Lee’s Summit Medical Center

“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: 46856 Based on policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#1 and #5) of 30 Emergency Department (ED) records reviewed. Findings included: Review of the hospital’s policy titled, “EMTALA - Medical Screening Examination and Stabilization Policy,” dated 07/18/24, showed: - An Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) obligation is triggered when an individual comes to a dedicated ED and the individual, or a representative acting on their behalf, requests an examination or treatment for a medical condition; or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. - The hospital must provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the dedicated ED, to determine whether or not an EMC exists. - If a law enforcement officer (LEO) brings a person who is exhibiting behavior that suggests that he or she is intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) to the ED and asks for an MSE, or if a prudent layperson observer would believe that the individual needed examination or treatment for a possible EMC, then an MSE must be performed. This is required because some medical conditions could present behaviors similar to those of an intoxicated individual. - An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. - If a physician or qualified medical personnel (QMP) has begun the MSE or any stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice (AMA), after being informed of the risks and benefits and the hospital’s obligations under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or AMA form. The medical record must contain a description of the screening and the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. - If an individual refuses to consent to examination or treatment and indicates his or her intention to leave prior to triage or prior to receiving an MSE or if the individual withdrew the initial request for an MSE, hospital personnel must request that the individual sign the Waiver of Right to MSE Form that is part of the sign-in sheet or document on the sign-in sheet the individual’s refusal to sign the waiver. Review of the hospital’s undated policy titled, “Rules and Regulations of the Medical Staff,” showed the ED shall provide medical services at all times for all emergency patients who present at the hospital for care. In the event an individual presents himself to the ED and a request is made on the individual’s behalf for an examination or treatment of a medical condition, the hospital must provide an appropriate MSE by a physician or other QMP within the capability of the hospital’s ED. Review of the hospital’s policy titled, “Elopement/Leaving against Medical Advice (AMA),” dated 08/2021, showed once an individual has made a decision or statement to the effect that he desires to leave the hospital AMA, hospital personnel should attempt to determine the reasons for wanting to leave AMA. If the patient is not ready for medical discharge, hospital staff, in collaboration with the patient’s attending physician, will make reasonable attempts to explain the risks, benefits, and alternatives of such a decision. Be respectful of the individual’s right to refuse treatment. Obtain the signature on the Leaving AMA form. Document in the medical record the patient’s stated reasons for wishing to leave AMA, the actions taken, and the information given to the patient. Please refer to 2406 for further details. 51509”

“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: 46856 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#1 and #5) of 30 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “EMTALA - Medical Screening Examination and Stabilization Policy,” dated 07/18/24, showed: - An Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) obligation is triggered when an individual comes to a dedicated ED and the individual, or a representative acting on their behalf, requests an examination or treatment for a medical condition; or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. - The hospital must provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the dedicated ED, to determine whether or not an EMC exists. - If a law enforcement officer (LEO) brings a person who is exhibiting behavior that suggests that he or she is intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) to the ED and asks for an MSE, or if a prudent layperson observer would believe that the individual needed examination or treatment for a possible EMC, then an MSE must be performed. This is required because some medical conditions could present behaviors similar to those of an intoxicated individual. - An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. - If a physician or qualified medical personnel (QMP) has begun the MSE or any stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice (AMA), after being informed of the risks and benefits and the hospital’s obligations under EMTALA, reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individuals refusal to sign the Partial Refusal of Care or the AMA form. The medical record must contain a description of the