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Based on interview, record review, review of the facility's video recording, and review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24(d)(1) regarding providing stabilizing treatment for one (1) of twenty-three (23) sampled patients, Patient #1, on 06/16/2022.

Refer to findings in Tag A-2407

Based on interview, record review, review of the facility's video recording, and review of the facility's policies, it was determined the facility failed to provide stabilizing treatment for one (1) of twenty-three (23) sampled patients, Patient #1.

The findings include:

Review of the facility's policy titled, "EMTALA-Medical Screening Examination and Stabilization", RI.039, #11611027, last revised 04/2017, revealed the policy's purpose was to establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment or an appropriate transfer. Further review revealed an individual would be deemed stabilized if the treating qualified medical professional (QMP) had determined within reasonable clinical confidence that the EMC had been resolved and that no material deterioration of the condition was likely within reasonable medical probability, to result from, or occurring from, the transfer of the individual from a facility.

Review of the facility's policy titled, "Code Gray - Uncontrolled Individual", EC.007, #9800022, last reviewed 04/2018, revealed the Code Gray was announced overhead if staff was unable to control the situation. Continued review revealed staff competent in Crisis Prevention Interventions (CPI) would respond immediately. Trained staff consisted of Engineering (Maintenance), Nursing House Supervisors, Charge Nurse, male ED staff, Security staff, or off-duty police officers. Further review revealed the Nursing Supervisor or Charge Nurse would act as the response leader.

Review of the facility's policy titled, "Patient Rights", CSG.QS.004, #7940974, last reviewed 04/2020, revealed patients had the right to receive considerate and respectful care. Continued review revealed the right was to individualized care that fostered the patient's comfort, dignity, and in an environment free from abuse, discrimination, and harassment.

Review of Emergency Medical Services (EMS) #1's Run Sheet, dated 06/16/2022, revealed Patient #1 was picked up at his/her work site with a chief complaint of heat exhaustion, at 2:03 AM, and arrived at Facility #1 at 2:29 AM. Vital signs (VS) were obtained at 2:08 AM. Patient #1's blood pressure (BP) was 110/70; respirations were at 12; pulse was 84 beats per minute (BPM); oxygen saturation was 99 percent on room air; and a Glasgow Coma Scale (GCS, a summation of scores for eye, verbal, and motor responses) score of 15, indicating Patient #1 was fully alert, awake, and followed commands. The sheet stated, at 2:20 AM, Patient #1's BP was 136/57; respirations were 12; pulse measured at 70 BPM; oxygen saturation was 98 percent on room air; and a GCS score of 15. Per the sheet, at 2:25 AM, Patient #1's BP was 117/71; respirations were 12; pulse was 76 BPM, oxygen saturation was at 96 percent on room air, and a GCS score of 15. The run sheet documented Patient #1 was alert and oriented to person, place, time, and event.

Continued review of EMS #1's Run Sheet, dated 06/16/2022, revealed Patient #1 complained of having a frontal headache. It was also documented Patient #1 was given Zofran (4) milligrams intravenously for nausea and vomiting. Continued review revealed Patient #1's condition was documented as unchanged upon arrival to Facility #1.

Review of Patient #1's Emergency Department (ED) clinical record revealed he/she arrived at Facility #1's ED, on 06/16/2022 at 2:32 AM, via Emergency Medical Services (EMS) #1, from his/her work site. The stated/chief complaint was Heat Exhaustion. Continued review revealed it was documented by Registered Nurse (RN) #1 that Patient #1 was alert and oriented to person, place, time, and event upon arrival. RN #1 also documented that Patient #1 was complaining of a headache that Patient #1 rated as 8/10 on the pain scale, which indicated severe pain. RN #1 also assessed Patient #1 of having a GCS score of 15. Continued review of Patient #1's ED clinical record revealed he/she had vital signs taken three (3) times while in the ED, and they remained stable. Additional treatment at Facility #1 included obtaining blood work, i.e. a comprehensive metabolic profile (CMP) and complete blood count (CBC), an electrocardiogram (EKG); and an IV line was started for the administration of IV fluids (IVF).

