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Based on review of facility video footage, medical records review, Autopsy Report review, Ambulance report review, Policy and procedure review, Drug Overdose Protocol review, and interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided 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 one (Patient #1) of 20 sampled patients. Patient #1 presented to the Emergency Department with a diagnosis of accidental drug overdose. The facility failed to provide a complete medical screening examination to patient #1 when he presented to the hospital's ED with signs and symptoms of drug overdose.

Refer to findings in Tag A -2406.



Based on review of facility's Overdose Toxic ingestion ED Nurse Panel,/Protocol, medical records review, and Emergency Department logs and interviews the facility failed to ensure that an individual who had an identified emergency medical condition was stabilized as required within the capability of the staff and facilities available at the hospital, failed to obtain blood toxicology screening, urine drug screening or an EKG as stated in the facility's drug overdose protocol; and failed to treat similar medical conditions consistently for one (#1) of twenty (20) emergency department. medical records reviewed.


Refer to findings in Tag A-2407

Based on review of facility video footage, medical records review, Autopsy Report review, Ambulance report review, Policy and procedure review, Drug Overdose Protocol review, and interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided 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 one (Patient #1) of 20 sampled patients. Patient #1 presented to the Emergency Department with a diagnosis of accidental drug overdose. The facility failed to provide a complete medical screening examination to patient #1 when he presented to the hospital's ED with signs and symptoms of drug overdose.

Findings included:

1. The ambulance report titled "Patient Care Report "dated 08/10/2023 for Patient #1 was reviewed. The chief complaint was listed as "poisoning/overdose-Substance Abuse ...Primary symptom altered mental status."
On 08/10/2023 at 8:10 PM the assessment shows Airway-Partially obstructed-Tongue, Pulses-Carotid-Bounding, Breathing-Absent.

Review of the narrative revealed in part, "19 YOM (year old male) laying on the floor with compressions being done by family member ...Per dispatch due to Patient not breathing even though Patient. had a pulse. Initially, Patient unresponsive, has pulse, and is not breathing Patient given 2 MG of Narcan (medication that rapidly reverses Opioid overdose) and being bagged (given ventilation with mask) Patient is Sinus tach (tachycardia- fast heart rate) on cardiac monitor ...IV (intravenous Line) is placed and Zofran (medication used for nausea and vomiting) given. Patient regained consciousness before IV attempt and is AOx4 (awake alert and oriented) .... Patient advises he took an unknown among of Percocet (pain medication). Patient is cooperative and is transported to the ER (Emergency room) with no decline in condition."

At 8:21 p.m., the patient's vital signs were listed as Blood Pressure: 102/57; Heart Rate: 110 (normal HR 60-100); Respiratory Rate: 12.

2. Patient #1's hospital medical record was reviewed. Patient #1 arrived at the facility Emergency Department (ED) via Fire Rescue Emergency Medical Services (EMS) on 08/10/2023 at 8:32 PM for accidental drug overdose. The record showed that on 08/10/2023 at 9:07 PM the patient was triaged by the Registered Nurse (RN) with an ESI level of 2. (Emergency Severity Index. The Emergency Severity Index is a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. A level of 2 indicates Emergent patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found). A note at that time showed that the patient was found by bystanders not breathing and unresponsive, CPR was performed prior to arrival of EMS. Patient was unresponsive with a pulse upon arrival of EMS. He was administered 2 mg (milligrams) of Narcan, and became alert and oriented. Per patient he took Percocet and did not intend to harm himself.

Review of the Columbia Suicide Severity Rating Scale (a suicide risk assessment tool), documented at 9:10 PM by the RN, indicated "Suicide risk: No Risk indicated." The patient's vital signs were listed as Temperature: Orally 37.2 degrees Celsius; Heart Rate 102 (normal Heart rate 60-100); Respirations: 15, Blood Pressure: 113/69; and oxygenation saturation was 95% on room air. Further review revealed the ED physician ordered the following laboratory diagnostic blood tests: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Red Top (Blood bank testing), Light blue top (for performing blood coagulation studies), Rainbow top (collecting extra blood tubes at the time of initial draw, to allow for add-on testing at a later time). A Urinalysis test with reflex microscopic and reflex culture was also ordered. The urinalysis with reflex microscopic and reflux culture test was discontinued because the patient was discharged. There was no documentation in the medical record to indicate that a toxicology screen test or urine drug screen was ordered by the ED physician. Additionally, no Electrocardiogram (EKG is a test to record the electrical signals in the heart) was ordered and while Patient #1 was in the ED.

