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Based on observation and interview, the facility failed to post the Right of the individuals with respect to examination and treatment of emergency medical conditions and women in labor in the following areas:
1. the vestibule/outer waiting area of the emergency department (ED);
2. the ambulance entrance.

These deficient practice failed to inform the right for healthcare service for patients or family members whose passage of ED visiting was only limited to the above two areas.

Findings:

1. During an ED tour and a concurrent interview with Senior Nurse Executive (SNE) 1 at 10:00 am on 10/14/20, it was noticed that the Patient's Right posting was missing from the vestibule/outer waiting area which was behind the security metal check point and in front of the Patient Registration desk. There were four sofas lined against the wall or glass wall. SNE 1 acknowledged the missing signage.

During an interview with ED Manager (EDM) 1 at 10:45 am on 10/14/20, EDM 1 stated the area behind the security metal check point was called vestibule where the visitors came into the ED and get registered after being metal tested. Family members or visitors sometimes stayed in the vestibule area waiting for transportation.

During an interview with Security Officer (Sec) 2 at 4:28 pm on 10/14/20, Sec 2 stated "I've seen ED technician taking vitals (signs) on patients waiting in the registration/outer waiting area sometimes."

During an interview Emergency Department Technician (Tech) 2 at 10:00 am on 10/15/20, Tech 2 stated, "Since Covid 19, the Registration desk was moved to the vestibule where used to be the security kiosk. Registered patients could also stay in the vestibule to have vitals checked, depending on patient's acuity."

2. During an ED tour and a concurrent interview with ED Manager (EDM) 1 at 10:54 am on 10/14/20, it was noticed that the Patient's Right posting was missing from the ambulance entrance. EDM 1 acknowledged that the posting was not available for patient to view from entrance through to the triage area (where the patient's condition was assessed and assigned an acuity score). Patient's Right posting was only available on the wall of the main ED waiting area. If patient was brought in by an ambulance, they could go through the ED without been able to see the posting.

Based on interview and record review, the facility failed to maintain an Emergency Department (ED) central log on Patient 1 who reentered and stayed in the ED vestibule/outer waiting area for three hours.

This deficient practice can impede the facility's ability to track the care provided to the patient who visits the ED seeking emergency medical care.

Findings:

Review of the ED video footage dated 9/3/20 to 9/4/20 with Manager of Protective (MP) and Emergency Department Manager (EDM1) at 2:17 pm on 10/14/20, indicated Patient 1 exited the ED and stepped outside to the ED drop-off area at 10:03 pm on 9/3/20. It took two minutes for Patient 1 to slowly walk approximately 25 feet. At 10:05 p.m., Patient 1 "collapses, falls backwards and hits his right shoulder and head". At 10:07, Patient 1 was transported via wheel chair by Security Officer (Sec) 1 and Emergency Department Technician (Tech) 1 back to the ED "outer waiting room" also known as the "vestibule". Using a walker, Patient 1 left the ED outer waiting room on 9/4/2020 at 1:35 a.m.

Review of the ED EMTALA (Emergency Medical Treatment and Labor Act) Log from 3/1/20 to 9/27/20 with EDM 1 indicated Patient 1 arrived at ED at 3:14 pm on 9/3/20 via ambulance for altered mental status. Patient 1 was discharged at 10:03 pm on 9/3/20. There was no record of Patient 1 reentered the ED at 10:07 pm on 9/3/20 and left the ED at 1:35 am on 9/4/20.

During an interview with EDM 1 at 2:20 pm on 10/16/20, EDM 1 acknowledged that Patient 1 should have been re-registered into the system and recorded on the ED Log for reentering the ED after a fall.

Review of the facility's "Policy - Emergency Department Triage" with a last review date of 12/19/19 indicated, "All individuals entering the Emergency Department seeking medical attention and / or treatment will be entered into the appropriate tracking system."

Review of the facility's "Policy - Patient Transfers Emergency Department" with last revised date of 8/19/20, indicated, "Record keeping: 1. The hospital, whether transferring or receiving patients, must maintain the following: ... c. A central log of each patient who comes to emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged."

Based on observation, interview and record review, the facility failed to provide medical screening exam to Patient 1 who was discharged shortly before and had reentered the emergency department following a fall on the hospital sidewalk.

This deficient practice had the potential for delayed assessment and treatment for Patient 1 medical condition, could have been the cause for Patient 1's cardiac arrest two hours later.

Findings:

Record review of Emergency Department Note on Patient 1 dated 9/3/20 indicated Patient 1 arrived at the ED at 3:14 pm on 9/3/20 via an ambulance for altered mental status. "Patient 1 was observed in the ED for several hours with improved mental status." The discharge diagnosis included: Poisoning by nitrous oxide, acute drug-induced confusion.

Review of the ED EMTALA (Emergency Medical Treatment and Labor Act) Log from 3/1/20 to 9/27/20 indicated Pt 1 arrived at ED at 3:14 pm on 9/3/20 via ambulance for altered mental status. Pt 1 was discharged at 10:03 pm on 9/3/20.

