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Based on policy review, clinical record review, surveillance video review and interview, it was determined, the facility failed to substantiate the provision of emergency services for 1 of 20 sampled patients (Patient #1) as evidenced by the failure to provide a medical screening exam and failure to
ensure the staff informed Patient #1 of the risks and benefits of refusing to consent to the examination and treatment, and failure to document in the medical record a description of the examination, treatment, or both if applicable, that was refused by the patient and steps taken to secure the patient's written informed refusal.

The hospital failed to ensure Patient #1 received a medical screening exam, the nursing staff posed a barrier to care, by questioning the patient, who was accompanied by a family member and two infants. The nursing staff requested the family member remain outside of the treatment area with the child. The hospital does not have a policy in place dictating who and how many individuals can accompany the patient during the emergency department visit. The conversation escalated and Patient #1 decided to leave the hospital, the staff failed to inform the patient of the risk and benefits of leaving without being seen by the provider to conduct a medical screening examination, failed to document and obtain signed refusal and failed to implement steps to deescalate the confrontation.

Cross Refer to findings in citation A-2406 and A-2407.

Based on policy review, record review, surveillance video review and interview, it was determined, the hospital failed to substantiate the provision of emergency services for 1 of 20 sampled patients (Patient #1) as evidenced by failure to perform a Medical Screening Exam (MSE) to determine if a medical condition exists and if so to provide care and treatment to relieve or eliminate the condition.

The findings included:

Hospital policy titled "EMTALA [Emergency Medical Treatment and Labor Act] Medical Screening and Stabilization, approved on 04/25/2025 documents "Jupiter Medical Center ("JMC") will provide a Medical Screening Examination ("MSE") when a person presents to the hospital and makes a request or has a request made on their behalf, for examination or treatment or it appears that the person needs an emergency examination or treatment, including active labor, regardless of an individual's ability to pay.

To provide guidance regarding the management of persons presenting with or appear to have an Emergency Medical Condition ("EMC") or who are in labor and in compliance with Emergency Medical Treatment and Labor Act ("EMTALA"), 42 U.S.C. 5 1395dd, and all federal regulations and interpretive guidelines and with section 5395.1041, Florida Statutes, and related administrative rules.

Policy Definitions
Medical Screening Examination or "MSE" - The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist which will be completed by a Qualified Medical Person "QMP" or qualified Medical Personnel "MP".

Emergency Services and Care - Refers to medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility.

To Stabilize or Stabilize or Stabilized means
With respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the Hospital;
With respect to a pregnant woman who is having contractions and who cannot be transferred or discharged before delivery without a threat to the health or safety of the woman or the unborn child, that the woman has delivered the child and the placenta.

1. JMC will provide a medical screening examination within the capability of the hospital's dedicated Emergency Department ("ED"), including ancillary services routinely available, to determine whether an EMC exists.
6. JMC will not base the provision of emergency services and care upon an individual's race, ethnicity, religion, national origin, citizenship, culture, language age, sex, preexisting medical condition, physical or mental disability, insurance status, sexual orientation, gender identity or expression, economic status or ability to pay for medical services, except to the extent that a circumstance is relevant to the provision of appropriate medical care."

Surveillance video review conducted on 08/26/25 revealed the following:
On 08/04/25 at 12:49 AM, two young women (one of them later identified as Patient #1, and the other one identified as the patient's sister) with two infants in two strollers entered the emergency department. They talk to the security officer and registration staff. Patient #1 is seen going thru the registration process and gets an identification band placed on her wrist. The sister is seen talking to the security officer and getting visitors badges for herself and the infant.
At 12:52 AM, Patient #1 approaches the security officer and gets a badge for her infant.
At 12:55 AM, all of the individuals are seen sitting in the lobby, there were no other patients in the area at the time.
At 12:57 AM, a nurse comes out of the back and talks to them.
At 12:58 AM, the nurse takes the patient to the back accompanied by the sister and the two infants in their strollers.
The hospital does not have surveillance cameras in the treatment areas or hallways inside the ED.
At 1:01 AM, Patient #1, her sister and the infants leave the ED and can hear them talking to the registrar upon exiting the building.

Clinical record review conducted on 08/26/25 revealed Patient #1 presented to the emergency department on 08/04/25 at 12:49 AM with complaints of vaginal bleeding, abdominal pain and being seven weeks pregnant. The record documents "patient came in with two infants, one was her sisters, patient's sister was asked to wait in the waiting room with their infant, both gave backslash to the charge nurse and decided to leave before triage was started."

There is no evidence that Patient #1, who presented to the emergency department on 08/04/25, seeking emergency care, received a medical screening exam.

Interview Staff A, triage nurse, conducted on 08/26/25 at 4:07 PM revealed the nurse recalls Patient #1, the patient stated she was newly pregnant, she was not sure, and she had abdominal pain and wanted to make sure she was okay. The nurse explained when she first encountered them in the lobby, she asked the other individual that was accompanying her to remain in the lobby with the two infants, at that time she did not know the relationship, but believed she was the patient's sister. One of the infants was like a month old, but the sister wanted to stay with the patient. The nurse then took them to the back for triage, and the charge nurse came into the room and spoke to them. The charge nurse explained that they had a lot of sick people, patients with COVID and it was not appropriate to have the infants in the area, then patient and the sister got loud with the charge nurse and decided to leave and stating they were going to Hospital B. The nurse stated she did not get the opportunity to triage the patient or say anything else to the patient.

