HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that a suicidal patient was monitored for safety and a medical screening examination was completed to determine if a medical emergency existed. (A-2406 A.)

2. The Hospital failed to ensure that a patient who presented to the emergency department and had a security incident was provided a medical screening examination. (A-2406 B.)


The immediate jeopardy (IJ) began on 3/31/2024, due to the hospital's failure to monitor the patient for safety and conduct a medical screening examination to determine if a medical emergency existed for 1 of 4 patients (Pt #21) who presented to the hospital's emergency department (ED) with suicidal ideation. Subsequently, Pt #21 was able to leave the ED and did not receive a medical screening examination. The IJ was announced on 7/2/2024 at 2:40 PM during a meeting with the Director of Regulatory, Manager of Regulatory Compliance, the hospital's Executive Director Chief Nursing Officer, and Executive Director Chief Nursing Officer (from affiliated hospital). The IJ was not removed by the survey exit date of 7/2/2024.

A. Based on document review, observation and interview, it was determined that the Hospital failed to ensure signage was posted conspicuously in places that are noticed by all individuals entering the emergency department and the wording was in languages of the population served by the hospital.

Findings included:

1. The Hospital's policy titled, "Emergency Medical Treatment and Labor Act: EMTALA (5/17/2017)" was reviewed on 6/26/2024 and included, "Posted Signs: The hospital, ... shall post conspicuous signs, specifying the rights of individuals under EMTALA who come to the Emergency Department seeking treatment with emergency medical conditions and indicate whether or such facility participants in the Medicaid program. See Exhibit C for sign requirements. Exhibit C included EMTALA language in English and Spanish."

2. A tour of the emergency department (ED) was conducted with the Patient Care Manager for the ED (E#9) on 6/24/2024 from 1:00 PM - 2:30 PM. The EMTALA signage (in English) was located on a pillar at the walk-in entrance to the ED, at the registration desk and on a pillar, below desk level in the ED by the registration desk for ambulance entrance. The signs were approximately 8 by 11 inches and blended in with other signage. During another tour of the ED, conducted on 6/26/2024 at 9:20 AM, the EMTALA sign by the registration desk was observed to be blocked by a computer on wheels and was not visible to patients.

3. The Hospital's Fiscal Year Equity & Opportunity Lens graph was reviewed on 6/26/2024 and indicated that English speaking and Spanish speaking are the top two demographic populations that the Hospital serves.

4. The Medical Chair of the Emergency Department (MD#4) was interviewed on 7/1/2024 at 9:45 AM. MD#4 stated that the hospital's patient population is 95-97% English speaking, but there is a very small percentage of patients for whom Spanish is their spoken language. MD#4 stated, "I suppose we could look into posting a Spanish sign. The requirement is that the sign is visible. We are the safety net for the community, and no one is ever turned away."

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) reviewed for disposition code of 'Arrived in Error', the Hospital failed to ensure that the disposition code on the emergency department log was defined and universally used.

Findings included:

1. The Hospital's policy titled, "Emergency Medical Treatment and Labor Act: EMTALA (5/17/2017)" was reviewed on 6/26/2024 and required, "Central Log: A central log must be maintained in the hospital Emergency Department. ... The log must include: name of each individual seeking treatment for an emergency condition; date; time; and disposition (i.e.., transferred, admitted, discharge, left against advice, left without treatment)."

2. The clinical record of Pt. #1 was reviewed on 6/24/2024. The timeline from Pt. #1's emergency department (ED) visit on 3/24/2024 indicated that Pt. #1 arrived and was checked-in by Financial Counselor (E#7) to the ED on 3/24/2024, at 5:28 AM with a chief complaint of MVA (motor vehicle accident). The ED timeline included that Pt. #1's disposition was set to "Arrived in Error" on 3/24/2024 at 5:51 AM by Charge Nurse E#6 and was marked as "Patient dismissed" on 3/24/2024 at 6:43 AM by ED Nurse (E#8).

