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Based on observation, interview, policy review, record review, and review of video surveillance, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at 489.24: (refer to Appendix V). The facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for six patients (#s 6, 27, 28, 29, 32, and 33); and the facility failed to provide stabilizing treatment for one patient (# 27) of 33 sampled patients.

Findings include:

Review of a facility document titled, Emergency Medical Treatment and Labor Act (EMTALA), with a last review dated 12/19/22, showed, "It is the policy of the Hospital that it shall:
1. Provide an MSE by a physician or other QMP to any individual who comes to the Emergency Department to determine if the individual has an EMC; and
2. If it is determined that the individual has an EMC, provide the individual with such further medical examination and treatment as required to stabilize the EMC within the capability and capacity of the hospital or to arrange for an appropriate transfer of the individual to another medical facility ..."

-Patients #s 6, 27, 28, 29, 32 and 33 did not receive an appropriate MSE after seeking care in the emergency department. (Refer to A-2406).

-Patients # 27 did not receive stabilizing treatment in the emergency department before being discharged. (Refer to A-2407).

Based on observation, interview, record review, and review of video surveillance, the facility failed to maintain an accurate emergency department log, whereas the facility deleted 1 (#27) of 33 sampled patients from the ED log.

Findings include:

Review of the hospital ED log for 9/16/23 showed, patient #27 registered for the ED at 4:31 p.m. and at 10:12 p.m. The facility ED log failed to show patient #27's registration on 9/16/23 at 10:24 p.m.

Review of patient #27's EMR, "Encounter Status History," showed staff member EE had deleted the encounter from the ED log on 9/16/23 at 10:24 p.m.

During an interview on 11/7/23 at 1:57 p.m., staff member V stated the registration clerk deleted the encounter for patient #27 because she did not know what to do after the nurse told the patient to leave and he could not be seen in the ED.

During an interview on 11/9/23 at 10:50 a.m., staff member EE stated she registered patient #27 for his third encounter on 9/16/23 at 10:24 p.m. but a nurse came out and told the patient he had already been seen, there was nothing wrong with him, and he needed to leave. Staff member EE stated she did not know what to do with the registration of the patient after the nurse made him leave. Staff member EE asked the triage nurse what to do with patient #27's registration, and the triage nurse told her to delete the encounter completely, so she deleted the encounter.

Observation of a facility security video of the front desk and triage area, dated 9/16/23 at 10:24 p.m., showed, patient #27 presented the registration clerk in the lobby. Patient #27 was then observed walking over to the triage desk, and a nurse came out of the ED and escorted him out of the hospital.

Based on observation, interview and record review, the facility failed to provide a appropriate MSE for 6 (#s 6, 27, 28, 29, 32 and 33) of 33 sampled patients.

Findings include:

1) Patient #6 was seen in the ED on 10/11/23 at 8:35 a.m. for multiple complaints. Patient #6 was concerned he may have contracted HIV due to his history of drug abuse. Patient #6 was assessed in triage to be having thoughts of harming himself or others for the last several days. Patient #6 was seen and evaluated for his HIV concerns, but he was not evaluated for his psychiatric concerns prior to being discharged. Patient #6 returned to the ED at 1:06 p.m. after attempting suicide at his primary physician's office when attempting to schedule an appointment. Patient #6's MSE for his first ED visit psychological evaluation did not assess his suicide risk after admitting to having ideas of self-harm for the previous several days.

Emergency department visit #1:

A review of patient 6's emergency department record, dated 10/11/23 at 8:35 a.m., patient #6 arrived at the emergency room reception with multiple complaints. Staff member O performed a triage assessment on patient #6 that showed; distress level as mild. Patient #6 presented to ED for evaluation of possible HIV concerns related to his IV drug use and was requesting lab work to "make sure he doesn't have anything majorly wrong with him." The SI/HI portion of the assessment showed patient #6 answered no to thoughts of harming himself or others. A PHQ Depression Assessment was performed by staff member O. Patient #6 responded he had been bothered by feeling down, depressed, and hopeless for the last several days. He also responded He had trouble falling/staying asleep or slept too much more than 50% of the time. Patient #6 said he was feeling tired/low energy for the last several days and had a poor appetite/overate for the last several days. He was feeling bad/failure, letting himself/family down more than 50% of the time with trouble concentration for the last several days. Patient #6 responded he had thoughts of death/hurting himself for the last several days.

During an interview on 11/8/23 at 12:36 p.m., staff member O said he triaged patient #6 during his first ER visit. He asked the patient if he was having thoughts of harming himself or others and patient #6 responded, no. Staff member O said when he asked the questions for the PHQ assessment, patient #6 responded that he was having thoughts of death and hurting himself for the last several days. Staff member O said he recognized the discrepancy and called back to the nurse assigned to his care, reporting the discrepancy so it could be discussed with the physician.

