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Based on interview, policy review, and record review, the facility failed to comply with the conditions of participation outlined in 489.20 and related requirements at 489.24:(refer to appendix V). The facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for six patients (#s 15, 16, 17, 22, 23, and 24); and the facility failed to provide stabilizing treatment for 1 (#16) of 24 sampled patients.

Findings include:

Review of a facility policy titled, EMTALA Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, "Any person who comes to Hospital or an off-campus provider-based department of Hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening examination (MSE) performed by a qualified medical person to determine whether an EMC exists ... If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capabilities of Hospital, or an appropriate transfer, as defined by and required by EMTALA. Stabilizing treatment must be provided in a non-discriminatory manner."

-Patients #s 15, 16, 17, 22, 23, and 24 did not receive complete MSEs after seeking care in the emergency department. (Refer to A-2406).

-Patient #16 did not receive stabilizing treatment in the emergency department before being discharged. (Refer to A-2407).

Based on interview and record review the facility failed to maintain an accurate ED log for 1 (#17) of 24 sampled patients.

Findings include:

Review of a facility policy titled EMTALA- Medical Screening Examination and Stabilization Policy, dated 6/2023 showed,

" ... 6. Central Log is a record maintained of all individuals who come to a department seeking emergency care. The log shall be kept for five years and shall contain specific patient information including:

a. Patient identification
b. Medical record and encounter number
c. Presentation time
d. Triage time
e. MSE time
f. Discharge time
g. Disposition ...

The purpose of the Central Log is to track the care provided to each individual who comes to Hospital seeking emergency medical care..."

During an interview on 12/6/23 at 1:31 p.m., staff member F stated she was a Registration Clerk for the facility ED. She stated, "If the hospital is on internal disaster status, there is a form that staff can read to patients to tell them how long the wait will be." Staff member F said in some cases it can take up to twelve hours to be seen in the ED. She stated the registration clerks are permitted to give patients options of where they can go to be seen more quickly. Staff member F stated, "If a patient decides to leave, we ask the patient to sign a form saying they are choosing to leave." She said some patients will sign the form and others do not. Staff member F stated some patients choose to leave right away after they are told how long the wait will be; these patients choose not to stay and do not get registered or placed on the ED log.

During an interview on 12/11/23 at 10:00 a.m., patient #17 stated he went to Benefis Hospital on 12/4/23 because he was having abdominal pain and thought he might be having another pancreatitis attack. He stated he could not remember the exact time he went to the ED. Patient #17 said the registration clerk at the ED told him there was going to be an 8-12 hour wait to be seen by a physician. Patient #17 told the registration clerk he was also vomiting blood and didn't think he could wait that long. He stated the registration clerk told him he could try going to the other hospital in town. Patient #17 said he did not know there was another hospital in town, so the registration clerk told him how to get there. Patient #17 said the registration clerk did not take his name or register him in the computer. He stated he did not go to triage, and he did not receive a patient name band.

During a phone interview on 12/8/23 at 9:45 p.m., NF4 stated he was an ED physician at another local hospital. He stated he had a patient (#17) that came to his facility on 12/4/23 to be seen in his emergency department. NF4 stated the patient had recently been admitted and discharged from Benefis Hospital for pancreatitis. NF4 said he asked the patient why he had not gone back to Benefis, as he had been treated there previously. He stated the patient (#17) told him he was told by the registration clerk he would be waiting 8-12 hours and he was afraid that since he was vomiting blood, he could not wait that long. NF4 stated patient #17 told him he was unaware there was even another hospital in the area, so the registration staff had to give him directions to get to the other location.

Review of Benefis Hospital ED logs failed to show patient #17 presented to the facility ED on 12/4/23.

Based on interview and record review the facility failed to provide an MSE for 6 (#s 15, 16, 17, 22, 23, and 24) of 24 sampled patients. This deficient practiced caused five of the six patients to seek care at another hospital, and all required inpatient admissions. One patient was discharged home and was pronounced dead the following day.

Findings include:

Review of a facility policy titled EMTALA- Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, " ...Hospital must provide an appropriate MSE within the capability of Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine whether or not an EMC exists: (a) to any individual, including a pregnant woman having contractions, who requests such an examination; (b) to any individual who has such a request made on his or her behalf; and (c) to any individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE ...Triage is not equivalent to an MSE."

