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Based on hospital polices, Emergency Department (ED) video footage, medical records (MR), and staff interviews, it was determined the hospital failed to:

1. Provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department to determine whether an emergency medical condition exists for all patients who presented to the ED.

2. Explain the risk and benefits of receiving or refusing an MSE and/or stabilizing treatment for a patient that refused triage.

3. Ensure a psych patient was re-evaluated for the mental competency to leave the hospital against medical advice (AMA).

4. Place a patient who presented to the Emergency Department (ED) with Suicidal Ideation on an involuntary hold to transfer the patient for the completion of the Medical Screening Examination (MSE).

These deficient practices affected one of three patients that left without being seen, including Patient Identifier (PI) # 1, and one of three psychiatric MRs reviewed, including PI # 8.

Findings Include:

Cross Refer to A 2406 and A 2407 for findings.

Based on review of the hospital policies, medical records (MR), video surveillance, and interviews with staff it was determined the hospital failed to:

1. Provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department to determine whether an emergency medical condition exists for all patients who presented to the Emergency Department (ED).

2. Explain the risk and benefits of receiving or refusing an MSE and/or stabilizing treatment for a patient that refused triage.

This deficient practice affected one of one patient reviewed via video footage, including Patient Identifier (PI) #1, and had the potential to affect all patients served by the hospital ED.

Findings include:

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) - General Requirements and Definitions

Policy Number: 12521339

Revised Date: 05/2022

III. Overview of EMTALA:

All persons presenting for emergency care at ... (Hospital) will be considered to have, "come to the hospital", if a request is made by the individual or on the individual's behalf for emergency medical care. Each individual shall receive a MSE and stabilizing treatment...

8. Obtain or attempt to obtain written and informed refusal of examination, treatment or transfer in the case of an individual who refuses examination, treatment or transfer.

Definitions:

Emergency Medical Condition (EMC) means: A condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances...) such that the absence of immediate medical attention could reasonably be expected to result in:

...iii. Serious dysfunction of any bodily organ or part.

...13. MSE is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exits...

Hospital Policy: Refusal of Treatment and Leaving Against Medical Advice, ADM 211

Policy Number: 17859460

Revised Date: 05/2025

Policy:

...The attending physician or his/her designee must be notified of any instances when a patient is refusing care or treatment or desires to leave the hospital without discharge orders or without physician approval.

When refusing care or treatment, the patient should be educated on the risks and benefits of receiving or refusing the care/treatment. Education may be provided by the nurse or provider as appropriate.

...Documentation should be made in the electronic medical record of the patient's refusal of treatment or leaving against medical advice as well as education provided to the patient, the provider interaction, and any observations surrounding the patient's departure.

1. Review of the MR dated 5/31/25 at 10:00 PM revealed PI # 1 complained of left leg pain, no active bleeding observed, PI # 1 refused to be triaged if an ED bed was not open and said he/she would go to Florence.

There was no documentation the risk and benefits of receiving or refusing an MSE and/or stabilizing treatment was explained to PI # 1. There was no documentation the physician was notified of the patient leaving the ED.

Review of the ED video surveillance dated 5/31/25 from 8:30 PM to 10:30 PM was conducted with Employee Identifier (EI) # 11, ED Registered Nurse (RN). The video surveillance revealed the following:

At 8:31 PM, a black sports utility vehicle (SUV) arrived at the ED entrance. Two males exit the SUV, enter the ED, and walks to the registration desk.

At 8:37 PM, an ED technician, accompanies the two males to the SUV with a wheelchair.

At 8:43 PM, the ED technician enters the ED waiting area with PI # 1 in a wheelchair. PI # 1 was placed in the left corner of the ED lobby.

At 8:45 a female joined PI # 1.

At 8:47 PM, the female received a clipboard from Registration Clerk, and appeared to speak with PI # 1 while filling out information on the clipboard. During the video review the ED nurse confirmed the clipboard was a sign in sheet to register the patient.

At 8:51 PM the female walked to the registration desk and handed the clipboard to Registration Clerk.

At 8:54 PM the Registration Clerk placed an armband on PI # 1.

At 9:05 PM the female walked to the registration desk and returned to PI # 1 at 9:06 PM.

At 9:12 PM one of the males walked out of the ED lobby with a cell phone in hand while the other male walked to the registration desk and returned to PI # 1 at 9:13 PM.

At 9:20 PM the female walked to the registration desk and returned to PI # 1 at 9:21 PM.

At 9:31 PM one of the males walked to the registration desk and returned to PI # 1 at 9:32 PM.

At 9:38 PM the female walked to the registration desk and at 9:39 PM walked past the registration desk with a phone in hand. The female appeared to be talking on the phone when one of the males joined her in the hallway near the registration desk at 9:40 PM.

At 9:56 PM an ambulance arrived at the ED entrance, two Emergency Medical Services (EMS) employees, entered the ED lobby, and appear to talk with PI # 1.

