Based on interviews, document review, and during the course of a complaint investigation, it was determined the facility staff failed to comply with §489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases. The findings include: The facility staff failed to provide a Medical Screening Exam (MSE) for an individual who presented to the facility's emergency department (ED) waiting area/registration desk; the individual had a family member with him/her. Prior to the individual being registered as an ED patient, he/she exited the ED waiting area. The individual started to exhibit behaviors that resulted in the facility's security staff using pepper spray on the individual, restraining the individual, and calling the local police. The local police arrived at the facility. The individual was arrested and removed from the facility's campus prior to having a MSE completed. Please see tag A-2406 for additional information.

Based on interviews, review of facility documents, review of security video footage, and in the process of a complaint investigation, it was determined the facility staff failed to provide a medical screening exam (MSE) for 1 of 20 sampled patients (Patient #7). The findings include: Patient #7, an adult, presented to the facility's emergency department (ED) waiting area/registration desk (one of Patient #7's parents was with him/her). According to an interview with a facility's registration clerk (Staff Member (SM) #9), Patient #7 asked for someone named 'Rudy'. SM #9 reported the parent was speaking but SM #9 could not understand what was being said because of the activity in the area. SM #9 stated another individual (not with Patient #7) was attempting to go through the locked doors leading toward the facility's main lobby. SM #9 stated Patient #7 told the other individual he/she would get the doors. SM #9 stated Patient #7 preceded to push his/her way through the magnetically locked doors and continued toward the facility's main lobby calling out for 'Rudy'. Patient #7 was at the registration desk for less than 60 seconds according to security camera footage. Patient #7's parent followed him/her. SM #9 reported he/she call for security. SM #9 stated he/she had never seen anyone force their way thought the aforementioned locked doors. Video from facility security cameras showed that after Patient #7 left the waiting area he/she preceded to throw a drink, knock items off a desk/counter, briefly roll a luggage rack, and pull potted plants out of their containers and throw them onto the floor. Video footage showed facility staff present for all of the aforementioned activity with the possible exception of the individual throwing the drink. The security guard (SM #3), who interacted with Patient #7 during the activity, was interviewed. SM #3 reported he/she witnessed Patient #7 having an argument with another visitor and 'smashing' things on the registration desk/counter. SM #3 reported he/she attempted to talk to the individual to deescalate the situation. SM #3 reported he/she offered to walk the individual back to the ED. SM #3 stated Patient #7 continued to be destructive. SM #3 stated he/she felt threatened because the behavior was violent. SM #3 stated, Patient #7 was "coming at me as if (he/she) was going to assault me." SM #3 reported he/she warned Patient #7 multiple times prior to using the pepper spray. Patient #7 was then restrained by security and several nurses; SM #3 stated the individual's hands were cuffed behind his back. Interviews with four (4) registered nurses (RNs) (SM #5, SM #6, SM #7, and SM #8) acknowledged Patient #7's aggressive behaviors prior to the use of the pepper spray. The RNs and the security guard reported Patient #7 continued to be aggressive after the use of the pepper spray; reported behaviors included kicking and spitting. Video footage failed to capture the use of the pepper spray and the application of the handcuffs. After Patient #7 was cuffed, he/she was escorted to a chair in an area that did have video monitoring. The local police arrived and Patient #7 was escorted from the facility at 9:16 p.m. by one (1) police officer and the facility's security guard. Interviews with SM #5 and SM #8 revealed Patient #7's parents had indicated they had wanted the patient to be seen at the facility's ED at the time of the encounter when the patient was arrested. SM #7 reported he/she had heard one of Patient #7's parents say "(He/She) needs help"; this was after the individual had been pepper sprayed. On 9/5/18, the local police department's Chief Deputy and the arresting officer (AO) were interviewed. The AO reported the local police department was called for someone "out of control" at the hospital. The AO reported he/she arrived and found Patient #7 being held down by four (4) people and Patient #7 was still resisting. The AO reported Patient #7 was arrested and removed from this facility for the patient's safety and for the safety of others. No evidence was found by or provided to the survey team to indicate Patient #7 had been seen by a medical provider prior to being arrested and escorted from the facility. The following information was found in the facility's 'Medical Staff Rules & Regulations': "Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel ("QMP") who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (1) Emergency Department: (i) members of the Medical Staff with clinical privileges in Emergency Medicine; (ii) other Active Staff members; including Nurse Practitioners and Physician Assistants in the Emergency Department (iii) Residents who are appropriately qualified in Emergency Medicine. (iv) appropriately credentialed allied health professionals ... The results of the medical screening examination must be documented in a timely fashion at the conclusion of an Emergency Department or Family Birth visit." Interviews with the facility's Administrator and Risk Manager revealed the facility and the local police department are working to develop a process to handle similar situations in the future. The facility's Risk Manager reported the facility had not had a precedence for a situation like this; the Risk Manager reported a meeting is planned with local law enforcement to define roles and setup expectations in case of a future event. Patient #7 returned to the facility approximately four (4) hours later, at 1:32 a.m., under an emergency custody order (ECO) with a policy escort. At the time of Patient #7's return to the facility, he/she was medical screened/cleared and then transferred to another facility to address the patient's needs.

