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Based on a review of medical records, staff interviews, policies and procedures, it was determined that the facility failed to provide a medical screening examination (MSE) and stabilizing treatment for one (P#1) of 21 sampled patients. Specifically: P#1 presented to the facility's property on 9/11/24 at 4:30 a.m. with complaints of "pain, body locked, and chest pain". Public Safety Officer (CC) established face to face contact with P #1 and called for medical assistance around 4:30 a.m. Emergency Medical Tech (Tech FF) and Registered Nurse (RN GG) arrived on scene and offered P#1 medical assistance. P #1 refused medical assistance, became verbally violent and made physical threats to the Security Officers, Tech FF and RN GG. Tech FF and RN GG left the scene when P #1 became violent. County police was contacted by facility's dispatch and arrived on scene at approximately 5:18 a.m. As P #1 refused to calm down and made threats to shoot Public Safety Officers. County police Officers put P #1 in handcuffs and transported P #1 to another facility ED for medical and psychiatric treatments Tech FF, RN GG and Public Safety Officers on scene failed to request that the County Police Officer take P #1 to the ED for medical and psychiatric evaluations after P #1's behavior was under police control and P #1 was no longer a threat.

Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate medical screening examination to P#1.

Based on review of policy and procedures, medical staff bylaws a security incident report, and staff interviews it was determined that the facility failed to provide an appropriate medical screening examination (MSE) for one patient (P) (P#1) of 21 sampled patients. Specifically, P #1 was found on the facility's property and complained of 'pain, body locked, and chest pain'. Although the facility's staff witnessed county police obtain physical control of P #1, staff failed to request that county police bring P#1 into the ED for a medical and psychiatric evaluation. County police transported P#1 to another acute care facility for treatment.

Findings included:

Review of policy title "Medical Screening, Treatment and Related Issues", effective date: 10/03/23 revealed the purpose of the policy sets forth procedures to ensure that all Hospitals with Dedicated Emergency Departments (DED) in the Emory Health Care (EHC) system meet all the requirements set forth in the Emergency Medical Treatment and Labor Act ("EMTALA") for the examination and treatment of patients for whom a request for emergency care is made. The policy indicated that all facility workforce members, including employees, volunteers, house staff, and Medical Staff members are responsible for adhering to these guidelines in their interactions with patients, families and visitors or any individual who comes to the EHC facilities.
Policy:
The policy delineated that any individual who comes to the Emergency Department or Labor & Delivery Department requesting care should be offered an appropriate Medical Screening Examination to determine if the individual has an Emergency Medical Condition. If an Emergency Medical Condition exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the policy, "EMTALA - Transfers To/From Other Facilities".
Procedure:
The policy stated that an appropriate Medical Screening Examination should be provided by a Qualified Medical Personnel (QMP) to any individual who comes to the Emergency Department (and/or on Hospital Property) and: (1) the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or (2) it is apparent that the person needs an examination or treatment of a medical condition based on the individual's appearance or behavior. If an Emergency Medical Condition is determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer if the Hospital lacks the capacity and capability to provide the stabilizing treatment. Stabilizing treatment should be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, ethnicity, insurance status, color, national origin, sexual orientation, disease or handicap).

The policy further indicated that if an individual presents on Hospital Property that is located outside of the DED and appears to be suffering from an Emergency Medical Condition or requests an examination or treatment for a medical condition, the individual should be transported to the DED or another area in the Hospital that is capable of providing a Medical Screening Examination and delivering emergency services appropriate to the individual's condition.

Medical Screening Examination:
1. "Medical Screening Examination" or "MSE" means the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not the patient has an Emergency Medical Condition. An MSE is not an isolated event. It is an ongoing process that begins but does not end with Triage.
2. All individuals coming to the Emergency Department should be provided an MSE appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the Hospital. Depending on the individual's presenting signs and symptoms, an appropriate MSE can involve a wide spectrum of actions.
3. The medical record should reflect continued monitoring according to the individual's needs until it is determined whether or not the individual has an Emergency Medical Condition and, if they do, until they are stabilized and/or appropriately transferred. There should be evidence in the medical record of this ongoing monitoring of the individual prior to discharge or transfer.

Under section "Definitions" of the policy "Emergency Medical Condition" is defined as:
a. The presence of acute symptoms (including pain or the psychiatric symptoms discussed below) of such severity that the absence of immediate medical attention could reasonably be expected to result in:
1. Placing an individual's health in serious jeopardy.
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part.
c. With response to an individual with psychiatric symptoms, an Emergency Medical Condition
is one in which:
1. Acute psychiatric or acute substance abuse symptoms are manifested; or
2. An individual is expressing suicidal or homicidal thoughts or gestures or other thoughts or gestures that indicate the potential to harm self or others and is determined to be a danger to self or others.
"Hospital Property" means the entire main Hospital campus, including the Hospital's main buildings and other areas and structures owned by the Hospital that are not attached to the Hospital's main buildings but are located within 250 yards of the Hospital's main buildings, including parking lots, sidewalks, driveways, and Hospital Departments.
"Qualified Medical Personnel" or "QMP" means individuals qualified to perform a Medical Screening Examination as designated by the Hospital's Bylaws (except, as provided below, at all Emory Hospitals, this must be a physician, physician's assistant or advanced practice registered nurse).