screening and the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. - If an individual refuses to consent to examination or treatment and indicates his or her intention to leave prior to triage or prior to receiving an MSE or if the individual withdrew the initial request for an MSE, hospital personnel must request that the individual sign the Waiver of Right to MSE Form that is part of the sign-in sheet or document on the sign-in sheet the individual’s refusal to sign the waiver. Review of the hospital’s undated policy titled, “Rules and Regulations of the Medical Staff,” showed the ED shall provide medical services at all times for all emergency patients who present at the hospital for care. In the event an individual presents himself to the ED and a request is made on the individual’s behalf for an examination or treatment of a medical condition, the hospital must provide an appropriate MSE by a physician or other QMP within the capability of the hospital’s ED. Review of the hospital’s policy titled, “Elopement/Leaving against Medical Advice (AMA),” dated 08/2021, showed once an individual has made a decision or statement to the effect that he desires to leave the hospital AMA, hospital personnel should attempt to determine the reasons for wanting to leave AMA. If the patient is not ready for medical discharge, hospital staff, in collaboration with the patient’s attending physician, will make reasonable attempts to explain the risks, benefits, and alternatives of such a decision. Be respectful of the individual’s right to refuse treatment. Obtain the signature on the Leaving AMA form. Document in the medical record the patient’s stated reasons for wishing to leave AMA, the actions taken, and the information given to the patient. Review of Patient #1’s medical record, dated 06/10/25, showed she was a 14-year-old female who presented to Lee’s Summit Medical Center (LSMC) ED at 3:38 AM for a mental health evaluation. Documentation showed she left prior to receiving an MSE, at 3:45 AM. A notation indicated that she was handcuffed and in custody of law enforcement. Review of LSMC security report, titled “Incident Report #4244675,” dated 06/10/25, showed: - Between the hours of 3:20 AM and 4:00 AM, Police Department B LEO’s arrived with Patient #1 in custody from a domestic dispute. - LEO’s requested to register the patient to be seen for a mental health evaluation. - Parents Patient #1, who were involved in the domestic dispute, arrived shortly after and became verbally combative with the patient. - Staff D, Security Officer (SO), removed the stepfather from the building, then requested the LEO’s to assist in de-escalation (reduce the intensity of a conflict or potentially violent situation). - LEO’s contacted their sergeant, then left the facility with the patient and did not finish the registration process. Review of Police Department B’s report titled, “Case LSPD25-04355,” dated 06/10/25, showed: - At 3:18 AM, Staff K, LEO, and his partner were dispatched to a local residence for a reported disturbance where a 14-year-old female (Patient #1) had been physical with her mother, locked herself in the bathroom and was pouring chemical cleaners everywhere. - Upon arrival at the residence they heard banging and thuds coming from inside. They were escorted to the bathroom door where Patient #1 was screaming obscenities, banged on the door, and yelled “No, get the fuck away from me!” - The LEOs received permission to unlock the bathroom door with a utensil provided by the mother. Patient #1 tried to block the door. Once inside, Patient #1 dropped to the floor, screamed “Don’t touch me!” and kicked the LEO’s multiple times while they dragged her to the hallway and placed her in handcuffs. - Staff K asked Patient #1 what happened that evening and she responded, “Bro, she put her hands on me! Do you see my fucking face?” She remained vulgar and combative as she was removed from the home. - Staff K documented that he observed redness on top of Patient #1’s forehead and on her cheeks, and what appeared to be blood on one of her ears. - Patient #1 was transported to LSMC ED for a mental health evaluation per her mother’s wishes. - Inside the ED waiting area, Patient #1 would not remain seated, resisted all restraint movements, constantly tried to free herself and cursed profusely. No one was able to have a conversation with her. - Although permission to take photos of the patient’s injuries was given by the mother, Patient #1 refused to allow the photos. She turned and kicked at the phone when attempts were made. - A SO notified Staff K that Patient #1 would not be accepted to the ED due to her past behavior during previous visits. - While driving away, a hospital representative approached them, stating that Patient #1 had not been released and needed to stay. LEO’s informed hospital staff that they were taking her to another hospital. - With permission of her parents, Patient #1 was transported to Hospital C (a nearby acute care hospital) and released into custody of hospital staff. Review of LSMC video footage, titled “LSPD06-10-25EDlobby0336hours,” showed: - Two LEO’s presented to the ED waiting