During an interview on 11/8/23 at 11:56 a.m., staff member P said, staff member O had called to notify her of patient #6's response of having thoughts of harming himself or others. Due to the varied discrepancies in patient #6's responses during triage, the patient's suicide information did not trigger an electronic notification to the ED provider, and staff member P failed to notify the provider of the patient's suicide risk or the discrepancy in the patient's responses.

During an interview on 11/8/23 at 1:05 p.m., staff member L said she was not made aware of patient #6's triage assessment and was only aware of his HIV concerns. Staff member L said the patient was acting "odd" and was a little anxious, but she did not see anything that was concerning and did not investigate further. She does not usually go through a psychological evaluation unless the patient tells her something that would indicate a need or if it was reported to her by nursing staff. Staff member L said she tested patient #6 for HIV and he waited in the department for his results. She answered all his questions, he was discharged and instructed to schedule a follow-up appointment with his primary physician.

A review of an "ED Provider Note," dated 10/11/23 at 9:06 a.m., showed patient #6 had a chief complaint of abnormal lab results and addiction problem. Patient #6's past medical history showed, alcoholism in recovery, history of methamphetamine abuse, schizophrenia, shellfish allergy and tobacco abuse. Patient #6 was not currently using alcohol or drugs (IV, marijuana, heroin, methamphetamines). His current medication was Trazadone 50mg, 1-2 every night. Patient #6's psychiatric evaluation showed his affect normal, judgement normal, and anxious mood. Patient #6 tested negative for HIV and was advised to contact his primary physician by phone today to schedule a follow up appointment.

Patient #6 was discharged from visit at 10:42 a.m.

A review of patient #6's emergency department record, dated 10/11/23 at 1:06 p.m., 2 hours and 24 minutes after his first ED visit, patient #6 arrived in ED by wheelchair for attempted suicide. Staff member O performed a triage assessment on patient #6 that showed; distress level as severe and no vital signs were documented for the triage assessment. Patient #6 presented to the ED for evaluation of attempting to "kill himself" with a pen. He went to his primary physician's office building to schedule an appointment, grabbed a pen from the reception desk, and proceeded to stab himself in the throat numerous times. Patient #6 was verbalizing that he "should have done it with the razor blade that he had yesterday." Staff member O notified ED staff and held patient #6 at the triage desk until a room was made available in the ED.

2) Patient #27 arrived at the emergency department on 9/16/23 seeking care for chest pain and palpitations on three separate occasions. During the patient's first visit, the physician completed a history and physical and ordered a single troponin test (elevation can indicate a heart attack). The physician did not ensure that a second troponin level or chest x-ray was completed prior to the patient's discharge.

Review of patient #27's EMR dated 9/16/23, showed:

-4:31 p.m. Patient #27 presented to the emergency department for chest pain.

-4:48 p.m., triage was started. Patient #27's vital signs were BP 158/83, P 80 bpm, R 18, and Spo2 98%. (Normal vital signs include BP <120/<80, P 60-100, R 12-18 and Spo2 >90%.)

-4:49:33 p.m., Patient #27 was placed in room 12

-4:49:56 p.m. Staff member S assigned himself as the provider of the MSE for patient #27.

-5:10 p.m., Staff member S performed an examination on patient #27. The physician's documentation showed the patient was "Awake, alert, in no acute distress." The physician documented the patient's heart rate was 75 and indicated when the patient stands, his heart rate will increase to 100 then begin to decrease.

-5:11 p.m., Staff member S placed an order for a single troponin

-6:01 p.m. Staff member S made the patient "ready for discharge."

-6:22 p.m. Patient #27's triage documentation was complete, vital signs were BP 144/86, P 84, R 15, and Spo2 of 100%.

-6:25 p.m. patient #27 was discharged. The EMR did not indicate that a second troponin level or chest x-ray was completed to ensure the patient was not experiencing a heart attack, pneumonia, or collapsed lung.

Patient #27 arrived at the emergency department via ambulance, his second visit, seeking care for chest pain and palpitations on 9/16/23. The patient's second visit for complaints of chest pain and palpitations lasted approximately three minutes from arrival to discharge, and the patient was determined ready for discharge by the ED physician prior to staff documenting the patient's vital signs. Patient #27 was registered again for the third visit to the emergency department, again seeking care for chest pain, and was told to leave by the ED nurse before he had been seen by the physician. Patient #27 was subsequently injured in the facility entryway and transported to a nearby facility ED for care.

Review of patient #27's EMR dated 9/16/23, showed:

-10:12 p.m. Patient #27 presented to the emergency department for a second visit of the day by ambulance, for chest pain after smoking marijuana.

