HospitalInspections.org

Based on clinical record review, document review and interview conducted on 06/03/24 and 06/04/24, the facility failed to ensure Patient #20 received a medical screening examination, that was within the capacity and capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed.

Please refer to the findings in Tag A- 2406, for detailed documentation of the deficient practice.

Based on medical record review, Security Case Report, Police Report, policy review and interview, it was determined the facility failed to ensure that when an individual comes to the emergency department, the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients (Patient #20) who presented to the hospital with complaints of psychiatric symptoms.

The findings included:

Clinical record review conducted on 06/03/24 and 06/04/24 revealed Patient #20 presented to the Emergency Department (ED) on 05/26/24 at 12:06 PM with Psychiatric Symptoms. The patient was triaged (helps determine the order in which patients are treated, ensuring that those with the most serious conditions are seen first) as semi-urgent and placed in a room.

Review of the triage note dated 5/26/34 at 12:17 PM, revealed in part, "Pt (patient) walks in, reports "my mind won't shut off or slow down. I just need something to help my mind sleep." Pt reports her (he) is witnessing people being sex trafficked around him and raped. Pt. denies calling LEO (Law enforcement officer), stating can't call them as they are the ones doing it. Pt. admits to cigarettes, marijuana and meth (methamphetamine-illicit highly addictive drug) use, Denies CP (chest Pain), SOB (Shortness of Breath), NVD (nausea, vomiting, diarrhea), HA (headache), Dizziness, SI (Suicidal ideation) or HI (Homicidal ideation). G/F (Girlfriend) at bedside." The Columbia Suicide risk assessment (suicide risks assessment tool used to help identify weather or not someone is at risk for suicide) was reviewed and the patient suicide risk was listed as low.

The Physician and nursing documentation dated 05/26/24, signed at 1:35 PM and 1:40 PM, indicates the patient eloped the facility, therefore did not receive a medical screening examination (MSE).
The physician documented (signed at 1:35 PM), "Patient not seen or evaluated. He presented to the emergency department but eloped prior to my interview, exam and evaluation".
The Nurse documented (documented at 1:40 PM), "Patient eloped from room at this time, seen in lobby. Knife given to staff by girlfriend and given to law enforcement officer and security. Patient in hallway prior pacing and angry, stating I'm leaving." Disposition was documented as "Left without being seen at 1:40 PM." There was no documentation in the medical record to indicate that the ED Medical Doctor was notified of the change in Patient #20's behavior. Additionally, there was no documentation of a repeat assessment of the patient's suicidal thoughts were made after the discovery of the knife that was taken away from the patient by the girlfriend and discarded by the police officer in a needles sharp box.

The Security Case Report Notes dated 05/26/24 at 12:30 PM documented, "Patient in room 9 departed the ED prior to being examined due to knife being found in his belongings. During this time the ED charge nurse contacted the Sheriff's office due to comments made to her by the patient's girlfriend, law enforcement contacted patient in the ED registration waiting room and took patient into custody relative to a Baker Act and transported patient to another facility".

The Police Report documented, "On Sunday, May 26, 2024, at 1250 hours [12:50 PM], I was dispatched to a disturbance at Sebastian River Medical Center [Hospital A] in reference to a white male who came to the location for a mental health evaluation. Prior to arrival, I was advised by public safety dispatch that the subject had come in with a knife on his person and the girlfriend .....stated during triage, he pulled the knife out and told her that if anyone touches him he would slit his throat.
On my arrival, the subject and his girlfriend were seated in the waiting room being watched by a security guard. I spoke to the charge nurse who turned over a box cutter knife to me and stated she did not want to return it to the subject because of what the girlfriend stated he said. The Charge nurse also advised that since the comments were not made to her and that due to his behavior, he was unable to see a doctor therefore they would not Initiate a baker act. The staff requested he leave the premises." My contact with the patient showed him agitated with my presence and he kept attempting to leave. The patient denied making any comments of self-harm but his comments of God, the prophecy and the messiah showed he was not in the right frame of mind to make a determination for himself whether treatment was needed or not. He continued his unusual behavior by becoming violent and banging his head on the partition. At the hospital [Hospital B, where LE took Patient #20], he required sedation and the situation was briefed to the hospital staff."


