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Based on interview and record review, the facility failed to ensure Medical Screening Examinations (MSE) were conducted by a qualified emergency services personnel, when a Registered Nurse (RN) provided MSE's for two Obstetrics (OB/pregnant women) patients (Patient 11 and 17).

This failure had the potential to compromise the patient's health and safety if an emergency medical condition was not identified and addressed during their Emergency Department (ED) visit.

Findings:

On March 26, 2024, at 9:00 a.m., an unannounced visit was conducted at the facility.

On March 26, 2024, at 1:15 p.m., a concurrent interview and record review was conducted with the Chief Quality Officer (CQO). The CQO indicated patients who are 20 weeks pregnant will receive a quick triage in the Emergency Room (ER) and will then be transferred to the OB Labor and Delivery Department. The CQO stated OB MSE is provided by RNs who have the qualifications according to their policy.

A review of the facility's document titled, "Triage Report" dated March 14, 2024, at 5:57 p.m. and authored by RN 1, was reviewed. It indicated Patient 11 arrived at the facility on March 14, 2024, at 5:57 p.m., with complaints of vaginal pressure and pain.

A review of the facility's document titled, "Triage Report", dated March 13, 2024, at 3:32 a.m. and authored by RN 2, was reviewed. It indicated Patient 17 arrived at the facility on March 13, 2024, at 3:32 a.m., with complaints of uterine contractions (tightening of uterine muscle fibers) and pain every two minutes.

On March 27, 2024, at 2 p.m., an interview was conducted with the CQO. The CQO stated there was no documented evidence that RN 1 and RN 2, who conducted the OB MSE on Patient's 11 and 17, had been approved by the board of governing body in the hospital. The CQO stated the nurses had to pass a competency validation that includes Advance Fetal Monitoring, at least one year of experience as a labor nurse, and three MSE's previously performed in the last 12 months. The CQO stated both are not qualified to conduct MSE on their own.

On March 27, 2024, at 2:14 p.m., a concurrent interview and record review was conducted with RN 1. RN 1 stated she cared for Patient 11 on March 14, 2024, and had conducted Patient 11's MSE. RN 1 stated she had not been signed off, nor "hit" one year of labor and delivery experience, and was not qualified to conduct the MSE. RN 1 stated Patient 11 should have been seen by an OB doctor or that a qualified person should have conducted the MSE.

On March 27, 2024, at 2:57 p.m., an interview with RN 2 was conducted. RN 2 stated she cared for Patient 17 on March 12, 2024, and conducted Patient 17's MSE. RN 2 stated she was not qualified to conduct an MSE per the facility's policy.

A review of the facility policy and procedure titled, EMTALA - MEDICAL SCREENING EXAMINATION AND STABILIZATION POLICY", dated April 27, 2023, indicated, "PURPOSE...To establish guidelines for providing appropriate medical screening examinations ("MSE") and any necessary stabilizing treatment or an appropriate transfer for the individual...D...Who May Perform the MSE...1. Only the following individuals may perform an MSE...A qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...or...A qualified staff member who is qualified to conduct such an examination through appropriate privileging and demonstrated competencies; ii. Is functioning within the scope of his or her license and in compliance with the state law and applicable practice acts (e.g., Medical or Nurse Practice Acts); iii. Is performing the screening examination based on medical staff approved guidelines, protocols or algorithms; and iv. Is approved by the facility's governing board as set forth in a document such as the hospital bylaws or medical staff rules and regulations, which document has been approved by the facility's governing body and medical staff. It is not acceptable for the facility to allow informal personnel appointments that could change frequently..."

