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Based on interview, record review, policy review, and video review the hospital failed to provide, within its capability and capacity, an appropriate and complete medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #10) out of 20 Emergency Department (ED) records reviewed from 11/01/22 through 08/16/23. This failed practice had the potential to cause harm to all patients who presented to Phelps Health ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 2,572.

Findings included:

Review of hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 03/2023, showed the following:
- Hospital personnel will respond when an individual comes to the Hospital's Emergency Department and a request is made for emergency care, or if a reasonable person would believe that the individual needs emergency care, the Hospital will provide a MSE in the Emergency Department.
-The MSE should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms to determine whether an EMC exists.
- The MSE is an ongoing process and the medical records should document continued monitoring based on the patient's needs until the patient is stabilized or appropriately transferred.
- The ED attending physician will supervise and assume responsibility of the evaluation, stabilization and treatment of all patients who come to the ED.
-When a physician or qualified medical person (QMP) determines that an individual has an EMC, the hospital will within the capability of the staff and facilities available at the hospital, provide further medical examination and treatment as necessary to stabilize the EMC until discharge, the individual was admitted or, if necessary, arrange for an appropriate transfer to another medical facility

Review of the hospital's policy titled, "Assessment and Reassessment of Patient(s)," reviewed 12/21/22, showed the following:
- A primary assessment is completed upon a patient's presentation to the ED to identify actual or potential, life threatening illness or injury.
- A secondary assessment is completed when the patient's presenting problem warrants a more thorough evaluation to identify other non-life threatening illness or injury.
- Reassessments included the patient's overall condition as well as vital sign (body temperature, blood pressure, heart rate, and breathing rate) monitoring and the frequency of reassessment was based on the patient's acuity, condition, or as indicated by the ED physician.
- A patient with an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) acuity of three was assessed at a minimum every 30-60 minutes for the first four hours and then at least every four hours if stable.
- A complete set of vital signs should be obtained within five minutes of a patient's discharge.

Review of the hospital's policy titled, "Post Use of Force," dated 05/2023, showed the following:
- Following any use of force beyond de-escalation (reduction of the intensity of a conflict or potentially violent situation), patients should be assessed for injuries and there will be documentation of stabilization. Medical care will be offered for any physical injuries.
- Use of force is physical force necessary to prevent harm from occurring or to control a violent individual who is a threat to themselves or to others.
- After use of force, the patient will receive an assessment by a nurse for stability and injury. When safety permitted, the assessment should include vital signs. All findings were documented in the medical record.
- Medical care will be provided as needed.
- Individuals that will be taken into custody by law enforcement (LE) will be assessed and a fit for confinement (patient is medically and psychiatrically [relating to mental illness] stable to go to jail) exam will be completed and documented prior to release.

Review of the undated document titled, "Fit for Confinement," showed the following:
- Fit for Confinement includes a complete MSE.
- If a patient had injuries (especially post use of force) or is seriously impaired by alcohol or other controlled substances, further assessment may be needed.
- A complete set of vital signs should be assessed prior to discharge, if it is safe to do so.
- The provider documents all elements of the screening examination and the Fit for Confinement form in the patient's medical record.
- The nurse documents all required documentation, including discharge vital signs.

Review of Patient #10's medical record showed the following:
- On 01/24/23 at 6:42 PM, he presented to the ED by ambulance for a well-being check related to alcohol intoxication (to be affected by alcohol or drugs where physical and mental control is markedly diminished).
- Physician notes on 01/25/23 at 2:21 AM and 2:22 AM acknowledged a critical high elevated blood alcohol (amount of alcohol in the blood) result from 01/24/23 at 9:41 PM and the patient was feeling better, his condition was improved and he was stable for discharge. The patient verbalized that he understood discharge instructions and agreed to discharge from the ED.
- Nursing documentation on 01/25/23 at 2:30 AM showed Patient #10 began to curse and threaten a Public Safety Officer (PSO). The patient stood and walked toward the PSO in an aggressive (behavior that is intended to harm another individual) manner and was tased (deployed conducted energy device used to incapacitate people). The patient fell to the ground and was placed in handcuffs.
- A Fitness for Confinement form was signed and dated by the physician on 01/25/23 at 2:34 AM (after the patient had been tased and handcuffed by PSOs). The form showed the patient was not suicidal (thoughts of causing one's own death), homicidal (thoughts or attempts to cause another's death) and without risk for self-harm. The form contained no additional documentation regarding the patient's medical status.
- Nursing documentation on 01/25/23 at 2:41AM showed the patient was discharged and removed from the ED by LE.
- There was no documentation in the medical record that the patient was assessed for injuries after the PSO deployed the taser and no documentation of assessment of vital signs after 01/24/23 at 9:29 PM.