-10:13 p.m. Staff member S assigned himself as the provider of the MSE for patient #27.

-10:13:06 p.m. Patient 27 was placed in ED room 23.

-10:13:23 p.m. Staff member S made the patient "ready for discharge."

-10:15 p.m. Patient #27's triage documentation was complete, vital signs were BP 171/83, P 72, R 14, and Spo2 of 98%.

-10:15 p.m. patient #27 was discharged. The EMR did not indicate that an EKG, chest x-ray, or troponin were completed to ensure the patient's ongoing chest pain was not a result of the patient suffering from an acute myocardial infarction (heart attack), pneumonia, collapsed lung, or other serious illness.

-10:23 p.m. patient #27 registered to be seen in the emergency department, again.

-10:24 p.m. staff member EE deleted the encounter on the ED log.

Observation of facility video surveillance footage from 9/16/23, showed:

-10:20 p.m. Patient #27 was seen walking out of the emergency department carrying paperwork. He exited the building.

-10:21 p.m. Patient #27 was seen returning to the emergency department registration desk and speaking with the registration clerk. The registration clerk was seen removing patient #27's wrist band and placing a new wristband on patient #27's wrist.

-10:24 p.m. Staff member BBB was seen coming out of the emergency department and escorted patient #27 out of the hospital entrance door, and was seen gesturing while speaking to the patient, before BBB reentered the hospital without patient #27.

-10:26 p.m. Patient #27 was seen reentering the hospital and taking a seat in a chair in the hospital entrance area.

-10:26 p.m. Staff member BBB, staff member AA, and staff member AAA were observed speaking to patient #27. Staff member BBB was standing near patient #27, with her arms folded across her chest, and shaking her head no.

-10:35 p.m. Three police officers were seen entering the facility and appeared to be speaking to patient #27.

-10:37 p.m. Two of the police officers walked toward patient #27, who was still seated in the chair, occasionally crossing and uncrossing his legs. Patient #27 did not appear to be showing any aggressive behavior at any time. The police officers were observed picking patient #27 up out of the chair, and patient #27 appeared to stiffen his body and resist.

-10:38 p.m. The police officers were observed shoving patient #27 into a nearby wall and down to the ground. Patient #27's head was observed bouncing off the floor while he was taken down.

-10:40 p.m. One of the police officers stood up and a large amount of blood was observed on the floor next to patient #27's head.

-10:41 p.m. The police were observed picking patient #27 up from the floor. Patient #27 attempted to kick one of the officers and he was again taken to the ground, a second time. Staff member BBB was present and at no time was observed to attempt to assess or provide care for patient #27's injury.

-10:42 p.m. Staff member BBB exited the area toward the emergency department lobby. Patient #27 was escorted to a patrol car by police. Patient #27 was still a registered patient of the facility during the incident and was not provided an MSE by a provider prior to or following the injuries he sustained.

During an interview on 11/14/23 at 8:56 a.m., patient #27 stated he had wanted to be seen in the emergency department. He stated the doctor did not want to help him and the nurse was yelling at him. Patient #27 could not remember the police taking him to the ground, being arrested, or going to another hospital for care.

Review of a facility document titled, "Interview with [BBB]," dated 9/21/23, showed: BBB said she was made aware of patient #27 returning to the ED for a second time via ambulance. BBB said she and staff member S "made a plan" to discharge patient #27 "as quickly as possible." When patient #27 arrived via ambulance, BBB got patient #27's vitals and entered them into her triage note. Patient #27 was complaining of chest pain after smoking marijuana. BBB stated an EKG was not done. BBB said staff member S brought a registration clerk back as quickly as possible to get patient #27 registered, so the EMR system would allow patient #27 to be marked as discharged. BBB then printed the discharge paperwork and walked patient #27 out of the hospital. BBB stated, "10 minutes later" staff member S came to her stating patient #27 had registered again to be seen. BBB said she then went out to the lobby to speak with patient #27 and walked him outside of the building, where she pointed the patient in the direction of the other local hospital nearby. Staff member BBB had noticed patient #27 had returned inside the entrance and was seated in a chair. BBB reported to security the patient would not leave. BBB, staff members AA, and AAA went to the entrance to speak to patient #27. Patient #27 was complaining of his legs not working and that he did not want to leave. BBB said security called local police to assist, things escalated, and the patient was injured. BBB stated the police decided to transport the patient to another local hospital to be seen and treated for his injuries.