Review of obtained lab work revealed a sodium level of 125 (normal 135-145, critical low 115, requiring immediate treatment) and a potassium level of 2.9 (normal 3.6-5.2, critical low 2.5, requiring immediate treatment). Continued review revealed Physician #1 ordered IVF and potassium replacement therapy prior to Patient #1's discharge. Per the record, the EKG showed normal sinus rhythm.

Review of ED Physician #1's Note, dated 06/16/2022, revealed a medical screening exam (MSE) was initiated for Patient #1's chief complaint of heat exhaustion. The note stated Patient #1 had Hyponatremia (low sodium level); Hypokalemia (low potassium level); and Mild Dehydration based on results of the lab work.

Review of Patient #1's Physical Exam revealed Patient #1 was lethargic but in no acute distress (NAD). Further review revealed Patient #1 was tachycardic (fast heartbeat); however Patient #1's pulse was 68 BPM with a regular rhythm. Also, all other reviewed Physician documentation stated Patient #1 was not tachycardic. Per the exam, Patient #1's skin was warm and dry. Patient #1 was drowsy, oriented to person, place, and time, but with a flat mood. Additional review revealed vital signs were stable (VSS) with an oral temperature of 97.5 degrees Fahrenheit; pulse rate of 68 BPM; respirations 16; BP of 124/56; and oxygen saturation was 100 percent on room air.

Per ED Physician #1's Note, dated 06/16/2022, Patient #1 presented with reported nausea/vomiting and presumed heat exhaustion. Upon arrival, he/she was lethargic although arousable and would answer questions with short, two (2) to three (3) word answers. Per the note, Patient #1 no longer had nausea/vomiting after EMS gave Zofran 4 mg IV, prior to arrival (PTA). The note stated Patient #1 had a nontender abdomen, vital signs were within normal limits, afebrile, not tachycardic, and clinically did not appear dehydrated. However, per the note, Physician #1 gave 1000 milliliters (ml) of Lactated Ringers (a solution given to replace water and electrolytes such as sodium and potassium) IV, given the history of Patient #1's nausea and vomiting. The note stated the CBC showed a slight elevation of white blood cells; and the CMP showed a sodium level of 125 and a potassium level of 2.9. The note stated the electrolyte abnormalities were most likely due to the nausea and vomiting and slight dehydration. The note stated Patient #1 was still above the threshold for severe Hyponatremia. The note stated Patient #1 was given Potassium 10 milliequivalents (mEq) IV.

Continued review of ED Physician #1's Note, dated 06/16/2022, revealed he went to talk to Patient #1 about the work-up and discharge. He stated Patient #1 became upset that he/she was awakened, crossed his/her arms, turned over, and would not speak to the provider. The note stated Patient #1 was allowed to sleep for one (1) to two (2) hours. The note stated Patient #1 was now bradycardic (low heart rate), with a pulse rate in the forties (40's) and respirations were slowing. Per the note, at this point, the patient was lethargic, not easily arousable, and Ammonia Salt was administered with some response; however, the patient was upset and again, not speaking to staff nor the Physician. The note stated because of the bradycardia, slowed respirations, and presentation, there was concern for possible narcotic use; Narcan (used to treat a narcotic overdose) was administered with immediate response by Patient #1 being alert and very upset.

Continued review of ED Physician #1's Note, dated 06/16/2022, revealed, at this point, Patient #1 got out of the bed, in the exam room, exited the exam room, and walked around the ED with the IV (saline lock) intact. The note stated staff tried to get the patient to return to the exam room and get in the bed and relax. Per the note, the patient continued to walk around the ED, refusing to allow IV removal. The note stated, at this point, law enforcement was involved and unbeknownst to Physician #1, was arrested and taken to jail.

Continued review of ED Physician #1's Note, dated 06/16/2022, revealed Patient #1's presentation did not exhibit any signs of heat exhaustion or heat stroke given Patient #1 was afebrile and not tachycardic. The note stated Patient #1 did exhibit some dehydration; however, his/her sodium was not low enough to cause any altered mental status, and it was presumed the reversal in his/her mental status was due to the administration of Narcan. Per the note, it seemed Patient #1's presentation was due to some type of opioid use and possible overdose.