3. The Hospital's disposition (discharge code) key was reviewed on 6/26/2024. The code 'Arrived in Error" was included on the list. There was no definition for the use of the disposition code 'Arrived in Error'.

4. The triage nurse (E#14) was interviewed on 6/24/2024 at 2:10 PM. E#14 stated, "We have many patients that request to be seen just to come in because they want shelter or food. Once we do that the patient leaves without being seen. Sometimes we use the code 'Arrived in Error' for patients who really don't need to be seen."

5. The Patient Care Manager (E#9) was interviewed on 6/24/2024 at 3:00 PM. E#9 stated that the patient is entered in the log starting at registration and finished at disposition. The disposition codes are a drop-down selection in the computer. E#9 stated, " 'Arrived in Error' is a code used when someone presents to the registration desk and really wanted to go to another department, like ultrasound or x-ray. The patient might have already been entered, but really didn't need to be seen in the ED."

6. The Director Emergency Service Line (E#16) was interviewed on 6/26/2024 at 9:00 AM. E#16 stated that the discharge disposition on the ED log is entered by the nursing staff from a standardized list of EPIC (computer system) codes. Three of the codes are monitored formally for quality purposes: 1. Left Without Being Seen, 2. Left Before Triage, and 3. Left before Treatment Complete. E#16 stated, "I review/audit these codes daily and if the wrong code has been entered, I will change and enter the correct code into the system." E#16 stated the two other discharge codes that are reviewed but not reported are: 1. Arrived in Error and 2. AMA (against medical advice). E#16 stated, "I look at those codes to see if they are being used correctly, but do not report on them for quality. The disposition 'Arrived in Error' is used when a patient registers then decides not to be seen by a physician, and that code can only be entered by the charge nurse."

7. The Medical Chair of the Emergency Department (MD#4) was interviewed on 7/1/2024 at 9:45 AM. MD#4 stated that the disposition code 'Arrived in Error' is used to remove the patient from the active board. The name remains on the log. MD#4 stated, "I'm not sure there is a real definition for Arrived in Error."

A. Based on document review and interview, it was determined that for 1 of 4 (Pt #21) records reviewed for patients presenting to the emergency department (ED) for suicidal ideation who scored a high risk for suicide on assessment during triage, the hospital failed to ensure that the patient was monitored for safety and a medical screening examination was completed to determine if a medical emergency existed. Subsequently, Pt #21 left the ED waiting room without being seen by a qualified medical provider.

Findings include:

1. On 6/25/2024 at approximately 2:00 PM, a security incident report, dated 3/31/2024, was reviewed and included, "In summary on 3/31/24 at approximately 18:57 hours officers were dispatched to the emergency room waiting area for the patient elopement. The patient [Pt #21], was who was in the emergency waiting area, Left the emergency room waiting area with an unknown male ... The patient was wearing a red top and has blond hair. Per the nursing staff the patient was here for suicidal ideation ...After a search of the area, we [were] unable to locate the patient on or around hospital premises. Nothing further to report at this time."

2. The clinical record for Pt #21's ED visit on 3/31/2024 was reviewed on 6/25/2024 and included that Pt #21 presented to the ED on 3/31/2024 at 6:11 PM for psychiatric evaluation. The RN's (E #20) triage note on 3/31/2024 at 6:23 PM included, "Patient presents with complaint of positive suicidal ideation and states feeling depressed. Patient states came here to stop it before it happens. AOX4 [alert and oriented to person, place, time, and situation]." Pt #21's vital signs in triage were: heart rate 91, blood pressure 164/106, respiratory rate 18, temperature 97.5, and SpO2 96% on room air. Pt #21's suicide risk screening was completed by E #20 at 6:27 PM and included that Pt #21 was a high risk for suicide. The suicide screening included, " ... suicidal intent with specific plan: Yes (overdose on pills)". The triage note included Pt #21's ED Acuity was "2" (1-5 scale; 2 being high risk situation). The record indicated that orders were placed by E #20 (Nursing order set for behavioral health patients that can be placed by nursing in triage) at 6:29 PM for: point of care urine pregnancy test; lab-blood - CBC [complete blood count] and differential; comprehensive metabolic panel; serum alcohol; urine toxicology screen; COVID-19 Rapid Respiratory. The record indicated that all labs were collected by E #20 by 6:38 PM. There was no documentation in the record that Pt #21 was taken into the main ED or placed in a bed/room. The next nursing note was on 3/31/2024 at 7:05 PM which included, "ED Disposition set to Left Before Treatment Complete." The record did not include documentation of Pt #21 being monitored or Pt #21 receiving a medical screening exam by a qualified practitioner from the time of triage at 6:23 PM through time Pt #21 left at 7:05PM.

