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Based on review of facility policy, medical record review, review of facility video footage, review of local police body camera footage, hospital security report, and interviews, the facility failed to provide a complete and thorough medical screening examination and stabilizing treatment for one (1) patient, (Patient #26) who presented with abdominal pain and constipation, of 32 medical records reviewed.

The findings included:

Patient #26 presented to the Emergency Department (ED) at Facility A on 2/4/2023 at 11:57 PM with complaints of lower abdominal pain and constipation. She had been seen and evaluated at Facility B on 2/4/2023 at 8:00 PM with the same complaints where she had a medical screening examination initiated and was discharged. Patient #26 obtained a cab and presented to the ED at Facility A. She had acute behaviors while in the ED which resulted in the patient being placed in restraints. A medical screening examination and diagnostic testing was initiated. While in the ED the patient had a bowel movement and remained uncooperative with the ED staff. The patient was discharged and placed in the ED lobby for a ride home. The patient refused to give phone numbers or an address for discharge. During this time, the patient remained uncooperative and was attempting to smoke in the lobby where security officers encountered the patient. The patient was taken to the ED parking garage to smoke and remained uncooperative. The patient was issued a no-trespassing citation and requested for the local police to be called. When the local police arrived the patient remained in the ED parking garage, she was resistant with the officers and she was arrested by the local police department. While in the parking garage the contracted security officers and the local police were in attendance with the patient. The local police department had requested a transport vehicle to transport the patient to the jail. During this time, the patient was taken to the street where attempts were made to get the patient into the transport vehicle. There were three hospital contracted security officers and three local police officers in attendance with the patient. During this time, the patient complained of difficulty in breathing and was requesting help. The patient was not evaluated by a medical professional during this time. The patient was placed in a local police cruiser and transported to the local jail. During the transport the patient become unresponsive. Emergency Medical Services (EMS) was called and they found the patient in cardiac arrest. She was resuscitated and transported back to Facility A. The patient was admitted to the Intensive Care Unit and expired on 2/6/2023.

Refer to A-2406 and A-2407

Based on review of facility policy, medical record review, review of facility video footage, review of local police body camera footage, hospital security report, and interviews, the facility failed to provide a complete and thorough medical screening examination for 1 patient (#26) who presented with abdominal pain and constipation of 32 medical records reviewed.

The findings included:

Review of facility policy, Emergency Medical Treatment & Active Labor Act (EMTALA), last reviewed 10/21/2022, showed "...the purpose of this policy is to establish guidelines for EMTALA compliance and outline processes designed to provide in a consistent and non-discriminatory manner a medical examination and required treatment to those patients who have come to a [named facility] designated emergency department...Comes to the Emergency Department- with respect to an individual who is not a patient has presented at a hospital's dedicated emergency department or on hospital property and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition...Emergency Medical Condition [EMC] a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain, psychiatric disturbances and/or symptoms of substance abuse] such that the absence of immediate medical attention could be reasonably be expected to result in [a] placing the health of the individual...in serious jeopardy [b] serious impairment to bodily function [c] serious dysfunction of any bodily organ or part...Hospital Property - the entire main campus, including the parking lot, sidewalk, and driveway and other physical areas immediately adjacent to the Hospital's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings...Medical Screening Examination [MSE] is defined as the process required to reach, with a reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition [EMC] or not. An MSE is an ongoing process that begins with triage..."

Medical record review of an Emergency Department (ED) record from Facility B dated 2/4/2023 at 8:00 PM showed the patient presented to the ED with complaints of lower abdominal pain. A medical screening examination was initiated where the following diagnostic testing was completed: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Blood Alcohol, Lipase, and a Computed Tomography (CT) of the abdomen was performed which showed a large volume of colonic stool compatible with constipation. During the patient's admission she was uncooperative and argumentative with the staff regarding her care. She had a bowel movement while in the ED. She was medically cleared for discharge and had refused to leave. She had requested to leave and to be transported to Facility A.

Medical record review of an ED Nurses Note from Facility A dated 2/5/2023 at 1:30 AM showed "...called from the red desk by our clinical registration tech [technician] who came to the lobby around by the bathroom to evaluate a patient. Security was present, our clinical registration tech, another tech, who witnessed the patient trying to throw herself out of her wheelchair into the floor. Patient was laying in the floor and was lowered down to the ground by our tech into the floor. Pt. [patient] did not fall to the ground and a witnessed lowering of the patient was done. I asked the patient why she wanted to lay into the floor, and she stated, 'I did not want to sit in a wheelchair, I want to lay in the cold floor'. I asked her to get back into the chair and we would get a stretcher for her. She declined. We tried to help her into the chair but she was resisting. We asked for the doctor [Physician #2] to come to the lobby to see [if] the patient was a danger to herself. Doctor [Physician #2] gave me a verbal order for soft limb restraints. Pt. was placed into a stretcher safely, was taken to be triaged and immediately taken into room #4... "

Medical record review of an ED Triage Record dated 2/5/2023 at 1:31 AM showed the patient presented with complaints of constipation for 2 weeks, and abdominal pain. Her vital signs were as follows: Pulse 110, Blood Pressure 93/72, Respirations 20, pulse oximeter 92% on room air and temperature 98.1 degrees Fahrenheit. Her pain score showed the patient rated her pain as 8 out 10 (0 being no pain and 10 the worst pain possible). She was triaged with an Emergency Severity Index (ESI) of a 3 indicating urgent but not emergent needs.

