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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for three of 20 patients, Patients (Pt) 1, 16 and 20, when:

1. Pt 1 was brought to the ED on 3/2/22 by ambulance with chief complaint of suspected drug overdose (an Emergency Medical Condition [EMC]) and Pt 1's signs and symptoms were reversed with Narcan (medicine used to treat suspected drug overdose). No further stabilizing treatment was provided Pt 1 despite the Registered Nurse (RN) 1 assessment for a need to administer an additional dose of Narcan. This resulted in the inappropriate discharge of Pt 1 without stabilizing treatment. Pt 1 was discharged by the assigned ED physician on 3/2/22 at 1:06 p.m. but did not leave the hospital until 7:24 p.m. Pt 1 was found unresponsive in his home on 3/3/22 at 7:00 a.m. and Emergency Services 911 was called. Resuscitative efforts provided by emergency services were unsuccessful and the patient expired less than 13 hours after leaving the hospital. (Refer to A2407)

2. Pt 16 was brought into the ED by family on 10/20/21 with a chief complaint of hand pain and hallucinations. Pt 16 had a history of a brain tumor, surgery, and a stroke less than six months prior to this ED visit. The family was not allowed to accompany Pt 16. The family's concern about Pt 16 having hallucinations was not addressed, no tests were ordered, and Pt 16 was discharged with a prescription for an opiate pain medication and discharge diagnoses of arm and leg pain, and non-compliance. Later that day, Pt 16 had a seizure and was taken to another area hospital (Hospital 2) for care. These failures resulted in an incomplete MSE being performed and a delay in determining whether an EMC was present. (Refer to A2406, Finding 1)

3. Pt 20 came to the ED on 12/12/21 with a chief complaint of severe pain (pain level 10/10) in his chest and abdomen, vomiting, and reported that his Automatic Implantable Cardioverter Defibrillator (AICD) had fired a dozen times that day. Pt 20 was triaged and classified an Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient ' s condition and the resources needed, ESI 1 being the most serious) level of 2. The EKG performed 25 minutes after arrival was "abnormal with atrial fibrillation and nonspecific ST and T wave abnormality ..." Pt 20 was sent to wait in the lobby for the physician, without a nurse assigned, and without a cardiac monitor on. Approximately 2.5 hours later nursing staff were unable to locate Pt 20 in the lobby. These failures resulted in Pt 20 being left unattended and in pain in the lobby while waiting to have a medical screening exam. Pt 20 eventually left the hospital unwitnessed and in an unknown condition. (Refer to A2406, Finding 2)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on observation, interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for two of 20 patients, Patients (Pt) 16, and 20 when:

1. Pt 16 was brought into the ED by family on 10/20/21 with a chief complaint of hand pain and hallucinations. Pt 16 had a history of a brain tumor, surgery, and a stroke less than six months prior to this ED visit. The family was not allowed to accompany Pt 16. The family's concern about Pt 16 having hallucinations was not addressed, no tests were ordered, and Pt 16 was discharged with a prescription for an opiate pain medication and discharge diagnoses of arm and leg pain, and non-compliance. Later that day, Pt 16 had a seizure and was taken to another area hospital (Hospital 2) for care.

These failures resulted in an incomplete MSE being performed and a delay in determining whether an EMC was present.

2. Pt 20 came to the ED on 12/12/21 with a chief complaint of severe pain (pain level 10/10) in his chest and abdomen, vomiting, and reported that his Automatic Implantable Cardioverter Defibrillator (AICD) had fired a dozen times that day. Pt 20 was triaged and classified an Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient ' s condition and the resources needed, ESI 1 being the most serious) level of 2. The EKG performed 25 minutes after arrival was "abnormal with atrial fibrillation and nonspecific ST and T wave abnormality ..." Pt 20 was sent to wait in the lobby for the physician, without a nurse assigned, and without a cardiac monitor on. Approximately 2.5 hours later nursing staff were unable to locate Pt 20 in the lobby.

These failures resulted in Pt 20 being left unattended and in pain in the lobby while waiting to have a medical screening exam. Pt 20 eventually left the hospital unwitnessed and in an unknown condition.