On 8/10/2023 at 9:43 PM, the physician documented MD history of present illness: ... "Patient found unresponsive at girlfriend 's house. Started CPR (cardiopulmonary resuscitation) by bystander who called EMS (Emergency Medical Services/ambulance). At time of EMS arrival patient unresponsive with a pulse, and breathing. Patient given Narcan 2 milligrams by EMS with subsequent patient waking up. No neurological defects. No history of injury. Patient with a history of polysubstance drug use, including Percocet and fentanyl. Patient with a history of previous drug overdose. Patient stated he just wanted to get high. Patient states took Percocet, 2 tablets. Patient denies any suicidal or homicidal ideation. No nausea vomiting. No chest pain or shortness of breath. No headache. No abdominal pain. No back pain. No weakness. No numbness or paresthesia. No incontinence."

The Physical examination revealed in part, "Eye: PERRLA (Pupils are equal, round and reactive to light and accommodation), Normal conjunctiva, EOMI (extra-ocular eye movements intact) ...Psychiatric... uncooperative. Tearful. Not suicidal. Not Homicidal. No Hallucinations. No delusions. Good eye contact. The section of the note titled "ED Course" documentation by the ED physician revealed that on 8/10/23 at 9:45 p.m., "Patient refused any blood work. Case discussed with patient. He now agrees to lab work ... Mother and aunt in the ER lobby ...Case discussed with patient, girlfriend, mother and aunt. Mother contacted Detox Center ...Patient speaking with detox center currently. Doing a pre- assessment. Patient will go to detox center upon discharge from the hospital. Patient is not suicidal or homicidal. He admits has a drug problem and is willing to get help ... He wants to be discharged right now. At 10:58 PM, the notes continue "Patient remains asymptomatic ...no withdrawal ...I spoke over the phone with intake male personal. He request[s] discharge paperwork, which has been provided to the patient already."
According to the medical record the patient was discharged from the ED on 8/10/2023 at 11:13 PM. The patient's "Discharge Disposition: Home or Self Care." The record showed the provider completed an evaluation on 08/10/2023 at 9:43 PM, 1 hour and 11 minutes after arrival in the ED.

There was also an entry documented in part by the ED physician "Diagnosis as 08/12/23 0247 Accidental drug overdose, initial encounter Drug abuse."

The facility failed to ensure that their own Drug Overdose Protocol and Policy and procedure were followed as evidenced by failing to obtain necessary laboratory testing Blood Toxicology screen and urine screen testing that was within the capabilities of the hospital in order to reach a definitive diagnosis for patient #1 on 8/10/23 with presenting signs and symptoms of drug overdose. As this resulted in an incomplete medical screening examination for patient #1.

3. On 08/24/2023 at approximately 8:45 AM, review of the video footage for the night of 08/10/2023 began.
a.) Fire Rescue Emergency Medical Services (EMS) arrived at the facility with Patient #1 on at 8:29 PM and were noted to be in the hallway of the ED with the patient on the stretcher at 08:30 PM. No facility staff were seen assessing the patient.
b.) At 9:07 PM, EMS wheeled the patient on the stretcher to an ED room. Patient #1 sat stood, then walked into the room and was off video. EMS waited with the patient on stretcher for 37 minutes. During this time no doctor or nurse approached or assessed the patient. EMS was observed to be talking to the RN.
c.) At 9:08 PM Staff L/RN entered Patient #1's room.
d.) 9:09 PM Staff J/triage nurse entered Patient #1's room.
e.) 9:45 PM Staff H/ED Physician moved toward Patient #1's room, looked inside and it appeared to be talking to someone inside the room.
f.) 9:50 PM Staff H/ED Physician and Staff K/ED CN (Charge Nurse) entered Patient #1's room.

The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to meet the emergency needs of patient #1 who was triaged as "Emergent" related to reported drug use by family members and the administration of Narcan by the EMT's as reported in the ambulance report.

4. Review of the autopsy report dated 9/14/23, revealed that an autopsy was performed on Patient #1 on 8/12/23 at 11:46 AM. The autopsy report revealed that Patient #1's date of death was 08/11/2023. The patient's cause of death was listed as "Multidrug Toxicity". The "Manner of Death as "Accident" and "How the injury Occurred: Used fentanyl (potent opioid drug, used for pain relief and anesthetic), Alprazolam (medication used to treat anxiety and panic disorders), and MDA (3-9/14/234 Methylenedioxyamphetamine- manmade synthetic drug noted for its stimulant properties, recreational drug).

