Lahey Hospital & Medical Center, Burlington

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41143 Based on observation, record review, and interview, the Hospital failed to ensure compliance with EMTALA regulations as an appropriate medical screening examination was never provided to one Patient (#1) who presented to the Hospital Emergency Department out of a total sample of 30 patients. Patient #1 presented to the Hospital’s Emergency Department on 12/3/23 with a head injury and bleeding and left the Hospital premises before being evaluated by a qualified staff member following a physical altercation with a Hospital security officer (SO #1) Findings include: Review of the Hospital policy titled “Emergency Medical Treatment and Labor Act Transfer of Patient from the Hospital to another Health Care Facility”, dated 5/6/21, indicated the following: -The Hospital shall provide an appropriate medical screening examination, by qualified medical personnel, within its capacity to determine whether an emergency medical condition exists. -The medical screening examination will be provided to all patients who present to the emergency department seeking treatment of a medical condition or who present elsewhere in the hospital or hospital property seeking examination or treatment for an emergency medical condition or there is reason to believe that the patient has an emergency medical condition. Patient #1 presented to the Hospital Emergency Department on 12/3/23 around 11:00 P.M with belligerent behaviors and visible blood covering his/her face. Review of the Hospital’s Electronic Medical Record (EMR) failed to indicate any documentation entered for Patient #1 on 12/3/23. Review of the Hospital’s incident report for Patient #1 dated 12/3/23 indicated SO #1 witnessed Patient #1 with blood covering his/her face yelling at his/her family members and destroying hospital property in front of the Emergency Department. Patient #1 entered the triage area with his/her family members; Patient #1’s family members informed security staff that Patient #1 was intoxicated and had been in physical altercation prior to arriving at the Hospital. Patient #1 continued to be belligerent and could not be checked in. Patient #1 began to walk out and screamed at other patients in the waiting area. SO #1 documented he used verbal de-escalation strategies in an attempt to de-escalate Patient #1. Patient #1 approached SO #1 and began yelling in his face in an aggressive manner. SO #1 utilized a modified middle block to control Patient #1 and push him/her back. Patient #1 began to violently resist and SO #1 utilized two closed fist strikes to Patient #1’s face and Patient #1 was brought to a supine position on the ground. The local police responded to the incident. Patient #1 and his/her family went to another hospital for evaluation. Patient #1 never had a physician or nurse assigned to his/her care. Review of the follow-up/investigation to Patient #1’s incident on 12/3/23 indicated SO #1’s actions did not match the training and expected conduct of the Hospital’s security team. Excessive force was used by SO #1 against Patient #1. SO #1 was placed on leave (currently no longer with the Hospital as he resigned following his placement on administrative leave). Patient #1 was not triaged or seen by any Emergency Department team members. Patient #1 went to another hospital’s emergency department following the incident at the Hospital. Patient #1 was loud and abrasive at the second hospital’s emergency department, however, the Patient was evaluated and reported being in a motor vehicle accident and having head pain; he/she also reported alcohol use. Patient #1 received pain medications, tetanus injection, and laceration repair with stitches to a deep laceration above his/her right eyebrow. Patient #1 was discharged from the second hospital’s emergency department. The surveyor observed the security footage of the incident involving Patient #1 on 12/3/23. Patient #1 was in the emergency department waiting area at the registration desk. Patient #1 had blood covering almost half of his/her face. SO #1 was standing behind Patient #1. Patient #1 was yelling at the staff at the registration desk and walked away from the desk. SO #1 spoke to Patient #1, Patient #1 turned to SO #1 and was yelling at him and walking towards him. SO #1 pushed his forearm into Patient #1’s chest and pushed him/her back several feet through the waiting room doorway and struck Patient #1 in the face. Patient #1 never re-entered the waiting room. No nursing or medical staff were observed in the video recording of the event. During an interview with the Director of Emergency Nursing on 12/13/23 at 10:44 A.M., she said patient registration for the emergency department is performed at the desk in the emergency department waiting room. She said triage of patients presenting to the emergency department is performed by a Registered Nurse (RN) and the RN performing triage is located behind the waiting room/registration desk. She said all patients are triaged and assigned an Emergency Severity Index (ESI) based on acuity when patients present to the emergency department. She said all medical screening evaluations take