During an interview on 12/6/23 at 1:31 p.m., staff member F stated she was a Registration Clerk for Benefis ED. She stated, "If the hospital is on internal disaster status, there is a form that staff can read to patients to tell them how long the wait will be." Staff member F said in some cases it can take up to twelve hours to be seen in the ED. She stated the registration clerks are permitted to give patients options of where they can go to be seen more quickly. Staff member F stated, "If a patient decides to leave, we ask the patient to sign a form saying they are choosing to leave." She said some patients will sign the form and others do not. Staff member F stated some patients choose to leave right away after they are told how long the wait will be; these patients choose not to stay and do not get registered.

1) Review of patient #15's EMR on 10/10/23 showed patient #15 presented to Benefis Hospital ED at 7:21 a.m. The patient went to triage at 7:33 a.m., and left without being seen at 7:34 a.m. There were no triage vital signs or assessments documented in the patient's medical chart.

During a telephone interview on 12/11/23 at 12:45 p.m., patient #15 stated, "They [Benefis ED] said there would be a very long time to wait. The lady at the front desk suggested we try the other hospital, [Other Hospital Name]." Patient #15 stated she did not see a nurse while at the ED and she did not have her vital signs taken. Patient #15 said the facility staff had her sign a form so she could go somewhere else due to the extended wait time. She stated she did not know what the form was for, and no one explained the risks of leaving the hospital to seek care elsewhere.

Review of patient #15's medical record from the other local hospital showed the patient presented to their emergency department on 10/10/23. The patient was complaining of a right lower quadrant pain which had worsened over the last 2 days. The patient had CT imaging and diagnostic laboratory testing conducted which indicated she was having appendicitis. The patient required admission to the facility for surgical management of her appendicitis.

2) Review of Benefis ED log for 11/15/23, showed, patient #16 presented to the Emergency Department at 3:00 p.m. for alcohol detoxification. During the patient's ED visit, patient #16 reported to facility staff that she was having thoughts of suicide in addition to her withdrawal from alcohol. The facility failed to provide an appropriate MSE for the patient. Patient #16 was discharged to home at 6:51 p.m., and the patient was pronounced dead the next day.

Review of patient #16's medical record showed: "32-year-old female nontoxic in appearance although visibly intoxicated presents today requesting admission for detox .... I have very low suspicion for current alcohol withdrawal. A conversation was had with the patient advising her that we do not admit patients for detox especially when they are still currently intoxicated. Patient subsequently became upset. Verbal de-escalation did ensue with subsequent consultation with social worker who came and personally evaluated the patient with advisement of having her follow-up in the outpatient setting ... Patient was discharged shortly afterwards."

Review of patient #16's ED behavioral health notes showed, "patient states she was referred to Benefis by [medical provider name]. 'I am trying to detox without killing myself.' ... Patient states she had about three fourths of a pint of vodka earlier today. Her last drink was around noon .... She states she was recently diagnosed with early cirrhosis of the liver. She has never been to treatment before but is agreeable to going and has been accepted to [detox center]. She states she is afraid to detox ..."

Review of a facility report titled, "Severity Measure for Depression Adult", adapted from the PHQ-9, dated 11/15/23, showed patient #16 scored 27 of 27, indicating the highest score possible for depression.