Findings:

1. During a concurrent interview and record review on 4/21/22 at 11 a.m., with the Director of the Emergency Department (DED), the ED Log (the hospital ' s record of every patient who comes to the ED seeking care), dated 10/20/21, was reviewed. The log indicated Patient (Pt) 16 was a 56 year old female who came to the ED on 10/20/21 at 1:48 p.m. with a chief complaint of leg pain-swelling, and left without treatment (LWOT) at 3:58 p.m. The DED stated LWOT refers to when a patient leaves after having been through the triage process but has not been seen or evaluated by a physician yet. The log also indicated Pt 16 came to the ED on 10/20/21 at 4:43 p.m. with a chief complaint of arm pain-swelling and leg pain-swelling and was discharged home at 6:11 p.m.
During a concurrent interview and record review on 4/21/22 at 11:05 a.m., with the DED, the document "ED Triage- Part 1" dated 10/20/21 at 2:04 p.m., indicated Pt 16 presented to the ED with a chief complaint (a statement that describes the symptom, problem, or reason the patient came to the ED, usually in the patient ' s own words) of worsening pain to left side. History of a brain tumor July 2021 with surgery and a stroke which left her with left-sided weakness. Pt 16 indicated she was supposed to see her primary care doctor that day, but the pain was "too bad." The clinical record indicated Pt 16 ' s pain level was a 10 on a scale of 0-10 (10 is most severe). Pt 16 was assessed by the triage nurse and assigned an Emergency Severity Index (ESI) level of 4 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient ' s condition and the resources needed, ESI 1 being the most serious). Vital signs were obtained, and Pt 16 was left in the lobby to wait. There was no further documentation in the record until 3:58 p.m. when a nurse documented Pt 16 left without being treated (LWOT).
During a concurrent interview and record review on 4/21/22 at 11:10 a.m. with the DED, the document "ED Triage- Part 1" dated 10/20/21 at 4:49 p.m., indicated Pt 16 presented to the ED with a chief complaint of "the same thing." The nurse indicated "Pt was recently seen but eloped. Pt had a CVA in July and had residual left sided hemiplegia. Pt is experiencing pain to the left arm and leg." The clinical record indicated the pain level was 5. VS were obtained and were "normal" except for a heart rate of 120 beats per minute. Pt 16 remained in the lobby to wait. Review of the nursing notes dated 10/20/21 at 5: 21 p.m., indicated, "Pt from a board and care CC 'seizure' after having an altercation with a roommate today. Pt reports that her hand was injured during altercation ...Pt reports she fell onto her bed during seizure, denies head trauma ...Pt cannot report what medications she takes but reports she 'takes all of them' ..."
Review of the document "ED Note- Physician," dated 10/20/21 at 5:26 p.m., indicated physician's assistant (PA) 2 assessed Pt 16 and documented that Pt 16 presented to the ED for pain control and had not been following up with her doctor after her stroke. PA 2 indicated, " ...She is concerned for her care-taker being able to get to work on time and is requesting pain control so that she can leave ..." PA 2 indicated Pt 16 was in a wheelchair and had "significant deficits to left upper and lower extremity ... strength is 0/5 ... Refrained from ordering any testing as history and physical exam are consistent with complaint and don't warrant need ...I suspect that the symptoms the patient is experiencing is caused by pain control secondary to nerve pain after CVA ..." There is no indication that PA 2 reviewed the triage RN's note entered at 5:21 p.m. The record indicated Pt 16 was prescribed an opiate pain medication (10 mg hydrocodone/325 acetaminophen), a medication for nausea, and Narcan 2 mg intranasal- two doses in case of overdose. The ED note signed by the PA at 6:09 p.m., indicated Pt 16 was discharged home with instructions and discharge diagnoses of "arm and leg pain; non-compliance." The supervising physician signed the PA's note on 10/22/21 at 2:25 p.m. The ED depart form dated 10/20/21 at 6:11 p.m. was reviewed and indicated, "Discharged by provider. Unseen by this RN."
During an interview with Pt 16's family member (FM 2), on 4/22/22, at 2:43 p.m., FM 2 stated, Pt 16 resided at a board and care home. He and another family member took Pt 16 to her primary care physician on 10/20/21 because she had been having hallucinations (A perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there) and were told to go to the ED. FM 2 stated they were unable to get Pt 16 out of the car due to Pt 16's pain and weakness, so several hospital staff assisted them. FM 2 stated he told the registrar that the patient had hallucinations, body aches, and history of stroke resulting in left sided weakness. FM 2 stated he wanted to stay with Pt 16, but he was not allowed in the ED although he was vaccinated and had his vaccination card. FM 2 stated he was called by Pt 16 to come pick her up and found her outside in a wheelchair. FM 2 took her back inside and asked if he could stay with the patient a second time and was told no because he did not have power of attorney. FM 2 stated he gave the registrar his phone number and gave her a history. FM 2 stated two other family members waited outside for the patient. FM 2 stated after a while someone came out and said the patient would be released. FM 2 stated the PA told him that Pt 16 said the caregiver had to go to work. FM 2 stated he told the PA that what Pt 16 said was not true and that everyone was already off work. FM 2 stated Pt 16 still did not get checked out and was just given an opiate pain medication. FM 2 stated they took Pt 16 home because she was tired and then she had a seizure. They took Pt 16 to Hospital 2 for care.
