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Based on interview, record review, digital video recordings, police reports,, emergency medical service reports (EMS, emergency response personnel, such as paramedics, first responders, etc.), and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) within its capacity and capability, for two patients (#6 and #22), and failed to ensure that an EMC was stabilized prior to being discharged, for three patients (#6, #22 and #29) out of 31 ED sampled patients' records from 02/01/23 through 08/01/23. The hospital had an average of 1,794 Emergency Department (ED) visits per month over the previous six months.

Findings included:

Review of the hospital's policy titled, "110324.1396 EMTALA," dated 10/2022, showed that any individual who "comes to the hospital emergency department" requesting examination or treatment shall be provided with an appropriate Medical Screening Exam (MSE). This MSE will determine whether an individual has an actual Emergency Medical Condition (EMC). The MSE is a continuous process reflecting ongoing monitoring in accordance with an individual's needs.

Review of the hospital's policy titled, "Discharge Disposition Selected," dated 08/2022, showed that Against Medical Advice (AMA) is defined as when a patient leaves a hospital against the advice of their doctor. While leaving before a medically specified endpoint may not promote the patient's health above their other values, competent patients (or their authorized surrogates) are entitled to decline recommended treatment. Elopement is defined as when a patient who is incapable of adequately protecting himself/herself, makes an intentional, unauthorized departure of the health care facility unsupervised and undetected. Elopement presents an imminent threat to the safety of the patient or others. Elopement does not include events involving competent adults with decision-making capacity who leave against medical advice or voluntarily leave without the knowledge of the staff or for those seen leaving by the staff. It is the policy of the hospital that all patients who intend to leave AMA are requested to sign the "Leaving the Hospital Against Medical Advice or Treatment" form. Any patient deemed harmful to self/others or unable to make decisions due to impairment will be safely redirected and de-escalated until unsuccessful upon which time the police department will be contacted for assistance. Any person desiring to be released will be advised by the physician of the inherent dangers in such actions. If the person desiring release refuses to sign the AMA release after having it presented to him/her in the presence of a third person, write "patient refuses to sign" across the release form and state the time. Make a note of the circumstances on the "Against Medical Advice" form. The hospital will make every attempt to collaborate with the patient to establish a care plan that is agreeable to both parties. If a patient disagrees with the care plan and no reasonable compromise can be reached, the patient can leave and should be discharged and not considered to leave AMA. Provider documentation should describe the discussion and options made available to the patient. Patients who are obviously mentally incompetent or who appear to be in shock or under the influence of drugs or alcohol should not be permitted to leave unless accompanied by family or another authorized adult person. If the patient is considered by the physician to be a danger to self or others, the police may be notified of the patient's intent to leave. When a patient elopes, notify the appropriate police department of the elopement due to the imminent danger to the patient or public. Disposition the patient in the electronic medical record (EMR) as elopement. Elopement of a patient is a sentinel event and requires immediate escalation to the house supervisor in addition to create a risk incident report.

Review of the hospital's document titled, "St. Mary's Medical Center Medical Staff Bylaws," dated 08/2019, showed that the responsibilities of the Medical Staff are to maintain and seek compliance with these Bylaws, Rules and Regulations or policies, and other patient care related Medical Center Policies, including, without limitation, the emergency services comprehensive policy in compliance with the requirements of the EMTALA and the regulations thereunder. In this regard, when an individual comes to emergency services and requests examination and/or treatment, emergency services has the obligation to (a) provide a MSE to determine whether an EMC exists, and (b) if an EMC exists, provide stabilizing treatment within the capabilities of the Medical Center.

Review of the hospital's document titled, "St. Mary's Medical Center Medical Staff Rules and Regulations," dated 09/25/13, showed that for the protection of patient, the medical and nursing staffs, and the Medical Center, certain precautions shall be taken in the care of known or suspected suicidal patients. Following a consultation, any known or suspected suicidal patient should have a consultation by a member of the psychiatric or clinical psychology staff of the Medical Center or arrangements made for post-discharge consultation. If consultation is refused, this must be noted in the progress note. Any medically stabilized patient known or suspected to be suicidal in intent should be transferred to another institution where suitable facilities are available. Should a patient leave the Medical Center against the advice of the attending practitioner or without proper discharge, annotation of the event shall be made in the patient's medical record and the patient shall be requested to sign an AMA form. Practitioners providing services in and through the ED are obligated to comply with all of the emergency services policies, including the emergency services comprehensive policy concerning the operation of emergency services in compliance with the requirements of EMTALA and the regulations thereunder.

Review of the hospital's document titled, "Suicidal Ideation Risk Assessment," dated 06/2022, showed that the hospital was committed to identifying the patient at risk for suicide, suicidal/harm to self and providing a safe environment until the patient is able to resume responsibility for his/her safety or is transitioned to the appropriate treatment setting. The hospital will properly identify and assess the level of suicide risk a patient presents with, implement safety precautions, provide interventions appropriate to the level of risk identified and develop a safe and individualized discharge plan utilizing all necessary resources. A suicide risk screen is completed on every patient who presents to the ED. Patients who screen positive for suicide risk are further assessed using a measurable, evidence based tool to determine the presenting degree of risk. Patient's that are screened in the ED, who have a positive screening on the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) will require further assessment by a Licensed Independent Practitioner (LIP) and will be under the treatment plan directed by the LIP. Patients at risk for suicide will continue on the determined level of observation unless changed and/or discontinued by the LIP or mental health practitioner.

Review of the hospital's undated document titled, "EMTALA and Psychiatric Patient Emergency Provider Education," showed that the hospital must provide a MSE within the capability of the hospital to determine if an EMC exists. If an EMC exists the hospital must either treat or transfer. Behavioral health and chemically dependent patients are included in this requirement because they may present with conditions that pose a serious physical threat. A behavioral health screening by ancillary services is considered part of the MSE. A suicidal patient remains unstable until no longer suicidal. A suicidal patient who becomes volatile, aggressive, injures themselves, or elopes has not been properly stabilized within the capabilities of the hospital. The behavioral health assessment is how we determine if an EMC occurs. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming themselves or others. The administration of chemical or medical restraints may remove the immediate EMC but the underlying condition may persist. Practitioners should use care when determining if the medical condition is in fact stable after such interventions. The definition for AMA included fully competent patients who made the decision to leave the facility having been informed of and appreciating the risks of leaving without completing treatment, fully competent patients are legally able to discharge themselves without completing treatment. The Physician should inform the patient of the risks/benefits associated with leaving, ideally the conversation is noted in the medical record and the patient is asked to sign a form indicating awareness of these risks. Patients should only be charted as an elopement if they are considered a danger to self/others or incapable of making safe decisions (intoxicated, confused, etc.). Documentation as elopement should mean immediate escalation to notify police department, public safety and the house supervisor. If an elopement patient is found by the police department, it is imperative that we insist the patient return to the ED to complete the MSE. A mental health examination must be part of the MSE for psychiatric chief complaints.