Review of a facility document titled, "Interview with [staff member Z]," dated 9/21/23, showed: staff member Z stated patient #27 told her he wanted to be seen again in the ED. The registration clerk cut off the old arm band and placed a new one for the visit. Staff member Z said the RN (staff member BBB) came out and began yelling at patient #27 saying, "No, no, no, no. You were just seen and there is nothing wrong with you." Staff member Z said she knew it was an EMTALA violation, but due to the RN that was involved she, "didn't want to get in the way of her." Staff member Z said the registration clerk did not know what to do with the registered encounter after the nurse told the patient he could not be seen, so the visit was canceled and patient #27 was deleted off the ED log.

During an interview on 11/8/23 at 11:20 a.m., staff member S said he did not recall "making a plan" with the nurse to discharge patient #27 as quickly as possible on his second visit. He agreed the marijuana could have been laced with other drugs or chemicals, which may have caused the patient's chest pain. Staff member S stated he spoke to the patient briefly, and he did not remember if cardiology was ever consulted. Staff member S said he was not aware the patient had checked in to be seen for a third visit. Staff member S said the patient should have been seen when he checked in the third time.

During a phone interview on 11/9/23 at 10:50 a.m. staff member EE stated she was working the night patient #27 came in for his second and third visit to the ED. Staff member EE said she was working triage and saw staff member S go in the examination room with the patient #27. Staff member EE said the patient was having chest pain and his entire visit was only six minutes in duration. The patient left the hospital, turned around and walked back into the facility and went to the reception desk, wanting to be evaluated. Staff member EE said patient #27 was reading his discharge notes and it said "if you have any of these symptoms to come back to the ED." Staff member EE said BBB came out from the ED department yelling "No, no, no" at patient #27, grabbed him by the arm, and walked him outside of the hospital entrance. Staff member EE stated, staff member S "is notorious for walking patients out of the emergency department. He takes patients that have come in by ambulance and he walks them from the ambulance door straight to the lobby." Staff member EE stated, staff member S "will watch the tracker board in the back, and if he sees a name he recognizes, he will come out to talk to them, and discharge them immediately." Staff member EE stated she has made complaints about his behavior to her supervisors.

During an interview on 11/9/23 at 1:31 p.m., Staff Z, Patient Access Supervisor, stated when a patient presented to the ED for emergency care, during the registration process, Staff S, EDP, would collect the patient and physically escort the patient through the ED and outside to the ambulance bay, where the patient was left by the physician without a MSE. Staff Z stated that she had personally witnessed this occur approximately five or six times over the past three years, that her staff had reported they too had witnessed Staff S escort patients out without an MSE, and that both she and her staff had reported this to her manager and director during a staff meeting, sometime around March 2023.

Review of patient #27's medical record from [local hospital name], dated 9/16/23 at 10:58 p.m., showed, patient #27 was treated in that hospital's emergency department after sustaining an injury to his face at St Vincent Hospital. The physician notes showed patient #27 arrived with an actively bleeding wound that required 6 stitches on his chin.

3) Patient #28 arrived to the ED and was registered on 11/3/23 at 5:01 a.m. for high blood pressure, anxiety, chest pain, and paranoia, with findings that included an elevated blood pressure of 164/110 (normal is less than 120/80) and a heart rate of 141 (normal is less than 100). The ED physician documented that he did not feel the patient needed further workup, and discharged the patient. Patient #28 presented to the ED a second time at 8:40 a.m. with complaints of weakness and dizziness. His heart rate was elevated at a rate of 122. The physician documented that he informed the patient that the ED was not a place for him to sleep, and discharged the patient without diagnostic studies. The patient's second visit for complaints of weakness and dizziness with an elevated heart rate lasted approximately seven minutes from arrival to discharge.

Review of patient #28's EMR, dated 11/3/23, showed:

-5:01 a.m. Patient #28 arrived to the emergency department, ambulatory, with complaints of anxiety and paranoia. The triage nurse noted the patient was paranoid in triage.

-5:01 a.m. triage was started. Patient #28's vital signs were BP 164/110, P 141 bpm, R 20, and Spo2 96%. (Normal vital signs include BP <120/<80, P 60-100, R 12-18 and Spo2 >90%.)

-5:18 a.m. Patient #28 was placed in room 15 (non-emergent care).

-5:23 a.m. An EKG was performed and showed sinus tachycardia with a rate of 134 bpm.

-5:35 a.m. Patient #28 was moved to room 3 (cardiac/trauma room) by the assigned nurse.

-5:37 a.m. The nurse's assessment showed the patient was fearful, impulsive, and agitated, appeared tense, exhibited poor judgment and his coping behaviors were impaired.

-5:49:54 a.m. Staff member S performed an examination on patient #28. The physician's documentation showed the patient was "alert and oriented x 3." There was no documentation related to the triage nurse assessment the patient was "paranoid" or the patient was fearful, agitated or impulsive. The physician documented the patient's heart rate was normal, despite the elevated pulse rate of 141 bpm and did not mention the EKG showing sinus tachycardia at a rate of 134 bpm.