During a concurrent interview and record review on 4/22/22 at 3 p.m. with the DED and the Director of Patient Access (DPA), the DED stated until a week ago, no visitors were allowed at all in the ED. The DPA stated she was not aware of Pt 16's specific case but stated the registration staff would not be the ones to refuse to let someone in the hospital to be with a patient. The DPA stated when a patient comes in they will ask their name, date of birth and what is the reason for the visit. Review of the face sheet (a document with information including patient's demographic information, insurance information, emergency contacts name and number completed by registration staff) for Pt 16's ED visit on 10/20/21 at 1:28 p.m., indicated a chief complaint of stroke, and had the name and phone number of FM 2. Review of the face sheet for Pt 16's ED visit for 10/20/21 at 4:43 p.m., also had FM 2's contact information, and indicated a chief complaint of "Pain; hallucinations." The DED did not have an explanation as to why the chief complaint of hallucinations as stated by FM 2 and recorded on the face sheet did not get addressed by nursing staff or the PA but stated "a lay person" gave that information not a nurse so that can change.
2. During a concurrent interview and record review on 4/21/22 at 3:45 p.m., with the Director of the Emergency Department (DED), the ED Log (the hospital ' s record of every patient who comes to the ED seeking care), dated 12/12/21, was reviewed. The log indicated Patient (Pt) 20 was a 63 year-old male who came to the ED on 12/12/21 at 1:27 p.m. with a chief complaint of abdominal and chest pain and left without treatment (LWOT) at 4:11 p.m. The DED stated LWOT refers to when a patient leaves after having been through the triage process but has not been seen or evaluated by a physician yet.
During a concurrent interview and record review on 4/21/22 at 3:50 p.m., with the DED, the document "ED Triage- Part 1" dated 12/12/21 at 1:32 p.m., indicated Pt 20 presented to the ED with a chief complaint (a statement that describes the symptom, problem, or reason the patient came to the ED, usually in the patient ' s own words) of "abdominal pain, chest pain, after vomiting. Also states AICD has fired a dozen times." (AICD [Automatic Implantable Cardioverter Defibrillator]- a device implanted under the skin in the upper chest designed to monitor the heartbeat and deliver an electrical impulse or shock to the heart when it senses a life-threatening change in the heart ' s rhythm). Pt 20 indicated his pain level was a 10 on a scale of 0-10 (10 is most severe). Pt 20 was assessed by the triage nurse and assigned an Emergency Severity Index (ESI) level of 2 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient ' s condition and the resources needed, ESI 1 being the most serious). The Triage problem list indicated Pt 20 ' s history included coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, cirrhosis and hypertension. The problem list also indicated Pt 20 had previously undergone an ablation for atrial flutter. Vitals signs obtained at 1:33 p.m. were within normal limits. An EKG was completed at 1:53 p.m. Review of the unconfirmed EKG report indicated, " ...Abnormal EKG ...Atrial Fibrillation ... Nonspecific ST and T wave abnormality ..." After the EKG was done at 1:53 p.m., there was no documentation in the medical record of any other vital signs, pain assessment, orders, or further contact with Pt 20. The DED stated Pt 20 was sent to wait in the lobby after having the EKG. The DED stated they do not know exactly when Pt 20 left the hospital because patients waiting in the lobby "do not have a nurse assigned to them." The DED stated the time of 4:11 p.m. was the time when staff had attempted to locate Pt 20 but were not successful. The DED was asked about the decision to place Pt 20, who was triaged as ESI level 2, in the lobby to wait without being on a cardiac monitor and without being observed given that his chief complaint included severe pain and multiple instances of his AICD firing (shocking). The DED stated patients with an ESI of 2 can wait in the lobby.
