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Based on review of facility policy, review of the Emergency Department (ED) Central Logs, review of an Emergency Medical Service (EMS) patient care report, review of a facility investigation, medical record review, and interviews, the facility failed to ensure 1 patient (Patient #1) was provided a Medical Screening Examination (MSE) and failed to provide stabilizing treatment for 1 patient (Patient #1) who presented to the ED via EMS with Suicidal Ideations of 30 ED patients reviewed.

The findings included:

Review of Hospital A's investigation report dated 4/28/2021 showed on 4/28/2021 the ED was notified by the communication center that EMS was enroute to the ED with a patient with a possible suicidal attempt. EMS arrived in the ambulance bay (at Hospital A) with the patient at approximately 12:40 AM. As the EMS crew was preparing the patient for exit from the ambulance, the patient had an acute mental status change, became unresponsive, and developed acute respiratory distress. The EMS crew initiated high flow oxygen to the patient and then one crew member went into the ED and told the nursing staff the patient had deteriorated, and they needed assistance in the ambulance. Registered Nurses (RN) #1 went to the EMS ambulance bay to assist with the patient. While the patient was in the ambulance, an intravenous line (IV) was established, the patient was given Narcan (medication used to treat suspected overdose of Opioids) intranasally, and a Rapid Sequence Intubation (RSI) was performed. After Patient #1 was intubated, the paramedic gave the patient Narcan IV. The paramedic told the ED nurse they were going to transport the patient to Hospital B because the patient had cardiac dysrhythmias and there was no cardiology specialty available at Hospital A and Hospital A would have to transfer the patient. The RN went back into the ED and EMS transported the patient to Hospital B at 1:20 AM (40 minutes after the EMS arrived at EMS ambulance bay at Hospital A). The patient's condition continued to deteriorate at Hospital B, and she went into cardiac arrest. She was pronounced dead on 4/28/2021 at 3:35 AM.

Hospital A failed to ensure Patient #1 was provided a MSE and failed to provide stabilizing treatment.

During an interview on 5/28/2021 at 4:30 PM, the Assistant Vice President (AVP) of Risk Management stated the facility immediately completed a detailed investigation of the incident which occurred on 4/28/2021 involving Patient #1 and implemented a corrective action plan to achieve compliance with Emergency Medical Treatment and Labor Act (EMTALA) requirements. She stated the action plan had been implemented and education had been provided to the ED staff. A meeting between the hospital leadership and EMS had occurred to establish the hospital's EMTALA obligations and EMTALA rules. EMS leadership had presented education to the EMS staff. Ongoing monitoring has occurred and will continue per the plan of correction with appropriate follow-up to the Quality Assurance Performance Improvement (QAPI) meetings to ensure compliance. The correction plan included:

1. To prevent the reoccurrence of this deficiency, the hospital implemented immediate and on-going focused EMTALA education/reeducation that includes the review of the definition of hospital property and the requirements for a Medical Screening Examination (MSE). EMTALA education will be mandatory for the following: ED Nursing staff team members. Any current ED Nursing Team members who do not have education completed prior to 4/30/2021 will not be allowed to work until EMTALA education is completed.
a. Responsible Party: Risk Management team
b. Target date of completion: 4/30/2021
c. Date action item completed: 4/30/2021 and ongoing for new team members orientation process prior to them working independently
d. Review of the sign-in sheets for the training 26 of the 29 ED Nursing staff had completed the required EMTALA training. One (1) Registered Nurse (RN) who was on family medical leave will be required to complete the training prior to returning to work on 6/21/2021.