An MSE with respect to psychiatric conditions at Emory Decatur Hospital may be performed by an associate professional counselor (APC), licensed professional counselor (LPL), a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW).

Review of the facility's Medical Staff Bylaws, Rules and Regulations approved by the Board on 8/14/23, Section 5 "Emergency Services" revealed A "medical screening examination (MSE)" is required by federal law and regulation (42 USC § 1395dd, 42 CFR § 489.24) to be provided to any person who comes to the Hospital's emergency room or Labor and Delivery Unit and requests examination or treatment. The Medical Screening Examination (MSE) may be provided in the emergency room by the following individuals:

a Practitioner with appropriate Clinical Privileges.
b.an Associate Professional Counselor (APC), a Licensed Professional Counselor (LPC) a Licensed Clinical Social Worker (LCSW) or a Licensed Master Social Worker (LMSW) with respect to psychiatric conditions; or a nurse practitioner or physician's assistant or by the emergency room Physicians.
The Bylaws delineated that no patient may be directed to another location, including but not limited to a Physician's office or a different hospital, until: (i) that patient has been fully evaluated according to law and the requirements of these Rules and Regulations, and (ii) the patient has been evaluated by a specialty Physician as deemed appropriate and available per the ED on-call coverage list, as determined by the emergency room Physician or other Hospital Physician.

A review of Incident Report, Case Number IR20240911-000824 Narrative Text revealed that on 9/11/24 at approximately 4:30 a.m. a public safety officer responded to the outside driver's entrance of the Women's Tower to a report of a male lying on the ground requesting medical assistance. The public safety officer found the individual blocking the interior drive of the Women's Tower. When asked, the individual relayed that he was in pain, his body locked up and he collapsed. He responded that he needed medical assistance. At 5:03 a.m., an ED nurse and ED technician arrived with a wheelchair to assist the individual to the ED for evaluation. The individual refused assistance and became verbally aggressive making threats toward medical staff and public safety officer. The individual refused to get up from the driveway. At 5:09 a.m. local law enforcement was called. At approximately 5:16 a.m., the individual began making physical gestures toward the public safety officers and threatened to shoot the public safety officers. At approximately 5:18 a.m. local law enformcement arrived. The individual continued to make threats and at approximately 5:36 a.m., the individual was restrained and placed in the police vehicle.

An interview with Operation Manager Public Safety (Manager) AA took place in a private office on 9/24/24 at 10:00 a.m. Public Safety Manager AA stated she was over public safety for the county; she also stated that the Lieutenants reported to her; she stated she did not have any direct contact with patients. Manager AA explained that the Safety Officers made rounds and some of them were posted in specific locations around the hospital campus. Manager AA said the officers did not have contact with patients except in cases where patients were aggressive, became a threat to the public, staff, and themselves. Manager AA said there was always an Officer stationed in the ED that monitored patients and the public activities in the ED main lobby and hallways via visual observation. Manager AA said officers did not make decision to send people away regardless of behavior they displayed, it was the decisions of nurses and doctors to request that patients be escorted out of the ED. Manager AA said that all Officers had a clear understanding of the EMTALA law which stated that everyone presented to the facility and asked for medical assistance should receive medical care until they were stable.


An interview with Public Safety Lieutenant (Lieutenant) BB took place in the conference room on 9/24/24 at 4:03 p.m. Lieutenant BB stated she had worked at the facility for 10 years. Lieutenant BB recalled the event of 9/11/24 regarding P #1. Lieutenant BB said dispatch received a call on the radio describing a black male laying on the ground near the entrance of the Women's Tower (a building located about on the other side of the ED). Lieutenant BB said she heard the call on the radio made by one of the Officers on campus that night. Lieutenant BB said the officer said male on the ground stated he had chest pain, and the male said he could not move, his legs hurt. Lieutenant BB said she was in the ED next to the triage nurse, and she related the call about the male individual to the nurse (RN GG). Lieutenant BB said RN GG and ED Tech FF took a wheelchair and went to the scene where the male individual was said to be located. Lieutenant BB said about two minutes later the same officer radioed again that the male individual was very aggressive, combative, and refused to get out of the roadway; stated the individual said he was fine, and he did not need medical assistance. Lieutenant BB said about two to three minutes after the radio call, the Nurse and the Tech returned to the ED. Lieutenant BB said the nurse stated that she went to the tower and the individual refused to come in the ED. Lieutenant BB said she decided to go to the scene and on her way there, the Officer radioed again that the individual threatened to shoot him and that he had a gun. Lieutenant BB said when she heard that, she asked dispatch to call the County police. Lieutenant BB said when she got to the scene, she saw a male individual standing and pacing, making physical and verbal gesture with hands inside a coat he carried. Lieutenant BB said the individual claimed that he had a gun. Lieutenant BB said the police arrived very quickly on scene (in about five minutes). Lieutenant BB said the male individual threatened the female police officer when she arrived; Lieutenant BB said the police officer put the individual in handcuffs after he said he was going to shoot them all. Lieutenant BB said once the police arrived and took control of the scene , she left to the ED because there was other behavior health issue they were dealing with in the ED. Lieutenant BB said she was aware that when a person came to the ED and asked for medical assistance, they should not turn the person away; but they must treat the person.

