HospitalInspections.org

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, Company Policy Officer Incident/Investigation Report review, and observations as referenced in the Life Safety Report of survey completed 10/16/2011, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights, an effective quality assessment and performance improvement program, an organized nursing service, a safe environment for patients, staff, and visitors, and emergency needs of patients were met.

The findings include:

1. The hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care in the Emergency Department.

~cross refer to 482.13 Patient Rights' Condition: Tag A0115

2. The hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

~cross refer to 482.21 Quality Assessment/Performance Improvement Condition: Tag A0263

3. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care in the Emergency Department.

~cross refer to 482.23 Nursing Services Condition: Tag A0385

4. The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

5. The hospital failed to meet the emergency needs of patients.

~cross refer to 482.55 Emergency Services Condition: Tag A1100

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to promote and protect patients' rights by failing to ensure a safe setting for patient care in the Emergency Department.

Findings include:

The hospital failed to ensure care in a safe setting by failing to ensure ED staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 52 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment.

~ cross refer to 482.13(c)(2) Patient Rights' Standard: Tag 0144

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to ensure care in a safe setting by failing to ensure ED staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 52 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Further closed record review revealed Patient #39 returned to the hospital's DED 11/12/2011 at 0909 via EMS with a chief complaint of abdominal pain. Review revealed the patient was triaged at 0918 and assigned an initial acuity of Level 3. Record review revealed documentation at triage of blood pressure 148/116, pulse 107, respirations 22, and pain level of 10 of 10. Record review revealed Patient #39 was medically screened by the DED physician at 0933, labs were ordered, and Toradol (pain medication) and Zofran (anti-nausea medication) were given intravenously. Further review revealed the patient was admitted to the hospital at 1915. Review of the physician's dictated History and Physical dated 11/12/2011 at 1656 revealed , "...Assessment and Plan 1. Acute Pancreatitis, based on the history, the clinical findings and the elevated lipase level (610, with normal of 73-393)...2. Type 2 diabetes...3. Intractable vomiting...4. Abdominal pain...5. History of ovarian cyst...6. Obesity...7. ...admitted to the medical unit...." Review of the physician's dictated discharge summary dated 11/14/2011 at 1435 revealed, "...Discharge Diagnoses 1. Acute exacerbation of pancreatitis 2. Uncontrolled type 2 diabetes mellitus....Disposition The patient is being discharged home in stable condition...."

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102). See Incident Report."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1315 with the Director of Security revealed he could not locate an incident report completed for Patient #39. Interview revealed, "We were not sending police or security reports to quality or risk in October." Interview revealed now all incidents are forwarded to the Quality Department, the Risk Department, and the Vice President of Post Acute Care.

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain. EMS told me she was here the other day and didn't get her medicine filled. I moved her to the lobby. She continued cursing and walking around. She went to the bathroom a couple of times. I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3). She was pushing and slinging wheelchairs. (RN #3) went outside to talk with her. She came back in, balled her fist up and said to (RN #2), 'I'm going to cut you'. I told (RN #3) I wasn't going to stay in triage if they allow this to happen. I didn't hear (RN #3) tell her to leave but she left and didn't come back." Interview further revealed, "She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening." Interview further revealed the RN had received EMTALA training every 6 months. Interview revealed, "Here recently, we've had training more often." Interview further revealed, "I would never kick a patient out of the ED. If the situation escalates, I would contact my supervisor, in this case, the charge nurse, (RN #3)."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. She got up out of wheelchair several times. She went outside at least twice on her own. I called the charge nurse, (RN #3). He went out to talk with her. He brought her back in and when she came by triage, she jumped at the window and started cussing again." Interview further revealed, "She did not receive a medical screening exam prior to being escorted off the property. She absolutely should have received a medical screening. I saw her come back in a couple of hours later. It was after 9:30. I didn't triage her again because she never checked by in." Interview further revealed, "We get EMTALA training at least twice a year. With this patient, our EMTALA policy was not followed. This patient should have been offered a medical screening."

Interview on 11/17/2011 at 1320 with RN #3 revealed the nurse is a permanent charge nurse in the hospital's DED and was the charge nurse when Patient #39 presented to the DED on 10/18/2011. Interview revealed, "I saw her (Patient #39) at the EMS bay when she came in. She was alert and oriented and was sent to triage. I got a call from (RN #1). She said (Patient #39) was in the lobby cursing and they had removed her from the lobby and took her outside. I went outside, got the client, talked to her and de-escalated her. She told me she'd be cooperative and actually apologized. I brought her back in. She saw the nurse and became irate and started cursing again. I told her because of her violent nature, I would have her escorted off the property. I had her escorted off by security, can't remember his name." Interview further revealed, "I assessed her before asking her to leave the property. I didn't have a room to put her in. She was not asked to sign out AMA (against medical advice). I asked that she be removed from the property." Interview further revealed, "During the shift, the buck stops with me. I have had EMTALA training annually, here lately, everyday." Interview further revealed, "Our EMTALA policy was not followed."

Interview on 11/17/2011 at 1420 with MD #1 revealed the physician is the medical director of the hospital's DED. Interview revealed, "It's always concerning to me when a patient is moved to the lobby or outside prior to seeing a physician. (Patient #39) should have been seen by a physician or if her behavior was escalating she should have been moved to another area other than the lobby, probably not the security office which is not the best area to place a patient." Interview further revealed, "I was not aware of (Patient #39) being escorted off property prior to a MSE until today."

Interview on 11/17/2011 at 1530 with RN #4 revealed the nurse is the service line director for the hospital's DED. Interview revealed, "We had more EMTALA training here in October. I helped develop the training. The education was about transfers, not medical screening exams." Interview further revealed, "MSEs can be performed in our ED by physicians, PAs (physician assistants) and nurse practitioners. I don't know why the nurses think they can provide MSEs." Interview further revealed, " I was made aware of the incident with (Patient #39). I asked the staff to complete a QCC (incident report). I didn't follow up with staff to make sure a QCC was done. I reminded staff that an MSE needed to be done irregardless of behaviors. I had a verbal discussion with (RN #3)." Interview further revealed, "I didn't notify risk management or PI (performance improvement). The two incidents on October 18 got confused. I only knew about this one." Interview further revealed, "Our EMTALA policy was not followed because they failed to give the patient a MSE by a licensed, qualified practitioner."

2. Closed medical record review for Patient #41 revealed a 28 year old female who presented to the hospital's Dedicated Emergency Department (DED) via Emergency Medical Services (EMS) ambulance on 10/18/2011 at 1358 (Presentation #1). Review revealed the patient was registered into the DED at 1402. Review of EMS documentation revealed the patient was transported to the DED for complaints of Right Flank Pain radiating in and towards the groin. Further review revealed the patient reported to EMS personnel "...AWOKE IN PAIN THIS MORNING ABOUT 0400 hrs (hours). CONTINUED TO GET WORSE INSTEAD OF BETTER. GOT NAUSEATED AND VOMITED. TRIED TO USE BATHROOM BUT COULD NOT...." Review of EMS assessment documentation revealed the patient was alert with guarding and tenderness in the right lower abdominal quadrant. Review of vital signs documented at 1345 revealed the following: Blood Pressure (BP) 132/80, Heart Rate (HR) 108, Respirations (R) 18. Review of EMS documentation revealed, "1420....AT THE DIRECTION OF THE CHARGE NURSE, PT (patient) WAS MOVED TO TRIAGE VIA WHEEL CHAIR, AND PT CARE WAS TRANSFERRED TO TRIAGE NURSE." Review of primary ("Frontline") triage nurse documentation revealed the patient was triaged at 1414 by a Registered Nurse (RN #1). Review revealed the patient complained of abdominal pain. Further review revealed at 1415 the patient's pain was assessed to be 9 out of 10 on a numerical pain scale (0 is pain free, 10 worse pain). Review revealed a past medical history of Asthma, Headache Migraine, Hypertension, and Urinary Tract Infections. Further review of "Primary Triage Info(rmation)" documented by RN #1 at 1417 revealed "....Note:~ pt to triage with RLQ (right lower quadrant) pain, states feels like pressure starting this am (morning) at 5. pt also states vomiting, denies diarrhea. Resp(irations) easy." Review revealed the patient was assigned "Initial Triage Acuity: 3 - Green (on a 1 to 5 Emergency Severity Index, with 1 being the most acute)." Review of documentation at 1427 by the secondary triage nurse (RN #2) revealed the patient's vital signs were assessed as Temperature (T) 100.0 (elevated) degrees Fahrenheit, BP 133/61, HR 107 (elevated), R 14, Pulse Oximetry 100% on room air. Review revealed "Orders: URINE-LAB PERFORMED U/A (urinalysis)" was ordered per DED protocol. Further review of RN #2's documentation at 1427 revealed, "....- Sepsis - (RN #2 name) Physician Notified: (MD #1 name) Sepsis Index of Suspicion: Unknown, Notify Physician/Provider." Review revealed at 1428 the patient was placed into the DED waiting room. Review of a "Triage Additional Note" documented by RN #3 (DED Charge Nurse on 10/18/2011 day shift) at 1552 revealed, "Note: Pt sitting at guest relations desk and will not move to have seat in lobby... pt ask to please have a seat in lobby and wait for available bed.. pt states she is not moving and began cursing at staff stating she has been waiting for 10 hours and patient has only been here 1.5 hours... Pt cursing still at staff, security notified and asked to escort pt out of lobby at this time. pt a (alert) and o (oriented) times 3 (person, place, time).. skin warm and dry.. resp(irations) even and non-labored and pt appears in no acute distress at this time.. pt refusing to cooperate and refrain from threatening behavior in triage... CPO (company police officer) notified and ask to remove patient from lobby..."

Review on 11/16/2011 of a CPO Incident/Investigation Report (NC02626249P, OCA1110-025) completed by CPO #1 and dated 10/18/2011 at 1550 revealed, "...Narrative Continued On or about 10/18/2011 15:50 hrs, Security Officer (SO) [name of SO #1] requested assisted in reference to a black female patient that Lead Charge Nurse (RN #3's name) wanted escorted out of the ED (emergency department) due to her refusing to cooperate with staff. I responded to same. I spoke with Officer (SO #1 name) who stated that the suspect, (Patient #41's name) was being disruptive with staff and refused to leave the ED. I requested Ms. (Patient #41's name) to leave and she refused. I advised her that if she didn't leave the ED she would be arrested for trespassing. Ms. (Patient #41's name) then left the ED and was walking toward the Tobacco store. Officer (SO #1's name) advised me that (RN #3's name) wanted her escorted off of the property. I advised Ms. (Patient #41's name) of same who had 2 white blankets that belonged to (name of Hospital). As we approached the edge of the property line, I advised Ms. (Patient #41's name) to give me the blankets. Ms (Patient #41's name) stated, 'No, I'm not giving you nothing, I'm cold.' I advised her that they belong to the hospital and she could be charged with larceny. Ms. (Patient #41's name) stated, 'No, I'm not giving them to you!' I tried to get the blankets from Ms. (Patient #41's name) who then pulled the blankets away from me. Ms. (Patient #41's name) continued to refuse to give me the blankets. I managed to get one blanket away from Ms. (Patient #41's name) who then started walking away off of property with the other blanket. Ms. (Patient #41's name) stated, 'There, you can have that one but I'm keeping this one. I advised (Patient #41's name) that she was under arrest and to put her hands behind her back. Ms. (Patient #41's name) refused to put her hands behind her back and continued to resist by trying to get her hands free from my hold. Officer (SO #1's name) arrived and assisted me so I could place handcuffs on Ms. (Patient #41's name). Officer (SO #1's name) and I escorted Ms. (Patient #41's name) to the CPO office (located adjacent to, but outside of the DED) to complete paperwork. I searched Ms. (Patient #41's name) and started the paperwork. Ms. (Patient #41's name) was very uncooperative and argumentative. Ms. (Patient #41's name) began to breath heavy, and stated that she has asthma. I asked her if she had her inhaler. Ms. (Patient #41's name) stated no. Ms. (Patient #41's name) stated that her chest felt tight. I called Lead Charge Nurse (RN #5's name) and requested him to check on Ms. (Patient #41's name). As I was on the phone with (RN #5's name) Ms. (Patient #41's name) began to vomit. I advised (RN #5's name) of same. (RN #5's name) checked Ms. (Patient #41's name) and stated that her lungs sound fine. (RN #5's name) advised me that she could be taken to room 31. I escorted Ms. (Patient #41's name) to room 31 and advised her that I wouldn't take her to jail but would charge her by citation (C 1713351-9)." Further review revealed Patient #41 was charged with Larceny and Resist, Delay, Obstruction.

Further medical record review for Patient #41 failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified (QMP) by hospital bylaws, rules and regulations, to determine whether or not Patient #41 had an emergency medical condition (EMC) after her initial presentation to the DED on 10/18/2011 at 1358 and before being escorted out of the DED lobby and off the hospital property at 1552 by a SO and CPO.

Further medical record review revealed Patient #41 was placed into DED treatment room Blue 31 South (Presentation #2) on 10/18/2011 at 1637 (45 minutes after being escorted off of hospital property). Review of the patient's vital signs documented at 1645 revealed the following: T 102.6 degrees Fahrenheit (2.6 degrees higher than on initial presentation), HR 122 (25 beats higher than on initial presentation), and R 32 (18 cycles higher than on initial presentation #1). Record review revealed the DED physician (MD #2) evaluated the patient at 1637. Review of documentation by MD #2 of the MSE performed on Patient #41 (after placement in room 31 - Presentation #2), dated 10/18/2011 (not timed), revealed Patient #41's complaint of abdominal pain, flank pain, and brief chest pain was described as constant and still present upon exam. Review revealed documentation the patient described the pain as sharp, stabbing with associated nausea and vomiting. Further review revealed the patient's pain severity was documented as severe. Review revealed documentation the patient had a past medical history of polycystic kidney disease. Review of physician documentation revealed the patient was assessed as being in moderate distress. Further review of physician documentation revealed the patient had tachycardia (elevated heart rate) and was awake and alert, but disoriented to place and time. Review revealed documentation the patient's abdomen was soft and non-tender. Record review revealed the patient was started on the "sepsis bundle" (sepsis treatment protocol). Review revealed MD #2 ordered multiple diagnostic blood, urine, and radiological studies and prescribed multiple medications, including pain medications, antibiotics, and intravenous fluids for the patient. Record review revealed diagnoses of Severe Sepsis, Acute Pyelonephritis, Altered Mental Status, Chest Pain, Abdominal Pain, Fever, and Tachycardia. Further record review revealed the patient was admitted to the hospital's intensive care unit for further treatment and was subsequently discharged on 10/25/2011 (7 days later) with final diagnoses of "1. Escherichia coli septicemia 2. Acute Pyelonephritis 3. History of polycystic kidney disease 4. Elevated blood pressure with a prior history of hypertension 5. Anemia (required blood transfusion) 6. Iron-deficiency anemia 7. Hypokalemia 8. Hypomagnesemia".