area with a minor female (Patient #1) in handcuffs. A man and woman followed directly behind them (identified as her stepfather and mother). - Patient #1 was placed in a waiting room chair. One of the LEO’s had a brief conversation with the registration clerk before returning to assist with Patient #1. A SO approached and observed the situation. - The footage had no audio, but it was obvious Patient #1 was yelling. She stood up in the seat of the chair multiple times and tried to climb over the LEO’s. She kicked and flailed her arms at the LEO’s with her stepfather behaving the same towards the patient. - Patient #1’s mother and the hospital SO escorted the stepfather out of the ED while he resisted. - Patient #1’s mother returned from outside and stood at the registration desk while the LEOs unsuccessfully attempted to take photos of the patient, while she continued to kick, squirm, and hide her face. - The hospital SO returned from inside the ED, pulled one of the LEO’s to the side briefly, then they both assisted with Patient #1’s behavior. - The hospital SO and the other LEO stepped aside and conversed momentarily. The SO shook his head no while they spoke. The LEO pulled out his phone and walked outside. - The SO excited and then returned with water for Patient #1. She remained seated but continued a heated conversation with the SO and the LEO. - The other LEO returned from outside, quickly gathered Patient #1 and his partner, then left the building. - The video footage was 11 minutes long. Review of Patient #1’s Hospital C medical record, dated 06/10/25, showed: - At 4:04 AM, Patient #1 presented in handcuffs at the ED with LEOs’. - LE reported they had originally taken her to LSMC. They were in the waiting room when a hospital representative told them they were not equipped to care for her, and she did not receive an MSE. - Patient #1 reported that she was beat up by her mother and brother around 2:00 AM. Her mother had called the police for assistance. Patient #1 claimed it was the second time in a month that her mother had beat her. - Patient #1 was placed on one-to-one (1:1, continuous visual contact with close physical proximity) observation status for homicidal ideation (HI, thoughts or attempts to cause another’s death) and her combative behavior. - An MSE was performed including a physical assessment, lab work and a mental health evaluation. - Abrasions were noted on the right side of her cheek adjacent to her nose and across the bridge of her nose. - A urine drug screen was positive for marijuana, and she admitted using it along with vaping. - The Division of Family Services (DFS) was notified and reported to the ED. Affidavits (a written statement confirmed by oath, for use as evidence in court) were obtained from the patient, her mother and the LEO. - St 4:26 PM, Patient #1 was transferred to a nearby, out-of-state, inpatient psychiatric hospital by ambulance services. During an interview on 07/09/25 at 8:20 AM, Staff D, SO, stated that: - He was present when Patient #1 presented to the ED. She arrived with two LEO’s and was acting out. - Her parents were present in the waiting room. Her stepfather told the LEO’s to remove Patient #1’s handcuffs so he could “beat her ass” while he motioned taking his belt off. - Staff D removed the patient’s stepfather from the building in an attempt to help de-escalate the situation. - There were several psychiatric (relating to mental illness) patients already in the ED awaiting placement. One of the other patients had been out of control, very aggressive and caused damage to the ED. - He spoke with the ED staff to try to figure out where they could place Patient #1 so she did not set off the other psychiatric patients. - While the ED staff figured that out, he asked the LEO’s for assistance monitoring Patient #1. The LEO’s told him that they need to call their supervisor. - After the LEO’s spoke with their supervisor, they took Patient #1 and left. - He observed Staff E, PCT, approach the LEO’s as they were leaving to inform them that Patient #1 need to stay to be seen and evaluated. - Staff D indicated that he should have called the house supervisor (nurse in charge of the hospital) for assistance and made sure that Patient #1 stayed to be evaluated. During a telephone interview on 07/09/25 at 8:40 AM, Staff E, PCT, stated that: - He was working in the ED triage (process of determining the priority of a patient’s treatment based on the severity of their condition) area the night that Patient #1 was brought in to receive a mental health evaluation. - She was accompanied by LEO’s and her parents. - The father was trying to fight the “little girl,” so security removed him from the building. - There was already one aggressive psychiatric patient in the ED, along with three additional psychiatric patients awaiting placement. - He was unaware of the conversation details between Staff D, SO, and the LEO’s. - He tried to get the LEO’s to bring Patient #1 back inside or to sign paperwork before they left, but they just drove away. - There was no reason why anyone would be turned away from the ED. During a telephone interview on 07/09/25 at 8:50 