5. The facility's policy titled "EMTALA" (Emergency Medical Treatment and Labor ACT). Policy # ED .330.02, Policy effective Date 10/04/22, Policy review date 10/04/22. The Policy stated in part, "IV, Procedures/Guidelines: All patients should receive a medical screening exam (MSE-Medical Screening examination) ... that includes providing necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires all necessary definitive treatment be given to the patient."

6. Review of the policy "Assessment, re-assessment in the Emergency Department" last reviewed 09/21/2022 showed "V2. Emergent: ESI Level 2: Patients who have conditions requiring emergent needs. These patients are high risk and need to be assessed promptly. Reassessments to be completed at a minimum of every hour."

7. The facility's Protocol/Standard of care for an overdose was requested for review. The protocol titled "Overdose Toxic Ingestion ED Nurse Panel (no date) revealed in part, "Vital Signs, STAT (orders that should be prioritized first and is urgently needed), ... continuous Pulse Oximetry STAT, Until discontinued ...Notify provider: Overdose or ingestion of toxic substance STAT ... Nursing communication ... STAT ... Contact Poison Control at 1-800-222-1222. Obtain applicable Toxicological Profile and document recommendations. Telemetry Monitoring 24 Overdose STAT, Until discontinued ... Indication for 24-hour telemetry: Overdose. Can the patient be off telemetry for activities (including therapy, ambulation, off-unit procedures, showers, bathroom)- No, if change in rhythm, notify Provider. Insert and Maintain Peripheral IV (Intravenous) ... STAT ... and Saline Lock IV Routine ... sodium chloride 0.9% flush Intravenous, Every 12 hours scheduled ... Oxygen Therapy ... CBC Auto Diff. Reflex Manual Diff if indicated ... Comprehensive metabolic panel STAT ... Acetaminophen (Tylenol) level STAT, ...Alcohol Ethyl level STAT ... Hepatic (Liver) function panel ... Protime-INR (test helps diagnose cause of bleeding or clotting disorders) ... APTT (Acquired thrombotic thrombocytopenia purpura- rare disorder results in blood clots) ... Urine Toxicology Panel. Drug Screen Urine, STAT ... Pregnancy, Urine ... EKG 12 lead STAT"


8.. During an interview on 8/25/2023 at 8:46 AM with Patient #1's family member, documentation of the incident provided by the family member was reviewed. The family member stated that when she arrived, Patient #1 had an IV in his arm, but no fluids or medications were being given. Patient #1 was very upset and did not make sense. His speech was erratic, and his pupils were very constricted. He was not mentally coherent in the sense he was very emotional, upset, agitated and all over the place with his thoughts. ... They began making phone calls to a sober living facility to get help. They began working trying to find a place that they could take him. She spoke to the physician and nurse letting them know that she was going to try and find somewhere that he could go. Patient #1 was not himself. You could not communicate with him in a way that he was understanding, and he was very emotional. They got a call back from sober living that a detox three hours away could take him ... They said that we would have to get him down to [the detox facility] and would not allow any other kind of transport due to Patient #1 not being ok. When Patient #1 stood up, he was rocking not completely balanced. He began to get very sick while the doctor spoke to detox and said he could be discharged to go there. Patient #1 began vomiting. He ran into the bathroom and was in there for at least ten minutes vomiting ...The doctor was going to discharge him for us to take him to detox three hours ways. Patient #1 finally agreed but when he stood up again in the hallway, his pupils were very constricted, he wasn't making sense and began throwing up again ran into the bathroom. He began screaming. She went into the bathroom and Patient #1 was vomiting and upset. The nurse nor the doctor checked on him. They allowed him to stay in the bathroom for another 8-10 minutes. He came out again wobbly and asked for socks, and something to throw up in. At that point she was very hesitant to take Patient #1 out of there, but the medical professionals were discharging him to us. As Patient #1 stood in the hallway, she even said "I don't think he's ok. They blew me off and handed him some socks" ... ultimately, we got him to the car to go get him clothes to take him to detox.
After they arrived to pick up his clothing, he was in the same condition and not of sound mind. He ran away and we couldn't find him. This was at approximately. 12:15 PM. We tried to go after him and look for him and kept calling him, but he didn't answer. I called the non-emergent police line. The police called me the next morning; a runner found my son by a pond dead not far from the girlfriend's house. The medical examiner has listed his death as pending until the toxicology comes back but he stated to me that it is very possible that the Narcan wore off and he still had too many drugs in his system, and he died. My son admitted to EMS after he became conscious that he took Percocet ... I do not recall any monitoring being done on him when I was taken to his room. It had been only one hour from the time Narcan was administered in the ambulance. My son was sick. He was battling an addiction that he desperately was trying to overcome.

