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Based on interview and record review the facility failed to ensure Emergency Department (ED) staff implement:

1.Left Without Being Seen, (LWBS), Left Before Treatment Complete (LBTC) policy for one of twenty-one sampled patients (Patient 4).

2.The Patient Elopement policy for two of twenty-one sampled patients (Patient 4 and 17).

3. The Against Medical Advice AMA policy for one of twenty-one sampled patients (Patient 12).

4. The Vital Signs policy for one of twenty-one sampled patients (Patient 14).

5. The Pain Assessment policy for one of twenty-one sampled patients (Patient 15)

These failures place patients at risk of not receiving the appropriate care as described in their policies and procedures thus resulting in negative outcome for patients.


Findings :

1.The facility policy and procedure titled "Electronic Documentation of Disposition When Left Without Being Seen (LWBS), Left Before Treatment Complete (LBTC) or Against Medical Advice (AMA)" dated 8/9/22, indicated "Patients who leave after the registration process without notification to staff and who have not yet been triaged or have had the medical screening exam (MSE) initiated, will have the disposition of LWBS... Staff will make reasonable attempts to locate patient using the contact information provided and looking in the last known location. If no response or unable to locate, staff member(s) accompanied by security personnel will search lobbies, proximal parking and adjacent areas prior to assuming a patient has LWBS. Attempts to locate the patient will be documented in the electronic health record (HER)."

During a review of the April 2025 ED Activity Log conducted on 9/15/25, the log indicated Patient 4 presented to the ED on 4/6/25 at 6:03 p.m., with complaints of psychological disorder. Patient's disposition was left without treatment at 6:22 p.m.

During a concurrent review of Patient 4's record for ED visit of 4/6/25 and interview with the regulatory compliance manager (RCM) on 9/16/25 at 11:45 a.m., the RCM acknowledged and confirmed the patient left without being seen by the provider. The only document in the patient's record was a Coding Summary indicating the patient was LWBS by the provider. The LWBS policy was reviewed with RCM. The RCM confirmed the patient's record does not have any documentation indicating attempts to locate the patient were conducted. Therefore, the ED staff did not implement their policy for this patient.

2. a) The facility policy and procedure titled "Code Green- Patient Elopement", dated 8/10/21, indicates "Every reasonable measure shall be taken to prevent the elopement of high-risk patients from the hospital. The hospital shall take all reasonable steps necessary, to safely retrieve or locate an eloped patient, as soon as possible." In part J Documentation of policy indicates that "1. Involved staff to document the entire elopement episode, including the time the patient was found to be missing, measures taken to activate the emergency response, the process of the search, areas of the facility that the staff members searched and the result of the search. Provide a sequential presentation of events."

During a review of the ED record for Patient 4's visit of 4/12/25, record indicated patient presented to the ED brought in by ambulance due patient was stating he needs to be on a voluntary hold or "I will kill somebody cause they are creeping upon me." The ED Physician Note, dated 4/12/25 at 5:43 a.m., indicated "42-year-old male with a past medical history of bipolar disorder presenting to the emergency room and requesting voluntarily hold because if he is "treated with psych meds or left on the streets, he will hurt someone ... "

During a concurrent review of Patient 4's record for ED visit of 4/12/25 and interview with the regulatory compliance manager (RCM) on 9/16/25 at 11:45 a.m., the RCM was asked to provide all the documentation indicating the patient had eloped. The RCM stated "in the doctor's notes, (dated 4/12/25 at 8:58 a.m.) indicates patient eloped from the ED. This is the only note in the record regarding the elopement episode. The policy language about what needed to be documented in the record was reviewed with the RCM. The RCM stated, "No, the staff did not follow the policy regarding the patient's elopement."




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2b) During a concurrent interview and record review on 9/17/25 at 1:20 p.m., with the emergency department registered nurse (EDRN 2), Patient 17's medical record was reviewed, EDRN 2 acknowledged and confirmed that the medical record indicated, Patient 17 eloped. Additionally, EDRN 2 acknowledged and confirmed that the staff did not follow the facility policy regarding the patient's elopement, the only documentation in the medical record related to elopement indicated, "Called [name of police department] per instructions left by [name of officer] when patient to be discharged. Left voicemail with the number [phone number] and called [name of police department] dispatch. Patient eloped at 1323. Psychiatry arrived to assess patient at 1340 but patient had already left."