2. Any ED Nursing team member hired after EMTALA education was completed on 4/30/2021 will have EMTALA education completed during their orientation process, prior to the team member working independently. EMTALA education will be completed before the team member can work independently.
a. Responsible party: ED Nurse Manager
b. Target date of completion: ongoing as new ED Nursing staff team members are hired
c. Action date item completed: 5/1/2021 and ongoing
d. Review of QAPI Action Worksheet showed as of 5/1/2021 no new team members had been hired

3. EMTALA Education compliance monitoring was completed for the following categories and numbers of team members and providers:
a. Nursing team member: 26 nursing team members EMTALA education completed at 96.15%. One nursing team member is on family leave and will have education completed on her return to work scheduled 6/21/2021
b. Certified Nursing Assistants EMTALA education completed at 100%
c. Paramedic Team member EMTALA completed at 100%
d. Nurse Intern EMTALA education completed at 100%
e. ED secretary EMTALA education completed at 100%

4. Annual EMTALA competency-based learning (CBLs) are offered on an ongoing basis to Nursing ED team members
a. Responsible party: ED Nurse Manager
b. Target date of completion: annual
c. Date action item completed: annual
d. Review of the CBLs showed an annual competency for all employees are completed annually

5. To prevent the reoccurrence of this deficiency, Risk Management had an immediate discussion with the EMS team members involved in the event. The intent of the discussion was to determine the chain of events with involved EMS team members and to provide information to EMS concerning the hospital's EMTALA obligation as it relates to Hospital Property and MSE requirements for EMTALA.
a. Responsible Person: AVP Risk Management Ballad Health
b. Target date of completion: 4/28/2021
c. Date action item completed: 4/28/201
d. Review of facility documentation related to the investigation showed the meeting was held with Paramedic #1 and EMT #1.

6. A meeting was scheduled and occurred with EMS leadership on 5/3/2021. The purpose of the meeting was to explain to EMS the hospital's EMTALA obligations and responsibilities and allowed for ongoing open communication between EMS and the hospital to address ongoing opportunities between the facility and local EMS.
* Review of the minutes dated 5/3/2021 showed the VP of Risk Management, the facility Risk Manager, EMS Caption, Deputy Chief of EMS, the Paramedic and EMT involved with the patient, the QA (Quality Assurance), Director of EMS, the Corporate Director of Trauma Services and EMS Liaison, and the ED/EMS Physician Director responsible for EMS services attended the meeting.
*Discussions were held with the paramedic and EMT involved on the transport of the patient
*The VP of Risk Management provided information related to the hospitals EMTALA obligations and how these collaboratively extend to EMS partners once on hospital property. An open discussion was held.
*The VP of Risk Management offered to provide a copy of EMTALA rules, as well as a tip sheet for EMS training. Deputy Chief shared he would be glad to provide this training education to all Sullivan County EMS personnel, and further provided his contact information for sharing of the education materials.
*Open collaborative discussion regarding many facets of EMTALA and how they affect hospitals and EMS was competed for expanded knowledge. Open discussions regarding the facility and local EMS initiatives was completed.

7. Education developed for EMS that reviews the hospital's EMTALA obligations with respect to Hospital property and MSE obligations.
a. Responsible Person: AVP Risk Management
b. Target date of completion: 5/7/201
c. Date action item completed: 5/6/2021
d. EMS has scheduled training days for EMS team members. Education will be presented by EMS Deputy Chief to team members. The education will be completed during team meetings, by zoom calls at shift changes
e. During an interview with the Corporate EMS Liaison for EMS on 5/28/2021 at 4:30 PM, showed the training for EMS had begun and was provided during shift changes by the shift leaders. This training was provided by virtual training at the beginning of the shifts.
f. Review of EMS training documentation showed EMS had 80 employees. 90% of the EMS staff had completed the training using virtual technology via Zoom.

8. The ED physician was unaware that the patient was on hospital property. EMTALA education was provided to the ED medical staff via electronic communication and was sent by the ED medical director.
a. Responsible Person: ED Medical Director
b. Target date of completion:5/3/2021
c. Date action item completed: 5/3/2021
d. This information was sent to the ED physicians and was sent as an education opportunity. Read receipts were not required for the physicians.
e. During an interview on 5/28/2021 at 4:50 PM, ED Physician #1 stated he was not aware Patient #1 was on hospital property on 4/28/2021. He stated any patient who presents to the ED requesting an evaluation should receive an MSE.