Review of the ED physician ' s (MD 5) note, dated 12/12/21 at 6:33 p.m., indicated, "Patient probably has eloped. I never had a chance to see the patient in person. I checked vital signs and brief history by triage [nurse], according to record, patient was not responding to multiple overhead calls." The DED was unable to find documentation in the medical record of the attempts by staff to contact the patient overhead or by phone call.
Review of the hospital's policy and procedure (P&P), "Standard of Care Policy" dated 1/23/19, indicated, " ...These are the fundamental components of care that are to be applied to any patient presenting for treatment to the Emergency Department (ED) ...nursing may implement the ED Chief Complaint Protocol on patients prior to the initial medical screening exam (MSE) by the provider ...the patient's nurse is responsible for continually assessing the patient's condition and obtaining vital signs as the situation warrants ...repeat vital signs to be measured and documented as follows ...for ESI Level 2: Upon arrival to the ED, then as situation warrants, but no less than every 2 hours ..."
Review of the hospital ' s P&P, "Triage Nurse Policy" dated 1/23/19, indicated, " ...All patients will be classified and prioritized as follows ... ESI Level 1: the patient requires immediate medical care. The presenting problem is a threat to life, limb, or organ function ...ESI Level 2: the patient is assessed as high-risk. The patient presents with a condition that has the potential for major life and organ threat. The patient ' s condition may deteriorate if left unattended and therefore should not wait. Upon the determination of an ESI Level 2 condition, the triage nurse will expedite placement of the patient in a treatment area, securing additional resources as necessary ...All patients are monitored, reassessed, and have repeat of vital signs based on their acuity ...documentation of triage classification, assessment, and all interventions performed are entered into the Emergency Department electronic documentation system ..."
Review of the P&P "Chief Complaint-Emergency Adult" dated 5/27/20, indicated, " ...The protocol is to be utilized for patients that have nor received a Medical Screening exam ...Registered Nurses [RNs] are authorized to implement the Emergency Department Adult Patient Chief Complaint Protocol ...Purpose: to expedite the assessment, treatment, and care of patients in the Emergency Department that have not yet received a medical screening exam ...After assessing the patient's chief complaint the RN will utilize the appropriate protocol. After selecting the appropriate protocol, the RN will order the appropriate tests ...all nursing interventions (i.e., IV starts, blood draws) will be documented on electronic medical record. The following chief complaint protocols may be utilized: ...Chest Pain-Suspected Cardiac in Nature ...EKG within 5 minutes and show to ED MD; O2 @ 2L via N/C, cardiac monitor, pulse oximeter, BP monitor; Troponin I, CMP, CBC; IV Saline Lock, Chest x-ray; Nitroglycerin 5 mg sublingual, Aspirin ... For Abdominal Pain ...EKG for age greater than 35 within 5 minutes and show to ED MD, CBC, CMP, lipase, UA, IV saline lock, Zofran 4 mg IV ..."
Review of the professional reference, Cardiology Advisor-ICD Shocks: Evaluation and Management, dated 2017, indicated, " ...Shocks, although lifesaving, are painful, often poorly tolerated, and not without at least transient detrimental effect to the heart in terms of myocardial dysfunction ...In general, there are four reasons for a patient to receive an AICD shock: Device malfunction, electromagnetic interference, supraventricular arrhythmias, and ventricular arrhythmias. The first three are considered as "inappropriate" in that device therapy was delivered for a non-life-saving reason ...Whether appropriate or not, repetitive shocks are a medical emergency... Repetitive shocks are associated with recurrent hospitalizations, anxiety, depression, and even posttraumatic stress disorder ...Timely interrogation of the device is usually the quickest and most effective way to determine the cause upon presentation ... A patient who receives multiple shocks is not difficult to identify. They will present to an emergency department with the specific complaint that their defibrillator has fired several times. At that point in time, it is critical to define the etiology of the shocks (i.e., what is the ICD "seeing" that is triggering therapy). The device needs to be fully interrogated, with careful analysis of all of the stored EGMs [intracardiac electrograms] recorded from the recent therapies ..."
Review of the hospital's Physician Assistant Protocols for Emergency Medicine dated 3/1/17, indicated, " ...Whenever a physician is consulted, a notation to that effect, including the physician's name, must be made in the medical record. Communication with a physician will be sought for each of the following situations:... prior to furnishing any Schedule II controlled substance for a particular patient ...The supervising physician shall review, countersign, and date the medical record of any patient cared for by any PA who has issued a Schedule II drug order ..."