Review of Patient #6's medical record showed the following:
- On 03/28/23 at 1:16 PM, he presented to the ED with a chief complaint of seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness).
- At 1:28 PM, his blood pressure was documented as 238/154 (normal is approximately 90/60 to 120/80), and his heart rate was 114 beats per minute (BPM, normal is approximately 60 to 100 BPM).
- At 1:51 PM, Staff L, ED Physician, documented that the patient had two episodes of fainting over the past month. The most recent was five days prior to his ED visit, and he was shaking afterward. He had no history of seizures, but did have a history of high blood pressure. Patient #6 requested a note to return to work. Staff L documented that Patient #6's vital signs were stable, no EMC was identified and that Patient #6 was safe for outpatient follow up. Staff L's diagnosis was weakness.
- He was discharged home at 2:15 PM.
- No additional blood pressure readings were documented. No diagnostic tests were performed. No medications were administered. No medications were prescribed at discharge.

Review of Patient #22's medical record showed the following:
- On 07/05/23 at 12:13 AM, she was brought into the ED for suicidal ideation and three affidavits were completed related to suicidal actions and verbal remarks of committing suicide.
- She was combative and violent during her ED visit and received medications to help calm her down. She was also placed in bilateral upper extremity and bilateral lower extremity restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) at one point and had a one to one (1:1, continuous visual contact with close physical proximity) sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety).
- At 6:00 AM, a behavioral health examination was ordered, since Patient #22 was more alert and able to cooperate with staff.
- On 07/05/23 at 8:32 AM, Patient #22 became aggressive, ripped out her own IV and left the hospital prior to being evaluated by a mental health professional. She left the ED in her hospital gown, barefoot to a busy city street. She was picked up by a stranger and taken to her home. Hospital staff documented that Patient #22 both eloped and left AMA, however there was no AMA paperwork or documentation that staff discussed the risks of the patient leaving before seeking treatment.

Review of Patient #22's medical record from Hospital B showed that she presented to the ED of Hospital B on 07/05/23 at 9:30 PM with suicidal ideation and was admitted for inpatient psychiatric treatment.

Review of Patient #29's medical record showed the following:
- On 06/21/23 at 7:31 PM, he presented to the ED for addiction problems.
- He was evaluated by a behavioral health assessor who recommended he be admitted to a detoxification center for inpatient treatment.
- Laboratory tests were indicative of issues with his kidneys and his urine specimen was sent for a culture.
- While waiting for his transfer to a treatment center the patient complained of not thinking right and seeing things that weren't there, he became agitated and aggressive and destroyed property in the ED waiting room.
- On 06/22/23 at 2:50 AM, he then left the ED. His discharge was listed as leaving AMA, however there was no AMA paperwork or documentation that staff discussed the risks of the patient leaving before seeking treatment.
- On 06/22/23 at 11:18 PM, Patient #29 presented to the ED a second time for addiction problems, hearing voices and having crazy thoughts.


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Based on interview, record review, digital video recordings, emergency medical service records, and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for two patients (#6 and #22) out of 31 Emergency Department (ED) records reviewed from 02/01/23 to 08/01/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average ED monthly census over the past six months was 1,794.

Findings included:

Review of the hospital's policy titled, "110324.1396 EMTALA," dated 10/2022, showed that any individual who "comes to the hospital emergency department" requesting examination or treatment shall be provided with an appropriate Medical Screening Exam (MSE). This MSE will determine whether an individual has an actual Emergency Medical Condition (EMC). The MSE is a continuous process reflecting ongoing monitoring in accordance with an individual's needs.

Review of the hospital's document titled, "St. Mary's Medical Center Medical Staff Rules and Regulations," dated 09/25/13, showed that for the protection of patient, the medical and nursing staffs, and the Medical Center, certain precautions shall be taken in the care of known or suspected suicidal patients. Following a consultation, any known or suspected suicidal patient should have a consultation by a member of the psychiatric or clinical psychology staff of the Medical Center or arrangements made for post-discharge consultation. Practitioners providing services in and through the Emergency Room Services Department are obligated to comply with all of the emergency services policies, including the emergency services comprehensive policy concerning the operation of emergency services in compliance with the requirements of the Emergency Medical Treatment and Active Labor Act and the regulations thereunder.

Review of the hospital's undated document titled, "EMTALA and Psychiatric Patient Emergency Provider Education," showed that the hospital must provide a medical screening exam within the capability of the hospital to determine if an EMC exists. If an EMC exists the hospital must either treat or transfer. Behavioral health and chemically dependent patients are included in this requirement because they may present with conditions that pose a serious physical threat. A behavioral health screening by ancillary services is considered part of the MSE. A suicidal patient remains unstable until no longer suicidal. A suicidal patient who becomes volatile, aggressive, injures themselves, or elopes has not been properly stabilized within the capabilities of the hospital. The behavioral health assessment is how we determine if an EMC occurs. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming themselves or others. The administration of chemical or medical restraints may remove the immediate EMC but the underlying condition may persist. Practitioners should use care when determining if the medical condition is in fact stable after such interventions. A mental health examination must be part of the MSE for psychiatric chief complaints.

Review of the hospital's documented titled, "Affidavit (a written statement confirmed by oath, for use as evidence in court) in Support of Application For Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 07/04/23, showed a notarized affidavit completed by Patient #22's father. Patient #22's father wrote that she told him that there was no need to keep trying, she just wanted to be done with life. That was not the first time, and she just wanted to be left alone to do what she needed to end it all.

Review of the hospital's document titled, "Affidavit in Support of Application For Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 07/05/23, completed by Staff R, Police Officer, showed the following:
- He responded to Patient #22's home regarding a suicidal person.
- Upon arrival he observed Patient #22 to be extremely agitated and combative.
- Patient #22's husband reported to Staff R that she had been drinking all day and making suicidal statements and looking for objects or pills to take for the past few hours.
- Staff R and two other officers had to restrain Patient #22 and placed her into the back of their patrol car. While Patient #22 was being placed in the patrol car she stated, "Fuck it, I'm going to kill myself!"
- Patient #22 was transported to St. Mary's Medical Center.

Review of the hospital's documented titled, "Affidavit in Support of Application For Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 07/04/23, showed a notarized affidavit completed by Patient #22's husband who wrote that Patient #22 told him on several occasions she was going to kill herself. She then went to the kitchen to raid the medicine cupboard for pills to take.

Review of Patient #22's EMS record showed the following:
- EMS was dispatched on 07/04/23 at 11:39 PM, for a psychiatric patient.
- When EMS arrived on scene Patient #22 was seated in the back of a cop car. Patient #22 was alert and screaming as loud as she possibly could with a Glasgow Coma Score (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) of 14, and did not appear to be in respiratory distress.
- Police reported to EMS that Patient #22 made suicidal statements. She was restrained using handcuffs behind her back and leg shackles.
- Patient #22 was thrashing around and striking her head against the back seat of the police car.
- Patient #22 could not be calmed after attempting to verbally deescalate (reduce the intensity of a conflict or potentially violent situation). It was determined that is would be safest for the patient and for the EMS crew, if the patient was sedated chemically for transport. Patient #22 was given Ketamine (short acting anesthetic) intramuscularly (IM, in the muscle), placed on a stretcher and transported to St. Mary's Medical Center, and arrived on 07/05/23 at 12:28 AM.