9. Involved patient was not registered on 4/28/2021 when they presented on hospital property. The patient was added to the ED log on 4/28/2021 at 1:21 PM.
a. Responsible person: Registration and ED staff leadership
b. Completion date: 4/28/2021
c. Date action item completed: 4/28/2021
d. Review of facility documentation showed the patient arrived on hospital property on 4/28/2021 by EMS and was not registered. She was manually added to the ED log on 4/28/2021 at 1:21 PM

10. To ensure compliance with EMTALA education provided to new ED Department clinical team members EMTALA education will be provided prior to the ED clinical team member being able to work independently. Threshold for compliance is set at 100%. Results of the monitoring will be presented at the Hospital QAPI committee quarterly. Monitoring will occur for six consecutive months and be reported quarterly. If the threshold is meet for two consecutive quarters (6 months) the monitor will be re-evaluated.
a. Responsible Party: ED Nurse Manager
b. Target date of completion: collection of data 5/2021, reporting to QAPI 7/2021

11. To ensure compliance with MSE's being performed on all patients presenting with an Emergency Medical Condition (EMC), 100% of the medical records for patients who leave against medical advice (AMA) and patients who leave without being seen (LWBS) will be reviewed for performance of an MSE when appropriate. Threshold for compliance is set at 100%. Results of monitoring will be presented at the hospitals QAPI committee quarterly. Monitoring will occur for six consecutive months and be reported quarterly. If the threshold is meet for two consecutive quarters (6 months) the monitor will be re-evaluated.
a. Responsible Party: ED Nurse Manager
b. Target date for completion: collection of data 5/2021, reporting 7/2021

Please refer to A-2406 and A-2407.

Based on review of facility policy, review of an Emergency Medical Service (EMS) patient care report, review of Emergency Department (ED) logs, medical record review, and interview, the facility failed to ensure 1 patient (Patient #1), who presented to the ED via EMS with a complaint of Suicidal Ideations was listed on the ED central log of 30 ED patients reviewed.

The findings included:

Review of the facility's policy titled "EMTALA" [Emergency Medical Treatment And Labor Act] last reviewed 9/8/2017, showed "...the hospital shall keep a central log of all patients who come to the hospital's emergency department seeking examination or treatment for a medical condition..."

Review of an EMS Patient Care Report dated 4/28/2021 at 12:40 AM showed EMS arrived at Hospital A's ambulance bay with Patient #1 with a complaint of suicidal ideations. The patient was initially awake and alert, but when EMS arrived at the facility the patient developed a change in mental status where she became unresponsive and developed respiratory distress. One of the EMS crew went inside the facility and asked for help from the nursing staff. Registered Nurse #1 went to the ambulance bay to assist with the patient's care. EMS initiated an IV (intravenous line), gave the patient intranasal Narcan (medication used to reverse suspected opioid overdose) and performed a Rapid Sequence Intubation (RSI). Patient #1 was then given Narcan intravenously. The decision was made by the EMS Paramedic to leave Hospital A and take the patient to Hospital B because the patient had developed cardiac dysrhythmias and cardiac services were not available at Hospital A. The patient was not taken into Hospital A's ED for evaluation and treatment.

Review of the ED central logs dated 4/28/2021 showed Patient #1 was placed on the ED log on 4/28/2021 at 1:21 PM (12 hours and 41 minutes) after the facility was made aware of the incident.

Review of ED medical records dated 4/28/2021 showed no ED triage or medical record for Patient #1.

