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Based on interview and recorded review, the facility failed to follow its own policy and procedure regarding to provide the discharge services to two of homeless patients (Patient 1 and Patient 11) prior to discharge. This failure had potential risk to affect the homeless patients' safety and health well-being.

Findings:

Review of Patient 1's facesheet (documentation including the patient's brief information) indicated Patient 1 arrived the Emergency Department (ED) on 8/26/22 at 10:05 a.m. and discharged at 10:37 a.m. Patient 1's provider notes dated 8/26/22 indicated Resident 1 was homeless.

During an interview with Emergency Department Nurse D (EDN D) on 9/7/22 at 9:34 a.m., EDN D stated she worked on 8/26/22 and Patient 1 was her patient. EDN D stated she did not discuss with Patient 1 regarding the transportation prior to Patient 1's discharge and she did not chart that the patient was offered the food prior to discharge. EDN D stated per EMS staff, Patient 1 was homeless.

During an interview with the director of quality (DOQ) on 9/12/22 at 10:02 a.m., he stated patient 1 stayed in the ED for approximately 15 minutes on 8/26/22, there was no documentation indicating the facility offered Patient 1 for the meal and the transportation services prior to discharge.

During an interview and record review with the manager of accreditation (MC) on 912/22 at 11:16 a.m., Patient 11 was discharged from the ED on 3/6/22 at 1:28 p.m. MC stated Patient 11 was homeless and there was no documentation indicating that the facility offered Patient 11 for the meal service prior to discharge.

Review of the facility's policy and procedure "Discharge Planning of the Homeless Patient" retrieved 09/2022, indicated the facility " ...will provide discharge planning services to homeless patients to prepare him/her for return to the community ...Each homeless patient will be offered the following services prior to discharge: ...The patient will be offered a meal. Depending upon factors such as time of day, amount of time needed, and dietary department availability, the meal may consist of to-go sandwiches up to and including a full meal tray ...The patient will be offered transportation to his or her chosen discharge destination, if that destination is within 30 miles of the hospital. Staff will offer options as available, which may include taxi voucher to a single destination, bus token, Uber/Lyft ..."

Based on observation, interview and record review, the facility failed to post Emergency Medical Treatment and Active Labor Act (EMTALA) sign regarding the patient's right to the examination and treatment for the emergency medical condition (EMC) and women in labor at the Emergency Department (ED). The facility failed to post a sign if the facility participated in the Medicaid program. This failure had the potential risk to violate the patients' right to get the proper examination and treatment for EMC in the facility.

Findings:

During an initial tour in the ED with ED Director (EDDIR), ED Assistant Clinical Manager (ACM), and ED Medical Director (MDED) on 9/6/22 at 11:10 a.m., observed two entrances (main entrance and ambulance entrance) in the ED. EDDIR stated patient could come to ED from the main entrance (for the patients who were able to walk) or the ambulance entrance (for the patients who came with the ambulance ).

During an observation with ACM in ED at the ambulance entry area (entrance, admitting area, waiting room or the treatment area) on 9/6/22 at 11:20 a.m., there was no EMTALA sign regarding the patient's right to the examination and treatment for EMC and women in labor. There was no sign post if the facility participated in the Medicaid program.

During an interview with ACM on 9/6/22 at 11:20 a.m., she stated there was no EMTALA patient's right posted at the ED Ambulance entrance area.

Review of the facility policy and procedure "Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA), retrieved 09/2022, indicated " ...Signage: The hospital shall post required signage conspicuously in required areas in the required form required by CMS that specifies the rights of individuals to examination and treatment for EMC and that ECH participates in the Medicaid program ..."

Based on observation, interview, and record review, the hospital failed to provide another medical screening exam for one patient (Patient 1) when hospital personnel felt Patient 1 was acting paranoid and disoriented and seemed like he was hallucinating in the main hospital lobby after recent discharge from the emergency department.

This deficient practice had the potential for Patient 1's condition to deteriorate.

