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Based on hospital video footage review, medical record review, electronic central log review, interviews conducted, EMS report, and facility policy review, the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed for 1 (Patient #8) of 20 patients reviewed.

Refer to Tag -A2406

Based on hospital video footage review, medical record review, electronic central log review, interviews conducted, EMS report, and facility policy review, the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for 1 (Patient #8) of 20 patients reviewed.


Findings included:

Review of hospital video footage from 04/24/2025 revealed:
7:49 PM Patient #8 brought into the ED by EMS via stretcher.
7:50 PM brought to nurses' station then immediately to fast track (a dedicated emergency department area that provides expedited care for patients with minor or less urgent conditions, ensuring efficient treatment while preserving resources for critical cases)
7:51 PM Patient #8 brought to the lobby and moved from stretcher to wheelchair.
7:53 PM EMS talking with Staff B, Medic to register Patient #8.
7:55 PM Patient #8 registered.
7:57 PM Staff B, Medic took Patient #8's temperature.
7:58 PM EMS hands Patient #8 an emesis bag and a tissue.
8:00 PM EMS in ED waiting room. Advanced Practice Registered Nurse (APRN) in waiting room, walks outside.
804 PM APRN in waiting room behind screen talking to patient. Hands in pockets.
8:05 PM APRN to triage room.
8:08 PM Staff A, Registered Nurse (RN) comes to Patient #8 in lobby. And transports him to Fast track Room 1.
8:14 PM Radiology picks up Patient #8.
8:28 PM Patient #8 back from radiology and placed in Room 1, staff in full Personal Protective Equipment (PPE).
8:34 PM Registration comes inside Room 1 with Patient #8.
8:36 PM Registration leaves Room 1 and talks with APRN.
8:44 PM Staff A, RN goes into Room 1 with paperwork in his hand.
8:45 PM Staff A, RN walked out of Room 1.
8:49 PM Staff A, RN back in Room 1.
8:50:28 PM Staff A, RN brings Patient #8 out lobby doors via wheelchair, Patient #8 is wearing a mask, black shirt, hat and blanket over his lap.
8:50:52 PM Staff A RN locks wheelchair and returns to the lobby and to the back of the ED (out of sight)
8:51:33 PM Patient #8 seen outside lobby doors on the right side, leaning forward in wheelchair.
8:51:49. PM Patient #8 slumped over, head leaning down with head down, Staff A, RN goes outside with paper in his hand to talk to patient, Paper given to patient.
8:52:07 PM Lobby doors open again due to Staff A, RN in proximity of doors, patient seen slumped over in chair.
8:53 PM Patient #8 seen on video moving blanket, slouched over.
9:02 PM A visitor from outside in black scrubs noted to get behind patient and moved him via wheelchair to lobby and met by Staff B, Medic in lobby. Staff B, Medic pushes patient back outside.
9:06 PM Staff D, Charge Nurse (CN) and 2 male RNs seen in lobby heading to lobby doors. Staff D, CN and 1 male nurse go outside to see patient.
9:06.19 PM Staff D, CN noted standing to right of patient with hands on hips.
9:11 PM Larger female nurse seen walking out talking to patient #8.
9:12 PM Nurse leaves patient and comes into ED, talks with Staff B, Medic and then returns to back of ED.
9:15 PM Staff B, Medic went out the lobby doors and moved patient #8 to the left side outside the lobby doors, outside of camera view.
9:28 PM A white male patient brought outside lobby doors on the right side by female tech.
9:29 PM The white male patient picked up by vehicle.
9:33 PM Staff B, Medic seen going outside lobby doors and returning to desk to grab gloves and going back outside, returning to desk at 9:34 PM.
9:36 PM Purple hair nurse seen leaving through lobby doors. 9:38 PM came back in with food.
9:43 PM Staff D, CN brings bottle of water outside to patient #8. Comes back into ED lobby and speaks with Staff B, Medic.
9:55 PM Security talking with patient #8 outside and then comes into lobby.
10:03 PM Staff B, Medic leaves, and the new staff member takes over for Medic.
10:20 PM Female black-haired nurse seen walking through lobby doors to outside, past Patient #8.
10:48 PM Medic seen going outside to get empty wheelchair and bring it into the ED for an incoming patient, no contact noted with Patient #8.
10:55 PM Staff D, CN seen double masked going outside. She walks to the left where Patient #8 is, appears to stand with hands on her hips. Then came back in at
10:57 PM and talked to Medic.
11:00 PM Fast track unit was closed, multiple staff members seen coming through to lobby to leave.
11:31 PM Medic went outside the lobby doors to get a wheelchair.
11:34 PM Staff D, CN seen coming out to lobby picking up a different patient and taking her to the back.
11:52 PM Patient #8 body moves - through the window, Patient #8 moves blanket into view and then unable to see further.

