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Based on interview, record review and policy review, the hospital failed to provide appropriate ongoing treatment and monitoring, after an Emergency Medical Condition (EMC) was identified, until the time the patient was appropriately transferred, for one patient (#2) out of 30 Emergency Department (ED) sampled cases reviewed from 04/11/23 through 09/11/23. Patient #2 presented to the ED seeking treatment for a mental health issue. She was placed in a room and treated for a critically low level of potassium (an essential mineral; low levels of potassium can lead to irregular heart rhythms). After treatment she was awaiting transfer to an inpatient psychiatric hospital. She was only observed via video monitor and through the window to her room, for over seven hours. The ambulance arrived to transport the patient and when the nurse entered the room she found the patient unresponsive and pulseless. The hospital's average monthly census over the past six months was 7,893.

Findings included:

Review of the hospital's policy, "Ministry Wide Compliance Emergency Medical Treatment and Labor Act (EMTALA) Requirements Policy," dated 08/24/21, showed that a Medical Screening Examination (MSE) was a process required to determine if an Emergency Medical Condition (EMC) exists. An EMC was any condition that may result in a risk of impairment or dysfunction to a bodily organ, or part of the patient, if not treated in the foreseeable future. The screening must be completed within the capabilities of the hospital and must determine what, if any, further medical examinations and/or treatments may be required to stabilize the patient. Stabilizing treatment was the treatment necessary to stabilize an EMC. Stabilized means that within reasonable clinical confidence, the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment could be reasonably performed, as an outpatient, or later as an inpatient.

Review of the hospital's policy, "Mercy East Behavioral Health Patient Observation Rounds," dated 05/16/22, showed that all patients undergo standard supervision safety observation during each 15-minute safety check. Responsibilities for rounds are as follows; a co-worker rounds as ordered for each patient every 15 minutes at irregular intervals, not to exceed 16 minutes; all rounds are documented in real time; and patient observations include visualization of the patient and their surrounding environment. For patients visualized in their bed, co-workers observe for respirations/breathing signs/sounds and are alert to the patient's positioning to ensure patient safety. To ensure nursing oversight and integrity of the rounding process, patient observation rounds are made by a nurse at least every two hours throughout the duration of the shift.

Review of Patient #2's ED record showed:
- She was a 48-year-old female that presented to the ED, via ambulance, on 04/21/23, at 11:44 AM, for a psychiatric (relating to mental illness) evaluation. She reported that she was drugged at her niece's house so she walked to a community center where an ambulance was called.
- She had a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), depression (extreme sadness that doesn't go away), anxiety (a feeling of fear or worry experienced intermittently) and substance abuse.
- She was placed in Room 60 and 15-minute observations were initiated.
- Blood test results showed her potassium level was critically low at 2.7 millimoles per liter (mmol/L; unit of measurement), normal range was 3.5-5.0 mmol/L.
- Electrocardiogram (ECG; test that records the electrical signal from the heart to check for different heart conditions) results showed an "abnormal ECG" with the following findings; sinus rhythm (normal heart rate); borderline prolonged PR interval (an electrical measurement that shows how well electrical signals pass between the atria and the ventricles); an interval over 200 milliseconds (ms; a unit of measurement) was prolonged, the patient's PR interval was 204ms; prolonged QTc (represents the time it takes for the heart ventricles to contract and relax), any time greater than 440ms in men, or 460ms in women, was prolonged. The patient's QTc interval was 492ms; non-specific (not necessarily caused by a medical condition) ST (when the ventricle is contracting but no electricity is flowing through it) changes; and delayed anterior (front) R-wave progression (the heart's electrical current as it passes through the ventricle's walls; the R-wave should increase gradually and then diminish, if there was no gradual increase the R-wave progression would be abnormal).
- At 11:44 AM, Staff J, Medical Doctor (M.D.), documented that the patient's medical work-up was concerning for mild alcoholic hepatitis (inflammation of the liver), that her bilirubin (byproduct of the breakdown of red blood cells) was slightly elevated and that the ECG showed U waves (last and smallest wave on ECG after the T wave; can indicate low potassium). He noted that after her electrolytes (minerals in the blood and other body fluids that carry an electric charge) were replaced, blood tests would be re-ordered, and she would be reassessed but would "likely be stable for admission to behavioral health."
- At 5:25 PM, Staff M administered the first round of IV potassium. At 7:52 PM, Staff M administered the second round of IV potassium.
- At 9:54 PM, a repeat blood draw was ordered, at 10:37 PM the blood work resulted, and the patient's potassium was 3.5 mmol/L. It was noted that the sample was "slightly hemolyzed (break down of red blood cells due to the mishandling of blood during routine blood collection and transport). Results may be falsely elevated."
- At 11:11 PM, Staff M, documented that Staff R, M.D. stated "patient ok to transfer." There was no documentation from Staff R, M.D. at any time on Patient #2.
- At 12:10 AM, Staff N, RN, documented that she assumed the care of Patient #2 from Staff M, that the patient was resting in bed, was in no apparent distress (NAD), that her respirations were even and unlabored, and that the patient was able to move freely in bed and self-adjust for comfort.
- At 2:11 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 3:59 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 5:30 AM, 15 minute observation documentation on Patient #2 stops.
- At 5:49 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 6:30 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 6:58 AM, Staff N documented "Emergency Medical Services (EMS) arrives to transport for inpatient admission. Patient found to be cool to touch, not breathing and no pulse. Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) immediately initiated."
- At 7:07 AM, Patient #2's time of death was called.