9. In an interview on 08/25/2023 at 7:07 PM with another one of Patient #1's family members, who was present in the ED with the patient on 08/10/2023, said Patient #1 was definitely under the influence of something. She stated that he asked for an emesis bowl, she did not see him vomit but she said she could hear it through the bathroom door. She said, "he looked under the influence, not in a normal state, agitated, crying and he was not happy with himself, visibly shaken." She said the family did not know what to do because "We are not the professionals here. He wanted to be released but someone in that state of mind, I am not an expert, he has been Baker-Acted (Florida Mental Health Act where patients are held involuntarily for up to 72 hours to be evaluated by mental health professionals) before and it has not helped. I don't know what he needed but I feel that he needed to be observed longer in a safe place." She stated that after he was discharged, he fell in the parking lot. He was verbally upset and wanted to go get his belongings prior to going to the detox center and I looked up and he was on the ground, I know he did not trip on anything because he was just standing there."

Additionally, she stated that she followed him home to get his belongings. He went inside to get his belongings, he came out of the house, and she thought he was coming to her car, but he just took off. They searched for him but could not find him and they called the police. Her family member was notified early in the morning that he was found by a jogger and was expired.

10. During the review of the video footage for the night of 08/10/2023, which began on 08/24/2023 at approximately 8:45 AM, a discussion regarding the time EMS was standing against the wall with the patient on the stretcher for 37 minutes before being directed to room 107 was initiated. Staff P/Director of Critical Care stated, "that is not a long time and if EMS were busy, they would put us on bypass."

Based on review of facility's Overdose Toxic ingestion ED Nurse Panel,/Protocol, medical records review, and Emergency Department logs and interviews the facility failed to ensure that an individual who had an identified emergency medical condition was stabilized as required within the capability of the staff and facilities available at the hospital, failed to obtain blood toxicology screening, urine drug screening or an EKG as stated in the facility's drug overdose protocol; and failed to treat similar medical conditions consistently for one (#1) of twenty (20) emergency department. medical records reviewed.

Findings included:

1. Review of the facility document "Overdose Toxic Ingestion ED Nurse Panel" revealed protocol for an overdose patient includes "vital signs, continuous pulse oximetry (used to monitor the oxygen in the blood), Notify provider: overdose or ingestion of toxic substance, Nursing communication contact poison control. Obtain applicable toxicological profile, Telemetry/ cardiac monitoring 24 hours overdose, Insert and maintain Intravenous (IV) access, IV fluid, Oxygen therapy, Labs- Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Acetaminophen (Tylenol) level, Alcohol level, hepatic function panel, PT/ INR, APTT, Urine Drug screen, Females- pregnancy test and 12 lead EKG."

2. Patient #1's medical record was reviewed. Patient #1 arrived at the facility's Emergency Department (ED) via Fire Rescue Emergency Medical Services (EMS) on 08/10/2023 at 8:32 PM for a drug overdose. On 08/10/2023 at 9:07 PM the patient was triaged by the Registered Nurse (RN) with an ESI level of 2. (Emergency Severity Index. The Emergency Severity Index is a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from 1 -most urgent to 5 -least urgent on the basis of acuity and resource needs.) A note at that time showed that the patient was found by bystanders not breathing and unresponsive, CPR (cardiopulmonary resuscitation) was performed prior to arrival of EMS. Patient was unresponsive with a pulse upon arrival of EMS. EMS administered 2 mg (milligrams) of Narcan, and became alert and oriented.

Staff E/MD (Medical Doctor) conducted an evaluation on 08/10/2023 at 9:43 PM. At 9:46 PM Patient #1 agreed to blood work. A notation at 10:41 PM states "discussed with family. Mother contacted a detox center; patient will go to detox center upon discharge." At 10:58 PM a note stating, "patient remains asymptomatic." At 11:13 PM, the patient was discharged home, although per video evidence did not leave the property. At 11:39 PM mother requested MD to speak to intake person at detox center. Staff E/MD spoke with intake personnel. discharge papers and lab results were requested, and subsequently given to the patient. Treatments Patient #1 received were lab work of CBC (complete blood count), CMP (complete metabolic panel).

A note was entered on 08/12/2023 2:47 AM stating "Patient improved. No distress. Discussed ED results with the patient. Careful and detailed instructions given on home care and observation, what to monitor for, signs and symptoms of complications, follow-up and when to return to the ED. Patient understand and agree, satisfied with care, and comfortable to go home with outpatient management. Documents reviewed: ED nursing notes, ED records, reviewed and interpreted previous ED visit documentation." The record review revealed no evidence that blood for toxicology screening, no urine drug screening or EKG was ordered/obtained as stated in the facility's "Overdose Toxic ingestion ED Nurse panel" protocol for patient #1 an overdose patient seeking treatment in the Emergency Department.