Review of Patient #22's medical record from St. Mary's Medical Center showed the following:
- She was a 31-year-old female who presented to the ED on 07/05/23 at 12:13 AM, via EMS and Police Officers for SI.
- The history of present illness showed that when police and EMS arrived the patient kicked and screamed and punched the house. She told her family she wanted to kill herself and looked for pill bottles. Patient #22 was given Ketamine, and was somewhat sedated upon her arrival to the ED.
- Staff P, Physician, documented that when Patient #22 woke up she began screaming stating that her father and brother were "fucking liars" and she did not want to kill herself. She was uncooperative and told the physician that psychiatric hospitals "do not fucking work."
- Vital signs upon arrival were blood pressure (BP, a measurement of force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) 127/98, a pulse (the number of heart beats per minute) of 125, and respiratory rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) of 25.
- Blood work was obtained which showed an alcohol level of 93 (normal is less than 10), and was otherwise unremarkable.
- At 12:15 AM, Patient #22 was assigned a one to one (1:1, continuous visual contact with close physical proximity).
- A Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) documented at 1:31 AM, showed that Patient #22 was at a high risk for suicide.
- At 1:38 AM, Patient #22 became agitated, yelled and screamed, tried to pull out her IV, made fists and threatened staff.
- At 1:41 AM, Patient #22 was moved to a different room which made the patient more combative, she attempted to remove her IV again, thrashed, kicked and tried to stand up. An order was placed for four-point restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) and medications.
- Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulty) was administered at 12:33 AM, 1:03 AM, and 1:30 AM, and Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder [manic depression]) was administered at 1:04 AM and 2:44 AM.
- Four point restraints were removed at 2:15 AM, and the patient continued to rest in her bed.
- A C-SSRS documented at 2:15 AM, showed that Patient #22 continued to be at a high risk for suicide.
- At 5:30 AM, Staff P, Physician, documented that Patient #22 awakened and ate a sandwich and drank liquids. She was far more coherent and cooperative. At 6:00 AM, the behavioral health assessor was called to evaluate Patient #22, they reported that they would have the staff member that started at 7:00 AM assess the patient for possible placement.
- Staff L, Physician, documented that Patient #22 became agitated and aggressive at 8:30 AM, and was insistent on leaving. Staff were able to talk the patient into letting them remove her IV. Patient #22 reported that she had been to psychiatric hospitals in the past and they did not work. The patient stated that she was leaving and they could not stop her. Patient #22 was extremely agitated and upset, she walked out of the ED under her own powers, with her hospital gown on. She would not wait to put on her clothes. Staff attempted to talk down the patient and make her understand, but now that she was sober, she did not understand why she was there and wanted to leave, again the patient was extremely agitated, angry and uncooperative. Due to the patient's sobriety, feeling better and poor affidavits he could not hold her against her will. Patient #22 was alert and oriented to herself, place and time and left AMA. Her ED discharge disposition was eloped.
- At 8:37 AM, nursing documentation showed that Patient #22 became agitated and stated she was leaving, then proceeded to rip out her own IV. The nurse then safely removed the IV from the patient's right arm. Several attempts were made to de-escalate, but were unsuccessful. Patient #22 then ripped off her cardiac monitor leads (noninvasive monitors of the heart that attach to the patient's chest and record heart rhythm) and stated that she was leaving the ED. Staff informed the patient that the police would be called since she was brought to the ED for SI. Patient #22 walked out the front door and continued to walk to the sidewalk. The nurse and another staff member followed the patient to ensure safety, Security Officers were called and also witnessed the patient walking out of the ED. Police were called and informed of the situation. Police picked the patient up down the street.
- At 8:45 AM, the behavioral health assessor arrived to evaluate Patient #22 and was updated on the current situation.

Review of Patient #22's EMS record showed the following:
- EMS was dispatched on 07/05/23 at 8:28 PM, for a suicidal patient.
- When EMS arrived on scene, Patient #22 was seated in the back of a patrol car attempting to bang her head against the car. The patient was handcuffed and very agitated. Patient #22 suffered from mental illness and had not been taking her medications for days.
- Patient #22 told EMS that she was tired and not going back to a facility because it didn't help, she was just going to get out and harm herself anyway. She wanted the police to shoot her as well as for EMS to overdose her on medications.
- Patient #22 attempted to get out of restraints, get off of the cot, and continued to be very agitated.
- During transport to Hospital B, EMS administered medications intramuscularly and the patient did stop screaming, but continued to try to get off the cot. She would not leave monitoring devices on.
- Family requested EMS transport Patient #22 to Hospital B and they arrived at 9:06 PM.

Review of Hospital A's digital video recordings titled, "1 - 2023-07-05 08-22-00-155," dated 07/05/23, showed a view of the ED hallway leading to the ED waiting room. Patient #22 walked into the hallway, still inside the ED, and staff walked behind her. Patient #22 was wearing a hospital gown and pulled the right side to cover her backside with her left hand. Staff then removed a blood pressure cuff from her right lower leg. Patient #22 reached into the front of her hospital gown and then what appears to be a monitoring device falls to the floor by her feet. Patient #22 then turned and walked out of the ED doors into the waiting room, three staff members followed her to the waiting room. There was no time stamp on the video.

Review of Hospital A's, digital video recordings titled, "1 - 2023-07-05 08-22-00-008," dated 07/05/23, showed a view of the outside of the ED entrance and parking lot. Patient #22 exited the main ED entrance and walked along the building's sidewalk. She was in a hospital gown and barefoot. Three staff members exited behind her and appeared to say something to her. She stopped, turned around and appeared to say something back to them and walked away. Staff followed Patient #22, Patient #22 then looked back, turned and ran away from staff. She ran around the side of the building across a parking lot, and into a grassy area, where she was no longer in camera view. Staff followed her a short distance, and stopped outside the ambulance entrance. The Security Officer got into a car and followed Patient #22 out of the hospital's entrance. There was no time stamp on the video.

Review of Patient #22's medical record from Hospital B showed the following:
- She presented to the ED on 07/05/23 at 9:30 PM with SI. The patient reported that her husband called the police and she was taken to the hospital, she was not currently having SI and denied any attempts to harm herself.
- Patient #22 became agitated and had to be placed in bilateral upper extremity and bilateral lower extremity restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) to protect herself and staff. Patient #22 was given medications IM to help her calm down, and a behavioral health assessment was ordered for when the patient was awake. Affidavits were on the chart.
- A behavioral health assessment showed that the patient was alert and oriented to who she was, where she was and the time. Her mood was anxious and she denied any thoughts of SI. Patient #22 became angry, hostile and refused to discuss her actions when arriving to the ED. Patient #22 attempted to grab the police officers gun and admitted that she grabbed the gun with the intent of shooting herself. Patient #22 had poor insight and was unable to do a safety plan. The recommendation was for Patient #22 to be admitted involuntarily for inpatient psychiatric treatment.