Review of the hospital's video recording showed the following:
- Patient #10 was tased outside of ED Room Five on 01/25/23 at approximately 2:29 AM.
- He fell to the ground and was lying on his right side. He rolled to his stomach and was handcuffed by a PSO.
- After the patient was tased, the patient was not touched by any medical or nursing staff. A staff member (presumably Staff U) bent over the patient, but did not touch the patient. The patient's vital signs were not assessed.
- LE arrived at 2:33 AM and the patient was pushed out of view by LE in a wheelchair at 2:39 AM.

Review of the document titled, "Department of Public Safety Incident Report," showed Staff V, PSO, was the investigating officer. The narrative of the report showed PSOs responded to a request for assistance in the ED with an uncooperative patient who had been discharged. The patient had requested to leave Against Medical Advice (AMA) and was encouraged to dress and leave the ED. The patient verbalized threats of harm toward Staff V and approached him in what was perceived as an aggressive manner. Staff V deployed his taser for five seconds. Patient #10 fell onto the ground with his arms under his body. Staff V directed Patient #10 to put his arms behind his back and when he did not comply, Staff V tased the patient again for two additional seconds. The patient was placed in handcuffs until LE arrived. LE arrived, took control of Patient #10 and the LE officer removed the taser barbs from Patient #10. Staff U, ED Physician, provided a "Fit for Confinement" and Patient #10 left in a wheelchair in the custody of LE. The incident report included a witness statement hand-written by Staff P, Registered Nurse (RN).

Review of the LE report titled, "Case RPD202300235," showed Staff V, PSO, reported to LE that Patient #10 had signed out AMA and was told to gather his belongings and leave the ED. Verbal exchanges occurred between the PSO and the patient. The patient kicked off his shoe, threatened to harm the PSO and walked toward him in an aggressive manner. The patient was tased and put in handcuffs by the hospital PSOs. When LE arrived, the LE officers checked the handcuffs for proper fit, arrested the patient and put him in the patrol car for transport to the jail. The date and time of arrest was documented as 01/25/23 at 2:40 AM.

During a telephone interview on 08/20/23 at 4:30 PM, Staff U, ED Physician, stated a physical assessment could be completed without actually laying hands on a patient. He did not witness the taser incident, did not recall if the patient was assessed or if he removed the taser barbs from the patient. A patient only needed reassessment after an incident (such as being tased) if they were injured or if the LE officer requested it. He expected that vital signs were assessed regularly on every patient in the ED and he was not aware that Patient #10 had not had vital signs assessed before his discharge.

During an interview on 08/17/23 at 10:45 AM, Staff G, Physician, Medical Director of the ED, stated that if a physical altercation occurred with a patient who had already received their MSE in the ED, a reassessment would be appropriate unless the patient refused. Staff G reviewed Patient #10's medical record and confirmed that there was no documentation of reassessment after the tasing incident and there was no documentation of vital signs on the patient after 01/24/23 at 9:29 PM, including within five minutes prior to discharge.

During an interview on 08/17/23 at 1:05 PM, Staff P, RN, stated that Patient #10 was intoxicated and used verbally abusive and foul language toward ED staff. The patient allowed her to give him an injection of medications, to draw blood for lab tests and then "basically slept it off" until the physician talked to him about being discharged. The patient did not want to leave. PSOs presence seemed to agitate the patient even more. The patient threw one of his shoes, stood up, approached the PSO and was tased. LE had already been called and arrived quickly after the incident. The provider came to the scene, removed the taser probes from the patient and assessed him immediately after. She did not recall that the patient was preparing to leave AMA. If a patient reported they were leaving AMA, the nurse and/or provider reviewed and documented the risks and benefits of leaving before treatment was complete, an AMA form printed, and the patient was asked to sign it. She did not know what documentation was required if the patient refused to sign the AMA form.

During a telephone interview on 08/17/23 at 2:25 PM, Staff Q, RN, stated that she was the charge nurse in the ED on 01/24/23. She became involved when Patient #10 was verbally aggressive and postured for physical aggression toward staff. The patient was warned that the PSO would use a taser if he continued to threaten physical harm. He stood up and walked toward the PSO, was warned again and was tased when he continued to approach. The patient fell to the ground and told to put his hands behind his back. He did not comply and was tased again. The provider was informed that Patient #10 was tased, but she was not sure if the patient received an assessment or vital signs after the incident.