AM, Staff F, ED Charge RN, stated that: - She was aware that Patient #1 had been brought to the ED by LEO’s but had no interaction with her. - The ED had four or five other psychiatric patients at that time. One of those patients was very agitated and destroyed their unit. - She notified the provider that Patient #1 had left prior to being seen and administration was made aware. - She was unaware of any conversations between Staff D, SO, and the LEO’s. During an interview on 07/09/25 at 10:15 AM, Staff G, ED Director, stated that: - Every patient should have an MSE and be seen no matter what. - She was not present the week of the incident with Patient #1 but she participated in the internal investigation. - It was determined that Patient #1 presented to the ED with her parents and LEO’s. The stepfather was instigating the situation. Staff E, PCT, checked the patient in and had a conversation with LEO’s about not leaving prior to being seen. - ED staff should have utilized the pods (cubicles) in the ED waiting area to de-escalate the situation and assess the patient. - There were already five psychiatric patients in the ED when Patient #1 presented. Each patient had a 1:1 sitter which made staffing a challenge. - One of the psychiatric patients already present had been very aggressive. He assaulted two nurses, blocked another nurse in a room and later destroyed the entire ED causing almost $30,000 worth of damage. - A house supervisor was not present. - They spoke to all staff involved and provided education through electronic assignments, interactive video discussions and emails directed to all security, ED personnel, admission staff and the house supervisor. - Administration approved security to double their current staffing, increasing from one to two SO’s on site at all times. During a telephone interview on 07/14/25 at 1:20 PM, Staff K, LEO, stated that: - Patient #1 was taken to the ED at her mother’s request. - She was very agitated and aggressive. Her parents were concerned that she may have gotten into some alcohol or drugs earlier in the night and wanted her checked out. - The patient’s parents accompanied them to the ED but were ultimately escorted out by security due to the stepfather’s disruptive behavior. - Staff D, SO, approached him and explained that Patient #1 had been assessed there multiple times in the past and would not be accepted due to her past behaviors. - He had experienced a similar issue with the same SO in the past, when an aggressive patient was taken in and they were turned away. - He believed Staff D was uncomfortable with aggressive and difficult patients. - He contacted his sergeant about the issue and was instructed to take the patient elsewhere. - He was not asked to stay and assist with monitoring the patient. - A hospital staff member came outside after he was driving away and wanted them to sign a paper, but he did not stop. Review of Patient #5’s ED medical record, dated 05/07/25, showed: - At 4:25 AM, a 40-year-old male presented to the ED with a chief complaint of a fall. - At 4:28 AM, a rapid initial assessment documentation indicated the patient had experienced a fall about six hours prior to his arrival at the ED. He stated that he was also being abused and requested resources. His Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake person) was 14, his pain was rated a ten out of ten on the pain assessment scale (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). He was slow to respond to some questions and unaware of his location or his own middle name. - At 4:29 AM, Staff O, ED Physician, documented that Patient #5 arrived with multiple hospital gowns tied around him in a shawl like fashion and with all of his personal belongings. He was presumed to be homeless. Patient #5 stated that he wanted his foot looked at and requested ointment and gauze. He initially reported to the triage nurse that he had fallen, but he denied that to Staff O. He was alert and his speech was clear. He had no facial droops and was using all extremities equally. He had paranoia (excessive suspiciousness without adequate cause), was uncooperative and mentioned that he was God at one point. His presentation seemed consistent with schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). He refused vital signs (VS, measurements of the body’s most basic functions: blood pressure [BP] normal between 90/60 and 120/80; pulse/heartbeats [HR] normal 60 to 100 per minute; respiration rate [RR] normal 12 to 20 breaths per minute[bpm]; and body temperature normal 97.8 to 99 degrees) and examination. He did allow Staff O to look at his left foot, but refused to let her examine it otherwise. There was a dried callus on the base of his left great toe, but there was no redness or open wounds. Multiple staff members attempted various techniques to get Patient #5 to allow Staff O to examine his foot more thoroughly, but he refused. He just wanted ointment, gauze, socks, and resources. Resources were provided, along with socks and food. He refused to let staff do anything further. At that point, he chose to leave. - At 4:51 AM, nursing staff documented his discharge. Staff