An interview with Public Safety Officer (Officer) CC took place in the conference room on 9/24/24 at 4:26 p.m. Officer CC said he was in post at the Women's Tower when one of the employees reported to him that she saw a male individual laying on the driveway near the entrance of the building. Officer CC said he went to the individual and asked him if he was okay. Officer CC said the individual said he was hurting and his legs "did not work" and he was in pain. Officer CC said he asked the individual if he needed medical assistance and replied yes. Officer CC said he called on the radio and it did not take long for RN GG and Tech FF to arrive with a wheelchair. Officer CC said the nurse and the male Tech offered the individual to go in the ED and to get in the wheelchair. Officer CC said the individual started cussing the nurse and calling her nasty names, in particular he was calling the nurse f ...ing bitch the whole time. The individual said he did not need help and that he did not want the nurse to touch him. Officer CC said the individual became really upset and reached to his coat and claimed that he had a gun in his pocket. Officer CC said at that point the nurse said they had to get back in the ED and left. Public Safety Officer CC said after the individual made threats to kill them, they called the police who arrived shortly after. By the time the police arrived the individual was up and walking, continuing to make threats even towards the police officer. Public Safety Officer CC said the police handcuffed him and took off. Public Safety Officer CC explained that he understood the law of EMTALA and stated they must provide medical care to all persons coming in the ED and requesting medical assistance; and that was the reason he went to him and asked if he needed medical assistance.

An interview with Public Safety Officer (Officer) DD took place in the conference room on 9/24/24 at 4:40 p.m. Officer DD said he was a Public Safety Officer for two years. Officer DD said he was on patrol when he heard the call coming on the radio about a black male individual laying in the driveway of the Women's tower. He said he remembered that Officer CC made the call and indicated that the male individual said he was in pain and needed medical assistance. Officer DD said he went to the scene and saw a black male laying on the driveway and said he just walked a few miles after someone was chasing him and he was in pain. Officer DD said within 2-3 minutes, the nurse and a Tech arrived with a wheelchair. Officer DD said the nurse asked the individual some questions and that was when he became hostile, loud and told the nurse not to touch him. Officer DD said the individual used foul language and lots of F word sentences. Officer DD said the individual said they could call the police and refused to get in the wheelchair. Officer DD said the individual also refused to get off the driveway. Officer DD said he believed the police was not far because the police cruiser arrived in about five minutes. Officer DD said it was a female police officer and she was trying to calm him down, but the individual continued to make threats to them and to the police officer as well. Officer DD said the goal was to get him to the ED, but he did not want to get in the chair. Officer DD said the police officer put the individual in handcuff, put him in the car and drove off. Public Safety Officer DD said he received EMTALA training and was able to explain the idea of the law was to give care to everyone who came to the ED and asked for medical help.

An interview with Public Safety Officer (Officer) EE took place in the conference room on 9/24/24 at 5:00 p.m. Officer EE said he remembered the event of early morning of 9/11/24. He heard Officer CC on the radio stating there was a black male laying in the driveway at the Women's tower and he needed medical assistance. Officer EE said he believed the Lieutenant (LT BB) answered the call and related the message to the triage nurse. Officer EE said the triage nurse (RN GG) came to the location with a wheelchair. Officer EE said he was listening to the call on the radio, and he heard that the individual did not want medical assistance. Officer EE said the next call that came on the radio from Officer CC indicated the male individual was aggressive and threatened to shoot officer CC. Public Safety Officer EE said he arrived at the scene at the same time the police pulled up; he said it was a female Officer who showed up. Officer EE who carried a weapon, said when he got there, the individual told him that he was going to shoot him right in between the eyes. Officer EE described the individual's demeaner as very angry. Officer EE said the police officer asked the individual to show his ID and he refused. Officer EE said he believed the individual might have elbowed the police Officer as she was approaching him and at that point, she put him in handcuff and forced him into the police vehicle. Officer EE said he was not sure where the police Officer was taking the gentleman. Public Safety Officer said he was not sure that anyone asked the police Officer to take the individual to the ED. Officer EE said he was aware that anyone presented in the ED for medical assistance should have a medical exam even if they were not able to pay. He said he received training on EMTALA law.