During a telephone interview on 08/21/23 at 11:47 AM, Staff V, PSO, stated when the PSOs were summoned to the ED on 01/25/23, they were told that Patient #10 had signed AMA and was no longer a patient. Their assistance was requested in escorting the patient off of hospital property. He did not recall who removed the barbs from Patient #10 or if the physician saw the patient after he was tased. He stayed with the patient after he was tased until he was taken off the property by LE.

During a telephone interview on 08/21/23 at 10:00 AM, Staff W, ED Patient Care Technician, stated she came onto shift at midnight on 01/25/23 and was assigned as the patient safety sitter for Patient #10 and two other ED patients. A patient in Room Five would usually be on a continuous vital signs monitor assessed every 30 minutes if they were not suicidal or homicidal. Patient #10 slept almost the entire time of her shift until he was getting dressed for discharge. She did not witness the incident with the PSO or the patient being tased. She could hear yelling and lots of noise, but she could not change her location as she was assigned line of sight (LOS, continuous visual contact with the patient) observation for two other ED patients at the same time. The physician walked to the hallway after the patient was tased.

During an interview on 08/17/23 at 12:05 PM, Staff D, RN, Director of ED, stated vital signs on ED patients were assessed at least every four hours unless behavioral issues were documented that prevented those assessments. Nursing staff received education that vital signs must be assessed even when a patient was sleeping or document why they were not obtained. If a patient indicated a desire to leave AMA, nursing or the physician reviewed the risks and benefits of continuing assessment and treatment and the patient was asked to sign an AMA form. If the patient refused to sign the AMA form, "Patient Refused to Sign" was documented within the medical record.

Review of hospital's policy titled, "Pain Management," current version 02/2023, showed the following:
-Screening for pain will be completed by the nurse during emergency department (ED) visits that should include the type of current pain-chronic or acute, the severity of the pain, and influencing factors such as patient's age, current medical conditions, and past medical history.
-A positive pain screening will result in the completion of a pain assessment.
-Pain assessment was to include the site, onset, character, radiation associated factors, time course, exacerbating and relieving factors, and severity.
-Pain management involves multiple members such as providers, nurses, and other health care professionals providing direct care to the patient.
-Pain reassessment should be done after each pain management intervention including both pharmacological and non-pharmacological and to be completed within 90 minutes of intervention.
-Patient's right to effective pain management was to include provider's orders for pharmacological and non-pharmacological interventions.

Review of Patient #2's medical record showed that she was a 65 year old who presented to the ED on 11/07/22, 11/09/22, and 11/12/22.
- On 11/07/22 she arrived at 7:51 PM at Phelps Health ED by ambulance for complaint of a fall at home and back pain. She was treated, diagnosed with an initial fall, back pain and was discharged.
- On 11/09/22 at 7:49 PM, she arrived at Phelps Health ED by ambulance with reported hypotension (low blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80]), lethargy (weak, sluggish) and confusion. Her vital signs at 8:03 PM showed her BP was 121/71 and pulse (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) was 125. At 8:13 PM, a pain assessment showed the patient complained of back pain and rated her pain at a six on a pain severity scale of zero to ten (zero means "no pain" and ten means "the worst possible pain"). Her pain was documented as chronic. At 9:31 PM vital signs showed an elevated BP at 190/100 and heart rate was 100. Staff O, ED Physician, ordered a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), urinalysis (UA, a laboratory examination of a person's urine), a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the head, a chest x-ray (test that creates pictures of the structures inside the body-particularly bones), glucose (sugar), troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01), lipase and electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions). At 10:10 PM, vital signs showed pulse was 115 and respirations were 22. Orders for cardiac monitoring were discontinued at 10:20 PM. At 10:25 PM the ECG was reviewed by the physician and showed sinus tachycardia (abnormal rapid heart rate, greater than 100 beats per minute). ED Provider Notes showed a review of systems was completed and documented that Patient #2 was alert and oriented to person, place, and time; negative for arthralgia (joint pain) and back pain. CT of the head was normal. The chest x-ray showed pulmonary hypertension (a type of BP that affects the arteries in the lungs and the right side of the heart). Labs showed an elevated blood urea nitrogen (BUN, blood test that specifies kidney function) at 24 (normal range 7-20), elevated creatinine (blood test that shows how the kidney is functioning) at 1.38 (normal range 0.7-1.3) and low sodium (a type of electrolyte in the blood) at 134 (normal range 135-145). Other lab results were normal. No results were shown for urinalysis. At 11:59 PM the patient was given one liter of normal saline intravenous (IV, in the vein) bolus (large volume). Staff O documented that there were no hypotensive episodes during her ED visit and that the patient had reported being lethargic and confused, but was now alert and able to answer questions. He wondered if her confusion was due to her just waking up. On re-evaluation the patient wanted to go home, the physician did not see a strong indication to keep her in the ED and she was discharged on 11/10/22 at 2:15 AM. She was instructed to return with any new concerning symptoms and to follow-up with her primary care physician. No further pain assessments were documented. The uncollected UA order was cancelled on 11/10/22 at 4:15 AM.
-On 11/12/22, Patient #2 was at the hospital visiting a friend, lost her balance and fell in the parking lot. She was assisted to the ED for evaluation on 11/12/22 at 6:46 PM. Triage documentation showed the patient had altered mental status (mental functioning ranging from slight confusion to coma) and was tachycardic. She complained of back pain and rated it at nine. A UA was obtained and showed white blood cells, moderate bacteria, and red blood cells. Her lactic acid (blood test that helps diagnose sepsis, a life-threatening reaction to a bacterial infection) was 2.3 (normal range 0.1-2.1). She was admitted to the hospital with the clinical impression of dehydration, acute cystitis without hematuria and altered mental status.

