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Based on review of records and staff interviews, the hospital with a dedicated emergency department (ED) failed to ensure that an appropriate medical screening examination was provided within the emergency department's capability and capacity for 1 patient (Patient #1) who presented to the hospital's emergency room complaining of vomiting for a three day period. The hospital staff also failed to provide informed refusal of care for 2 patients (Patient #13 and #14) prior to patients leaving without treatment to determine whether or not an emergency medical condition existed. Patient #13 presented with complaint of being woozy after giving blood causing a motor vehicle accident, and Patient #14 presented with urinary catheter problems.

Refer to findings in tag A-2406 and A-2407

Based on family and staff interviews, medical record review, and hospital policy review, the hospital failed to ensure that an appropriate medical screening examination was provided that was within the capabilities of the hospital's Emergency Department (ED) including ancillary services routinely available in the ED to determine whether or not an emergency medical condition existed for 1 (Patient #1) of 20 patients sampled who presented to the hospital emergency room (ER). Patient #1 was denied a medical screening exam because she was a minor.

Findings included:

1. Review of the hospital policy "EMTALA/Medical Screening/Transfer" effective 4/1/86 and last revised 11/18, "The medical screening examination of a minor who presents seeking emergency treatment will not be delayed in order to obtain parental consent."

Review of the hospital policy "Registration of Minors" effective 7/90 and last revised 5/13, "All minor patients will be triaged and will have a chart generated. The emergency room physician will determine whether an emergency medical condition exists."

Review of the Emergency Room medical record for Patient #1 showed she was a 15 year old female who presented to the ER on 8/21/19 with a "SORE THROAT, VOMITING."

On 8/21/19 at 1:48 a.m., Registered Nurse (RN) Staff A documented, "WENT TO TRIAGE PT [patient] AND MAN STATES HE IS LEGAL GUARDIAN BUT HAS NO PAPER WORK. STATED DCF [Department of Children and Families] JUST 'DROPPED HER ON HIS DOORSTEP' TOLD HIM WE CAN NOT TREAT A NON EMERGENT MINOR WITH OUT PARENTAL CONSENT."

On 8/21/19 at 2:05 a.m., RN Staff A documented, "SPOKE WITH DR [ER physician] AND SINCE NON-EMERGENT DID NOT WANT TO SEE WITH OUT PARENTAL OKAY. [RN Staff B] SPOKE WITH PT AND GENTLEMAN AT LENGTH. PT LEFT WITHOUT BEING SEEN BY MD [Medical Doctor]."

In an interview on 8/26/19 at 10:53 a.m., the Nursing Director of ER verified Patient #1 had never been triaged.

In a family interview on 8/26/19 at 11:11 a.m., Patient #1's Guardian verified he was told by the triage nurse Patient #1 could not be seen without consent from a guardian. He verified at the time he did not have any paperwork saying he was the patient's guardian. Patient #1's Guardian said prior to him bringing Patient #1 to the ER she had been unable to keep anything down for three days, and he thought she had been running a low-grade temperature. He said he was concerned for the minor's condition and that is why he brought her to the ER.

In a staff interview on 8/26/19 at 3:58 p.m., the ER Physician on duty when Patient #1 presented at the ER said the hospital protocol had not been followed. He said he would never know the patient was in the ER until she had been triaged. He said he had been told by the nurse the patient had a sore throat. He said he told the triage nurse sore throats are usually not an emergency. He said he was never told the patient had been vomiting. The physician said Patient #1 should have been triaged so he would have had the ability to medically assess the patient before she left the ER. The facility failed to ensure that multiple Policies and Procedures were followed as evidenced by failing to triage Patient #1 on 8/21/19 when she presented to the ED. The ED physician did not evaluate the patient to determine whether or not an emergency medical condition existed, causing a delay in the completion of the medical screening examination.

Based on patient family interview, staff interview, medical record review, policy and procedure review the hospital staff failed to offer individuals further medical evaluation and treatment, and failed to inform the individuals of the risks and benefits of evaluation and/or treatment; and failed to obtain written informed refusal of care prior to patients leaving without treatment for 2 (Patient #13, and #14) of 20 patients sampled who presented to the hospital emergency room (ER).

Findings included:


1. Policy and Procedure
The facility's policy and Procedure titled "Against Medical Advice" Effective date 12/09, Revised date 2/19 was reviewed. The Policy and Procedure, revealed in part, "Policy: ...when a patient makes a determination that treatment/care in the hospital setting is no longer their choice, the transition of the patient to a new environment will be accomplished, as effectively ...and as safely as will be allowed ...Procedure: When treatment/care is no longer desired, care providers will be expected to: ...B. Provide the patient with information that will allow him/her to make an informed decision about the benefits of following medical advice and the risks of not following ...Document clearly the reason(s) why the patient has elected to discontinue treatment/care ...Attempt to get the patient to sign a Release From Responsibility For Discharge when electing to discontinue treatment/care."

2. Patient #13

Review of Patient #13's ER record showed on 7/2/19 he was transported to the ER via ambulance for weakness after having a "slow speed" motor vehicle accident.

On 7/2/19 at 3:23 p.m., Registered Nurse (RN) Staff C documented Patient #13 was "WOOZY AFTER GIVING BLOOD AND DROVE VEHICLE SLOW SPEED IN THE PARKING LOT AND HIT WALL NO PAIN NOTED."

The ER record showed Patient #13 was triaged with the following vital signs: Blood Pressure (B/P) 163/77, Pulse 54, and Respirations 16. The patient was alert and oriented to person, place, and time. Further review of the medical record revealed the patient was "Dispositioned" as leaving without being seen on 7/2/19 at 7:27 p.m.

On 7/2/19 at 3:27 p.m., RN Staff C documented, "PATIEN [sic] TO ROOM VIA EMS (Emergency Medical Services) AND STATES DOES NOT WANT TO BE SEEN AND FEELS FINE. PATIENT AMBULATING AROUND ROOM WITHOUT DIFFICULTY. PATIENT DENIES DIZZINESS OR ANY WEAKNESS AT THIS TIME. PATIENT THANKS US FOR HIS CARE". There was no documentation in the medical record to indicate that on 7/2/19 Patient #13 was offered further evaluation and treatment, informed of the risks and benefits of an examination and treatment, or that staff attempted to get Patient #13 to sign an informed refusal form as stated in the facility's policy.

In an interview on 8/27/19 at 10:30 a.m., RN Staff C said he remembered Patient #13 arrived via EMS. He said Patient #13 had been in an accident at a local store, but RN Staff C did not remember if the physician was informed Patient #13 wanted to leave the ER.

3. Patient #14.

Review of Patient #14's ER record shows on 6/27/19 the patient came to the ER with a complaint of "CATHETER PROBLEMS."

On 6/27/19 at 4:07 p.m., RN Staff D documented Patient #14 left without being seen at 4:07 p.m., and the patient was stable. There is no documentation how the patient left the ER.

In an interview on 8/26/19 at 1:10 p.m., RN Staff D said he could not remember anything about the patient.

In an interview on 8/28/19 at 3:30 p.m., Patient #14's mother said they had gone to the ER because her son's urinary catheter was coming out. She said the staff at the ER gave her son a catheter strap and they left. The facility failed to ensure that their Policy and procedure were followed as evidenced by failing to offer Patient #14 further examination and treatment; and failed to inform the patient and his mother of the risks and benefits of receiving an examination, and/or treatment or both. The facility staff also failed to attempt to get patient #14 to sign the facility's informed refusal form as stated in the facility's policy and procedure.