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Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) and failed to follow their policy that addressed individuals who presented for treatment for one patient (#25) of 30 Emergency Department (ED) records reviewed from 04/01/23 through 10/30/23. 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 monthly ED census over the past six months was 2,728.

Findings included:

Review of the hospital's undated policy titled, "EMTALA", showed that if an individual presents to an "area of the hospital" other than the ED and seeks or appears to need treatment for an EMC, the following will occur: If the individual is within the main building of the hospital and it can be done safely, the individual will be escorted to the ED. If there is concern that this cannot be done safely, then a call will be made on 3501 to the ED or if the individual's condition presents an imminent (code) situation, then a call will be made on 3333. If the individual is at another area of the hospital, Boone Health will provide an MSE to the extent that qualified personnel are available and can do so. These personnel who are present will function as first responders. "Area of the Hospital" for purposes of this policy means any part of the hospital building or grounds.

Review of the hospital's undated policy titled "Medical Staff Rules and Regulations - MSEs", showed that individuals that present to the hospital seeking treatment or examination, should receive a MSE to rule out an EMC.

Patient #25 was driven to the hospital by a friend and arrived at the main entrance of the hospital. The friend entered the main entrance and asked for immediate help but was directed by the front desk staff to drive to the ED entrance.
Prior to arrival the patient complained of not feeling well, a sore throat, and a rash. During her transport to the hospital, she became unconscious.

Review of Patient #25's ED medical record, dated 04/13/23, showed:
- She was a 29-year-old female who arrived at 2:19 PM.
- Two hours prior to her arrival at the ED, she took a dose of an old prescription antibiotic and experienced an odd feeling of itching, and was overall, not feeling well. She took two antihistamine (a medication used to relieve allergy symptoms, such as hay fever, hives, and reactions to insect bites or stings) tablets.
- At 2:20 PM, her blood pressure (BP, normal was approximately 90/60 to 120/80) was low, at 78/39 and she was assessed by an ED Physician.
- At 2:24 PM, an intravenous (IV, in the vein) line was inserted.
- At 2:25 PM, blood work was drawn. Her BP was 100/49.
- At 2:27 PM, IV fluids were administered, along with IV steroids (drugs used to relieve swelling and inflammation).
- At 2:29 PM, she received a dose of IV antihistamine. Her strep throat culture was negative.
- At 2:30 PM, her BP was 121/66.
- At 4:25 PM, her BP was 134/79.
- At 7:15 PM, she was discharged home with diagnoses of anaphylaxis (severe, life threatening allergic reaction) and hypotension.

The failure of the hospital staff to follow their internal policy related to a individual who presents to any area other than the hospital ED delayed emergency medical care to determine an emergency medical condition when Patient #25 was driven to the main hospital entrance seeking emergency care. The ED is located on the opposite side of the main entrance. Travel to the ED required leaving the hospital campus and traveling down side streets to arrive at the ED entrance, which had the potential to further delay emergency care.

Review of Patient #14's first medical record, dated 08/07/23 at 11:28 AM, showed that she was a 51-year-old female who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.), due to alcohol intoxication. She reported that she consumes a fifth of vodka daily. She denied any drug use. During triage (process of determining the priority of a patient's treatment based on the severity of their condition) she stated, "I just want to kill myself. I would use a knife." She repeated that statement multiple times. She kept insisting that she needed to leave. At 11:49 AM, she left the ED, her disposition was left without being seen (LWBS). Law enforcement was alerted.

Review of Patient #14's second medical record, dated 08/07/23 at 2:58 PM, showed that she presented to the ED via EMS with complaints of alcohol intoxication and drunk in public. During triage she stated again that she was suicidal (thoughts of causing one's own death). At 5:38 PM, Patient #14 left against medical advice (AMA). Authorities were alerted again.

The police department found the patient and took her to Hospital B where she was placed on a 96-hour hold (court-ordered evaluation by behavior specialist to determine if a person is safe to themselves and others) and admitted for further care on 08/07/23.

Please refer to 2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) of 30 Emergency Department (ED) records reviewed from 04/01/23 through 10/30/23. 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 monthly ED census over the past six months was 2,728.