During an interview on 5/28/2021 at 12:30 PM, RN #1 stated EMS came inside the ED and told the staff the patient was unresponsive. RN #1 stated "...I went outside [in the EMS ambulance bay] and the paramedic was trying to start an IV on the patient...[paramedic] stated 'I think I need to intubate the patient'...we were still in the back of the truck in the EMS entrance bay. He performed an RSI on the patient and intubated her...After that, [paramedic] stated "...she [Patient #1] is stable, I think we need to go to [Hospital B] with her for higher level of care.' I got out of the back of the ambulance and went back inside. The charge nurse asked me where the patient was...I told her EMS had taken the patient to [Hospital B]. The charge nurse told me 'that was an EMTALA violation'.

During an interview on 5/28/2021 at 4:30 PM, the Assistant Vice President of Risk Management, confirmed the patient was not listed on the ED Central Log until 4/28/2021 at 1:21 PM, after the facility had become aware of the incident.

Based on review of facility policy, review of an Emergency Medical Services (EMS) patient care report, medical record review, and interviews, the facility failed to provide a Medical Screening Examination (MSE) for 1 patient (Patient #1) who presented to the Emergency Department (ED) via EMS for Suicidal Ideations of 30 ED patients reviewed.

The findings included:

Review of the facility's policy titled "EMTALA," (Emergency Medical Treatment and Labor Act) last reviewed 9/8/2019, showed "...it is the policy...to provide a MSE [medical screening examination] within its capability to: all individuals who present to a DED [dedicated emergency department] for examination or treatment of any medical condition, whether emergent or nonemergent; all individuals presenting on hospital property...Hospital property: includes all land contiguous with the hospital, including the parking lot, sidewalks, driveways, waiting rooms, and buildings not connected with the hospital but on the same contiguous parcel of land..."

Review of an EMS Patient Care Report dated 4/28/2021 at 12:40 AM showed EMS was requested to a hotel for a patient who was suicidal. On arrival EMS found Patient #1 alert and oriented and speaking with the police department. The patient admitted to suicidal ideations and to consuming alcohol but denied taking anything else which may cause harm to herself. The patient ambulated to the ambulance without assistance and was secured in the seat of the ambulance. Further review showed "...while we were pulling into the ambulance bay [at Hospital A], the patient began having a decrease in her level of consciousness. She was given Narcan [medication used to reverse suspected opioid overdose] intranasally with no changes. She then became unresponsive. She would not respond to painful stimuli. She was lifted and moved to the cot and placed on the cardiac monitor. She was initially showing a sinus rhythm [normal cardiac rhythm]. An IV [intravenous line] was established in the left AC [antecubital vein]...Narcan was administered via the IV as noted with no changes. The patient's respiratory efforts began to decrease. A non-rebreather [oxygen mask] was placed on the patient. She also began having periods of cardiac dysrhythmias [abnormal cardiac rhythm]. The decision was made to RSI [rapid sequence intubation] the patient in the ambulance and divert to [Hospital B] due to ECG [electrocardiogram] changes and cardiac services available at [Hospital B]... Etomidate [short acting anesthetic agent] and Rocuronium [paralytic agent] were administered for the RSI procedure. Intubation was successfully performed...The patient was then placed on the ventilator as noted without issue. Once the patient was confirmed stable on the ventilator, we began transport..." EMS arrived at Hospital B on 4/28/2021 at 1:27 AM (47 minutes after arrival at Hospital A's EMS ambulance bay).

Review of the ED medical records dated 4/28/2021 showed no ED triage record or medical record for Patient #1.

Medical record review of an ED Nursing Note at Hospital B dated 4/28/2021 at 1:35 AM showed the patient arrived via EMS after a welfare check had been requested by Mobile Crisis (mental health crisis team) related to the patient had called and reported she was suicidal. She was initially alert and oriented, self-ambulated to the ambulance, and while enroute to (Hospital A) she became unresponsive with agonal (gasping respirations) breathing which required RSI. EMS then proceeded to bring the patient to (Hospital B).