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 (#2) of 30 Emergency Department (ED) records reviewed from 04/11/23 through 09/11/23. 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 7,893.

Findings included:

Review of the hospital's policy, "Ministry Wide Compliance Emergency Medical Treatment and Labor Act (EMTALA) Requirements Policy," dated 08/24/21, showed that a MSE was a process required to determine if an EMC exists. An EMC was any condition that may result in a risk of impairment or dysfunction to a bodily organ, or part of the patient, if not treated in the foreseeable future. The screening must be completed within the capabilities of the hospital and must determine what, if any, further medical examinations and/or treatments may be required to stabilize the patient.

Review of Patient #2's ED record showed:
- She was a 48-year-old female that presented to the ED, via ambulance, on 04/21/23, at 11:44 AM, for a psychiatric (relating to mental illness) evaluation. She reported that she was drugged at her niece's house so she walked to a community center where an ambulance was called.
- She had a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), depression (extreme sadness that doesn't go away), anxiety (a feeling of fear or worry experienced intermittently) and substance abuse.
- Blood test results showed her potassium level was critically low at 2.7 millimoles per liter (mmol/L; unit of measurement), normal range was 3.5-5.0 mmol/L.
- No magnesium level was ordered.
- Liver Function Test (LFTs; group of tests that are performed together to detect, evaluate, and monitor liver disease or damage) showed elevated liver enzymes.
- No fractionated bilirubin (a byproduct of red blood cell breakdown that is eventually digested by the liver and excreted from the body) was ordered.
- Electrocardiogram (ECG; test that records the electrical signal from the heart to check for different heart conditions) results showed an "abnormal ECG" with the following findings; sinus rhythm (normal heart rate); borderline prolonged PR interval (an electrical measurement that shows how well electrical signals pass between the atria and the ventricles); an interval over 200 milliseconds (ms; a unit of measurement) was prolonged, the patient's PR interval was 204ms; prolonged QTc (represents the time it takes for the heart ventricles to contract and relax), any time greater than 440ms in men, or 460ms in women, was prolonged. The patient's QTc interval was 492ms; non-specific (not necessarily caused by a medical condition) ST (when the ventricle is contracting but no electricity is flowing through it) changes; and delayed anterior (front) R-wave progression (the heart's electrical current as it passes through the ventricle's walls; the R-wave should increase gradually and then diminish, if there was no gradual increase the R-wave progression would be abnormal).
- No troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) level was ordered.
- At 11:44 AM, Staff J, Physician, documented that the patient's medical work-up was concerning for mild alcoholic hepatitis (inflammation of the liver), that her bilirubin (byproduct of the breakdown of red blood cells) was slightly elevated and that the ECG showed U waves (last and smallest wave on ECG after the T wave; can indicate low potassium). He noted that after her electrolytes (minerals in the blood and other body fluids that carry an electric charge) were replaced, blood tests would be re-ordered, and she would be reassessed but would "likely be stable for admission to behavioral health."
- At 5:25 PM, Staff M, Registered Nurse (RN), administered the first round of intravenous (IV, in the vein) potassium chloride. At 7:52 PM, Staff M administered the second round of IV potassium chloride.
- No repeat ECG was ordered.
- There was no re-assessment of the patient after the initial testing or treatment.
- At 10:37 PM a repeat potassium level resulted, and was 3.5 mmol/L. It was noted that the sample was "slightly hemolyzed (break down of red blood cells due to the mishandling of blood during routine blood collection and transport). Results may be falsely elevated."
- No additional potassium level was ordered after the second potassium level showed the sample as hemolyzed and possibly falsely elevated.
- At 11:11 PM, Staff M, RN, documented that Staff R, Physician, stated "patient ok to transfer."
- There was no documentation from Staff R, Physician, on Patient #2.