During an interview on 12/8/23 at 3:51 p.m. NF2 stated he and patient #16 went to [health provider name] seeking substance abuse assistance for patient #16. NF2 stated they saw NF3 at [health provider name] because patient #16 wanted to stop her addiction to alcohol. NF2 said NF3 did an assessment and felt that patient #16 should be detoxed under medical supervision because of the extent of her alcohol use, and the patient had a history of having seizures from withdrawing from alcohol. NF2 stated he and patient #16 received some paperwork from NF3's office, and they went straight to Benefis ED as they were instructed to do by NF3. NF2 stated patient #16 checked in at the Benefis ED, they sat in the waiting room for a very long time. NF2 stated he and patient #16 were taken back into the emergency department. They were not placed in a patient room. NF2 said they were instructed to sit in a chair next to the nurse's station. When the doctor (staff member G) approached them, NF2 stated he handed the doctor the paperwork from NF3's office. NF2 stated the doctor looked at the paperwork, rolled his eyes, and stated, "They are going to have to stop doing this," and he walked away. When he came back, the doctor told NF2 and patient #16 that [health provider name] needed to stop sending people to be admitted, it was his decision to admit people, and he was not going to admit patient #16 to detox under medical supervision. NF2 stated patient #16 started crying and begged the physician to reconsider. NF2 said, "She was begging for her life. She told him he was going to kill her if she didn't get help in the hospital." NF2 said after patient #16 begged the doctor to help her, the doctor said he would have the counselor come to talk with her to arrange for help on an outpatient basis. NF2 said the hospital did not do any blood work on the patient, they just had her blow into a breathalyzer. Patient #16 blew a 0.4 (normal 0). NF2 stated a counselor (staff member H) came to talk to them and completed some assessments. NF2 said patient #16 told staff member H she was ready to get sober and told her about some of the things that happened in her life. By the time staff member H was done talking to them, NF2 said all of them were crying, including staff member H. NF2 said staff member H felt patient #16 should be admitted because she was also suicidal. NF2 said staff member H walked over to staff member G. He could not hear what was said, but he saw staff member H lower her head and walk away. NF2 stated staff member H looked "frustrated." Shortly after staff member H talked to the doctor (staff member G), the doctor came over to NF2 and patient #16 and told them he, "absolutely" was not going to admit patient #16 because she was still drunk. NF2 said, "She absolutely looked like she was in withdrawal to me. With her, it didn't take very much because she always drank so much. She was shaking and sweating. Since he told us he was not going to admit her no matter what, we just decided to leave. Some nurse said she had discharge instructions for us, but we didn't get them." NF2 stated, "(Patient #16) was determined to go to rehab which had been prearranged, but she had to be sober to get into the rehab facility". NF2 stated patient #16 did not consume alcohol after she left the hospital, she ate, and went to bed. NF 2 stated that when patient #16 woke the next morning, she was nauseated, unable to eat, shaking, and didn't look very good, but did not return to the ED because of how they were treated the day before. Patient #16 went back to bed, and when NF2 went to check on her, she was not breathing. NF2 initiated CPR and called 911. NF2 stated the sheriff showed up and took over CPR until the ambulance came to get patient #16. NF2 stated the ambulance arrived and took over patient #16's care. He stated, "That was the last time I saw her."

During an interview on 12/8/23 at 12:04, staff member H said she remembered patient #16. Staff member H stated she assessed patient #16 for suicidal ideation and homicidal ideations. Staff member H said patient #16 said, "If someone were to give me a handful of pills, I would take them." Staff member H said patient #16 scored 27 of 27 on the PHQ-9 (an assessment for a patient's suicidal thoughts. 27 is the highest possible). Staff member H said she was aware patient #16 had seizures with withdrawal in the past. Staff member H said she did not get to finish her evaluation.

During an interview on 12/8/23 at 10:45 a.m., staff member G said he remembered patient #16 presenting at the ED. Staff member G stated patient #16 came in requesting detoxification from alcohol. Staff member G stated he was not aware patient #16 had scored a 27 of 27 on the PHQ-9 assessment and said he was not sure what that was, but stated he was not aware that patient #16 was suicidal. Staff member G stated he normally asks all patients seeking detoxification from alcohol if they are suicidal, and it would not be typical to discharge a patient who had suicidal thoughts.

Patient #16 had two EMC's (emergency medical conditions); alcohol intoxication with concern for potential alcohol withdrawal and seizures, as well as suicide ideation with a history of prior suicide attempts. Patient #16's emergency department record for 11/15/23 showed one set of vital signs were obtained at 3:01 p.m., and a point of care breathalyzer test result of 0.4 was documented. No laboratory or diagnostic tests were ordered. Patient #16 did not receive a psychiatric evaluation, despite her reporting to staff that she was suicidal.

3) During an interview on 12/11/23 at 10:00 a.m., patient #17 stated he presented to Benefis Hospital ED on 12/4/23. He said he was worried he was having problems with pancreatitis again. The patient could not remember exactly what time it was when he arrived. Patient #17 said he went to the front desk and asked to be seen by a physician. The registration person told the patient it was very busy, and it would take 8-12 hours before he could be seen in the ED. When patient #17 told the staff member he was also vomiting blood and did not think he could wait that long, the staff member told him he could try going to the other hospital in town. The staff member gave the patient the name of the hospital and gave him directions to get there because he was unaware there was another hospital, and he did not know where it was located. Patient #17 stated, "She didn't even check me in or get my insurance information." He stated they did not take his vital signs and no one other than the registration clerk spoke to him during his time at the ED.

Review of Benefis ED log failed to show patient #17 presented in the ED on 12/4/23.

Review of patient #17's medical record from the other hospital showed, "labs are obtained and show evidence of acute pancreatitis. His lipase is significantly elevated ..." The ED physician who examined the patient contacted the on-call hospitalist and she agreed to admit the patient to the hospital for further observation and treatment.

