on 08/15/2024 at 6:45 AM with S7, non-clinical staff, it was confirmed P6 was removed by force because she was agitated and resisting the security guards when removing P6 from the ER. S7 confirmed that P6 was not safe at the bus stop with it being after midnight and did not have a ride.

I. During an interview on 08/15/2024 at 7:33 AM with S8 it was confirmed that P6 had to be carried out by security because she was not supporting her own weight.

J. During an interview on 08/15/2024 at 1:05 PM with S13, non-clinical, it was asked if the security officers handled the situation appropriately. S13 explained that it was handled appropriately but there were some lessons learned from the event; such as, once a patient is removed from the emergency room, security officers can stand back and wait for cops to arrive to remove them from the premises.

K. During an interview on 08/15/2024 at 2:30 PM with S14, non-clinical, it was asked if security escorts people to the bus stop often. S14 stated, "Yes."


49835

Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) requirements of explaining risks of refusing treatment and/or examination and failed to ensure a medical screening exam was done for all patients that present to the Emergency Department. This deficient practice is likely to lead to poor outcomes related to patients not being informed of risks and not being evaluated when seeking emergency medical care.

The findings are:

A. The facility failed to perform a medical screening exam. Refer to tag A-2406.




50656

Based on record review and interview the facility failed to provide a medical screening exam for 1 (P [patient] 6) out of 20 (P6, and P11-P29) patient reviewed for presenting to the emergency room. This deficient practice could possibly lead to patient's medical conditions being untreated, resulting in harm.

The findings are:

A. Record review of the facility's policy titled, "Emergency Medical Treatment & [and] Labor Act (EMTALA)" dated 10/13/2023 under "General Information" stated, "1. EMTALA requires hospitals with emergency rooms to provide a Medical Screening Examination (MSE) to every patient who comes to the hospital requesting emergency examination or treatment and to provide the patient with the necessary stabilizing treatment that is within the capabilities and capacity of the hospital until the patient is stable for transfer or discharge. 2. All patients who come to [Name of facility] Hospital Emergency Departments requesting emergency medical treatment shall receive an appropriate MSE to determine whether an emergency medical condition exists, without regard to a patient's ethnicity, religion, national origin, citizenship, age, gender, sexual orientation, pre-existing medical condition(s), physical or mental disability, insurance status, economic status or ability to pay for medical treatment. There is an implied request when the individual does not specifically request examination and treatment, but a reasonably prudent person would believe the individual needs examination and treatment. . . 5. Triage is not equivalent to an MSE. Triage merely determines the order in which patients will be provided an MSE, not the presence or absence of an emergency medical condition."

B. Record review of P6's medical record for visit dated 05/04/2024 revealed the following:

1. Emergency department note stated, "[Patient], well known to ED, presenting to ED from [name of psychiatric facility] not currently on a psych hold, presenting to ED reporting headache x [times] 3 days. Patient reporting it feels like her typical migraines."

2. Under, "Physical examination" in the emergency department note it stated, "Vital Signs Per nurse's notes. Constitutional: Alert, no acute distress. . . . Musculoskeletal: Moves all extremities. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit [impairments of nerve, spinal cord, or brain function that affects a specific region of the body] observed, normal speech observed. Psychiatric: Mood and affect: Hostile, Behavior: Uncooperative, Abnormal / Psychotic thoughts: not suicidal, not homicidal." There is no evidence that the patient had a complete neurological exam to include assessment of gait and movement, cranial nerve function, or stroke scale.

3. Under, "Medical Decision Making" in the emergency department note it stated, "Differential Diagnosis: not abdominal pain not fever, not anxiety. Rationale: [Patient], well known to ED for aggressive/manipulative behavior. Sent from [psychiatric facility] for evaluation of headache x 3 days. Initially called to [area of emergency department for triage] after patient throwing fit, stating she is not on a psychiatric hold and that she is not suicidal and does not need to be dressed out [changed from regular clothing to hospital provided paper scrubs]. Called [psychiatric facility] and confirmed with them that patient is not on a psychiatric hold. Returned to [area of emergency department for triage] to inform patient, informed that we will treat her for her headache, but she will be placed out in the waiting room. Patient then started screaming 'I'm not going out there', and then started threatening myself, nursing staff and security. Attempted many times for de-escalation without success. Patient is safe alert [facility generated alert to inform staff that patient is either known to be aggressive and a threat or that patient lacks decisional capacity], A&O [alert and oriented] and not currently on psychiatric hold, patient escorted out by security."

4. Under, "Plan" it stated patient's disposition from the emergency department was "Discharged (emergent medical condition stabilized or does not exist): to home. . . Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions."

5. The record did not contain any evidence of information regarding diagnosis, diagnostic results, treatment plan, or prescriptions.

6. The record did not contain any evidence of vital signs or full history and physical taken during visit on 05/04/2024.

C. During an interview on 08/13/2024 at 2:16 PM with P6, she confirmed that she presented to the emergency department for a really bad migraine, and she was removed from the emergency department because she refused to "dress out".

D. During an interview on 08/15/2024 at 7:33 AM with S(staff)8, clinical, it was asked if taking vital signs is a part of the triage process. S8 stated regarding P6, "Well she was brought in by ambulance and we just use the last set of vital signs they got on her." It was asked if those vital signs are charted. S8 stated, "There's no room in the triage note to document this. . . Wait, I think she refused vital signs." It was asked if the refusal of vital signs was charted, S8 stated, "No, she was disruptive."

E. During an interview on 08/15/2024 at 11:30 AM with S10, non-clinical, it was confirmed that the P6's medical record did not contain any of the ambulance documents for the visit dated 05/04/2024.

F. During an interview on 08/19/2024 at 9:12 AM with S15, clinical, it was asked why P6 was not considered psychiatric emergency. S15 stated, "I felt that it wasn't a psychiatric emergency because she was being manipulative. In the past, she has been restrained and sent to a room. Which is what she wanted, and she was demanding. I didn't deem this a psychiatric emergency because she was being manipulative." S15 explained that the "SAFE" alert on P6 was in place because she had been violent in the past and was in place to make staff aware.




50656