3. The hospital's policy titled, "Triage" (ED-033) (reviewed 5/25/2021) was reviewed on 7/1/2024 and required, " ...Route patients to the appropriate location: ... b. Take critical patients, including those who are suicidal or homicidal, into the Emergency Department treatment area immediately. c. All suicidal or homicidal patients should be triaged at an ESI [emergency severity index] 2 ..."

4. The hospital's policy titled, "Psychiatric Patient Care" (ED-024 - reviewed 12/27/2019) was reviewed on 7/1/2024 and required, " ...1. Patient arriving to the Emergency Department with psychiatric complaints should be placed in the Emergency Department and should be assessed whether the need for continuous observation is required. If required, follow hospital policy. A. During the triage assessment, all patients are screened by the RN for suicidal intention using the Columbia-Suicide Severity Rating Scale ..." The policy did not include procedures for monitoring patients in the waiting room when no ED beds are available.

5. The hospital's policy titled, "Suicide/Homicide/Safety Precautions/Video Monitoring" (reviewed 5/15/2022) was reviewed on 7/1/2024 and required, " ... It is a hospital wide policy that applies to any department providing patient care ... 1. All patients during the emergency department/urgent aid triage process and/or admission onto the medical units will undergo a suicide and homicidal ideation risk screening. 2. The Columbia-Suicide Severity Rating Scale should be utilized for suicidal risk screening. 3. The person conducting the screen is responsible for notifying the licensed independent practitioner (LIP) of any positive findings. 4. Suicide or Homicidal Ideation Precautions will be implemented for all patients at risk as identified by suicide screening, integrated assessment, psychiatric evaluation, and/or physician order. 5. An RN or LIP may initiate Precautions ..."

6. On 6/26/2024 at approximately 12:16 PM, an interview was conducted with the ED RN (E #20) who triaged Pt #21 on 3/31/2024. E #20 stated that E #20 conducted the triage for Pt #21 on 3/31/2024 and entered the standing order set for behavioral health patients (labs, pregnancy test, COVID test, urine toxicology). E #20 stated that a suicide risk assessment was completed, and Pt #21 was a high risk for suicide. E #20 stated that the lab tests were collected in triage, and Pt #21 was placed in the waiting room after triage because no beds were available in the ED at the time. E #20 stated that the provider can review the record and order a psychiatric assessment and referral consult, and the patient will be placed in a bed as soon as one becomes available. E #20 stated that they were not aware of any measures in place to stop a patient from walking out the door of the ED waiting room. E #20 stated that when they called for Pt #21 in the waiting room on 3/31/2024, the patient did not respond. E #20 stated that they checked the waiting room, both bathrooms, and looked out the front door of the ED, and Pt #21 was not to be found. E #20 then called Security to locate Pt #21.

7. On 6/26/2024 at approximately 11:00 AM, an interview was conducted with the ED Manager (E #9). E #9 stated that the hospital's ED gets a lot of walk-in patients. E #9 stated that there is always a greeter and a Triage RN in the waiting room that can see the patients in the waiting area. E #9 stated that they try to room behavioral health/suicidal patients if a bed is available. E #9 stated that if the patient is known to ED staff and no bed is available, the patient will sit by the triage room, and there is a Security staff posted in the ED waiting room. E #9 stated that the Charge Nurse is notified if a suicidal patient presents and is triaged, but "if ED is full, we do the best we can." E #9 stated that they try to recruit Security staff to keep an eye on the patient until a bed can be secured, or the patient can stay with the triage nurse in the triage room, if possible. E #9 stated that they do not assign sitters to patients in the waiting room. E #9 stated that Pt #21 frequently comes to the ED. E #9 stated, "Patient [Pt #21] is delightful, and staff is very familiar with her." E #9 was unable to provide a policy/procedure/stated practice for the monitoring of behavioral health/suicidal patients in the ED waiting room to ensure that patients are monitored for safety and receive a medical screening exam when no beds are available in the main ED.