During a telephone interview on 12/8/23 at 9:45 a.m., NF4 stated he was the ED physician who examined patient #17 in his ED on 12/4/23. NF4 stated patient #17 told him he was sent to his hospital from Benefis ED because they were very busy and had extreme wait times. NF4 stated he was worried because patient #17 had told Benefis ED staff that he was vomiting blood, and they sent him away. NF4 stated he felt the actions of the Benefis ED could be dangerous because patient #17 would not be monitored when he left and could have suffered negative consequences. NF4 stated he has had several patients present at his ED stating they were sent over by Benefis, and others come there on their own because the wait times are so long at Benefis. NF4 stated he called to speak to the registration clerks at the Benefis ED on a few occasions to inform them it was not acceptable for the facility to send patients to other places to receive care. NF4 stated some of the registration clerks at Benefis ED would argue with him, and one even told him, "We tell patients that our wait time is 11 hours, there is another ER in town, so if they chose to go there, that's on them." NF4 stated on 9/26/23 he had three patients tell him they had been sent over to his hospital from Benefis ED, so he called and talked to the charge nurse who was on duty. The charge nurse informed NF4 that Benefis ED staff had been instructed by hospital administration that the facility was on disaster status and staff were instructed to inform patients they were going to have a very long wait time before they could be seen in the ED. NF4 stated the charge nurse told him they were also sending patients home, and the facility would call them to come back when they were available to examine them.

Review of a facility document titled, ED Operations During an Internal Disaster, not dated, showed: " ...scripting for patients ... We have declared an internal disaster as a result of a large patient population needing care today. During this time, we change how we triage to a nationally accepted triage method that is color coded and right now you meet the green criteria and can expect a wait time from 8-12 hours to get into the ED. You are more than welcome to wait or to try walk-in, same day orthopedics, or your primary care. We know you need to be seen; we are just letting you know a realistic time to expect ...."

4) During an interview on 12/12/23 at 11:55 a.m., patient #22 stated he presented to Benefis Hospital ED on 10/23/23 because he was having chest pain. He stated the chest pain caused him to get very sweaty. Patient #22 stated, "I wasn't feeling too good. I felt like I was going to pass out." Patient #22 said the facility registration clerk checked him in and then told him he would be waiting 6-12 hours to be seen in the emergency room. Patient #22 stated he sat down in the lobby for a few minutes and then started feeling like he was going to pass out. He stated he went back up to talk to the registration clerk and he explained to her that he had a history of heart problems, and he was afraid he was having an emergency. Patient #22 stated the registration clerk told him again there would be a very long wait before he could be seen. Patient #22 stated, "She told me I should go to [the other hospital] if I felt I was having an emergency. They basically turned me away." Patient #22 stated he went to the other hospital because he was scared. He said when he got there, the other hospital checked him in right away and took him to a room. Patient #22 stated his blood sugar was very high and his troponin was elevated and kept increasing. Patient #22 said he was admitted to the hospital for monitoring and treatment.

Review of Benefis ED log showed patient #22 was registered on 10/23/23 at 7:36 p.m. Patient #22 was not triaged and left without being seen at 7:49 p.m.

Review of patient #22's medical record from the other hospital showed, "At 7 p.m. this evening, the patient developed 8/10 intensity pressure-like chest pain radiating to his left should/left upper extremity/left upper back associated with diaphoresis, shortness of breath, nausea; but completely resolved after 1 hour ... troponins (lab test indicating cardiac muscle damage) have increased from 0.108 at 9:00 p.m. to 0.12 (normal <0.04) at 11 p.m. ... Initial lactic acidosis with lactic acid level 4.4 (normal 0.5-2.2, lactic acid increases when the bodies tissues are deprived of oxygen, it can also be elevated if the liver or kidneys aren't able to metabolize it efficiently) ... elevated blood sugar 565 (normal is 80-130 for patients with type II diabetes) ... The patient is being admitted for myocardial injury/NSTEMI ... chest pain, nonketotic hyperglycemia, lactic acidosis, CAD ... uncontrolled diabetes mellitus ... hypertension, obesity."

5) During an interview on 12/14/23 10:06 a.m., Patient #23 stated he presented at Benefis ED and asked to be seen because he was not feeling well. Patient #23 stated he had diabetes, and he thought his blood sugar was off. He stated, "They refused to do anything for me, I sat there for about an hour throwing up and they were not helping me. They didn't even register me for a long time. Then, when they were going to triage me, the first thing they said was the wait time was going to be very long. They didn't even check my vital signs or check my blood sugar. My meter wasn't working so I didn't even know how high my blood sugar was and they would not check it either. They told me it would be at least 12 hours before a doctor would see me. It is not the first time they have done that either. DKA(Diabetic ketoacidosis, a life-threatening complication of type 1 diabetes) is very dangerous, and they just didn't seem to understand that it was dangerous. I am a drug addict and I have relapsed in the past. I think the reason they treated me that way is because they thought I was just seeking drugs or that I was on drugs, and they just didn't care. They don't treat people with drug or alcohol problems very well there."