Interview with Staff B, the Charge Nurse, conducted on 08/27/25 at 8:47 AM revealed her recollection of the event, the ED had just cleared many patients, and she was in the area and saw Patient #1 and another woman and the two infants going into a room. So, she went in and asked what was happening. Staff B spoke to the patient and told the other individual that she could go outside and wait in the lobby with her baby and explained that they had COVID patients and sick patients in the area. Then they started to get loud and yelling and said they were leaving and going to Hospital B. Staff B was asked what is the hospital policy in regard to visitors in the ED, and explained the facility does not have a policy, it is situational. Staff B explained she discourages children in the department, sometimes they have baker acted patients or sick patients and it can be scary for the kids. During this event, she did not have the chance to tell the patient that her friend could wait outside until she is seen by the provider, for some reason she triggered the patient and the conversation escalated and she subsequently left the room after the conversation. Staff B was asked if she explained to the patient the risk of leaving the emergency department without been seen and replied no, she did not but believed the triage nurse did so, adding the nurse told her she did it and she was going to put a note in the record. Staff B was made aware of the interview with the triage nurse and that information was not provided. Staff B was asked how they accommodate patient that may have a child or others with them and explained they typically accommodate them, in this case there was no time to deescalate the patient, she wanted to leave, and "I can't hold her against her will." Staff B was asked why she brought in Patient #1 to the ED at 1 AM in the morning with two infants and replied the patient complained of vaginal bleeding and that she was 7 week pregnant.

Interview with the Executive Director of Quality on 08/27/25 at 11:32 AM revealed that the facility does not have a policy regarding visitors in the ED, restrictions on how many people can accompany the patient or minors in the room.

Interview with the Executive Director of Quality conducted on 08/27/25 at 12:23 PM revealed that the facility does not have a policy for refusal of treatment, there is a form to be completed, and the surveyor was provided with a copy. The Director provided the hospital policy for AMA (leaving against medical advice).

Interview with ED Medical Director (MD) on 08/27/25 at 1:40 PM revealed the MD was briefed on the event involving Patient #1 and stated this is an opportunity for service recovery, the goal is to diminished patients leaving without being seen and the conversation could have been deescalated to the charge nurse or a provider, sometimes you have to do things different to manage a situation. The goal is to provide quality of care as patients now have many options as to where they can go for their care and if they are not satisfied you will lose them and everyone in the inner circle as well.

Based on record review, surveillance video review, policy review and interview, it was determined, that Patient #1 presented to the ED seeking emergency care and the hospital staff created barriers to care, escalating the event, and subsequently deterring the patient from receiving a medical screening examination. Patient #1 was accompanied by another individual and two infants at the time of the visit and the nursing staff instructed the accompanying individual to remain outside with the infants, despite the hospital having no written policy or procedure restricting who can accompany a patient during their ED visit. Patient #1 left the ED and sought care at Hospital B. It is noted the emergency department had the capacity and capability to provide a medical screening examination.

Based on policy review, record review, surveillance video review and interview, it was determined, the hospital failed to substantiate the provision of emergency services for 1 of 20 sampled patients (Patient #1) as evidenced by failure to inform the patient of the risk and benefits of refusing examination and treatment and failure to document that the patient was educated to make an informed decision.

The findings included:

Hospital policy titled Title: EMTALA [Emergency Medical Treatment and Labor Act] Medical Screening and Stabilization Procedure, approved: 05/02/2024 documents, "Jupiter Medical Center ("JMC") will provide a medical screening examination ("MSE") when a person presents to the hospital and makes a request or has a request made on their behalf, for examination or treatment for an Emergency Medical Condition ("EMC"), or it appears that the person needs an emergency examination or treatment, including active labor, regardless of an individual's ability to pay.
12. Patients Who Refuse Screening, Stabilizing Treatment, or Transfer
12.1. Informed refusal will be documented in accordance with JMC's policies and procedures.
12.2. The medical record will contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the patient.
12.3. JMC will take reasonable steps to secure the patient's written informed refusal (or that of the person acting on his or her behalf).
12.4. The written documentation will indicate that the patient has been informed of the risks and benefits of the offered examination, treatment, Transfer, or any combination of the foregoing."

Surveillance video review conducted on 08/26/25 revealed the following:
On 08/04/25 at 12:49 AM, two young women (one of them later identified as Patient #1, and the other one identified as the patient's sister) with two infants in two strollers entered the emergency department.
They talk to the security officer and registration staff. Patient #1 is seen going thru the registration process and gets an ID band placed on her wrist. The sister is seen talking to the security officer and getting visitors badges for herself and the infant.
At 12:52 AM, Patient #1 approaches the security officer and gets a badge for her infant.
At 12:55 AM, all of the individuals are seen sitting in the lobby, there were no other patients in the area at the time.
At 12:57 AM, a nurse comes out of the back and talks to them.
At 12:58 AM, the nurse takes the patient to the back accompanied by the sister and the two infants in their strollers.
The hospital does not have surveillance cameras in the treatment areas or hallways inside the ED.
At 1:01 AM, Patient #1, her sister and the infants leave the ED and can hear them talking to the registrar upon exiting the building.