8. On 6/26/2024 at approximately 11:15 AM, an interview was conducted with the ED Director (E #16). E #16 stated that if a psychiatric or suicidal patient elopes from the ED and Security cannot find the patient, then the police department should be contacted to do a wellness check on the patient. E #16 was unable to provide a policy/procedure/stated practice for the monitoring of behavioral health/suicidal patients in the ED waiting room to ensure that patients are monitored for safety and receive a medical screening exam when no beds are available in the main ED.

9. On 7/1/2024 at approximately 10:19 AM, an interview was conducted with the Public Service Officer (E #27) who completed the Security incident report regarding Pt #21 on 3/31/2024. E #27 stated that E #27 was notified by clinical staff after Pt #21 had been gone a while on 3/31/2024. E #27 stated that Security got the description of the patient from ED clinical staff. Security staff then checked the entire hospital property for Pt #21, then contacted ED staff to report that Security could not find Pt #21. E #27 stated that ED clinical staff will then contact the police department if indicated, and Security does the incident report. E #27 stated that the ED waiting room is usually monitored by contracted security staff who sit at the ED waiting area security desk which is located just inside the main ED entrance. E #27 stated that Security staff does not monitor the patients in the ED waiting room. Medical/clinical ED staff monitor the patients in the waiting room.

10. On 7/1/2024 at approximately 10:00 AM, an interview was conducted with the ED Medical Director (MD #4). MD #4 stated that patients who present to the ED for psychiatric evaluation/suicidal ideation should be taken directly to the main ED from triage, and if there are no beds available, patients should be placed in beds in the hallway in the main ED. MD #4 stated that if a psychiatric/suicidal patient leaves the hospital from the waiting room or elopes from the main ED, clinical staff would notify Security right away to look for the patient. If Security is unable to locate the patient, then clinical staff could notify the police department to look for the patient and check on their wellbeing. MD #4 stated that Pt #21 was a "frequent flyer" in the ED who presented with different complaints all the time. MD #4 stated that ED staff was very familiar with Pt #21. MD #4 stated that if Pt #21 presented with a complaint of suicidal ideation with a plan and was a high risk for suicide, then Pt #21 should be taken directly to the main ED in a bed if available or placed in a hallway bed. MD #4 stated that suicidal patients should not be left in the ED waiting room. MD #4 stated that if Security is unable to locate a suicidal patient who left the ED waiting room, then clinical staff should document in the record if police were contacted.

11. On 7/1/2024 at approximately 9:15 AM, an interview was conducted with the Director of Environmental Health Safety & Security (E #19). E #19 stated that clinical staff should monitor patients (including behavioral health patients) in the ED waiting area. Security staff do not monitor patients in the waiting area. If a patient leaves the ED waiting area, clinical staff will notify Security if they are looking for a patient with a clinical concern who has left. Security will check the immediate area around the ED and expand to check the hospital's campus, which includes an approximate 1 square mile area [North - South from 157th Street to 154th Street and West - East from Lincoln Avenue to Ashland Avenue]. If Security locates the patient, then they will try to talk to the patient to get them to return to the ED and prevent the patient from leaving.



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B. Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) emergency department clinical records reviewed for patients who had security incidents, the Hospital failed to ensure that individuals presenting to the emergency department (ED) seeking treatment were provided a medical screening examination.