-5:53 a.m. Patient #28 was discharged to home and was escorted out of the department by hospital security officers.

-5:56 a.m. Discharge instructions were entered into the EMR for patient #28.

-5:57 a.m. Patient #28 was removed from the ED system. No laboratory tests, or other diagnostic tests were ordered.

-8:35 a.m. Patient #28 returned to the emergency department, ambulatory, with complaints of weakness and feeling dizzy.

-8:36 a.m. Patient #28's triage was performed. The triage nurse documented the patient was anxious in triage. His vitals were BP 136/87, P 122, R 18, and Spo2 94%.

-8:37 a.m. Staff member S examined patient #28 in the north hallway. The physician's examination documentation showed the patient was alert and oriented, and did not indicate the patient was anxious, as assessed and documented by the triage nurse. There was no documentation that the physician examined the patient's cardiovascular system. The physician did note the patient's heart rate as 122 beats per minute, but there is no comment about the patient's heart rate being elevated. No labs, EKG, or imaging was completed for the patient during this visit, despite the patient's consistent tachycardia (rapid heartbeat).

-8:40 a.m. Patient #28 was documented as ready for discharge.

-8:42 a.m. Patient #28 was discharged, and no discharge instructions were printed.

Observation of facility video surveillance footage, dated 11/3/23, showed:

-8:35 a.m. Patient #28 was seen entering the emergency department registration area.

-8:36 a.m. Patient #28 was seen entering the triage desk area.

-8:39 a.m. Staff member S was seen coming out of the ED door. Staff member S escorted patient #28 through the door, into the ED.

-8:40 a.m. Patient #28 was seen leaving the ED and walking though the emergency room lobby. No paperwork was observed in his possession. Patient #28 walked out of the hospital entrance. Patient #28 appeared to turn around to go back into the facility, then shook his head, and he turned around and walked away.

An attempt was made to interview patient #28. His phone went to voicemail, and he did not return the call.

4) Patient #29 was seen on 5/3/23 at 3:45 a.m. for complaints of nausea, vomiting, diarrhea and abdominal pain rated at nine (on a 1-10 scale). The patient admitted that he had been drinking too much and believed he was experiencing problems with his liver, yet there were no diagnostic studies or medications ordered for the patient prior to his discharge. Patient #29 returned to the emergency department to be seen on 5/4/23 at 5:41 a.m. for nausea and was documented by nursing, to smell strongly of alcohol. The ED physician documented that the patient "seems to be malingering," and informed the patient he could go to a crisis center, but could not come to the ED for a "place to sleep." The patient was discharged without diagnostic studies, medications, or discharge instructions related to his alcohol abuse or nausea.

Review of patient #29's EMR, dated 5/3/23, showed:

-3:45 a.m., Patient #29 presented to the emergency department with complaints of nausea, vomiting and diarrhea.

-3:46 a.m., Patient #29's triage assessment was completed. His vital signs were BP 125/78, P 81, R 18, and Spo2 of 94%.

-3:49:46 a.m., Staff member DDD documented an MSE examination for patient #29.

-3:50:11 a.m., Patient #29 was documented as ready to discharge.

-3:56 a.m., Discharge instructions were printed for patient #29.

-4:02 a.m., Patient #29 was discharged. Patient #29's EMR did not include a past medical history or social history, despite the patient being a frequent patient at the ED and an admitted alcohol user. The EMR did not show any medication, laboratory studies, or diagnostic imagining were ordered by the physician to evaluate the reason for the patient's nausea and abdominal pain.

Review of patient #29's medical record, "Physician Notes," dated 5/3/23, showed:

"[Patient #29] is a 22 year old male who presents to the emergency department complaining of abdominal pain and vomiting ... He frequently comes in with a complaint like this and then just wants to sleep and not be bothered ... He says that he has pain all over his abdomen, that he has been drinking too much and he thinks his liver is acting up ... Final impression: homelessness."

Review of patient #29's EMR, dated 5/4/23, showed:

-5:41 a.m., Patient #29 returned to the emergency department with complaints of nausea.

-5:45 a.m., Patient #29 was taken to an ED exam room.

-5:48 a.m., Patient #29's triage documentation was completed. The triage note stated the patient had a very strong odor of alcohol. Patient #29's vital signs were BP 144/78, P 62, R 16, and Spo2 98%.

-5:50 a.m., Staff member DDD examined patient #29.

-5:50 a.m., Patient #29 was marked ready for discharge.