3. During a review of the facility's policy and procedure (P&P) titled, "Discharge Against Medical Advice (AMA)," dated 3/14/24, the P&P indicated, "When a patient ... requests to be discharged AMA, the procedure for discharge is as follows: Nursing staff should notify the treating physician of a patient's request to be discharged. The treating physician will meet with the patient to explain the risks involved in failing to continue treatment ... All patients will be encouraged to continue with medication regimen and to follow-up with outpatient services upon discharge ... Patients will be offered drug prescriptions and medical follow-up appointments. Aftercare Plan and chart will document patient refusal of medications and/or follow-up appointments ..."

During a concurrent interview and record review on 9/16/25 at 11:35 a.m., with the quality registered nurse (QRN 1), Patient 12's medical record was reviewed, QRN 1 acknowledged and confirmed that the medical record indicated, Patient 12 left AMA. Additionally, QRN 1 acknowledged and confirmed that the staff did not follow the facility policy regarding the patient's leaving AMA, the only documentation in the medical record related to leaving AMA indicated, "Disposition Obs" with no other documentation about leaving AMA.

4. During a review of the facility's P&P titled, "Documentation Standards in the Emergency Department," dated 3/20/25, the P&P indicated, "Nurses Charting to include ... ESI 2-3 patients vital signs should be repeated every 2 hours ..."

During a concurrent interview and record review on 9/17/25 at 10:35 a.m., with QRN 1, Patient 14's medical record was reviewed, QRN 1 acknowledged and confirmed that the medical record indicated, Patient 14 was assigned an ESI level of 2 (code used to determine the order in which a patient is seen in the emergency department, a level 2 is emergent). Additionally, QRN 1 acknowledged and confirmed that the staff did not follow the facility policy regarding documentation of the patient's vital signs every two hours, the medical record indicated, vital signs were documented on 8/7/25 at 9:00 a.m. and the next set was documented on 8/7/25 at 3:00 p.m.

5. During a review of the facility's P&P titled, " Pain Assessment, Management and Documentation," dated 4/15/24, the P&P indicated, "The goal of pain management is to incorporate non-pharmacological and pharmacological interventions to ease or lighten pain which may not include the elimination of pain. Pain assessment and pain management is an organizational priority. Conduct an appropriate assessment and/or reassessment of a patient's pain consistent with the scope of care, treatment, and services provided in the specific care setting in accordance with staff scope of practice ..."

During a concurrent interview and record review on 9/17/25 at 11:00 a.m., with QRN 1, Patient 15's medical record was reviewed, QRN 1 acknowledged and confirmed that the medical record indicated, Patient 15 had no pain assessment documented during the patient's visit to the emergency department. Additionally, QRN 1 acknowledged and confirmed that the staff did not follow the facility policy regarding pain assessment.

Based on observation, interview, and record review, the hospital failed to post signage-clearly visible to all-in critical areas including the Emergency Department (ED) entrance, ambulance entrance, treatment areas, main entrance, and main lobby waiting area which specified the rights of individuals under the Emergency Medical Treatment and Active Labor Act (EMTALA), regarding examination and treatment for emergency medical conditions and women in labor (ready to give birth).

This failure had the potential to leave patients and their families unaware of their federally protected rights under EMTALA, which could result in delayed or denied access to emergency medical care.

Findings:

During a concurrent observation and interview on 9/15/25 from 11:14 a.m. until 11:41 a.m. with emergency department registered nurse (EDRN 2), no signs were posted that specify the rights of individuals to examination and treatment for emergency medical conditions (EMC) and women in labor at the emergency room entrance, ambulance entrance, and treatment areas, as well as the main entrance and main lobby waiting area, as confirmed by EDRN 2.

During a review of the facility's policy and procedure (P&P) titled "Emergency Medical Treatment and Labor Act (EMTALA)," dated 1/10/23, the P&P indicated:

"SIGNAGE: Signs will be posted in lobbies and other appropriate locations where patients may be waiting for treatment or where examination may occur, specifying the rights of individuals to examination and treatment for emergency medical conditions and indicating the participation in the Medi-Cal program. The signs will also state the name, address, and telephone number for the State Department of Health Services. The signs will be posted in English and Spanish in the ED and Labor and Delivery..."

Based on interview and record review the facility failed to maintain the accuracy and completeness of the Emergency Department (ED) and Labor and Delivery (L&D) Emergency Medical Treatment and Active Labor Act (EMTALA) Central Logs when:

1. Five (5) sampled patients (Patients 1; 2; 5;11 and 13's) disposition (how the patient left the facility) was incorrect.

2. One hundred and two (102) unsampled patients had their disposition missing.

3. Patient 9's triage time was incorrect.

These failures resulted in the ED and L&D EMTALA Central Logs to be inaccurate, incomplete, and out of compliance per the regulation.