Medical record review of an ED Physicians Record dated 2/5/2023 at 1:36 AM showed the patient presented with complaints of constipation for 2 weeks and abdominal pain. The patient provided the history herself and was reported as a "good historian". She arrived at the ED via private vehicle where her pain started prior to arrival. She had been to Facility B on 2/4/2023 with the same pain and reported no relief. The patient had obtained a taxi to the facility related to "she likes it better". The patient stated she had not had a bowel movement in two weeks and described her pain as "poopy". She denied fever or chills. The physical examination showed the patient was awake, alert, cooperative and conversant. Her pupils were equal and reactive to light. Her lungs were clear bilaterally with no labored breathing. She had left sided weakness related to a previous stroke. Her mood and affect were appropriate. Diagnostic testing was ordered and completed to include the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and an Ethanol (alcohol level).

Medical record review of the restraint flowsheet dated 2/5/2023 at 2:00 AM, showed non-violent bilateral soft wrist restraints were applied to the upper extremities. At 2:30 AM the restraints were checked. The restraints were discontinued at 3:00 AM. The patient was alert and oriented and continued to scream belligerently at staff.

Medical record review of the Medication Administration Record dated 2/5/2023 showed Ativan (medication used for anxiety) 1 milligram (mg) was ordered at 3:38 AM and administered at 4:13 AM. Docusate (medication used for constipation) was ordered at 4:10 AM but the medication was not administered related to the patient had a bowel movement around 5:30 AM-6:00 AM.

Medical record review of the electronic orders dated 2/5/2023 at 3:58 AM showed a CT of the Abdomen and Pelvis without contrast was ordered and canceled at 4:11 AM.

Medical record review of an ED Physicians Progress Note dated 2/5/2023 at 4:25 AM showed "...patient had a computed tomography [CT scan] at [Facility B] yesterday at 8:00 PM. The CT showed a large volume colonic stool compatible with constipation with no evidence of obstruction...[4:30 AM] discussed with patient results, diagnosis, treatment plan, and need for follow up with Primary Care Physician [PCP]. Return to ED warnings were given. All questions answered...plan is agreed with and understood. Pt. is stable and ready for discharge. Patient initially agitated attempted to throw herself on the floor witnessed by security and staff. Patient was stopped prior to this. Neurologic deficits chronic..." The patient's White Blood Count was 14.7 (normal 4.0-11.0). Her diagnoses included Agitation and Constipation.

Medical record review of an ED Nurses Note dated 2/5/2023 at 6:00 AM showed "...pt. had defecated in the bed was again belligerent. Pt. had rubbed feces on the side rails of the bed, on her phone, and the equipment in the room. Pt. alert and oriented at this time. Pt. taken to the shower decontamination room by a nurse, paramedic, and two techs to assist in cleaning her off. Pt. placed in paper scrubs after shower, with multiple warm blankets. Pt. placed back in her room on the monitor... "

Medical record review of an ED Note dated 2/5/2023 at 6:00 AM showed "...the pt. had defecated herself in the bed. The patient, the floors were covered in feces. The patient was alert and oriented at this time. The patient was transported by myself [Paramedic #1], [Registered Nurse #2], and [ED Tech #1] to the decontamination shower to be cleaned. The patient was scrubbed with warm water and soap. The patient was then placed in paper scrubs and provided with warm blankets and socks. The patient was taken back to her room to gather her belongings and be discharged. The patient become violent with [ED Tech #1 and ED Tech #2]. They were attempting to assist her into a wheelchair for discharge. The patient gripped and scratched [ED Tech #1] arms and drew blood. Security was called. The patient was placed into the wheelchair and escorted by security after declining a 'Lyft ride'... "

Medical record review of an ED Note dated 2/5/2023 at 6:55 AM showed "...provider placed patient up for discharge. Pt. alert and oriented and vital signs stable [vss]. Pt. offered 'Lyft ride' to assist. Pt. declined this offer. Pt. placed in the lobby upon discharge [dc] by security with warm blankets... "

Medical record review of the discharge instructions dated 2/5/2023 at 6:55 AM showed the patient was given instructions related to constipation and follow-up with her Primary Care Physician in 2-4 days. The patient signed the discharge instructions.

Review of a Security Report dated 2/5/2023 showed security was called to assist with a discharged combative patient (Patient #26) who was refusing to leave the ED. The (named local Police Department) arrested the patient. On 2/5/2023 at 6:57 AM, the ED Registered Nurse (RN) had requested a standby/escort the patient who was refusing to leave and had become combative. Four (4) security officers had responded for standby to the patient's room. The security officer approached the patient and informed the patient she had to vacate the room, as she was discharged. The patient "...had thrown herself on the floor of ED 4 when medical staff attempted to assist her out. [Patient #26] would become combative each time medical staff would approach her to place in a wheelchair by trying to scratch and grab them. [Named security officers] deescalated [Patient #26] so medical staff could place in a wheelchair, this was conducted without further incident. [Security Officers #3 and #2] transported [Patient #26] by medical staff to the Emergency Department Waiting area at 7:05 hours [7:05 AM]. [Patient #26] was clearly told she can call for transportation and wait in the ED waiting area for her ride. Discharged [Patient #26] continued to cause a disturbance in the ED waiting area by yelling at registration staff, harassing other patients waiting, trying to light a cigarette, and wanting to go outside to smoke. [Patient #26] was warned if she didn't stop being a disturbance the [named local police department] would be notified. [Patient #26] requested that security call [named local police department] for her and requested she be brought outside to smoke and wait for [local police department]. At 7:19 AM, [named local police department] was dispatched. [named local police department] arrived on location at 8:18 AM. A criminal trespass was issued to [Patient #26] and signed. [Named local police Sergeant] and [named local police] arrest [Patient #26]. [Named local police officer] transports [Patient #26] from property. All officers clear without further incident at 9:10 hrs [9:10 AM]. An addendum (not dated or timed) and labeled as prior history showed:
" On 2/4/2023 at 2023 [Patient #26] was admitted and discharged at [Facility B] and placed in a taxicab and traveled from [Facility B] to [Facility A].
" 2/5/2023 the patient registered to be seen at [Facility A].
" 2/5/2023 2:07 AM standby requested for disruptive patient in the ED.
" 2/5/2023 at 6:57 AM [Patient #26] was discharged from [Facility A] and was transported by [named local police].
" 2/5/2023 at 9:50 AM [Patient #26] was brought back to [Facility A] by [named local police department]..."