Review of Patient #2's ambulance report dated 11/09/22, showed that Ambulance Service B responded to Patient #2's home at 7:57 PM. Her BP was low at 83/46, and pulse was elevated at 135. The patient was diaphoretic (excessive, abnormal sweating), lethargic, and staring into space. She was given one liter of lactated ringers (IV fluid that contains minerals used to treat dehydration and restore fluid balance in the body) on route to the hospital.

Review of Safety Event document, dated 11/12/22, showed that PSOs responded for a lift assist in the hospital's yellow parking lot. Patient #2 was on the ground and medical staff was at the scene.

During an interview on 08/17/23 at 10:25 AM, Staff O, ED Physician, stated that Patient #2, was back to baseline, wanted to go home and so he discharged her. He stated that her back pain was related to the fall she experienced two days prior and that was to be expected. He was unaware if she had gone to the bathroom after receiving IV fluids and stated the nurses took care of that. He was unaware the UA had not been obtained before discharge and stated that nursing notified the provider if something was not completed prior to discharge. He stated that someone with an altered mental status had a wide presentation and that he had reviewed the CT of the head with no acute findings. He stated that he could not make a person stay and give a urine sample.

During an interview on 08/17/23 at 11:30 AM, Staff G, Medical Director of the ED, stated that he had reviewed the grievance the patient filed with the hospital. He stated the UA had not been done. He stated the patient was clinically doing better, her judgement was back to baseline and she demanded to go home. He stated you can't hold someone against their will to get a urine sample. He felt that this patient was back to baseline and was discharged appropriately.

During an interview on 08/17/23 at 12:05 PM, Staff D, Director of Emergency Services, stated that urine outputs were part of the nursing documentation of all ED patients. She stated that the physician made the decision to discharge a patient, even if all lab work was not obtained. The physician decided if it was appropriate to discharge a patient without obtaining a urinalysis.

During an interview on 08/17/23 at 2:50 PM, Staff R, Registered Nurse (RN), stated that the goal was to get patients out of the ED in a timely manner. At discharge, the chart automatically flagged medications and lab work that had not been completed per the physician orders. She did not recall this patient and would have documented if the patient had attempted to void or was unable to void. She was not aware the UA had not been done or that the patient had complained of pain. She was not sure why the patient had been discharged prior to obtaining a UA and that she would have documented that in the chart. There was no documentation of attempting to get a UA or follow-up on the complaint of back pain. She stated nursing could do a straight catheter (a flexible tube that is inserted through the urethra to empty urine from the bladder intermittently).

During a phone interview on 08/22/23 at 9:00 AM, Staff X, RN Charge Nurse, stated that patients that had pain, whether chronic or acute, should have further assessment and interventions documented. It was expected for urine
outputs to be documented on ED patients and would include if the patient was able to go to the bathroom to void. If a patient had any problems urinating or was unable to ambulate to the bathroom and used a bedpan that should be documented. When a patient was discharged from the ED, a yellow flag showed outstanding tests that had not been completed and nursing asked the physician if the patient needed to complete the test prior to discharge. There were times when a physician would say they could be discharged without that test, but it was expected for the nurse to document that conversation.

See A-2406 for additional information.