However, ED Physician #1's documentation in the Physician Physical Exam stated Patient #1 was alert and oriented (A&O) x 3 (person, place, time) on admission. Also his documentation stated he had reviewed nursing documentation and agreed with the nursing documentation that stated Patient #1 was A&O x 4 (person, place, time, event) and had a GCS score of 15, which indicated Patient #1 was alert, oriented, and followed commands.

Further review of Patient #1's clinical record revealed that a Patient Discharge Instruction Sheet for Heat Exhaustion was in the discharge packet. The instruction sheet stated the symptoms included extreme tiredness, headache, weakness, and nausea/vomiting. Continued review of the instruction sheet also stated to call 911 for symptoms of confusion, irrational behavior, and trouble walking. Additional review of RN #1's documentation revealed Patient #1 was discharged into Police custody in good condition.

Review (with Risk Management) of Facility #1's ED video recording (no audio), dated 06/16/2022, for Patient #1, revealed at 5:31 AM, the Registration Clerk (RC-no longer employed at the facility); the House Supervisor (terminated); RN #1; and the Clinical Nurse Coordinator (CNC, terminated), were in the frame when Patient #1 entered the frame. Patient #1's gait was observed to be unsteady. The RC, House Supervisor, and CNC appeared to try to steady Patient #1 with their hands and lead him/her to a chair by the ED door. Patient #1 sat down in the chair, and slumped back. Patient #1 had his/her head down, was drowsy, appeared confused, and was non-combative. The Greeter and the ED Unit Clerk (UC) were observed to come from their stations and watch the event.

Additional review (with Risk Management) of Facility #1's ED video recording (no audio), dated 06/16/2022, for Patient #1, revealed, at 5:33:10 AM, the RC and CNC put their hands on Patient #1's arms to prevent him/her from standing up while the saline lock was removed. The House Supervisor put her feet on top of Patient #1's feet to prevent him/her from rising from the chair. Patient #1 tried to free arms from the RC and CNC. Continued review revealed that at 5:35:36 AM, Patient #1 was calmly sitting in the chair, with his/her head down and arms crossed. At 5:38:53 AM, police officer (PO #1) entered the frame.

Additional review (with Risk Management) of Facility #1's ED video recording (no audio), dated 06/16/2022, for Patient #1, revealed at 5:39:10 AM, the House Supervisor administered a quick sternal rub to arouse Patient #1. At 5:39:15 AM, the House Supervisor administered another sternal rub, lasting approximately three (3) seconds, to arouse Patient #1. Further review revealed, at 5:41:33 AM, the CNC shook Patient #1 to arouse him/her. Patient #1 continued to appear to be drowsy, with head down, arms crossed, and not confrontational. Per the video, at 5:45:11 AM, 5:45:28 AM, and 5:45:36 AM, PO #1 struck Patient #1's right lower extremity twice with his left foot. Per the video, at 5:46:03 AM, PO #2 entered the frame and stood away from Patient #1 but was close enough to assist if needed. Further review of the video revealed, at 5:47:56 AM, Patient #1 sat up straight, without provocation, but his/her head remained down with arms crossed. Additional review revealed, at 5:48:15 AM, Patient #1 shifted position in the chair, folding his/her legs, one upon the other. Continued review revealed, at 5:50:06 AM, PO #1 struck Patient #1's left knee repeatedly with his left foot.

Additional review (with Risk Management) of Facility #1's ED video recording (no audio), dated 06/16/2022, for Patient #1, revealed, at 5:57:37 AM, PO #1 and PO #2 attempted to remove Patient #1 from the chair by placing their hands on his/her left wrist and right forearm. Patient #1 still had his/her legs crossed as before. Further review revealed, at 5:57:40 AM, Patient #1 tried to pull away from the police officers. Per the video, PO #2 applied a hand cuff to Patient #1's left wrist, and his/her legs unfolded as he/she was removed from the chair by both police officers. The video showed the other hand cuff was applied to Patient #1's right wrist prior to both officers escorting Patient #1 out the ED door. Per the video, Patient #1 appeared confused and drowsy and had an unsteady gait. At 5:59:00 AM, the video of the inside of the ED ended.