Interview on 11/17/2011 at 0945 with SO #1 revealed he was the security officer on duty in the DED lobby on 10/18/2011 when Patient #41 presented to triage via wheelchair with EMS personnel. Interview revealed his post is approximately 10 feet from the triage nursing station in the DED lobby. Interview revealed the check-in nurse (RN #1) called him over to make him aware of the patient's (Patient #41) behavior and that she was using profanity. Interview revealed the patient was already in the lobby area when he was informed of the patient's behavior. Interview revealed the patient came up to the check-in station (triage) then went back into the lobby. Interview revealed the patient returned to the patient information desk (guest services desk) in a wheelchair. Interview revealed the patient started using profanity and became loud enough for the SO to hear the patient. Interview revealed RN #1 told him that the patient needed to move away from the guest relations desk. Interview revealed the SO spoke with the patient and told her she needed to move back. Interview revealed the SO went behind the patient's wheelchair to move the patient back into the lobby when the patient got up out of the wheelchair and sat down in a chair in front of the patient information desk. Interview revealed the patient was using profanity and said she was not leaving until she spoke with someone to find out why she was waiting in the lobby and having pain. Interview revealed RN #1 was checking in another patient and did not come over to reassess the patient. Interview revealed the SO assumed someone called the charge nurse (RN #3) because he came out to speak with the patient. Interview revealed while RN #3 spoke with the patient, he called the CPO to put them on stand-by if "it became a trespass issue" when the patient was asked to leave. Interview revealed when ever a person displays hostility and uses profanity they may be asked to leave the property. Interview revealed it may be patients, visitors, or family members. Interview revealed, "It may happen twice per day or go weeks at a time and not happen." Interview revealed when the SO is asked to escort a patient out of the DED lobby or off the hospital property he is unsure if they have or have not had a medical screening examination by a QMP. Interview revealed the practice of SO or CPO escorting patients/visitors/family members out of the DED lobby or off hospital property has been in place since he has worked at the hospital (at least 7 years). Interview revealed he asks individuals to leave the DED lobby or property under the direction of clinical staff such as doctors and nurses. Interview revealed on 10/18/2011 RN #3 came out and spoke with the nurse who called him and then he talked to Patient #41. Interview revealed afterwards he told him (SO #1) "She (Patient #41) can leave." Interview revealed the patient was verbally hostile, loud, and using profanity but he did not observe her being a danger to herself or others. Interview revealed he did not witness RN #3 reassess the patient, but he (RN #3) just walked back through the double doors into the DED treatment area. Interview revealed the SO called the CPO for assistance. Interview revealed CPO #1 arrived to the DED lobby and he (SO #1) discussed the patient (#41) with the CPO. Interview revealed CPO #1 asked the patient to leave. Interview revealed the patient stated she would not leave until waited upon. Interview revealed the patient was using profanity. Interview revealed the patient then got up and said she was going to leave and not wait for her ride. Interview revealed the patient had two hospital blankets in which the CPO told her she could take outside. Interview revealed the patient then went out the door with the CPO and himself following. Interview revealed another SO was outside of the DED and SO #1 asked that SO to keep an eye on the CPO and patient. Interview revealed SO #1 then returned back inside the DED lobby. Interview revealed he last viewed the patient stepping up on the curb in the DED parking lot by the fire hydrant with the CPO. Interview revealed after returning into the DED lobby he received a radio call from the base operator requesting him to go out and assist CPO #1. Interview revealed he went outside and saw CPO #1 and Patient #41 at the corner of the Tobacco Shop building (a private commercial establishment adjacent to hospital's DED parking lot). Interview revealed the CPO was struggling with the patient and holding her left arm. Interview revealed the patient was up against the fence (property line) facing towards the tobacco store parking lot. Interview revealed he assisted the CPO place Patient #41 into handcuffs. Interview revealed he escorted the CPO and patient back to the hospital entrance. Interview revealed the CPO and patient went to the CPO office adjacent to the DED and he went back into the DED lobby.

Interview on 11/17/2011 at 1100 with CPO #1 revealed she was the company police officer on duty 10/18/2011 when Patient #41 was escorted out of the DED lobby and arrested. Interview revealed SO #1 called for assistance in the DED lobby. Interview revealed when she arrived Patient #41 was sitting in a chair in front of the visitors' information desk (guest services desk). Interview revealed the patient was acting out, using profanity, and was disruptive. Interview revealed SO #1 stated RN #3 wanted the patient escorted off of the property because she would not move out from in front of the guest services desk and was cursing. Interview revealed when the CPO arrived the patient was not appearing suicidal, homicidal or a danger to self or others. Interview revealed the patient was verbally abusive, using profanity, and being loud. Interview revealed, "If the Lead Charge Nurse wants a patient escorted off of the property then we do what the Charge Nurse requests regardless of medical treatment and condition." Interview revealed she approached the patient while on her cell phone and she advised the patient she was going to have to leave because the hospital was requesting her to leave. Interview revealed the patient continued to talk on the cell phone telling someone "they are kicking me out of the hospital. Can you come and pick me up". Interview revealed the patient ignored the officer's request to leave 3-4 times. Interview revealed the CPO informed Patient #41 if she did not leave she (CPO #1) would have to arrest her for trespassing. Interview revealed the patient continued to ignore the CPO until she unsnapped her handcuff case to remove her handcuffs. Interview revealed the patient then stood up and walked out of the DED lobby without assistance. Interview revealed when the patient walked towards the exit doors the patient stated she was cold and was advised by her (CPO#1) that she (Patient #41) could hold onto the two blankets she had wrapped around her for right then. Interview revealed, "(SO #1) stated, 'He (RN #3) wants the patient off the property.'" Interview revealed CPO #1 advised the patient that she was to be escorted off hospital property. Interview revealed as she escorted the patient off the property the patient was very argumentative and "venting." Interview revealed the CPO and patient walked towards the smoking area where the patient wanted to wait for her ride. Interview revealed the patient was informed she could not wait at the smoking area because it was still hospital property. Interview revealed the patient was instructed by the CPO that she could wait at the bus stop or on the tobacco store property (not on hospital property). Interview revealed the patient requested to wait at the tobacco store. Interview revealed the CPO requested the patient to give back the two hospital blankets and the patient became argumentative. Interview revealed the patient refused to give the blankets back. Interview revealed the officer advised the patient if she did not give the blankets back she would be charged with larceny. Interview revealed the patient refused to give back the blankets and the CPO grabbed for the blankets and retrieved one. Interview revealed the patient refused to give her the second blanket. Interview revealed the CPO reached for the other blanket and the patient went to grab for the CPO's hands. Interview revealed the CPO then advised the patient she was under arrest. Interview revealed she (CPO #1) struggled with the patient to get her into handcuffs. Interview revealed SO #1 arrived and assisted with placing the patient into handcuffs. Interview revealed the patient was escorted back to the CPO office. Interview revealed the CPO initiated paperwork for the magistrate in preparation to take Patient #41 to jail. Interview revealed the patient was searched and was being very difficult and verbally abusive. Interview revealed while completing the paperwork for the magistrate, the patient started breathing heavy and complained of chest tightness. Interview revealed the CPO called the Lead Charge Nurse

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

The findings include:

1. The hospital failed evaluate and analyze 2 of 2 sampled events in which nursing staff instructed security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination and treatment in the ED from the ED lobby, rather than ensuring the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed.

~cross refer to 482.21(a)(2) QAPI Standard: Tag A0267

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to evaluate and analyze 2 of 2 sampled events in which nursing staff instructed security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102)...."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1315 with the Director of Security revealed he could not locate an incident report completed for Patient #39. Interview revealed, "We were not sending police or security reports to quality or risk in October." Interview revealed now all incidents are forwarded to the Quality Department, the Risk Department, and the Vice President of Post Acute Care.

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain....I moved her to the lobby. She continued cursing and walking around....I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3)....She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. She got up out of wheelchair several times. She went outside at least twice on her own. I called the charge nurse, (RN #3). He went out to talk with her. He brought her back in and when she came by triage, she jumped at the window and started cussing again....She did not receive a medical screening exam prior to being escorted off the property. She absolutely should have received a medical screening. I saw her come back in a couple of hours later. It was after 9:30. I didn't triage her again because she never checked by in....This patient should have been offered a medical screening."

Interview on 11/17/2011 at 1320 with RN #3 revealed the nurse is a permanent charge nurse in the hospital's DED and was the charge nurse when Patient #39 presented to the DED on 10/18/2011. Interview revealed, "I saw her (Patient #39) at the EMS bay when she came in. She was alert and oriented and was sent to triage. I got a call from (RN #1). She said (Patient #39) was in the lobby cursing and they had removed her from the lobby and took her outside. I went outside, got the client, talked to her and de-escalated her. She told me she'd be cooperative and actually apologized. I brought her back in. She saw the nurse and became irate and started cursing again. I told her because of her violent nature, I would have her escorted off the property. I had her escorted off by security, can't remember his name." Interview further revealed, "I assessed her before asking her to leave the property. I didn't have a room to put her in. She was not asked to sign out AMA (against medical advice). I asked that she be removed from the property." Interview further revealed, "During the shift, the buck stops with me....Our EMTALA policy was not followed."

Interview on 11/17/2011 at 1420 with MD #1 revealed the physician is the medical director of the hospital's DED. Interview revealed, "It's always concerning to me when a patient is moved to the lobby or outside prior to seeing a physician. (Patient #39) should have been seen by a physician or if her behavior was escalating she should have been moved to another area other than the lobby, probably not the security office which is not the best area to place a patient." Interview further revealed, "I was not aware of (Patient #39) being escorted off property prior to a MSE until today."

Interview on 11/17/2011 at 1530 with RN #4 revealed the nurse is the service line director for the hospital's DED. Interview revealed, "I was made aware of the incident with (Patient #39). I asked the staff to complete a QCC (incident report). I didn't follow up with staff to make sure a QCC was done. I reminded staff that an MSE needed to be done irregardless of behaviors. I had a verbal discussion with (RN #3)." Interview further revealed, "I didn't notify risk management or PI (performance improvement). The two incidents on October 18 got confused. I only knew about this one."

2. Closed medical record review for Patient #41 revealed a 28 year old female who presented to the hospital's Dedicated Emergency Department (DED) via Emergency Medical Services (EMS) ambulance on 10/18/2011 at 1358 (Presentation #1) with complaints of abdominal pain. Record review revealed RN #1 performed a primary triage assessment of the patient at 1414. Review of documentation at 1427 by the secondary triage nurse (RN #2) revealed the patient's vital signs were assessed as Temperature (T) 100.0 (elevated) degrees Fahrenheit, BP 133/61, HR 107 (elevated), R 14, Pulse Oximetry 100% on room air. Review revealed at 1428 the patient was placed into the DED waiting room. Review of a "Triage Additional Note" documented by RN #3 (DED Charge Nurse on 10/18/2011 day shift) at 1552 revealed, "Note: Pt sitting at guest relations desk and will not move to have seat in lobby... pt ask to please have a seat in lobby and wait for available bed.. pt states she is not moving and began cursing at staff stating she has been waiting for 10 hours and patient has only been here 1.5 hours... Pt cursing still at staff, security notified and asked to escort pt out of lobby at this time. pt a (alert) and o (oriented) times 3 (person, place, time).. skin warm and dry.. resp(irations) even and non-labored and pt appears in no acute distress at this time.. pt refusing to cooperate and refrain from threatening behavior in triage... CPO (company police officer) notified and ask to remove patient from lobby..."

Review on 11/16/2011 of a CPO Incident/Investigation Report (NC02626249P, OCA1110-025) completed by CPO #1 and dated 10/18/2011 at 1550 revealed, "...Narrative Continued On or about 10/18/2011 15:50 hrs, Security Officer (SO) [name of SO #1] requested assisted in reference to a black female patient that Lead Charge Nurse (RN #3's name) wanted escorted out of the ED (emergency department) due to her refusing to cooperate with staff. I responded to same. I spoke with Officer (SO #1 name) who stated that the suspect, (Patient #41's name) was being disruptive with staff and refused to leave the ED. I requested Ms. (Patient #41's name) to leave and she refused. I advised her that if she didn't leave the ED she would be arrested for trespassing. Ms. (Patient #41's name) then left the ED and was walking toward the Tobacco store. Officer (SO #1's name) advised me that (RN #3's name) wanted her escorted off of the property. I advised Ms. (Patient #41's name) of same who had 2 white blankets that belonged to (name of Hospital). As we approached the edge of the property line, I advised Ms. (Patient #41's name) to give me the blankets. Ms (Patient #41's name) stated, 'No, I'm not giving you nothing, I'm cold.' I advised her that they belong to the hospital and she could be charged with larceny. Ms. (Patient #41's name) stated, 'No, I'm not giving them to you!' I tried to get the blankets from Ms. (Patient #41's name) who then pulled the blankets away from me. Ms. (Patient #41's name) continued to refuse to give me the blankets. I managed to get one blanket away from Ms. (Patient #41's name) who then started walking away off of property with the other blanket. Ms. (Patient #41's name) stated, 'There, you can have that one but I'm keeping this one. I advised (Patient #41's name) that she was under arrest and to put her hands behind her back. Ms. (Patient #41's name) refused to put her hands behind her back and continued to resist by trying to get her hands free from my hold. Officer (SO #1's name) arrived and assisted me so I could place handcuffs on Ms. (Patient #41's name). Officer (SO #1's name) and I escorted Ms. (Patient #41's name) to the CPO office (located adjacent to, but outside of the DED) to complete paperwork. I searched Ms. (Patient #41's name) and started the paperwork. Ms. (Patient #41's name) was very uncooperative and argumentative. Ms. (Patient #41's name) began to breath heavy, and stated that she has asthma. I asked her if she had her inhaler. Ms. (Patient #41's name) stated no. Ms. (Patient #41's name) stated that her chest felt tight. I called Lead Charge Nurse (RN #5's name) and requested him to check on Ms. (Patient #41's name). As I was on the phone with (RN #5's name) Ms. (Patient #41's name) began to vomit. I advised (RN #5's name) of same. (RN #5's name) checked Ms. (Patient #41's name) and stated that her lungs sound fine. (RN #5's name) advised me that she could be taken to room 31. I escorted Ms. (Patient #41's name) to room 31 and advised her that I wouldn't take her to jail but would charge her by citation (C 1713351-9)." Further review revealed Patient #41 was charged with Larceny and Resist, Delay, Obstruction.

Further medical record review for Patient #41 failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified (QMP) by hospital bylaws, rules and regulations, to determine whether or not Patient #41 had an emergency medical condition (EMC) after her initial presentation to the DED on 10/18/2011 at 1358 and before being escorted out of the DED lobby and off the hospital property at 1552 by a SO and CPO.

Further medical record review revealed Patient #41 was placed into DED treatment room Blue 31 South (Presentation #2) on 10/18/2011 at 1637 (45 minutes after being escorted off of hospital property). Review of the patient's vital signs documented at 1645 revealed the following: T 102.6 degrees Fahrenheit (2.6 degrees higher than on initial presentation), HR 122 (25 beats higher than on initial presentation), and R 32 (18 cycles higher than on initial presentation #1). Record review revealed the patient was evaluated by the DED physician (MD #2) at 1637 and was subsequently admitted to the hospital's intensive care unit with diagnoses of Severe Sepsis, Acute Pyelonephritis, Altered Mental Status, Chest Pain, Abdominal Pain, Fever, and Tachycardia. Record review revealed the patient was discharge on 10/25/2011 (7 days later) with final diagnoses of "1. Escherichia coli septicemia 2. Acute Pyelonephritis 3. History of polycystic kidney disease 4. Elevated blood pressure with a prior history of hypertension 5. Anemia (required blood transfusion) 6. Iron-deficiency anemia 7. Hypokalemia 8. Hypomagnesemia".