Findings include:

1. The Hospital's policy titled, "Emergency Medical Treatment and Active Labor Act: EMTALA" (revised 5/17/2017), was reviewed and required, "...II. Obligations to Emergency Patients under EMTALA: A. Screening requirments: 1. The hospital (including dedicated emergency departments) shall provide an appropriate medical screening examination ("MSE") to all inviduals who come to the facility seeking treatment for an emergency medical condition, whether or not they are eligible for benefits under Medicare/Medicaid programs..."

2. The clinical record of Pt. #1 was reviewed on 6/24/2024. The timeline for Pt. #1's first ED visit on 3/24/2024 indicated that Pt. #1 arrived and was checked-in by Financial Counselor (E#7) to the ED on 3/24/2024, at 5:28 AM with a chief complaint of MVA (motor vehicle accident). The record lacked any documentation that Pt. #1 was triaged or seen by a physician. The ED timeline included Pt #1 was documented as "Patient dismissed" by ED Nurse (E #8), and Pt. #1's disposition was set to "Arrived in Error" on 3/24/2024 at 5:51 AM by the Charge Nurse E#6. The record lacked documentation of Pt #1 receiving a medical screening exam.

3. Public Safety Department Incident Reports from 3/20/2024-3/31/2024 were reviewed on 6/24/2024 and included one incident report involving Pt. #1 that was filed by Public Safety Officer (E#2) on 3/24/2024 at 6:30 AM. The report indicated that an incident involving Pt. #1 and Officer [E#2] occurred on 3/24/2024 at 5:30 AM in the ER [emergency room] waiting area, The report included, "On 3/24/2024 at 05:30 AM, Officer [E#1] informed me of a banned individual [Pt. #1] was in the ER triage with a friend [identified as Pt. #2]. When we approached them, I [E#2] asked [Pt. #1] was [Pt. #1] here to see a doctor and [Pt. #1] stated 'No, I'm with [friend], why[?].' I informed [Pt. #1] that [Pt. #1] would have to leave the property if not seeking medical treatment. [Pt. #1] began to record the waiting area shouting and crying that [Pt. #1] does not have to register in order to stay in the ER. At that moment, I [E #2] called [E#5] the House Manager to be a witness for this incident. [Pt. #1] also stated that [Pt. #1] called the police on me and Officer [E#3] for telling [Pt. #1] to leave. [Pt. #1] registered and we [Officers] were about to leave when [Pt. #1] began to threaten the ER Tech[nician] in the waiting area. The House Manager and Officers [E#3] & [E#4] also witnessed this incident. We went to speak to the Charge Nurse [E#6] and told [E#6] of the events that had just occurred and it was decided that [Pt. #1] should be escorted out for making threats to staff. I informed [Pt. #1] that [Pt. #1] would have to leave the property immediately and [Pt. #1] did so while calling [Local] P.D. [police department]..."

4. A telephone interview was conducted with ED Charge Nurse (E#6) on 6/25/2024, at approximately 9:00 AM. E#6 stated that EMTALA means that every patient that comes through our door will be seen. E#6 stated that every patient that comes in to be seen will be screened by a provider and provided treatment until they are stable or need to be admitted or transferred. E#6 stated that a person becomes a patient the moment that check-in and are registered to be seen by the doctor. E#6 stated that if a patient that comes to be seen becomes aggressive or combative, they will call security for the safety of staff and other patients. E#6 stated that the Hospital has a zero tolerance policy (for violent/threatening behavior) and that is discussed with the patient. E#6 stated that they will try to talk with the patient and calm them down; however, if they can't de-escalate, security will get involved. E#6 stated that if the patient is alert and oriented, not altered, and not a harm to themselves, and are of competent mind, and still are threatening staff, they may be escorted out of the hospital and in that case it should be documented in the medical record. E#6 stated that Pt. #1 did come to the Hospital at some point but did not recall speaking to Pt. #1. E#6 stated that there was some incident between Pt. #1 and security but was not sure how it all escalated. E#6 stated, "I didn't know [Pt. #1] was officially a patient" at that time. E#6 stated that a patient's disposition can be set to "arrived in error" when registration typed in something wrong (i.e. date of birth), the patient already has an account, or may have just clicked the wrong thing. E#6 did not recall why Pt. #1's disposition was set to arrived in error.