Based on interview, record review, policy review, and video review the hospital failed to provide, within its capability and capacity, an appropriate and complete medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #10) out of 20 Emergency Department (ED) records reviewed from 11/01/22 through 08/16/23. This failed practice had the potential to cause harm to all patients who presented to Phelps Health ED seeking care for an EMC. The hospital's average monthly ED census over the past six months was 2,572.

Findings included:

Review of hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," dated 03/2023, showed the following:
- Hospital personnel will respond when an individual comes to the Hospital's Emergency Department and a request is made for emergency care, or if a reasonable person would believe that the individual needs emergency care, the Hospital will provide a MSE in the Emergency Department.
-The MSE should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms to determine whether an EMC exists.
- The MSE is an ongoing process and the medical records should document continued monitoring based on the patient's needs until the patient is stabilized or appropriately transferred.
- The ED attending physician will supervise and assume responsibility of the evaluation, stabilization and treatment of all patients who come to the ED.
- When a physician or qualified medical person (QMP) determines that an individual has an EMC, the hospital will within the capability of the staff and facilities available at the hospital, provide further medical examination and treatment as necessary to stabilize the EMC until discharge, the individual was admitted or if necessary, arrange for an appropriate transfer to another medical facility

Review of the hospital's policy titled, "Assessment and Reassessment of Patient(s)," reviewed 12/21/22, showed the following:
- A primary assessment is completed upon a patient's presentation to the ED to identify actual or potential, life threatening illness or injury.
- A secondary assessment is completed when the patient's presenting problem warrants a more thorough evaluation to identify other non-life threatening illness or injury.
- Reassessments included the patient's overall condition as well as vital sign (body temperature, blood pressure, heart rate, and breathing rate) monitoring and the frequency of reassessment was based on the patient's acuity, condition, or as indicated by the ED physician.
- A patient with an Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients) acuity of three was assessed at a minimum every 30-60 minutes for the first four hours and then at least every four hours if stable.
- A complete set of vital signs should be obtained within five minutes of a patient's discharge.

Review of the hospital's policy titled, "Post Use of Force," dated 05/2023, showed the following:
- Following any use of force beyond de-escalation (reduction of the intensity of a conflict or potentially violent situation), patients should be assessed for injuries and there will be documentation of stabilization. Medical care will be offered for any physical injuries.
- Use of force is physical force necessary to prevent harm from occurring or to control a violent individual who is a threat to themselves or to others.
- After use of force, the patient will receive an assessment by a nurse for stability and injury. When safety permitted, the assessment should include vital signs. All findings were documented in the medical record.
- Medical care will be provided as needed.
- Individuals that will be taken into custody by law enforcement (LE) will be assessed and a fit for confinement (patient is medically and psychiatrically [relating to mental illness] stable to go to jail) exam will be completed and documented prior to release.

Review of the undated document titled, "Fit for Confinement," showed the following:
- Fit for Confinement includes a complete MSE.
- If a patient had injuries (especially post use of force) or is seriously impaired by alcohol or other controlled substances, further assessment may be needed.
- A complete set of vital signs should be assessed prior to discharge, if it is safe to do so.
- The provider documents all elements of the screening examination and the Fit for Confinement form in the patient's medical record.
- The nurse documents all required documentation, including discharge vital signs.

Review of Patient #10's medical record showed the following:
- On 01/24/23 at 6:42 PM, he presented to the ED by ambulance for a well-being check related to alcohol intoxication (to be affected by alcohol or drugs where physical and mental control is markedly diminished).
- Physician notes on 01/25/23 at 2:21 AM and 2:22 AM acknowledged a critical high elevated blood alcohol (amount of alcohol in the blood) result from 01/24/23 at 9:41 PM and the patient was feeling better, his condition was improved and stable for discharge. The patient verbalized that he understood discharge instructions and agreed to discharge from the ED.
- Nursing documentation on 01/25/23 at 2:30 AM showed Patient #10 began to curse and threaten a Public Safety Officer (PSO). The patient stood and walked toward the PSO in an aggressive (behavior that is intended to harm another individual) manner and was tased (deployed conducted energy device used to incapacitate people). The patient fell to the ground and was placed in handcuffs.
- A Fitness for Confinement form was signed and dated by the physician on 01/25/23 at 2:34 AM (after the patient was tased and handcuffed by PSOs). The form showed the patient was not suicidal (thoughts of causing one's own death), homicidal (thoughts or attempts to cause another's death) and without risk for self-harm. The form contained no additional documentation regarding the patient's medical status.
- Nursing documentation on 01/25/23 at 2:41 AM showed the patient was discharged and removed from the ED by LE.
- There was no documentation in the medical record that the patient was assessed for injuries after the PSO deployed the taser and no documentation of assessment of vital signs after 01/24/23 at 9:29 PM.