Medical record review of an ED Provider Note from Hospital B dated 4/28/2021 at 1:43 AM showed the patient presented to the ED after ingestion of an unknown substance related to suicidal ideations. The "...patient was driven to nearest ED, [Hospital A], when patient went into respiratory distress and went unresponsive. EMS states that they then requested assistance from nursing [at Hospital A] who helped start a [IV] line on the patient. She was intubated and then transported to [Hospital B]...patient stated possible ingestion but of unknown product or intent. Mobile Crisis decided to send [someone] out [to do] a welfare check in order to help identify severity of patient's symptoms. Upon EMS arrival patient was able to walk out to the EMS vehicle but had slight staggering and slurring of speech..." The physician documented "...patient had unclear etiology of current medical process...ACLS [advanced cardiac life support] utilized and patient was given several rounds of Sodium Bicarb [medication to treat acidosis] as well. Very unclear why patient continued to deteriorate despite being intubated and with respirations. Patient rapid deterioration concerning possibility for pulmonary embolism [blood clot in the lung]. Patient was provided with TPA [tissue plasminogen activator/used to break up blood clots] as a concern possibility pulmonary embolism sudden on-set cardiac failure. Patient was also treated possibility of ingestion ethylene glycol [antifreeze] given a prior history of overdose. Unfortunately, patient had recurrent loss of pulse, code was ran extended period of time resulting in futile resolved. Unclear exact cause..." The patient was pronounced dead on 4/28/2021 at 3:35 AM.

During an interview on 5/26/2021 at 12:45 PM, the Assistant Vice President (AVP) of Risk Management (RM) stated on 4/28/2021 Patient #1 had made a call to the Crisis Management, reported she was in a hotel and she was suicidal. Based on this information, Crisis Management notified the local police department and EMS for a health welfare check where they responded and found the patient. The patient agreed to go to the ED for evaluation and treatment. The patient was transported by EMS to Hospital A's ED. On arrival in the ED ambulance bay, the patient developed an acute mental status change where she became unresponsive and reportedly developed cardiac dysrhythmias. The patient was intubated in the back of the ambulance and was never taken inside the ED at Hospital A, but was transported by EMS to Hospital B, which is 6 minutes from Hospital A. At Hospital B the patient suffered a cardiac arrest, possibly related to ingestion of antifreeze. Patient #1 expired on 4/28/2021. The AVP confirmed Patient#1 was, on hospital property, but was not evaluated at Hospital A and did not receive a MSE.

During a telephone interview on 5/28/2021 at 10:00 AM, Paramedic (EMT-P) #1 stated he transported Patient #1 on 4/28/2021 to Hospital A related to a possible suicidal attempt. On arrival at Hospital A's EMS ambulance bay they were going to get her on the cot and take her into the ED, but the patient suddenly became unresponsive to verbal stimuli. EMT-P#1 stated his partner got in the back of the ambulance with him and he told his partner to go into the ED and tell the staff they were going to be delayed in coming in. He stated "...I gave her Narcan [medication used to treat Opioid overdose] intranasally and was trying to get an IV [intravenous line] started on her. The nurse [Registered Nurse #1] came out to the truck to assist and we finally got an IV. I gave her Narcan IV at that point and started her on high flow oxygen. She was having agonal respirations, so I decided we need to perform RSI [rapid sequence intubation] and intubate her. The monitor cardiac dysrhythmias. I got her intubated and on the ventilator. I decided she needed to go to [Hospital B] related to [Hospital A] did not have cardiology available and she would need transfer anyway to [Hospital B]..." The Paramedic confirmed they were in the ED ambulance bay at [Hospital A] and they did not take the patient into the ED for stabilization. The patient was transported to [Hospital B] on 4/28/2021.