Findings:

1a. During a concurrent interview and record review on 9/16/25 at 10:55 a.m. with the quality registered nurse (QRN 1), Patient 11's medical record and the ED EMTALA central logs were reviewed, QRN 1 acknowledged and confirmed that Patient 11 was admitted and the disposition on the ED log was wrong, the log indicated patient left against medical advice.

During a concurrent interview and record review on 9/16/25 at 1:00 p.m. with QRN 1, Patient 13's medical record and the L&D EMTALA central logs were reviewed, QRN 1 acknowledged and confirmed that Patient 13 was admitted and the disposition on the L&D log was wrong, it indicated patient was discharged/transferred to Cancer Center or Children's Hospital.

2a. During a concurrent interview and record review on 9/17/25 at 11:35 a.m., with the regulatory compliance manager (RCM), the ED and L&D EMTALA central logs from April 15 to April 31, 2025, the log indicated there were nineteen (19) patients who were missing the patient's disposition in the logs. On August 1, 2025, there were nine (9) patients who were missing their disposition in the log. RCM acknowledged and confirmed the ED and L&D EMTALA Central Logs were missing the patient's disposition.



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1b. On 9/15/25 an emergency department (ED) and obstetrics (OB) central log or EMTALA log were requested from the facility leadership. It was explained that an ED and OB central log is a log where all patients presenting to the ED and L&D seeking for a medical screening and/or treatment for their symptoms are logged in. The quality registered nurse (QAPI RN 1) established the ED Activity log, and the Maternity Activity log were the facility's central or EMTALA logs.

During a concurrent review of the ED Activity log and medical records for sampled patients 1, 2, and 5 and interview with the quality registered nurse (QAPI RN 2) on 9/16/25 at 9:30 a.m., the log was noted to be missing the patients' disposition. QAPI RN 2 confirmed the patients' disposition was missing from the log for these three patients.

2b. During a concurrent review of the ED activity logs for the month of April and May 2025 and interview with the regulatory compliance manager (RCM) on 9/17/25 at 11:35 a.m., from April 1 to April 15, 2025, the log indicated there were sixty-two (62) patients who were missing the patient's disposition in the logs. For May 30, 2025, there were seven (7) patients who were missing their disposition in the log. For May 29, 2025, there were four (4) patients who were missing their disposition in the log. For May 24, 2025, there was one (1) patient who was missing the disposition in the log. The RCM acknowledged and confirmed the ED central or EMTALA log was missing the patient's disposition.

3. During a concurrent review of the OB activity log and Patient 9's medical record with the maternal health manager (MHM) on 9/17/25 at 10:00 a.m., the log indicated Patient arrived at the L&D department on 4/1/15 at 9:12 a.m. The OB Triage/Admission Assessment, dated 4/1/25 indicated the triage was performed at 9:00 a.m. The MHM was asked how it is possible to triage the patient before the patient arrives at the OB/L&D department. The MHM stated "The log's time is incorrect. The log is wrong."

Based on interviews and record reviews, the facility failed to ensure the Emergency Department (ED):

1. That the medical screening examination (MSE-an evaluation by a physician to determine if an emergency medical condition exists) for one of 21 patients (Patient 21), who was brought to the ED on 5/21/25 and assessed by the admitting nurse and Licensed Clinical Social Worker (LCSW), included a reassessment of the patient's pain and stabilization of the patient ' s mental condition through collaboration with other health professionals involved in the assessment prior to discharging the patient home. Patient 21 had an emergency medical condition (EMC-severe symptoms placing the patient at risk and requiring immediate medical attention) secondary to verbalizations of wanting to "end it all."

This failure resulted in the patient dying by suicide approximately six hours post-discharge.

2. That a psychiatric consult, screening, or examination was performed as part of the MSE for one of 21 patients (Patient 14).
This failure has the potential to result in inappropriate triage and delay the implementation of proper care for the patient ' s reason for visit, which can result in harm.

3. That obstetrical staff performed a timely MSE for one of 21 patients (Patient 10).

This failure or delay in performing the MSE placed Patient 10 at risk for complications from possible spontaneous rupture of membranes (SROM-the breaking of the amniotic sac, which surrounds and protects the baby in the womb) before labor begins.

Findings:


1. During a review of Patient 21's medical record, it indicated a 35-year-old male with diagnoses including history of suicide attempts, in-patient psychiatric (mental and behavioral issues) treatment, Major Depressive Disorder (MDD - deep, ongoing sadness), Generalized Anxiety Disorder (constant, uncontrollable worry), and chronic pain (long-term physical pain).