Review of the ED video footage dated 9/3/20 to 9/4/20 with Manager of Protective (MP) and Emergency Department Manager (EDM) 1 at 2:17 pm on 10/14/20, indicated Patient 1 exited the ED and stepped outside to the ED drop-off area at 10:03 pm on 9/3/20. It took two minutes for Patient 1 to slowly walk approximately 25 feet. At 10:05 p.m., Patient 1 "collapses, falls backwards and hits his right shoulder and head". At 10:07, Patient 1 was transported via wheel chair by Security Officer (Sec) 1 and Emergency Department Technician (Tech) 1 to the ED "outer waiting room" also known as the "vestibule". Using a walker, Patient 1 left the ED waiting room on 9/4/2020 at 1:35 a.m.

During an interview with EDM 1 at 2:20 pm on 10/16/20, EDM 1 acknowledged that there was no record of Patient 1 reentered the ED at 10:07 pm on 9/3/20 and left the ED at 1:35 am on 9/4/20. Patient 1 should have been re-registered into the system and recorded on the ED Log for reentering the ED after a fall.

During an interview on 10/14/2020 at 4:30 p.m. with Tech 1, Tech 1 stated someone told him that someone was down outside on 9/3/20 at around 10:10 pm. Tech 1 went outside with Sec 2 and find Patient 1 lying on the ground. Patient 1 did not respond to Tech 1's question "Are you ok." Tech 1 went on to ask Patient 1 "did you hit your head." Patient 1 answered "no". Tech 1, with the help of Sec 1, got Patient 1 into a wheel chair and wheeled Patient 1 back to the ED outer waiting room. Tech 1 asked Patient 1 twice whether she wanted to be seen, Patient 1 did not response. Tech 1 parked the wheel chair in front of the registration desk. Tech 1 stated, Patient 1 was "not verbalizing [talking] ... dazed ...confused ...didn't look okay". Tech 1 stated he told the Triage Nurse (RN 1) "There was a patient found outside down on the ground." RN 1 asked whether the patient was registered. Tech 1 replied "no". Tech 1 stated, "Twenty minutes later, Sec 2 asked 'is anyone seeing the patient (1),' I asked the triage nurse (RN 1) again."

During an interview on 10/14/2020 at 3:40 p.m. with Sec 2, Sec 2 stated, "I saw the patient (1) went out at around 10:10 pm 9/3/20. Two bystanders notified me the patient (1) was on the ground." Sec 2 went outside and helped Tech 1 to bring Patient 1 via wheel chair to the ED outer waiting room. Sec 2 stated, Patient 1 "didn't look good ...disoriented ...pale ...needed to be seen ...sweating. I asked the ED tech (Tech 1) two to three times, 'Did you ask somebody? Who is coming to check the patient? I was hoping that someone would come to see him, he looked like he need medical care. He did not approach the registration (desk), he was not in the right mind to do that".

During an interview with the Triage Nurse (RN 1) on 10/15/20 at 8:37 am, RN 1 confirmed he was the ED triage nurse on 9/3/20 from 7:00 p.m. until 9/4/20 7:30 a.m. RN 1 acknowledged that he was the most senior and the only qualified licensed staff in the outer waiting room/registration area/vestibule area to assess a patient's medical needs. RN 1 stated "Triage nurse is to see who is the sickest person who needs medical care, ... reassessing patient for changes of conditions." RN 1 stated registration was not a requirement for care, and "it is a gray area if patients do not have capacity to ask for help." RN 1 acknowledged that he did not assess Patient 1's disability and level of consciousness. The only interaction RN 1 had with Patient 1 was to tell Patient 1 it was time to leave at 1:35 am on 9/4/20. RN 1 stated, "It was three hours, I told him it's time to go. He did not resist, no verbal response."

Record review of Emergency Department Physician Note on Patient 1 dated 9/4/20 indicated Patient 1 was found to be in PEA (pulseless electric activity - stoppage of heart function with the presence of electricity of the heart) by paramedics and was brought back to the ED at 02:47 am on 9/4/20 via ambulance for cardiopulmonary arrest (heart and lung ceased to function). Patient 1 was declared dead at 3:32 am on 9/4/20.

Review of the facility's "Policy - Emergency Department Triage" with a last review date of 12/19/19 indicated, "All patients presenting to the Emergency Department (ED) for treatment will be assessed by a Registered Nurse to determine the urgency of the patient's condition and assigned a triage / acuity level based on the Emergency Severity Index (ESI) algorithm ... The ESI level establishes prioritization of a medical screening exam by the ED physician. Patients awaiting a medical screening exam will be reassessed based on acuity level and the reassessment documented in the medical record."

Review of the facility's "Policy - Emergency Department Triage" with a last review date of 12/19/19 indicated, "All individuals entering the Emergency Department seeking medical attention and / or treatment will be entered into the appropriate tracking system."