were unable to obtain any additional information, and the patient continued to refuse all attempts at an MSE. He also refused to answer any medical history questions. - At 4:55 AM, he was discharged. His VS were BP of 97/51, HR 62, temperature 97.1, RR 18, and oxygen saturation (SpO2, measure of how much oxygen is in blood. A normal is between 95% and 100%) of 98%. His GCS was 15. - There was no AMA form or refusal of treatment form, nor documentation of Patient #5’s refusal to sign. - There was no order or documentation related to a behavioral health assessment. - He was in the ED for a total of 30 minutes. Review of the hospital’s document titled, “Incident report #4159445,” dated 05/07/25, showed that at approximately 7:44 AM, security received a phone call from a concerned staff member that stated a black male, with a hospital blanket wrapped around him, carrying multiple bags, had walked into Medical Office Building (MOB) #1. He was talking to himself and cursing loudly. He entered the public bathroom near that area. Local LEO’s responded at the same time to a 911 call from a separate party, regarding the same individual for possible trespassing. He was belligerent with people and had no business on the property. Security, LEO’s, and the house supervisor responded to the last reported location of the male individual. The male was later identified as Patient #5. Security spoke to the patient, who commented “I ain’t doing no faggot shit; this is some racist bullshit; you can fucking go now; I ain’t going to knock you the fuck out mother fucker;” and other statements. Staff L, House Supervisor, and Staff H, Security Supervisor, attempted to facilitate obtaining Patient #5’s medical record for him, per his request. Patient #5 did not want to be seen in the ED as a patient and no longer had business on hospital property, so Staff H asked Patient #5 to leave and gave him a verbal trespass warning. Patient #5 then voluntarily exited the main entrance of the hospital leaving the property without further incident. Review of Patient #5’s Emergency Medical Services (EMS, emergency personnel, such as paramedics, first responders, etc.) report, dated 05/07/25, showed they were dispatched for a fall at 2:31 PM. Upon arrival, Patient #5 was standing on a porch wrapped in a hospital blanket with multiple bags. He reported he had walked down the street and fell after he had left the hospital. He complained of his “anus and elephant nuts” hurting. He denied losing consciousness, hitting his head, or having any head, neck or back pain. He was oriented times four (O x 4, a person is oriented to person, place, time and situation) and his GCS was 15. He was able to walk from the porch to the ambulance, where he was helped into the ambulance and his VS were obtained. He was transported to LSMC ED. His condition remained unchanged throughout transport. Report was given to the receiving RN, and patient care was transferred. Review of Patient #5’s second ED medical record, dated 05/07/25, showed: - At 2:57 PM, he presented via EMS with a chief complaint of a fall, rape, anal pain and testicular pain. - At 3:01 PM, Staff J, ED Physician, documented that Patient #5 presented with a chief complaint of foot pain. He was seen overnight for the same complaint. He refused VS and was uncooperative. He was awake, alert and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time), in no acute distress, and appeared disheveled. His ankle and foot had full range of motion. There were chronic wounds to the furthest part of most of the toes on the left foot, consistent with a prior frostbite injury. There was no swelling or redness. Patient #5 refused to let Staff J assess him. He had no acute complaints and was stable for discharge at that time. Security was called to escort him out of the ED. He was referred to podiatry (medical specialty dealing with feet) as needed. - At 3:05 PM, rapid initial assessment documentation indicated he was A&O x 3, did not follow conversation, and asked Staff A, ED RN, to rebuke Satan. His chief complaint was documented as psychiatric related. Patient #5’s description of the reason for his ED visit was bilateral foot pain after falling. His VS were within normal limits, and his GCS was 15. - At 3:12 PM, Staff I, ED RN, documented that the patient was discharged accompanied by security. - There was no AMA form or refusal of treatment form and there was no documentation that the patient refused to sign a refusal of treatment form. - There was no documentation or assessment related to the EMS chief complaints of a fall, rape, anal pain or testicular pain. - There was no order or documentation of a behavioral health assessment. - He remained in the ED for a total of 15 minutes. Review of the hospital’s document titled, “Incident report #4160007,” dated 05/07/25, showed that at 3:13 PM, Staff H, Security Supervisor, responded to the ED for a manpower assist request from Staff L, House Supervisor, for Patient #5. The patient was brought to the ED by EMS and had been discharged but refused to leave. Staff H was able to gain voluntary compliance from the patient and got him to leave the property. He