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Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#2) of 20 Emergency Department (ED) records reviewed.

Findings Included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," revised 12/13/23, showed:
- A MSE shall be provided to any individual who presents to the ED and/or hospital and requested emergency care regardless of diagnosis, financial status, race, color, national origin, and/or disability.
- A request for care does not have to be specifically expressed by the individual.
- A MSE is an examination which is sufficiently detailed to reveal whether an EMC exists and must include medically indicated screens, tests, mental status evaluations, and a history and physical examination within the capability of the hospital's ED.
- Individuals have the right to refuse an MSE. If they choose to leave without a MSE or treatment, then they would be determined to be leaving against medical advice (AMA), after they have been informed of the risks and benefits of treatment. The hospital's EMTALA obligation ends once they have been informed of the risks of refusing care. Reasonable attempts should be made to obtain a written refusal to consent to examination, treatment or both if applicable. A "release of responsibility" form should be completed and placed in the medical record.

Review of the hospital's policy titled, "Perinatal Initial Assessment of Obstetrical Patients Arriving to the ED or Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Triage (process of determining the priority of a patient's treatment based on the severity of their condition)," revised 08/13/24, showed any pregnant patient presenting to the ED must be assessed by an ED nurse. Patients less than 16 weeks gestational age (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) shall be evaluated in the ED.

Please refer to 2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#2) of 20 Emergency Department (ED) records reviewed.

Findings Included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," revised 12/13/23, showed:
- A MSE shall be provided to any individual who presents to the ED and/or hospital and requested emergency care regardless of diagnosis, financial status, race, color, national origin, and/or disability.
- A request for care does not have to be specifically expressed by the individual.
- A MSE is an examination which is sufficiently detailed to reveal whether an EMC exists and must include medically indicated screens, tests, mental status evaluations, and a history and physical examination within the capability of the hospital's ED.
- Individuals have the right to refuse an MSE. If they choose to leave without a MSE or treatment, then they would be determined to be leaving against medical advice (AMA), after they have been informed of the risks and benefits of treatment. The hospital's EMTALA obligation ends once they have been informed of the risks of refusing care. Reasonable attempts should be made to obtain a written refusal to consent to examination, treatment or both if applicable. A "release of responsibility" form should be completed and placed in the medical record.

Review of the hospital's policy titled, "Perinatal Initial Assessment of Obstetrical Patients Arriving to the ED or Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Triage (process of determining the priority of a patient's treatment based on the severity of their condition)," revised 08/13/24, showed any pregnant patient presenting to the ED must be assessed by an ED nurse. Patients less than 16 weeks gestational age (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) shall be evaluated in the ED.

Although requested an ambulance report was not provided.

Review of Patient #2's medical record, dated 12/25/24, showed:
- At 7:18 PM, she arrived via ambulance to the ED with flu-like symptoms.
- Nursing documentation indicated that she had begun to yell and was verbally aggressive toward ED staff. She demanded to go to OB, stating she was two months pregnant. She refused to be educated on the hospital's policy and admission the Women's Evaluation Unit (WEU). She refused to stop yelling and screaming at the ED staff. She was escorted out by security due to her aggressive behavior towards the ED staff.
- At 7:21 PM, she was discharged with a disposition of "left AMA/discontinued care."
- No AMA paperwork was included in the medical record.

During a telephone interview on 04/22/25 at 10:00 AM, Staff O, Medical Director, stated that Patient #2 should have received a MSE even if she was difficult to work with. The nurse should have gotten a provider before removing a patient by force to ensure that patient did not have an EMC. She expected documentation to state the patient refused an examination and was aware of the risks and benefits of leaving before a MSE or some kind of documentation that indicated she had refused evaluation.

During an interview on 04/22/25 at 12:47 PM, Staff P, Platform Chief Nursing Officer (CNO), and Staff Q, Associate CNO, stated that they expected patients to be assessed before being escorted out, if they were willing to be assessed. Based on the documentation they were unable to determine if Patient #2 agreed to or declined an assessment. They expected a patient to be examined if it was safe for staff to do so. They felt the nursing documentation indicated that the patient refused education on the WEU admission policy meant that she had declined an exam. Per the policy, the patient would have required an evaluation in the ED. They expected staff to follow the policy related to AMA forms or refusal of care documentation. They were not familiar with the specifics of the WEU admission policy or the AMA policy.

During a telephone interview on 04/22/25 at 10:30 AM, Staff N, RN, stated that Patient #2 requested to be evaluated, but wanted it to by OB instead of the ED. She exhibited threatening behavior in the waiting room towards staff, so he had security escort her out. He did not recall speaking to a provider and a provider did not assess her. He was unable to recall which ambulance service escorted her to the ED. He did not recall whether he had included the ambulance report in the medical record since she left before she was evaluated.

During an interview on 04/22/25 at 11:03 AM, Staff J, Registered Nurse (RN), stated that if she had a patient such as Patient #2, she would have had a provider see the patient before discharging her. She had never forced a patient to leave without a provider evaluating them first. She would have attempted to complete an AMA form before the patient was escorted out. If the patient refused to sign, she would document the refusal in the medical record.