Review of the facility's "Policy - Emergency Medical Screening and Access to Emergency Care and Treatment" with a last review date of 3/17/17 (the effective version at the time of the incident) indicated, "Procedure: 1. Emergency Department: The individual will be seen by a triage nurse to determine the order in which the individual will be seen by the Emergency Department physician on duty for a Medical Screening Examination. 2. Following the completion of the Medical Screening Examination, if an Emergency Medical Condition has been ruled out, the patient may be referred to registration for completion of financial screening. 3. If an Emergency Medical Condition has been identified the patient will continue to receive whatever treatment is required to evaluate and stabilize his or her condition, including admission or transfer to another facility offering specialized treatment services. Once the Emergency Medical Condition has been stabilized, the patient may be referred to registration for completion of financial screening ... 5. Should a patient refuse to consent to examination or stabilizing treatment: The patient will be informed of the benefits and risks of further examination and treatment, and the reasonably foreseeable consequences of refusing examination and treatment."

Tag 2407

Based on observation, interview and record review HOSP emergency department (ED) failed to provide one of one patients (Patient 1)stabilizing medical treatment and mitigate the continued material deterioration and provide the necessary care to prevent relapse or worsening of an emergency medical conditions (EMC) in accordance with hospital policies and/or medical staff bylaws when:

1. A comprehensive medical screening exam (MSE) work-up was not complete,
2. An ongoing assessment and medical monitoring was not continued throughout emergency room admission,
3. Pt 1 was discharged without convincing evidence the EMC resolved.

The failure to treat and stabilize Patient (Pt) 1's changing vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation (oxygen level in blood)), pain, bladder and bowel incontinence (unable to control release of bowel movements and urine), substance abuse (drug and/or alcohol abuse), abnormal laboratory test results, and mental status changes contributed and/or resulted in Pt 1's collapse, cardiac arrest (heart stops beating) and death. Preliminary autopsy report showed lethal blood clots in lungs.

Findings:

During a series of concurrent interviews, review of records and security video observation from 10/14/2020 to 10/16/2020, the timeline of Pt 1's medical care was determined with Emergency Department Physician Director (EDD), Registered Nurse (RN) 1, Emergency Department Nursing Manager (EDM) 1, Emergency Department physician (MD) 1, Manager of Protective Services (MP), Security ( Sec) 2, Emergency Department Technician (Tech) 1, and Patient Services Registration (Reg) 1; plus, interviews and concurrent record review on 10/16/2020 at 8:43 a.m. with EDM 1, and on 10/16/2020 at 3:12 p.m. with MD 1, regarding the details of medical care and documentation of care on 8/22/2020, 9/2/2020, 9/3/2020 and 9/4/2020 for Pt 1.

Pt 1 was described by ED nurses, ED technicians and physicians as a transgender person, who was born a male, but identified as a female. Pt 1 had a history of substance abuse, cognitive lapses (ability to make decisions, communicate effectively, comprehend), medical issues, physical disability, and APS evaluations (APS, State law requires immediate report of cases of suspected abuse or neglect of an elder or dependent adult). Pt 1 resided at a Single Room Occupancy (SRO, housing solutions that support vulnerable individuals through outreach, social services, needs assessment, housing retention, and general advocacy). Within the past year, Pt 1 had ED visits on 8/22/2020, 9/2/2020, 9/3/2020 and 9/4/2020 for documented medical issues of altered mental status such as confusion, slow to respond and sleepiness, inability to care for self, dizziness, weakness, foot drop, covered in feces and urine, 8/10 pain (0 no pain, 10 severe pain), walker use, fall risk, inability to care for self, drug overdose of whipits (illegal use of nitrous oxide, a gas used to relax and put patients to sleep for surgeries) and substance abuse intoxication/withdrawal (illegal use and side effects of drugs and/or alcohol) of stimulant methamphetamine/speed intoxication or GHB withdrawal. (Methamphetamine, a highly addictive illegal drug that can lead to an abnormal heart rhythm and injure heart muscle. GHB or Gamma-hydroxybutyrate, also known as the date rape drug or Ecstasy, can cause memory loss, sleepiness and slow responses).

Timeline of Pt 1's care on 9/3/2020:

At 3:14 p.m., Pt 1 arrived at the ED via ambulance. The paramedics documented that Pt 1 was alert and oriented (individuals who can recall person, time, place and events), but was confused and had altered mental status (includes, but not limited to behavior changes, slow responses, poor concentration, forgetfulness, inappropriate responses caused by medical conditions, psychological or psychiatric disease, drugs and/or environmental factors).

At 3:16 p.m., Pt 1 was evaluated by RN 2 who documented "altered mental status", "continued abuse of whipits", "pain to buttocks from bad self-care" and "incontinent of large stool upon arrival". Pt 1 was placed on monitors for blood pressure, heart rate and rhythm, and oxygen saturation. Pt 1 was also placed on a cardiac (heart) telemetry (continuous heart monitoring which displays a picture of heart rhythm, rate and possible abnormalities).

At 3:38 p.m., the record documented, MD 1 ordered blood tests, chest x-ray, brain scan, Zofran (medication for vomiting), blood alcohol level and urine toxicology (Urine drug screen, also known as Utox, is typically ordered in trauma, mental health illness, and altered mental status patients where the results can assist in patient management). There was no documentation that the ED RNs (RN 2, RN 3, RN4, RN 5, RN 6, RN 7 and RN 8), who cared for Pt 1 from 3:14 p.m. to 10:03 p.m., notified MD 1 that the UTox was not obtained or the continuous status of Pt 1's physical and psychological status.