Interview on 11/17/2011 at 0945 with SO #1 revealed he was the security officer on duty in the DED lobby on 10/18/2011 when Patient #41 presented to triage via wheelchair with EMS personnel. Interview revealed the check-in nurse (RN #1) called him over to make him aware of the patient's (Patient #41) behavior and that she was using profanity. Interview revealed the patient was already in the lobby area when he was informed of the patient's behavior. Interview revealed the patient came up to the check-in station (triage) then went back into the lobby. Interview revealed the patient returned to the patient information desk (guest services desk) in a wheelchair. Interview revealed the patient started using profanity and became loud enough for the SO to hear the patient. Interview revealed RN #1 told him that the patient needed to move away from the guest relations desk. Interview revealed the SO spoke with the patient and told her she needed to move back. Interview revealed the SO went behind the patient's wheelchair to move the patient back into the lobby when the patient got up out of the wheelchair and sat down in a chair in front of the patient information desk. Interview revealed the patient was using profanity and said she was not leaving until she spoke with someone to find out why she was waiting in the lobby and having pain. Interview revealed RN #1 was checking in another patient and did not come over to reassess the patient. Interview revealed the SO assumed someone called the charge nurse (RN #3) because he came out to speak with the patient. Interview revealed while RN #3 spoke with the patient, he called the CPO to put them on stand-by if "it became a trespass issue" when the patient was asked to leave. Interview revealed when ever a person displays hostility and uses profanity they may be asked to leave the property. Interview revealed it may be patients, visitors, or family members. Interview revealed, "It may happen twice per day or go weeks at a time and not happen." Interview revealed when the SO is asked to escort a patient out of the DED lobby or off the hospital property he is unsure if they have or have not had a medical screening examination by a QMP. Interview revealed the practice of SO or CPO escorting patients/visitors/family members out of the DED lobby or off hospital property has been in place since he has worked at the hospital (at least 7 years). Interview revealed he asks individuals to leave the DED lobby or property under the direction of clinical staff such as doctors and nurses. Interview revealed on 10/18/2011 RN #3 came out and spoke with the nurse who called him and then he talked to Patient #41. Interview revealed afterwards he told him (SO #1) "She (Patient #41) can leave." Interview revealed the patient was verbally hostile, loud, and using profanity but he did not observe her being a danger to herself or others. Interview revealed he did not witness RN #3 reassess the patient, but he (RN #3) just walked back through the double doors into the DED treatment area. Interview revealed the SO called the CPO for assistance. Interview revealed CPO #1 arrived to the DED lobby and he (SO #1) discussed the patient (#41) with the CPO. Interview revealed CPO #1 asked the patient to leave. Interview revealed the patient stated she would not leave until waited upon. Interview revealed the patient was using profanity. Interview revealed the patient then got up and said she was going to leave and not wait for her ride. Interview revealed the patient had two hospital blankets in which the CPO told her she could take outside. Interview revealed the patient then went out the door with the CPO and himself following. Interview revealed another SO was outside of the DED and SO #1 asked that SO to keep an eye on the CPO and patient. Interview revealed SO #1 then returned back inside the DED lobby. Interview revealed he last viewed the patient stepping up on the curb in the DED parking lot by the fire hydrant with the CPO. Interview revealed after returning into the DED lobby he received a radio call from the base operator requesting him to go out and assist CPO #1. Interview revealed he went outside and saw CPO #1 and Patient #41 at the corner of the Tobacco Shop building (a private commercial establishment adjacent to hospital's DED parking lot). Interview revealed the CPO was struggling with the patient and holding her left arm. Interview revealed the patient was up against the fence (property line) facing towards the tobacco store parking lot. Interview revealed he assisted the CPO place Patient #41 into handcuffs. Interview revealed he escorted the CPO and patient back to the hospital entrance. Interview revealed the CPO and patient went to the CPO office adjacent to the DED and he went back into the DED lobby.

Interview on 11/17/2011 at 1100 with CPO #1 revealed she was the company police officer on duty 10/18/2011 when Patient #41 was escorted out of the DED lobby and arrested. Interview revealed SO #1 called for assistance in the DED lobby. Interview revealed when she arrived Patient #41 was sitting in a chair in front of the visitors' information desk (guest services desk). Interview revealed the patient was acting out, using profanity, and was disruptive. Interview revealed SO #1 stated RN #3 wanted the patient escorted off of the property because she would not move out from in front of the guest services desk and was cursing. Interview revealed when the CPO arrived the patient was not appearing suicidal, homicidal or a danger to self or others. Interview revealed the patient was verbally abusive, using profanity, and being loud. Interview revealed, "If the Lead Charge Nurse wants a patient escorted off of the property then we do what the Charge Nurse requests regardless of medical treatment and condition." Interview revealed she approached the patient while on her cell phone and she advised the patient she was going to have to leave because the hospital was requesting her to leave. Interview revealed the patient continued to talk on the cell phone telling someone "they are kicking me out of the hospital. Can you come and pick me up". Interview revealed the patient ignored the officer's request to leave 3-4 times. Interview revealed the CPO informed Patient #41 if she did not leave she (CPO #1) would have to arrest her for trespassing. Interview revealed the patient continued to ignore the CPO until she unsnapped her handcuff case to remove her handcuffs. Interview revealed the patient then stood up and walked out of the DED lobby without assistance. Interview revealed when the patient walked towards the exit doors the patient stated she was cold and was advised by her (CPO#1) that she (Patient #41) could hold onto the two blankets she had wrapped around her for right then. Interview revealed, "(SO #1) stated, 'He (RN #3) wants the patient off the property.'" Interview revealed CPO #1 advised the patient that she was to be escorted off hospital property. Interview revealed as she escorted the patient off the property the patient was very argumentative and "venting." Interview revealed the CPO and patient walked towards the smoking area where the patient wanted to wait for her ride. Interview revealed the patient was informed she could not wait at the smoking area because it was still hospital property. Interview revealed the patient was instructed by the CPO that she could wait at the bus stop or on the tobacco store property (not on hospital property). Interview revealed the patient requested to wait at the tobacco store. Interview revealed the CPO requested the patient to give back the two hospital blankets and the patient became argumentative. Interview revealed the patient refused to give the blankets back. Interview revealed the officer advised the patient if she did not give the blankets back she would be charged with larceny. Interview revealed the patient refused to give back the blankets and the CPO grabbed for the blankets and retrieved one. Interview revealed the patient refused to give her the second blanket. Interview revealed the CPO reached for the other blanket and the patient went to grab for the CPO's hands. Interview revealed the CPO then advised the patient she was under arrest. Interview revealed she (CPO #1) struggled with the patient to get her into handcuffs. Interview revealed SO #1 arrived and assisted with placing the patient into handcuffs. Interview revealed the patient was escorted back to the CPO office. Interview revealed the CPO initiated paperwork for the magistrate in preparation to take Patient #41 to jail. Interview revealed the patient was searched and was being very difficult and verbally abusive. Interview revealed while completing the paperwork for the magistrate, the patient started breathing heavy and complained of chest tightness. Interview revealed the CPO called the Lead Charge Nurse desk and requested the charge nurse (RN #5) come evaluate the patient. Interview revealed RN #5 came to evaluate the patient and stated the patient's chest was clear and she was "fine." Interview revealed he went back to the DED. Interview revealed the patient vomited. Interview revealed the CPO called the Lead Charge Nurse desk and informed RN #5 the patient had vomited. Interview revealed she spoke with the RN #5 on the phone and he assigned the patient to treatment room 31 Blue. Interview revealed the patient's handcuffs were removed and she was escorted to the treatment room. Interview revealed Patient #41 would have been transported from the Hospital's CPO office to jail had she not vomited in the CPO office. Interview revealed the CPO and SO are requested to escort and remove patients/visitors/family members from the DED lobby and off hospital property "quiet often on a regular basis". Interview revealed the CPOs and SOs do not know if patients have been provided an MSE by a QMP prior to being escorted out of the DED lobby or off hospital property.

Interview on 11/17/2011 at 1200 with RN #1 revealed she was the "Frontline" (primary) triage nurse on 10/18/2011 when Patient #41 presented to the DED. Interview revealed the patient was sent to secondary triage. Interview revealed the nurse went to the bathroom and then returned and Patient #41 was sitting at the guest services desk. Interview revealed the patient was cursing and vulgar towards staff and would not move from the desk to the lobby. Interview revealed she called the charge nurse (RN #3). Interview revealed RN #3 came out to speak with the patient at the guest services desk. Further interview revealed, "As an RN, I can give Medical Screenings but can not diagnose." Interview revealed according to hospital policy only MDs, PAs, and FNPs can do MSEs in the ED. Interview revealed any provider or Charge nurse can instruct a SO or CPO to ask a patient to leave the ED. Interview revealed Patient #41 did not receive a MSE by a QMP while in the DED on 10/18/2011 from the time of triage until 1552, when she was escorted out of the DED lobby. Interview revealed the patient should have had a MSE performed before she was asked to leave. Interview confirmed the hospital staff did not follow the hospital's EMTALA policy.

Interview on 11/17/2011 at 1235 with RN #2 revealed she was the secondary triage nurse on 10/18/2011 when Patient #41 presented to the DED. Interview revealed the patient was placed into the lobby after triage. Interview revealed she observed the patient come back up to the guest services desk. Interview revealed the patient was cursing at staff. Interview revealed RN #1 was standing behind the guest services attendant and told the patient "we're not going to tolerate that kind of language in the lobby". Interview revealed the patient was asked to stop cursing. Interview revealed RN #1 told her (RN #2) to call RN #3 to come out and talk with the patient. Interview revealed RN #3 came out and spoke with the patient. Interview revealed the patient continued "cursing and raising cane". Interview revealed security staff and the CPO were called. Interview revealed she saw the SO and CPO walk outside with the patient. Further interview revealed, "Only a provider in the facility performs the MSE, but I can per the Board of Nursing." Interview revealed the patient had no MSE performed by a QMP before being escorted out of the ED lobby. Interview confirmed the hospital staff did not follow the hospital's EMTALA policy.

Interview on 11/17/2011 at 1320 with RN #3 revealed he is a permanent charge nurse in the hospital's DED and was the charge nurse on 10/18/2011 when Patient #41 presented to the DED. Interview revealed RN#3 became involved with the patient when the triage nurse called him to advise him the patient was in the lobby and was upset. Interview revealed he did not immediately go out to assist the patient. Interview revealed he received a second telephone call from the guest services desk and he could hear the patient in the back ground. Interview revealed he went out to the lobby to talk with the patient Interview revealed the he explained to the patient that she would be placed into a room when a bed was available. Interview revealed the patient requested something for pain. Interview revealed he offered the patient Tylenol and she refused the medication. Interview revealed the patient became increasingly upset and was verbally abusive and cursing at staff. Interview revealed he asked the patient to refrain from her behavior. Interview revealed a security officer (SO #1) was present in the DED lobby. Interview revealed no CPO was present at that time. Interview revealed he asked the SO to escort the patient outside of the DED lobby. Interview revealed he returned to the DED treatment area. Interview revealed he did not see the SO physically escort the patient outside of the DED lobby. Interview revealed the patient was escorted outside of the DED lobby because of her uncooperative behavior. Interview revealed at that time he was unaware the patient was escorted off of the hospital property and subsequently arrested by a CPO. Interview revealed he did not ask the SO to escort the patient off of hospital property just out of the lobby. Interview revealed when the patient was escorted out of the DED lobby the patient had not been provided a MSE by a QMP. Interview revealed later in the day he was called by a CPO and advised of a patient in the CPO office who was sick and needed a DED treatment room. Interview revealed the patient was placed into a treatment room. Interview revealed RN #3 was unaware the patient was Patient #41. Interview revealed after being placed into a treatment room, the patient was evaluated by a MD and was subsequently admitted to the hospital's intensive care unit. Interview revealed, "Any staff nurse can request a patient be removed from the DED lobby." Interview revealed the Charge Nurse should be involved. Interview revealed only MDs, PAs, and NPs can do MSEs at the DED. Intervie

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care in the Emergency Department.

The findings include:

The hospital failed to ensure Emergency Department (ED) nursing staff supervised and evaluated patient care by failing to ensure nursing staff did not instruct security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed, for 2 of 52 sampled patients that presented to the hospital's ED and requested medical treatment.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to ensure Emergency Department (ED) nursing staff supervised and evaluated patient care by failing to ensure nursing staff did not instruct security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed, for 2 of 52 sampled patients that presented to the hospital's ED and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102)...."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain. EMS told me she was here the other day and didn't get her medicine filled. I moved her to the lobby. She continued cursing and walking around. She went to the bathroom a couple of times. I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3). She was pushing and slinging wheelchairs. (RN #3) went outside to talk with her. She came back in, balled her fist up and said to (RN #2), 'I'm going to cut you'. I told (RN #3) I wasn't going to stay in triage if they allow this to happen. I didn't hear (RN #3) tell her to leave but she left and didn't come back." Interview further revealed, "She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening." Interview further revealed the RN had received EMTALA training every 6 months. Interview revealed, "Here recently, we've had training more often." Interview further revealed, "I would never kick a patient out of the ED. If the situation escalates, I would contact my supervisor, in this case, the charge nurse, (RN #3)."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. She got up out of wheelchair several times. She went outside at least twice on her own. I called the charge nurse, (RN #3). He went out to talk with her. He brought her back in and when she came by triage, she jumped at the window and started cussing again." Interview further revealed, "She did not receive a medical screening exam prior to being escorted off the property. She absolutely should have received a medical screening. I saw her come back in a couple of hours later. It was after 9:30. I didn't triage her again because she never checked by in." Interview further revealed, "We get EMTALA training at least twice a year. With this patient, our EMTALA policy was not followed. This patient should have been offered a medical screening."

Interview on 11/17/2011 at 1320 with RN #3 revealed the nurse is a permanent charge nurse in the hospital's DED and was the charge nurse when Patient #39 presented to the DED on 10/18/2011. Interview revealed, "I saw her (Patient #39) at the EMS bay when she came in. She was alert and oriented and was sent to triage. I got a call from (RN #1). She said (Patient #39) was in the lobby cursing and they had removed her from the lobby and took her outside. I went outside, got the client, talked to her and de-escalated her. She told me she'd be cooperative and actually apologized. I brought her back in. She saw the nurse and became irate and started cursing again. I told her because of her violent nature, I would have her escorted off the property. I had her escorted off by security, can't remember his name." Interview further revealed, "I assessed her before asking her to leave the property. I didn't have a room to put her in. She was not asked to sign out AMA (against medical advice). I asked that she be removed from the property." Interview further revealed, "During the shift, the buck stops with me. I have had EMTALA training annually, here lately, everyday." Interview further revealed, "Our EMTALA policy was not followed."

Interview on 11/17/2011 at 1530 with RN #4 revealed the nurse is the service line director for the hospital's DED. Interview revealed, "We had more EMTALA training here in October. I helped develop the training. The education was about transfers, not medical screening exams." Interview further revealed, "MSEs can be performed in our ED by physicians, PAs (physician assistants) and nurse practitioners. I don't know why the nurses think they can provide MSEs." Interview further revealed, "Our EMTALA policy was not followed because they failed to give the patient a MSE by a licensed, qualified practitioner."

