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Based on interview and record review, the facility failed to ensure the facility complied with the provisions in 42 CFR 489.20 and 42 CFR 489.24, when the facility's policies and procedures were not implemented, for two of 20 sample patients (Patients 1 and 2). Patient 1 was not stabilized before the patient was discharged from the Emergency Department (ED) while on a 5250 hold and Patient 2's Medical Screening Exam was not completed timely by the ED physician.

This failure had the potential to result in delay in treatment, compromise the patient's health, and could have contributed to patient death.

Based on interview and record review, the facility failed to ensure medical screening examination (MSE, the process a hospital uses to determine if a patient presenting to the emergency department has an emergency medical condition) and treatment were provided timely in the Emergency Department (ED), for one of 20 sampled patients (Patient 2). In addition, the facility failed to ensure the MSE was conducted by a qualified provider, in accordance with the facility's policy and procedure and rules and regulations.

This failure resulted in a delay of treatment for Patient 2. In addition, this failure may have contributed to Patient 2's death.

Findings:

On July 15, 2025, at 11 a.m., a review of Patient 2's record and concurrent interview were conducted with the Patient Safety Coordinator (PSC). A facility document titled, "Triage [a system to prioritize which patient needs treatment first]," dated June 15, 2025, authored by Registered Nurse (RN) 1, was reviewed. The document indicated, "...Triage start: 15-Jun-2025 [June 15, 2025]18:22 [6:22 p.m.]...Triage Stop...18:27 [6:27 p.m.] Chief Complaint: Low back pain, bilat [bilateral, both sides] leg numbness...Acuity [the severity of a patient's illness or injury, determining the level of care and monitoring needed] 3-Urgent [a score using the Emergency Severity Index (ESI), an algorithm to quickly assess and categorize patients based on acuity-1 most urgent to 5 least urgent]..."

A facility document titled, "Emergency Department Record," dated June 15, 2025, at 8:24 p.m., authored by Resident (a physician in training) 1 was reviewed. The document indicated, "...Location: RME [rapid medical exam, a treatment area in the ED where patients with less severe illnesses are cared for]...Care Start Date/Time: 06/15/2025 [June 15, 2025] 19:07 [7:07 p.m.]...Chief Complaint...presents to the ER [emergency room] via POV [private vehicle] for evaluation of low back pain and LE [lower extremity, leg] weakness...sudden onset of low back pain...unable to feel his b/l [bilateral] lower extremities, and has numbness and tingling...pt [Patient 2] urinated on himself in the ER lobby and seems more disoriented and lethargic...has no sensation to light touch, pinprick. No active ROM [range of motion, the full movement potential of a joint] B/l feet feel cool to touch, pulses difficult to palpate. Absent DTR's [deep tendon reflexes, involuntary muscle contractions triggered by tapping a tendon]...Differential Diagnoses: cauda equina syndrome [syndrome where a bundle of nerves at the end of the spinal cord become compressed causing weakness of legs, urinary incontinence, and bowel disfunction]...Talked to charge nurse about obtaining an acute bed [a bed in the hospital]. There are no vascular surgery [a specialized field of medicine focused on the diagnosis, management, and treatment of diseases affecting the blood vessels] or neurovascular surgery [a branch of medicine which deals with the diagnosis, treatment, and prevention of diseases affecting the brain and spinal cord] consultants on service at this hospital...Care transferred to [name of Physician 1]. Pending imaging studies and lab [laboratory] results. Pending possible transfer..." (1 hour and 57 minutes from the time Patient 2 was triaged).