During an interview on 12/14/23 at 9:46 a.m., NF6 stated she was with patient #23 on 10/6/23 when he went to Benefis for emergency care. She stated, "They said the doctor wouldn't be able to see him for like 12 hours or something like that. That upset him because he has type 1 diabetes and when he has ketoacidosis it is very dangerous for him. That can kill him. They wouldn't even just check his sugar for him. His meter wasn't working but he knew by the way he felt he had a serious problem, and they were not taking him seriously at all."

Review of patient #23's medical record from Benefis Hospital showed patient #23 presented to Benefis ED on 10/6/23. The patients ED notes did not show vital signs were recorded or blood glucose testing. There was one nursing note that showed, "Patient was acting hostile toward staff. Pt walked out of triage stating 'take me to [other facility name]' to Mother and staff, patient walked out of the waiting room door ..."

Review of Benefis ED log for 10/6/23 showed patient #23 presented to the ED at 9:47 p.m. Patient #23 left at 10:07 p.m. There was no triage level or presenting complaint listed on the log.

Review of patient #23's medical record from the other hospital showed, on 10/6/23 at 10:15 p.m., patient #23 presented to be seen in their emergency department. The patient had a 30-year history of type one diabetes. Patient #23 went to the ED because he thought he was in DKA. He told the doctor in the ED he could usually tell when he was in DKA, and he began vomiting and feeling poorly that day. Patient #23 thought he must not have gotten the needle for his insulin pump properly inserted into his skin, causing the insulin not to be pumped into his body correctly. Patient #23's blood glucose was elevated to 688 (normal for type 1 diabetes is 80-130), his pH was 7.27 (normal is between 7.35 and 7.45) indicating acidosis, and his anion gap was 37.5 (normal is 3-11) indicating he was in Diabetic Keto-acidosis. Patient #23 was admitted to the hospital to correct his blood sugar with an IV (intravenous) insulin infusion and for medical monitoring.

6) During an interview on 12/12/23 at 12:52 p.m., NF1 said she takes care of patient #24 and his mother. Patient #24 has a history of advanced, rapidly progressive Parkinson's disease/dementia/severe neurocognitive deficits/wheelchair and bedbound and had urinary retention requiring the use of a Foley catheter (indwelling catheter to drain urine). NF1 said patient #24 had been residing at a local care facility because his care needs had been more than his mom could handle at home. NF1 and her employees had been taking care of patient #24's mother and had been taking her back and forth to see patient #24 at the care facility where he resides. On 9/21/23 one of NF1's employees and patient #24's mother went to the care facility to see patient #24 and they were told that he had been sent to Benefis ED. When they arrived at Benefis ED they found patient #24 sitting in the waiting area, alone. Patient #24 did not have anyone with him, and he was unable to communicate. NF1 stated her staff called her to inform her of the situation. NF1 stated she went directly to Benefis ED to see what was transpiring. NF1 stated when she arrived at Benefis ED, she saw patient #24 sitting in a wheelchair, slumped over, and drooling on himself. She stated patient #24 had been sitting in the waiting area for roughly three hours. NF1 stated she was very concerned when she saw the condition patient #24 was in. NF1 stated she asked the registration person what was happening. NF1 stated she was told the ED was very busy and there would be a very long wait for him to be seen by the doctor. NF1 said, "I am convinced that if I had not shown up when I did, he would have died. I felt like we needed to save his life and the registration person just did not care. She said we could take him elsewhere if we felt he was having an emergency." NF1 said she didn't even talk to the nurses, at that point, she just took him to her car. NF1 said, "I was focused on getting him the hell out of there." NF1 said it took three people to get patient #24 in the car. She took the patient directly to the other hospital in town. NF1 stated the other hospital took him straight back to a room in the ED. She said the nurses and doctors worked quickly because patient #24 was so sick. NF1 stated they took patient #24's temperature, and it was 103.1 F. NF1 stated they inserted a foley catheter, and during insertion, all that came out was puss. NF1 stated the doctor told her he was not sure patient #24 was going to survive.