place within the emergency department after a patient has been triaged and called into the emergency department from the waiting room. She said if a patient is having behaviors (aggressive, belligerent, violent, etc ...) in the emergency department waiting room, security staff are generally called/notified for assistance in de-escalation of the patient. She said a RN or clinician should also be involved in de-escalation of a patient exhibiting behaviors and should also begin assessing the patient as well. She was not aware of the event involving Patient #1 on 12/3/23. During an interview with Risk Manager #1 on 12/13/23 at 12:50 P.M., she said no medical or nursing staff were involved during the incident with Patient #1 on 12/3/23. She said Patient #1 entered the emergency department registration area/waiting room and was taken out of the waiting room by security staff. During an interview with Registration Staff #1 on 12/14/23 at 8:57 A.M., he said Patient #1 came into the emergency department waiting room on 12/3/23 with a head bleed and had a laceration on his/her head. He said the females accompanying Patient #1 were attempting to convince him/her to complete the registration process. He said the females with Patient #1 said he/she had been in a motor vehicle accident. He said his colleague was attempting to register Patient #1, however, he/she was yelling at her and making insensitive comments towards her; she called for additional security at that time. He said an RN was working in triage at the time. He said after the physical altercation between Patient #1 and SO #1, he called 911. He said at that point, Patient #1 was outside, and he did not see the Patient again; he was leaving at that time as his shift was ending. The Hospital failed to ensure compliance with EMTALA regulations as Patient #1 never received a medical screening examination despite presenting to the emergency department on the Hospital’s premises with a laceration/injury and his/her family members reporting the Patient had been intoxicated and had sustained trauma.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) 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 exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41143 Based on observation, record review, and interview, the Hospital failed to ensure an appropriate medical screening examination was provided to one Patient (#1) who presented to the Hospital Emergency Department out of a total sample of 30 patients. Patient #1 presented to the Hospital’s Emergency Department on 12/3/23 with a head injury and bleeding and left the Hospital premises before being evaluated by a qualified staff member following a physical altercation with a Hospital security officer (SO #1) Findings include: Review of the Hospital policy titled “Emergency Medical Treatment and Labor Act Transfer of Patient from the Hospital to another Health Care Facility”, dated 5/6/21, indicated the following: -The Hospital shall provide an appropriate medical screening examination, by qualified medical personnel, within its capacity to determine whether an emergency medical condition exists. -The medical screening examination will be provided to all patients who present to the emergency department seeking treatment of a medical condition or who present elsewhere in the hospital or hospital property seeking examination or treatment for an emergency medical condition or there is reason to believe that the patient has an emergency medical condition. Review of the Hospital policy titled “Assessment and Reassessment of Patients-Emergency Department Policy”, dated 10/20/23, indicated the following: -Rapid Triage by Registered Nurse: Patients will be seen in order of arrival or by severity of chief complaint and/or presenting symptoms. The triage nurse will conduct a visual assessment evaluating the patient’s general appearance for any problems that will require immediate attention. Patient #1 presented to the Hospital Emergency Department on 12/3/23 around 11:00 P.M with belligerent behaviors and visible blood covering his/her face. Review of the Hospital’s Electronic Medical Record (EMR) failed to indicate any documentation entered for Patient #1 on 12/3/23. Review of the Hospital’s incident report for Patient #1 dated 12/3/23 indicated SO #1 witnessed Patient #1 with blood covering his/her face yelling at his/her family members and destroying hospital property in front of the Emergency Department. Patient #1 entered the triage area with his/her family members; Patient #1’s family members informed security staff that Patient #1 was intoxicated and had been in physical altercation prior to arriving at the Hospital. Patient #1 continued to be belligerent and could not be checked in. Patient #1 began to walk out and screamed at other patients in the waiting area. SO #1 documented he used verbal de-escalation strategies in an attempt to de-escalate Patient #1. Patient #1 approached SO #1 and began yelling in his face in an aggressive manner. SO #1 utilized a modified middle block to control Patient #1 and push him/her back. Patient #1 began to violently resist and SO #1 utilized two closed fist strikes to Patient #1’s face and Patient #1 was brought