A facility document titled, "Emergency Continuation," dated June 15, 2025, at 9:22 p.m., authored by Physician 1, was reviewed. The document indicated, "...Reason: Patient care transferred to me due to end of shift...sudden onset of low back pain around 5:30PM [p.m.]...started abruptly...unable to feel his b/l lower extremities, and has numbness and tingling in b/l LE...pt [Patient 2] urinated on himself in the ER lobby and seems more disoriented and lethargic...Procedures in the Emergency Department while patient was getting CT angio [computed tomography angiography, an imaging procedure to visualize the blood vessels and blood flow] completed he went into full arrest [when the heart stops beating and the patient stops breathing]...Patient was resauated [sic, resuscitated, revived]...for 22 minutes. In no pint [sic, point] were pateint [sic, patient] puelse [sic, pulse] brought back. Patient had no signs of life during the entire time. Patient was in agumal [sic, agonal, a very slow and erratic heart rhythm, usually less than 20 beats per minute, which occurs before the heart stops beating in dying patients] rythem [sic, rhythm] and was asystole [flatline, no heart beat] the whole time...patient unfortunately expired...This patient was seen by...resident...rotating in the emergency department and I took care of the patient after she left. On examination patient's lower extremities were cool to touch with diminished pulses bilaterally [sic, .] patient also had no strength, no motor or sensory sensation in the lower extremities. Initially patient had MRI [magnetic resonance imaging, an imaging procedure creating detailed images of soft tissues, organs, and structures within the body] and CT scan of the lumbar spine [lower back] ordered in order to rule out...cauda equina syndrome. However when I saw the patient I suspected a vascular [veins that carry blood] compromise for the cause of patient's neurologic symptoms despite the fact that patient had no abdominal pain and no chest pain diagnosis of aortic dissection [tear in the inner layer of the aorta, the main blood vessel which carries the blood from the heart to the body] or ruptured aneurysm [burst of the blood vessel causing bleeding] was suspected and CT scan angio of the chest abdomen pelvis with extension in the proximal [near the center] extremities was ordered...About an hour after the patient expired I received a call from the radiologist informing me that the patient had a complete dissection of aorta infrarenally [situated below kidneys] with with [sic] complete cessation [ending] of blood flow and also dissection into the ascending aorta [large blood vessel supplying blood to the brain] all the way into the coronary arteries [blood vessels of the heart] with pericardial [sac around the heart] tamponade [compression of the heart due to accumulation of blood in the pericardium, the sac around the heart]..." (58 minutes from the time Resident 1 examined Patient 2, three hours from the time the patient was triaged).

A facility document titled, "...Orders Report," dated June 15, 2025, was reviewed. The document indicated, "...CT Angio Chest/Abdomen/Pelvis...Start Date: 06/15/2025 21:02 [9:02 p.m.]..."

A facility document titled, "Daily Focus Assessment Report," dated June 15, 2025, at 9:50 p.m., was reviewed. The document indicated, "...first contact with pt [Patient 2]...pt very gray/pale in color...pt taken to CT..." (58 minutes from the time the CT angio was ordered for Patient 2).

A facility document titled, "FINAL REPORT," dated June 15, 2025, was reviewed. The document indicated, "...Procedure: CT Angio Abdomen and Bil [bilateral] Lower Extremities...Acute dissection [a life threatening emergency due to a tear in the aorta causing sudden chest or back pain requiring immediate surgical treatment to avoid rupture of the artery] involving ascending colon [the first part of the large intestine] near reaching the level of coronary arteries...dissection is extending to the aortic arch [large vessel connecting the top and bottom portion of the aorta] and descending thoracic aorta [large vessel which carries blood from the heart to theabodmen and lower extremities]....aortic arch [the curved portion of the aorta which connects the ascending aorta to the descending aorta] major branches are arising from the true lumen [inner passageway in the blood vessel through which the blood flows] with evidence of extensions of the dissection into the left subclavian [a major artery found in the upper body] and right innominate artery [the first and largest branch of the aortic arch]. Large hemorrhagic [bleeding] pericardial effusions [accumulation of blood in the pericardium] indicating that the dissection has extending into the pericardium with collapse of the cardiac chamber [a hollow space in the heart] indicating progressive cardiac tamponade [blood build up in the space between the lining and the muscles of the heart causing pressure on the heart preventing it from pumping]...Impression: Extensive thoracic [chest] aorta dissection extending to the heart resulting in cardiac tamponade and hemorrhagic pericardial effusion. Extensive abdominal aorta dissection as described in detail above with occlusion [a block] of the true lumen in the infrarenal [below the kidneys] abdominal aorta resulting in absent blood flow bilateral lower extremities..."