At 4:11 p.m., MD 1 evaluated Pt 1 and wrote an ED admission note. MD 1 documented "flat affect", "diaphoretic [sweaty]", "well hydrated", "alert and oriented", unremarkable male genitalia exam, and normal heart, lung, abdominal, extremity, neurological and head exam. MD 1 did not document patient medical findings such as dehydration, dizziness, pain, nausea, vomiting, loss of bowel and bladder control, confusion, slow to respond, sleepiness, weakness, foot drop, walker use, fall risk, cognitive function, inability to care for self or substance abuse history of stimulant methamphetamine/speed intoxication or GHB withdrawal. MD 1 treated Pt 1 with intravenous fluid (liquid given directly into a vein) and Zofran.

At 4:29 p.m., Pt 1's lab results showed an abnormal creatine kinase (CK) level of 456 (A normal CK is 20-260. An elevated level of creatine kinase is seen when the heart muscle is damaged, or damage to the skeletal muscles or brain. An elevated CK can signal a heart attack or other emergency). In an interview on 10/16/2020 at 3:12 p.m., MD 1 stated an abnormal CK levels could be from "ACS [acute coronary syndrome, heart attack] or muscle [damage]". MD 1 indicated that significant elements of a cardiac evaluation were not reassessed. MD 1 stated a cardiac evaluation, would include heart and lung exam, heart monitoring, ECG (electrocardiogram, a tracing of heart rate, rhythm and possible abnormalities), troponins (laboratory test for heart muscle injury), and CK.

At 4:53 p.m., RN 4 documented communication with social worker (SW) 1 to follow-up with Pt 1 about the APS referral made on 8/22/2020.

At 5:12 p.m. RN 4 documented that Pt 1 was "slow to respond", respiratory rate 19 (normal 12 to 16 breaths per minute), and oxygen saturation (level) of 95% (normal level of oxygen in the blood in a healthy adult is 100%). There was no print out record saved or documentation related to Pt 1's heart rate, rhythm or possible abnormalities. There was no nursing documentation that MD 1 was informed of Pt 1's mental status or abnormal vital signs.

At 5:55 p.m., MD 1 documented a "conditional discharge". MD 1 documented a reassessment of "no evidence of rhabdomyolysis, renal failure, and head trauma or alcohol intoxication." MD 1 did not document a reassessment related to ongoing mental status changes, pain, and heart-lung function, abnormal vital signs, incontinent of stool and urine, possible harm to self, APS referral and/or physical or mental disabilities.

At 6:02 p.m., Pt 1's registration was completed. During an interview on 10/15/2020 at 1:50 p.m. with Reg 1, Reg 1 stated that she unable to obtain information or tell if Pt 1 understood the questions. Reg 1 stated, it was "hard, [Pt 1 did] not answering anything". Pt 1 was unable to sign the consents.

At 6:29 p.m., RN 4 documented "large incontinence of stool", respiratory rate of 24 and oxygen saturation 97%. There was no nursing documentation that MD 1 was informed of Pt 1's abnormal findings.

MD 1 stated in an interview and review of records on 10/16/2020 at 3:14 p.m., she left the hospital at 7:30 p.m. MD 1 stated, that before departing she did not complete a reassessment at 7:30 p.m. MD 1 acknowledged, she did not address Pt 1's disabilities, abnormal vital signs or abnormal labs, i.e. CK. MD 1 stated she did not follow-up on status of the Utox and determine if there were unexpected drugs or toxic level substances that could potentially affect the mental status changes, low blood oxygen levels and/or heart functioning. MD 1 acknowledged Pt 1 did not receive a re-evaluation of cognitive function, mental status changes, possible harm to self, or inability to care for self. MD 1 did not document if Pt 1 was still intoxicated from drugs verses medical conditions that could interfere with Pt 1's ability to communicate physical, psychological and medical needs.

At 10:03 p.m., the chart documented Pt 1 was discharged by RN 7. There was no MD 1, RN 7 or SW 1 discharge assessment documented.

At 10:05 p.m., during an interview on 10/14/2020 at 2:30 p.m. with MP1 and EDM 1, MP1 and EDM 1 concurred, outside in the ED drop off area, Pt 1 "collapsed", fell backwards, hit her head and shoulder minutes after leaving the ED. Pt 1 was on hospital property in the ED drop off area when she collapsed.

At 10:07 p.m., during an interview on 10/14/2020 at 4:58 p.m. with Tech 1, Tech 1 stated he helped Sec 2, bring Pt 1 via wheel chair to the ED outer waiting room. Tech 1 stated, Pt 1 was "not verbalizing [talking] ... dazed ...confused ...didn't look okay".