Clinical record review conducted on 08/26/25 revealed Patient #1 presented to the emergency department on 08/04/25 at 12:49 AM with complaints of vaginal bleeding, abdominal pain and being seven weeks pregnant. The record documents "patient came in with two infants, one was her sisters, patient's sister was asked to wait in the waiting room with their infant, both gave backlash to the charge nurse and decided to leave before triage was started.

The clinical record failed to provide evidence that Patient #1 was informed of the risk and benefits of leaving the emergency department without examination and treatment.

Refusal of Care and Leaving Against Medical Advice forms were blank.

Interview Staff A, triage nurse, conducted on 08/26/25 at 4:07 PM revealed the nurse recalls Patient #1, the patient stated she was newly pregnant, she was not sure, and she had abdominal pain and wanted to make sure she was okay. The nurse explained when she first encountered them in the lobby, she asked the other individual that was accompanying her to remain in the lobby with the two infants, at that time she did not know the relationship, but believed she was the patient's sister. One of the infants was like a month old, but the sister wanted to stay with the patient. The nurse then took them to the back for triage, and the charge nurse came into the room and spoke to them. The charge nurse explained that they had a lot of sick people, patients with COVID and it was not appropriate to have the infants in the area, then patient and the sister got loud with the charge nurse and decided to leave and stating they were going to Hospital B. The nurse stated she did not get the opportunity to triage the patient or say anything else to the patient.

Interview with Staff B, the Charge Nurse, conducted on 08/27/25 at 8:47 AM revealed her recollection of the event, the ED had just cleared many patients, and she was in the area and saw Patient #1 and another woman and the two infants going into a room. So, she went in and asked what was happening. Staff B spoke to the patient and told the other individual that she could go outside and wait in the lobby with her baby and explained that they had COVID patients and sick patients in the area. Then they started to get loud and yelling and said they were leaving and going to Hospital B. Staff B was asked what the hospital policy in regard to visitors in the ED was, and explained the facility does not have a policy, it is situational. Staff B explained she discourages children in the department, sometimes they have baker acted patients or sick patients and it can be scary for the kids. During this event, she did not have the chance to tell the patient that her friend could wait outside until she is seen by the provider, for some reason she triggered the patient and subsequently left the room after the conversation.

Staff B was asked if she explained to the patient the risk of leaving the emergency department without been seen and replied no, she did not but believed the triage nurse did so, adding the nurse told her she did it and she was going to put a note in the record. Staff B was made aware of the interview with the triage nurse and that information was not provided. Staff B was asked how they accommodate patient that may have a child or others with them and explained they typically accommodate them, in this case there was no time to deescalate the patient, she wanted to leave, and "I can't hold her against her will." Staff B was asked what brought Patient #1 to the ED at 1 AM in the morning with two infants and replied the patient complained of vaginal bleeding and that she was 7 week pregnant.

Interview with the Executive Director of Quality on 08/27/25 at 11:32 AM revealed that the facility does not have a policy regarding visitors in the ED, restrictions on how many people can accompany the patient or minors in the room.

Interview with the Executive Director of Quality conducted on 08/27/25 at 12:23 PM revealed that the facility does not have a policy for refusal of treatment, there is a form to be completed, and the surveyor was provided with a copy. The Director provided the hospital policy for AMA (leaving against medical advice).

Interview with ED Medical Director (MD) on 08/27/25 at 1:40 PM revealed the MD was briefed on the event involving Patient #1 and stated this is an opportunity for service recovery, the goal is to diminished patients leaving without being seen and the conversation could have been deescalated to the charge nurse or a provider, sometimes you have to do things different to manage a situation. The MD confirmed there is no policy dictating who and how many people can accompany the patient in the ED. Most of the time it is very helpful to have family members in the room to obtain collateral information and sometimes depending in the situation it is better to have a conversation with the patient in private. The goal is to provide quality of care as patients now have many options as to where they can go for their care and if they are not satisfied you will lose them and everyone in the inner circle as well. The MD agrees the patients need to be informed of the risk of leaving the hospital without being seen, so they can make an informed decision.

Based on record review, surveillance video review, policy review and interview, it was determined, that Patient #1 presented to the ED seeking emergency care and the hospital staff created barriers to care, escalating the event, and subsequently deterring the patient from receiving examination and treatment. Patient #1 was accompanied by another individual and two infants at the time of the visit and the nursing staff instructed the accompanying individual to remain outside with the infants, despite the hospital having no written policy or procedure restricting who can accompany a patient during their ED visit. Patient #1 left the ED and sought care at Hospital B.

The hospital staff failed to educate Patient #1 on the risk and benefits of leaving before the provision of a medical screening exam and treatment to ensure the patient was able to make an informed decision. In addition, the hospital staff failed to document written informed refusal, and steps taken to secure the patient signature.