A facility document titled, "Code Blue Record," dated June 15, 2025, indicated the code blue [a hospital code for a patient experiencing a life-threatening medical emergency when the patient stops breathing and the heart stops beating] initiated at 2200 [10 p.m.]....Time of Death 2224 [10:24 p.m.]..." (Three hours and 55 minutes after arriving to the ED)

During a concurrent interview with the PSC, the PSC stated Patient 2 arrived in the ED at 6:19 p.m., on June 15, 2025.

On July 15, 2025, at 11:14 a.m., an interview was conducted with the Chief Quality Officer (CQO). The CQO stated Resident 1 was a first-year medical resident. She stated the MSE should not have been conducted by a resident physician. The CQO stated the facility's rules and regulations indicated the MSE needed to be completed by an attending licensed emergency room physician.

On July 21, 2025, at 11:02 a.m., an interview was conducted with Emergency Room Physician (Physician) 1. Physician 1 stated Patient 2 was first assessed by a resident (Resident 1) who was a first-year resident. Physician 1 stated Resident 1 presented the case to him after the resident's assessment. Physician 1 stated he thought he saw Patient 2 in a reasonable time, but an hour is not an acceptable time. Physician 1 stated he took over the case because Resident 1 signed off for the day, and ultimately, he was responsible for the patient. Physician 1 stated the patient was flagged as not being very critical, with an ESI of 3. Physician 1 stated he was not aware the Medical Screening Examination (MSE) needed to be completed by an ED physician and not a resident.

On July 21, 2025, at 12:59 p.m., an interview was conducted with Resident 1. Resident 1 stated that at the time of this incident, she was a first-year resident. Resident 1 stated residents were not assigned to patients. Resident 1 stated the residents were able to look at the ED list and pick who to see from patients listed with an ESI of 2 or 3. Resident 1 further stated Patient 2 was triaged with an ESI of 3 which was urgent but not emergent. Resident 1 stated Patient 2 had been in the lobby for a while before she called Patient 2 back for the exam. Resident 1 stated she presented the case to Physician 1 right after assessment and Physician 1 instructed her to place orders for what was thought to be cauda aquina. Resident 1 stated, later she went back to reassess Patient 2, and the patient looked less stable than before and that was when she requested Physician 1 to come see the patient. Resident 1 stated Patient 2 should have been an ESI of 2.

On July 21, 2025, at 1:46 p.m., an interview was conducted with RN 1. RN 1 stated she is not a triage nurse and had never been trained to be a triage nurse. RN 1 stated the day Patient 2 presented to the ED was the first day she was assigned to be a triage nurse. RN 1 stated the ED was short staffed and the ED charge nurse asked her to triage patients due to staff shortage.

On July 21, 2025, at 3:05 p.m., an interview was conducted with the ED Manager (EDM). The EDM stated the charge nurse assigned RN 1 to triage patients at the ED and she should not have. The EDM stated RN 1 was not trained to be a triage nurse. The EDM stated there was another nurse in the ED who was trained to be a triage nurse who should have been assigned to triage. She stated if the triage would have been done sooner, Patient 2's outcome could have been different.

A review of the facility document titled, "GENERAL RULES AND REGULATIONS," dated May 22, 2024, were conducted. The document indicated, "...Medical Screening Examinations...Medical screening examinations may be performed by the following categories of professionals...Credentialed physicians on the Medical Staff with privileges in Emergency Department. Mid-level practitioners with service authorizations to perform such exams. Registered Nurse assigned to the Labor and Delivery (L&D) Department who has met criteria for certification as outlined in standardized procedure for L&D patients only..."

A review of the facility's policy and procedure titled, "EMTALA - MEDICAL SCREENING AND STABILIZATION POLICY," dated April 2023, was reviewed. The document indicated, "...The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC (emergency medical condition) exists...Only the following individuals may perform an MSE...qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges; or...A qualified staff member who...is qualified to conduct such an examination through appropriate privileging and demonstrated competencies...is functioning within the scope of his or her license...is performing the screening examination based on medical staff approved guidelines, protocols or algorithms...is approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations..."