Review of the hospital's video recording showed the following:
- Patient #10 was tased outside of ED Room Five on 01/25/23 at approximately 2:29 AM.
- He fell to the ground and was lying on his right side. He rolled to his stomach and was handcuffed by a PSO.
- After the patient was tased, the patient was not touched by any medical or nursing staff. A staff member (presumably Staff U) bent over the patient, but did not touch the patient. The patient's vital signs were not assessed.
- LE arrived at 2:33 AM and the patient was pushed out of view by LE in a wheelchair at 2:39 AM.

Review of the document titled, "Department of Public Safety Incident Report," showed Staff V, PSO, was the investigating officer. The narrative of the report showed PSOs responded to a request for assistance in the ED with an uncooperative patient who had been discharged. The patient had requested to leave Against Medical Advice (AMA) and was encouraged to dress and leave the ED. The patient verbalized threats of harm toward Staff V and approached him in what was perceived as an aggressive manner. Staff V deployed his taser for five seconds. Patient #10 fell onto the ground with his arms under his body. Staff V directed Patient #10 to put his arms behind his back and when he did not comply, Staff V tased the patient again for two additional seconds. The patient was placed in handcuffs until LE arrived. LE arrived, took control of Patient #10 and the LE officer removed the taser barbs from Patient #10. Staff U, ED Physician, provided a "Fit for Confinement" and Patient #10 left in a wheelchair in the custody of LE. The incident report included a witness statement hand-written by Staff P, Registered Nurse (RN).

Review of the LE report titled, "Case RPD202300235," showed Staff V, PSO, reported to LE that Patient #10 had signed out AMA and was told to gather his belongings and leave the ED. Verbal exchanges occurred between the PSO and the patient. The patient kicked off his shoe, threatened to harm the PSO and walked toward him in an aggressive manner. The patient was tased and put in handcuffs by the hospital PSOs. When LE arrived, the LE officers checked the handcuffs for proper fit, arrested the patient and put him in the patrol car for transport to the jail. The date and time of arrest was documented as 01/25/23 at 2:40 AM.

During a telephone interview on 08/20/23 at 4:30 PM, Staff U, ED Physician, stated a physical assessment could be completed without actually laying hands on a patient. He did not witness the taser incident, did not recall if the patient was assessed or if he removed the taser barbs from the patient. A patient only needed reassessment after an incident (such as being tased) if they were injured or if the LE officer requested it. He expected that vital signs were assessed regularly on every patient in the ED and he was not aware that Patient #10 had not had vital signs assessed before his discharge.

During an interview on 08/17/23 at 10:45 AM, Staff G, Physician, Medical Director of the ED, stated that if a physical altercation occurred with a patient who had already received their MSE in the ED, a reassessment would be appropriate unless the patient refused. Staff G reviewed Patient #10's medical record and confirmed that there was no documentation of reassessment after the tasing incident and there was no documentation of vital signs on the patient after 01/24/23 at 9:29 PM, including within five minutes prior to discharge.

During an interview on 08/17/23 at 1:05 PM, Staff P, RN, stated that Patient #10 was intoxicated and used verbally abusive and foul language toward ED staff. The patient allowed her to give him an injection of medications, to draw blood for lab tests and then "basically slept it off" until the physician talked to him about being discharged. The patient did not want to leave. PSOs presence seemed to agitate the patient even more. The patient threw one of his shoes, stood up, approached the PSO and was tased. LE had already been called and arrived quickly after the incident. The provider came to the scene, removed the taser probes from the patient and assessed him immediately after. She did not recall that the patient was preparing to leave AMA. If a patient reported they were leaving AMA, the nurse and/or provider reviewed and documented the risks and benefits of leaving before treatment was complete, an AMA form printed, and the patient was asked to sign it. She did not know what documentation was required if the patient refused to sign the AMA form.

During a telephone interview on 08/17/23 at 2:25 PM, Staff Q, RN, stated that she was the charge nurse in the ED on 01/24/23. She became involved when Patient #10 was verbally aggressive and postured for physical aggression toward staff. The patient was warned that the PSO would use a taser if he continued to threaten physical harm. He stood up and walked toward the PSO, was warned again and was tased when he continued to approach. The patient fell to the ground and was told to put his hands behind his back. He did not comply and was tased again. The provider was informed that Patient #10 was tased, but she was not sure if the patient received an assessment or vital signs after the incident.