During a telephone interview on 08/03/23 at 9:30 AM, Staff A, RN, stated that her shift began at 7:00 AM on 07/05/23. She was told by the night nurse that Patient #22 was brought into the ED intoxicated. She was combative and had been given medications to help her sleep. A 1:1 was assigned to the patient who informed staff that she tried to take out her IV. Patient #22 stated that she was leaving and the patient was "with it." The Behavioral Health Assessor was on her way to evaluate Patient #22 so Staff A tried to calm the patient down. Staff A asked Patient #22 if she knew why she was in the ED and told her that she needed to be evaluated before she left. Patient #22 tried to rip out her IV, so Staff A removed it. Staff A told Patient #22 that they could not let her leave but the patient stated that she was leaving and they could not stop her. Staff A and two other staff members followed the patient out of the ED and watched her until the police showed up. Staff A felt that Patient #22 was mentally cognizant, but emotionally she wasn't sure. The patient was very upset and stated that psychiatric hospitals did not help her. She did not remember the physician assessing the patient after she woke up, before she left the ED. She tried to explain the risks of leaving the hospital AMA, and told the patient that police would be called if she left the hospital. A C-SSRS needed to be completed initially and then just before discharge. Staff were not able to de-escalate Patient #22. Since Patient #22 had come into the ED with SI, she would have needed to be evaluated by a Behavioral Health Assessor before she could be discharged.

During an interview on 08/03/23 at 10:00 AM, Staff L, Physician, stated that when he came on shift at 7:00 AM on 07/05/23 Patient #22 was still in the ED beginning to wake up and come around. Patient #22 was agitated and did not want to stay in the ED. Patient #22 said she was not suicidal, she wanted to leave and he felt there was nothing the hospital could do to get her to stay. She was still waiting for a behavioral health assessment when she left the hospital. She did not sign AMA papers, so technically she eloped from the hospital. A reasonable person would absolutely leave a hospital in a hospital gown and barefoot, she was not happy about being there. She had a steady gait (a person's manner of walking), was alert and oriented to herself, the place and time, and was making sense.

During an interview on 08/03/23 at 10:30 AM, Staff M, RN, stated that she was working the night shift on 07/05/23 when Patient #22 presented to the ED. The patient arrived via EMS and police and was very intoxicated, upset, and became a danger to herself. Patient #22 attempted to leave the hospital, threw herself down and bit staff. Patient #22 just wanted to leave the ED, but made several suicidal statements. After they administered medications and placed the patient into restraints she was able to calm down. Patient #22 slept for the rest of Staff M's shift. Clinical practice was to redraw an alcohol level prior to having a behavioral health assessment.

During an interview on 08/03/23 at 12:00 PM, Staff O, Certified Nurse's Aide, stated that she performed the 1:1 for Patient #22 on 07/05/23. Patient #22 slept almost the entire time she sat with her. Patient #22 woke up and left the hospital. A nurse and a security officer followed the patient outside, she was concerned for the patient's safety and did not feel good about the patient's ability to make good decisions.

During a telephone interview on 08/07/23 at 4:55 PM, Staff P, Physician, stated that she worked the night shift on 07/05/23 when Patient #22 presented to the ED and transferred her care to Staff L, Physician at 7:00 AM when she went off shift. Patient #22 was brought into the ED by EMS after she became out of control at her home and threatened suicide. EMS had given the Patient Ketamine in-route to the hospital so she was very drowsy when they arrived. The patient was listening but was unable to answer questions. When Patient #22 woke up more she was angry, very intoxicated and yelled at staff. The patient was given medications to help her calm down and sleep. Staff P did not call for a behavioral health assessment until 6:00 AM due to the patient's drowsiness and inability to cooperate. The behavioral health assessor was going to see Patient #22 around 7:00 AM. There were three affidavits completed for the patient so Staff P did not feel that she needed to fill out another. When Patient #22 woke up around 6:30 AM, she was calm, relaxed, her speech was no longer slurred and she was not yelling. Staff P did not go in to re-evaluate the patient, but wanted the behavioral health assessors to see Patient #22 before she was discharged. Staff P felt that the affidavits completed for Patient #22 were very specific and the patient had a history of SI. Staff P did try to explain to Patient #22 why she needed to stay and be evaluated by the behavioral health assessor, but the patient just yelled at her.

During a telephone interview on 08/08/23 at 8:49 AM, Staff Q, Dispatcher for Facility D, stated that there was no report of Facility D picking up Patient #22, but she was able to find a call logged into dispatch on 07/05/23 at 8:34 AM. The call came in from St. Mary's Medical Center reporting a woman who left the ED and needed to be brought back. The woman was combative and in a hospital gown. Police officers were dispatched to the scene. There was no other information in the call and there were no police reports showing anyone was picked up near that time with the patient's name.

During a telephone interview on 08/09/23 at 11:00 AM, Staff S, Security Officer, stated that he was called to the ED on 07/05/23 when Patient #22 attempted to leave. Nursing staff told him that the patient wanted to leave and that he should not try to stop her. Patient #22 was very angry, upset and dead set on leaving. He wasn't sure what to do since staff told him not to try to stop the patient from leaving. He followed her in his car as she walked away from the hospital. Police Officers did make contact with Patient #22 after she left the hospital, but he did not see her get into the car or go with police. He did not know who the police officer was that spoke with Patient #22 and he did not know what was discussed. After he saw police speaking with Patient #22 he went back to the hospital.

During a telephone interview on 08/09/23 at 12:55 PM, Staff R, Police Officer, stated that on 07/04/23 he was dispatched to a call for a psychiatric emergency at Patient #22's home. When he arrived Patient #22 was completely out of her mind, saying things that didn't make any sense. When they went to transport her to St. Mary's Medical Center the patient had to be carried to the patrol car. Staff R placed a call to EMS to assist with transport. EMS had to administer Ketamine to Patient #22 to get her in the ambulance. As soon as Patient #22 woke up from the Ketamine she was completely out of control again. He completed an affidavit on her related to suicidal statements that were made, and her history. He was very familiar with, and had completed several affidavits for unsafe patients. He did not feel that Patient #22 was simply under the influence of alcohol or drugs, but having a psychiatric emergency.

During a telephone interview on 08/09/23 at 3:00 PM, Staff B, ED Director, stated that affidavits assisted to keep a psychiatric patient in the ED until a behavioral health assessment could be completed. The behavioral health assessor and the ED physician would make a decision together regarding patient treatment and admission. For a patient to be discharged AMA, the patient would need to be able to make good decisions. Her expectation for ED staff was to make sure each patient was safe throughout their stay and at discharge.

Although attempted we were not able to determine what officer spoke with Patient #22 after she left the ED.