A review of Patient 21's ED Triage Note (TN - process that determines severity of illness) dated 5/21/2025 indicated the following:

Patient 21 was brought to the ED by ambulance on 5/21/25 at 10:54 a.m. from a government based clinic (GBC) with complaints of suicidal ideation (thoughts of killing oneself) with a plan and chronic pain. Patient 21 stated, "I want to end it all. My chronic pain affects my everyday life."

An Emergency Severity Index (ESI - tool used to prioritize patients in the emergency room on a scale from 1-5, where level 1 is life threatening and level 5 is non-urgent) was performed on Patient 21, and the result was a Level 2 (indicates a potentially life-threatening condition or a high-risk situation, requiring immediate medical attention).

A Columbia Suicide Risk Assessment (CSRA - clinical tool to assess the risk of suicide ranging from low to high) was also performed on Patient 21, and the result was moderately high.

During a review of Patient 21's physician orders (PO) dated 5/21/25, indicated the following orders:

Ibuprofen (mild pain reliever/fever reducer) 400 mg (milligram- unit of measure) p.o. (by mouth)
Ketorolac (Toradol - moderate to severe pain reliever) 30 mg IM (in a muscle)
Psychiatric diagnostic evaluation (psychological evaluation- comprehensive assessment of patient's mental and for patient's at risk of harming or killing themselves).

During a review of Patient 21's electronic Medication Administration Record (eMAR) dated 5/21/25, the eMAR indicated Patient 21 received one tablet of Ibuprofen 400 mg p.o. at 11:24 a.m. The eMAR had no documentation of the location of pain or a level of pain .The eMAR dated 5/2/25 further indicated Toradol 30 mg. IM was administered to Patient 21 at 3:39 p.m. The eMAR did not indicate the location or level of pain.

According to the Rehabilitation Measures Database, last updated on January 17, 2013, pain is rated on a scale from 0 to 10: 0 means no pain; 1-3 is mild (noticeable but doesn't interfere); 4-6 is moderate (affects activities but manageable); and 7-10 is severe (hard to focus or function).

During an interview on 9/17/25 at 9:15 a.m. with Emergency Department Registered Nurse (EDRN5), EDRN5 indicated medicating Patient 21 with Ibuprofen for neck pain rated as 8 out of 10 on pain scale.

During a review of Patient 21's Pain Assessment Flowsheet (PAF) dated 5/21/25, indicated a follow-up pain reassessment at 12:00 p.m., Patient 21's pain level remained an 8 out of 10 with a new location reported as "back".

During a review of the facility's policy and procedure (P&P) titled "Pain Assessment, Management and Documentation" dated 4/15/2024, the P&P indicated: "Patients have the right to pain management which is determined through discussion with their providers and care team members." "The healthcare workers of the [name of facility] shall do the following in accordance with staff scope of practice: Conduct an appropriate assessment and/or reassessment of a patient's pain consistent with the scope of care, treatment, and services provided in the specific care setting in accordance with the staff scope of practice. All assessments and reassessments for PRN (as needed) and scheduled medication shall be documented on the Medication Administration Record (MAR). Assess the patient's response to care, treatment, and service implemented to address pain. If the patient does not achieve their pain goal or if the pain is not reduced to a tolerable state, the care team member should notify the physician and follow the chain of command to advocate for the patient." The P&P further indicates in the Emergency Department section: "Patients may be treated for acute exacerbation [worsening] of chronic pain, but otherwise should be encouraged to seek long-term treatment for chronic pain." "If at any time during the patient's stay in the ED pain issues are identified, the process of assessment/reassessment should be initiated. If acute pain issues are identified, then the patient should be reassessed at least at time of discharge or transfer. At a minimum, this reassessment shall consist of noting the intensity and severity of the patient's pain."

Upon further review of Patient 21's medical record and eMAR dated 5/21/25, no documentation was located indicating whether the pain reassessment at 12:00 p.m. on 5/21/25-where the pain location was noted as the patient's "back"-was addressed, or whether the pain in the patient's neck was resolved after EDRN5 administered Ibuprofen at 11:24 a.m. on the same day. There was also no documentation found referring to a reassessment of pain when Toradol was administered on 5/21/25 at 3:39 p.m.

During an interview on 9/16/25 at 1:13 p.m. with Licensed Clinical Social Worker (LCSW), LCSW stated "I assessed [Patient 21] to be a danger to himself and recommended that psych place [Patient 21] on a hold." (a 'hold' is a legal process for emergency psychiatric care when a person is at risk of killing themselves). LCSW acknowledged Patient 21's suicidal ideation was triggered by chronic pain and confirmed that pain was identified as a contributing factor in the patient's risk assessment.