2. Closed medical record review for Patient #41 revealed a 28 year old female who presented to the hospital's Dedicated Emergency Department (DED) via Emergency Medical Services (EMS) ambulance on 10/18/2011 at 1358 (Presentation #1). Review of primary ("Frontline") triage nurse documentation revealed the patient was triaged at 1414 by a Registered Nurse (RN #1). Review revealed the patient complained of abdominal pain. Further review revealed at 1415 the patient's pain was assessed to be 9 out of 10 on a numerical pain scale (0 is pain free, 10 worse pain). Review revealed a past medical history of Asthma, Headache Migraine, Hypertension, and Urinary Tract Infections. Further review of "Primary Triage Info(rmation)" documented by RN #1 at 1417 revealed "....Note:~ pt to triage with RLQ (right lower quadrant) pain, states feels like pressure starting this am (morning) at 5. pt also states vomiting, denies diarrhea. Resp(irations) easy." Review revealed the patient was assigned "Initial Triage Acuity: 3 - Green (on a 1 to 5 Emergency Severity Index, with 1 being the most acute)." Review of documentation at 1427 by the secondary triage nurse (RN #2) revealed the patient's vital signs were assessed as Temperature (T) 100.0 (elevated) degrees Fahrenheit, BP 133/61, HR 107 (elevated), R 14, Pulse Oximetry 100% on room air. Review revealed "Orders: URINE-LAB PERFORMED U/A (urinalysis)" was ordered per DED protocol. Further review of RN #2's documentation at 1427 revealed, "....- Sepsis - (RN #2 name) Physician Notified: (MD #1 name) Sepsis Index of Suspicion: Unknown, Notify Physician/Provider." Review revealed at 1428 the patient was placed into the DED waiting room. Review of a "Triage Additional Note" documented by RN #3 (DED Charge Nurse on 10/18/2011 day shift) at 1552 revealed, "Note: Pt sitting at guest relations desk and will not move to have seat in lobby... pt ask to please have a seat in lobby and wait for available bed.. pt states she is not moving and began cursing at staff stating she has been waiting for 10 hours and patient has only been here 1.5 hours... Pt cursing still at staff, security notified and asked to escort pt out of lobby at this time. pt a (alert) and o (oriented) times 3 (person, place, time).. skin warm and dry.. resp(irations) even and non-labored and pt appears in no acute distress at this time.. pt refusing to cooperate and refrain from threatening behavior in triage... CPO (company police officer) notified and ask to remove patient from lobby..."

Review on 11/16/2011 of a CPO Incident/Investigation Report (NC02626249P, OCA1110-025) completed by CPO #1 and dated 10/18/2011 at 1550 revealed, "...Narrative Continued On or about 10/18/2011 15:50 hrs, Security Officer (SO) [name of SO #1] requested assisted in reference to a black female patient that Lead Charge Nurse (RN #3's name) wanted escorted out of the ED (emergency department) due to her refusing to cooperate with staff. I responded to same. I spoke with Officer (SO #1 name) who stated that the suspect, (Patient #41's name) was being disruptive with staff and refused to leave the ED. I requested Ms. (Patient #41's name) to leave and she refused. I advised her that if she didn't leave the ED she would be arrested for trespassing. Ms. (Patient #41's name) then left the ED and was walking toward the Tobacco store. Officer (SO #1's name) advised me that (RN #3's name) wanted her escorted off of the property. I advised Ms. (Patient #41's name) of same who had 2 white blankets that belonged to (name of Hospital). As we approached the edge of the property line, I advised Ms. (Patient #41's name) to give me the blankets. Ms (Patient #41's name) stated, 'No, I'm not giving you nothing, I'm cold.' I advised her that they belong to the hospital and she could be charged with larceny. Ms. (Patient #41's name) stated, 'No, I'm not giving them to you!' I tried to get the blankets from Ms. (Patient #41's name) who then pulled the blankets away from me. Ms. (Patient #41's name) continued to refuse to give me the blankets. I managed to get one blanket away from Ms. (Patient #41's name) who then started walking away off of property with the other blanket. Ms. (Patient #41's name) stated, 'There, you can have that one but I'm keeping this one. I advised (Patient #41's name) that she was under arrest and to put her hands behind her back. Ms. (Patient #41's name) refused to put her hands behind her back and continued to resist by trying to get her hands free from my hold. Officer (SO #1's name) arrived and assisted me so I could place handcuffs on Ms. (Patient #41's name). Officer (SO #1's name) and I escorted Ms. (Patient #41's name) to the CPO office (located adjacent to, but outside of the DED) to complete paperwork. I searched Ms. (Patient #41's name) and started the paperwork. Ms. (Patient #41's name) was very uncooperative and argumentative. Ms. (Patient #41's name) began to breath heavy, and stated that she has asthma. I asked her if she had her inhaler. Ms. (Patient #41's name) stated no. Ms. (Patient #41's name) stated that her chest felt tight. I called Lead Charge Nurse (RN #5's name) and requested him to check on Ms. (Patient #41's name). As I was on the phone with (RN #5's name) Ms. (Patient #41's name) began to vomit. I advised (RN #5's name) of same. (RN #5's name) checked Ms. (Patient #41's name) and stated that her lungs sound fine. (RN #5's name) advised me that she could be taken to room 31. I escorted Ms. (Patient #41's name) to room 31 and advised her that I wouldn't take her to jail but would charge her by citation (C 1713351-9)." Further review revealed Patient #41 was charged with Larceny and Resist, Delay, Obstruction.

Further medical record review for Patient #41 failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified (QMP) by hospital bylaws, rules and regulations, to determine whether or not Patient #41 had an emergency medical condition (EMC) after her initial presentation to the DED on 10/18/2011 at 1358 and before being escorted out of the DED lobby and off the hospital property at 1552 by a SO and CPO.

Further medical record review revealed Patient #41 was placed into DED treatment room Blue 31 South (Presentation #2) on 10/18/2011 at 1637 (45 minutes after being escorted off of hospital property). Review of the patient's vital signs documented at 1645 revealed the following: T 102.6 degrees Fahrenheit (2.6 degrees higher than on initial presentation), HR 122 (25 beats higher than on initial presentation), and R 32 (18 cycles higher than on initial presentation #1). Record review revealed the DED physician (MD #2) evaluated the patient at 1637. Review of documentation by MD #2 of the MSE performed on Patient #41 (after placement in room 31 - Presentation #2), dated 10/18/2011 (not timed), revealed Patient #41's complaint of abdominal pain, flank pain, and brief chest pain was described as constant and still present upon exam. Review revealed documentation the patient described the pain as sharp, stabbing with associated nausea and vomiting. Further review revealed the patient's pain severity was documented as severe. Review revealed documentation the patient had a past medical history of polycystic kidney disease. Review of physician documentation revealed the patient was assessed as being in moderate distress. Further review of physician documentation revealed the patient had tachycardia (elevated heart rate) and was awake and alert, but disoriented to place and time. Record review revealed diagnoses of Severe Sepsis, Acute Pyelonephritis, Altered Mental Status, Chest Pain, Abdominal Pain, Fever, and Tachycardia. Further record review revealed the patient was admitted to the hospital's intensive care unit for further treatment and was subsequently discharged on 10/25/2011 (7 days later) with final diagnoses of "1. Escherichia coli septicemia 2. Acute Pyelonephritis 3. History of polycystic kidney disease 4. Elevated blood pressure with a prior history of hypertension 5. Anemia (required blood transfusion) 6. Iron-deficiency anemia 7. Hypokalemia 8. Hypomagnesemia".

Interview on 11/17/2011 at 0945 with SO #1 revealed he was the security officer on duty in the DED lobby on 10/18/2011 when Patient #41 presented to triage via wheelchair with EMS personnel. Interview revealed his post is approximately 10 feet from the triage nursing station in the DED lobby. Interview revealed the check-in nurse (RN #1) called him over to make him aware of the patient's (Patient #41) behavior and that she was using profanity. Interview revealed the patient was already in the lobby area when he was informed of the patient's behavior. Interview revealed the patient came up to the check-in station (triage) then went back into the lobby. Interview revealed the patient returned to the patient information desk (guest services desk) in a wheelchair. Interview revealed the patient started using profanity and became loud enough for the SO to hear the patient. Interview revealed RN #1 told him that the patient needed to move away from the guest relations desk. Interview revealed the SO spoke with the patient and told her she needed to move back. Interview revealed the SO went behind the patient's wheelchair to move the patient back into the lobby when the patient got up out of the wheelchair and sat down in a chair in front of the patient information desk. Interview revealed the patient was using profanity and said she was not leaving until she spoke with someone to find out why she was waiting in the lobby and having pain. Interview revealed RN #1 was checking in another patient and did not come over to reassess the patient. Interview revealed the SO assumed someone called the charge nurse (RN #3) because he came out to speak with the patient. Interview revealed while RN #3 spoke with the patient, he called the CPO to put them on stand-by if "it became a trespass issue" when the patient was asked to leave. Interview revealed when ever a person displays hostility and uses profanity they may be asked to leave the property. Interview revealed it may be patients, visitors, or family members. Interview revealed, "It may happen twice per day or go weeks at a time and not happen." Interview revealed when the SO is asked to escort a patient out of the DED lobby or off the hospital property he is unsure if they have or have not had a medical screening examination by a QMP. Interview revealed the practice of SO or CPO escorting patients/visitors/family members out of the DED lobby or off hospital property has been in place since he has worked at the hospital (at least 7 years). Interview revealed he asks individuals to leave the DED lobby or property under the direction of clinical staff such as doctors and nurses. Interview revealed on 10/18/2011 RN #3 came out and spoke with the nurse who called him and then he talked to Patient #41. Interview revealed afterwards he told him (SO #1) "She (Patient #41) can leave." Interview revealed the patient was verbally hostile, loud, and using profanity but he did not observe her being a danger to herself or others. Interview revealed he did not witness RN #3 reassess the patient, but he (RN #3) just walked back through the double doors into the DED treatment area. Interview revealed the SO called the CPO for assistance. Interview revealed CPO #1 arrived to the DED lobby and he (SO #1) discussed the patient (#41) with the CPO. Interview revealed CPO #1 asked the patient to leave. Interview revealed the patient stated she would not leave until waited upon. Interview revealed the patient was using profanity. Interview revealed the patient then got up and said she was going to leave and not wait for her ride. Interview revealed the patient had two hospital blankets in which the CPO told her she could take outside. Interview revealed the patient then went out the door with the CPO and himself following. Interview revealed another SO was outside of the DED and SO #1 asked that SO to keep an eye on the CPO and patient. Interview revealed SO #1 then returned back inside the DED lobby. Interview revealed he last viewed the patient stepping up on the curb in the DED parking lot by the fire hydrant with the CPO. Interview revealed after returning into the DED lobby he received a radio call from the base operator requesting him to go out and assist CPO #1. Interview revealed he went outside and saw CPO #1 and Patient #41 at the corner of the Tobacco Shop building (a private commercial establishment adjacent to hospital's DED parking lot). Interview revealed the CPO was struggling with the patient and holding her left arm. Interview revealed the patient was up against the fence (property line) facing towards the tobacco store parking lot. Interview revealed he assisted the CPO place Patient #41 into handcuffs. Interview revealed he escorted the CPO and patient back to the hospital entrance. Interview revealed the CPO and patient went to the CPO office adjacent to the DED and he went back into the DED lobby.

Interview on 11/17/2011 at 1100 with CPO #1 revealed she was the company police officer on duty 10/18/2011 when Patient #41 was escorted out of the DED lobby and arrested. Interview revealed SO #1 called for assistance in the DED lobby. Interview revealed when she arrived Patient #41 was sitting in a chair in front of the visitors' information desk (guest services desk). Interview revealed the patient was acting out, using profanity, and was disruptive. Interview revealed SO #1 stated RN #3 wanted the patient escorted off of the property because she would not move out from in front of the guest services desk and was cursing. Interview revealed when the CPO arrived the patient was not appearing suicidal, homicidal or a danger to self or others. Interview revealed the patient was verbally abusive, using profanity, and being loud. Interview revealed, "If the Lead Charge Nurse wants a patient escorted off of the property then we do what the Charge Nurse requests regardless of medical treatment and condition." Interview revealed she approached the patient while on her cell phone and she advised the patient she was going to have to leave because the hospital was requesting her to leave. Interview revealed the patient continued to talk on the cell phone telling someone "they are kicking me out of the hospital. Can you come and pick me up". Interview revealed the patient ignored the officer's request to leave 3-4 times. Interview revealed the CPO informed Patient #41 if she did not leave she (CPO #1) would have to arrest her for trespassing. Interview revealed the patient continued to ignore the CPO until she unsnapped her handcuff case to remove her handcuffs. Interview revealed the patient then stood up and walked out of the DED lobby without assistance. Interview revealed when the patient walked towards the exit doors the patient stated she was cold and was advised by her (CPO#1) that she (Patient #41) could hold onto the two blankets she had wrapped around her for right then. Interview revealed, "(SO #1) stated, 'He (RN #3) wants the patient off the property.'" Interview revealed CPO #1 advised the patient that she was to be escorted off hospital property. Interview revealed as she escorted the patient off the property the patient was very argumentative and "venting." Interview revealed the CPO and patient walked towards the smoking area where the patient wanted to wait for her ride. Interview revealed the patient was informed she could not wait at the smoking area because it was still hospital property. Interview revealed the patient was instructed by the CPO that she could wait at the bus stop or on the tobacco store property (not on hospital property). Interview revealed the patient requested to wait at the tobacco store. Interview revealed the CPO requested the patient to give back the two hospital blankets and the patient became argumentative. Interview revealed the patient refused to give the blankets back. Interview revealed the officer advised the patient if she did not give the blankets back she would be charged with larceny. Interview revealed the patient refused to give back the blankets and the CPO grabbed for the blankets and retrieved one. Interview revealed the patient refused to give her the second blanket. Interview revealed the CPO reached for the other blanket and the patient went to grab for the CPO's hands. Interview revealed the CPO then advised the patient she was under arrest. Interview revealed she (CPO #1) struggled with the patient to get her into handcuffs. Interview revealed SO #1 arrived and assisted with placing the patient into handcuffs. Interview revealed the patient was escorted back to the CPO office. Interview revealed the CPO initiated paperwork for the magistrate in preparation to take Patient #41 to jail. Interview revealed the patient was searched and was being very difficult and verbally abusive. Interview revealed while completing the paperwork for the magistrate, the patient started breathing heavy and complained of chest tightness. Interview revealed the CPO called the Lead Charge Nurse desk and requested the charge nurse (RN #5) come evaluate the patient. Interview revealed RN #5 came to evaluate the patient and stated the patient's chest was clear and she was "fine." Interview revealed he went back to the DED. Interview revealed the patient vomited. Interview revealed the CPO called the Lead Charge Nurse desk and informed RN #5 the patient had vomited. Interview revealed she spoke with the RN #5 on the phone and he assigned the patient to treatment room 31 Blue. Interview revealed the patient's handcuffs were removed and she was escorted to the treatment room. Interview revealed Patient #41 would have been transported from the Hospital's CPO office to jail had she not vomited in the CPO office. Interview revealed the CPO and SO are requested to escort and remove patients/visitors/family members from the DED lobby and off hospital property "quiet often on a regular basis". Interview revealed the CPOs and SOs do not know if patients have been provided an MSE by a QMP prior to being escorted out of the DED lobby or off hospital property.