Review of Patient #6's medical record showed the following:
- He presented to the ED on 03/28/23 at 1:16 PM with a chief complaint of seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness).
- At 1:28 PM, his blood pressure was documented as 238/154 (normal is approximately 90/60 to 120/80), and his heart rate was 114 beats per minute (BPM, normal is approximately 60 to 100 BPM).
- At 1:36 PM, Staff N, RN, documented that Patient #6's neurological (neuro, relating to or affecting the nervous system) exam was normal.
- At 1:51 PM, Staff L, ED Physician, documented that the patient had two episodes of fainting over the past month. The most recent was five days prior to his ED visit, and he was shaking afterward. He had no history of seizures, but did have a history of high blood pressure. Patient #6 requested a note to return to work. Staff L documented that Patient #6's vital signs were stable, no EMC was identified and that Patient #6 was safe for outpatient follow up. Staff L's diagnosis was weakness.
- An excuse letter, dated 03/28/23 noted that Patient #6 was seen and treated in the ED and was able to return to work on 03/28/23.
- He was discharged home at 2:15 PM.
- No additional blood pressure readings were documented. No diagnostic tests were performed. No medications were administered. No medications were prescribed at discharge.

During a telephone interview on 08/07/23 at 11:00 AM, Staff N, RN, stated that she did not recall Patient #6. If a patient came in with an elevated BP like Patient #6, she would have immediately rechecked their BP, notified the provider and documented the initial BP and recheck BP.

During an interview on 08/03/23 at 10:00 AM, Staff L, ED Physician, stated that 99 percent of the time, he did not know what caused a syncopal episode. If a patient was not symptomatic, he would not address an elevated blood pressure. He stated that "downtown, everyone's blood pressure is 220" and that Patient #6 had a medical management issue, "not an EMC."

During an interview on 08/09/23 at 3:00 PM, Staff B, ED and ICU Director, stated that she
would expect staff to retake an abnormal vital sign, document it, notify the provider, and make a
note about what the provider said. She would expect the provider to assess the patient and see if
there was anything they needed to do.



46856

Based on interview, record review, digital video recordings, police reports, emergency medical service reports (EMS, emergency response personnel, such as paramedics, first responders, etc.) and policy review, the hospital failed to ensure an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) was stabilized for three patients (#6, #22 and #29), of 31 patient's records reviewed from 02/01/23 through 08/01/23, when they were discharged with an unstable medical condition. The hospital's average monthly Emergency Department (ED) census over the past six months was 1,794.

Findings included:

Review of the hospital's policy titled, "110324.1396 EMTALA," dated 10/2022, showed that any individual who "comes to the hospital emergency department" requesting examination or treatment shall be provided with an appropriate Medical Screening Exam (MSE). This MSE will determine whether an individual has an actual Emergency Medical Condition (EMC). The MSE is a continuous process reflecting ongoing monitoring in accordance with an individual's needs.

Review of the hospital's policy titled, "Discharge Disposition Selected," dated 08/2022, showed that Against Medical Advice (AMA) is defined as when a patient leaves a hospital against the advice of their doctor. While leaving before a medically specified endpoint may not promote the patient's health above their other values, competent patients (or their authorized surrogates) are entitled to decline recommended treatment. Elopement is defined as when a patient who is incapable of adequately protecting himself/herself, makes an intentional, unauthorized departure of the health care facility unsupervised and undetected. Elopement presents an imminent threat to the safety of the patient or others. Elopement does not include events involving competent adults with decision-making capacity who leave against medical advice or voluntarily leave without the knowledge of the staff or for those seen leaving by the staff. It is the policy of the hospital that all patients who intend to leave AMA are requested to sign the "Leaving the Hospital Against Medical Advice or Treatment" form. Any patient deemed harmful to self/others or unable to make decisions due to due to impairment will be safely redirected and de-escalated until unsuccessful upon which time the police department will be contacted for assistance. Any person desiring to be released will be advised by the physician of the inherent dangers in such actions. If the person desiring release refuses to sign the AMA release after having it presented to him/her in the presence of a third person, write "patient refuses to sign" across the release form and state the time. Make a note of the circumstances on the "Against Medical Advice" form. The hospital will make every attempt to collaborate with the patient to establish a care plan that is agreeable to both parties. If a patient disagrees with the care plan and no reasonable compromise can be reached, the patient can leave and should be discharged and not considered to leave AMA. Provider documentation should describe the discussion and options made available to the patient. Patients who are obviously mentally incompetent or who appear to be in shock or under the influence of drugs or alcohol should not be permitted to leave unless accompanied by family or another authorized adult person. If the patient is considered by the physician to be a danger to self or others, the police may be notified of the patient's intent to leave. When a patient elopes, notify the appropriate police department of the elopement due to the imminent danger to the patient or public. Disposition the patient in the electronic medical record (EMR) as elopement. Elopement of a patient is a sentinel event and requires immediate escalation to the house supervisor in addition to create a risk incident report.

Review of the hospital's document titled, "St. Mary's Medical Center Medical Staff Bylaws," dated 08/2019, showed that the responsibilities of the Medical Staff are to maintain and seek compliance with these Bylaws, Rules and Regulations or policies, and other patient care related Medical Center Policies, including, without limitation, the emergency services comprehensive policy in compliance with the requirements of the EMTALA and the regulations thereunder. In this regard, when an individual comes to emergency services and requests examination and/or treatment, emergency services has the obligation to (a) provide a MSE to determine whether an EMC exists, and (b) if an EMC exists, provide stabilizing treatment within the capabilities of the Medical Center.

Review of the hospital's document titled, "St. Mary's Medical Center Medical Staff Rules and Regulations," dated 09/25/13, showed that for the protection of the patient, the medical and nursing staffs, and the Medical Center, certain precautions shall be taken in the care of known or suspected suicidal patients. Following a consultation, any known or suspected suicidal patient should have a consultation by a member of the psychiatric or clinical psychology staff of the Medical Center or arrangements made for post-discharge consultation. If consultation is refused, this must be noted in the progress note. Any medically stabilized patient known or suspected to be suicidal in intent should be transferred to another institution where suitable facilities are available. Should a patient leave the Medical Center against the advice of the attending practitioner or without proper discharge, annotation of the event shall be made in the patient's medical record and the patient shall be requested to sign an AMA form. Practitioners providing services in and through the ED are obligated to comply with all of the emergency services policies, including the emergency services comprehensive policy concerning the operation of emergency services in compliance with the requirements of EMTALA and the regulations thereunder.