3. The ED log was reviewed for the time period of 08/10/2023 6:00 PM through 08/12/2023 12:00 AM, which notes the arrival to triage times, as well as the arrival to Physician times. It was noted that 4 patients arriving after Patient #1 (at 8:32 PM) with ESI of 2 or less (lower acuity) were triaged prior to Patient #1. Two of those patients were seen by the physician prior to Patient #1.

4. A review of Patient #2's medical record was completed. Patient #2 arrived at the facility's ED brought in by police on 08/13/2023 10:48 PM for drug overdose.

Staff E/ED MD Assessed Patient #2 on 08/13/2023 10:56 PM. Nursing assessment completed at 11:00 PM, ESI 2, with note stating "the patient was in the middle of traffic not obeying commands. The Patient may have taken spice or something per LEO" (Law Enforcement Officer).

Treatments received were labs of Urine Drug screen, CBC, CMP, EKG (electrocardiogram-records the electrical signal from the heart to check for different heart conditions), CK (creatine kinase is a type of protein. High levels can mean you have damage to the skeletal muscles, heart, or brain), lab, Hcg serum (tests for pregnancy), restraints (violent), Ethanol labs (measures the amount of alcohol in your blood), IV (intravenous) fluids, Haldol (antipsychotic that rebalances dopamine to improve thinking, mood, and behavior), Benadryl (an antihistamine medication which in its injected form, it can treat severe allergic reactions, motion sickness, and symptoms of Parkinson's disease), Versed (It helps to cause drowsiness, decrease anxiety, and to decrease your memory of a surgery or procedure. It may also be used to help with anesthesia or to sedate people who need a tube or machine to help with breathing)

A note by Staff E/MD on 08/14/2023 1:44 AM stated, "38-year-old female presenting for evaluation of drug intoxication patient states she wanted to smoke opiates when she felt like she was given a bad batch. Causing her to become more not like herself denies any trouble breathing, denies any chest pain, states she just wants to be left alone.... Response to treatment and evaluation: patient tolerating oral, patient walked to bathroom without support, patient understands what happened this evening, feels comfortable for discharge." Patient #2 was discharged on 08/14/2023 6:29 AM to follow up with [local behavioral health center] in 2 days.

5. A review of Patient #4's medical record was completed. Patient #4 arrived at the facility's ED brought in by EMS on 08/04/2023 8:19 PM for drug overdose. Triage was completed at 8:24 PM, ESI 3. Nursing assessment was completed at 8:24 PM. Staff R/PA (Physician's Assistant) Assessed patient at 8:23 PM. Treatments received were labs of CBC, CMP, medications of IV fluids, Potassium bicarbonate (used as an antacid, electrolyte replenisher and potassium supplement), and Cardiac Telemetry (monitoring of heart rhythm).

A note by Staff R/PA at 9:26 PM stated "Patient is 21-year-old male presenting with drug overdose. Patients state that approximately 1 hour ago he took a total of 50 mg of a delta 8 CBD [Delta-8 Tetrahydrocannabinol is a psychoactive substance found in the Cannabis sativa plant] gummy. Patient states that the night before he took half of the dose without any issues. He states that he has been experiencing what he describes as losing consciousness. No seizure like activity, head trauma, altered mental status. Not homicidal or suicidal intent. Patient alert and oriented without any deficits appreciated. Patient given IV fluids and on re-eval states that he feels better. Conservative management education provided as well as PCP [Primary Care Provider] follow-up. ED attending was present and available for consultation for the entirety of this ED encounter." Patient #4 was discharged home 08/04/2023 9:26 PM

6. During an interview on 08/24/2023 at 6:10 AM the Staff E/ ED MD stated, "there is not an exact protocol for overdoses".

7. During an interview on 08/25/2023 at 11:00 AM the Staff K/ RN stated, "overdoses need to have an assessment, EKG, VS, labs (CMP, CBC, alcohol level, salicylate level, Tylenol level). Monitor the patient, see if they are suicidal, our hope is to get a urine tox screen but sometimes that is not feasible."

8. During an interview on 08/25/2023 at 2:06 PM staff I/ MD was asked if a patient comes in the ED by ambulance who received Narcan and chest compression done prior to arrival, what test would be ordered? Staff I/ MD stated, "initially order a toxicology screening, basic labs, chest x-ray."

The facility failed to have an effective and/or consistent system in place as it relates to patients who present to the emergency department seeking treatment for drug overdose.