Interview on 11/17/2011 at 1200 with RN #1 revealed she was the "Frontline" (primary) triage nurse on 10/18/2011 when Patient #41 presented to the DED. Interview revealed she remembers the patient because she (Patient #41) was "all over" the newspaper. Interview revealed the patient came in by EMS and was brought to triage via wheelchair. Interview revealed the patient complained of abdominal pain. Interview revealed a quick assessment was performed and the patient was assigned a ESI (emergency severity index) level of 3 - Green. Interview revealed ESI 3 is "non-emergent, requires a certain number of interventions, needs to see a doctor within a certain amount of time, I think 2 hours for green". Interview revealed vital signs were not obtained at primary triage. Interview revealed the patient was sent to secondary triage. Interview revealed the nurse went to the bathroom and then returned and Patient #41 was sitting at the guest services desk. Interview revealed the patient was cursing and vulgar towards staff and would not move from the desk to the lobby. Interview revealed she did not reassess the patient at the guest services desk. Interview revealed she called the charge nurse (RN #3). Interview revealed RN #3 came out to speak with the patient at the guest services desk but she did not hear the conversation because she was with another patient at triage when RN #3 came out to speak with the patient. Interview revealed patients in the lobby are to be reassessed if they come up to the desk with additional complaints or worsening symptoms. Interview revealed patients must be reassessed at least every 2 hours if they are green. Interview revealed the amount of reassessment depends on the symptoms. Interview revealed, "As an RN, I can give Medical Screenings but can not diagnose." Interview revealed according to hospital policy only MDs, PAs, and FNPs can do MSEs in the ED. Interview revealed any provider or Charge nurse can instruct a SO or CPO to ask a patient to leave the ED. Interview revealed Patient #41 did not receive a MSE by a QMP while in the DED on 10/18/2011 from the time of triage until 1552, when she was escorted out of the DED lobby. Interview revealed the patient should have had a MSE performed before she was asked to leave. Interview confirmed the hospital staff did not follow the hospital's EMTALA policy.

Interview on 11/17/2011 at 1235 with RN #2 revealed she was the secondary triage nurse on 10/18/2011 when Patient #41 presented to the DED. Interview revealed the patient came in by EMS. Interview revealed the patient complained of abdominal pain. Interview revealed RN #2 obtained Patient #41's vital signs. Interview revealed the patient was placed into the lobby after triage. Interview revealed she observed the patient come back up to the guest services desk. Interview revealed the patient

Based on observations as referenced in the Life Safety Report of survey completed 10/16/2011, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710

2. The hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709

3. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701

4. The hospital failed to ensure the safety of patients by failing to ensure the proper function of emergency power and lighting systems.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0702

5. The hospital failed to ensure the safety and well-being of patients by failing to ensure trash was stored in an approved container.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0713

Based on observations as referenced in the Life Safety Report of survey completed 11/16/2011, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

A. Observations of Building 1 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following interior finish was non-compliant: There was untreated plywood used to mount wall TV in break room, express care area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0015
2. The following illumination of means of egress was non-compliant:
a. 2D waiting room leaves area in darkness PST4-004 (family birth center, south tower)upon normal power loss.
b. Admin and CS&H waiting room leaves area in darkness upon loss of normal power.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0045

3. The following was non-compliant:
a. In CYSTO 2 surgery room the Relative Humidity gauge was not operational.
b. In the OR suites the Relative Humidity gauges were not operational.
c. In Short Stay surgical suite there were not Relative Humidity gauges present.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0078

4. The following was non-compliant:
a. The medication refrigerator located on 4th floor in the intermediate NICU unit (small refrigerator) is not connected to emergency power.
b. The pyxis station at old nursery and med room is not connected to emergency power.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147

B. Observations of Building 2 on 11/09/2011 - 11/16/2011 revealed the following:

The following was non-compliant: The electrical ground was not a consistent green ground throughout, it was taped at both ends with green tape. 1st floor IST room VP1C118 and near VP1C120 to the copper water line.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147

C. Observations of Building 3 on 11/09/2011 - 11/16/2011 revealed the following:

The following was non-compliant: There was not emergency egress lighting on the exit discharge path from the back courtyard gate to the front of the building/public way. Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0045

D. Observations of Building 6 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following illumination of means of egress was non-compliant:
a. There was not a light on emergency power or a battery operated emergency light located in the two ultra sound rooms.
b. The emergency light near the MRI door did not function properly when tested.
c. There is not proper coverage of emergency illumination in the back hall office area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0045

2. The following was non-compliant: In the pre-surgery suite there are receptacles throughout the suite that are cracked and/or broken and not maintained in good repair.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147

Based on observations as referenced in the Life Safety Report of survey completed 11/16/2011, the hospital failed to ensure the safety of patients by failing to ensure the proper function of emergency power and lighting systems.

The findings include:

A. Observations of Building 1 on 11/09/2011 - 11/16/2011 revealed the following:

The following operational inspection and testing was non-compliant: Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0144

B. Observations of Building 5 on 11/09/2011 - 11/16/2011 revealed the following:

The following was noted: Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.

NFPA 99 3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110 6-4.2 (1999 edition) generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
NFPA 110 6-4.2.2 (1999 edition) Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (load bank testing)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0144

Based on observations as referenced in the Life Safety Report of survey completed 11/16/2011, the hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

The findings include:

A. Observations of Building 1 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following was non-compliant: Room 1-118 has med gas lines penetrating the room and was not properly enclosed in the wall and ceiling.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0011

2. The following building construction type items were non-compliant:
a. In Patient Service Tower, ground floor above door PST-0-078, there are holes and/or penetrations that were not sealed in order to maintain the required rating of the area.
b. Main Building 7th floor, the Patient Care Managers office is located in the elevator lobby area and not construction in order to maintain the required 1-hr fire resistance rating for the room.
c. Corridor Door Main 4W-4-056 is not a rated door. Door is required to be a ? hour fire rated door in order to meet the construction requirements for the area.
d. 4th floor piping and electrical closet, location 4N-4-034 has holes and penetrations that are not sealed and/or protected in order to meet the 2-hr fire rated construction requirements for the area.
e. The two hour rated corridor wall for the Main Computer Room was not properly sealed. Non rated foam insulation was used to seal penetrations in the wall.
f. The rated wall in the UPS Battery Room has a hole that was not sealed in order to maintain the required rating of the wall.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012

3. The following corridor doors were non-compliant: The doors to rooms listed did not close and latch tightly in their frames: 402, 418 (family birth center, south tower) 4-217 rehab, and 2-053.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018

4. The following vertical opening was non-compliant: In the Pent House area, the access door to the 2 hr. fire rated vertical shaft did not close, latch and seal.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0020

5. The following smoke wall was non-compliant:
a. Smoke Wall 7th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.
b. Smoke Wall 6th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.
c. Smoke wall located above the ceiling in the Soiled holding room Main 3S-3-032 has holes that have not been sealed in order to maintain the required rating of the area.
d. Smoke tight shutters in the labs rated wall did not close after three fire alarm tests were conducted.
e. There was not a rated sleeve on the penetration in one hour rated wall on 2 South (main 2S-2-2006)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0025

6. The following doors in smoke barriers was non-compliant:
a. Cross corridor doors not smoke tight in the family birth center, South tower.
b. Cross corridor doors 2S-2-079 did not close with fire alarm activation, 2 South.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0027

7. The following hazardous areas were non-compliant:
a. The Soiled holding/linen corridor door (Main 5W-5-019) did not close latch and seal.
b. The Soiled utility/linen room corridor door (Main 8-8-096) did not close latch and seal.
c. Housekeeping storage closet corridor door, (Main8-8-010) was not self closing.
d. Corridor door to storage room, location Main 4N-4-046 is not rated and not self closing. (Room labeled as Women and Children Services)
e. Door to the clean supply room PST 2-057 does not have positive latching.
f. The wall to the clean supply storage room in PACU PST-2-109 had holes that are not sealed.
g. The storage room PST 2-107 does not meet the requirements for hazardous area. Patient care room was converted to storage room.
h. The equipment storage room corridor door did not close, latch and seal. (PST-2-034)
i. The storage room door, to room labeled Main 2N-2-043/045, was not self-closing.
j. The soiled linen room corridor door Main 2N-2-009 did not close, latch and seal.
k. The oxygen storage room Main 2N-2-024 was not self closing.
l. Dry storage room #2 did not have positive latching.
m. Door to janitor's closet PST 1-036 did not have positive latching.
n. Door to soiled utility/linen room AS3-092 (ICU) does not have positive latching.
o. Door to storage room, main 2S-2-052 and 2S-2-019, was a non-rated door.
p. Door to storage room, old cat lab/2 west: 2W-2-023, was a non-rated door.
q. Door to storage room, Administration: 2W-2-003, was a non-rated door.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029

8. The following exit and directional signs were non-compliant:
a. Additional exit and directional signage is needed from the 4th Floor West Wing corridor back into the NICU unit. At present exit directional signage is provided in one direction only.
b. Additional exit and directional signage is needed from the 3rd Floor West Wing corridor back into the Respiratory Therapy Unit. At present exit directional signage is provided in one direction only.
c. Additional exit and directional signage is need in the connecting corridor between NICU and 4th floor west wing.
d. Additional exit and directional signage needed between A and UB Lab 2nd Floor Main Connecting Corridor.
e. Additional exit and directional signage needed in the outer center core of the surgical suite.
f. Exit signage is need above exit door PST 1-006.
g. Additional exit and directional signage needed In the Medical Records and Health Management suite leading individual to a second means of egress from the area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047

9. The following fire alarm component was non-compliant: There was not a smoke detector in old cath lab/2 west storage room.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051

10. The following sprinkler system and components were non-compliant:
a. The recessed sprinkler head located in the patient room Main 6-634 located in front of patient bed was out of adjustment and would not provide coverage for the area.
b. There is no sprinkler coverage in the shower stalls in sleep lab bathrooms 1, 3, & 5 and in rehab.
c. The sprinkler heads, on the loading dock, are not uniform across the entire area and are not properly rated in all areas. 200 degree (green) heads are mixed in with 155 degree (red) heads. Sprinkler head ratings in the area should be 155 degree (red) unless documentation would indicate otherwise.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056

11. The following sprinkler system supervision was non-compliant:
a. In the South Tower there are three valves on the main sprinkler line that are not supervised with an electronically supervised tamper alarms.
b. In the South Tower the tamper alarms on the fire pump did not activate and alarm when tested.
c. In the Patient Service Tower area in main building the tamper alarm on the fire pump did not sound an alarm when tested.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0061

12. The following was non-compliant:
a. In Pent House smoke duct detector NS-M1-12 located in the HVAC unit was not maintained clean and in good condition.
b. The smoke duct detector located in the corridor in front of room Main 6S-6-101 was not clean and not maintained in good condition.
c. The smoke duct detector #17 located in pediatric (5N-5-033) was not clean and maintained in good condition.
d. The Phase # Recovery Suite did not have an emergency HVAC shut down switch.
e. The GI Lab 2nd floor main did not have an emergency HVAC shut down switch.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067

13. The following means of egress was non-compliant:
a. Multiple items such as equipment and a charting table stored in front of each ICU breakaway door. In an emergency rolling multiple beds out of the suite would be difficult because of multiple items that would be rolled in the exit egress to use the breakaway door.
b. IST workstation did not close, blocking exit path between rooms 2 & 3 (express care).
c. IST workstation did not close, blocking exit path across from fire door main 2S-2-701.
d. IST workstation did not close, blocking exit path from CSICU/2 west.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0072

14. The following medical gas storage was non-compliant:
a. Full and empty oxygen cylinders were stored together. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (8th and 5th floor oxygen storage rooms)
b. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] Medical gas cylinders located in room Main 3W-3-080 were found gang chained together.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076

B. Observations of Building 2 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following building construction type item was non-compliant: There were unsealed penetrations in ceiling 1st floor IST room VP1C118.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012

2. The following corridor doors were non-compliant: The CT-Scan corridor room door VP-GA026 was not equipped with positive latching.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018

3. The following doors in smoke barriers was non-compliant: The door in smoke wall located next to VP-GD021A did not close smoke tight.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0027

4. The following hazardous areas were non-compliant:
a. The corridor door to storage room VP-GA038A does not close, latch and seal.
b. The corridor door to Clean Utility Room 2nd FloorVP-2C226, did not close, latch and seal.
c. The Soiled Utility room door VP-2C225, did not close, latch and seal.
d. The equipment storage room corridor door was not self closing. VP-2A254
e. The Soiled utility room corridor door VP-2A240 did not close, latch and seal.
f. Door to storage room, old peds ed waiting room, was a non-rated door.
g. Doors to environmental room storage on green hall and outside yellow hall ED, were a non-rated doors.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029

5. The following was non-compliant:
a. The 5th floor elevator equipment room had an individual Heating Ventilating and Air Conditioning (HVAC) unit within the two hour enclosure that did not shut down with fire alarm activation.
b. The 3rd floor HVAC unit did not have an emergency HVAC shut down switch.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067

C. Observations of Building 3 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following was non-compliant: During the inspection and testing of the facility fire alarm system, that consisted of multiple components, the automatic dialer component, when placed in trouble from phone line failure did not send a trouble signal to the main fire alarm control panel (FACP) located at the nurses station.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051

2. The following was non-compliant: Curtains in the shower of bedroom 118 did not have 1/2" mesh in the upper eighteen inches to provide sprinkler coverage.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056

D. Observations of Building 5 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following was non-compliant:
The facility renders one or more incapable of self-preservation by the use of a linear accelerator. Provide plans to confirm Ambulatory Health Care (AHC) with the following items addressed:
a. Area and building construction type to be surveyed as AHC. One side is protected construction, the other area was not protected. Different building area divisions were discussed with no final plan.
b. Ambulatory health care (AHC) occupancies are separated from other tenants and occupancies by fire barriers with at least a 1 hour fire resistance rating. Currently there is one tenant occupying the space on the second floor.
c. Ambulatory health care facilities are divided into at least two smoke compartments with smoke barriers having at least 1 hour fire resistance rating. Identify the smoke compartments for the area rendered AHC or state the exception to be used.
d. Ambulatory health care facilities have heating ventilation and air-conditioning (HVAC) comply with 20.5.2.1 Currently not all spaces have ducted returns.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012

2. The following was non-compliant: The bulk oxygen room had H tanks gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)]

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0076

E. Observations of Building 6 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following corridor door was non-compliant: Corridor Door OB-18-1-072 did not close, latch and seal.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018

2. The following hazardous area was non-compliant: The corridor hall door to the Janitor storage closet OB-18-1-035 was not self closing.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029

3. The following was non-compliant: The exterior exit access/discharge from the rear of building, near x-ray area, was not a solid path (easily maintained in inclement weather) to a public way.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0032

4. The following exit and directional signs were non-compliant: Additional exit and exit direction signs are needed in the back corridor and hall.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047

5. The following fire alarm component was non-compliant:
a. The FACP and it's components had not been inspected and tested in the past year. The last test was conducted in 2008.
b. During the inspection and testing of the facility fire alarm system, that consisted of multiple components, there was not a visual/audible trouble signal at the Fire Alarm Control Panel (FACP) with loss of AC power and battery back-up power.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051

6. The following was non-compliant:
a. The smoke duct detector located in the AC Unit #2 did not have an access door for visual inspection and maintenance. Note: Additional information is needed on the remaining HVAC units concerning CFM output in order to determine if additional smoke duct detectors are need in the units.
b. The Heating Ventilating, and Air Conditioning (HVAC) unit in the main mechanical/electrical room was under replacement during the survey. Mechanical and electrical components were incomplete.
c. The HVAC system did not shut down with fire alarm activation.
d. The HVAC shut down switch located behind the receptionist desk did not function properly when tested.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067

Based on observations as referenced in the Life Safety Report of survey completed 11/16/2011, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

A. Observations of Building 1 on 11/09/2011 - 11/16/2011 revealed the following:

The following exit accesses were non-compliant:
a. Facility is equipped with special locking and the facility is not 100% sprinkler coverage. Areas not cover by sprinkler coverage will need to be protected with heat and/or smoke detector. The Doctor wash closets located in PST-4-042 Labor and Delivery does not have sprinkler coverage and is not provided with smoke detectors.
b. The override switch for mag locks at nurses station not labeled (ICU)
c. Machine blocking access to override switch for magnetic locking devices at nurses station (express care)
d. The exit cross corridor door Main 2NA-2-011 is equipped with mag locks and when tested did not drop out upon activation of fire alarm. The doors did release with switch at the door and master override switch.
e. Exit door PST 1-006 required more that 15 lbs of force to open.
Doors shall be operable with not more than one releasing operation, 7.2.1.5.4
f. Main Building 4th floor, Flower shop, requires two motions of the hand to exit the room.
g. Clinical educator office and adjoining room has bathroom that requires two motions of the hand exit the room. Location North Hall 4th floor 4-016 and 4-011.
h. The restroom located in the elevator lobby location 3-W-3-080 requires two motions of the hand to exit the room.
i. 2 South door going into old prep room, requires two motions of the hand to exit the room.
j. Rehab bathroom 2-662 and nourishment room 2-038, requires two motions of the hand to exit the room.
k. Door in old cath lab, 2W-2-038, requires two motions of the hand to exit the room.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038

B. Observations of Building 2 on 11/09/2011 - 11/16/2011 revealed the following:

The following exit accesses were non-compliant:
a. The cross corridor door in the lobby area location VP-GAO25 is in the means of egress and does not have an emergency override switch located within 3 feet of the door.
b. The Red Zone ED area is equipped with magnetic locking devices with Key Override switches. None of the staff when asked could provide keys for the override switched. The center cross corridor control doors did not release with master override switch and switches at the doors did release doors. Doors would release upon activation of fire alarm activation.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038

Based on observations as referenced in the Life Safety Report of survey completed 11/16/2011, the hospital failed to ensure the safety and well-being of patients by failing to ensure trash was stored in an approved container.