Review of the ED video footage dated 2/5/2023 showed the following:
ED Lobby camera
7:02 AM (26 seconds): the patient was wheeled to the ED Lobby by the ED staff member with a security officer in attendance.
7:03 AM: the patient had her cell phone and was talking on the phone. She had scrub shirt and pants on and was moving all 4 extremities.
7:10 AM (58 seconds): the patient had her cell phone in her hand.
7:13 AM (55 seconds): the patient got a cigarette out of her purse and placed it in her mouth (the cigarette was not lit). She had a cigarette lighter in her other hand.
7:14 AM (43 seconds): security officer went to the patient and spoke with the patient.
7:16 AM (26 seconds): security officer went to the patient and spoke with the patient for the second time.
7:18 AM (39 seconds): the patient remained in the ED Lobby and was restless moving about in the wheelchair. She still had a cigarette lighter in her right hand. The security officer was with the patient.
7:25 AM (52 seconds): security officer was present with the patient and the patient was looking at her phone.
7:29 AM (03 seconds): 2 security officers placed the patient's jacket on her and provided the patient with 2 blankets.

ED Parking Lot garage camera
7:31 AM: the patient was taken by wheelchair to the ED Parking Lot garage.
7:57 AM (28 seconds): the local police department arrived in the garage. The patient was sitting in the wheelchair and moving all extremities.
8:02 AM (51 seconds): the local police officer went to the patient and was speaking with the patient. There were two facility contracted security officers and 3 additional local police cruisers arrived.

Review of a local police department body camera video dated 2/5/2023 showed the following:
7:57 AM: the local police department arrived in the facility's parking garage which was adjacent to the ED entrance. There was a discussion between the police department officers and the patient related to the patient had been discharged and the "patient needed to leave". The patient told the officer the staff had beat her up and dragged her out of her wheelchair. The patient stated she had a stroke, her ankle was fractured, and the facility had kicked her out.
8:00 AM (16 seconds): the local police and the contracted security company discussed the patient and the patient had requested the local police department to be called. The patient was not cooperative with providing telephone numbers or an address.
8:04 AM (08 seconds): the local police officer informed the patient she was going to jail and requested for a transport wagon to transport the patient.
8:34 AM (39 seconds): the transport wagon arrived, and the local police officers and facility's contracted security officers were present.
8:36 AM (20 seconds): the local police officer informed the patient they were going to assist the patient into the transport wagon. The local police and the hospital contracted security officers were assisting the patient.
8:38 AM (20 seconds): The local police and contracted security officers attempted to get the patient in the transport wagon. The patient stated, "Oh my God, I can't breathe". The video showed the patient had audible wheezing.
8:39 AM: the patient was asking for her inhaler. The officers found the top of the patient's inhaler in her purse but were unable to find the inhaler part.
8:43 AM (43 seconds): the patient was yelling "please help me, I can't breathe".
8:44 AM (37 seconds): the contracted security officer informed the police officers the patient had been discharged from the facility. The police officer stated, "this is an act". The patient stated she was going to pass out.
8:45 AM (07 seconds): the patient asked, "take me into the hospital' and the hospital contracted security officer told the patient she was not going back into the ED.
8:47 AM (55 seconds): the patient stated, "I'm going to fall". The contracted security officer yelled at the patient "then lean back". All 3 of the contracted security officers and local police officers were present.
8:48 AM (29 seconds): officer yelled at the patient "don't you dare [expletive] throw yourself on the ground". (there was a police department officer and contracted security officer present but it was unclear which officer made this statement).
8:50 AM (27 seconds): the patient asked for a stretcher and stated she could not breathe.
8:51 AM (30 seconds): the contracted security officer and the local police were with the patient. A statement was made "if we can't get you in there [the transport wagon], what the [expletive] do you think we can get you on a stretcher". (it was not clear which officer made this statement).
8:52 AM (52 seconds): the patient's inhaler was found in the patient's luggage bag and was given to the patient. The police officer stated, "you did not even get in your mouth".
8:54 AM (22 seconds): the local police officer informed the patient "medical professionals have discharged you and said you are all right".
8:54 PM (35 seconds): the contracted security officer stated to the patient "we set you up ten [expletive] times and you threw yourself in the floor, just like you did all night". The patient was laying on the pavement. Contracted security officers and local police officers were standing around the patient. The patient was yelling "sit me up, please set me up, OH my God".
8:55 AM (27 seconds): there was a male who walked into the ED garage and the patient yelled at the male and stated, "doctor, doctor".
8:56 AM (38 seconds): the patient stated, "I am going to have a stroke" 2 contracted security officers were standing bedside the patient along with 2 police officers.
8:57 AM (08 seconds): the patient stated, "get me a stretcher".
8:57 (30 seconds): the patient stated, "I am sick, I am gonna die".
8:59 AM (15 seconds): the patient was asking for her inhaler. The contracted security officer stated to the patient "when you settle down and use your inhaler the right way we will help you sit up".
8:59 (21 second): the patient was asking for help. The contracted security officer stated, "we have tried to sit you sit you up, but you keep laying yourself back down".
9:00 AM (15 seconds): the patient was yelling "please help me up, you're trying to kill me". The patient was laying on the ground. There were 2 contracted security officers and 2 police officers with the patient.
9:01 AM (01 seconds): the patient was lifted by 2 contracted security officers and the local police to the police cruiser. The patient was laying on her back and was lifted into the seat of the police cruiser.