A phone interview with Emergency Medical Technician (Tech FF) FF took place on 9/25/24 at 9:30 a.m. Tech FF said he was in triage that night; Tech FF said he remembered there was an individual laying in the driveway of the Women's tower during the overnight hours. He said public safety sent a radio call to the ED and he along with the triage nurse went on scene to see what was happening. Tech FF said he saw the individual laying on the concrete in the middle of the road. Tech FF said they both were trying to convince the guy to get in the wheelchair, but he refused. Tech FF said he remembered the individual said he was running away from a car that was chasing him and he covered a long distance running and he was out of breath. Tech FF said when the nurse asked him if he needed medical treatment, he said yes but became very aggressive. Tech FF said he believed they were trying to lift him off the ground but refused to be touched. Tech FF said the individual said they needed to bring a bed for him right where he was instead of a wheelchair. Tech FF said then he and the nurse decided to leave and return to the ED. Tech FF said he had been working in the ED for a year and he was well aware that anyone who came to the ED for medical treatment should receive treatment regardless of insurance status.

A phone interview with Registered Nurse (RN GG) took place on 9/25/24 at 10:15 a.m. RN GG said she remembered the event. RN GG said security called about a male individual laying on the ground entrance at the Women's tower. RN GG said she went to the scene with a Tech that was in triage with her. RN GG said as soon as she asked the individual what was going on, he started cussing staff. RN GG said the individual stated that a car was chasing him, and his chest now was hurting. RN GG said the individual wanted to fight with security. RN GG said the individual was agitated and violent that they ended up calling the police as the individual was making gun threats. RN GG said they went there with a wheelchair to bring the guy in the ED, but he just refused care. RN GG said from his appearance the guy was in the right state of mind, he was not in any kind of distress from what she could observe. And there was no indication to place him in restraint to force him in the ED. RN GG said as things were getting hot, she decided to go back in the ED because the conversation was not getting anywhere. RN FF said the individual was verbally aggressive and it was unsafe to remain on scene.

An interview with the ED Nurse Director (Director) HH took place in the conference room on 9/25/24 at 11:55 a.m. Director HH said he was not familiar with the incident because the individual did not make it to the ED. Director HH said they got calls all the times about behavior health patients coming to the ED with violent behavior. Director HH said when EMS brought a violent person in the ED, first thing they called security. Security would control the scene to make sure everyone was safe. Director HH said they maintained four seclusion rooms in the ED for that purpose and they had sitter and security officers to watch over violent behavior health patients. Director HH said they had a rapid response team that dealt with these types of calls. Director HH said in any case, they had protocol in place dealing with violent behavior health patient in the ED. Director HH explained that security was always the first line of defense, then seclusion until the patient was assessed by the doctor and declared safe. Director HH said in any case all behavior health patients got to see a Behavior Health Counselor at least. Director HH said aggressive patient was something they dealt with daily in the ED and they always had security stationed in the ED to intervene if necessary.

An interview with ED Medical Director (Doctor) II took place in the conference room on 9/25/24 at 12:10 p.m. Doctor II explained that Behavior Health Patients coming to the ED had the opportunity to see the EMTALA signage first as they had it posted at the main entrance and in the ambulance bay. Director II said the triage nurse did a quick triage, and the behavior health patients went to the back area reserved for Behavior Health patients. Director II said they had security involved sometimes immediately if the patients was aggressive. Director II said security directed the patients to change in scrubs and the patient was placed in a safe room in line of sight. Director II said all behavior health patients had to have a medical screening exam before Behavior Health could see the patient. Director II said the ED doctor put a consult for behavior health after he completed the MSE. Director II said then the Behavior Health professional made recommendations for inpatient or discharge to outpatient. Doctor II said when it came to the incident related to the Gentleman, it remained unclear to him why the gentleman was taken to Grady because they could treat him here. Doctor II said they received calls about violent patients all the time and they had protocol and security in the ED for these cases. Director II said even if the gentleman was under police custody, they still required to provide care to him. Director II stated that violent behavior did not disqualify a person to get the care he deserved. Director II said this individual fell under the critical care category. Director II said they had policy on Physical and Chemical Restraints; he clarified that restraint was always the last option, but it was an option when there was no other choice. Director II said misbehavior on the part of a patient should not constitute a barrier to care delivery. Director II said he was not aware of the details, but he still did not understand why the police took the gentleman to Grady; something they were well equipped to deal with in their ED.