Based on interview and record review, the facility failed to stabilize the Emergency Medical Condition (EMC) for one of twenty patients (Patient [Pt] 1) when Pt 1 was brought to the ED on 3/2/22 by ambulance with chief complaint of suspected drug overdose and Pt 1's signs and symptoms were reversed with Narcan (medicine used to treat suspected drug overdose). No further stabilizing treatment was provided Pt 1 despite the Registered Nurse (RN) 1 assessment for a need to administer an additional dose of Narcan.

This failure resulted in the inappropriate discharge of Pt 1 without stabilizing treatment. Pt 1 was discharged by the assigned ED physician on 3/2/22 at 1:06 p.m. but did not leave the hospital until 7:24 p.m. Pt 1 was found unresponsive in his home on 3/3/22 at 7:00 a.m. and Emergency Services 911 was called. Resuscitative efforts provided by emergency services were unsuccessful and the patient expired less than 13 hours after leaving the hospital.

Findings:

During review of Pt 1's clinical record, dated 3/2/22 from 11:10 a.m. to 3/2/22 7:23 p.m. Pt 1's electronic health record (EHR) indicated the following timeline beginning on 3/2/22:

10:31 a.m. Pt 1 was found unresponsive and hypoxic (having too little oxygen) on the bathroom floor of his home and EMS was called and vital signs (v/s) obtained by first responders were blood pressure (BP) 137/72 millimeters of mercury (mmHg), heart rate (HR) 140 beats per minute (bpm), respirations 4 per minute (rpm), shallow and ineffective. Emergency personnel provided ventilation (artificial respiration) with a bag valve mask (BVM- hand-held device used to provide ventilation to patients who are not breathing or not breathing adequately) and oxygen. Pt 1's primary symptom was altered mental status with a Glasgow Coma Scale (GCS- used to describe the extent of impaired consciousness in all types of acute medical and trauma patients) score of 3 (severe impairment). The primary impression was suspected drug overdose. Naloxone (Narcan) 4 milligrams (mg) (medicine used to treat suspected drug overdose) was administered intranasal (IN- in the nose) in two, 2 mg doses. Pt 1's medical history of psychiatric illness, substance abuse, and current medication list were obtained by EMS personnel.
10:45 a.m. Pt 1 ' s symptoms improved. Vital signs were BP 98/68, HR 88, rpm 12, oxygen saturation (spO2) 97% on room air. GCS score of 13 (moderate impairment).

10:52 a.m. Pt 1 transported to hospital via ambulance. Vital signs were BP 115/81, HR 85, rpm 12, spO2 99% on room air. Pt 1 remained sleepy during the transport.
10:53 a.m. Regional Base Hospital (RBH) Report" (a form used by the ED RN to document communication from EMS about a patient being transported from somewhere outside the hospital by ambulance to the ED), indicated Pt 1 was transported to the ED from an assisted living facility due to opiate overdose. Narcan was administered nasally (through the nose) and Pt 1's GCS improved to a level of 13 (moderate mental impairment) prior to ED arrival. Vital signs were BP 115/81, HR 83, SpO2 (oxygen saturation in the blood) 99% on room air.

11:00 a.m. Pt 1 ' s spO2 dropped to 75%.

11:07 a.m. Pt 1 arrived at the hospital ' s emergency department (ED) door and roomed in A11.

During a review of the electronic health record (EHR) for Pt 1's ED visit on 3/2/22, the ED Triage Form indicated the following:

11:25 a.m. Pt 1 triaged. VS: BP 118/62, HR 81, rpm 18, temperature 98.6°F (degrees Fahrenheit), and spO2 98% on room air. Registered Nurse (RN) 1 evaluated Pt 1 and assigned an Emergency Severity Index (ESI - scale used to determine level of acuity or seriousness for the chief complaint with the scale ranging from 1-5, 1 representing the most serious) score of 3 (stable, will require two or more resources to reach disposition from the ED). Pt 1 ' s documented chief complaint was, " Pt presents with accidental Opiate [drug that affects mood or behavior and causes drowsiness, daze, numbness, or unconsciousness] OD [overdose]. Pt was under the impression he had meth [methamphetamine- highly addictive stimulant]. " RN 1 did not complete the medical history, medication list, lung/respiratory assessment, neurological assessment, or GCS sections of the patient assessment.

11:47 a.m. The Emergency Department Physician (EDP) 1 initiated the Medical Screening Exam (MSE - the examination conducted by a Qualified Medical Professional [QMP] for the purpose of determining if an emergency medical condition exists). The ED Physician Note dated 3/2/22 at 12:02 p.m., indicated, Pt 1, a 60 yr. old male, was brought in by ambulance with a report of accidental overdose with Fentanyl (powerful opioid used for severe pain) and given Narcan (given by first responders) with some improvement of mental status. A physical exam was performed and EDP 1 indicated, Pt 1 " awakens to verbal stimuli but falls asleep quickly through exam taking. incoherent speech, moves all four extremities equally. " EDP 1 documented Impression/Plan: " Narcan administered, patient watched for 1 hr after Narcan administration without return of symptoms. " It is unclear from the record what time this occurred.