Findings included:

Review of the hospital's undated policy titled "Medical Staff Rules and Regulations - MSEs", showed that individuals that present to the hospital seeking treatment or examination, should receive a MSE to rule out an EMC.

Review of Patient #14's first ambulance report, dated 08/07/23 at 10:45 AM, showed that law enforcement located this female lying in a parking lot and was slow to respond to officers. She was initially unaware of Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) upon approach. She was slow to wake up with verbal prompts. Throughout EMS interaction, the patient refused to answer most questions, proving to EMS that she was alert and oriented only to self. After evaluation, the patient requested EMS transport to a hospital ED, but refused to inform EMS as to why she wished to be transported. Upon arrival to the ED, patient care was transferred to ED nursing staff and patient then informed nursing staff that she was suicidal (SI, thoughts of causing one's own death).

Review of Patient #14's first ED medical record, dated 08/07/23, showed that:
- She was a 51-year-old female who arrived in the ED via ambulance due to alcohol intoxication at 11:21 AM.
- At 11:22 AM, her triage (process of determining the priority of a patient's treatment based on the severity of their condition) assessment noted the patient presented for alcohol intoxication, confirmed she was homeless, reported drinking a fifth of vodka that day and denied any drug use. During her triage, she said "I just want to kill myself. I would use a knife." multiple times and insisted she "needs to leave". Multiple staff members tried to talk the patient into being evaluated. 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) showed her as high risk. The protocol orders listed in the triage note included one to one observation (1:1, continuous visual contact with close physical proximity), elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury), notify provider, prepare a psychiatric (relating to mental illness) safe room (a room that has been cleared of any objects a patient might use to harm themselves or others), paper scrubs, and to provide resources at discharge.
- At 11:23 AM, her vital signs (VS, body temperature, blood pressure, heart rate, and breathing rate) were blood pressure (BP, a measurement of the 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), 115/87, temperature (T, degree of hotness or coldness of the body, normal is 98.6 °F) 97.7 degrees, heart rate (HR, the number of times the heart beats within a certain time period, usually a minute) 80, respiration rate (RR, the number of breaths per minute, normal range for adults at rest is 12 to 20) 16, and oxygen saturation (SPO2, measure of how much oxygen is in blood) 100%.
- At 11:39 AM, she denied treatment, asked to leave, and left the ED. Disposition was charted as left without being seen (LWBS).
- At 11:40 AM, Staff AA, ED Physician, noted that Patient #14 left prior to seeing her. A nurse called 911 due to the patient's intoxication.
- At 11:41 AM, Staff Y, ED Clinical Supervisor, noted that she insisted that she needed to leave and verbalized multiple times of SI. Multiple staff members tried to talk the patient into being evaluated. The patient ripped off the heart monitor and walked out of the ED.
- At 11:45 AM, Staff BB, ED Social Worker (EDSW), noted that Patient #14 reported SI, but had no plan. She requested to leave, and EDSW tried to convince her to stay for mental health treatment. Patient #14 denied treatment, asked to leave, and left the department. EDSW contacted Boone County Joint Communications to report patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility).

During a phone interview on 11/01/23 at 1:55 PM, Staff BB, EDSW, stated that she had been called to assist with the triage of Patient #14 during her first ED visit. She was pretty intoxicated. The patient had voiced to the triage nurse that she wanted to harm herself with a knife. When Staff BB spoke with her, she did not disclose any type of plan, but had stated repeatedly that she was, "tired of living," and she just "wanted to die." When Staff BB attempted to discuss a treatment plan, Patient #14 became agitated. She just kept repeating, "I'm tired of living," and "I just want to die." The next thing she knew, Patient #14 pulled the heart monitor wires and the blood pressure cuff off, got up and left the room. She stated that staff members attempted to get her to stay for treatment, but she just stated, "I want to leave." When Patient #14 left the ED, she contacted local law enforcement out of concern, to notify them that the patient was intoxicated.