Review of Facility #1's canopy video (showed outside the ED) revealed, at 5:59:00 AM, both officers escorted Patient #1 to the police paddy wagon. Patient #1 was still in hand cuffs, appeared confused, drowsy, and his/her head was down. Per the canopy video, Patient #1 had an unsteady gait. At 6:02:30 AM, the canopy video ended.

Interview with the Vice President of Quality (VPQ) and the Director of Patient Safety and Risk Management (DPS), on 10/10/2022 at 2:07 PM, revealed that Human Resources (HR) and the DPS both had pieces of the investigation; HR attended to the employee side of the investigation and DPS, the patient safety aspect of the investigation. Both stated they were notified, on 06/16/2022 at approximately 8:00 AM to 8:30 AM, by the Patient Advocate, that the father and spouse of Patient #1 had filed a grievance with her. They stated the father was upset that it was reported to him that Patient #1 had been combative while in the ED. Continued interview revealed when they reviewed the ED video, the actions of the staff present in the ED on 06/16/2022 "did not feel right". They stated that some actions of the staff on the video raised questions such as "what were they thinking?"

Continued interview with the VPQ and the DPS, on 10/10/2022 at 2:07 PM, revealed that during the day, on 06/16/2022, involved staff were interviewed via phone. Also, over the next few days, as part of the investigation, they met with the Unit Clerk (UC), Primary Nurse (RN #1), Clinical Nurse Coordinator (Charge Nurse), House Supervisor, and Physician #1. Also, they both stated the facility had undertaken several educations since the incident, including a facility-wide EMTALA refresher education. Additional interview revealed, on 06/17/2022, the facility contacted the facility's Division of Ethics Department regarding the incident and to discuss the ED staff actions and behaviors that led to the decision to discharge Patient #1. They stated the focus during these discussions was whether Patient #1 needed to stay and not be discharged. They stated, during the next few days, the Corporate Ethics Department was contacted; and it was during these discussions that the Corporate Legal Department stated they felt it was a possible EMTALA violation. The DPS stated there had been differing views on whether it was an EMTALA violation and asked if staff should be second guessing Physician #1's decision to discharge, and was Patient #1 medically stable for discharge to Police custody?

Continued interview with the VPQ and the DPS, on 10/10/2022 at 2:07 PM, revealed the CNC and the House Supervisor had been terminated related to their actions. They stated that both employees, in their supervisory capacity, did not utilize good judgement. They stated RN #1, a newer ED staff member, had sought guidance from the CNC and House Supervisor.

Interview with Patient #1's father, on 10/11/2022 at 2:13 PM, revealed he, Patient #1's mother, and Patient #1's spouse worked at Facility #1, so Patient #1 would have been known to the facility's staff. He stated he had been notified by a co-worker of Patient #1 that the patient was being taken to the facility for a heat related event. He stated the spouse and mother were already on their way for their shift at Facility #1. He stated when he arrived at work at the facility, the night shift engineers (Maintenance) told him they had never been notified that the ED had an unruly patient (Code Gray). He stated the process for a Code Gray, especially on night shift, was that the engineers were to respond to the announced location. He stated, when he went to find out what had happened with Patient #1, he was taken to a Consultation Room in the ED. There, he stated, he spoke to Patient #1's primary nurse (RN #1) about the event.