At 10:03 PM PI # 1 was wheeled to the registration desk by the two EMS employees.

At 10:04 PM PI # 1 was wheeled out of the ED lobby by the two EMS employees accompanied by the female and male.

At 10:05 PM one of the EMS employees opened the ambulance back doors, obtained a stretcher, walked to the side of the ambulance.

At 10:12 PM an EMS employees placed PI # 1, on a stretcher, and into the ambulance.

At 10:25 PM the ambulance left the ED entrance.

An interview was conducted on 6/26/25 at 3:34 PM with EI # 1, Chief Nursing Officer, who
confirmed the hospital failed to provide an appropriate MSE, explain the risk and benefits of receiving or refusing an MSE and/or stabilizing treatment for a patient that refused triage.

Based on review of the hospital policy, medical records (MR), and interviews with staff it was determined the hospital failed to:

1. Ensure a psych patient was re-evaluated for the mental competency to leave the hospital against medical advice (AMA).

2. Place a patient who presented to the Emergency Department (ED) with Suicidal Ideation on an involuntary hold to transfer the patient for the completion of the Medical Screening Examination (MSE).

This deficient practice affected one of three psychiatric MRs reviewed, including Patient Identifier (PI) # 8, and had the potential to affect all patients with a psychiatric complaint served by the hospital ED.

Findings include:

Hospital Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) - General Requirements and Definitions

Policy Number: 12521339

Revised Date: 05/2022

III. Overview of EMTALA:

All persons presenting for emergency care at ... (Hospital) will be considered to have, "come to the hospital," if a request is made by the individual or on the individual's behalf for emergency medical care. Each individual shall receive an MSE and stabilizing treatment...

Definitions:

Emergency Medical Condition (EMC) means: A condition manifesting itself by acute symptoms of sufficient severity (... psychiatric disturbances...) such that the absence of immediate medical attention could reasonably be expected to result in:

...v. Psychiatric related symptomatic patients.

a. Acute psychiatric or acute substance abuse symptoms are manifested.

b. Individuals are expressing suicidal or homicidal thoughts or gestures and are determined to be a danger to self or others.

1. PI # 8 presented to the hospital ED on 5/31/25 at 4:51 PM via ambulance with a chief complaint of altered mental status and suicidal ideations.

Review of the ED Physician Note dated 5/31/25 at 5:41 PM revealed PI # 8 presented to ED via ambulance with report of having a psychosis episode at Target. After arrival to the ED PI # 8 had a violent outburst and assaulted ED staff. PI # 8 was saying, "wanted someone to shoot him/her." PI # 8 reported he/she was unable to provide for self or get basic necessities. PI # 8 was placed on one-on-one monitored observation and one hour four-point restraints.

Review of the Columbia Suicide Severity Rating Scale (CSSRS) dated 5/31/25 at 7:33 PM revealed PI # 8 had a high suicide risk level.

PI # 8 received a Psychosocial Assessment Consult dated 6/1/25 at 12:27 AM revealed PI # 8 with diagnosis of schizophrenia and history of aggression with short temper, frequent outburst and fights. PI # 8's thought process was circumstantial, loose, disorganized with poor judgement and insight.

Review of the ED Physician Note dated 6/1/25 at 1:42 AM revealed PI # 8 was recommended for psychiatric inpatient placement by the tele-psych physician, who was searching for placement for the patient.

Review of the ED Nursing Note dated 6/1/25 at 4:00 AM revealed PI # 8 was at the nurse's desk, requested a different room, denied he/she had any psychiatric problems, then proceed to walk in-between the ambulance doors. The ED physician was notified and verbalized, "if the patient wants to leave then he/she is free to go." PI # 8 refused to sign the AMA form and walked out of the ED escorted by security.

An interview was conducted on 6/26/25 at 9:01 AM with EI # 10 ED Triage Registered Nurse (RN) for PI # 8, who stated, "I was shocked that the patient left AMA. The patient could not make own medical decisions. The patient had a guardian due to mental health illness."

An interview was conducted on 6/26/25 at 10:32 AM with EI # 8, ED physician for PI # 8, who stated, "the patient expressed suicidal ideations and was aggressive toward the staff. When a psych patient requests to leave AMA a re-evaluation of the patient should be conducted. The patient just left the ED."

An interview was conducted on 6/26/25 at 11:08 AM with EI # 4 ED Evening shift RN for PI #8, who stated, " the patient started getting angry, defensive, agitated and wanted to leave the hospital." The surveyor asked EI # 4, was PI # 8 re-evaluated or re-examined by a physician before leaving the hospital AMA. EI # 4 stated, "No"

An interview was conducted on 6/26/25 at 3:37 PM with EI # 1, Chief Nursing Officer, who confirmed PI # 8 was not re-evaluated by the ED physician for the mental competency to leave the hospital against medical advice (AMA). EI # 1 also confirmed the tele-psych physician was not notified the patient left AMA, and there was no documentation of an involuntary hold.