04/25/2025
6:51 AM Medic went outside,
6:57 AM Staff F, CN, went outside.
6:58 AM Patient #8 wheeled in by Staff F, CN. Staff F, CN pointing to the bottom of wheelchair.
6:59 AM Patient #8 taken to the bathroom. PCT joins Staff F, CN.
701 AM Staff C, CN came to the outside and looked at where patient had been sitting.
7:16 AM Patient #8 brought out of bathroom via wheelchair by nurse and tech, and transported into Room 6
7:18 AM Patient #8 placed in bed and wheelchair removed from room.
7:30 AM. Nurses still in the room caring for patient #8, bringing him linens and such.


The EMS report for Patient #8 dated 4/24/2025 at 7:31 PM was reviewed. The patient's vital signs at 7:43 PM were listed as: Blood Pressure: 108/60; Pulse: 100; Respirations: 18; oxygen saturation 100% on Room air; pain score (rates pain on a scale of 0-10, pain 4-6 moderate pain) 4. The patient had a medical history of: a.) Colostomy (surgical creation of an opening for the colon through the belly); b.) Kidney stones; c.) Seizures; and d.) Spina Bifida (a condition that occurs when the spine and spinal cord don't form properly -permanently disabling). Further review revealed the patient was assessed at 7:33 PM revealed in part, "Mental status: Normal Baseline for patient ...Pelvis/GU (genitourinary)/GI (gastrointestinal) Incontinence (involuntary loss of urine or stool), Extremities general deconditioning (decline in physical function due to prolonged inactivity and/or bedrest) see pmhx (past medical history). Documentation in the narrative section revealed in part, 62 y/o (year-old) ...complains of generalized pain (see PMHX), Pt (patient) was found lying on the floor, he stated he was transferring from sofa to mobility scooter, and he fell to the floor ...Physical Findings: Unremarkable, pt. complained of pain all over for the last 2 weeks that has worsen today ...constant and sharp ...Pt was transported to HCA ER ...then released to the care of RN(registered Nurse)."


Review of electronic central log on 04/24/2025 at 7:55 PM, Patient #8 was brought in by ambulance with a chief complaint pain all over for 2 weeks.


Review of the medical record (ED Patient Report) revealed Patient #8 arrived via EMS on 04/24/2025 at 7:55 PM with a chief complaint of pain all over for two weeks. The documented vital signs on arrival were, oral temperature was "37.8" degrees Celsius (100.0 degrees Fahrenheit Normal 98.6), pulse:100 beats per minute, respiratory rate: 18 breaths per minute. His blood pressure (BP)was 108/60, his oxygen saturation was 100% on room air, and his pain intensity was two (2- mild pain) out of ten. The patient's ESI Level 4 (semi-urgent).

Further review of the medical record revealed that at 8:06 PM a medical screening examination was completed by the APRN (Advanced Practice Registered Nurse) and revealed "no relevant medical history presents to ED today with complaints of bilateral pain after suffering a fall today prior to arrival. Patient brought in by EMS. Patient stated that he lives alone but appears to be a poor historian. He says he gets around on an electric scooter and a walker but cannot tell me why he needs a walker or a scooter to ambulate. When asked how long he was on the floor he replied, "not for long" and he also stated that the pain has eased up a bit. The section of the medical record titled, "Review of Systems Statements" revealed in part, "Past Medical History-Adult- Pt. Reports no significant: Past surgical history. Musculoskeletal: Reports: joint pain. Physical Exam (Examination): Appearance/Presentation: Hygiene poor."
First and last documented Vital Signs 4/24/25 at 7:56 PM were Oxygen saturation: 100%; B/P 108/60; Temp (temperature normal 37 degrees Celsius/98.6 Degrees Fahrenheit) 37.8; Pulse: 100; Respirations: 18. Patient is awake and alert. Flank/Spine/Paraspinal: Lumbar paraspinal tend (tender) ...
Lab (laboratory) Results Interpretation (this section was blank).

At 8:17 PM a hip X-ray was ordered and at 8:32 PM the hip X-ray revealed negative for hip fracture. Patient #8 was reevaluated by the APRN at 8:27 PM with an "Unchanged" assessment. Clinical Impression- Primary Impression: Fall Secondary Impressions: Contusion, Hip Pain. Patient Instructions: ED fall with Uncertain Cause, ED soft Tissue Contusion.


Patient #8 was physically discharged home at 8:41 PM. No reevaluation of initial vital signs pain prior to discharge from the ED, and no administration of medication were noted in his medical record. The Physical Examination by the APRN revealed no documentation of a physical examination of the patient's hip, or extremities. Review of the "Discharge Assessment indicated in part, "Discharge information provided: Instructions/Prescription. Patient discharged from ED by provider and not seen by RN: No patient left to: Home. Pt Left with: Family. Mode patient left: Ambulatory, Patient Left via: Family member." Review of the video footage dated 4/24/25 verified the patient was not ambulatory, seen sitting in the wheelchair outside of the ED entrance for 10 hours, and the patient never left the hospital's ED with family.