During a review of Patient 21's "ED/Hospital Suicide Risk Assessment" dated 5/21/25, indicated, "Pt" (patient) endorsed suicidal ideation with plan to hang himself triggered by chronic pain in hand and back. History of attempted suicide and in-patient psychiatric treatment. Pt. reports he would not be suicidal if pain was "ameliorated" (better or more tolerable).

Further a review of Patient 21's "ED/Hospital Suicide Risk Assessment" dated 5/21/25 indicated Patient 21 was at "Moderate Suicide Risk" with a recommended mitigation plan to include a Psychiatry consultation (formal request for a specialist's opinion on a specific medical issue) and transfer to psychiatric unit .

During a review of the facility's P&P titled, "Suicide Risk Assessment" dated 11/19/2024 indicated, "The RN will complete the validated suicide screening tool during triage on every patient aged 12 and up." "If the patient is found to be at no, low, or moderate risk of suicide; the RN will rescreen the patient and if there is a new occurrence of suicidal behavior, ideation, statement or other noteworthy clinical change".

Upon further review of Patient 21's medical record, the department found no documentation indicating Patient 21's suicide risk was ever reassessed.

During an interview on 9/16/25 at 3:16 p.m. with EDRN 4, EDRN 4 acknowledged there was no documentation of a suicide risk reassessment following the patient's reported change in pain location and continued pain rated as 8 out of 10, nor evidence of physician notification.

During a review of Patient 21's "Psych Evaluation" dated 5/21/25, indicated "Per Emergency Room Medical Doctor (ERMD) 35-year-old male presents to the emergency department for evaluation of suicidal ideation. Patient requests voluntary admission to psychiatric facility. Patient reports he wants to end his life due to chronic pain. When questioned patient states that he is pain in multiple areas however identifies his thoracic lumbar spine as well as lower lumber spine is causing most pain. Patient noted to the nurse that he had had neck and thumb pain. Patient denies recent injury to the above symptoms no symptoms of bladder overflow incontinence no recent surgical procedures. Patient cannot recall having had imaging of his back performed. Symptoms of pain have been ongoing for "several months". Further indicated Patient 21 was not suicidal at the time of the evaluation and "was just in pain".

During an interview on 9/16/25 at 12:11 p.m. with Psychiatric Consultant (PC), PC confirmed conducting Patient 21's psychiatric evaluation. When asked about the evaluation process, PC confirmed he did not review the LCSW's recommendation to admit Patient 21 to an in-patient psychiatric unit, did not assess or address Patient 21's pain, and did not speak with ERMD regarding Patient 21's condition or disposition. PC further stated, that he doesn't make disposition plan (discharge plan).

During a review of the hospital record titled "Individualized Patient Discharge Instructions and Plan" dated 5/21/25 indicated Patient 21 was discharged from the facility at 3:59 p.m., approximately five hours after admission in the ED around 10:54 a.m.

During a review of the facility's policy and procedure titled, "Emergency Medical Treatment and Labor Act (EMTALA), dated 1/10/2025, indicated, " A medical screening examination (MSE) will be offered to any individual presenting for examination of a medical condition. The examination will be the same appropriate screening examination that would be performed on any individual with similar signs and symptoms, regardless of the individual's ability to pay for medical care. Emergency Medical Condition: (EMC) A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in either placing the health of the individual in serious jeopardy; serious impairment of bodily functions; or serious dysfunction of any bodily organ or part."

The policy further defines a "Medical Screening Exam (MSE) An MSE is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition (EMC) or not. An appropriate MSE is dependent on the presenting signs and symptoms and may involve a wide spectrum of actions ranging from a simple process involving only a brief history and examination of the presenting symptoms to a complex process that includes ancillary [providing support] studies and procedures. Medical includes both physiological and psychological symptoms."

During an interview on 9/15/25 at 4:30 p.m. with the facility's Chief Medical Officer (CMO), CMO stated that the expectation for an emergency medical condition (EMC) in the ED is for the EDMD to perform the evaluation, and if a consult is requested, there should be communication by phone at a minimum.

During a review of Patient 21's Coroners Report dated 5/21/25 indicated, approximately at 21:20 (9:20 p.m.) indicated in part...a 35 year old male driver of vehicle struck a tree and was pronounced deceased on the scene. The collision appeared an intentional act on the part of the decedent. Manner of death is suicide.