During a telephone interview on 08/21/23 at 10:00 AM, Staff W, ED Patient Care Technician, stated she came onto shift at midnight on 01/25/23 and was assigned as the patient safety sitter for Patient #10 and two other ED patients. A patient in Room Five would usually be on a continuous vital signs monitor assessed every 30 minutes if they were not suicidal or homicidal. Patient #10 slept almost the entire time of her shift until he was getting dressed for discharge. She did not witness the incident with the PSO or the patient being tased. She could hear yelling and lots of noise, but she could not change her location as she was assigned line of sight (LOS, continuous visual contact with the patient) observation for two other ED patients at the same time. The physician walked to the hallway after the patient was tased.

During a telephone interview on 08/21/23 at 11:47 AM, Staff V, PSO, stated when the PSOs were summoned to the ED on 01/25/23, they were told that Patient #10 had signed AMA and was no longer a patient. Their assistance was requested in escorting the patient off of hospital property. He did not recall who removed the barbs from Patient #10 or if the physician saw the patient after he was tased. He stayed with the patient after he was tased until he was taken off the property by LE.

During an interview on 08/17/23 at 12:05 PM, Staff D, RN, Director of ED, stated vital signs on ED patients were assessed at least every four hours unless behavioral issues were documented that prevented those assessments. Nursing staff received education that vital signs must be assessed even when a patient was sleeping or document why they were not obtained. If a patient indicated a desire to leave AMA, nursing or the physician reviewed the risks and benefits of continuing assessment and treatment and the patient was asked to sign an AMA form. If the patient refused to sign the AMA form, "Patient Refused to Sign" was documented within the medical record.

Review of hospital's policy titled, "Pain Management," dated 02/2023, showed the following:
- Screening for pain will be completed by the nurse during ED visits that should include the type of current pain-chronic or acute, the severity of the pain, and influencing factors such as patient's age, current medical conditions, and past medical history.
- A positive pain screening will result in the completion of a pain assessment.
- Pain assessment was to include the site, onset, character, radiation associated factors, time course, exacerbating and relieving factors, and severity.
- Pain management involves multiple members such as providers, nurses, and other health care professionals providing direct care to the patient.
- Pain reassessment should be done after each pain management intervention including both pharmacological and non-pharmacological and to be completed within 90 minutes of intervention.
- Patient's right to effective pain management was to include provider's orders for pharmacological and non-pharmacological interventions.

Review of Patient #2's medical record showed that she was a 65 year old who presented to the ED on 11/07/22, 11/09/22, and 11/12/22.
- On 11/07/22 at 7:49 PM she arrived at Phelps Health ED by ambulance for complaint of a fall at home and back pain. She was treated, diagnosed with an initial fall, back pain and was discharged.
- On 11/9/22 at 7:49 PM, she arrived at Phelps Health ED by ambulance with reported hypotension (low blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80]), lethargy (weak, sluggish) and confusion. Her vital signs at 8:03 PM showed her BP was 121/71 and pulse (the number of heart beats per minute, normal range for adults is 60 to 100 bpm) was 125. At 8:13 PM, a pain assessment showed the patient complained of back pain and rated her pain at a six on a pain severity scale of zero to ten (zero means "no pain" and ten means "the worst possible pain"). Her pain was documented as chronic. At 9:31 PM vital signs showed an elevated BP at 190/100 and heart rate was 100. Staff O, ED Physician, ordered a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), urinalysis (UA, a laboratory examination of a person's urine), a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the head, a chest x-ray (test that creates pictures of the structures inside the body-particularly bones), glucose (sugar), troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01), lipase and electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions). At 10:10 PM, vital signs showed pulse was 115 and respirations were 22. Orders for cardiac monitoring were discontinued at 10:20 PM. At 10:25 PM the ECG was reviewed by the physician and showed sinus tachycardia (abnormal rapid heart rate, greater than 100 beats per minute). ED Provider Notes showed a review of systems was completed and documented that Patient #2 was alert and oriented to person, place, and time; negative for arthralgia (joint pain) and back pain. CT of the head was normal. The chest x-ray showed pulmonary hypertension (a type of BP that affects the arteries in the lungs and the right side of the heart). Labs showed an elevated blood urea nitrogen (BUN, blood test that specifies kidney function) at 24 (normal range 7-20), elevated creatinine (blood test that shows how the kidney is functioning) at 1.38 (normal range 0.7-1.3) and low sodium (a type of electrolyte in the blood) at 134 (normal range 135-145). Other lab results were normal. No results were shown for urinalysis. At 11:59 PM the patient was given one liter of normal saline intravenous (IV, in the vein) bolus (large volume). Staff O documented that there were no hypotensive episodes during her ED visit and that the patient had reported being lethargic and confused, but was now alert and able to answer questions. He wondered if her confusion was due to her just waking up. On re-evaluation the patient wanted to go home, the physician did not see a strong indication to keep her in the ED and she was discharged on 11/10/22 at 2:15 AM. She was instructed to return with any new concerning symptoms and to follow-up with her primary care physician. No further pain assessments were documented. The uncollected UA order was canceled on 11/10/22 at 4:15 AM.
- On 11/12/22, Patient #2 was at the hospital visiting a friend, lost her balance and fell in the parking lot. She was assisted to the ED for evaluation on 11/12/22 at 6:46 PM. Triage documentation showed the patient had altered mental status (mental functioning ranging from slight confusion to coma) and was tachycardic. She complained of back pain and rated it at nine. A UA was obtained and showed white blood cells, moderate bacteria, and red blood cells. Her lactic acid (blood test that helps diagnose sepsis, a life-threatening reaction to a bacterial infection) was 2.3 (normal range 0.1-2.1). She was admitted to the hospital with the clinical impression of dehydration, acute cystitis without hematuria and altered mental status.