Continued interview with Patient #1's father, on 10/11/2022 at 2:13 PM, revealed, after he spoke to RN #1, he spoke to both the night shift House Supervisor and the day shift House Supervisor. He stated the night shift House Supervisor told him that Patient #1 had been arrested for public intoxication (PI). He stated Patient #1 was charged with criminal trespassing, not PI. He stated, when he arrived at the police station, jail staff asked if Patient #1 had post traumatic stress disorder (PTSD) because he/she was being non-compliant. He stated the jail staff told him that Patient #1's presentation at the jail did not look like a drug related event. Patient #1's father stated he had viewed and listened to the police body cam footage from Facility #1 and at the jail. He stated that at the jail, staff were heard asking, "Did Facility #1 discharge him/her like this?" He stated he felt that Facility #1's ED staff remarks were derogatory, uncalled for, and felt that Patient #1's rights had been violated.

Continued interview with Patient #1's father, on 10/11/2022 at 2:13 PM, revealed Patient #1 was not able to answer the booking questions. He stated jail staff asked him if he could assist them because Patient #1 was not comprehending the questions. The jail staff stated, if he would assist them, they could book Patient #1 and release him/her to the father. He stated jail staff had to "drag/walk" Patient #1 to the viewing room for him to assist in the booking process. He stated Patient #1 was "still out of it" during the booking process. He stated, upon Patient #1's release, he went past the house long enough to let the mother and the spouse know he was taking Patient #1 to Facility #2. Additional interview revealed that upon arrival to Facility #2, it took three (3) "burly" Paramedics to lift Patient #1 onto a stretcher. He stated once in Facility #2's ED, Patient #1 had to be intubated, put on a ventilator, stabilized, and transported to Facility #3. He stated, at Facility #3, Patient #1 was on the ventilator a couple of days, weaned off, and discharged home.

Review of the website www.google.com revealed Facility #2, a community acute care hospital, was located twenty and two-tenths (20.2) miles from Facility #1.

Review of Patient #1's medical record from Facility #2's ED revealed Patient #1 arrived at the ED, on 06/16/2022 at 5:59 PM, from an incarceration facility, via privately owned vehicle (POV), with his/her father. The initial ED diagnosis was Altered Mental Status.

Review of Facility #2's ED Nursing documentation revealed, on the Screening Assessment, Patient #1 appeared distressed and uncomfortable. The assessment stated Patient #1's behavior was agitated, anxious, and inappropriate for age (it did not say how). It stated Patient #1 was alert and oriented.

Review of Facility #2's ED Physician documentation revealed an appropriate MSE was completed. Further review revealed that at 7:03 PM, Patient #1 was intubated due to Respiratory Failure, with ongoing Altered Mental Status.

Further review of Facility #2's ED record for Patient #1 revealed the patient was transferred to Facility #3, on 06/17/2022 at 2:12 PM, intubated, via EMS. The transfer diagnoses were Altered Mental Status and Respiratory Failure.

Facility #2's ED Physician was unable to be contacted for interview on 10/20/2022 and 10/21/2022. Attempts to interview were made on those dates, but the person was unavailable.

Review of the website www.google.com revealed Facility #3, a tertiary acute care hospital, was located thirteen and one-half (13.5) miles from Facility #2 and approximately thirty-one (31) miles from Facility #1.

Review of Patient #1's clinical record from Facility #3 revealed, on 06/17/2022 at 2:35 PM, Patient #1 arrived intubated, via EMS, for a higher level of care, and with a diagnosis of Altered Mental Status and Respiratory Failure. Diagnostic blood work and radiological testing was obtained during Patient #1's admission of 06/17/2022 through 06/20/2022. Patient #1 was discharged to home from Facility #3 on 06/20/2022. The final diagnosis was Respiratory Failure secondary to Encephalopathy.

Interview with Facility #1's Physician #2, on 10/11/2022 at 3:50 PM, revealed he had received EMTALA training through his company and had refresher EMTALA training after the incident. Continued interview revealed he did not have direct knowledge of the incident and was hesitant to verbalize what he might have done in that situation. He stated there were no criteria for stabilizing care, and he felt it was on a case-by-case basis. He stated a patient could still be discharged even if symptoms were still present. He stated treatment should be done to rule out any further concerns. Physician #2 further stated that stabilizing care was different for everyone.