Interview with Staff A, the Charge Nurse, who triaged Patient #20, was conducted on 06/03/24 at 12:57 PM. The staff recalled the patient walked in and was triaged, put in a room, he was saying he had a hard time sleeping, his mind won't shut off, he denied suicidal ideations. Some time elapsed and he was in the hallway pacing and making noise, they found a knife in his pocket and gave it to another staff member. The staff showed her the knife and told her the girlfriend was in the room and she took the knife away, it was a modified box cutter, the blade was exposed with electrical tape to hold it in place, the girlfriend said the patient was making statements, the nurse could not recall the specifics of the statement, she then called security. The police officer arrived and took the knife, disposed of the blade in the sharp box. The nurse stated the patient had left the ED, and the nurse was asked where the patient was when the police arrived and stated she did not see him, but he left the ED, he went through the doors. The nurse stated she spoke to the officer and told him the patient denied suicidal and homicidal ideations and the officer said he would take care of it. The nurse confirmed she did not see the patient leave, but the patient was not in the room.

Interview with the Security Officer, conducted on 06/03/24 at 1:35 PM, revealed he was on duty on Sunday May 26th and recalls he was called to the ED, the patient had a knife, but the staff already had it in their possession. The patient was in the ED registration area and was talking weird "he was out there", he claimed the girlfriend was being sex trafficked, and the girlfriend said he has not slept for days and was even sleeping in front of her door, blocking it, so she could not get out. The security officer stated he remained with the patient until the police arrived. The police officer talked to the patient, then talked to the girlfriend and then went to talk to the nurse and said the patient was being baker acted and took the patient with him to another facility.

The interview with the Physician, conducted on 06/03/24 at 1:45 PM, revealed he did not see the patient, after prompting for more details, the physician stated he heard the noise, he heard the patient had a knife and wanted it back, maybe the staff called security, but is not sure. The physician confirmed he was not called to see the patient when the incident began or during the police interaction.

The investigation determined Patient #20 left his room in the ED, went to the waiting room but did not elope from the facility. The patient was placed under involuntary examination by law enforcement and was subsequently transferred to another hospital (Hospital B) designated as a Baker Act receiving facility. The facility staff had access to the patient and had the capacity and capability to provide a medical screening exam. The medical record failed to provide evidence that a medical screening examination (MSE) was provided, for Patient #20 when he presented the hospital's ED on 5/26/2024 seeking medical assistance for psychiatric symptoms.

The facility's policy, titled, Emergency Medical Treatment Active Labor Act (EMTALA), last revised: 10/4/2022 was reviewed. The policy revealed in part, ""Medical Screening Examination (MSE): Means the screening process required to determine with reasonable clinical confidence whether an EMC (Emergency Medical Condition) does or does not exist. Depending on the patient's presenting symptoms, the MSE represents a spectrum 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 within the capability of the Hospital ...Procedure l. Medical Screening Examination Requirements.
All patients who present to the Hospital's DED or on Hospital Property and request examination or treatment of a potential EMC, shall receive an appropriate MSE.
A. Request for Examination or Treatment
The request for examination or treatment may come directly from the patient or from someone who makes the request on the patient's behalf. In the absence of such a request by or on behalf of the patient, a request on behalf of the patient will be considered to exist if a prudent layperson observer would believe, based on the patient's appearance or behavior, that the patient needs examination or treatment for a medical condition.
B. scope of the MSE
l. A physician or QMP must perform the MSE to determine if an EMC exists. The MSE must be appropriate to the patient's presenting complaint and symptoms, and the medical history of the patient.
2. The MSE may range from a simple process involving only a brief history and physical examination to a more complex process involving ancillary studies routinely available to the emergency department, such as laboratory and x-ray testing, CAT scans, MRIs, other diagnostic tests/procedures or specialty consultation until the physician or QMP has reasonably determined whether an EMC exists."
examination, or treatment, or refuses any further care, the patient should be informed of the risks and benefits of such refusal and of the Hospital's obligation to provide stabilizing treatment (if necessary) under EMTALA.