Further review of the Coroner's Report indicated the incident of suicide by Patient occurred approximately six hours post discharge from the ED.

During a telephone interview on 9/16/25 at 11:42 a.m. with ERMD, ERMD confirmed not speaking with PC regarding PC's psychiatric evaluation, condition, or disposition. ERMD further confirmed that there was no documentation in Patient 21's medical record indicating that the patient's pain or suicidal ideation had been stabilized prior to discharge. ERMD further stated "physiologically ready to go home, psychologically patient can say anything and we see this in higher risk. "


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2. During a concurrent interview and record review on 9/17/25 at 10:35 a.m. with the Quality Registered Nurse (QRN1) and the Chief Nurse Executive (CNE), Patient 14 ' s medical record was reviewed. QRN1 acknowledged and confirmed that the medical record indicated Patient 14 arrived on 8/7/25 at 8:56 a.m. with a reason for visit that included bipolar depression and a psychiatric screening exam. A consult to a Mental Health Clinician was ordered on 8/7/25 at 10:57 a.m. QRN1 further acknowledged and confirmed that there was no documentation of a completed consult to a Mental Health Clinician, and that Patient 14 was transferred on 8/8/25 at 5:35 p.m. When asked about the expectation for a psychiatric consult, the CNE stated, "I will reach out to the Chair of Psychiatry, Medical Doctor (MD) 3, for that information and let you know." The CNE later provided information that the expectation is for a patient in the Emergency Department (ED) to receive a psychiatric consult within 24 hours. QRN1 confirmed and acknowledged that Patient 14 remained in the ED for over 24 hours without receiving a psychiatric consult.


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3. During a concurrent review of Patient 10's medical record and interview with the MHM on 9/17/25 at 10:00 a.m., the record indicated patient arrived at the labor and delivery (L&D) on 4/12/25 at six (6) minutes past midnight. The OB Triage/Admission Assessment was conducted on 4/12/25 at forty-eight (48) minutes past midnight. The L&D admission note, dated 4/12/25 at 4:16 a.m., indicated patient was a 17-year-old at 40 weeks and two days ... presenting for possible spontaneous rupture of membranes (SROM) breaking of the amniotic sac, which surrounds and protects the baby in the womb, before labor starts. Patient reports from approximately 11:00 p.m., on 4/11/25, she has had gradual and intermittent leakage of fluid that has soaked through her clothes. Patient initially felt a gush of fluid at the time and have had persistent leaking of fluid every several hours since then. Patient reports feeling contractions every one to three minutes. The MHM was asked to provide the documentation as to when and who performed the medical screening examination (MSE). The MHM stated "The MSE was performed by the OB doctor around the time the patient was triaged by the RN." The MHM was asked to show me in the record the time the MSE was performed. The MHM confirmed the only OB physician note in the record was the L&D admission note, dated 4/12/25 at 4:16 a.m. MHM was asked if approximately 4 hours between the time the patient is triaged and the MSE is performed and documented was standard practice in the L&D department. MHM stated "No, four hours is too long to do an MSE for someone with SROM. I understand what you mean. If the OB doctor performs the MSE right after the triage is done, then the MSE time needs to be documented in the record." The MHM confirmed the MSE was not documented timely in the record.

Based on interview and record review the facility failed to ensure:

1. Discharge assessment/ decision to discharge a patient with verbalization of suicide was coordinated and discussed among the healthcare workers, who had identified the patient with an Emergency Medical Condition (EMC)-a serious mental or physical issue needing immediate care to prevent harm )- was stabilized prior to discharge for one of 21 patients (Patient 21).

This failure possible contributed to Patient 21's action to commit suicide .

2. Patient's transfer forms were completed for four of 21 patients (Patient 6, Patient 8, Patient 15, and Patient 16).


These failures resulted in the facility ' s noncompliance with EMTALA requirements and had the potential to cause serious harm. The lack of completed transfer forms also placed additional patients at risk by failing to ensure safe and appropriate transfers.


Findings:

1.During a closed record review for Patient 21, the ambulance electronic patient care report (AEPCR) indicated the patient was brought in from a GBC, to the hospital ED on 5/21/25 at 10:54 a.m. The AEPCR narrative notes dated 5/21/25, included statements in part of.., " Patient told staff at the GBC, he was suicidal and had a plan . Patient wanted to go to the hospital to seek treatment.... patient was stable during transport... patient care was transferred to RN ( registered nurse )."

The face sheet for Patient 21 dated 5/21/25, indicated an admission date of 5/21/25 at 10:54 a.m., with the admit reason of : voluntary hold (voluntary admission for psychiatric treatment).