was last seen walking westbound off hospital property without further incident. During a telephone interview on 07/10/25 at 2:35 PM, Staff N, Former ED RN, stated that she was the triage nurse in the early morning of 05/07/25. She had roomed the patient, but he refused most care, or only let staff do certain things, such as applying his wristband, but would refuse other things, such as VS. Patient #5 “seemed off” but capable of making decisions. He was slow to respond to questions, but did answer all their questions. He did not make any odd comments to her. If he had, she would have documented that. Normally, they tried to bring patients back, the provider would do an MSE, and then patients were discharged. If patients refused care, the provider would evaluate the patient and determine if they were safe and explain the risks/benefits of refusing care. During a telephone interview on 07/10/25 at 2:15 PM, Staff M, Former ED RN, stated that she checked in Patient #5 during his first ED visit. He had a chief complaint of a foot wound. He was not compliant at all. She tried to get a BP on him, but he had six other BP cuffs on. When she asked if she could remove the extra BP cuffs, he refused. The provider came in to assess the patient and he was wearing three pair of hospital socks. He did allow them to remove the socks, but refused to let the provider touch his foot. When the provider asked him what he wanted, he just said he wanted some ointment. The provider wanted to do lab work, but the patient refused. The patient started getting frustrated and raised his voice, so security was called. The provider told him that she needed to examine his foot, otherwise they would not be able to do anything for him. The patient asked for some food, and it was provided. The patient refused to sign a refusal of care form. Security was able to guide the patient outside. Staff M thought he “was a little odd.” He knew his name, the situation and time. It “potentially” could have been “psychosis (mental illness characterized by defective or lost contact with reality), but they were unable to know for sure because he refused to let them do anything.” During a telephone interview on 07/10/25 at 3:15 PM, Staff O, ED Physician, stated that Patient #5 came in wearing a lot of things around himself. He refused to let staff take them off. She was able to palpate (using one’s hands to assess the body) his foot, and it felt like he had a hard callus. There was no redness or pus. They would not have been able to do anything for him and she would have sent him to podiatry. He got agitated very quickly, it one of those encounters where “you don’t want to push the patient too far.” He requested ointment for his foot, then he wanted to leave, and he left. Staff O did not recall him making any other statements except for the one time he said he was God. If a patient was refusing care, if she had the chance, she would have the patient sign a refusal of care form, but “patients with mental illness did not always sign that form.” During a telephone interview on 07/10/25 at 12:35, Staff L, House Supervisor, stated that on the morning of 05/07/25, she had gotten a call from security, who said local LEO’s had been called for a disturbance. A bystander had called LEO’s because Patient #5 was in a restroom yelling at people. She approached Patient #5; he had several belongings with him, but he was calm and cooperative in his interactions with her. He told her he wanted to wash his face. She asked him if he needed medical attention, which he denied. He denied any suicidal (SI, thoughts of causing one’s own death) or homicidal ideation (HI, thoughts or attempts to cause another’s death) and requested his medical record. She walked with him to medical records, with security and LEO’s behind them. He did not have any identification with him and was unable to get his medical record, so he told her never mind. He then walked out the front door of the hospital. She did not remember anything about his second encounter, later that afternoon, other than staff had called her because Patient #5 refused to leave the ED. During a telephone interview on 07/10/25 at 9:25 AM, Staff H, Security Supervisor, stated that on the morning of 05/07/25, he received a call from staff that there was a patient in the public bathroom in the MOB. He made contact with Patient #5, who had been seen in the ED and discharged previously that morning. Patient #5 was a larger man, about six feet five inches tall. He was very belligerent and loud. He had multiple duffle bags with statues sticking out from them and was “very suspicious looking.” He made multiple statements, such as “I’m not doing any of this faggot shit.” The patient wanted paperwork from medical records, and did not want to be seen in the ED. He was told he could return to the ED for emergency medical care if needed, but otherwise he would be trespassing on the property. Later that afternoon, EMS brought Patient #5 to the ED. He was seen and discharged from the ED but refused to leave. There “was nothing more medically to be done for him.” Staff H told Patient #5 he had to leave, and he left. Later that