Based on interview and record review, the facility failed to ensure stabilizing treatment was provided, for one of 20 sample patients (Patient 1), when Patient 1, who was determined to be a danger to self and was gravely disabled (inability of the patient to provide for his or her basic personal needs for food, clothing, or shelter) and was on a 5250 (a legal 14 day involuntary hold) hold was discharged from the Emergency Department (ED).

This failure resulted in Patient 1 being discharged while on a legal hold and could have resulted in harm and/or injury to Patient 1.

Findings:

On July 15, 2025, a review of Patient 1's record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "Triage," dated May 23, 2025, was reviewed. The document indicated, "...Triage [a preliminary assessment of patients using a number system with 1 being most urgent and 5 being least urgent] start: 23-May-2025 [May 23, 2025] 11:00 [a.m.]...Chief Complaint: Social Problem...BIBA [brought in by ambulance] after walking into clinic and refused to answer any questions - pt [Patient 1] appears ti [sic, to] be hallucinating [seeing or hearing things which are not there] upon triage..."

A facility document titled, "Emergency Department Record," date May 23, 2025, at 11:21 a.m., was reviewed. The document indicated, "...presenting to the emergency room via EMS [emergency medical services, an ambulance service] for evaluation of social problem...Differential Diagnosis [a physician's assessment of two or more conditions which share similar signs or symptoms]: psychosis [a mental health condition characterized by a loss of contact with reality], drug intoxication, schizophrenia [a seious mental condition which impacts a person's feelings and behaviors, including delusions (a fixed, false belief that is not based on reality) and hallucinations (an experience of seeing or hearing something which is not present)]...Nurse reports patient [Patient 1] is trying to leave the department [ED] but she is not fully A&Ox4 [alert and oriented to person, place, time, and situation]...Patient placed on an 8 [eight] hour hold by myself until she is able to be evaluated by REACH [Response, Early intervention, and Assessment in Community Mental Health, programs which aim to improve mental health outcomes through early intervention, crisis support, and community-based services]...1900 [7:00 p.m.] Patient care transitioned to the next ED attending physician due to change of shift..."

A facility document titled, "APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT," dated May 23, 2025, was reviewed. The document indicated, "...pursuant to...Code 5150 [a 72 hour involuntary legal hold]...[name of Patient 1]...for up to 72 hour assessment, evaluation and crisis intervention or placement for evaluation treatment at a designated facility pursuant to Section 5150...The Above person's condition was called to my attention under the following circumstances: client was placed on a 8 [eight] our hold due to experiencing bizarre behavior. Hospital requesting re-evaluation...Client [Patient 1] presented with flat affect [reduced or absent expression of emotions]. She appears to be responding to internal stimuli [sensations and feelings originating from within the body that can influence behavior and perception] as evidenced by mumbling and looking from side to side. Has history of psychosis, when asked safety questions she was unable to verbalize... anger to self... Date:05/23/2025 [May 23, 2025]...Time: 11:54 p.m..."

A facility document titled, "DETENTION OF PATIENT WITH PSYCHIATRIC EMERGENCY IN A NON DESIGNATED [sic] HEALTH FACILITY," dated May 23, 2025, at 2:09 p.m., was reviewed. The document indicated, "... [Name of Patient 1]...Danger to self...Gravely disabled...If the patient is detained beyond 8 hours, but less than 24 hours, both of the following additional conditions must be met: A discharge or transfer for appropriate evaluation or treatment for the patient has been delayed because of the need for continuous and ongoing care, observation, or treatment that the hospital is providing...The Patient named above continues to be, as a result of a mental disorder, one or more of the following: a danger to herself...Gravely disabled...Date:05/23/25...Time: 2224 [10:24 p.m.]..."

A facility document titled, "Notice of certification for intensive treatment pursuant to section 5250 ," dated May 26, 2025, was reviewed. The document indicated, "...14-day hold...[Name of Patient 1]... Address unknown... A danger to self as a result of a mental health disorder...Gravely disabled...The specific facts which formed the basis of our opinion that the above named person meets one or more of the classification indicated above are as follows...Danger to self by not being able to express an ability to provide her medications, food, shelter...Date: 05/26/25 [May 26, 2025] Time: 0900 [9 a.m.]..."