Interview with Facility #1's Unit Clerk/PCT (Patient Care Technician), on 10/13/2022 at 10:42 AM, revealed she heard staff saying that Patient #1 was not alert and oriented, and the CNC asked for smelling salts and Narcan. She stated, at that point, she went to stand in Patient #1's exam room doorway because sometimes patients came up fast and aggressive after getting Narcan, and she would be there for patient/staff safety. She stated Patient #1 did not come up aggressively, and he/she came up looking around as if confused and was not speaking. She stated the facility used Code Gray for an unruly individual, and if any ED staff had requested a Code Gray, as the Unit Clerk, she would have been the one to announce the Code overhead. She stated she was not asked to announce a Code Gray.

Interview with Facility #1's RN #2, on 10/13/2022 at 11:13 AM, revealed she had received general EMTALA education upon hire, but there was more in-depth EMTALA training when she went to work in the ED. She stated the additional training discussed appropriate transfer/discharges and stabilizing treatment. She stated her understanding of stabilizing treatment meant that even though the patient's presenting symptoms might still exist, through examination and treatment by the Physician, it was determined the patient could safely be transferred or discharged. She stated, if she felt a patient was not appropriate for discharge or transfer, she would discuss it with the Physician first and, if not satisfied, she would continue up the chain of command. Further interview revealed if anything was not safe for the patient, she would not sign off on it, document the incident, and follow up.

Interview with Facility #1's RN #1, on 10/14/2022 at 11:02 AM, revealed she took over care for Patient #1 about 3:30 AM to 3:45 AM. She stated Patient #1 was resting with eyes closed when she took over. She stated Patient #1 had complained of a headache and nausea/vomiting during transport to the facility, and EMS had administered Zofran (anti-emetic) enroute to the facility. RN #1 further stated that at some point in the exam room, the CNC had requested smelling salts and Narcan from Physician #1. She stated the smelling salts had no effect on Patient #1, and Narcan two (2) milligrams was administered. She stated that after the Narcan was administered, Patient #1 became a little more alert, but the alertness was not sustained, and he/she returned to his/her admission base-line mentation of drowsiness and confusion. RN #1 had documented that Patient #1 was alert and oriented to person, place, time, and event upon admission. She stated Patient #1 also exhibited confused, mumbling speech. RN #1 stated Patient #1 was looking at staff, like he/she was wondering who these people were and where was he/she. She stated staff was trying to re-orient Patient #1, and to her knowledge, he/she had only been administered the Narcan.

Continued interview with RN #1, on 10/14/2022 at 11:02 AM, revealed, when Patient #1 left the exam room to sit in a chair in the ED hallway, his/her gait was unsteady. RN #1 stated she felt Patient #1 was not an appropriate discharge, based on her observations of continuing confusion, drowsiness, and unsteady gait. She further stated she was a new nurse with one and one-half (1.5) years experience. She stated that was why she asked for guidance from the CNC and the House Supervisor. She stated, when she voiced her concern over the discharge, she was told by the CNC and the House Supervisor that unfortunately it was not up to them, it was up to Physician #1.

Interview with Facility #1's Medical Director of ED Physicians, on 10/17/2022 at 10:35 AM, revealed he had no direct knowledge or involvement with the incident of 06/16/2022. He stated his job description was as a liaison between the ED Physicians group and the facility. He stated that stabilizing treatment meant every patient received a medical screening exam (MSE) to try to identify if an emergency medical condition (EMC) existed and to try to alleviate the EMC. He stated, if a Physician, in good faith, felt stabilizing treatment had been rendered for the presenting symptoms and no additional concerns were present, then the patient could be considered stable for discharge, even though the presenting systems were still present.

Telephone interview with Facility #1's Physician #1, his legal counsel, and an associate of the law firm, on 10/21/2022 at 10:02 AM, revealed legal counsel stated that Physician #1 would not be answering any specific questions related to the events of 06/16/2022. When Physician #1 was asked what was his definition of stabilizing care, he stated that if a patient was conscious, alert, and had been treated to the best of the facility's ability, then the patient could be admitted, discharged, transferred or whatever the patient requested.