During an interview on 11/01/23 at 11:20 am, Staff Y, ED Clinical Supervisor, stated that Patient #14 came in by EMS, and was uncooperative with staff and answering questions. She was highly intoxicated, got agitated, and wanted to leave. She started ripping everything off. Other staff and Staff BB were in the room. The protocol would be initiated if the patient's C-SSRS evaluation score was moderate to high risk. The ED would start 1:1 observation, clear the room, and secure the patient's belongings at the nurses' station. 1:1 observers were to fill out a form and place in the patient's chart. When asked what elopement was, Staff Y responded "That's a great question," its patients leaving the hospital not in their right mind and unable to make decisions for themselves. A disposition of elopement was not seen a lot. Staff could refer to the policy or ask the SW if they had questions regarding which disposition to use.

During an interview on 11/01/23 at 2:20 PM, Staff Z, ED Manager, stated that he could not find any 1:1 observation documentation for either visit for Patient #14.

During a concurrent interview with Staff CC, RN, and Staff Z, ED Manager, on 11/01/23 at 2:20 PM, they stated that ED staff were not allowed to hold patients in the ED per the hospital's legal staff.

During an interview on 11/01/23 at 1:30 PM, Staff AA, ED Physician, stated that Patient #14's first visit, she arrived via EMS, and by the time she got to see her, the patient had walked out. Staff called 911.

Review of Patient #14's second ambulance report, dated 08/07/23 at 2:31 PM, showed EMS found her sitting on a curb by a building, and still had her hospital bracelet on. She was holding a gallon jug of vodka. She refused to answer questions. She had discharge paperwork for alcohol intoxication from her earlier ED visit, approximately three hours prior. When she stood up, she defecated on the Emergency Medical Technician (EMT).

Review of Patient #14's second ED medical record, dated 08/07/23, showed that:
- At 2:58 PM, she arrived via ambulance, with a complaint of alcohol intoxication and drunk in public.
- At 2:59 PM, she was assessed by an ED Physician.
- At 2:59 PM, Staff CC, ED RN, triage assessment noted EMS was called again due to the patient sitting up against a wall of a gas station and appeared to be under the influence of alcohol with a large bottle of vodka sitting behind her. Patient refused to answer any questions, therefore EMS had to bring patient to the ED to be medically evaluated. During triage, the patient would intermittently respond to some questions but was not clear with responses due to slurred speech. BP was 125/75, C-SSRS risk level was high risk. Response protocol was initiated which included 1:1 observation, EP, notify provider, prepare a psychiatric safe room, paper scrubs, notify dietary, and provide resources at discharge.
- At 3:16 PM, ethyl alcohol (ETOH, amount of alcohol in the blood. Normal range is less than 10) was elevated at 386, urinalysis (a laboratory examination of a person's urine) returned positive for a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra), and she tested negative for illegal drugs.
- At 3:41 PM, a Point-of-Care testing (POC, medical testing done at or near the point of care of patient) Arterial Blood Gas (ABG, a blood test that measures the amount of oxygen and carbon dioxide in the blood) test was completed, and abnormal findings include Partial Pressure of Oxygen (pO2, measures the pressure of oxygen dissolved in your blood. It helps show how well oxygen moves from your lungs to your bloodstream. Normal range is 74-108) was low at 47.
- At 3:48 PM, Staff AA, ED Physician, noted Patient #14 had altered mental status, and appeared under the influence. Patient #14 was not talking at first, then had slurred speech when she did start talking to the RN. She admitted to SI, but had no plan.
- At 3:55 PM, Staff CC, ED RN, noted she was disorientated, restless, alert to person only, slurred speech, resistive to care, alcohol intoxication, diarrhea, and urinary incontinent upon arrival.
- At 4:09 PM, her care was transferred from Staff AA, ED Physician to Staff X, ED Physician Assistant (PA).
- At 5:07 PM, her VS were BP 157/111, HR 129, and SPO2 99%.
- At 5:10 PM, Staff CC, ED RN, rounding documentation noted Patient #14 was restless and stated "I need to go to the bathroom." She told Patient #14 that she did have a female external urinary catheter in place, but the patient removed it from herself. She asked the patient to stand so they could place new clean linens on the bed while Staff BB, EDSW, was at bedside conversing with patient. Patient then began to say "I need to go. I need to go. Where's my debit card? I need to go." Which mimics the same statements and attitude patient exhibited earlier today upon her first visit, RN and EDSW attempted to inform the patient that they could help her feel better and get her the long-term help she was seeking, but if she left again, they would be legally forced to notify law enforcement of her against medical advice (AMA) status while she also claims to be SI. A few minutes later, patient started dressing herself and said "I need to go." Staff X, ED PA, was notified. The patient walked to the bathroom and then shortly after wandered out to a side exit of the ED, became lost, needed a provider to buzz the patient back into the ED and then Staff CC asked patient if she was looking for the exit still and patient replied "Yeah." Staff CC then showed the patient the direction to the exit. Law enforcement was notified by EDSW immediately.
- At 5:38 PM, Staff CC, ED RN, documented she left AMA, dressed herself, walked to the bathroom, and then to the exit without assistance.
- EDSW noted she was alerted to patient upon her arrival to the ED. Patient #14 arrived via EMS with reports of alcohol intoxication. Patient #14 endorsed SI thoughts at that time but denied a plan. She appeared altered and answered questions after they have been repeated several times. EDSW later spoke with patient who endorses SI again, denied a plan, and requested to leave at that time. EDSW attempted to work with patient to get her to stay to seek mental health treatment. Patient left the ED and EDSW contacted Boone County Joint Communications and updated them on the patient's location and concerns for her safety. EDSW spoke with a law enforcement officer who came to the ED to follow up and obtain a description of patient.
- Staff X, ED PA, noted she was seen walking the department and her VS remained stable. She did not speak with nursing staff, but spoke freely with EDSW. She was supposedly under arrest sometime today. She continued to wander the floors and at one point got stuck in the hallways behind our locked doors. She eventually eloped, and 911 was called, as she was considered a danger to herself.