During an interview on 09/13/23 at 8:15 AM, Staff J, Physician, stated that his role in the patient's care was to treat her EMC, which was her electrolyte imbalance. The patient was "going in the right direction and there was no reason to be on high alert." The patient never reported chest pain to him. When he looked at an ECG he would read and interpret the strip himself and not just go by the findings printed on the strip. He did not feel the patient needed a repeat ECG after receiving potassium. He did not believe that between 10:00 PM, and the time that the patient was found unresponsive, that her potassium level would have dropped back down to a critical level. The oncoming provider would have no need to assess this patient, as her "abnormality had been corrected", unless the nurses reported a change in condition.

During a telephone interview on 09/26/23 at 3:00 PM, Staff R, Physician, stated that when she signed onto Patient #2's care she had already been treated and only was awaiting a repeat potassium check before she could be discharged. She stated that she did not review any of the patient's medical record, including any previous test results or Staff J's progress note on the patient. The repeat blood draw showed the potassium was within the normal range. She did not recall seeing the note under the result that stated the sample was slightly hemolyzed. She stated that if the sample was "too hemolyzed" the instrument at the lab would not result a number. The lab would then send out a notification that a re-draw was necessary. She did not receive any notification and since the equipment resulted in a number she would not have had the potassium level re-drawn again. At that time, she gave Staff M the order to discharge Patient #2. She stated there would be no reason for her to assess, or see the patient, unless nursing staff alerted her to a change in the patient's condition.

Based on interview, record review and policy review, the hospital failed to provide appropriate ongoing treatment and monitoring, after an Emergency Medical Condition (EMC) was identified, until the time the patient was appropriately transferred, for one patient (#2) out of 30 Emergency Department (ED) sampled cases reviewed from 04/11/23 through 09/11/23. Patient #2 presented to the ED seeking treatment for a mental health issue. She was placed in a room and treated for a critically low level of potassium (an essential mineral; low levels of potassium can lead to irregular heart rhythms). After treatment she was awaiting transfer to an inpatient psychiatric hospital. She was only observed via video monitor and through the window to her room, for over seven hours. The ambulance arrived to transport the patient and when the nurse entered the room she found the patient unresponsive and pulseless. The hospital's average monthly census over the past six months was 7,893.