During an interview on 10/14/2020 at 4:30 p.m. with Sec 2, Sec 2 indicated that Pt 1 collapsed outside of the ED. At 10:07 p.m., he helped Tech 1 bring Pt 1 via wheel chair inside to the ED. Sec 2 stated between 10:07 p.m. to 11:00 p.m. he informed the "nurse 2 to 3 times ... [Pt 1] didn't look good ...disoriented ...pale ...needed to be seen ...sweating".

At 10:53 p.m., SW 1 documented an encounter with Pt 1 to follow-up on the APS report filed 8/22/2020. SW 1 documented "today, 9/3/20 with clothes and socks drenched in urine and feces ... [Pt 1's] 'addiction'". SW 1 describe that Pt 1 was unable to care for self independently, continued to harm self, had physical disabilities, and abused drugs. SW 1 documented she planned to file a new APS report. SW 1 did not document that she communicated her findings and plans to MD 1 or ED nursing staff, or ensure Pt 1's was discharged after the EMC resolved.

During an interview on 10/15/2020 at 8:37 a.m. with RN 1, RN 1 stated Sec 2 and Tech 1 brought Pt 1 back to the ED via a wheelchair after falling outside striking head and shoulder at on 9/3/2020. RN 1 stated, Pt 1 was never evaluated by a physician or nursing staff, or had vital signs taken. During the 3 ½ hours Pt 1 sat in the waiting room, RN 1 stated that he "glanced" at Pt 1 who was sitting in a chair in the outer waiting room. RN 1 stated, he "didn't ask if [Pt 1] needed help". RN 1 stated, he told Pt 1 "it's time to go" at around 1:30 a.m., and this was the only communication he had with Pt 1. RN 1 stated, Pt 1 left using walker.

At 2:47 a.m., Pt 1 returned to the ED via ambulance in cardiac arrest.

At 3:32 a.m., MD 2 documented the time of death of Pt 1 and referred the case to the coroner (official who investigates violent, sudden, or suspicious deaths).

During an interview and observation of a security video on 10/14/2020 at 2:30 p.m., with MP and EDM 1, MP and EDM 1 confirmed the time and date of the video, starting from 9/3/2020 at 10:03 p.m. to 9/4/2020 at 1:35 a.m. EDM 1 and MP identified persons in the video, and described Pt 1's and staff's activity. At 10:03 p.m., Pt 1 exited the ED. Pt 1 stepped outside to the ED drop-off area. Pt 1 walked slowly approximately 25 feet in two minutes. At 10:05 p.m. EDM 1 described Pt 1 "collapses falls backwards and hits his right shoulder and head". Pt 1 was still on hospital grounds. At 10:07, Pt 1 was transported via wheelchair by Sec 2 and Emergency Tech 1 to the ED outer waiting room also known as the vestibule. Pt 1 sat in a chair in the outer waiting room for over three hours. Pt 1 did not leave until RN 1 told Pt 1 to leave. Using a walker, Pt 1 left the ED waiting room on 9/4/2020 at 1:35 a.m. MP and EDM 1 stated that the video could not capture Pt 1's activity while sitting in the waiting room chair because a pole blocked the view of Pt 1. EDM 1 and MP stated Pt 1 sat in the same chair from 10:07 p.m. to 1:34 a.m. 1 EDM 1 stated, Pt 1 was not logged into the ED log and no assessment by a RN 1 or physician was documented from 10:07 to 1:35 a.m. EDM 1 confirmed Pt 1 returned via ambulance in cardiac arrest on 9/4/2020 at 2:47 a.m. EDM 1 stated that she spoke with the coroner's office and per the preliminary autopsy report, Pt 1's cause of death was a pulmonary emboli.

During an interview and concurrent record review on 10/16/2020 at 8:43 a.m. with EDM 1, for Pt 1's care on 9/3/2020, EDM 1 stated, per hospital policy ED nurses are required to document and communicate with physicians and other staff members about patient status and care. EMD 1 stated she could not locate records of communication between nurses and physicians, physicians and social workers, and physicians and physicians. EDM 1 stated there were no documented ongoing reassessment regarding the stabilization of Pt 1's emergency medical conditions by MD 1, SW 1 or ED RNs (RN 2, RN 3, RN4, RN 5, RN 6, RN 7 or RN 8). EDM 1 could not locate documentation for a completed urine toxicology, electrocardiogram (ECG), heart monitoring strips, cognitive function, suicide assessment, or psychiatric evaluation. EDM acknowledged there was no documentation that MD 1, the SW 1, or ED RNs (RN 2, RN 3, RN4, RN 5, RN 6, RN 7 or RN 8) addressed and communicated with each other about the abnormal fluctuating vital signs, incontinence, failure to collect Utox, mental health changes, inability to care for self or other medical conditions. Documented in the chart was Pt 1's heart rate and respiratory rate changed 25 to 33 % from baseline from 3:16 p.m. to 9:00 p.m.: Respiratory rate ranged from 18 to 24, fluctuating oxygen saturation 95 to 100%, unmatched pulse (heart rated taken at artery, usually in wrist) 64 to 79 beats per minute and heart monitor 60 to 89 beats per minute (unmatched pulse and heart monitor recordings could signal a heart abnormality). Per hospital discharge policies, more than 20 percent change in vital signs, required nursing staff to notify MD 1, and MD 1 to re-evaluate the patient.