to a supine position on the ground. The local police responded to the incident. Patient #1 and his/her family went to another hospital for evaluation. Patient #1 never had a physician or nurse assigned to his/her care. Review of the follow-up/investigation to Patient #1’s incident on 12/3/23 indicated SO #1’s actions did not match the training and expected conduct of the Hospital’s security team. Excessive force was used by SO #1 against Patient #1. SO #1 was placed on leave (currently no longer with the Hospital as he resigned following his placement on administrative leave). Patient #1 was not triaged or seen by any Emergency Department team members. Patient #1 went to another hospital’s emergency department following the incident at the Hospital. Patient #1 was loud and abrasive at the second hospital’s emergency department, however, the Patient was evaluated and reported being in a motor vehicle accident and having head pain; he/she also reported alcohol use. Patient #1 received pain medications, tetanus injection, and laceration repair with stitches to a deep laceration above his/her right eyebrow. Patient #1 was discharged from the second hospital’s emergency department. The surveyor observed the security footage of the incident involving Patient #1 on 12/3/23. Patient #1 was in the emergency department waiting area at the registration desk. Patient #1 had blood covering almost half of his/her face. SO #1 was standing behind Patient #1. Patient #1 was yelling at the staff at the registration desk and walked away from the desk. SO #1 spoke to Patient #1, Patient #1 turned to SO #1 and was yelling at him and walking towards him. SO #1 pushed his forearm into Patient #1’s chest and pushed him/her back several feet through the waiting room doorway and struck Patient #1 in the face. Patient #1 never re-entered the waiting room. No nursing or medical staff were observed in the video recording of the event. During an interview with the Director of Emergency Nursing on 12/13/23 at 10:44 A.M., she said patient registration for the emergency department is performed at the desk in the emergency department waiting room. She said triage of patients presenting to the emergency department is performed by a Registered Nurse (RN) and the RN performing triage is located behind the waiting room/registration desk. She said all patients are triaged and assigned an Emergency Severity Index (ESI) based on acuity when patients present to the emergency department. She said all medical screening evaluations take place within the emergency department after a patient has been triaged and called into the emergency department from the waiting room. She said if a patient is having behaviors (aggressive, belligerent, violent, etc ...) in the emergency department waiting room, security staff are generally called/notified for assistance in de-escalation of the patient. She said a RN or clinician should also be involved in de-escalation of a patient exhibiting behaviors and should also begin assessing the patient as well. She was not aware of the event involving Patient #1 on 12/3/23. During an interview with Risk Manager #1 on 12/13/23 at 12:50 P.M., she said no medical or nursing staff were involved during the incident with Patient #1 on 12/3/23. She said Patient #1 entered the emergency department registration area/waiting room and was taken out of the waiting room by security staff. During an interview with the Security Operations Manager on 12/13/23 at 1:30 P.M., he said the actions of SO #1 were outside of the expected practice of security staff. He said while striking techniques can be used by security staff in self-defense, they were not appropriately utilized during the incident with Patient #1. He said while attempting to de-escalate a patient, security staff should continue to use verbal interventions with a behavioral patient, while stepping back from a patient before engaging a patient physically. He said Patient #1 never registered with the emergency department and was not cooperative while speaking with the registration staff. During an interview with Registration Staff #1 on 12/14/23 at 8:57 A.M., he said Patient #1 came into the emergency department waiting room on 12/3/23 with a head bleed and had a laceration on his/her head. He said the females accompanying Patient #1 were attempting to convince him/her to complete the registration process. He said the females with Patient #1 said he/she had been in a motor vehicle accident. He said his colleague was attempting to register Patient #1, however, he/she was yelling at her and making insensitive comments towards her; she called for additional security at that time. He said an RN was working in triage at the time. He said after the physical altercation between Patient #1 and SO #1, he called 911. He said at that point, Patient #1 was outside, and he did not see the Patient again; he was leaving at that time as his shift was ending. The Hospital failed to ensure Patient #1 received a medical screening examination despite presenting to the emergency department on the Hospital’s premises with a laceration/injury and his/her family members reporting the Patient had been intoxicated and had sustained trauma.”