Findings included:

Review of the hospital's policy, "Ministry Wide Compliance Emergency Medical Treatment and Labor Act (EMTALA) Requirements Policy," dated 08/24/21, showed that stabilizing treatment was the treatment necessary to stabilize an EMC. Stabilized means that within reasonable clinical confidence, the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment could be reasonably performed, as an outpatient, or later as an inpatient.

Review of the hospital's policy, "Mercy East Behavioral Health Patient Observation Rounds," dated 05/16/22, showed that all patients undergo standard supervision safety observation during each 15-minute safety check. Responsibilities for rounds are as follows; a co-worker rounds as ordered for each patient every 15 minutes at irregular intervals, not to exceed 16 minutes; all rounds are documented in real time; and patient observations include visualization of the patient and their surrounding environment. For patients visualized in their bed, co-workers observe for respirations/breathing signs/sounds and are alert to the patient's positioning to ensure patient safety. To ensure nursing oversight and integrity of the rounding process, patient observation rounds are made by a nurse at least every two hours throughout the duration of the shift.

Review of Patient #2's ED record showed:
- She was a 48-year-old female that presented to the ED, via ambulance, on 04/21/23, at 11:44 AM, for a psychiatric (relating to mental illness) evaluation. She reported that she was drugged at her niece's house so she walked to a community center where an ambulance was called.
- She had a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), depression (extreme sadness that doesn't go away), anxiety (a feeling of fear or worry experienced intermittently) and substance abuse.
- She was placed in Room 60 and 15-minute observations were initiated.
- Blood test results showed her potassium level was critically low at 2.7 millimoles per liter (mmol/L; unit of measurement), normal range was 3.5-5.0 mmol/L.
- Electrocardiogram (ECG; test that records the electrical signal from the heart to check for different heart conditions) results showed an "abnormal ECG" with the following findings; sinus rhythm (normal heart rate); borderline prolonged PR interval (an electrical measurement that shows how well electrical signals pass between the atria and the ventricles); an interval over 200 milliseconds (ms; a unit of measurement) was prolonged, the patient's PR interval was 204ms; prolonged QTc (represents the time it takes for the heart ventricles to contract and relax), any time greater than 440ms in men, or 460ms in women, was prolonged. The patient's QTc interval was 492ms; non-specific (not necessarily caused by a medical condition) ST (when the ventricle is contracting but no electricity is flowing through it) changes; and delayed anterior (front) R-wave progression (the heart's electrical current as it passes through the ventricle's walls; the R-wave should increase gradually and then diminish, if there was no gradual increase the R-wave progression would be abnormal).
- At 11:44 AM, Staff J, Physician, documented that the patient's medical work-up was concerning for mild alcoholic hepatitis (inflammation of the liver), that her bilirubin (byproduct of the breakdown of red blood cells) was slightly elevated and that the ECG showed U waves (last and smallest wave on ECG after the T wave; can indicate low potassium). He noted that after her electrolytes (minerals in the blood and other body fluids that carry an electric charge) were replaced, blood tests would be re-ordered, and she would be reassessed but would "likely be stable for admission to behavioral health."
- At 5:25 PM, Staff M administered the first round of IV potassium chloride. At 7:52 PM, Staff M administered the second round of IV potassium chloride.
- At 9:54 PM, a repeat blood draw was ordered, at 10:37 PM the blood work resulted, and the patient's potassium was 3.5 mmol/L. It was noted that the sample was "slightly hemolyzed (break down of red blood cells due to the mishandling of blood during routine blood collection and transport). Results may be falsely elevated."
- At 11:11 PM, Staff M, documented that Staff R, Physician, stated "patient ok to transfer." There was no documentation from Staff R, M.D. at any time on Patient #2.
- At 12:10 AM, Staff N, RN, documented that she assumed the care of Patient #2 from Staff M, that the patient was resting in bed, was in no apparent distress (NAD), that her respirations were even and unlabored, and that the patient was able to move freely in bed and self-adjust for comfort.
- At 2:11 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 3:59 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 5:30 AM, 15 minute observation documentation on Patient #2 stops.
- At 5:49 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 6:30 AM, Staff N documented "Patient resting in bed. Appears to be sleeping and in NAD at this time. Respirations even and unlabored. Able to move freely and self-adjust in bed for comfort."
- At 6:58 AM, Staff N documented "Emergency Medical Services (EMS) arrives to transport for inpatient admission. Patient found to be cool to touch, not breathing and no pulse. Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) immediately initiated."
- At 7:07 AM, Patient #2's time of death was called.