During a phone interview on 11/01/23 at 1:55 PM, Staff BB, EDSW, stated that during Patient #14's second ED visit, she was returned by EMS. ED staff had prepared room two for her, since it had direct line of sight (LOS, continuous visual contact with the patient) for all staff members. When Staff BB spoke with the patient and asked about intent to harm herself, Patient #14 denied a plan. She had repeated multiple times that she, "wanted to die," and she, "didn't want to live anymore." When they began discussing a treatment plan, she was kind of agreeable to receiving help. The second time Staff BB entered the room, Patient #14 stated that she did not want placement and did not want help. Staff CC, RN, and Staff BB, were both in the room when Patient #14 wanted to "find my debit card and leave." She grabbed her clothes, got dressed, and left the room. Staff BB was present in the room when Patient #14 got dressed. Once the patient left, Staff BB, placed a call to local law enforcement. Staff BB stated that the plan had been to find placement for Patient #14 the entire time. She had not sent any referrals out yet, because the patient's intoxication level was too high for placement. If a patient's alcohol level was too high, they would need to sober up and would be held in the ED. She was unsure whether or not Patient #14 was safe. She had been able to answer questions, she seemed alert and orientated. She was able to walk, wasn't stumbling, but wasn't 100% steady.

During an interview on 11/01/23 at 2:20 PM, Staff CC, RN, stated that she was the nurse assigned on the second ED visit. She had not been aware of the patient's first visit. Patient #14 had been brought in to the ED by EMS. She was drunk and disorderly. It had been difficult to get through the triage process. Patient #14 had not been cooperative and would not respond to questions. She would just look around, or not answer, or only supply half answers. She had asked about SI, but had to ask several times. Patient #14 would answer, "Yeah." She did not verbalize that she had a plan. By the end of the triage questions, she was very antsy. She seemed frantic, and kept searching for answers. The provider asked Patient #14 if she was SI and she would say, "No." But when the EDSW asked if she was SI, then she would say, "Yes." Patient #14 had been cooperative for the first couple of sets of VS, then all of the sudden she was pulling the cords off and the external urinary catheter. She was asking for her debit card. She would say she was, "ready to go." She became frantic and kept asking about her debit card. Patient #14 stated she wanted her clothes, she then got dressed. She asked to use the bathroom and was showed the way. She was trapped in a back hallway and security had to open the door for her, and let her out. Staff called local law enforcement to report that Patient #14 had left the ED and was visibly intoxicated. She was definitely pretty intoxicated and did not want to cooperate. She had been with it enough to demand to leave. Staff CC stated that staff members tried to get Patient #14 to stay and to de-escalate her. She was a danger to herself, something could have happened, or she could injure herself. Staff contacted law enforcement because they were concerned for her safety, she was still saying she was SI. Staff cannot hold a patient against their will or physically hold them down for treatment.