EMD 1 indicated MD 1, SW 1, and the ED RNs did not follow hospital discharge policies. EDM 1 stated she could not locate documentation that before Pt 1 was discharged Pt 1, RN 7 communicated with MD 1 to reevaluate Pt 1 before discharge. EDM 1acknowledged RN 6 and RN 7, and MD 1 did not complete a discharge reassessment or document if the EMC had been stabilized and if Pt 1 was ready for safe discharge. EDM 1 stated, Pt 1 was discharged at 10:03 p.m.

EDM 1 stated after Pt 1 collapsed at 10:05 p.m., Pt 1 was escorted by Tech 1 and Sec 2 back to the ED via a wheel chair. EDM 1 stated when Pt 1 returned to the ED at 10:07, Pt 1 needed to "re-register as a new patient" to be evaluated by a physician. EDM 1 acknowledged RN 1, triage nurse (nurses who assess how sick a patient is and how quickly needs to be seen by a physician), should have assessed Pt 1 in the waiting room and determined how quickly Pt 1 needed to be evaluated by a physician. EDM 1 stated it was not required that Pt 1 be registered before RN assessed Pt 1. EDM 1 stated, "communication barriers" between the nurses, physicians and other hospital staff regarding Pt 1's care, and Pt 1's inability to voice, identify, or communicate medical needs contributed to Pt 1's outcome. EDM 1 stated, Pt 1 died of a "saddle emboli" (large blood clot in the lungs) and cardiac arrest.

During the interview and reord review on 10/16/2020 at 8:43 a.m. with EDM , a follow-up request for HOSP ED policies and procedures related to ED patient care were requested from EDM1. (HOSP polices had been requested starting 10/14/2020 to 10/16/2020 from EDM 1 and Director of Accreditation & Licensing (DAL)). EDM 1 stated she could not locate hospital polices for the emergency department management of acute behavior and psychiatric patients, substance use disorder, safe discharge of patients with mental health needs, mental health patients and behavior monitoring, MSE stabilization, discharge guidelines, ED readmission minutes after discharge, or ED staff communication for safe patient care. EDM 1 stated if there were no specific ED polices, the ED followed HOSP wide policies and procedures, such as discharge, falls, communication, chain of command, documentation, outpatient emergency procedures, standardized RN outside ED EMTALA (Emergency Medical Treatment and Labor Act) polices. EDM 1 stated per hospital policy, ED RNs can discharge patients, request social workers to complete APS patient evaluations, plan patient discharge, and arrange patient transportation without physician orders; but, "only physicians can complete MSE". EDM 1 stated neither the ED nor hospital set expectation for communication for serious patient conditions.

During an interview and concurrent record review on 10/16/2020 at 3:12 p.m. with MD 1, MD 1, an Emergency Department physician, stated she commonly cared for patients with substance use disorder. MD 1 reviewed and discussed details of medical care and documentation of care on 8/22/2020, 9/2/2020, 9/3/2020 and 9/4/2020 for Pt 1, and stated she provided medical cared to Pt 1 on 9/3/2020. MD 1 stated the Pt 1 arrived via ambulance 24 hours after an ED visit on 9/2/2020 with "similar complaints [of] non-focal confusion and slow to respond" and "whipits" substance abuse (illegal drug use). MD 1 stated, she "reviewed" physician notes for Pt 1's care on 8/22/2020 and 9/2/2020, and "don't have time ...takes too much time"" to read the nurses note and other parts of the chart.

MD 1 acknowledged that she did not accurately document a physical exam or review of systems. MD 1 stated she "didn't chart" many aspects of the history and physical, such as medical history, past surgical history, social history, drug abuse, alcohol use, mental health, adult protective service (APS) investigation, family history, medication use, or a complete review of systems. MD 1 stated she "didn't appreciate" Pt 1's medical issues such as dizziness, fall risk, right foot drop, walker use, right leg brace, covered in feces and urine, pain 8/10, inability to care for self, substance abuse intoxication/withdrawal of meth and/or GBH. MD 1 stated she documented that Pt 1 was mildly diaphoretic (sweaty), flat affect, alert and oriented, and moved all extremities spontaneously. MD 1 stated because Pt 1 was laying down for a long time, she was concerned about muscle and kidney injury, drug overdose, alcohol intoxication, hypoxia (not enough oxygen), stroke, head injury, postictal (symptoms after a seizure). MD 1 stated she ordered IV fluid for possible dehydration (poor water intake) and Vitamin B for possible peripheral neuropathy (injury to the nerves in the legs). She could not recall why Zofran was ordered.