Review of the local police body camera video footage showed the camera changed from the officer body camera to the camera in the back of the police cruiser. These times did not match the officer body cam and were two different times. This review will show the times of the actual video footage (located at the bottom of the video) for the 1 hour and 16 minutes video release.
57:26: the patient was located in the back of the police cruiser. The patient stated "help me, help me up. I can't breathe. Sit me up". Her breathing was labored.
58:57: The police officer attempted to sit the patient up. The police officer stated, "you pulled yourself down to that position".
1:01 (27 seconds): the patient stated, "take me to the hospital, the one across from the Sonic". The patient's breathing was labored.
1:01 (53 seconds): the transport to the local jail was started.
1:05 (23 seconds): the patient stated, "help me, I can't breathe". The officer stated, "we have tried to help you multiple times". The patient had labored respirations and slurred speech.
1:06 (23 seconds): The patient was not talking or yelling.
1:08 (47 seconds): The patient was not talking or yelling. The officer stated, "wake up".
1:10 (56 seconds): the police cruiser was stopped on the road.
1:12 (57 seconds): the officer opened the door of the police cruiser and stated, "are you up...she is not responding". The patient was not talking or making any noise.
1:13 (25 seconds): the police officer radioed dispatch "she is not responding, send me a 47 [ambulance], female patient unconscious".
1:14 (05 seconds): the officer stated, "sit up". The officer was holding the patient up in the back of the police cruiser.
1:14 (57 seconds): the police officer pulled the patient's hair and stated, "I don't know if she is faking, she's not answering".
1:16 (07 seconds): the video stopped. The screen showed EMT's [emergency medical technicians] arrived on scene shortly after Patient #26 was found unresponsive and transported her back to Facility A, where she expired 2/6/2023.

Medical record review showed on 2/5/2023 at 10:00 AM the patient was readmitted to Facility A after suffering a cardiac arrest. She was successfully resuscitated and admitted to the Intensive Care Unit (ICU). The patient expired on 2/6/2023 at 9:57 PM.

Medical record review of an ED Nurses Note dated 2/5/2023 at 10:00 AM showed the patient arrived by Emergency Medical Services (EMS) after being found unresponsive by the police department. EMS found the patient with no pulse where Cardiopulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS) were initiated. She was given 4 rounds of Epinephrine (medication to stimulate the heart) and a pulse was obtained. The patient was intubated on arrival at the ED.

Medical record review of an ED Physicians Progress Noted dated 2/5/2023 at 10:21 AM showed "...patient arrived post cardiac arrest. Reportedly was being transported by law enforcement when she became unresponsive. Patient was seen earlier and discharged. Patient became combative, argumentative. Patient then reportedly told security call law enforcement which they did. Patient refused to cooperate with transport. Afterwards she became unresponsive in police cruiser at which time EMS was called. Paramedics noted patient to be in cardiac arrest began resuscitative efforts. Return of pulse and blood pressure enroute... " The patient was intubated on arrival at the ED. Her 12 lead EKG showed a sinus rhythm (normal heart rhythm) with a rate of 87 and T-Wave inversions (representing ischemia). The patient's case was discussed with the Hospitalist for admission to the ICU..."

Medical record review of an admission History and Physical (H&P) dated 2/5/2023 at 2:27 PM showed the patient had been evaluated at Facility B on 2/4/2023 with abdominal pain and was discharged on 2/4/2023. A CT of the abdomen performed at Facility B showed constipation. She presented to Facility A on 2/4/2023 at 11:57 PM with abdominal pain. The patient stated she had not had a bowel movement in 2 weeks. The CT scan from Facility B was reviewed and showed colonic distention with constipation. She was discharged from the ED. The patient had been combative and argumentative and had refused to cooperate with transportation. Security and the local police department were involved. The patient was placed in a police cruiser and was being transported to the jail. During the transport, the patient became unresponsive, and EMS was requested. Paramedics found the patient in cardiac arrest where resuscitation efforts were initiated. The patient suffered additional cardiac arrest while in the ED where she was successfully resuscitated. The patient was admitted to the Intensive Care Unit (ICU). Her diagnoses included Cardiac Arrest with an unclear etiology, Respiratory Failure, Shock (likely cardiogenic in nature), Alerted Mental Status, Metabolic Acidosis, and advanced Chronic Obstructive Pulmonary Disease (COPD).

Medical record review of a Record of Death dated 2/7/2023 at 6:56 PM (1 day after the patient expired) showed the patient's condition continued to deteriorate after admission to the ICU. A CT of the head was completed in the ED which showed suggestions of an anoxic injury to the brain and no evidence of hemorrhage or other acute processes. A Magnetic Resonance Imaging (MRI) was performed while in the ICU which showed "...marked mass effect originating in the left cerebral hemisphere [part of the brain] with what appeared to be edematous cortex [outer layer of the brain], though no definitive extensions of uncertain etiology. There was also hemorrhage that appeared to originate from the left caudate [part of the brain function] with a degree of intraventricular extension of uncertain etiology... " The brain injury was determined as a nonsurvivable brain injury. Discussions with the patient's family were completed and it was agreed to stop resuscitation efforts. The patient expired on 2/6/2023 at 9:57 PM.