During a telephone interview on 5/28/2021 at 10:15 AM, Emergency Medical Technician (EMT) #1 stated when they arrived at Hospitals A's ED, they were going to stand the patient up to place her on the cot and she became unresponsive. He stated "...I got in the back of the truck to help get her on the cot and secured...I went into the ED and told the staff we were going to be delayed in getting the patient in the ED because her condition had deteriorated...I told the charge nurse and another RN...I went back out to the truck to help. A few minutes later the RN came out to the truck to help us, and she assisted in starting the IV on the patient. The patient was unresponsive and in respiratory distress. The paramedic performed RSI on the patient and intubated the patient in the back of the truck. The paramedic wanted to go to [Hospital B] with the patient since she required intubation, [Hospital A] did not have onsite cardiology. We transported the patient to [Hospital B] emergency traffic..."

During an interview on 5/28/2021 at 12:30 PM, RN #1 stated the communication center had notified the ED of the EMS was coming in with a patient who was suicidal. The EMT came in and told the staff the patient was initially responsive, but she had become unresponsive in the back of the truck. She stated "...I went outside [in the EMS ambulance bay] and the paramedic was trying to start an IV on the patient. The paramedic stated 'I think I need to intubate the patient'...we were still in the back of the truck...He performed an RSI on the patient and intubated her. After that, the paramedic stated "...'she is stable. I think we need to go to [Hospital B] with her for higher level of care'. I got out of the back of the ambulance and went back inside. The charge nurse asked me where the patient was, and I told her EMS had taken the patient to [Hospital B]. The charge nurse told me that was an EMTALA violation...." RN #1 confirmed Patient #1 was on hospital property and was not evaluated by the physician.

During a telephone interview on 5/28/2021 at 3:35 PM, RN #2 stated EMS notified the ED they were transporting a female patient who was suicidal. RN #2 stated EMT came inside the ED when they arrived and said they needed help with the patient and "...I just assumed they would bring the patient in once they got her took care of. [RN #1] came back in the ED and I asked her where the patient was. She said EMS had intubated the patient and then transported her to [Hospital B]..." RN #2 confirmed the patient was on hospital property and the patient did not receive a medical screening examination.

During an interview on 5/28/2021 at 4:45 PM, the ED Nurse Manager, stated she was notified by the charge nurse at the end of the shift the EMS had presented to the EMS entrance bay with the patient, the patient's condition deteriorated, and EMS intubated the patient and then transported her to Hospital B. The ED Nurse Manager confirmed the patient did not receive a medical screening examination at Hospital A.

During an interview on 5/28/2021 at 4:50 PM, ED Physician #1 confirmed the patient never came into the ED and he was not aware of the patient being in the EMS ambulance bay on 4/28/2021.

During an interview on 5/28/2021 at 4:55 PM, the AVP of Risk Management, stated the facility had implemented an action plan and education had been provided to the ED staff. A meeting between the hospital leadership and EMS had occurred to establish the hospital's EMTALA obligations and EMTALA rules. EMS leadership had presented education to the EMS staff. Ongoing monitoring had occurred and will continue with appropriate follow-up to the Quality Assurance and Performance Improvement committee to ensure compliance.

Based on review of facility policy, review of an Emergency Medical Services (EMS) patient care report, medical record review, and interviews, the facility failed to provide stabilizing treatment for 1 patient (Patient #1) who presented to the Emergency Department (ED) via EMS for Suicidal Ideations of 30 ED patients reviewed.

The findings included:

Review of the facility's policy titled "EMTALA," (Emergency Medical Treatment and Labor Act) last reviewed 9/8/2019, showed "...it is the policy...to provide a MSE [medical screening examination] within its capability to: all individuals who present to a DED [dedicated emergency department] for examination or treatment of any medical condition, whether emergent or nonemergent; all individuals presenting on hospital property...Hospital property: includes all land contiguous with the hospital, including the parking lot, sidewalks, driveways, waiting rooms, and buildings not connected with the hospital but on the same contiguous parcel of land..." Further review showed "...the examination must include all ancillary services routinely available to the ED...in the judgment of the emergency physician or other treating physician are necessary to screen and/or stabilize an individual with an Emergency Medical Condition..."