The findings include:

Observations of Building 1 on 11/09/2011 - 11/16/2011 revealed the following:

The following trash collection was non-compliant: Trash containers greater than 32 gallons were found stored in the corridor area leading to central supply.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0075

Based on review of medical staff rules and regulations, hospital transcription line instructions, medical records, and staff interviews, the hospital failed to ensure the completion of an operative report immediately following surgery for 4 of 7 surgical records reviewed (#44, #45, #24 and #25).

The findings include:

Review of the hospital's Medical Staff Rules and Regulations, revised 02/2006, revealed, "...D. Surgical Care...3. Operative reports shall be written or dictated immediately following surgery, and shall include a detailed account of the findings at surgery and the details of the surgical technique. Such reports shall be signed and placed in the patient's medical record promptly...."

Review of the hospital's "Acute Care Call-in for Listen Line" revealed "Call-In Instructions for Acute Care Reports (H&P [history and physical], OP [operative], Consults, Etc) 1. From any regular phone, dial X5672. Outside dial 615-5672. 2. Enter user ID# 6622 followed by the #key. 3. Enter 1-job number. 4. Enter job number followed by the # key. 5. Dictation will begin...".

1. Open record review of Patient #44 revealed a 50 year-old admitted 11/14/2011 with gastric outlet obstruction. Record review revealed the patient had an EGJ (esophago-gastro jejunoscopy) on 11/15/2011. Record review revealed a physician's handwritten Endoscopy Report Progress Note with Post Procedure note (not timed). Record review revealed a physician's dictated operative report at 0812, transcribed at 1242. Review of the dictated report revealed it was not signed by the physician.

Interview on 11/15/2011 at 1100 with the Director of Surgical Services revealed the post procedure note should be written immediately following a surgical procedure. Interview confirmed the post procedure note was not timed by the physician.

Further interview on 11/15/2011 at 1600 with the Director of Surgical Services revealed any physician or nurse could call in to the hospital's dictation system and audibly retrieve any physician notes that were dictated, including operative reports, thus making dictated operative reports immediately available to all staff.

Interview on 11/16/2011 at 0950 with nursing staff while on tour revealed the nurses do not use the transcription number to call for an immediate operative report. Interview revealed the nurses need that report immediately in the PACU (post-anesthesia care unit) and would not have time to call. Interview revealed the nurses had not been instructed to obtain operative reports from the transcription line.

2. Open record review of Patient #45 revealed a 56 year-old admitted 11/14/2011 with right knee osteoarthritis. Record review revealed the patient had a right total knee replacement on 11/14/2011. Record review revealed a physician's handwritten Brief Operative Progress Note (not dated or timed). Record review revealed a physician's dictated operative report at 0940, transcribed at 1131. Review of the dictated report revealed it was not signed by the physician.

Interview on 11/15/2011 at 1100 with the Surgical Services Administration revealed the post procedure note should be written immediately following a surgical procedure. Interview confirmed the post procedure note was not dated or timed by the physician.

Further interview on 11/15/2011 at 1600 with the Director of Surgical Services revealed any physician or nurse could call in to the hospital's dictation system and audibly retrieve any physician notes that were dictated, including operative reports, thus making dictated operative reports immediately available to all staff.

Interview on 11/16/2011 at 0950 with nursing staff while on tour revealed the nurses do not use the transcription number to call for an immediate operative report. Interview revealed the nurses need that report immediately in the PACU (post-anesthesia care unit) and would not have time to call. Interview revealed the nurses had not been instructed to obtain operative reports from the transcription line.



16369

3. Closed record review of Patient #24 revealed a 26 year-old male admitted for a surgical procedure on 10/03/2011. Review of the record revealed the patient had a left testicular tumor and radical left ordchiectomy (surgical procedure) performed under general anesthesia on 10/03/2011. Review of the record revealed the surgery started at 1045 and ended at 1100. Review of physician's "Brief Operative Progress Note" revealed a note documented by the surgeon that described the surgical procedure performed on 10/03/2011. Further review revealed the progress note was dated 10/03/2011 and timed 1000 (prior to the surgical procedure start time). Record review revealed an "Operative Note" that was dictated on 10/04/2011 at 1642 and transcribed on 10/06/2011 at 0713 (available 3 days after the surgery). Record review revealed no further documentation of an immediate post operative note.

Interview on 11/15/2011 at 1245 with a surgical administrative staff member revealed a brief operative note should be documented by the surgeon immediately after surgery. The staff member reviewed the progress note and stated the immediate operative note was written prior to the surgery start time. The staff member was unable to explain how details of the surgical procedure could be documented prior to the surgical procedure being performed.

Telephone interview on 11/15/2011 at 1315 with the surgeon revealed a brief surgical note should be documented immediately following the surgery. The surgeon stated "I usually do it (operative note) when I finish the case. It must have been a mistake. There is no way to do that because you never know what you are going to find."



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4. Closed medical record review for Patient #25 revealed a 62 year-old male that was admitted on 09/03/2011 with Coronary Artery Disease. Record review revealed on 09/04/2011 the patient underwent a surgical Coronary Artery Bypass Graft. Record review revealed the surgery ended on 09/04/2011 at 1210. Record review revealed documentation of an operative note dictated by the surgeon on 09/04/2011 at 1223 and transcribed on 09/05/2011 at 1338. Further record review revealed documentation of a handwritten post-operative noted dated 09/04/2011 (no time) and signed by the surgeon. Record review revealed no documented evidence a physician's post-operative report was completed and immediately available in the record immediately following the patient's surgery.

Interview on 11/15/2011 at 1600 with the Director of Surgical Services confirmed the handwritten post-operative report was not timed and thus the Director did not know when it was completed. Interview confirmed there was no documented evidence a physician's post-operative report was completed and immediately available in the record immediately following the patient's surgery. Further interview revealed any physician or nurse could call in to the hospital's dictation system and audibly retrieve any physician notes that were dictated, including operative reports, thus making dictated operative reports immediately available to all staff.

Interview on 11/16/2011 at 0950 with nursing staff while on tour revealed the nurses do not use the transcription number to call for an immediate operative report. Interview revealed the nurses need that report immediately in the PACU (post-anesthesia care unit) and would not have time to call. Interview revealed the nurses had not been instructed to obtain operative reports from the transcription line.

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to meet the emergency needs of patients.

The findings include:

The hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 52 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment.

~cross refer to 482.55(a) Emergency Services Standard: Tag A1101

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 52 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Further closed record review revealed Patient #39 returned to the hospital's DED 11/12/2011 at 0909 via EMS with a chief complaint of abdominal pain. Review revealed the patient was triaged at 0918 and assigned an initial acuity of Level 3. Record review revealed documentation at triage of blood pressure 148/116, pulse 107, respirations 22, and pain level of 10 of 10. Record review revealed Patient #39 was medically screened by the DED physician at 0933, labs were ordered, and Toradol (pain medication) and Zofran (anti-nausea medication) were given intravenously. Further review revealed the patient was admitted to the hospital at 1915. Review of the physician's dictated History and Physical dated 11/12/2011 at 1656 revealed , "...Assessment and Plan 1. Acute Pancreatitis, based on the history, the clinical findings and the elevated lipase level (610, with normal of 73-393)...2. Type 2 diabetes...3. Intractable vomiting...4. Abdominal pain...5. History of ovarian cyst...6. Obesity...7. ...admitted to the medical unit...." Review of the physician's dictated discharge summary dated 11/14/2011 at 1435 revealed, "...Discharge Diagnoses 1. Acute exacerbation of pancreatitis 2. Uncontrolled type 2 diabetes mellitus....Disposition The patient is being discharged home in stable condition...."

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102). See Incident Report."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain. EMS told me she was here the other day and didn't get her medicine filled. I moved her to the lobby. She continued cursing and walking around. She went to the bathroom a couple of times. I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3). She was pushing and slinging wheelchairs. (RN #3) went outside to talk with her. She came back in, balled her fist up and said to (RN #2), 'I'm going to cut you'. I told (RN #3) I wasn't going to stay in triage if they allow this to happen. I didn't hear (RN #3) tell her to leave but she left and didn't come back." Interview further revealed, "She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening." Interview further revealed the RN had received EMTALA training every 6 months. Interview revealed, "Here recently, we've had training more often." Interview further revealed, "I would never kick a patient out of the ED. If the situation escalates, I would contact my supervisor, in this case, the charge nurse, (RN #3)."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. She got up out of wheelchair several times. She went outside at least twice on her own. I called the charge nurse, (RN #3). He went out to talk with her. He brought her back in and when she came by triage, she jumped at the window and started cussing again." Interview further revealed, "She did not receive a medical screening exam prior to being escorted off the property. She absolutely should have received a medical screening. I saw her come back in a couple of hours later. It was after 9:30. I didn't triage her again because she never checked by in." Interview further revealed, "We get EMTALA training at least twice a year. With this patient, our EMTALA policy was not followed. This patient should have been offered a medical screening."

Interview on 11/17/2011 at 1320 with RN #3 revealed the nurse is a permanent charge nurse in the hospital's DED and was the charge nurse when Patient #39 presented to the DED on 10/18/2011. Interview revealed, "I saw her (Patient #39) at the EMS bay when she came in. She was alert and oriented and was sent to triage. I got a call from (RN #1). She said (Patient #39) was in the lobby cursing and they had removed her from the lobby and took her outside. I went outside, got the client, talked to her and de-escalated her. She told me she'd be cooperative and actually apologized. I brought her back in. She saw the nurse and became irate and started cursing again. I told her because of her violent nature, I would have her escorted off the property. I had her escorted off by security, can't remember his name." Interview further revealed, "I assessed her before asking her to leave the property. I didn't have a room to put her in. She was not asked to sign out AMA (against medical advice). I asked that she be removed from the property." Interview further revealed, "During the shift, the buck stops with me. I have had EMTALA training annually, here lately, everyday." Interview further revealed, "Our EMTALA policy was not followed."

Interview on 11/17/2011 at 1420 with MD #1 revealed the physician is the medical director of the hospital's DED. Interview revealed, "It's always concerning to me when a patient is moved to the lobby or outside prior to seeing a physician. (Patient #39) should have been seen by a physician or if her behavior was escalating she should have been moved to another area other than the lobby, probably not the security office which is not the best area to place a patient." Interview further revealed, "I was not aware of (Patient #39) being escorted off property prior to a MSE until today."

Interview on 11/17/2011 at 1530 with RN #4 revealed the nurse is the service line director for the hospital's DED. Interview revealed, "We had more EMTALA training here in October. I helped develop the training. The education was about transfers, not medical screening exams." Interview further revealed, "MSEs can be performed in our ED by physicians, PAs (physician assistants) and nurse practitioners. I don't know why the nurses think they can provide MSEs." Interview further revealed, " I was made aware of the incident with (Patient #39). I reminded staff that an MSE needed to be done irregardless of behaviors. I had a verbal discussion with (RN #3)." Interview further revealed, "Our EMTALA policy was not followed because they failed to give the patient a MSE by a licensed, qualified practitioner."

2. Closed medical record review for Patient #41 revealed a 28 year old female who presented to the hospital's Dedicated Emergency Department (DED) via Emergency Medical Services (EMS) ambulance on 10/18/2011 at 1358 (Presentation #1). Review revealed the patient was registered into the DED at 1402. Review of EMS documentation revealed the patient was transported to the DED for complaints of Right Flank Pain radiating in and towards the groin. Further review revealed the patient reported to EMS personnel "...AWOKE IN PAIN THIS MORNING ABOUT 0400 hrs (hours). CONTINUED TO GET WORSE INSTEAD OF BETTER. GOT NAUSEATED AND VOMITED. TRIED TO USE BATHROOM BUT COULD NOT...." Review of EMS assessment documentation revealed the patient was alert with guarding and tenderness in the right lower abdominal quadrant. Review of vital signs documented at 1345 revealed the following: Blood Pressure (BP) 132/80, Heart Rate (HR) 108, Respirations (R) 18. Review of EMS documentation revealed, "1420....AT THE DIRECTION OF THE CHARGE NURSE, PT (patient) WAS MOVED TO TRIAGE VIA WHEEL CHAIR, AND PT CARE WAS TRANSFERRED TO TRIAGE NURSE." Review of primary ("Frontline") triage nurse documentation revealed the patient was triaged at 1414 by a Registered Nurse (RN #1). Review revealed the patient complained of abdominal pain. Further review revealed at 1415 the patient's pain was assessed to be 9 out of 10 on a numerical pain scale (0 is pain free, 10 worse pain). Review revealed a past medical history of Asthma, Headache Migraine, Hypertension, and Urinary Tract Infections. Further review of "Primary Triage Info(rmation)" documented by RN #1 at 1417 revealed "....Note:~ pt to triage with RLQ (right lower quadrant) pain, states feels like pressure starting this am (morning) at 5. pt also states vomiting, denies diarrhea. Resp(irations) easy." Review revealed the patient was assigned "Initial Triage Acuity: 3 - Green (on a 1 to 5 Emergency Severity Index, with 1 being the most acute)." Review of documentation at 1427 by the secondary triage nurse (RN #2) revealed the patient's vital signs were assessed as Temperature (T) 100.0 (elevated) degrees Fahrenheit, BP 133/61, HR 107 (elevated), R 14, Pulse Oximetry 100% on room air. Review revealed "Orders: URINE-LAB PERFORMED U/A (urinalysis)" was ordered per DED protocol. Further review of RN #2's documentation at 1427 revealed, "....- Sepsis - (RN #2 name) Physician Notified: (MD #1 name) Sepsis Index of Suspicion: Unknown, Notify Physician/Provider." Review revealed at 1428 the patient was placed into the DED waiting room. Review of a "Triage Additional Note" documented by RN #3 (DED Charge Nurse on 10/18/2011 day shift) at 1552 revealed, "Note: Pt sitting at guest relations desk and will not move to have seat in lobby... pt ask to please have a seat in lobby and wait for available bed.. pt states she is not moving and began cursing at staff stating she has been waiting for 10 hours and patient has only been here 1.5 hours... Pt cursing still at staff, security notified and asked to escort pt out of lobby at this time. pt a (alert) and o (oriented) times 3 (person, place, time).. skin warm and dry.. resp(irations) even and non-labored and pt appears in no acute distress at this time.. pt refusing to cooperate and refrain from threatening behavior in triage... CPO (company police officer) notified and ask to remove patient from lobby..."