The RN triage notes dated 5/21/25, performed at 10:54 a.m., for Patient 21, had chief complaints of suicidal ideation with a plan, patient was at a GBC and endorsed thoughts and voluntarily asked to go to ER ( emergency room)." I want to end it all, my chronic pain affects my everyday life. " Has pain in the neck and thumb. No prior injuries /trauma. History of suicidal attempts. The triage notes indicated :

Under the emergency severity index notes (ESI- tool used to prioritized patients in the ER from the scale of 1-5 - were 1 is life threatening and 5 is non urgent ), the recommended ESI level of Pastient 21 is 2 ( potential life threatening condition/high risk situation requring immediate medical attention).

Under the columbia suicide risk assessment notes (CSSRS- assessment tool for persons at risk for suicide) the following were noted in part.....Wish to be dead = yes ..Current suicidal thoughts =yes ..Suicidal thoughts with a method =yes....Suicidal intent without a plan =yes...Intent with a plan =yes...Suicidal behavior lifetime=yes
Suicidal behavior past 3 months =no.. Active diagnosis = Suicidal Ideation


During a review of the emergency room physician (ERP) notes dated 5/21/25, performed at 11:33 a.m., the history of present illness, indicated in part ... the patient was brought in for evaluation of suicidal ideation. patient requests voluntary admission to psychaitric facility. Patient reports he wants to end his life due to chronic pain. pain, pain in multiple areas, specific thoracic, lumbar and lower lumbar spine.. in part.

During a review of Patient 21's physician orders and electronic medication administration report (eMAR) dated 5/21/25, indicated Patient 21 was administered with Ibuprofen ( Motrin) 400 mg ,1 tablet by mouth on 5/21/25 at 11:34 a.m., and Toradol 30 mg , IM ( intramascular injection) on 5/21/25 at 15:33 ( 5:33 p.m.,) for pain.


During a review of the Pain assessment flowsheet dated 5/21/2025, the flowsheet indicated no pain assessment was done to address if the patient's complaints of pain was resolved prior to discharge.

During a review of the ED/Hospital Suicidal Risk Assessment ( EDSRA) performed on 5/21/25 at 11:41 a.m., by the LCSW, indicated in part : Psychiatry assessment: no (not seen by the psychiatrist yet or at this time)any suicidal: in part .... Patient was brought in by ambulance voluntarily due to danger to self (DTS), patient endorsing with SI ( suicidal ideation) to hang himself , denies homicidal, visual and auditory hallucinations (experiencing things that are not there). Patient reports suicidal ideation is triggered by chronic pain,in hand and back ...Risk level:moderate suicide risk....Mitigation plan: Psychiatry consultation or transfer to a psychaitric unit while maintaining suicide safety plan.. in part

During a review of the Psychiatric Consultant (PC) notes dated 5/21/25, performed on Patient 21 at 3:27 p.m., indicated in part.. the patient's chief complaint was pain, and per Emergency Room Physician (ERP) notes, the patient presents for evaluation of suicidal ideation and symptoms of pain have been going on for months .. patient denies having suicidal ideation and " I was just in pain". Further review of the PC notes under : Dispo ( Disposition- plan of care after they receive treatment in health care ) per ERP.


During a review of the ERP notes dated 5/21/25 verifed at 3:11 p.m., indicated in part.. Patient was treated with Motrin ( ibuprofen) for pain control.. medically cleared and stable to go to acute psychiatric facility , was seen and evaluated by psychiatry and determined to be safe for discharge home... in part

During a virtual interview on 9/16/25 at 1:13 p.m. with the Licensed Clinical Social Worker (LCSW), the LCSW stated," Patient was suicidal and I assessed him to be a danger to himself and recommended that the patient be placed on a hold (a legal process for emergency psychiatric care when a person is at risk of killing themselves). LCSW acknowledged not speaking to the PC after making the recommendation of having Patient 21 admitted to a psychiatric hospital for further evaluation.


During an telephone interview on 9/16/2025 at 11:42 a.m. with ERP, ERP confirmed treating Patient 21 at the ED on 5/21/25 for expressed suicidal ideation" and "back pain in various areas . ERP further confirmed, Patient 21 was a transfer from a GBC and was screened positive on the suicidal ideation assessment. ERP stated, initally the patient was cleared to go to a psychiatric unit , but ERP based the decision to sent Patient 21 home, from what the EDRN 3 told him that PC said it is ok to send the patient home. ERP acknowledged not speaking to the PC regarding Patient 21's condition and confirmed not reviewing the LCSW's notes of admitting the patient to a psychiatric unit.