Review of an EMS Patient Care Report dated 4/28/2021 at 12:40 AM showed EMS was requested to a hotel for a patient who was suicidal. On arrival EMS found Patient #1 alert and oriented and speaking with the police department. The patient admitted to suicidal ideations and to consuming alcohol but denied taking anything else which might cause harm to herself. The patient ambulated to the ambulance without assistance and was secured in the seat of the ambulance. Further review showed "...while we were pulling into the ambulance bay [at Hospital A], the patient began having a decrease in her level of consciousness. She was given Narcan [medication used to reverse suspected opioid overdose] intranasally with no changes. She then became unresponsive. She would not respond to painful stimuli. She was lifted and moved to the cot and placed on the cardiac monitor. She was initially showing a sinus rhythm [normal cardiac rhythm]. An IV [intravenous line] was established in the left AC [antecubital vein]...Narcan was administered via the IV as noted with no changes. The patient's respiratory efforts began to decrease. A non-rebreather [oxygen mask] was placed on the patient. She also began having periods of cardiac dysrhythmias [abnormal cardiac rhythm]. The decision was made to RSI [rapid sequence intubation] the patient in the ambulance and divert to [Hospital B] due to ECG [electrocardiogram] changes and cardiac services available at [Hospital B]... Etomidate [short acting anesthetic agent] and Rocuronium [paralytic agent] were administered for the RSI procedure. Intubation was successfully performed...The patient was then placed on the ventilator as noted without issue. Once the patient was confirmed stable on the ventilator, we began transport..." EMS arrived at Hospital B on 4/28/2021 at 1:27 AM (47 minutes after arrival at Hospital A's EMS ambulance bay).

Review of the ED medical records dated 4/28/2021 showed no medical record for Patient #1.

Medical record review of an ED Provider Note from Hospital B dated 4/28/2021 at 1:43 AM showed the patient presented to the ED after ingestion of an unknown substance related to suicidal ideations. The "...patient was driven to nearest ED, [Hospital A], when patient went into respiratory distress and went unresponsive. EMS states that they then requested assistance from nursing [at Hospital A] who helped start a [IV] line on the patient. She was intubated and then transported to [Hospital B]..." The physician documented "...patient had unclear etiology of current medical process...ACLS [advanced cardiac life support] utilized and patient was given several rounds of Sodium Bicarb [medication to treat acidosis] as well. Very unclear why patient continued to deteriorate despite being intubated and with respirations. Patient rapid deterioration concerning possibility for pulmonary embolism [blood clot in the lung]. Patient was provided with TPA [tissue plasminogen activator/used to break up blood clots] as a concern possibility pulmonary embolism sudden on-set cardiac failure. Patient was also treated possibility of ingestion ethylene glycol [antifreeze] given a prior history of overdose. Unfortunately, patient had recurrent loss of pulse, code was ran extended period of time resulting in futile resolved. Unclear exact cause..." The patient was pronounced dead on 4/28/2021 at 3:35 AM.

During an interview on 5/26/2021 at 12:45 PM, the Assistant Vice President (AVP) of Risk Management (RM) stated on 4/28/2021 Patient #1 had made a call to Crisis Management (mental health services) and reported she was in a hotel and was suicidal. Based on this information, Crisis Management notified the local police department and EMS for a health welfare check. The police department and EMS responded to the hotel. The patient agreed to go to the ED for evaluation and treatment. The patient was transported by EMS to Hospital A's ED. On arrival in the ED ambulance bay, the patient developed an acute mental status change where she became unresponsive and reportedly developed cardiac dysrhythmias. The patient was intubated in the back of the ambulance and was never taken inside the ED at Hospital A. Patient #1 was transported by EMS to Hospital B where she suffered a cardiac arrest and expired on 4/28/2021. The AVP confirmed Patient#1 was on hospital property, but was not evaluated or stabilized at Hospital A.