-5:54 a.m., Patient #29 was discharged. Patient #29's EMR did not show any medication, laboratory studies, or diagnostic imagining were ordered by the physician to determine the reason for the patient's persistent nausea, or to determine if the patient was intoxicated. There is no description of the patient's past medical history or social history, despite the patient's frequent visits to the ED and suspected alcohol intoxication. Further, the patient was not provided with discharge instructions related to the patient's alcohol abuse or nausea.

Review of patient #29's medical record, "Physician Notes," dated 5/4/23, showed:

"I explained to [patient #29] that he can go to the crisis center somewhere else but that he could not just come here as a place to sleep ... Final impression: homelessness."

Patient #29 presented to the emergency department via EMS on 11/1/23 at 9:02 a.m., complaining of alcohol withdrawal. He was a known alcoholic that had stopped drinking the day before; he had tremors and appeared anxious. His total time in the ED was 12 minutes, where he received an oral medication and was discharged 5 minutes after taking the medication.

Review of patient #29's EMR, dated 11/1/23, showed:

-9:02 a.m.,. Patient #29 presented to the ED via ambulance with complaints of alcohol withdrawal, shortness of breath, anxiety, abdominal pain, and heartburn. The patient stated he stopped drinking the day before. Initial vital signs were; BP 140/86, HR 74, and Spo2 98%. The patient stated his pain was a 9 out of 10.

-9:03 a.m., staff member S assigned himself to the patient.

-9:08 a.m., Patient #29 was marked ready for discharge.

-9:09 a.m., Patient #29 was given Ativan 1 mg orally.

-9:14 a.m., Patient #29 was discharged. Patient #29's EMR did not show a past medical history or social history was reviewed by the physician, despite the patient's frequent visits to the ED and complaint of alcohol withdrawal. No laboratory studies, or diagnostic imagining were ordered by the physician to determine the reason for the patient's abdominal pain or heartburn. No neurologic or psychologic examination was completed. Following the administration of Ativan to patient #29 no repeat vital signs were taken.

5) Patient #32 arrived at the ED and registered on 10/6/23 at 12:56 a.m., for "guts being messed up." Patient #32 had multiple vital signs outside of normal limits that were not addressed before she was discharged. On 10/6/23 at 4:54 a.m., patient #32 returned with cold exposure. According to video review, the patient's time in the ED was approximately six minutes, of which the physician spent 30 seconds with patient. The ED physician then documented portions of an examination that based on video review, did not occur.

Review of patient #32's EMR showed, patient #32 presented to the emergency department on 10/6/23 at 12:56 a.m.

-At 1:04 a.m. triage notes showed patient #32 was complaining of her "guts being messed up." The nurse noted, "pt was very drowsy at triage, disoriented X 3 (patient #32 did not know who she was, where she was or what day it was), and was not interactive with staff. Pt denies drugs or etoh (alcohol)." Vital signs in triage were BP 169/112 (normal range is less than 120/80), HR 97, RR 19 and Spo2 100%.

-1:27:07 a.m., patient #32 was placed in room 15.

-1:28:15 a.m., provider S assigned himself to provide the MSE for patient #32.

-2:04 a.m., vital signs were BP 146/126 HR 85 Spo2 98%.

-2:05 a.m., patient #32 was given Zofran 4 mg orally for nausea.

-2:19 a.m., patient #32's vital signs were 147/97 HR 79 and Spo2 93%.

-2:33 a.m., discharge orders were placed.

-2:34 a.m., patient #32's vital signs were BP 163/136 HR 33 Spo2 100%.

-3:00 a.m., patient #32 was given Compazine 10 mg IM for nausea.

-3:04 a.m., patient #32's vital signs were 158/103, HR 46, and Spo2 82%.

-3:15 a.m., patient #32 was discharged. There was no neurological examination or diagnostic studies related to the patient's altered mentation, no diagnostic studies related to the patient's complaint of nausea, and no reassessment of the patient's high blood pressure and low blood oxygen reading. The consent to treat and notice of privacy paperwork was signed by registration staff and showed "pt physically unable to sign." The physicians note stated the patient was difficult to understand, other than nausea he was unable to get any significant history from the patient and indicated the patient was taken to a gas station by security after discharge.

Review of an ambulance report for patient #32, dated 10/6/23, showed, "upon arrival PD stated patient was just dropped off by St Vincent security approx. 20 minutes ago ... patient states that she is cold and unable to walk and requests transport to St. Vincent Hospital. ...found patient laying on sidewalk..."{sic}

Review of patient #32's EMR showed, on 10/6/23 patient #32 returned to the emergency department via ambulance with complaints of cold exposure.

-4:54 a.m., patient #32 arrived in the ED.