afternoon, he was seen loitering in the neighborhood. During both encounters with security, Patient #5 was belligerent, difficult to speak to and “was a bear to deal with.” He made “very outlandish comments” during both encounters. He was verbally loud, and he would scream “you need to renounce the devil.” During a telephone interview on 07/11/25 at 8:57 AM, Staff Q, Fire Department D Paramedic, stated that upon arrival on scene, Patient #5 was standing on the front porch of a house. The homeowner had called EMS for him. Patient #5 was wearing a hospital blanket and had multiple bags. The patient reported he had walked down the street and fell. There were no visual signs of trauma. Patient #5 requested to go back to the hospital. He was “not the most respectful person.” He said his “anus and elephant nuts” hurt and that was why he wanted to be seen in the ED. He didn’t really answer any questions and was not very cooperative. When Staff Q asked him questions, Patient #5 would raise his voice and act like Staff Q should have known everything already without asking. He was talking about God and asked if Staff Q believed. He answered all the orientation questions correctly. His answers made sense, but he got mad or ignored Staff Q when Staff Q asked him to elaborate. He did allow his VS to be taken, and he was able to walk to the ambulance with his belongings. They were approximately two minutes away from the hospital. When they arrived at the ED, staff “didn’t seem happy” he was back. ED staff didn’t say anything specific, just that they knew who he was and said the last visit didn’t end well. It sounded like they had told him it was time to go during his last visit. He gave report, and the patient was already raising his voice at staff. It “didn’t sound like it was going very well.” During a telephone interview on 07/10/25 at 9:35 AM, Staff I, ED RN, stated that it was hard to get information from Patient #5. His “thoughts were all over the place.” Staff J, ED Physician, tried to assess the patient, but Patient #5 did not want to be touched. He “didn’t let us do much.” He chose which questions he wanted to answer. He was alert, not verbally combative, just a little agitated. He “seemed with it,” he “knew what he did not want done.” He kept mentioning his foot over and over. He was alert and oriented times three, he did get one orientation question wrong. He got agitated when staff asked any other questions. Staff J attempted to assess his foot. Staff I did not recall doing anything else for Patient #5. Staff J thought he was stable for discharge, and the patient was discharged. Later on, security was called because Patient #5 was “chilling in the waiting room.” During a telephone interview on 07/10/25 at 10:44 AM, Staff A, ED RN, stated that EMS brought in Patient #5. Initially, he would not let anyone do anything. He refused to let the triage nurse get VS but allowed Staff A to get VS. He had a lot of bugs and told Staff A “multiple times” to “rebuke Satan.” She did not believe he made any other statements; if he had, she would have documented them. The provider came over to assess him. Staff A did not note any wounds, and the patient was able to transfer himself from the EMS stretcher to the bed. He was alert, and more cooperative for her than for other staff. He answered to his name, knew he was in the hospital, but he wasn’t cooperative when staff asked him about his injury. He stated that he had come in for his feet. During a telephone interview on 07/10/25 at 9:45 AM, Staff J, ED Physician, stated that Patient #5 came in via EMS and he did not have a chief complaint. He denied the reported fall, the reported rape, anal pain, and testicular pain. The only thing he wanted was for staff to look at his foot. He was “a tough patient.” He was alert and oriented times three. He had a labile affect (abnormal variability in mood with repeated, rapid, and abrupt shifts in emotional expression), but had no SI or HI. He was able to listen to Patient #5’s heart and lungs, and looked at the patient’s foot. He had a chronic wound on his foot and was wearing a hospital blanket. Staff J offered blood work, but the patient refused. Nursing staff redressed the patient’s foot wound, and he was discharged. The patient refused to leave, but didn’t say why he didn’t want to leave; he “didn’t delve into that,” and the patient was escorted off the property. Staff J did not recall Patient #5 making any delusional statements, such as rebuking Satan. During a telephone interview on 07/10/25 at 3:38 PM, Staff P, ED Medical Director, stated that he expected the provider to make sure patients had the capacity to make decisions. If the provider thought that a patient was unsafe to self, then he expected them to go down the psychiatric pathway. In his experience, people said off the wall stuff. The key was making sure patients had decision making capacity to be able to refuse testing or treatments. There was no formal policy for signing paperwork for refusal of care. He would have explained the risks and benefits of staying, discussed the second-best plan with the patient, and then had them sign an AMA form. 51509”