5. A telephone interview was conducted with Public Safety Officer/PSO (E#2) on 6/25/2024, at approximately 9:20 AM. E#2 stated that the only time a person may be escorted out for threatening or aggressive behavior is when that are not a patient. E#2 did recall Pt. #1 and stated that Pt. #1 came to the Hospital with a friend and Pt. #1 said the friend had been in a car accident and that Pt. #1 came to check on the friend. E#2 stated that Pt. #1 had a previous history of trying to break into the ER and trying to grab an officer's gun. E#2 told Pt. #1 that if Pt. #1 was not here to see a doctor, Pt. #1 was not allowed to stay. E#2 stated that Pt. #1 stated, "I don't have to do any of that" and E#2 responded, "Then there is no reason for you to be here." E#2 stated that as Pt. #1 was about to leave, Pt. #1 stated that Pt. #1 now wanted to see a doctor. E#2 stated that Pt. #1 then went to register to see a doctor and E#2 stated that they (security) broke off engaging with Pt. #1. E#2 stated that Pt. #1 registered and made it to triage. E#2 stated, "We didn't stop her at that point." E#2 stated that Pt. #1 then started to threaten a staff member (ER Tech, identified as E#15 by E#2) and wouldn't calm down. E#2 stated Pt. #1 was threatening to kill the ER Tech. E#2 stated that the ER Tech went back and told the charge nurse and who talked to Pt. #1 as well as with the House Manager. E#2 stated Pt. #1 was there for 5-10 minutes and would not calm down. E#2 stated the House Manager and Charge Nurse were involved and they let us know that they wouldn't want Pt. #1 to be at the Hospital. E#2 stated at this point they refused service to Pt. #1, and the doctor (possibly identified as MD#2 by E#2) agreed, as well. E#2 stated that Pt. #1 was doing it just to stay in the hospital and we all agreed upon her leaving. E#2 stated, "I'm not sure if the doctor went to see the patient as Pt. #1 didn't even make it to the back."

6. A telephone interview was conducted with ED Physician (MD#2) on 6/26/2024, at approximately 3:26 PM. MD#2 stated that EMTALA requires every patient to have a medical screening exam. MD #2 stated that they did not recall Pt #1. MD#2 stated that MD#2 will see every patient before making a medical decision. MD#2 stated that even if the patient doesn't want to be seen, MD#2 will do a mental status exam to ensure that patient is capable of making a decision. MD#2 stated that even if the patient becomes a physical threat, "we would have to assess if they're competent and whether they have a life-threatening condition. There should be documentation of this in the record. Aggression could be a sign of altered mental status."

7. An interview was conducted on 6/25/2024, at approximately 2:00 PM with the ED Nurse (E#8) in triage the morning of 3/24/2024. E#8 stated that E#8 was told that Pt. #1 was a former staff member who isn't allowed to come on premises anymore after making threats to another employee. E#8 stated that if Pt. #1 comes to seek treatment, Pt. #1 can stay. E#8 stated that Pt. #1 came in with a friend who stated that they were in a car accident. E#8 stated that the friend was getting seen as a patient, but Pt. #1 wasn't. E#8 stated that around 5:30 AM (close to shift change at 7:00 AM), security staff came to the triage room and stated that Pt. #1 wasn't allowed on premises and was asked to leave. E#8 stated that Pt. #1 started to record them and was threatening to harm staff. E#8 stated that security came and escorted Pt. #1 away, while E#8 completed triage for the friend. E#8 stated that E#8 overheard that Pt. #1 was going to get registered as patient but did not know if Pt. #1 ever did check-in, as E#8 did not end up triaging Pt. #1. E#8 stated that at some point Pt. #1 left. E#8 stated that if a patient is waiting to be seen but starts to become aggressive or threatening, they are still seen, but will be seen in the psychiatric part of the ED for their safety and the safety of others. E#8 stated that even if the patient becomes threatening, they are still a patient and need to be seen by a physician or PA (Physician Assistant).