Findings:

During a review of the hospital's Unusual Occurrence Event Report to the state survey agency, dated August 26, 2022, indicated Patient 1 was seen and discharged from the Emergency Department (ED) on 8/26/22. The report indicated Patient 1 was seen soon after in the main hospital lobby acting belligerent. Security staff were called and, after Patient 1 left the main hospital lobby, the security staff called 911 and followed the patient. Patient 1 ended up on top of the Sobrato Pavilion Parking Garage. The report indicated Patient 1 was agitated, and police responded and took over the situation. The report indicated Patient 1 climbed over the wall of the top floor of the parking garage and fell to the ground. Patient 1 died after unsuccessful CPR [cardiopulmonary resuscitation, pushing down on chest and giving rescue breaths when the heart stops beating] efforts.

During a review of Patient 1's medical records, indicated Patient 1 was seen in the emergency department (ED) by Emergency Department Physician on 8/26/2022. Patient 1 was a 55 year old male who was brought in by ambulance staff for paranoia [mental disorder in which person has extreme fear and distrust of others]. Patient arrived on 8/26/2022 at 10:05 a.m. In her ED Notes, dated 8/26/2022 10:19 a.m., ED Nurse D documented "... Pt [patient] paranoid stating "someone is watching me, I deserve what is coming to me." ... Refusing to go into assigned room staying in hallway stating "I am not going in there with 2 guys, I know what is going to happen, you guys are going to hold me down." ... Pt wanting to leave. [ED Physician] at bedside for exam. Pt calm and cooperative and [sic] this time. Answering all questions and following basic commands ... denies any SI/HI [suicidal ideation or thoughts of killing oneself / homicidal ideation or thoughts of killing other people]. Still wanting to leave. Pt walked to WR [waiting room] ...". In his ED Provider Notes, dated 8/26/2022 10:27 a.m., ED Physician noted Patient 1 presented "... for evaluation of erratic behavior ... According to 1st responders the patient was paranoid, concerned that people are out to get him. He does admit to methamphetamine use [powerful drug that has excitatory and hallucinogenic effects on body], as recently as this morning. No other complaints ...". ED Physician also noted "... Symptoms are likely explained by stimulant use disorder, amphetamine toxicity. Mild psychosis [mental disorder characterized by disconnection from reality] and paranoia may be present. The patient does not exhibit any SI HI or grave disability. In the emergency department he is calm, redirectable, cooperative ... Doubt ... worrisome psychiatric illness ... I believe the patient to be a reasonable candidate for discharge ... Further ancillary studies, diagnostic imaging, specialty consultation, and hospitalization while entertained I do not believe are indicated at the present time ...". Patient 1 was discharged on 8/26/2022 at 10:37 a.m., condition was noted as stable by ED Physician. Patient 1 was instructed to follow up with a community health clinic.

During a concurrent interview and record review on 9/6/22 at 1:07 p.m. with Emergency Department Physician (EDP), Patient 1's medical record was reviewed. The EDP confirmed he was the ED physician caring for Patient 1 on 8/26/22. The EDP stated Patient 1 was brought in by ambulance for erratic behavior. The EDP stated Patient 1 admitted to using methamphetamines but did not have any complaints. The EDP stated they offered their help but Patient 1 made it clear he did not want to be in the ED, did not want their help, and wanted to leave. When asked how Patient 1 seemed to him, the EDP stated Patient 1 was alert, cooperative, calm, oriented, and answered questions. When asked if there were tests he wanted to order for Patient 1, the EDP stated he considered ordering bloodwork, meals, intravenous [into a vein] hydration, social work, psychiatric care, and diagnostic imaging. The EDP stated they offered further testing and Patient 1 declined, and they did not have a specific reason to keep Patient 1 in the ED against his will. The EDP stated they considered whether Patient 1 met criteria for a 5150 hold [involuntary psychiatric hold for patient deemed to be a danger to self, to others, or gravely disabled] but it was not indicated. When asked why it was not indicated, the EDP stated Patient 1's mental status was that of someone who knew where he was, and that Patient 1 was awake, calm, had good insight, and denied wanting to hurt himself or other people. The EDP stated Patient 1 was medically stable upon discharge.