Review of the hospital's document titled, "Suicidal Ideation Risk Assessment," dated 06/2022, showed that the hospital was committed to identifying the patient at risk for suicide, suicidal/harm to self and providing a safe environment until the patient is able to resume responsibility for his/her safety or is transitioned to the appropriate treatment setting. The hospital will properly identify and assess the level of suicide risk a patient presents with, implement safety precautions, provide interventions appropriate to the level of risk identified and develop a safe and individualized discharge plan utilizing all necessary resources. A suicide risk screen is completed on every patient who presents to the ED. Patients who screen positive for suicide risk are further assessed using a measurable, evidence based tool to determine the presenting degree of risk. Patient's that are screened in the ED, who have a positive screening on the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) will require further assessment by a Licensed Independent Practitioner (LIP) and will be under the treatment plan directed by the LIP. Patients at risk for suicide will continue on the determined level of observation unless changed and/or discontinued by the LIP or mental health practitioner.

Review of the hospital's undated document titled, "EMTALA and Psychiatric Patient Emergency Provider Education," showed that the hospital must provide a MSE within the capability of the hospital to determine if an EMC exists. If an EMC exists the hospital must either treat or transfer. Behavioral health and chemically dependent patients are included in this requirement because they may present with conditions that pose a serious physical threat. A behavioral health screening by ancillary services is considered part of the MSE. A suicidal patient remains unstable until no longer suicidal. A suicidal patient who becomes volatile, aggressive, injures themselves, or elopes has not been properly stabilized within the capabilities of the hospital. The behavioral health assessment is how we determine if an EMC occurs. Psychiatric patients are considered stable when they are protected and prevented from injuring or harming themselves or others. The administration of chemical or medical restraints may remove the immediate EMC but the underlying condition may persist. Practitioners should use care when determining if the medical condition is in fact stable after such interventions. The definition for AMA included fully competent patients who made the decision to leave the facility having been informed of and appreciating the risks of leaving without completing treatment, fully competent patients are legally able to discharge themselves without completing treatment. The Physician should inform the patient of the risks/benefits associated with leaving, ideally the conversation is noted in the medical record and the patient is asked to sign a form indicating awareness of these risks. Patients should only be charted as an elopement if they are considered a danger to self/others or incapable of making safe decisions (intoxicated, confused, etc.). Documentation as elopement should mean immediate escalation to notify police department, public safety and the house supervisor. If an elopement patient is found by the police department, it is imperative that we insist the patient return to the ED to complete the MSE. A mental health examination must be part of the MSE for psychiatric chief complaints.

Review of the hospital's documented titled, "Affidavit (a written statement confirmed by oath, for use as evidence in court) in Support of Application For Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 07/04/23, showed a notarized affidavit completed by Patient #22's father. Patient #22's father wrote that she told him that there was no need to keep trying, she just wanted to be done with life. That was not the first time, and she just wanted to be left alone to do what she needed to end it all.

Review of the hospital's documented titled, "Affidavit in Support of Application For Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 07/05/23, completed by Staff R, Police Officer, showed that he responded to Patient #22's home regarding a suicidal person. Upon arrival he observed Patient #22 to be extremely agitated and combative. Patient #22's husband reported to Staff R that she had been drinking all day and making suicidal statements and looking for objects or pills to take for the past few hours. Staff R and two other officers had to restrain Patient #22 and placed her into the back of their patrol car. While Patient #22 was being placed in the patrol car she stated, "Fuck it, I'm going to kill myself!" Patient #22 was transported to St. Mary's Medical Center.

Review of the hospital's documented titled, "Affidavit in Support of Application For Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 07/04/23, showed a notarized affidavit completed by Patient #22's husband who wrote that Patient #22 told him on several occasions she was going to kill herself. She then went to the kitchen to raid the medicine cupboard for pills to take.

Review of Patient #22's EMS record showed the following:
- EMS was dispatched on 07/04/23 at 11:39 PM, for a psychiatric patient.
- When EMS arrived on scene Patient #22 was seated in the back of a cop car. Patient #22 was alert and screaming as loud as she possibly could with a Glasgow Coma Score (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) of 14, and did not appear to be in respiratory distress.
- Police reported to EMS that Patient #22 made suicidal statements. She was restrained using handcuffs behind her back and leg shackles.
- Patient #22 was thrashing around and striking her head against the back seat of the police car.
- Patient #22 could not be calmed after attempting to verbally deescalate (reduce the intensity of a conflict or potentially violent situation). It was determined that is would be safest for the patient and for the EMS crew, if the patient was sedated chemically for transport. Patient #22 was given Ketamine (short acting anesthetic) intramuscularly (IM, in the muscle), placed on a stretcher and transported to St. Mary's Medical Center, and arrived on 07/05/23 at 12:28 AM.

Review of Patient #22's medical record from St. Mary's Medical Center showed the following:
- She was a 31-year-old female who presented to the ED on 07/05/23 at 12:13 AM, via EMS and Police Officers for SI.
- The history of present illness showed that when police and EMS arrived the patient kicked and screamed and punched the house. She told her family she wanted to kill herself and looked for pill bottles. Patient #22 was given Ketamine, and was somewhat sedated upon her arrival to the ED.
- Staff P, Physician, documented that when Patient #22 woke up she began screaming stating that her father and brother were "fucking liars" and she did not want to kill herself. She was uncooperative and told the physician that psychiatric hospitals "do not fucking work."
- Vital signs upon arrival were blood pressure (BP, a measurement of force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) 127/98, a pulse (the number of heart beats per minute) of 125, and respiratory rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) of 25.
- Blood work was obtained which showed an alcohol level of 93 (normal is less than 10), and was otherwise unremarkable.
- At 12:15 AM, Patient #22 was assigned a one to one (1:1, continuous visual contact with close physical proximity).
- A C-SSRS documented at 1:31 AM, showed that Patient #22 was at a high risk for suicide.
- At 1:38 AM, Patient #22 became agitated, yelled and screamed, tried to pull out her IV, made fists and threatened staff.
- At 1:41 AM, Patient #22 was moved to a different room which made the patient more combative, she attempted to remove her IV again, thrashed, kicked and tried to stand up. An order was placed for four-point restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) and medications.
- Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulty) was administered at 12:33 AM, 1:03 AM, and 1:30 AM, and Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder [manic depression]) was administered at 1:04 AM and 2:44 AM.
- Four point restraints were removed at 2:15 AM, and the patient continued to rest in her bed.
- A C-SSRS documented at 2:15 AM, showed that Patient #22 continued to be at a high risk for suicide.
- At 5:30 AM, Staff P, Physician, documented that Patient #22 awakened and ate a sandwich and drank liquids. She was far more coherent and cooperative. At 6:00 AM, the Behavioral Health Assessor was called to evaluate Patient #22, they reported that they would have the staff member that started at 7:00 AM assess the patient for possible placement.
- Staff L, Physician, documented that Patient #22 became agitated and aggressive at 8:30 AM, and was insistent on leaving. Staff were able to talk the patient into letting them remove her IV. Patient #22 reported that she had been to psychiatric hospitals in the past and they did not work. The patient stated that she was leaving and they could not stop her. Patient #22 was extremely agitated and upset, she walked out of the ED under her own powers, with her hospital gown on. She would not wait to put on her clothes. Staff attempted to talk down the patient and make her understand, but now that she was sober, she did not understand why she was there and wanted to leave, again the patient was extremely agitated, angry and uncooperative. Due to the patient's sobriety, feeling better and poor affidavits he could not hold her against her will. Patient #22 was alert and oriented to herself, place and time and left AMA. Her ED discharge disposition was eloped.
- At 8:37 AM, nursing documentation showed that Patient #22 became agitated and stated she was leaving, then proceeded to rip out her own IV. The nurse then safely removed the IV from the patient's right arm. Several attempts were made to de-escalate, but were unsuccessful. Patient #22 then ripped off her cardiac monitor leads (noninvasive monitors of the heart that attach to the patient's chest and record heart rhythm) and stated that she was leaving the ED. Staff informed the patient that the police would be called since she was brought to the ED for SI. Patient #22 walked out the front door and continued to walk to the sidewalk. The nurse and another staff member followed the patient to ensure safety, Security Officers were called and also witnessed the patient walking out of the ED. Police were called and informed of the situation. Police picked the patient up down the street.
- At 8:45 AM, the behavioral health assessor arrived to evaluate Patient #22 and was updated on the current situation.
- There were no C-SSRS evaluations documented after 2:15 AM, when she scored a high risk for suicide.
- There was no AMA form, or documentation of a conversation that included the risks and benefits of leaving prior to receiving treatment in Patient #22's medical record.