MD 1 stated Pt 1's "altered mental status" resolved when she evaluated Pt 1 at 4:11 p.m., and ordered a "conditional discharge" at 5:55 p.m. MD 1 stated this meant Pt 1 was "medically cleared", "keyed-up" for discharge, and "ready to go", because there were no longer concerns for rhabdomyolysis, renal failure, head trauma, or alcohol intoxication. MD 1 stated Pt 1 "didn't seem to have OD [overdosed on drugs] ... [She] can tell if a patient has taken or used meth [methamphetamine]". MD 1 acknowledged she could not visually determine if Pt 1 had used illegal drugs, such as methamphetamine or GHB, and did not follow-up on the status of the Utox and determine if there were unexpected drugs or toxic level substances that could potentially affect the mental status changes, low oxygen levels and/or heart functioning. MD 1 stated an abnormal CK levels could be from "ACS [acute coronary syndrome, heart attack] or muscle [damage]". MD 1 stated a cardiac evaluation, would include heart and lung exam, ECG (electrocardiogram, a tracing of heart rate, rhythm and possible abnormalities), troponins (lab test for heart muscle injury), and CK. MD 1 did not document consideratio of heart or lung problems. MD 1 did not document a reassessment related to continued mental status changes, harm to self, inability to care for self, continued incontinence, pain, heart and lung function, abnormal vital signs or physical or mental disabilities. MD 1 stated "it was the end of my shift", 10:00 a.m. to 6:00 p.m., and it was "not reasonable ... to stay for the disposition [of Pt 1] and follow-up on the UTox and social worker [APS evaluation]".

Before leaving the ED at 7:30 p.m., MD 1 stated she did not document a hand-off to another physician to assume the medical care and monitoring of Pt 1, because she was the physician "solely" responsible for the continuous care of Pt 1, and the oncoming ED physician taking over her shift "would not do anything or evaluate [Pt 1]". MD 1 stated after leaving the ED, she did not have any communication with the Pt 1, ED RNs, physicians, ED staff or social worker. MD 1 stated she did not document a discharge assessment and ensure Pt 1's MEC was stabilized and Pt 1 was safe to discharge. MD 1 stated "it was not reasonable to stay four hours after my shift" because Pt 1 was "40 years old, able to navigate getting home on [her] own".

MD 1 stated, the next morning on 9/4/2020, that she was notified that Pt 1 died of a cardiac arrest approximately on hour after leaving the ED at 1:35 a.m. MD 1 stated Pt 1's death was a "tragic outcome of addiction". In retrospect, she stated, after Pt 1 collapsed, should "bring him back in [to the ED] for e-evaluation, maybe missed something."

During an interview and concurrent record review on 10/14/2020 at 10:25 a.m. with Emergency Director and physician (EDD), EDD stated Pt 1 should have had a "comprehensive evaluation" on 9/3/2020 by an emergency department (ED) physician and there was a "communication breakdown" with the physicians, Pt 1 and ED staff.

Review of policy and procedure titled, "Policy- Code Blue (Adult and Pediatric)" - policy identification number 6402658, effective date 10/31/2019, next review 10/30/2022, documented for hospital locations, including any medical Center property, "patients who appear to have a deteriorating condition or questionable clinical status activate the Rapid Response Team".

Review of policy and procedure titled, "Policy Medical Emergencies on the [Hospital Names] and in outpatient Clinics and Departments Not Contiguous with the Main Campus (EMTALA)", policy identification number 6273656, effective date 6/20/2019, next review 6/19/2022, documented ....Emergency Services and Care: An appropriate medical screening examination and evaluation within the capability of the facility, by qualified medical personnel to determine if an emergency medical condition exists. The Policy documented an Emergency Medical Condition as an "acute medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in 1. Placing the individual in serious jeopardy, 2. Serious impairment of bodily functions or 3. Serious dysfunction of any bodily organ or part ..." and a Medical Screening Exam (MSE) was required. The policy documented was is a process of Medical evaluation to identify or rule out the existence of an Emergency Medical Condition. The Scope of a medical screening exam must be tailored to the presenting symptoms and the medical history of the patient. The policy further documented patients "Stabilizing Treatment" for "patients with Emergency Medical conditions will receive evaluation and treatment with in the capability of the facility and the available qualified medical personnel necessary to assure within reasonable probability that the Emergency Medical Condition has been relieved and/or no material deterioration to the condition is likely to result from or occur during a transfer, transport or discharge". [Hospital Name] "Obligation [is] to provide both further examination and treatment sufficient to stabilize the patient's Emergency Medical Condition ..." During an interview on 10/16/2020 at 8:43 a.m. with EDM 1, EDM 1 stated the above outpatinet clinic EMTALA policy was the ED EMTALA policy.

Review of HOSP Medical Staff Rules and Regulations, dated 9/18/2019, documented under Article III, Appointment and Reappointment, medical staff "agrees to be bound by the Bylaws and Rules and Regulations as they exist and as they may be modified from time to time and other Hospital policies consistent with these Bylaws ..." 1. Under the section, Emergency Department Care and Emergency Admissions documented that medical Staff (licensed physician) member "shall make arrangements for continuous patient coverage" to a qualified member of the Medical staff who shares the appropriate privileges." The responsibility of care always remains with the physician and "whenever an Attending [physician] transfers such responsibilities to another Medical Staff member, he/she shall enter a note in the medical record transferring responsibility, stating the date and time of transfer." 2. Under the section Emergency Medical Screening Exam (MSE), documented a MSE shall be conducted by an independent licensed practitioner who is a member of the Medical staff of by an Allied Health Practitioner (APH for example, nurse practitioner) and "Upon determination that an emergency medical condition exist, all routinely available diagnostics and medical treatment within the capability of the Hospital will be provided to alleviate the emergency ..."
3. Elements of the Medical Record. The medical record "shall contain sufficient information to identify the patient, to support the diagnosis, to justify the treatment and to accurately document the results of treatment management. History and physical examination (H&P), medical history, medication and allergies, summary of psychosocial and disability needs, relevant physical exam and statement of impression with a plan of treatment, clinical observations through progress notes, reports of procedures and tests, medication reconciliation, results of therapy, discharge summary, discharge instructions.