During an interview on 9/16/2025 at 12:11 p.m. with PC, PC stated Patient 21 " said he wasn't in pain anymore" and acknowledged that a pain assessment is not reflected in PC's documentation. PC further stated he did not communicate directly with ERP the results of his consultation.
PC further confirmed conducting Patient 21's psych evaluation at the ED hallway. PC confirmed not reviewing the LCSW's recommendation to admit Patient 21 to a psychiatric unit, did not assess or address Patient 21's pain, and did not speak or collaborated with ERP regarding Patient 21's evaluation, condition, or disposition. PC further stated, that he doesn't make any disposition plan when a patient is in the ED.

During a review of the facility's policy and procedure (P&P) titled " Emergency Medical Treatment and Labor Act (EMTALA)" dated 1/10/2023, the P&P indicated in part that the hospital will not transfer any patient with an unstable emergency medical condition and defines in part an emergency medical condition as "a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonable be expected to result in either placing the health of the individual in serious jeopardy; serious impairment of bodily functions; or serious dysfuntcion of any bodily organ or part..."


The complaint filed to the Department dated 7/28/25, indicated on 5/21/25 approximately six hours after being discharged from the hospital, (admitted 10:54 a.m., discharged 3:59 p.m.)Patient 21 committed suicide (car versus tree).


During a phone interview on 9/3/25 at 2:37 p.m., with the Office of Vital records personnel (OVRP) , the OVRP stated, the death certificate confirmed death on 5/21/25 at 9:01 p.m., originally entered as blunt trauma / injuries at the death scene and amended to suicide by medical examiner.













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3a. During a concurrent review of Patient 6's medical record and interview with the regulatory compliance manager (RCM) on 9/17/25 at 10:15 a.m., the record indicated patient was a 14-year-old male with a past medical history of depression and insomnia that presents to the ED with suicidal ideations on 5/24/25. Patient was evaluated by the crisis team (evaluates patients and place a 72 hour hold if needed) and recommended inpatient psychiatric admission. The Emergency Department Interfacility Transfer Summary form dated 5/24/25 was reviewed with the RCM. The form did not indicate the method of transfer, none of the options were checked on the form. The patient/representative signature date and time were left blank. The RCM confirmed the areas that were left blank and stated, "The transfer form is not complete."


3a. During a concurrent review of Patient 8's medical record and interview with the regulatory compliance manager (RCM) on 9/17/25 at 9:54 a.m., the record indicated patient was a 51-year-old female presenting for 8 days of fatigue, feeling of heaviness in her head, loss of balance and dizziness. In the medical decision-making part of the record indicated "Given concerning of repetitive ataxia, and loss of balance, tele neurology recommended obtaining CT and CTA (series of radiographic imaging), which showed 1.3 cm aneurysm (bulge in the wall of a blood vessel) at the bifurcation of the left carotid artery ... recommend transfer to [hospital's name} for neuro-endovascular repair. Will initiate transfer process." The electronic interfacility transfer document, dated 5/24/25 at 2:45 a.m., was reviewed with the RCM. The RCM was asked where in the electronic form indicates the patient gave consent for this transfer. The RCM inspected the document thoroughly and stated "this transfer form does not have a place where the patient or representative can sign the document electronically. No, there is no consent by the patient for this transfer."




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3b. During a concurrent interview and record review on 9/17/25 at 11:00 a.m., with the quality registered nurse (QRN 1), Patient 15's medical record was reviewed, QRN 1 acknowledged and confirmed that the medical record indicated, Patient 15 arrived on 5/16/25 at 7:46 p.m. and the reason for visit included Suicidal ideation, Patient 15 was determined to be medically stable and a transfer form was initiated for transfer to [name of facility], the transfer form did not have the patient's diagnosis, the patient's signature, who was accompanying the patient, and the patient's vital signs. Additionally, QRN 1 acknowledged and confirmed Patient 15 was transferred to [name of facility] and the transfer form was incomplete.

During a concurrent interview and record review on 9/17/25 at 11:50 a.m., with QRN 1, Patient 16's medical record was reviewed, QRN 1 acknowledged and confirmed that the medical record indicated, Patient 16 arrived on 8/14/25 at 6:20 a.m. and the reason for visit included motor vehicle crash, Patient 16 was determined to be stable to transfer to [name of facility]. Additionally, QRN 1 acknowledged and confirmed Patient 16 was transferred to [name of facility] and there was no transfer form or documentation of risk and benefits for transfer discussion with any medical doctor and Patient 16.