Based on interviews and facility document review, it was determined the facility staff failed to comply with §489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases. The findings include: The facility staff failed to ensure the facility's written policies and procedures for 'on-call physicians' addressed: (a) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call and (b) if an on-call physician is allowed to have simultaneous on-call duties. Please see Tag A2404 for additional information.

Based on interviews and facility document review, it was determined the facility staff failed to ensure the facility's written policies and procedures for 'on-call physicians' addressed: (a) if an on-call physician is allowed to schedule elective surgeries during the time he/she is on call and (b) if an on-call physician is allowed to have simultaneous on-call duties. The findings include: On the morning of 6/6/17 the facility's policy and procedure entitled "EMERGENCY MEDICAL TREATMENT AND PATIENT TRANSFER" (the effective date and the reviewed date both were February 11, 2015) was reviewed by the surveyor. The surveyor was unable to find evidence of the policy and procedure addressing: (a) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call and (b) if an on-call physician is allowed to have simultaneous on-call duties. On 6/6/17 at 10:30AM, the facility's Quality Manager (Staff Member (SM) #5) was asked to provide the facility policies and procedures that addressed if on-call physicians can have simultaneous on-call duties and/or be allowed to schedule elective surgeries during the time he/she is on call. On 6/6/17 at 11:19AM, the facility's Risk Manager (Staff Member (SM) #4) reported there was not a policy and procedure addressing if a physician could schedule elective surgeries for the same time the physician was on-call. SM #4 stated physicians are allowed to do elective surgeries during the time they are on-call but would be expected to have a back-up plan to deal with emergency on-call cases. During an interview on 6/6/17 at 2:00PM, SM #4 added that an emergency patient would bump an elective procedure. On 6/6/17 at 2:00PM, SM #4 stated the facility does not allow simultaneous on-call duties. SM #4 had earlier provided the survey team with a 'COMMUNITY CALL POLICY' (this policy was documented as effective from January 1, 2017 - December 31, 2017; the last date of the signatures of those approving this policy was 1/25/17); this policy detailed the facility providing "emergency on-call coverage for general surgery and gastroenterology" for another local hospital. The survey team was not provided with a policy and procedure that detailed guidance for simultaneous on-call duties other than the aforementioned policy which only addressed the approval of simultaneous on-call duties for two specific specialties at two specific facilities. On 6/6/17 at 4:15PM, the survey team met with the facility's administrative team; the administrative team included but was not limited to SM #4, SM #5, the facility's CEO, and the facility's CNO. The failure to have written policies and procedures to address scheduling elective surgeries for the same time period a physician is on-call and the failure to have written policies and procedures to address simultaneous on-call duties for situation that would not be covered by the 'COMMUNITY CALL POLICY' was discussed.