A facility document titled, "Daily Focus Assessment Report," dated May 23, 2025, through May 27, 2025, was reviewed. The document indicated, "...05/24/2025 [May 24, 2025] 00:00 [12 a.m.]...Reach placed pt [Patient 1] on 5150 hold for danger to self due to continued bizarre behavior, appears to be hallucinating...05/26/2025 07:30 [7:30 a.m.]...Pt informed at 0905 [9:05 a.m.] of 5250 hold signed by MD...at 0900 [9 a.m.]..."

A facility document titled, "Daily Focus Assessment Report, dated May 23, 2025, through May 27, 2025, authored by Registered Nurse (RN) 2, was reviewed. The document indicated, "...05/26/2025 20:00 [8 p.m.]...PT BIBA for 5150 hold...22:00 [10 p.m.]...Pt updated on plan of care. Pt Developmentally delayed [individual who continues to experience significant limitations in one or more major life activities due to a mental or physical impairment ] and does not answer questions appropriately...00:26 [12:26 a.m.]...Pt to be discharged home patient is alert and oriented x3-4, MD [physian] at bedside. Pt vitals [measurable physiological parameters that indicate the body's essential functions, temperature, heart rate, respiratory rate, and blood pressure] stable for DC [discharge]..."

A facility document titled, "CPOE Orders Report," dated May 23, 2025, through May 27, 2025, was reviewed. The document indicated, "...Discharge to Home...Start Date: 05/27/2025 [May 27, 2025] 00:19 [12:19 a.m.]..."

A facility document titled, "Discharge Instructions," dated May 27, 2025, at 00:30 [12:30 a.m.] was reviewed. The document indicated, "...Discharge Instructions...Patient Departed from the ED Date and Time...05/27/2025 [May 27, 2025] 00:28 [12:28 a.m.]..."

During review of Patient 1's record, there was no documented evidence the night shift (7 a.m. to 7 a.m.) RN acknowledged Patient 1 was on a 5250 hold.

During a concurrent interview, the PSC indicated Patient 1 arrived in the ED on May 23, 2025, at 10:40 a.m. The PSC stated Patient 1 was discharged on May 27, 2025, at 12:28 a.m.

On July 21, 2025, at 2:02 p.m., an interview was conducted with ED Physician (ED) 2. ED 2 stated he cannot cancel a 5250 hold. He stated the 5250 hold can only be interrupted or broken by a psychiatrist. ED 2 stated he was not aware Patient 1 was on a 5250 hold. ED 2 stated there was a communication error, and he should have never discharged Patient 1.

On July 21, 2025, at 3:34 p.m., an interview was conducted with RN 2. RN 2 stated she was aware a patient on a 5250 hold could not be discharged. RN 2 stated she was unable to find the 5250-hold documentation in Patient 1's record. RN 2 stated she spoke to ED 2 and ED 2 told her he did not know Patient 1 was on a 5250 hold. RN 2 stated Patient 1's 5250 hold documentation was placed in a wrong patient's chart.

On July 21, 2025, at 3:45 p.m., an interview was conducted with the Chief Quality Officer (CQO) and the Deputy Regional Director of Quality (DRDQ). The CQO stated Patient 1, who was on a 5250 hold, was discharged in error. She stated it was due to a lack of communication. The CQO stated ED 2 was not aware Patient 1 was on a 5250 hold. The CQO stated ultimately a 5250-hold patient should not have been discharged.

A facility policy and procedure titled, "Behavior Health Management," dated September 2024, was reviewed. The document indicated, "...To appropriately manage patients in the Emergency Department (ED) with an acute psychiatric condition...includes, but is not limited to, identifying whether the patient is a danger to self or others or gravely disabled (and is already on a involuntary 5150 or 8 hour hold or requires one), determining whether the patient's condition warrants an appropriate transfer to a psychiatric facility, and ensuring the health and safety of the patient...Physicians will reassess for continued need for an additional involuntary hold, leading to a 5250..."