Review of Hospital A's digital video recordings titled, "1 - 2023-07-05 08-22-00-155," dated 07/05/23, showed a view of the ED hallway leading to the ED waiting room. Patient #22 walked into the hallway, still inside the ED, and staff walked behind her. Patient #22 was wearing a hospital gown and pulled the right side to cover her backside with her left hand. Staff then removed a blood pressure cuff from her right lower leg. Patient #22 reached into the front of her hospital gown and then what appears to be a monitoring device falls to the floor by her feet. Patient #22 then turned and walked out of the ED doors into the waiting room, three staff members followed her to the waiting room. There was no time stamp on the video.

Review of Hospital A's digital video recordings titled, "1 - 2023-07-05 08-22-00-008," dated 07/05/23, showed a view of the outside of the ED entrance and parking lot. Patient #22 exited the main ED entrance and walked along the building's sidewalk. She was in a hospital gown and barefoot. Three staff members exited behind her and appeared to say something to her. She stopped, turned around and appeared to say something back to them and walked away. Staff followed Patient #22, Patient #22 then looked back, turned and ran away from staff. She ran around the side of the building across a parking lot, and into a grassy area, where she was no longer in camera view. Staff followed her a short distance, and stopped outside the ambulance entrance. The Security Officer got into a car and followed Patient #22 out of the hospital's entrance. There was no time stamp on the video.

Review of Patient #22's EMS record showed the following:
- EMS was dispatched on 07/05/23 at 8:28 PM, for a suicidal patient.
- When EMS arrived on scene, Patient #22 was seated in the back of a patrol car attempting to bang her head against the car. The patient was handcuffed and very agitated. Patient #22 suffered from mental illness and had not been taking her medications for days.
- Patient #22 told EMS that she was tired and not going back to a facility because it didn't help, she was just going to get out and harm herself anyway. She wanted the police to shoot her as well as for EMS to overdose her on medications.
- Patient #22 attempted to get out of restraints, get off of the cot, and continued to be very agitated.
- During transport to Hospital B, EMS administered medications intramuscularly (IM, in the muscle) and the patient did stop screaming, but continued to try to get off the cot. She would not leave monitoring devices on.
- Family requested EMS transport Patient #22 to Hospital B and they arrived at 9:06 PM.

Review of Patient #22's medical record from Hospital B showed the following:
- She presented to the ED on 07/05/23 at 9:30 PM with SI. The patient reported that her husband called the police and she was taken to the hospital, she was not currently having SI and denied any attempts to harm herself.
- Patient #22 became agitated and had to be placed in four point restraints to protect herself and staff. Patient #22 was given medications IM to help her calm down, and a behavioral health assessment was ordered for when the patient was awake. Affidavits were on the chart.
- A behavioral health assessment showed that the patient was alert and oriented to who she was, where she was and the time. Her mood was anxious (a feeling of fear or worry experienced intermittently) and she denied any thoughts of SI. Patient #22 became angry, hostile and refused to discuss her actions when arriving to the ED. Patient #22 attempted to grab the police officers gun and admitted that she grabbed the gun with the intent of shooting herself. Patient #22 had poor insight and was unable to do a safety plan. The recommendation was for Patient #22 to be admitted involuntarily for inpatient psychiatric treatment.

During a telephone interview on 08/03/23 at 9:30 AM, Staff A, RN, stated that her shift began at 7:00 AM on 07/05/23. She was told by the night nurse that Patient #22 was brought into the ED intoxicated. She was combative and had been given medications to help her sleep. A 1:1 was assigned to the patient who informed staff that she tried to take out her IV. Patient #22 stated that she was leaving and the patient was "with it." The Behavioral Health Assessor was on her way to evaluate Patient #22, so Staff A tried to calm the patient down. Staff A asked Patient #22 if she knew why she was in the ED and told her that she needed to be evaluated before she left. Patient #22 tried to rip out her IV, so Staff A removed it. Staff A told Patient #22 that they could not let her leave, but the patient stated that she was leaving and they could not stop her. Staff A and two other staff members followed the patient out of the ED and watched her until the police showed up. Staff A felt that Patient #22 was mentally cognizant, but emotionally she wasn't sure. The patient was very upset and stated that psychiatric hospitals did not help her. She did not remember the physician assessing the patient after she woke up, before she left the ED. She tried to explain the risks of leaving the hospital AMA, and told the patient that police would be called if she left the hospital. A C-SSRS needed to be completed initially and then just before discharge. Staff were not able to de-escalate Patient #22. Since Patient #22 had come into the ED with SI, she would have needed to be evaluated by a Behavioral Health Assessor before she could be discharged.

During an interview on 08/03/23 at 10:00 AM, Staff L, Physician, stated that when he came on shift at 7:00 AM on 07/05/23 Patient #22 was still in the ED beginning to wake up and come around. Patient #22 was agitated and did not want to stay in the ED. Patient #22 said she was not suicidal, she wanted to leave and he felt there was nothing the hospital could do to get her to stay. She was still waiting for a behavioral health assessment when she left the hospital. She did not sign AMA papers, so technically she eloped from the hospital. A reasonable person would absolutely leave a hospital in a hospital gown and barefoot, she was not happy about being there. She had a steady gait (a person's manner of walking) was alert and oriented to herself, the place and time, and was making sense.

During an interview on 08/03/23 at 10:30 AM, Staff M, RN, stated that she was working the night shift on 07/05/23 when Patient #22 presented to the ED. The patient arrived via EMS and police and was very intoxicated, upset, and became a danger to herself. Patient #22 attempted to leave the hospital, threw herself down and bit staff. Patient #22 just wanted to leave the ED, but made several suicidal statements. After they administered medications and placed the patient into restraints she was able to calm down. Patient #22 slept for the rest of Staff M's shift. Clinical practice was to redraw an alcohol level prior to having a behavioral health assessment.