-4:57 a.m., staff member S documented a physical examination that included:
- listening to the patient's heart, lungs and abdomen
- inspecting the patient's range of motion to be intact
- feeling the patient's neck and abdomen
- neurological status to be normal
- the patient's psychiatric status to be oriented to person, place and time
The clinical impression found patient #32 to be nauseated, homeless, suffering from polysubstance abuse, and a mental health disorder.

-4:59 a.m., triage showed, Temp 98.4 F, BP 148/80, HR 72, RR 18 and Spo2 of 98%.

-5:00 a.m., patient #32 was shown ready for discharge.

-5:02 a.m., patient #32 was discharged. No laboratory studies were completed for the patient, despite the patient having ongoing nausea and weakness. Additionally, no neurologic exam was completed by the ED physician. ED notes showed, "AVS (discharge instructions) discussed with patient at discharge. Patient wheeled out of department in wheelchair. Instructed to follow-up with PCP and to return with any concerns."

Review of a hospital video surveillance footage showed, on 10/6/23 at 4:53:16 a.m. patient #32 was removed from the ambulance. She was on the gurney hunched over and not sitting up. Ambulance personnel were all wearing jackets and two were wearing stocking caps.

-4:54:10 a.m., the ambulance personnel wheeled patient #32 down the hall into the ED. Staff member QQ was seen getting a wheelchair.

-4:55:06 a.m., patient #32 was placed in the wheelchair and EMS left the ED.

-4:55:30 a.m., registration placed a patient ID band on the patient.

-4:56:24 a.m., staff member S placed a fan on the counter and aimed it in patient #32's direction. Staff member QQ started taking vital signs.

-4:56:45 a.m., staff member S walked over to patient #32 and appeared to be speaking to her. He did not touch the patient.

-4:57:15 a.m., staff member S walked away from patient #32. At 4:58:31 a.m., staff member QQ finished taking patient #32's vital signs.

-4:59:01 a.m., staff member QQ wheeled patient #32 into the lobby. Patient #32 was hunched over in the wheelchair and appeared unable to sit up.

-5:01:00 a.m., staff member QQ brought out another wheelchair full of patient #32's belongings.

-5:06:25 a.m., a security officer was seen checking on patient #32. The patient appeared to try to lift her head up to look at him, but remained hunched over, turning her head to the side to look up at the officer.

During a phone interview on 11/13/23 at 1:52 p.m., NF2 stated his crew picked up patient #32 that morning (6/10/23). He stated she was right where [facility] security left her laying on the sidewalk. He stated patient #32 told them she could not walk. NF2 stated when staff member S was working in the ED, "he tries to discharge the patients before we leave. He told us once that he has a challenge to try to discharge someone faster than we can be back in service. I would not be surprised if he discharged her (patient #32) before we even left. That happens on a pretty consistent basis." NF2 said frequently, if the patient is able to walk, staff member S would walk them straight out of the department without being seen. If it is a patient they see frequently, like a homeless person, or a patient with alcohol intoxication, they would be discharge as quickly as possible. NF2 said, "I had a patient one time that I brought in complaining of a headache and he (staff member S) walked out to the ambulance bay and asked him if he wanted Tylenol or Motrin. He went inside the ED, retrieved Tylenol for the patient, and told him to leave. Sometimes he doesn't even talk to them."

During a phone interview on 11/14/23 at 11:03 a.m., staff member QQ stated she did

Based on interview, record review, and video surveillance review, the facility failed to provide stabilizing treatment for one patient (#27), who was visibly injured during an altercation with law enforcement and hospital security officers, after he presented to the ED. A sample of 33 patient records were reviewed.

Findings include:

1) Patient #27 arrived at the emergency department on 9/16/23 seeking care for chest pain and palpitations on three separate occasions. On the first visit, the patient arrived at the ED at 4:31 p.m., and the physician completed a history and physical and ordered a single troponin test. The patient was discharged at 6:25 p.m. The patient presented to the ED a second time at 10:12 p.m. for chest pain and the patient was discharged at 10:15 p.m. At 10:23 p.m., patient #27 was registered for his third visit to the emergency department, again seeking care for chest pain, and was told to leave by the ED nurse before he had been seen by the physician. Patient #27 was subsequently injured in the facility entryway during an altercation with law enforcement and hospital security officers, and transported to a nearby ED for care of his injury sustained at St. Vincent Hospital.

During a phone interview on 11/9/23 at 10:50 a.m. staff member EE stated that the patient left the hospital (second ED discharge for 01/14/23), turned around and walked back in to the reception desk, wanting to be evaluated. Staff member EE said patient #27 was reading his discharge notes and it said "if you have any of these symptoms to come back to the ED." Staff member EE said BBB came out from the ED department yelling "No, no, no" at patient #27, grabbed him by the arm, and walked him outside of the hospital entrance.