During a telephone interview on 3/1/2023 at 3:30 PM, Registered Nurse (RN) #1 stated the patient was alert and oriented to time and place. The patient had presented to the ED with complaints of abdominal pain and constipation. She had been evaluated at another facility the same night with the same complaints. She had previous history of a stroke with residual weakness to her left side. In the ED lobby, she was yelling and had attempted to lay down in the floor in the lobby. She had refused to get back into the wheelchair and when the staff tried to assist her from the floor back into the wheelchair, the patient become combative and was felt to be a harm to herself and the ED staff. The ED Physician evaluated the patient and ordered nonviolent wrist restraints. She was placed in restraints on 2/5/2023 at 2:00 AM and the restraints were removed at 3:00 AM after the patient calmed down and was cooperative with her care. The ED Physician evaluated the patient and ordered diagnostic testing related to the patient's complaints of abdominal pain. The patient did not complain of any pain to her ankles. After the diagnostic testing was completed, the patient was evaluated by the ED physician and deemed stable for discharge. While in the ED the patient had a bowel movement. The staff assisted the patient with incontinence care and placed the patient in clean scrubs. The patient had been resistant to leaving the ED and stated she did not have a ride. The staff attempted to get an address for discharge, but the patient would not give them an address or any contact information. The patient was offered a 'lyft ride', a cab voucher, and possible EMS transport but the patient refused to give an address and declined the staff's offer. The patient did not complain of any stroke like symptoms and was not in acute distress upon discharge. She did not have any shortness of breath and her oxygen saturations were stable. The patient was discharged to the ED Lobby and was waiting on transportation.

During a telephone interview on 3/1/2023 at 3:50 PM, RN #2 stated the patient was awake and alert. She did have some deficits to her left arm from a previous stroke but did not show any acute neurological deficits. The patient presented with complaints of abdominal pain and constipation. She had assisted other ED staff members with incontinence care after the patient had a bowel movement.

During a telephone interview on 3/1/2023 at 4:30 PM, Paramedic #1 stated the patient was initially combative, belligerent, and aggressive with the staff including scratching and trying to hit the staff. The patient had to be placed in nonviolent soft wrist restraints. The ED Physician had evaluated the patient and ordered diagnostic testing. The records from Facility B were requested which showed the patient had a CT of the abdomen which showed constipation. While in the ED the patient had a bowel movement in the bed. The ED Physician discussed the diagnostic findings with the patient and the plan of care was discussed. The patient did not want to leave the ED. She had refused to give the staff phone numbers or an address where she could be transported to.

During a telephone interview on 3/1/2023 at 4:50 PM, Physician #1 stated he evaluated the patient on 2/5/2023 after the patient had been placed in the restraints. The evening ED physician evaluated the patient in the ED lobby and ordered the restraints. The patient had been combative and uncooperative with the staff and required the restraints. After the patient calmed down, the restraints were discontinued. The patient presented with abdominal pain and constipation. She had been on a plane where she came from Rhode Island. On arrival at the airport, the patient was taken to Facility B by ambulance on 2/4/2023 where diagnostic testing was completed. A CT of the abdomen was completed which showed constipation. The patient had left Facility B and came to Facility A. Diagnostic testing was completed to include a CBC, CMP, and Blood Alcohol level which showed no acute findings. A CT scan of the abdomen was ordered but after review of the CT scan from Facility B was received, the order was canceled. While in the ED the patient had a bowel movement with resolution of her symptoms. The patient was discharged and was in stable condition. The patient had previous neurological deficits to her left side related to a previous stroke. She did not have any neurological symptoms during the admission on 2/4/2023 and did not have complaints of any stroke like symptoms. She did not complain of any pain to her lower extremities and had no signs of any injuries to the lower extremities. The patient stated she was going to a boyfriend's house to stay with him but would not give any phone numbers or an address.

During a telephone interview on 3/7/2023 at 1:30 PM, contracted Security Officer #2 stated around 7:00 AM (on 2/5/2023) security had received a call from the ED related to a patient who was refusing to leave the ED after she was discharged. The officer responded to the ED and stood outside the room. The patient was resistant getting off the stretcher and into the wheelchair. He assisted the ED Tech escorting the patient to the ED Lobby. The patient was disruptive, belligerent with the staff and other patients. He stated "...we were informed the patient was medical seeking and she would not give any information who to call or an address. I was told this was normal behaviors for her and she was 'dead weight' when trying to get the patient out of the wheelchair...after the fact, I regret my course with her. I don't know if she was or was not medically stable. I thought she was just acting out...I do not have any medical background. If I had thought she was in distress I would have notified the ED staff, but she was in [local police custody] and had been discharged from our ED..."

During an interview on 3/21/2023 at 3:05 PM, with the Assistant Chief of Operations for security showed the contracted security officers completed EMTALA training through the contracted company and through the facility during orientation. The security officers were given education related to any patient seeking medical treatment would be evaluated by a medical provider. Patients who were discharged into custody of the local police must have a medical screening and be discharged prior to being placed in the custody of the police. The security officers sign an EMTALA Tip sheet specifically related to EMTALA obligations. The officers sign the tip sheet as confirmation they received the training. The security officers were given a 'quick card' for reference which they carry in their pocket. He stated "...the patient was discharged, and we cannot interfere with any patient in the custody of law enforcement. We are not law enforcement officers, and we function under a security officer role..."

During a telephone interview on 3/21/2023 at 5:18 PM, contracted Security Officer #2 confirmed he had completed EMTALA training through the contracted security company and the facility. The security officers were told the patient had behavioral health issues and she had been acting out during her admission. He had been informed the patient was discharged and was waiting on a ride. He stated "...my training included any patient who presented and request a medical screening would be provided a medical screening regardless of the ability to pay. The patient continued with behaviors and was arrested by the local police..."