A review of the facility obstetrics policy and procedure titled, "(sic) STANDORDIZED PROCEDURE: MEDICAL SCREENING EXAMINATION" dated April 2021 indicated, "PURPOSE: To define the standardized procedure providing a medical screening exam (MSE) for an OB patient. During the performance of this exam, the qualified RN may perform identified assessments that alternatively would require a physician's order. The purpose of this procedure is also to define who is competent to perform an MSE...3. Definitions...d. A qualified RN is a Registered Nurse who is certified to perform emergency medical examinations as defined in the OB Department Rules and Regulations who meet the following requirement. Experience, training and/or education and evaluation of competency: Initial Competency. I. Demonstration of competence in skills and knowledge for evaluation and care of the woman in labor via Competency Validation Tool (refer to Appendix A). II. At least one year of experience as a labor nurse. III. Demonstrated competency in AWHONN Advance Fetal Monitoring. IV. Successful completion of written examination for performance of Medical Screening Examination. V. Successful completion of observed/precepted Medical Screening Examination with three (3) MSE's performed. Ongoing Competency. VI. Three previous MSE's performed in the last 12 months without any identified opportunity for improvement (refer to Appendix A). VII. Annual review of Policy/Procedure for Medical Screening Examination during Skills Day..."

Based on interview and record review, the facility failed to ensure stabilizing treatment and to provide safety and security relevant to the psychiatric emergency medical condition (EMC) for one of 21 sampled patients (Patient # 1) when Patient #1 was admitted on a psychiatric hold (5150 - when a person is deemed a danger to self, others, or gravely disabled, could be involuntary detained for 72 hours).

This failure resulted in Patient #1 to elope (patient leaving the hospital before discharged) from the Emergency department (ED) and running out of the ED, into the middle of the street, then jumping inside a moving vehicle, where he sustained life threatening injuries when forcefully ejected when the vehicle suddenly stopped.

Findings:

On March 26, 2024, an unannounced visit was conducted at the facility for an EMTALA survey.

A review of Patient 1's medical record was conducted. Review of a document, titled "ED [Emergency Department] [Name of Hospital] Triage Report", dated March 21, 2024, indicated, "...Acuity 2...Chief Complaint...Suicidal: 5150 HOLD...Triage D/T [date/time]: 03/21/2024 [March 21, 2024] 15:06 [3:06 p.m.]...Patient Narrative...Pt [patient-Patient #1] BIBA [brought in by ambulance] for DTS [delirium tremens - the most severe form of alcohol withdrawal]. Pt told PD [police department] that he wants a car to hit him..."

A review of the facility's document for Patient 1 titled, "PHH Emergency Department Record (Scribe to Physician)", dated, March 21, 2024, was conducted. It indicated, "Provider Contact time...03/21/2024 [March 21, 2024] 1505 [3:05 p.m.] ...Chief Complaint...suicidal Ideation...Narrative...present to the ED for evaluation of suicidal ideation. As per police, patient was found walking...in and out of traffic. Patient then told police he wanted to die, and therefore PD placed him on a 5150 hold..."

A review of the facility's document titled, "[Name of Facility] CPOE [ Computerized Provider Order Entry] Orders Report" dated March 21, 2024, was conducted. It indicated "...1503 [3:03 p.m.], Suicide Precaution..."

A review of Patient 1's "Daily Focus Assessment Report", dated March 21, 2024 was conducted. It indicated, "...Suicide Risk...Interventions 1:1 observation..."

A review of the document titled, "Application for 72-hour Detention for Evaluation and Treatment", dated March 21, 2024, was conducted. It indicated, "Subject (Patient 1) stated he wants to die and wanted a vehicle to hit him ...Based upon the above information it appears there is a probable cause to believe that said person is, as a result of mental disorder: [box checked] a danger to himself/herself."

A review of the facility's video footage was conducted on March 26, 2024, at 1:35 p.m., with the Director of Facilities (DOF), Chief Nurse Officer (CNO) and Chief Quality Officer (CQO). The video footage dated March 21, 2024 indicated,

a. Video 1 - At 2:47 p.m. observed Patient 1 arriving via ambulance, Emergency Medical Staff (EMS) at the bedside.

b. Video 2 - At 3:04 p.m. observed Patient 1 arriving in Bay #1 with EMS. Did not observed any ED staff at bedside.

c. Video 2 - At 3:08 p.m. observed Registered Nurse 1(RN1) talking to EMS. DOF stated RN1 was receiving report from EMS.