Under the section Discharge of Patient, documented, "Patients shall be discharged only by the Attending [physician] or his/her designee ....At the time of discharge, the physician discharging the patient must state his/her final diagnosis and complete the Discharge instruction sheet." Elements of the Medical Record. The medical record "shall contain sufficient information to identify the patient, to support the diagnosis, to justify the treatment and to accurately document the results of treatment management. History and physical examination (H&P), medical history, medication and allergies, summary of psychosocial and disability needs, relevant physical exam and statement of impression with a plan of treatment, clinical observations through progress notes, reports of procedures and tests, medication reconciliation, results of therapy, discharge summary, discharge instructions.

Review of policy and procedure titled, "Policy- Discharge Planning", policy identification number 7293161, effective date 8/19/2020, next review 8/19/2023, documented "high risk patients including but not limited to Patients readmitted within 30 days of discharge and psychosocial factors.." documented, the "discharge planner and social Worker is responsible for developing a discharge plan of care through early identification of patient needs and resources, was well as facilitating a coordinated and safe discharge." Discharge planning should incorporate "plan of care goals ...discuss results of the evaluation ...anticipated discharge plan ...discuss mode of transportation with attending physician and arranging safe and necessary transportation upon discharge. " Interview nurse manager applies to ED patients.

Review of policy and procedure titled, "Policy - Falls Prevention/Management- Outpatient/Ancillary Areas", policy identification number 6656001, effective date 10/31/2019, next review 10/30/2022, documented "High Fall Risk-Outpatients" as ones who use of assistive devices (walker, canes)due to injury, ability or functional problems "patients are considered high risk in the following situations: altered sensorium, disoriented, cognitively impaired mental health history, history of incontinence, unsteady gait/balance, dizzy, significant fluid shifts (dehydration, low water intake). The policy also documented to consider that "many patients may use recreational drugs, so attention to both overt and covert Patient behavior should be considered".

Review of policy and procedure titled, "Policy -EP Medical Emergency Protocol for Security Services", policy identification number 6656001, effective date 7/2/2019, next review 7/1/2022, documented "emergency medical condition as "an acute medical condition manifesting itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and/or symptoms of substance abuse), such that the absence of immediate medical attention could reasonably be expected to result in 1. Placing the individual in serious jeopardy, 2. Serious impairment of bodily function, or 3. Serious dysfunction of any bodily organ or part ..."

Review of policy and procedure titled, "Policy - Documentation, Nursing", policy identification number 4091396, effective date 12/15/2017, next review 12/14/2020, documented that patient care "documentation communicates the nursing care provided to the patient. The effectiveness of interventions, and the collection, analysis and synthesis of patient-specific data. Nursing documentation is maintained to meet legal, regulatory, and professional requirements and to ensure safe patient care." Documentation will include, but not limited to, initial assessment, any changes from baseline, observations, interventions, education, collaboration/consultation with the interdisciplinary Team, vital signs (heart rate, blood pressure, breathing, weight, pain level) and response to care and treatment. "At the time of discharge, the nurse writes a brief discharge note describing the patient's condition".

Review of policy and procedure titled, "RN Group Standardized Procedure for Discharge of Outpatients by the Registered Nurse (RN)", policy identification number 7260014, effective date 3/19/2020, next review 3/19/2023, documented circumstances under which RN may discharge an outpatient. The protocol "covers outpatients who have had an invasive procedure, surgery and/or sedation/anesthesia and are discharged home with a physician order, but without a discharge examination by a physician". The nursing assessment "all patients shall be assessed by a qualified RN to determine suitability for discharge. To qualify for RN discharge using approved discharge vital signs 20% of pre-procedure/baseline values, for patient who do not meet outpatient discharge criterion and require consultation with the supervising physician, for example vital with 20% of baseline, without orthostatic changes, do not have a responsible adult to accompany home, do not comprehend their discharge instruction, "Do not discharge the patient; notify the physician in charge for evaluation by the MD".

Review of policy and procedure titled, "Policy - Standardized Procedure Policy Statement- Registered Nurses and Nurse Practitioners", policy identification number 7262516, effective date 3/19/2020, next review 3/19/2023, documented, the "supervising physician (or his/her designee as outlines in the Standardized Procedure) will assess and document competency on the standard form prior to authorizing independent practice by the RN or NP [nurse practitioner]". Physician consultation is to be obtained when "emergent conditions requiring prompt medical intervention after initial stabilizing case has been started".