During a telephone interview on 3/22/2023 at 10:01 AM, the Vice President (VP) of Operations and Chief Nursing Officer (CNO) were present. Interview confirmed the contracted security officers received EMTALA training

Based on review of facility policy, medical record review, review of facility video footage, review of local police body camera footage, hospital security report, and interviews, the facility failed to provide stabilizing treatment for 1 patient (#26) who presented with abdominal pain and constipation of 32 medical records reviewed.

The findings included:

Review of facility policy, Emergency Medical Treatment & Active Labor Act (EMTALA), last reviewed 10/21/2022, showed "...the purpose of this policy is to establish guidelines for EMTALA compliance and outline processes designed to provide in a consistent and non-discriminatory manner a medical examination and required treatment to those patients who have come to a [named facility] designated emergency department...stabilizing treatment-if an individual has an emergency condition, further medical examination and treatment as within the hospitals capacity and capability will be administered as required to stabilize the medical condition. The hospital must continue to provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility..."

Medical record review of an ED Nurses Note from Facility A dated 2/5/2023 at 1:30 AM showed "...called from the red desk by our clinical registration tech [technician] who came to the lobby around by the bathroom to evaluate a patient. Security was present, our clinical registration tech, another tech, who witnessed the patient trying to throw herself out of her wheelchair into the floor. Patient was laying in the floor and was lowered down to the ground by our tech into the floor. Pt. [patient] did not fall to the ground and a witnessed lowering of the patient was done. I asked the patient why she wanted to lay into the floor, and she stated, 'I did not want to sit in a wheelchair, I want to lay in the cold floor'. I asked her to get back into the chair and we would get a stretcher for her. She declined. We tried to help her into the chair but she was resisting. We asked for the doctor [Physician #2] to come to the lobby to see [if] the patient was a danger to herself. Doctor [Physician #2] gave me a verbal order for soft limb restraints. Pt. was placed into a stretcher safely, was taken to be triaged and immediately taken into room #4... "

Medical record review of an ED Triage Record dated 2/5/2023 at 1:31 AM showed the patient presented with complaints of constipation for 2 weeks, and abdominal pain. Her vital signs were as follows: Pulse 110, Blood Pressure 93/72, Respirations 20, pulse oximeter 92% on room air and temperature 98.1 degrees Fahrenheit. Her pain score showed the patient rated her pain as 8 out 10 (0 being no pain and 10 the worst pain possible). She was triaged with an Emergency Severity Index (ESI) of a 3 indicating urgent but not emergent needs.

Medical record review of an ED Physicians Record dated 2/5/2023 at 1:36 AM showed the patient presented with complaints of constipation for 2 weeks and abdominal pain. The patient provided the history herself and was reported as a "good historian". She arrived at the ED via private vehicle where her pain started prior to arrival. She had been to Facility B on 2/4/2023 with the same pain and reported no relief. The patient had obtained a taxi to the facility related to "she likes it better". The patient stated she had not had a bowel movement in two weeks and described her pain as "poopy". She denied fever or chills. The physical examination showed the patient was awake, alert, cooperative and conversant. Her pupils were equal and reactive to light. Her lungs were clear bilaterally with no labored breathing. She had left sided weakness related to a previous stroke. Her mood and affect were appropriate. Diagnostic testing was ordered and completed to include the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and an Ethanol (alcohol level).

Medical record review of the restraint flowsheet dated 2/5/2023 at 2:00 AM, showed non-violent bilateral soft wrist restraints were applied to the upper extremities. At 2:30 AM the restraints were checked. The restraints were discontinued at 3:00 AM. The patient was alert and oriented and continued to scream belligerently at staff.

Medical record review of the Medication Administration Record dated 2/5/2023 showed Ativan (medication used for anxiety) 1 milligram (mg) was ordered at 3:38 AM and administered at 4:13 AM. Docusate (medication used for constipation) was ordered at 4:10 AM but the medication was not administered related to the patient had a bowel movement around 5:30 AM-6:00 AM.

Medical record review of the electronic orders dated 2/5/2023 at 3:58 AM showed a CT of the Abdomen and Pelvis without contrast was ordered and canceled at 4:11 AM.

Medical record review of an ED Physicians Progress Note dated 2/5/2023 at 4:25 AM showed "...patient had a computed tomography [CT scan] at [Facility B] yesterday at 8:00 PM. The CT showed a large volume colonic stool compatible with constipation with no evidence of obstruction...[4:30 AM] discussed with patient results, diagnosis, treatment plan, and need for follow up with Primary Care Physician [PCP]. Return to ED warnings were given. All questions answered...plan is agreed with and understood. Pt. is stable and ready for discharge. Patient initially agitated attempted to throw herself on the floor witnessed by security and staff. Patient was stopped prior to this. Neurologic deficits chronic..." The patient's White Blood Count was 14.7 (normal 4.0-11.0). Her diagnoses included Agitation and Constipation.

Medical record review of an ED Nurses Note dated 2/5/2023 at 6:00 AM showed "...pt. had defecated in the bed was again belligerent. Pt. had rubbed feces on the side rails of the bed, on her phone, and the equipment in the room. Pt. alert and oriented at this time. Pt. taken to the shower decontamination room by a nurse, paramedic, and two techs to assist in cleaning her off. Pt. placed in paper scrubs after shower, with multiple warm blankets. Pt. placed back in her room on the monitor... "

Medical record review of an ED Note dated 2/5/2023 at 6:00 AM showed "...the pt. had defecated herself in the bed. The patient, the floors were covered in feces. The patient was alert and oriented at this time. The patient was transported by myself [Paramedic #1], [Registered Nurse #2], and [ED Tech #1] to the decontamination shower to be cleaned. The patient was scrubbed with warm water and soap. The patient was then placed in paper scrubs and provided with warm blankets and socks. The patient was taken back to her room to gather her belongings and be discharged. The patient become violent with [ED Tech #1 and ED Tech #2]. They were attempting to assist her into a wheelchair for discharge. The patient gripped and scratched [ED Tech #1] arms and drew blood. Security was called. The patient was placed into the wheelchair and escorted by security after declining a 'Lyft ride'... "

Medical record review of an ED Note dated 2/5/2023 at 6:55 AM showed "...provider placed patient up for discharge. Pt. alert and oriented and vital signs stable [vss]. Pt. offered 'Lyft ride' to assist. Pt. declined this offer. Pt. placed in the lobby upon discharge [dc] by security with warm blankets... " Documentation revealed last heart rate prior to discharge was 115 (high).