Review of Patient #2's ambulance report dated 11/09/22, showed that Ambulance Service B responded to Patient #2's home at 7:57 PM. Her BP was low at 83/46, and pulse was elevated at 135. The patient was diaphoretic (excessive, abnormal sweating), lethargic, and staring into space. She was given one liter of lactated ringers (IV fluid that contains minerals used to treat dehydration and restore fluid balance in the body) on route to the hospital.

Review of Safety Event document, dated 11/12/22 at 5:30 PM, showed that PSOs responded for a lift assist in the hospital's yellow parking lot. Patient #2 was on the ground and medical staff was on the scene.

During an interview on 08/17/23 at 10:25 AM, Staff O, ED Physician, stated that Patient #2, was back to baseline, wanted to go home and so he discharged her. He stated that her back pain was related to the fall she experienced two days prior and that was to be expected. He was unaware if she had gone to the bathroom after receiving IV fluids and stated the nurses took care of that. He was unaware the UA had not been obtained before discharge and stated that nursing notified the provider if something was not completed prior to discharge. He stated that someone with an altered mental status had a wide presentation and that he had reviewed the CT of the head with no acute findings. He stated that he could not make a person stay and give a urine sample.

During an interview on 08/17/23 at 11:30 AM, Staff G, Medical Director of the ED, stated that he had reviewed the grievance the patient filed with the hospital. He stated the UA had not been done. He stated the patient was clinically doing better, her judgement was back to baseline and she demanded to go home. He stated you can't hold someone against their will to get a urine sample. He felt that this patient was back to baseline and was discharged appropriately.

During an interview on 08/17/23 at 12:05 PM, Staff D, Director of Emergency Services, stated that urine outputs were part of the nursing documentation of all ED patients. She stated that the physician made the decision to discharge a patient, even if all lab work was not obtained. The physician decided if it was appropriate to discharge a patient without obtaining a urinalysis.

During an interview on 08/17/23 at 2:50 PM, Staff R, Registered Nurse (RN), stated that the goal was to get patients out of the ED in a timely manner. At discharge, the chart automatically flagged medications and lab work that had not been completed per the physician orders. She did not recall this patient and would have documented if the patient had attempted to void or was unable to void. She was not aware the UA had not been done or that the patient had complained of pain. She was not sure why the patient had been discharged prior to obtaining a UA and that she would have documented that in the chart. There was no documentation of attempting to get a UA or follow-up on the complaint of back pain. She stated nursing could do a straight catheter (a flexible tube that is inserted through the urethra to empty urine from the bladder intermittently).

During a phone interview on 08/22/23 at 9:00 AM, Staff X, RN, Charge
Nurse, stated that patients that had pain, whether chronic or acute, should
have further assessment and interventions documented. It was expected for urine
outputs to be documented on ED patients and would include if the patient was able
to go to the bathroom to void. If a patient was unable to ambulate to the bathroom and utilized a bedpan, or if there were problems urinating that should be included in the documentation. When a patient was discharged from the ED, a yellow flag showed outstanding tests that had not been completed and nursing asked the physician if the patient needed to complete the test prior to discharge. There were times when a physician would say they could be discharged without that test, but it was expected for the nurse to document that conversation.


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