1:06 p.m. The EDP 1 entered a discharge order for Pt 1.

1:07 p.m. " Pt awake and alert. Ready to go home. Provided with Narcan and opiate overdose kit."

2 p.m. VS: HR 111, rpm 20, and spO2 92 %. RN 1 provided oxygen to Pt 1 via high flow nasal cannula at 3L/min.

5:58 p.m. Review of the medication record from the automated medication dispensing system, indicated, RN 1 removed Naloxone (Narcan) 2 mg/ 2 ml syringe for Pt 1. RN 1 did not document the administration of Narcan.

6:04 p.m. RN 1 entered a verbal order from EDP 1 to give Pt 1 Narcan 2 mg IV push stat. The EDP 1 validated the verbal order seven days later on 3/9/22 at 7 p.m.

7:23 p.m. RN 2 documented the disposition of Pt 1 as discharged home in stable condition. RN 2 indicated Pt 1 was discharged by RN 1 and that Pt 1 was not in the ED room when RN 2 started her shift.

During a concurrent interview and record review on 3/23/22, at 10:35 a.m., with RN 1 and the Director of the Emergency Department (DED) RN 1 stated he was assigned to Pt 1 on 3/2/22. RN 1 stated Pt 1 presented to the ED on 3/2/22 at 11:10 a.m. with a chief complaint of opiate overdose. RN 1 stated when he triaged Pt 1 on 3/2/22 at 11:29 a.m., Pt 1 was alert and oriented, his vital signs were stable, and Pt 1 did not voice any complaints. RN 1 stated he did not attempt to collect Pt 1's medical or medication history during his initial screening. RN 1 stated he was not aware of Pt 1's psychiatric illness and the information provided by the board and care facility was not passed on to him. RN 1 referred to the " RBH " report as the basis for his screening assessment.

RN 1 stated around one hour later the physician wrote a discharge order. RN 1 stated he entered Pt 1's room with the discharge instructions in hand and noticed Pt 1's oxygen level "dropped" to 92%. RN 1 stated he notified the physician and Narcan (Naloxone) 4 mg (dosage) IV was ordered, which he administered to Pt 1 intramuscularly (IM- in a muscle). RN 1 stated he left Pt 1 in the room "hooked up to monitors" (5- lead Electrocardiogram- ECG [machine that monitors the heart], BP and SpO2) which were remotely monitored at the nurse's station. RN 1 stated he noticed "sometime after" that Pt 1 was not registering on the monitors. RN 1 stated he went to Pt 1's room and discovered Pt 1 was gone. RN 1 stated he assumed Pt 1 left the building for "a smoke as patients often do." RN 1 stated he expected Pt 1 to return to the ED, but Pt 1 did not. RN 1 stated he did not attempt to locate Pt 1, nor did he alert security or the charge nurse. RN 1 stated he completed his shift and left the ED without documenting Pt 1 leaving the hospital. RN 1 reviewed his documentation and stated, "My charting is very poor in this chart." RN 1 acknowledged he did not perform assessments and did not document vital signs, medication administration, and Pt 1's response to interventions. The DED stated "many" patients leave the ED before being seen by a practitioner or before discharge, especially those who presented with accidental overdose. The DED stated she expected nurses to document in the medical record when patients unexpectedly leave the hospital. The DED also stated she expected nurses to conduct a focused assessment (assessment based on a patient's chief complaint) upon arrival to the ED, and to document all nursing care provided. The DED acknowledged RN 1 did not follow hospital policy and nursing standards of practice. The DED stated the ED did not have protocols in place for patients who arrive in the ED with opiate overdose.

Review of the hospital ' s policy and procedure (P&P) "Chief Complaint-Emergency Adult" dated 5/27/20, indicated, " ...The protocol is to be utilized for patients that have not yet received a Medical Screening exam ...Registered Nurses [RNs] are authorized to implement the Emergency Department Adult Patient Chief Complaint Protocol ... to expedite the assessment, treatment, and care of patients in the Emergency Department ...After assessing the patient's chief complaint the RN will utilize the appropriate protocol. After selecting the appropriate protocol, the RN will order the appropriate tests ...all nursing interventions (i.e., IV starts, blood draws) will be documented on electronic medical record. The following chief complaint protocols may be utilized: ... Suspected overdose ... O2 as appropriate, Cardiac monitor, BP monitor & continuous pulse oximetry; FSBS; IV saline lock; CBC w/ diff; CMP; Draw if appropriate Acetaminophen level, Salicylate level, ETOH levels; EKG within 5 minutes ... urine dip ... "