Review of medical record revealed on 04/25/2025 at 07:15 AM, Patient #8 was brought back into the ED by the ED staff for check in. Chief complaint states "patient arrived to ED via ambulance last night- patient was seen and discharged, patient was waiting outside in a wheelchair; when nurse went outside patient was severely weak, unable to stand and covered in feces; significant wounds are noted to patient's bottom with active bleeding, states he is just "in so much pain". Per ED MD note, "62 yr old man with a past medical history of ostomy reversal and current urostomy here complaining of generalized weakness and diarrhea over past several days. Patient states he has had pain all over his body for the past week or so and was seen at this facility last night where he was determined to have no acute traumatic injury and discharged home. While waiting for ride, patient developed urinary and fecal incontinence and was struggling to care for himself. He was not able to ambulate by himself without a wheelchair. Patient stated he lives alone and has no one to help care for him. Nursing assessment revealed unstageable wound on coccyx, alert and awake, skin is cool and diaphoretic, tachycardic (having an abnormally fast heart rate), unable to stand by himself. Lab results revealed hemoglobin (an iron-rich protein in red blood cells that carries oxygen from the lungs to the rest of the body) 2.4 (normal levels 13.7-17.5) and lactic acid (indicates whether body tissues are receiving enough oxygen. Elevated levels can suggest tissue hypoxia, shock, sepsis, heart failure, or liver disease.) 17 (normal levels 0.4- 2.0). Patient admitted and transferred to [another hospital] for severe anemia (a condition where the body has an abnormally low level of red blood cells (RBCs) or hemoglobin, the protein in RBCs that carries oxygen) and septic shock (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage). The facility's "EMTALA Memorandum of Transfer" form dated 4/25/2025 was reviewed. The form revealed in part, "Emergency Medical Condition Identified ...I. Anemia (lower than normal amount of health red blood cells), Lactic Acidosis (when lactic acids build up in the blood), skin injuries (skin injury occurs in the buttock region) and pancytopenia (medical condition in which there is significant reduction in the number of almost all blood cells). The patient was being transferred because it was medically indicated; and no GI physician is available at this facility. The patient was transferred via helicopter on 4/25/2025 at 2:39 PM, with blood infusing at 200 ml/hr.


During a group interview on 05/12/2025 at 4:47 PM, the CEO (Chief Executive Officer), CNO (Chief Nursing Officer), VPQ, Director of Patient Safety, ED Director, ED Manager, and Staff C, ED CN confirmed the patient was not worked up properly, was not stable for discharge and was not provided a safe discharge. Allowing a patient to sit outside the ED entrance all night, approximately 10 hours, in a wheelchair is "not ok."

An interview was conducted on 5/14/25 at 10:00 AM with the ED Director and the ED Manager. The ED Director said there was an issue with the initial exam the APRN did on Patient #8 because "it was not thorough." The ED Director said he thought Patient #8 was stabilized prior to discharge and The ED Manager said she did not know if Patient #8 was stabilized or not because vitals were never taken or reevaluated during his first visit. The ED Director said Emergency Medical Treatment and Labor Act (EMTALA) is to ensure patients are seen and evaluated by a provider, no one gets turned away, they are stabilized prior to discharge, or they are transferred appropriately if the services cannot be met in their ED.

During an interview on 05/15/2025 at 9:30 AM, the CNO (Chief Nursing Officer) stated, "yes, I agree the APRN assessed him in the lobby in front of other people, and it looks as if he did not even really assess the hip."

Review of facility policy EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening Examination and Stabilization last reviewed 04/2024. The policy revealed "An EMTALA obligation is triggered when: an individual or a representative acting on the individual's behalf, including EMS or a transferring hospital, request emergency services and care .....When a MSE (Medical Screening Examination ) is required" A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED (Dedicated Emergency Department), to determine whether or not an EMC (Emergency Medical Condition) exists: (i) to any individual, ...who requests an examination; (ii) an individual who has such a request made on his or her behalf ...3. Extent of the MSE ...c. An on-going Process. The individual will be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC ...the medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer .... Extent of MSE varies by presenting signs and symptoms. The MSE may vary depending on the individual's signs and symptoms: Depending on the individuals presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures."


The facility failed to ensure that their policy and procedures were followed as evidenced by failing to ensure that an appropriate MSE was provided for Patient #8 when he presented to the hospital's ED on 4/24/2025 at 7:55 PM; with presenting signs and symptoms of s/p fall at home and reported chief complaint of hurting all over for the past 2 weeks. The facility failed to perform ancillary services, clinical laboratory tests that were available when the patient initially presented to the hospital's ED. Additionally, the facility failed to re-evaluate the patient's vital signs and pain status prior to discharge. The patient did not have an appropriate discharge evaluation. The discharge evaluation did not demonstrate Patient #8's ability to care for himself status/post a fall at home, given the patient reported to the ED staff living independently with baseline mobility problems with transfers, using a walker and electric scooter prior to discharge.