During an interview on 08/03/23 at 12:00 PM, Staff O, Certified Nurse's Aide, stated that she performed the 1:1 for Patient #22 on 07/05/23. Patient #22 slept almost the entire time she sat with her. Patient #22 woke up and left the hospital. A nurse and a security officer followed the patient outside, she was concerned for the patient's safety and did not feel good about the patient's ability to make good decisions.

During a telephone interview on 08/07/23 at 4:55 PM, Staff P, Physician, stated that she worked the night shift on 07/05/23 when Patient #22 presented to the ED and transferred her care to Staff L, Physician, at 7:00 AM when she went off shift. Patient #22 was brought into the ED by EMS after she became out of control at her home and threatened suicide. EMS had given the Patient Ketamine in-route to the hospital so she was very drowsy when they arrived. The patient was listening but was unable to answer questions. When Patient #22 woke up more she was angry, very intoxicated and yelled at staff. The patient was given medications to help her calm down and sleep. Staff P did not call for a behavioral health assessment until 6:00 AM due to the patient's drowsiness and inability to cooperate. The Behavioral Health Assessor was going to see Patient #22 around 7:00 AM. There were three affidavits completed for the patient so Staff P did not feel that she needed to fill out another. When Patient #22 woke up around 6:30 AM, she was calm, relaxed, her speech was no longer slurred and she was not yelling. Staff P did not go in to re-evaluate the patient, but wanted the Behavioral Health Assessors to see Patient #22 before she was discharged. Staff P felt that the affidavits completed for Patient #22 were very specific and the patient had a history of SI. Staff P did try to explain to Patient #22 why she needed to stay and be evaluated by the behavioral health assessor, but the patient just yelled at her.

During a telephone interview on 08/09/23 at 11:00 AM, Staff S, Security Officer, stated that he was called to the ED on 07/05/23 when Patient #22 attempted to leave. Nursing staff told him that the patient wanted to leave and that he should not try to stop her. Patient #22 was very angry, upset and dead set on leaving. He wasn't sure what to do since staff told him not to try to stop the patient from leaving. He followed her in his car as she walked away from the hospital. Police Officers did make contact with Patient #22 after she left the hospital, but he did not see her get into the car or go with police. He did not know who the police officer was that spoke with Patient #22 and he did not know what was discussed. After he saw police speaking with Patient #22 he went back to the hospital.

During a telephone interview on 08/09/23 at 12:55 PM, Staff R, Police Officer, stated that on 07/04/23 he was dispatched to a call for a psychiatric emergency at Patient #22's home. When he arrived Patient #22 was completely out of her mind, saying things that didn't make any sense. When they went to transport her to St. Mary's Medical Center the patient had to be carried to the patrol car. Staff R placed a call to EMS to assist with transport. EMS had to administer Ketamine to Patient #22 to get her in the ambulance. As soon as Patient #22 woke up from the Ketamine she was completely out of control again. He completed an affidavit on her related to suicidal statements that were made, and her history. He was very familiar with and had completed several affidavits for unsafe patients. He did not feel that Patient #22 was simply under the influence of alcohol or drugs, but having a psychiatric emergency.

During a telephone interview on 08/09/23 at 3:00 PM, Staff B, ED Director, stated that affidavits assisted to keep a psychiatric patient in the ED until a behavioral health assessment could be completed. The Behavioral Health Assessor and the ED physician would make a decision together regarding patient treatment and admission. For a patient to be discharged AMA, the patient would need to be able to make good decisions. Her expectation for ED staff was to make sure each patient was safe throughout their stay and at discharge.

Although attempted we were not able to determine what officer spoke with Patient #22 after she left the ED.

Review of Patient #6's medical record showed the following:
- He presented to the ED on 03/28/23 at 1:16 PM with a chief complaint of seizure (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness).
- At 1:28 PM, his blood pressure was documented as 238/154 (normal is approximately 90/60 to 120/80), and his heart rate was 114 beats per minute (BPM, normal is approximately 60 to 100 BPM).
- At 1:36 PM, Staff N, RN, documented that Patient #6's neurological (neuro, relating to or affecting the nervous system) exam was normal.
- At 1:51 PM, Staff L, ED Physician, documented that the patient had two episodes of fainting over the past month. The most recent was five days prior to his ED visit, and he was shaking afterward. He had no history of seizures, but did have a history of high blood pressure. Patient #6 requested a note to return to work. Staff L documented that Patient #6's vital signs were stable, no EMC was identified and that Patient #6 was safe for outpatient follow up. Staff L's diagnosis was weakness.
- An excuse letter, dated 03/28/23 noted that Patient #6 was seen and treated in the ED and was able to return to work on 03/28/23.
- He was discharged home at 2:15 PM.
- No additional blood pressure readings were documented. No diagnostic tests were performed. No medications were administered. No medications were prescribed at discharge.

During a telephone interview on 08/07/23 at 11:00 AM, Staff N, RN, stated that she did not recall Patient #6. If a patient came in with an elevated BP like Patient #6, she would have immediately rechecked their BP, notified the provider and documented the initial BP and recheck BP.

During an interview on 08/03/23 at 10:00 AM, Staff L, ED Physician, stated that 99 percent of the time, he did not know what caused a syncopal episode. If a patient was not symptomatic, he would not address an elevated blood pressure. He stated that "downtown, everyone's blood pressure is 220" and that Patient #6 had a medical management issue, "not an EMC."

During an interview on 08/09/23 at 3:00 PM, Staff B, ED and ICU Director, stated that she would expect staff to retake an abnormal vital sign, document it, notify the provider, and make a note about what the provider said. She would expect the provider to assess the patient and see if there was anything they needed to do.

Review of Patient #29's medical record showed the following:
- He was a 29-year-old male who presented to the ED via EMS on 06/21/23 at 7:31 PM, with a chief complaint of an addiction problem.
- Staff P, Physician, documented that Patient #29 reported having thoughts that he knew were not real. He had a history of methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) use and admitted to use that day. He was in a treatment facility one month prior. He denied SI or homicidal ideation (HI, thoughts or attempts to cause another's death). He was paranoid (excessive suspiciousness without adequate cause) and anxious but cooperative.
- Vital signs obtained during triage showed a BP of 155/94, and a heart rate of 112.
- Blood work was obtained and showed an elevated white blood cell count (WBC, the number of white cell [infection-fighting cells] in the blood, normal range is 3.5 to 10.5) of 16.90, elevated Creatinine (blood test that shows how the kidney is functioning, normal range is 0.6 to 1.2) of 1.3, elevated calcium (amount of calcium in the blood, normal range is 8.6 to 10.4) of 10.5, Total Protein (measurement of albumin and globulin levels, high levels may mean indicate inflammation or infection, normal range is 6.4 to 8.4) of 8.8, albumin (a measurement of