During concurrent interviews on 3/25/22 at 9:45 a.m., with RN 1 and the DED, RN 1 was asked what the route of administration was for the Narcan given to Pt 1 on 3/2/22. RN 1 responded that he gave two doses. The first dose was IN and the second dose was IM. RN 1 could not remember the time of the two doses and Narcan. RN 1 stated the Narcan was ordered to be given IV but Pt 1 did not have an IV and he gave it IM. The DED stated RN 1 gave Narcan without a physician ' s order and for the first dose. RN 1 did not have an order to give not IM for the second dose.

During an interview on 4/19/22, at 1:50 p.m., with the ED Nurse Educator (EDNE), the EDNE stated she expected nurses to complete and document a focused assessment and patient medical history. She also stated she would expect laboratory studies to be done for patients with altered mental status who overdosed when the drug type and duration of the drug use was unknown. The EDNE stated patients with chronic (long-term) drug use were susceptible to electrolyte imbalances and may develop rhabdomyolysis (a serious medical condition that can result in death).During an interview on 4/19/22, at 2:30 p.m., with RN Charge Nurse (RNCN) 2, RNCN 2 stated there was no basic standard for assessing and monitoring patients who presented to the ED with a drug overdose, however it was critical for nurses to assess and monitor their mentation (reasoning and thinking) and breathing. RNCN 2 stated at a focused assessment related to the patient ' s chief complaint should be done every shift and vital signs monitored every four hours at minimum to help determine if the patient was stable for discharge. RNCN 2 stated if the patient eloped or left without completing treatment, the nurse was expected to take reasonable efforts to contact or find the patient. In some instances, they would be expected to call local law enforcement if the nurse was unable to contact the patient or their responsible person.

During an interview on 4/19/22, at 3:20 p.m., with the Emergency Department Medical Director (EDMD), the EDMD stated he was not the ED physician who treated Pt 1, however he was " vaguely aware " of Pt 1 ' s case and reviewed Pt 1 ' s chart. The EDMD stated he had " seen many patients like this before " , with altered mental status and given Narcan in the field with improved symptoms. The EDMD stated the reversal agent [Narcan] worked and this was evidence enough that it was an opiate overdose, no further toxicology tests or other diagnostics were needed. He stated there was no set protocol for working up ED patients who were suspected of having overdosed on opiates. The EDMD stated it was safe to assume Pt 1 overdosed on Fentanyl since methamphetamines (meth) laced with Fentanyl was prevalent to the area. He stated Fentanyl metabolized quickly. " He stated he expected the nurse assigned to Pt 1 to document the patient ' s response to the treatment.

During a telephone interview on 4/20/22 at 10:15 a.m., with Pt 1's Responsible Person (RP 1), RP 1 stated Pt 1 resided at her (level 1) board and care facility (residential home that provides 24-hour staffing assistance and limited care and supervision for persons with self-care skills and no behavior problems). RP 1 stated, on 3/2/22, Pt 1 was transported to the ED by ambulance after being found unresponsive. RP 1 stated Pt 1's medical history, medication list, and board and care contact information were provided to the EMT prior to Pt 1 being transported to the ED. RP 1 stated Pt 1 returned to the board and care by bus on 3/2/22 at 8:20 p.m. RP 1 stated Pt 1 was very "sleepy" and refused to eat and went straight to bed. RP 1 stated on 3/3/22 at 7 a.m., Pt 1 was found unresponsive in his room and paramedics were called. RP 1 stated Pt 1 was pronounced dead on 3/3/22 around 8 a.m., by emergency personnel.

During an interview on 4/20/22, at 1:45 p.m., with EDP 1, EDP 1 stated she was the physician that evaluated Pt 1 in the ED on 3/2/22. She stated she recalled Pt 1 being brought to the ED by ambulance with a suspected accidental drug overdose. She obtained information about the patient from EMS staff when Pt 1 arrived. EDP 1 stated EMS reported Pt 1 had smoked meth. EDP 1 stated Pt 1 was groggy but had normal vital signs. She stated Pt 1 was placed on a monitor and Narcan was ordered. She reassessed Pt 1 one hour after the Narcan was administered by the RN. She stated, " I ' ve seen hundreds of opiate overdoses and it is extremely common. When asked why she didn ' t order a drug screen, she responded, " Just because labs are available doesn ' t mean we must order them. " EDP 1 stated Pt 1 was observed for " 2 half-lives of Narcan " which was more than enough time to monitor Pt 1 ' s response then, discharge. EDP 1 stated she gave the one- time verbal order for Narcan right after Pt 1 arrived at the ED and was not aware other doses of Narcan was administered to Pt 1 by the RN. EDP 1 stated she would not reorder Narcan without first evaluating the patient. She stated if she had been told that Pt 1 needed oxygen, she would have reevaluated the patient. She stated she did not order additional doses of Narcan, and she did not order oxygen. EDP 1 stated Pt 1 was stable for discharge when she last evaluated the patient at 1:07 p.m., and was uncertain when Pt 1 left the ED.