Medical record review of the discharge instructions dated 2/5/2023 at 6:55 AM showed the patient was given instructions related to constipation and follow-up with her Primary Care Physician in 2-4 days. There was no specific education provided to Patient #26 related to her presenting complaint of abdominal pain.

Review of a Security Report dated 2/5/2023 showed security was called to assist with a discharged combative patient (Patient #26) who was refusing to leave the ED. The (named local Police Department) arrested the patient. On 2/5/2023 at 6:57 AM, the ED Registered Nurse (RN) had requested a standby/escort the patient who was refusing to leave and had become combative. Four (4) security officers had responded for standby to the patient's room. The security officer approached the patient and informed the patient she had to vacate the room, as she was discharged. The patient "...had thrown herself on the floor of ED 4 when medical staff attempted to assist her out. [Patient #26] would become combative each time medical staff would approach her to place in a wheelchair by trying to scratch and grab them. [Named security officers] deescalated [Patient #26] so medical staff could place in a wheelchair, this was conducted without further incident. [Security Officers #3 and #2] transported [Patient #26] by medical staff to the Emergency Department Waiting area at 7:05 hours [7:05 AM]. [Patient #26] was clearly told she can call for transportation and wait in the ED waiting area for her ride. Discharged [Patient #26] continued to cause a disturbance in the ED waiting area by yelling at registration staff, harassing other patients waiting, trying to light a cigarette, and wanting to go outside to smoke. [Patient #26] was warned if she didn't stop being a disturbance the [named local police department] would be notified. [Patient #26] requested that security call [named local police department] for her and requested she be brought outside to smoke and wait for [local police department]. At 7:19 AM, [named local police department] was dispatched. [named local police department] arrived on location at 8:18 AM. A criminal trespass was issued to [Patient #26] and signed. [Named local police Sergeant] and [named local police] arrest [Patient #26]. [Named local police officer] transports [Patient #26] from property. All officers clear without further incident at 9:10 hrs [9:10 AM]. An addendum (not dated or timed) and labeled as prior history showed "...On 2/4/2023 at 2023 [Patient #26] was admitted and discharged at [Facility B] and placed in a taxicab and traveled from [Facility B] to [Facility A]. 2/5/2023 the patient registered to be seen at [Facility A]. 2/5/2023 2:07 AM standby requested for disruptive patient in the ED. 2/5/2023 at 6:57 AM [Patient #26] was discharged from [Facility A] and was transported by [named local police]. 2/5/2023 at 9:50 AM [Patient #26] was brought back to [Facility A] by [named local police department]..."

Medical record review showed on 2/5/2023 at 10:00 AM the patient was readmitted to Facility A after suffering a cardiac arrest. She was successfully resuscitated and admitted to the Intensive Care Unit (ICU). The patient expired on 2/6/2023 at 9:57 PM.

Medical record review of an admission History and Physical (H&P) dated 2/5/2023 at 2:27 PM showed the patient had been evaluated at Facility B on 2/4/2023 with abdominal pain and was discharged on 2/4/2023. A CT of the abdomen performed at Facility B showed constipation. She presented to Facility A on 2/4/2023 at 11:57 PM with abdominal pain. The patient stated she had not had a bowel movement in 2 weeks. The CT scan from Facility B was reviewed and showed colonic distention with constipation. She was discharged from the ED. The patient had been combative and argumentative and had refused to cooperate with transportation. Security and the local police department were involved. The patient was placed in a police cruiser and was being transported to the jail. During the transport, the patient became unresponsive, and EMS was requested. Paramedics found the patient in cardiac arrest where resuscitation efforts were initiated. The patient suffered additional cardiac arrest while in the ED where she was successfully resuscitated. The patient was admitted to the Intensive Care Unit (ICU). Her diagnoses included Cardiac Arrest with an unclear etiology, Respiratory Failure, Shock (likely cardiogenic in nature), Alerted Mental Status, Metabolic Acidosis, and advanced Chronic Obstructive Pulmonary Disease (COPD).

Medical record review of a Record of Death dated 2/7/2023 at 6:56 PM showed a CT of the head was completed in the ED which showed suggestions of an anoxic injury to the brain and no evidence of hemorrhage or other acute processes. A Magnetic Resonance Imaging (MRI) was performed while in the ICU showed "...marked mass effect originating in the left cerebral hemisphere [part of the brain] with what appeared to be edematous cortex [outer layer of the brain], though no definitive extensions of uncertain etiology. There was also hemorrhage that appeared to originate from the left caudate [part of the brain function] with a degree of intraventricular extension of uncertain etiology... "