Review of Benefis ED log showed, patient #24 arrived via ambulance on 9/21/23 at 6:26 p.m. with a complaint of a "fall" and left without treatment at 9:59 p.m.

Review of patient #24's ambulance report showed, on 9/21/23 at 6:25 p.m., the ambulance service transferred care of patient #24 to Benefis Hospital. The ambulance report showed the patient was transported to Benefis because he had fallen and hit his head at the care center where he resided. The Ambulance report showed the patient had a temperature of 100.2 F (Normal is 98.6) and his heart rate was elevated at 104 (normal is 60-100). The ambulance reported the patient had slurred/incomprehensible speech.

Review of patient #24's medical record from Benefis Hospital showed, on 9/21/23 at 6:26 p.m. the patient was registered to the emergency department. Initial vital signs were recorded. Patient #24's temperature was 100.3, heart rate 104, respirations 14, blood pressure was 104/62, and his oxygen saturation was 95%. No doctor was assigned to patient #24. Review of patient #24's medical chart showed there were no other assessments, vital signs, or notes for patient #24. The chart read, "ELOPED" at 9:59 p.m.

Review of patient #24's medical record from the other hospital showed patient #24 presented to their emergency department at 10:00 p.m. on 9/21/23. The physician notes showed, "In the emergency department, the patient was found to be severely septic/dehydrated/almost unresponsive/confused/disoriented on top of dementia, fever 103.1 degrees (normal 98.5), tachycardic 102 (normal 60-100), tachypneic with respiratory rate 22 (normal 12-18) blood pressure 112/65 (normal 90/60-120/80) pulse oximetry 94% (normal >90%) on room air, purulent urine obtained with Foley catheter placement with urinalysis consistent with UTI, met sepsis criteria, cultures taken, antibiotics given, IV hydration ...HPI (history of present illness) 65 yo male presents to the emergency department after being brought from outside facilities waiting room. Patient apparently was taken to Benefis by ambulance from [assisted living facility name] where he resides on a long-term basis for end-stage Parkinson's disease ..." Patient #24 was admitted to the hospital for severe sepsis (life threatening infection), acute UTI (urinary tract infection), toxic metabolic encephalopathy (brain disfunction due to metabolic issues, i.e. fever and infection), acute urinary retention, dehydration, severe protein-calorie malnutrition, abnormal weight loss and Parkinson disease.

Based on interview and record review, the facility failed to provide stabilizing medical treatment before discharge for 1 (#16) of 24 sampled patients. Patient #16 expired the following day.

Findings include:

Review of a facility policy titled, EMTALA- Medical Screening Examination and Stabilization Policy, dated 6/2023 showed, "Stabilizing Treatment Within Hospital Capability. The determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when, the physician treating the individual in the Emergency Department determines within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability, to result from, or occur during, the transfer of the individual from a facility ...or in the case of an individual with a psychiatric or behavioral condition, the individual is protected and prevented from injuring himself or herself or others ... Stable for discharge. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, the treating physician determines that the individual has reached the point where his or her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The EMC that caused the individual to present to the Emergency Department must be resolved, but the underlying medical condition may persist ..."