d. Video 3 - At 4:00 p.m. observed Patient 1 being moved to Bay#2. Observed Patient Sitter 2 (Sitter 2) and Sitter 3 sitting in the hallway across from Bay #2. The DOF stated Sitter 3 was the sitter assigned to Patient 1 and Sitter 2 was assigned to another patient in the hallway (Patient 21). At 4:08 p.m. observed Patient 1 approaching the doorway while Sitter 2 stood up and approached Patient 1. During a concurrent interview, the DOF stated Patient 1 was asking for assistance to go to the restroom because he felt dizzy. A few seconds later observed Patient 1 pushing Sitter 2 and Patient 1 started running.

e. Video 4 - At 4:12 p.m. Patient 1 was observed running towards the door with Sitter 2 following him.

f. Video 5 - At 4:12 p.m. Patient 1 was observed running across the parking lot without any hospital staff chasing him. During a concurrent interview, the DOF stated a call was already made to the security staff and it is their practice not to follow the patient, so the patient can concentrate on where he/she is going and reduce further accident. The DOF further stated, at that time the security guard patrolling the south side of the hospital had already been informed.

g. Video 6 - Patient 1 was observed in the middle of a busy street. During a concurrent interview, the DOF stated at this time a security guard had already responded, however, he is not seen on the video because view was obstructed by a structure.

There was no documented evidence the "Sitter Observation Documentation" was initiated until Patient 1 was moved to Bay#2 at 4:00 p.m.

There was no documented evidence the "Environmental Checklist for Psychiatric Patients" was initiated when Patient 1 was moved to Bay#2.

An interview on March 27, 2024, at 10:56 a.m., with the Safety Officer 1 (SO1), was conducted. The SO1 stated he responded to the call of a patient eloping. He stated he saw Patient 1 in the middle of the street trying to talk to the drivers passing by. He stated he was at the sidewalk coaching Patient 1 to safety however, he wasn't sure if Patient 1 could hear him, or if he was ignoring him. The SO1 further stated Patient 1 jumped inside an open window of a moving vehicle and was forcefully ejected when the vehicle suddenly stopped.

An interview and record review was conducted on March 27, 2024, at 10:31 a.m., with Sitter 3. Sitter 3 stated, Sitter 2 who was assigned another 5150 patient was helping her watch Patient 1 because he had more experience with 5150 patients than she did.

An interview was conducted on March 27, 2024, at 1:16 p.m., with Sitter 2. Sitter 2 stated, "I was assigned as a 1:1 sitter for a patient (Patient 21) in the hallway but I was also helping (name of Sitter 3), so technically I was watching two patients."

On March 27, 2024, at 1:34 p.m., video 3 dated March 21, 2024, was reviewed with the Director of Facilities (DOF), Chief Nurse Officer (CNO) and Chief Quality Officer (CQO). The video indicated Sitter 3 seated
across Bay #2 was engaged in a conversation with a staff member while Sitter 2 was across Bay #2 watching Patient 1. At this time, the CQO stated Sitter 3 was not watching/observing Patient 1 as she should. She further stated the 1:1 observation should have started when Patient 1 arrived in the ED.

During continued interview, the CNO stated, Sitter 3 was not watching any patients, and that no one was watching Patient 21 or documenting the every 15-minute observations. The CNO further stated her expectation for 1:1 observation is for one (1) sitter to be assigned one (1) patient and for them to perform the assigned task e.g., environmental checklist, and every 15 minutes observations.

A review of the facility's policy and procedures (P&P), titled, " Behavioral Health Management (ED)" dated August 2019, was conducted. It indicated, "Purpose: To appropriately manage patients in the ED with an acute psychiatric condition...Definition: 5150 custodial hold: is authorized under the LPS Act as a process for holding persons involuntarily for evaluation and treatment...One to one observation is the process where a patient is observed on a one to one staff patient ratio by trained staff. The patient is in line of sight by the staff at all times..."