During a telephone interview on 3/1/2023 at 3:30 PM, Registered Nurse (RN) #1 stated the patient was alert and oriented to time and place. The patient had presented to the ED with complaints of abdominal pain and constipation. She had been evaluated at another facility the same night with the same complaints. She had previous history of a stroke with residual weakness to her left side. In the ED lobby, she was yelling and had attempted to lay down in the floor in the lobby. She had refused to get back into the wheelchair and when the staff tried to assist her from the floor back into the wheelchair, the patient become combative and was felt to be a harm to herself and the ED staff. The ED Physician evaluated the patient and ordered nonviolent wrist restraints. She was placed in restraints on 2/5/2023 at 2:00 AM and the restraints were removed at 3:00 AM after the patient calmed down and was cooperative with her care. The ED Physician evaluated the patient and ordered diagnostic testing related to the patient's complaints of abdominal pain. The patient did not complain of any pain to her ankles. After the diagnostic testing was completed, the patient was evaluated by the ED physician and deemed stable for discharge. While in the ED the patient had a bowel movement. The staff assisted the patient with incontinence care and placed the patient in clean scrubs. The patient had been resistant to leaving the ED and stated she did not have a ride. The staff attempted to get an address for discharge, but the patient would not give them an address or any contact information. The patient was offered a 'lyft ride', a cab voucher, and possible EMS transport but the patient refused to give an address and declined the staff's offer. The patient did not complain of any stroke like symptoms and was not in acute distress upon discharge. She did not have any shortness of breath and her oxygen saturations were stable. The patient was discharged to the ED Lobby and was waiting on transportation.

During a telephone interview on 3/1/2023 at 3:50 PM, RN #2 stated the patient was awake and alert. She did have some deficits to her left arm from a previous stroke but did not show any acute neurological deficits. The patient presented with complaints of abdominal pain and constipation. She had assisted other ED staff members with incontinence care after the patient had a bowel movement.

During a telephone interview on 3/1/2023 at 4:30 PM, Paramedic #1 stated the patient was initially combative, belligerent, and aggressive with the staff including scratching and trying to hit the staff. The patient had to be placed in nonviolent soft wrist restraints. The ED Physician had evaluated the patient and ordered diagnostic testing. The records from Facility B were requested which showed the patient had a CT of the abdomen which showed constipation. While in the ED the patient had a bowel movement in the bed. The ED Physician discussed the diagnostic findings with the patient and the plan of care was discussed. The patient did not want to leave the ED. She had refused to give the staff phone numbers or an address where she could be transported to.

During a telephone interview on 3/1/2023 at 4:50 PM, Physician #1 stated he evaluated the patient on 2/5/2023 after the patient had been placed in the restraints. The evening ED physician evaluated the patient in the ED lobby and ordered the restraints. The patient had been combative and uncooperative with the staff and required the restraints. After the patient calmed down, the restraints were discontinued. The patient presented with abdominal pain and constipation. She had been on a plane where she came from Rhode Island. On arrival at the airport, the patient was taken to Facility B by ambulance on 2/4/2023 where diagnostic testing was completed. A CT of the abdomen was completed which showed constipation. The patient had left Facility B and came to Facility A. Diagnostic testing was completed to include a CBC, CMP, and Blood Alcohol level which showed no acute findings. A CT scan of the abdomen was ordered but after review of the CT scan from Facility B was received, the order was canceled. While in the ED the patient had a bowel movement with resolution of her symptoms. The patient was discharged and was in stable condition. The patient had previous neurological deficits to her left side related to a previous stroke. She did not have any neurological symptoms during the admission on 2/4/2023 and did not have complaints of any stroke like symptoms. She did not complain of any pain to her lower extremities and had no signs of any injuries to the lower extremities. The patient stated she was going to a boyfriend's house to stay with him but would not give any phone numbers or an address.

During a telephone interview on 3/7/2023 at 1:30 PM, contracted Security Officer #2 stated around 7:00 AM (on 2/5/2023) security had received a call from the ED related to a patient who was refusing to leave the ED after she was discharged. The officer responded to the ED and stood outside the room. The patient was resistant getting off the stretcher and into the wheelchair. He assisted the ED Tech escorting the patient to the ED Lobby. The patient was disruptive, belligerent with the staff and other patients. He stated "...we were informed the patient was medical seeking and she would not give any information who to call or an address. I was told this was normal behaviors for her and she was 'dead weight' when trying to get the patient out of the wheelchair...after the fact, I regret my course with her. I don't know if she was or was not medically stable. I thought she was just acting out...I do not have any medical background. If I had thought she was in distress I would have notified the ED staff, but she was in [local police custody] and had been discharged from our ED..."

During an interview on 3/21/2023 at 3:05 PM, with the Assistant Chief of Operations for security showed the contracted security officers completed EMTALA training through the contracted company and through the facility during orientation. The security officers were given education related to any patient seeking medical treatment would be evaluated by a medical provider. Patients who were discharged into custody of the local police must have a medical screening and be discharged prior to being placed in the custody of the police. The security officers sign an EMTALA Tip sheet specifically related to EMTALA obligations. The officers sign the tip sheet as confirmation they received the training. The security officers were given a 'quick card' for reference which they carry in their pocket. He stated "...the patient was discharged, and we cannot interfere with any patient in the custody of law enforcement. We are not law enforcement officers, and we function under a security officer role..."

During a telephone interview on 3/21/2023 at 5:18 PM, contracted Security Officer #2 confirmed he had completed EMTALA training through the contracted security company and the facility. The security officers were told the patient had behavioral health issues and she had been acting out during her admission. He had been informed the patient was discharged and was waiting on a ride. He stated "...my training included any patient who presented and request a medical screening would be provided a medical screening regardless of the ability to pay. The patient continued with behaviors and was arrested by the local police..."

The hospital failed to provide stabilizing treatment for the identified medical conditions. Patient #26 did not have pain management or pain interventions provided and there was no documentation abnormal clinical findings were addressed.

Refer to A2406 for additional findings and video reviews.