Review on 11/16/2011 of a CPO Incident/Investigation Report (NC02626249P, OCA1110-025) completed by CPO #1 and dated 10/18/2011 at 1550 revealed, "...Narrative Continued On or about 10/18/2011 15:50 hrs, Security Officer (SO) [name of SO #1] requested assisted in reference to a black female patient that Lead Charge Nurse (RN #3's name) wanted escorted out of the ED (emergency department) due to her refusing to cooperate with staff. I responded to same. I spoke with Officer (SO #1 name) who stated that the suspect, (Patient #41's name) was being disruptive with staff and refused to leave the ED. I requested Ms. (Patient #41's name) to leave and she refused. I advised her that if she didn't leave the ED she would be arrested for trespassing. Ms. (Patient #41's name) then left the ED and was walking toward the Tobacco store. Officer (SO #1's name) advised me that (RN #3's name) wanted her escorted off of the property. I advised Ms. (Patient #41's name) of same who had 2 white blankets that belonged to (name of Hospital). As we approached the edge of the property line, I advised Ms. (Patient #41's name) to give me the blankets. Ms (Patient #41's name) stated, 'No, I'm not giving you nothing, I'm cold.' I advised her that they belong to the hospital and she could be charged with larceny. Ms. (Patient #41's name) stated, 'No, I'm not giving them to you!' I tried to get the blankets from Ms. (Patient #41's name) who then pulled the blankets away from me. Ms. (Patient #41's name) continued to refuse to give me the blankets. I managed to get one blanket away from Ms. (Patient #41's name) who then started walking away off of property with the other blanket. Ms. (Patient #41's name) stated, 'There, you can have that one but I'm keeping this one. I advised (Patient #41's name) that she was under arrest and to put her hands behind her back. Ms. (Patient #41's name) refused to put her hands behind her back and continued to resist by trying to get her hands free from my hold. Officer (SO #1's name) arrived and assisted me so I could place handcuffs on Ms. (Patient #41's name). Officer (SO #1's name) and I escorted Ms. (Patient #41's name) to the CPO office (located adjacent to, but outside of the DED) to complete paperwork. I searched Ms. (Patient #41's name) and started the paperwork. Ms. (Patient #41's name) was very uncooperative and argumentative. Ms. (Patient #41's name) began to breath heavy, and stated that she has asthma. I asked her if she had her inhaler. Ms. (Patient #41's name) stated no. Ms. (Patient #41's name) stated that her chest felt tight. I called Lead Charge Nurse (RN #5's name) and requested him to check on Ms. (Patient #41's name). As I was on the phone with (RN #5's name) Ms. (Patient #41's name) began to vomit. I advised (RN #5's name) of same. (RN #5's name) checked Ms. (Patient #41's name) and stated that her lungs sound fine. (RN #5's name) advised me that she could be taken to room 31. I escorted Ms. (Patient #41's name) to room 31 and advised her that I wouldn't take her to jail but would charge her by citation (C 1713351-9)." Further review revealed Patient #41 was charged with Larceny and Resist, Delay, Obstruction.

Further medical record review for Patient #41 failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified (QMP) by hospital bylaws, rules and regulations, to determine whether or not Patient #41 had an emergency medical condition (EMC) after her initial presentation to the DED on 10/18/2011 at 1358 and before being escorted out of the DED lobby and off the hospital property at 1552 by a SO and CPO.

Further medical record review revealed Patient #41 was placed into DED treatment room Blue 31 South (Presentation #2) on 10/18/2011 at 1637 (45 minutes after being escorted off of hospital property). Review of the patient's vital signs documented at 1645 revealed the following: T 102.6 degrees Fahrenheit (2.6 degrees higher than on initial presentation), HR 122 (25 beats higher than on initial presentation), and R 32 (18 cycles higher than on initial presentation #1). Record review revealed the DED physician (MD #2) evaluated the patient at 1637. Review of documentation by MD #2 of the MSE performed on Patient #41 (after placement in room 31 - Presentation #2), dated 10/18/2011 (not timed), revealed Patient #41's complaint of abdominal pain, flank pain, and brief chest pain was described as constant and still present upon exam. Review revealed documentation the patient described the pain as sharp, stabbing with associated nausea and vomiting. Further review revealed the patient's pain severity was documented as severe. Review revealed documentation the patient had a past medical history of polycystic kidney disease. Review of physician documentation revealed the patient was assessed as being in moderate distress. Further review of physician documentation revealed the patient had tachycardia (elevated heart rate) and was awake and alert, but disoriented to place and time. Review revealed documentation the patient's abdomen was soft and non-tender. Record review revealed the patient was started on the "sepsis bundle" (sepsis treatment protocol). Review revealed MD #2 ordered multiple diagnostic blood, urine, and radiological studies and prescribed multiple medications, including pain medications, antibiotics, and intravenous fluids for the patient. Record review revealed diagnoses of Severe Sepsis, Acute Pyelonephritis, Altered Mental Status, Chest Pain, Abdominal Pain, Fever, and Tachycardia. Further record review revealed the patient was admitted to the hospital's intensive care unit for further treatment and was subsequently discharged on 10/25/2011 (7 days later) with final diagnoses of "1. Escherichia coli septicemia 2. Acute Pyelonephritis 3. History of polycystic kidney disease 4. Elevated blood pressure with a prior history of hypertension 5. Anemia (required blood transfusion) 6. Iron-deficiency anemia 7. Hypokalemia 8. Hypomagnesemia".

Interview on 11/17/2011 at 0945 with SO #1 revealed he was the security officer on duty in the DED lobby on 10/18/2011 when Patient #41 presented to triage via wheelchair with EMS personnel. Interview revealed his post is approximately 10 feet from the triage nursing station in the DED lobby. Interview revealed the check-in nurse (RN #1) called him over to make him aware of the patient's (Patient #41) behavior and that she was using profanity. Interview revealed the patient was already in the lobby area when he was informed of the patient's behavior. Interview revealed the patient came up to the check-in station (triage) then went back into the lobby. Interview revealed the patient returned to the patient information desk (guest services desk) in a wheelchair. Interview revealed the patient started using profanity and became loud enough for the SO to hear the patient. Interview revealed RN #1 told him that the patient needed to move away from the guest relations desk. Interview revealed the SO spoke with the patient and told her she needed to move back. Interview revealed the SO went behind the patient's wheelchair to move the patient back into the lobby when the patient got up out of the wheelchair and sat down in a chair in front of the patient information desk. Interview revealed the patient was using profanity and said she was not leaving until she spoke with someone to find out why she was waiting in the lobby and having pain. Interview revealed RN #1 was checking in another patient and did not come over to reassess the patient. Interview revealed the SO assumed someone called the charge nurse (RN #3) because he came out to speak with the patient. Interview revealed while RN #3 spoke with the patient, he called the CPO to put them on stand-by if "it became a trespass issue" when the patient was asked to leave. Interview revealed when ever a person displays hostility and uses profanity they may be asked to leave the property. Interview revealed it may be patients, visitors, or family members. Interview revealed, "It may happen twice per day or go weeks at a time and not happen." Interview revealed when the SO is asked to escort a patient out of the DED lobby or off the hospital property he is unsure if they have or have not had a medical screening examination by a QMP. Interview revealed the practice of SO or CPO escorting patients/visitors/family members out of the DED lobby or off hospital property has been in place since he has worked at the hospital (at least 7 years). Interview revealed he asks individuals to leave the DED lobby or property under the direction of clinical staff such as doctors and nurses. Interview revealed on 10/18/2011 RN #3 came out and spoke with the nurse who called him and then he talked to Patient #41. Interview revealed afterwards he told him (SO #1) "She (Patient #41) can leave." Interview revealed the patient was verbally hostile, loud, and using profanity but he did not observe her being a danger to herself or others. Interview revealed the SO called the CPO for assistance. Interview revealed CPO #1 arrived to the DED lobby and he (SO #1) discussed the patient (#41) with the CPO. Interview revealed CPO #1 asked the patient to leave. Interview revealed the patient stated she would not leave until waited upon. Interview revealed the patient was using profanity. Interview revealed the patient then got up and said she was going to leave and not wait for her ride. Interview revealed the patient had two hospital blankets in which the CPO told her she could take outside. Interview revealed the patient then went out the door with the CPO and himself following. Interview revealed another SO was outside of the DED and SO #1 asked that SO to keep an eye on the CPO and patient. Interview revealed SO #1 then returned back inside the DED lobby. Interview revealed he last viewed the patient stepping up on the curb in the DED parking lot by the fire hydrant with the CPO. Interview revealed after returning into the DED lobby he received a radio call from the base operator requesting him to go out and assist CPO #1. Interview revealed he went outside and saw CPO #1 and Patient #41 at the corner of the Tobacco Shop building (a private commercial establishment adjacent to hospital's DED parking lot). Interview revealed the CPO was struggling with the patient and holding her left arm. Interview revealed the patient was up against the fence (property line) facing towards the tobacco store parking lot. Interview revealed he assisted the CPO place Patient #41 into handcuffs. Interview revealed he escorted the CPO and patient back to the hospital entrance. Interview revealed the CPO and patient went to the CPO office adjacent to the DED and he went back into the DED lobby.

Interview on 11/17/2011 at 1100 with CPO #1 revealed she was the company police officer on duty 10/18/2011 when Patient #41 was escorted out of the DED lobby and arrested. Interview revealed SO #1 called for assistance in the DED lobby. Interview revealed when she arrived Patient #41 was sitting in a chair in front of the visitors' information desk (guest services desk). Interview revealed the patient was acting out, using profanity, and was disruptive. Interview revealed SO #1 stated RN #3 wanted the patient escorted off of the property because she would not move out from in front of the guest services desk and was cursing. Interview revealed when the CPO arrived the patient was not appearing suicidal, homicidal or a danger to self or others. Interview revealed the patient was verbally abusive, using profanity, and being loud. Interview revealed, "If the Lead Charge Nurse wants a patient escorted off of the property then we do what the Charge Nurse requests regardless of medical treatment and condition." Interview revealed she approached the patient while on her cell phone and she advised the patient she was going to have to leave because the hospital was requesting her to leave. Interview revealed the patient continued to talk on the cell phone telling someone "they are kicking me out of the hospital. Can you come and pick me up". Interview revealed the patient ignored the officer's request to leave 3-4 times. Interview revealed the CPO informed Patient #41 if she did not leave she (CPO #1) would have to arrest her for trespassing. Interview revealed the patient continued to ignore the CPO until she unsnapped her handcuff case to remove her handcuffs. Interview revealed the patient then stood up and walked out of the DED lobby without assistance. Interview revealed when the patient walked towards the exit doors the patient stated she was cold and was advised by her (CPO#1) that she (Patient #41) could hold onto the two blankets she had wrapped around her for right then. Interview revealed, "(SO #1) stated, 'He (RN #3) wants the patient off the property.'" Interview revealed CPO #1 advised the patient that she was to be escorted off hospital property. Interview revealed as she escorted the patient off the property the patient was very argumentative and "venting." Interview revealed the CPO and patient walked towards the smoking area where the patient wanted to wait for her ride. Interview revealed the patient was informed she could not wait at the smoking area because it was still hospital property. Interview revealed the patient was instructed by the CPO that she could wait at the bus stop or on the tobacco store property (not on hospital property). Interview revealed the patient requested to wait at the tobacco store. Interview revealed the CPO requested the patient to give back the two hospital blankets and the patient became argumentative. Interview revealed the patient refused to give the blankets back. Interview revealed the officer advised the patient if she did not give the blankets back she would be charged with larceny. Interview revealed the patient refused to give back the blankets and the CPO grabbed for the blankets and retrieved one. Interview revealed the patient refused to give her the second blanket. Interview revealed the CPO reached for the other blanket and the patient went to grab for the CPO's hands. Interview revealed the CPO then advised the patient she was under arrest. Interview revealed she (CPO #1) struggled with the patient to get her into handcuffs. Interview revealed SO #1 arrived and assisted with placing the patient into handcuffs. Interview revealed the patient was escorted back to the CPO office. Interview revealed the CPO initiated paperwork for the magistrate in preparation to take Patient #41 to jail. Interview revealed the patient was searched and was being very difficult and verbally abusive. Interview revealed while completing the paperwork for the magistrate, the patient started breathing heavy and complained of chest tightness. Interview revealed the CPO called the Lead Charge Nurse desk and requested the charge nurse (RN #5) come evaluate the patient. Interview revealed RN #5 came to evaluate the patient and stated the patient's chest was clear and she was "fine." Interview revealed he went back to the DED. Interview revealed the patient vomited. Interview revealed the CPO called the Lead Charge Nurse desk and informed RN #5 the patient had vomited. Interview revealed she spoke with the RN #5 on the phone and he assigned the patient to treatment room 31 Blue. Interview revealed the patient's handcuffs were removed and she was escorted to the treatment room. Interview revealed Patient #41 would have been transported from the Hospital's CPO office to jail had she not vomited in the CPO office. Interview revealed the CPO and SO are requested to escor

Based on review of medical staff rules and regulations, hospital transcription line instructions, medical records, and staff interviews, the hospital failed to ensure the completion of an operative report immediately following surgery for 4 of 7 surgical records reviewed (#44, #45, #24 and #25).

The findings include:

Review of the hospital's Medical Staff Rules and Regulations, revised 02/2006, revealed, "...D. Surgical Care...3. Operative reports shall be written or dictated immediately following surgery, and shall include a detailed account of the findings at surgery and the details of the surgical technique. Such reports shall be signed and placed in the patient's medical record promptly...."

Review of the hospital's "Acute Care Call-in for Listen Line" revealed "Call-In Instructions for Acute Care Reports (H&P [history and physical], OP [operative], Consults, Etc) 1. From any regular phone, dial X5672. Outside dial 615-5672. 2. Enter user ID# 6622 followed by the #key. 3. Enter 1-job number. 4. Enter job number followed by the # key. 5. Dictation will begin...".

1. Open record review of Patient #44 revealed a 50 year-old admitted 11/14/2011 with gastric outlet obstruction. Record review revealed the patient had an EGJ (esophago-gastro jejunoscopy) on 11/15/2011. Record review revealed a physician's handwritten Endoscopy Report Progress Note with Post Procedure note (not timed). Record review revealed a physician's dictated operative report at 0812, transcribed at 1242. Review of the dictated report revealed it was not signed by the physician.

Interview on 11/15/2011 at 1100 with the Director of Surgical Services revealed the post procedure note should be written immediately following a surgical procedure. Interview confirmed the post procedure note was not timed by the physician.