During an interview on 12/8/23 at 3:51 p.m. NF2 stated he and patient #16 went to [health provider name] seeking substance abuse assistance for patient #16. NF2 stated they saw NF3 at [health provider name] because patient #16 wanted to stop her addiction to alcohol. NF2 said NF3 did an assessment and felt that patient #16 should be detoxed under medical supervision because of the extent of her alcohol use, and the patient had a history of having seizures from withdrawing from alcohol. NF2 stated he and patient #16 received some paperwork from NF3's office, and they went straight to Benefis ED as they were instructed to do by NF3. NF2 stated patient #16 checked in at the Benefis ED, they sat in the waiting room for a very long time. NF2 stated he and patient #16 were taken back into the emergency department. They were not placed in a patient room. NF2 said they were instructed to sit in a chair next to the nurse's station. When the doctor (staff member G) approached them, NF2 stated he handed the doctor the paperwork from NF3's office. NF2 stated the doctor looked at the paperwork, rolled his eyes, and stated, "They are going to have to stop doing this," and he walked away. When he came back, the doctor told NF2 and patient #16 that [health provider name] needed to stop sending people to be admitted, it was his decision to admit people, and he was not going to admit patient #16 to detox under medical supervision. NF2 stated patient #16 started crying and begged the physician to reconsider. NF2 said, "She was begging for her life. She told him he was going to kill her if she didn't get help in the hospital." NF2 said after patient #16 begged the doctor to help her, the doctor said he would have the counselor come to talk with her to arrange for help on an outpatient basis. NF2 said the hospital did not do any blood work on the patient, they just had her blow into a breathalyzer. Patient #16 blew a 0.4 (normal 0). NF2 stated a counselor (staff member H) came to talk to them and completed some assessments. NF2 said patient #16 told staff member H she was ready to get sober and told her about some of the things that happened in her life. By the time staff member H was done talking to them, NF2 said all of them were crying, including staff member H. NF2 said staff member H felt patient #16 should be admitted because she was also suicidal. NF2 said staff member H walked over to staff member G. He could not hear what was said, but he saw staff member H lower her head and walk away. NF2 stated staff member H looked "frustrated." Shortly after staff member H talked to the doctor (staff member G), the doctor came over to NF2 and patient #16 and told them he, "absolutely" was not going to admit patient #16 because she was still drunk, and to him, she did not seem to be having bad enough withdrawal symptoms to warrant being admitted. NF2 said, "She absolutely looked like she was in withdrawal to me. With her, it didn't take very much because she always drank so much. I was so worried about her. We went there to get help and we were just turned away. She was shaking and sweating. Since he told us he was not going to admit her no matter what, we just decided to leave. Some nurse said she had discharge instructions for us, but we didn't get them." NF2 stated, "(Patient #16) was determined to go to rehab which had been prearranged, but she had to be sober to get into the rehab facility". NF2 stated patient #16 did not consume alcohol after she left the hospital, she ate, and went to bed. NF 2 stated that when patient #16 woke the next morning, she was nauseated, unable to eat, shaking, and didn't look very good, but did not return to the ED because of how they were treated the day before. Patient #16 went back to bed, and when NF2 went to check on her, she was not breathing. NF2 initiated CPR and called 911. NF2 stated the sheriff showed up and took over CPR until the ambulance came to get patient #16. NF2 stated the ambulance arrived and took over patient #16's care. He stated, "That was the last time I saw her."

During an interview on 12/8/23 at 8:07 a.m., NF5 said she was on the phone with patient #16 off and on while she was in the emergency department on 11/15/23. NF5 said patient #16 was very scared to detox; she had tried a few times before and had seizures. NF5 said patient #16 told her she was afraid she was going to die before she could make it to the rehab center. NF5 said she saw patient #16 a few days before and she talked to her about getting help. She seemed very motivated to get well. NF5 said patient #16 came to her house a few times to try to detox and she had seizures and shakes. When patient #16 told her she was going to the hospital to detox she told NF5 she was very scared. NF5 said she did not know patient #16 had not been admitted to the hospital until she found out patient #16 was in the ambulance on her way back to the hospital. NF5 said she was devastated when she found out patient #16 was dead. NF5 stated, "I want to go up to that doctor (staff member G) with my granddaughter, stand her in front of him, and show him this beautiful little girl that is going to have to grow up without her mother because he didn't care, and he didn't listen to her about her past experiences or how scared she was."

During an interview on 12/7/23 at 10:44 a.m., NF 3 said she did a full chemical dependency workup on patient #16. Patient #16 told her she had seizures when she tried to detox on her own in the past. NF3 said patient #16 applied for an inpatient bed at a rehab facility in Butte Montana and she was accepted to their program, but she would have to be sober upon entrance to the facility. Because of her history, NF3 felt patient #16 should be monitored medically while she detoxed from alcohol. NF3 said, "I assured her that the hospital would take good care of her." NF3 said after she heard patient #16 died the next day, she said she was devastated. NF3 stated she spoke to patient #16's mother and husband and found out what happened. NF3 said, "I just could not let it go. I assured her that the hospital would take good care of her. The patient was so scared, and I sent her there for help. She was only 32 years old." NF3 said patient #16's husband told her Benefis Hospital refused to help his wife.

During an interview on 12/6/23 at 1:50 p.m., staff member I stated if a patient comes to the hospital for alcohol detoxification and has a history of seizures, the patient can be admitted for medical management during their detoxification, and phenobarbital can be administered to minimize the patient's risk of seizures. Staff member I stated the hospital had a progressive care unit where these patients can be cared for, or if they are very sick, they can be admitted to the intensive care unit where Precedex (a medication used for severe alcohol withdrawal syndrome) can be administered.

During an interview on 12/7/23 at 9:16 p.m. staff member J stated the hospital could admit intoxicated patients, especially those with a history of alcohol withdrawal seizures, and manage the patient with the CIWA protocol (used to manage the symptoms of alcohol withdrawal to improve outcomes).