During an interview on 09/13/23 at 8:15 AM, Staff J, Physician, stated that after care, the patient was "going in the right direction" and there was no reason to be on high alert. The oncoming provider would not have needed to assess this patient, as her "abnormality had been corrected", unless a nurse reported a change in condition. He did not believe that between the repeat potassium check and the time that the patient was found that her potassium level could have dropped low enough to have a negative impact. He estimated that Patient #2 could have been deceased for one to two hours before she was found, based on the documentation.

During a telephone interview on 09/26/23 at 3:00 PM, Staff R, Physician, stated that when she signed onto Patient #2's care she had already been treated and only was awaiting a repeat potassium check before she could be discharged. She stated that she did not review any of the patient's medical record, including any previous test results or Staff J's progress note on the patient. The repeat blood draw showed the potassium was within the normal range. She did not recall seeing the note under the result that stated the sample was slightly hemolyzed. She stated that if the sample was too hemolyzed the instrument at the lab would not result a number. The lab would then send out a notification that a re-draw was necessary. She did not receive any notification and since the equipment resulted in a number she would not have had the potassium level re-drawn again. At that time she gave Staff M the order discharge Patient #2. She stated there would be no reason for her to assess, or see the patient, unless nursing staff alerted her to a change in the patient's condition.

During an interview on 09/13/23 at 10:15 AM, Staff N, RN, stated that she received report on Patient #2 and was told the patient was stable and awaiting transfer to another hospital. The patient did not require an assessment, vitals or any medications. She did round on the patient and observed her through a window where she was able to see the patient's respirations. She stated that the last time she looked through the window to observe the patient was at 3:00 or 4:00 AM. She did not enter the patient's room her entire shift until the ambulance arrived to transfer the patient. When she entered the room to inform the patient that's when she found the patient unresponsive.

During an interview on 09/13/23 at 9:00 AM, Staff K, Physician, stated that on the morning of 04/22/23 a nurse urgently approached her stating there was a need for a doctor in Room 60. When she entered the room and saw Patient #2 she was cold, pale and had blood pooling in her back, she knew the patient could not be revived as she was already in livor mortis (settling of blood in body due to gravity). She stated that this patient could have been dead for at least one hour and up to four hours based on her observation. Staff unsuccessfully attempted ACLS and her time of death was called at 7:07 AM.

During an interview on 09/14/23 at 8:00 AM, Staff P, PCT, stated that he wasn't able to "realistically lay eyes on her (Patient #2) every 15 minutes due to another patient who was a high fall risk and kept getting out of bed." He stated that when he wasn't able to observe Patient #2 he would ask the team if there had been any changes with the patient. He stated that after 5:30 AM he did not document any rounds on the patient as he was trying to de-escalate the other uncooperative patient. He stated that normally if he was unable to complete his observations due to having to be with a patient that he would give the observation sheets to the nurse and they would complete them. He was unable to do so that night because other nurses were busy with medication passes and Staff N, RN, was working on the required documents to have Patient #2 discharged.

During an interview on 09/13/23 at 10:45 AM, Staff O, RN ED Director, stated that psychiatric patients who have been medically cleared would no longer fall under the policies of the ED, but under the policies of a BH inpatient, meaning that assessments and vital signs were only required every 12 hours and observations every 15 minutes. She stated that if a patient was in a room sleeping with the lights out staff could not have accurately seen if a patient's respirations were even and unlabored through the window.