Review of a facility document titled, "Interview with [staff member Z]," dated 9/21/23, showed: staff member Z stated patient #27 told her he wanted to be seen again in the ED. The registration clerk cut off the old arm band and placed a new one for the visit. Staff member Z said the RN (staff member BBB) came out and began yelling at patient #27 saying, "No, no, no, no. You were just seen and there is nothing wrong with you." Staff member Z said she knew it was an EMTALA violation, but due to the RN that was involved she, "didn't want to get in the way of her."

Review of a facility document titled, "Interview with [BBB]," dated 9/21/23, showed: BBB said that after patient #27 was discharged (second ED discharge for 01/14/23), he registered again to be seen (third ED presentment). BBB said she went out to the lobby to speak with patient #27 and walked him outside of the building, where she pointed the patient in the direction of the other local hospital nearby. Staff member BBB had noticed patient #27 had returned inside the entrance and was seated in a chair. BBB reported to security the patient would not leave. BBB, staff members AA, and AAA went to the entrance to speak to patient #27. Patient #27 was complaining of his legs not working and that he did not want to leave. BBB said security called local police to assist, things escalated, and the patient was injured. BBB stated the police decided to transport the patient to another local hospital to be seen and treated for his injuries.

During an interview on 11/14/23 at 8:56 a.m., patient #27 stated he had wanted to be seen in the emergency department. He stated the doctor did not want to help him and the nurse was yelling at him. Patient #27 could not remember the police taking him to the ground, being arrested, or going to another hospital for care.

During an interview on 11/8/23 at 11:20 a.m., staff member S said he was not aware the patient had checked in to be seen for a third visit. Staff member S said the patient should have been seen when he checked in the third time.

Review of patient #27's medical record showed:

-10:23 p.m. patient #27 registered to be seen in the emergency department for his third visit for chest pain

-10:24 p.m. staff member EE deleted the encounter on the ED log.

Observation of facility video surveillance footage from 9/16/23, showed:

-10:20 p.m. Patient #27 was seen walking out of the emergency department (this correlated with the discharge from his second visit to the ED on 09/16/23) carrying paperwork. He exited the building.

-10:21 p.m. Patient #27 was seen returning to the emergency department registration desk and speaking with the registration clerk. The registration clerk was seen removing patient #27's wrist band and placing a new wristband on patient #27's wrist.

-10:24 p.m. Staff member BBB was seen coming out of the emergency department and escorted patient #27 out of the hospital entrance door, and was seen gesturing while speaking to the patient, before BBB reentered the hospital without patient #27.

-10:26 p.m. Patient #27 was seen reentering the hospital and taking a seat in a chair in the hospital entrance area.

-10:26 p.m. Staff member BBB, staff member AA, and staff member AAA were observed speaking to patient #27. Staff member BBB was standing near patient #27, with her arms folded across her chest, and shaking her head no.

-10:35 p.m. Three police officers were seen entering the facility and appeared to be speaking to patient #27.

-10:37 p.m. Two of the police officers walked toward patient #27, who was still seated in the chair, occasionally crossing and uncrossing his legs. Patient #27 did not appear to be showing any aggressive behavior at any time. The police officers were observed picking patient #27 up out of the chair, and patient #27 appeared to stiffen his body and resist.

-10:38 p.m. The police officers were observed shoving patient #27 into a nearby wall and down to the ground. Patient #27's head was observed bouncing off the floor while he was taken down.

-10:40 p.m. One of the police officers stood up and a large amount of blood was observed on the floor next to patient #27's head.

-10:41 p.m. The police were observed picking patient #27 up from the floor. Patient #27 attempted to kick one of the officers and he was again taken to the ground, a second time. Staff member BBB was present and at no time was observed to attempt to assess or provide care for patient #27's injury.

-10:42 p.m. Staff member BBB exited the area toward the emergency department lobby, and reentered carrying towels, dropping a towel over one of the bloody areas on the floor.

- 10:44 p.m. One of the hospital security officers shined a flashlight on the patient's face, and staff member BBB peered over to observe the patient's face. Staff BBB left and then reentered the vestibule and placed gloves on her hands.

- 10:48 p.m. Patient #27 is wheeled out of the vestibule exit by police, while staff member BBB exited the vestibule to the ED waiting room, and security officer staff clean up the blood on the floor with towels. Patient #27 was still a registered patient of the facility during the incident and was not provided stabilizing treatment following the injuries he sustained.

Review of patient #27's medical record from [local hospital name], dated 9/16/23 at 10:58 p.m., showed, patient #27 was treated in that hospital's emergency department after sustaining an injury to his face at St Vincent Hospital. The physician notes showed patient #27 arrived with an actively bleeding wound that required 6 stitches on his chin.