During an interview on 11/01/23 at 1:30 PM, Staff AA, ED Physician, stated that during Patient #14's second visit, she was awake and alert, but she didn't want to talk. She did take her clothes off and was given a paper gown. Patient #14 did eventually report SI. The mental health assessment was based on nursing documentation, and the provider evaluation. At the end of her shift, she signed Patient #14 over to Staff X, ED PA.

During an interview on 11/01/23 at 11:05 AM, Staff X, ED PA, stated that Patient #14 was handed off to her at shift change and she needed to find her psychiatric placement. Staff X was shocked that the ED RN showed her out to the exit. She was not capable of making her own decisions, and she was still intoxicated.

During an interview on 11/01/23 at 11:20 am, Staff Y, Clinical Supervisor, stated that during Patient #14's second visit, she had a 1:1 observer. Patient #14 refused to talk. Her RN and physician did believe she was SI. If a SI patient walked out, we contacted Joint Communications and the Police Department, and gave a description.

During an interview on 11/01/23 at 11:20 AM, Staff Z, ED Manager, stated that psychiatric patients should be 1:1 observation until they have been cleared or admitted to a mental health treatment facility. He would expect his staff to verbally convince a psychiatric patient to stay for treatment.

Review of Police Department E's document titled, "Reporting Officer Narrative - 2023-007248," dated 08/07/23 at 6:31 PM, showed:
- Law enforcement officers had been called for a female wandering around a parking lot, getting into random cars.
- There had been two previous calls in relation to Patient #14. She had presented to Hospital A both times, stated she was SI, and then left the hospital before being treated. She was gone before law enforcement officers could arrive at Hospital A.
- The officer located Patient #14. She was extremely intoxicated, and had appeared to have vomited on herself. She told the officer she wanted to "go to the hospital." She stated that she was having SI thoughts.
- Upon arrival at Hospital B, Patient #14 attempted to leave multiple times. She informed hospital staff that she was very drunk and SI, she wanted to kill herself using a knife.
- 96-hour hold (court-ordered evaluation by behavioral specialist to determine if a person is safe to themselves or others) paperwork was completed.

Review of Hospital B's document titled, "Notice of Admission of Involuntary Patient," dated 08/07/23, showed that Patient #14 was placed on a 96-hour hold for detention, evaluation and treatment due to reasonable cause that she was suffering from a mental disorder or alcohol and drug abuse, and presented a likelihood of serious physical harm to herself or others.

Review of Hospital B's document titled, "Application for 96 Hour Imminent Harm Admission," dated 08/07/03 at 7:13 PM, showed that Patient #14 was highly intoxicated and was observed going into other persons vehicles and drinking from bottles she found inside of the vehicles. She had previously presented to Hospital A twice that day, stating that she wanted to kill herself.

Review of Patient #14's Hospital B ED medical record, dated 08/07/23, showed that:
- At 7:07 PM, she arrived at the hospital very intoxicated, reporting that she was SI and would use a knife to stab herself.
- She was being admitted on a 96-hour hold.
- She reported drinking one pint of vodka per day, but recently as much as a gallon per day for the last few days.
- She had been experiencing auditory and visual hallucinations (hearing and seeing things that are not heard by others, imaginary).
- She was discharged from medical on 08/14/23, and admitted to psychiatry. Ultimately being discharged from the hospital on 08/17/23, 10 days after admission to the ED.