Further interview on 11/15/2011 at 1600 with the Director of Surgical Services revealed any physician or nurse could call in to the hospital's dictation system and audibly retrieve any physician notes that were dictated, including operative reports, thus making dictated operative reports immediately available to all staff.

Interview on 11/16/2011 at 0950 with nursing staff while on tour revealed the nurses do not use the transcription number to call for an immediate operative report. Interview revealed the nurses need that report immediately in the PACU (post-anesthesia care unit) and would not have time to call. Interview revealed the nurses had not been instructed to obtain operative reports from the transcription line.

2. Open record review of Patient #45 revealed a 56 year-old admitted 11/14/2011 with right knee osteoarthritis. Record review revealed the patient had a right total knee replacement on 11/14/2011. Record review revealed a physician's handwritten Brief Operative Progress Note (not dated or timed). Record review revealed a physician's dictated operative report at 0940, transcribed at 1131. Review of the dictated report revealed it was not signed by the physician.

Interview on 11/15/2011 at 1100 with the Surgical Services Administration revealed the post procedure note should be written immediately following a surgical procedure. Interview confirmed the post procedure note was not dated or timed by the physician.

Further interview on 11/15/2011 at 1600 with the Director of Surgical Services revealed any physician or nurse could call in to the hospital's dictation system and audibly retrieve any physician notes that were dictated, including operative reports, thus making dictated operative reports immediately available to all staff.

Interview on 11/16/2011 at 0950 with nursing staff while on tour revealed the nurses do not use the transcription number to call for an immediate operative report. Interview revealed the nurses need that report immediately in the PACU (post-anesthesia care unit) and would not have time to call. Interview revealed the nurses had not been instructed to obtain operative reports from the transcription line.



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3. Closed record review of Patient #24 revealed a 26 year-old male admitted for a surgical procedure on 10/03/2011. Review of the record revealed the patient had a left testicular tumor and radical left ordchiectomy (surgical procedure) performed under general anesthesia on 10/03/2011. Review of the record revealed the surgery started at 1045 and ended at 1100. Review of physician's "Brief Operative Progress Note" revealed a note documented by the surgeon that described the surgical procedure performed on 10/03/2011. Further review revealed the progress note was dated 10/03/2011 and timed 1000 (prior to the surgical procedure start time). Record review revealed an "Operative Note" that was dictated on 10/04/2011 at 1642 and transcribed on 10/06/2011 at 0713 (available 3 days after the surgery). Record review revealed no further documentation of an immediate post operative note.

Interview on 11/15/2011 at 1245 with a surgical administrative staff member revealed a brief operative note should be documented by the surgeon immediately after surgery. The staff member reviewed the progress note and stated the immediate operative note was written prior to the surgery start time. The staff member was unable to explain how details of the surgical procedure could be documented prior to the surgical procedure being performed.

Telephone interview on 11/15/2011 at 1315 with the surgeon revealed a brief surgical note should be documented immediately following the surgery. The surgeon stated "I usually do it (operative note) when I finish the case. It must have been a mistake. There is no way to do that because you never know what you are going to find."



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4. Closed medical record review for Patient #25 revealed a 62 year-old male that was admitted on 09/03/2011 with Coronary Artery Disease. Record review revealed on 09/04/2011 the patient underwent a surgical Coronary Artery Bypass Graft. Record review revealed the surgery ended on 09/04/2011 at 1210. Record review revealed documentation of an operative note dictated by the surgeon on 09/04/2011 at 1223 and transcribed on 09/05/2011 at 1338. Further record review revealed documentation of a handwritten post-operative noted dated 09/04/2011 (no time) and signed by the surgeon. Record review revealed no documented evidence a physician's post-operative report was completed and immediately available in the record immediately following the patient's surgery.

Interview on 11/15/2011 at 1600 with the Director of Surgical Services confirmed the handwritten post-operative report was not timed and thus the Director did not know when it was completed. Interview confirmed there was no documented evidence a physician's post-operative report was completed and immediately available in the record immediately following the patient's surgery. Further interview revealed any physician or nurse could call in to the hospital's dictation system and audibly retrieve any physician notes that were dictated, including operative reports, thus making dictated operative reports immediately available to all staff.

Interview on 11/16/2011 at 0950 with nursing staff while on tour revealed the nurses do not use the transcription number to call for an immediate operative report. Interview revealed the nurses need that report immediately in the PACU (post-anesthesia care unit) and would not have time to call. Interview revealed the nurses had not been instructed to obtain operative reports from the transcription line.

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to ensure Emergency Department (ED) nursing staff supervised and evaluated patient care by failing to ensure nursing staff did not instruct security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed, for 2 of 52 sampled patients that presented to the hospital's ED and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102)...."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain. EMS told me she was here the other day and didn't get her medicine filled. I moved her to the lobby. She continued cursing and walking around. She went to the bathroom a couple of times. I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3). She was pushing and slinging wheelchairs. (RN #3) went outside to talk with her. She came back in, balled her fist up and said to (RN #2), 'I'm going to cut you'. I told (RN #3) I wasn't going to stay in triage if they allow this to happen. I didn't hear (RN #3) tell her to leave but she left and didn't come back." Interview further revealed, "She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening." Interview further revealed the RN had received EMTALA training every 6 months. Interview revealed, "Here recently, we've had training more often." Interview further revealed, "I would never kick a patient out of the ED. If the situation escalates, I would contact my supe

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to ensure care in a safe setting by failing to ensure ED staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 52 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Further closed record review revealed Patient #39 returned to the hospital's DED 11/12/2011 at 0909 via EMS with a chief complaint of abdominal pain. Review revealed the patient was triaged at 0918 and assigned an initial acuity of Level 3. Record review revealed documentation at triage of blood pressure 148/116, pulse 107, respirations 22, and pain level of 10 of 10. Record review revealed Patient #39 was medically screened by the DED physician at 0933, labs were ordered, and Toradol (pain medication) and Zofran (anti-nausea medication) were given intravenously. Further review revealed the patient was admitted to the hospital at 1915. Review of the physician's dictated History and Physical dated 11/12/2011 at 1656 revealed , "...Assessment and Plan 1. Acute Pancreatitis, based on the history, the clinical findings and the elevated lipase level (610, with normal of 73-393)...2. Type 2 diabetes...3. Intractable vomiting...4. Abdominal pain...5. History of ovarian cyst...6. Obesity...7. ...admitted to the medical unit...." Review of the physician's dictated discharge summary dated 11/14/2011 at 1435 revealed, "...Discharge Diagnoses 1. Acute exacerbation of pancreatitis 2. Uncontrolled type 2 diabetes mellitus....Disposition The patient is being discharged home in stable condition...."

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102). See Incident Report."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1315 with the Director of Security revealed he could not locate an incident report completed for Patient #39. Interview revealed, "We were not sending police or security reports to quality or risk in October." Interview revealed now all incidents are forwarded to the Quality Department, the Risk Department, and the Vice President of Post Acute Care.

Intervi

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 52 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Further closed record review revealed Patient #39 returned to the hospital's DED 11/12/2011 at 0909 via EMS with a chief complaint of abdominal pain. Review revealed the patient was triaged at 0918 and assigned an initial acuity of Level 3. Record review revealed documentation at triage of blood pressure 148/116, pulse 107, respirations 22, and pain level of 10 of 10. Record review revealed Patient #39 was medically screened by the DED physician at 0933, labs were ordered, and Toradol (pain medication) and Zofran (anti-nausea medication) were given intravenously. Further review revealed the patient was admitted to the hospital at 1915. Review of the physician's dictated History and Physical dated 11/12/2011 at 1656 revealed , "...Assessment and Plan 1. Acute Pancreatitis, based on the history, the clinical findings and the elevated lipase level (610, with normal of 73-393)...2. Type 2 diabetes...3. Intractable vomiting...4. Abdominal pain...5. History of ovarian cyst...6. Obesity...7. ...admitted to the medical unit...." Review of the physician's dictated discharge summary dated 11/14/2011 at 1435 revealed, "...Discharge Diagnoses 1. Acute exacerbation of pancreatitis 2. Uncontrolled type 2 diabetes mellitus....Disposition The patient is being discharged home in stable condition...."

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102). See Incident Report."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated s

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to evaluate and analyze 2 of 2 sampled events in which nursing staff instructed security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102)...."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1315 with the Director of Security revealed he could not locate an incident report completed for Patient #39. Interview revealed, "We were not sending police or security reports to quality or risk in October." Interview revealed now all incidents are forwarded to the Quality Department, the Risk Department, and the Vice President of Post Acute Care.

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain....I moved her to the lobby. She continued cursing and walking around....I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3)....She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. S

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital failed to evaluate and analyze 2 of 2 sampled events in which nursing staff instructed security staff to remove patients awaiting medical screening examinations and treatment in the ED from the ED lobby, before the patients had an appropriate medical screening examination by qualified medical personnel to determine whether or not an emergency medical condition existed (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102)...."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1315 with the Director of Security revealed he could not locate an incident report completed for Patient #39. Interview revealed, "We were not sending police or security reports to quality or risk in October." Interview revealed now all incidents are forwarded to the Quality Department, the Risk Department, and the Vice President of Post Acute Care.

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain....I moved her to the lobby. She continued cursing and walking around....I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3)....She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. S

Based on observations as referenced in the Life Safety Report of survey completed 11/16/2011, the hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

The findings include:

A. Observations of Building 1 on 11/09/2011 - 11/16/2011 revealed the following:

1. The following was non-compliant: Room 1-118 has med gas lines penetrating the room and was not properly enclosed in the wall and ceiling.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0011

2. The following building construction type items were non-compliant:
a. In Patient Service Tower, ground floor above door PST-0-078, there are holes and/or penetrations that were not sealed in order to maintain the required rating of the area.
b. Main Building 7th floor, the Patient Care Managers office is located in the elevator lobby area and not construction in order to maintain the required 1-hr fire resistance rating for the room.
c. Corridor Door Main 4W-4-056 is not a rated door. Door is required to be a ? hour fire rated door in order to meet the construction requirements for the area.
d. 4th floor piping and electrical closet, location 4N-4-034 has holes and penetrations that are not sealed and/or protected in order to meet the 2-hr fire rated construction requirements for the area.
e. The two hour rated corridor wall for the Main Computer Room was not properly sealed. Non rated foam insulation was used to seal penetrations in the wall.
f. The rated wall in the UPS Battery Room has a hole that was not sealed in order to maintain the required rating of the wall.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012

3. The following corridor doors were non-compliant: The doors to rooms listed did not close and latch tightly in their frames: 402, 418 (family birth center, south tower) 4-217 rehab, and 2-053.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018

4. The following vertical opening was non-compliant: In the Pent House area, the access door to the 2 hr. fire rated vertical shaft did not close, latch and seal.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0020

5. The following smoke wall was non-compliant:
a. Smoke Wall 7th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.
b. Smoke Wall 6th floor south center section there are penetrations in the rated smoke wall that were not sealed in order to maintain the required rating of the area.
c. Smoke wall located above the ceiling in the Soiled holding room Main 3S-3-032 has holes that have not been sealed in order to maintain the required rating of the area.
d. Smoke tight shutters in the labs rated wall did not close after three fire alarm tests were conducted.
e. There was not a rated sleeve on the penetration in one hour rated wall on 2 South (main 2S-2-2006)

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0025

6. The following doors in smoke barriers was non-compliant:
a. Cross corridor doors not smoke tight in the family birth center, South tower.
b. Cross corridor doors 2S-2-079 did not close with fire alarm activation, 2 South.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0027

7. The following hazardous areas were non-compliant:
a. The Soiled holding/linen corridor door (Main 5W-5-019) did not close latch and seal.
b. The Soiled utility/linen room corridor door (Main 8-8-096) did not close latch and seal.
c. Housekeeping storage closet corridor door, (Main8-8-010) was not self closing.
d. Corridor door to storage room, location Main 4N-4-046 is not rated and not self closing. (Room labeled as Women and Children Services)
e. Door to the clean supply room PST 2-057 does not have positive latching.
f. The wall to the clean supply storage room in PACU PST-2-109 had holes that are not sealed.
g. The storage room PST 2-107 does not meet the requirements for hazardous area. Patient care room was converted to storage room.
h. The equipment storage room corridor door did not close, latch and seal. (PST-2-034)
i. The storage room door, to room labeled Main 2N-2-043/045, was not self-closing.
j. The soiled linen room corridor door Main 2N-2-009 did not close, latch and seal.
k. The oxygen storage room Main 2N-2-024 was not self closing.
l. Dry storage room #2 did not have positive latching.
m. Door to janitor's closet PST 1-036 did not have positive latching.
n. Door to soiled utility/linen room AS3-092 (ICU) does not have positive latching.
o. Door to storage room, main 2S-2-052 and 2S-2-019, was a non-rated door.
p. Door to storage room, old cat lab/2 west: 2W-2-023, was a non-rated door.
q. Door to storage room, Administration: 2W-2-003, was a non-rated door.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029

8. The following exit and directional signs were non-compliant:
a. Additional exit and directional signage is needed from the 4th Floor West Wing corridor back into the NICU unit. At present exit directional signage is provided in one direction only.
b. Additional exit and directional signage is needed from the 3rd Floor West Wing corridor back into the Respiratory Therapy Unit. At present exit directional signage is provided in one direction only.
c. Additional exit and directional signage is need in the connecting corridor between NICU and 4th floor west wing.
d. Additional exit and directional signage needed between A and UB Lab 2nd Floor Main Connecting Corridor.
e. Additional exit and directional signage needed in the outer center core of the surgical suite.
f. Exit signage is need above exit door PST 1-006.
g. Additional exit and directional signage needed In the Medical Records and Health Management suite leading individual to a second means of egress from the area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047

9. The following fire alarm component was non-compliant: There was not a smoke detector in old cath lab/2 west storage room.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051

10. The following sprinkler system and components were non-compliant:
a. The recessed sprinkler head located in the patient room Main 6-634 located in front of patient bed was out of adjustment and would not provide coverage for the area.
b. There is no sprinkler coverage in the shower stalls in sleep lab bathrooms 1, 3, & 5 and in rehab.
c. The sprinkler heads, on the loading dock, are not uniform across the entire area and are not properly rated in all areas. 200 degree (green) heads are mixed in with 155 degree (red) heads. Sprinkler head ratings in the area should be 155 degree (red) unless documentation would indicate otherwise.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056

11. The following sprinkler system supervision was non-compliant:
a. In the South Tower there are three valves on the main sprinkler line that are not supervised with an electronically supervised tamper alarms.
b. In the South Tower the tamper alarms on the fire pump did not activate and alarm when tested.
c. In the Patient Service Tower area in main building the tamper alarm on the fire pump did not sound an alarm when tested.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0061

12. The following was non-compliant:
a. In Pent House smoke duct detector NS-M1-12 located in the HVAC unit was not maintained clean and in good condition.
b. The smoke duct detector located in the corridor in front of room Main 6S-6-101 was not clean and not maintained in good condition.
c. The smoke duct detector #17 located in pediatric (5N-5-033) was not clean and maintained in good condition.
d. The Phase # Recovery Suite did not have an emergency HVAC shut down switch.
e. The GI Lab 2nd floor main did not have an emergency HVAC shut down switch.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067

13. The following means of egress was non-compliant:
a. Multiple items such as equipment and a charting table stored in front of each ICU breakaway door. In an em