During an interview on 4/21/22, at 8:20 a.m., with RN 2, RN 2 stated RN 1 reported Pt 2 "was gone" during the shift change report. RN 2 stated she made rounds and noticed Pt 1's room was empty. RN 2 stated she discharged Pt 1 from the computer system to enable other patients to be assigned to the room. RN 2 stated she did not see Pt 1 and assumed Pt 1 was discharged home in stable condition.

During an interview on 4/21/22, at 10:30 a.m., with the DED, the DED stated nurses cannot change the time the medication orders were entered in the computer system but can and should enter the exact time when medications were administered. The DED stated RN 1 did not enter the time he administered either of the Narcan doses. The DED stated based on the documentation Narcan was administered to Pt 1 at 5:58 p.m. on 3/2/22 just before Pt 1 left the ED.

During a telephone interview on 4/21/22, at 1:00 p.m., with RP 1, RP 1 stated she found the " Narcan kit " given to the patient at discharge. RP 1 stated the kit was already opened and one dose was missing.

During an interview on 4/21/22, at 2:20 p.m., with EDP 1, EDP 1 stated she gave a verbal order for Narcan when Pt 1 arrived at the ED because he appeared sleepy. She stated when she authenticated the order on 3/9/22, she did not realize the verbal order was entered to be given at 6:04 p.m.

During a professional reference review of an article in the National Library of Medicine (PubMed) National Center for Biotechnology Information (NCBI) titled, " Naloxone Interventions in Opioid Overdoses: A Systematic Review Protocol " , dated 6/11/19, the article indicated, " ... Opioids are a powerful class of drugs that inhibit the transmission of pain signals to the brain and spinal cord ... Fentanyl and other ultra-potent opioids have been found in a substantial of recent opioid overdoses and are thought to be the driver of the current epidemic of overdose deaths. They are between 50 and 10,000 times more potent than heroin ... [people] commonly experience rapid respiratory and central nervous system depression and may die or survive with anoxic brain damage ... Naloxone [Narcan] can reverse opioid toxicity ... However, if administered too high of a dose, or repeat doses are administered too rapidly, naloxone may precipitate acute opioid withdrawal syndrome consisting of vomiting, tachycardia, shivering, sweating, and tremor. Additional serious adverse effects include pulmonary edema hypertensive emergencies, ventricular dysrhythmias, delirium seizures, and death."

During a review of the hospital's policy and procedure "Standard of Care Policy", dated 1/23/19, the policy and procedure indicated, " These are fundamental components of care that are to be applied to any patient presenting for treatment to the Emergency Department (ED). This standard of care must be used in conjunction with more specific protocols that are relevant to the patient ' s chief complaint ... The patient ' s nurse is responsible for continually assessing the patient ' s condition and obtaining vital signs as warrants ... Repeat vital signs to be measured and documented ... ESI level 3 ... Upon arrival to the ED, then as the situation warrants, but no less than every four ... Documentation of any changes in patient status and physician notification when significant changes occur. Documentation of treatments, patient tolerance to treatment, and outcomes defines by the protocols specific to the patient ' s chief complaint ... the disposition of the patient will be documented, including time of departure, method of transport ... Elopement- is defined as patient comes to the ED, triaged, registered, and medical screening exam (MSE)[initial exam performed when a patient presents to a dedicated emergency department and requests care] has been done but leaves unnoticed or without informing staff. Attempt to locate patient, document attempt ... "

During a review of the hospital ' s policy and procedure " Triage Nurse Policy " , dated 1/23/19, the policy and procedure indicated, " To outline the responsibilities and function of the Triage Nurse in the Emergency Department ... All patients are monitored, reassessed, and have repeat of vital signs based on their acuity. The patient ' s triage category may be upgraded based on this reassessment ... Documentation of the triage classification, assessment, and all interventions performed are entered into the Emergency Department electronic documentation system ... "