During a telephone interview on 5/28/2021 at 10:00 AM, Paramedic (EMT-P) #1 stated he transported Patient #1 on 4/28/2021 to Hospital A related to a possible suicidal attempt. On arrival at Hospital A's EMS ambulance bay they were going to get her on the cot and take her into the ED, but the patient suddenly became unresponsive to verbal stimuli. EMT-P #1 stated his partner got in the back of the ambulance with him and he told his partner to go into the ED and tell the staff they were going to be delayed in coming in. He stated "...I gave her Narcan intranasally and was trying to get an IV started on her. The nurse [Registered Nurse #1] came out to the truck to assist and we finally got an IV. I gave her Narcan IV at that point and started her on high flow oxygen. She was having agonal respirations, so I decided we need to perform RSI and intubate her. The monitor showed she was having cardiac dysrhythmias. I got her intubated and on the ventilator. I decided she needed to go to [Hospital B] related to [Hospital A] did not have cardiology available and she would need transfer anyway to [Hospital B]..." The Paramedic confirmed they were in the ED ambulance bay at [Hospital A] and they did not take the patient into the ED for stabilization.

During a telephone interview on 5/28/2021 at 10:15 AM, Emergency Medical Technician (EMT) #1 stated when they arrived at Hospitals A's ED, they were going to stand the patient up to place her on the cot and she became unresponsive. He stated "...I got in the back of the truck to help get her on the cot and secured...I went into the ED and told the staff we were going to be delayed in getting the patient in the ED because her condition had deteriorated...I told the charge nurse and another RN...I went back out to the truck to help. A few minutes later the RN came out to the truck to help us and she assisted in starting the IV on the patient. The patient was unresponsive and in respiratory distress. The paramedic performed RSI on the patient and intubated the patient in the back of the truck. The paramedic wanted to go to [Hospital B] with the patient since she required intubation, [Hospital A] did not have onsite cardiology. We transported the patient to [Hospital B] emergency traffic..."

During an interview on 5/28/2021 at 12:30 PM, RN #1 stated the communication center had notified the ED of the EMS was coming in with a patient who was suicidal. The EMT came in and told the staff the patient was initially responsive, but she had become unresponsive in the back of the truck. She stated "...I went outside [in the EMS ambulance bay] and the paramedic was trying to start an IV on the patient. The paramedic stated 'I think I need to intubate the patient'...we were still in the back of the truck...He performed an RSI on the patient and intubated her. After that, the paramedic stated "...'she is stable, I think we need to go to [Hospital B] with her for higher level of care'. I got out of the back of the ambulance and went back inside. The charge nurse asked me where the patient was, and I told her EMS had taken the patient to [Hospital B]. The charge nurse told me that was an EMTALA violation...." RN #1 confirmed Patient #1 was on hospital property and was not evaluated by the physician.

During a telephone interview on 5/28/2021 at 3:35 PM, RN #2 stated EMS notified the ED they were transporting a female patient who was suicidal. RN #2 stated the EMT came inside the ED when they arrived and said they needed help with the patient and "...I just assumed they would bring the patient in once they got her took care of. [RN #1] came back in the ED and I asked her where the patient was. She said EMS had intubated the patient and then transported her to [Hospital B]..." RN #2 confirmed the patient was on hospital property and the patient did not receive a medical screening examination or stabilization.

During an interview on 5/28/2021 at 4:45 PM, the ED Nurse Manager, stated she was notified by the charge nurse at the end of the shift the EMS had presented to the EMS entrance bay with Patient #1. The patient's condition deteriorated, and EMS intubated the patient and then transported her to Hospital B. The ED Nurse Manager confirmed the patient did not receive a medical screening examination or stabilization at Hospital A.

During an interview on 5/28/2021 at 4:50 PM, ED Physician #1 confirmed the patient never came into the ED and stabilization was not performed. He stated he was not aware the patient was in the EMS ambulance bay on 4/28/2021.