During an interview on 12/8/23 at 12:04, staff member H said she remembered patient #16. Staff member H said the patient told her she had been accepted as a patient in a rehab facility and was seeking medical detox. She said patient #16 had never been to treatment before. Staff member H stated she assessed patient #16 for suicidal ideation and homicidal ideations. Staff member H said patient #16 said, "If someone were to give me a handful of pills, I would take them." Staff member H said patient #16 scored 27 of 27 on the PHQ-9 (an assessment for a patient's suicidal thoughts. 27 is the highest possible). Staff member H said she was aware patient #16 had seizures with withdrawal in the past. Staff member H said, "She (patient #16) was scared to go through a seizure." Staff member H said she never told staff member G she did not recommend in-patient admission for patient #16. Staff member H said she went to talk to staff member G to explain her findings. Staff member H stated she then went to talk to the staff in behavioral health to formulate a plan. When she came back to talk to the patient, the patient was gone. Staff member H said she did not get to finish her evaluation and she did not have the opportunity to tell patient #16 she would be detoxed under medical supervision if it was determined she needed to be admitted to the behavioral health department.

During an interview on 12/8/23 at 10:45 a.m., staff member G said he remembered patient #16 presenting at the ED. Staff member G stated patient #16 came in requesting detoxification from alcohol. Staff member G stated, "She got upset when I told her she was not going to be admitted." Staff member G stated he was not aware patient #16 had scored a 27 of 27 on the PHQ-9 assessment and said he was not sure what that was, but stated he was not aware that patient #16 was suicidal. Staff member G stated he normally asks all patients seeking detoxification from alcohol if they are suicidal, and it would not be typical to discharge a patient who had suicidal thoughts. Staff member G stated detoxing from alcohol can be dangerous, but a patient needs to be exhibiting alcohol withdrawals before he would admit them to the hospital.

Benefis ED log for 11/15/23, showed, patient #16 presented to the Emergency Department at 3:00 p.m. and was discharged to home at 6:51 p.m.

Review of patient #16's medical record showed:

-Patient #16's EMR showed she had a history of alcoholic pancreatitis with two hospital admissions. Her previous visit on 8/10/23, showed she was hypokalemic (low potassium level) and had EKG changes on her visit on 8/10/23. Patient #16 required IV fluids and potassium replacement.

-On 11/15/23 at 3:00 p.m., patient #16 presented to Benefis Emergency Department, the ED physician's notes showed, "32-year-old female nontoxic in appearance although visibly intoxicated presents today requesting admission for detox .... I have very low suspicion for current alcohol withdrawal. A conversation was had with the patient advising her that we do not admit patients for detox especially when they are still currently intoxicated. Patient subsequently became upset. Verbal de-escalation did ensue with subsequent consultation with social worker who came and personally evaluated the patient with advisement of having her follow-up in the outpatient setting ... Patient was discharged shortly afterwards." ED behavioral health notes showed, "patient states she was referred to Benefis by [medical provider name]. 'I am trying to detox without killing myself.' ... Patient states she had about three fourths of a pint of vodka earlier today. Her last drink was around noon .... She states she was recently diagnosed with early cirrhosis of the liver. She has never been to treatment before but is agreeable to going and has been accepted to [detox center]. She states she is afraid to detox ..." A point of care breathalyzer test result of 0.4 was documented. A report titled, "Severity Measure for Depression Adult", adapted from the PHQ-9, showed patient #16 scored 27 of 27, indicating the highest score possible for depression.

-Patient #16 presented to Benefis Emergency Department on 11/16/23 at 2:21 p.m. via ambulance. The patient was unresponsive with CPR in progress. The emergency room report for 11/16/23 showed, "32-year-old female with history of alcohol abuse presents with ongoing CPR and an unwitnessed cardiac arrest. Unknown downtime ... Due to prolonged nature of the arrest and the persistent asystole (no cardiac electrical activity) both in the field and during our attempts in the emergency department, resuscitative efforts were terminated, and patient was pronounced dead at 1427. (2:27 p.m.)."

Review of patient #16's medical record showed the patient was mildly tachycardic. The patient required frequent monitoring for alcohol withdrawal symptoms, to include neurological checks and CIWA scores. Patient #16 required admission, as per the hospital policy for alcohol withdrawal, as the patient had a history of known alcohol withdrawal seizures. Additionally, patient #16 reported having suicidal ideation. The patient should have had a psychiatric consultation, been placed on an involuntary hold, and admitted to the hospital to ensure the patient had a safe environment and was provided with constant observation.