During a concurrent interview and record review on 9/7/22 at 10:47 a.m. with the Chief Administrative Officer (CAO), Director of Safety and Security (DSS), and Director of Quality (DOQ), hospital security video footage of Patient 1 was reviewed. For Video One, the footage showed 8/26/22 at 9:57 a.m. The DSS stated the actual time was 10:05 a.m. Patient 1 was observed walking from the ambulance to the hospital. The CAO stated Patient 1 walked toward the ED ambulance entrance.

For Video Two, the footage showed 8/26/22 at 9:57 a.m. The DSS stated the actual time was 10:05 a.m. Patient 1 and two ambulance staff were waiting at the ED ambulance entrance. The CAO stated the hospital does not have video cameras in the care area so that was the end of footage for the ED.

For Video Three, the footage showed 8/26/22 at 10:09 a.m. The DSS stated the actual time was 10:18 a.m. Patient 1 was observed wandering around the ED waiting room, speaking with the registration desk staff, screener nurse, and security guard. Patient 1 spoke with the security guard at 10:20 a.m. in actual time. The DSS stated the security guard was Security Guard C. The DSS stated Security Guard C asked Patient 1 to leave, the patient was headed toward the main hospital so Security Guard C redirected him out of the main ED entrance. Patient 1 and Security Guard C were observed going off camera at 10:21 a.m. actual time.

For Video Four, the footage showed 8/26/22 at 10:12 a.m. The DSS said the actual time was 10:21 a.m. Patient 1 was observed speaking with Security Guard C at 10:22 a.m. actual time. Security Guard C pointed left of the camera, and Security Guard C and Patient 1 walked toward the camera. The DSS stated Security Guard C was trying to direct Patient 1 to the bus stop. The CAO stated Patient 1 was walking toward South Drive. Patient 1 went off camera at 10:22 a.m. actual time.

For Video Five, the footage showed 8/26/22 at 10:18 a.m. The CAO said the actual time was 10:27 a.m. Patient 1 was observed walking in through the main hospital lobby entrance, and a screener was present inside of the doors. Patient 1 went off camera at 10:27 a.m. actual time. The DSS stated he received a text message from the Director of Quality at 10:30 a.m. that there was a visitor upset in the main hospital lobby and asking him to assist. The DSS stated he was with the Security Account Manager and they both went to the main hospital lobby to engage with Patient 1. The DSS stated this was the first time he interacted with Patient 1. The DSS stated Patient 1 seemed nervous and agitated, but was not threatening anyone and was not combative. The DSS stated he noticed Patient 1 had an emergency department bracelet on. The DSS stated Patient 1 kept asking them to call 911 and said they were not real cops and that they needed cops. The DSS stated the security staff tried to keep Patient 1 calm and used their de-escalation techniques. The DSS stated, after four to five minutes, they were able to get Patient 1 to agree to leave the main hospital lobby. When asked if Patient 1 asked for help, the DSS said maybe Patient 1 did a few times. The DSS said he did not know if the security staff would have called 911 if Patient 1 remained in the hospital, that their goal was to get Patient 1 out of the main hospital lobby. The DSS stated the agreement with Patient 1 was if the patient left the main hospital lobby then he would call 911. When asked if he actually called 911 then, the DSS stated he did not. The CAO and DSS stated Patient 1 was in the main hospital lobby for about seven minutes.

For Video Six, the footage showed 8/26/22 at 10:26 a.m. The CAO said the actual time was 10:35 a.m. Patient 1 was observed walking out of the main hospital lobby, escorted by the DSS, the Security Account Manager, and Security Guard G. The CAO confirmed the identities of the DSS, Security Account Manager, and Security Guard G. The Security Account Manager pointed right of the camera. Patient 1 went off camera at 10:35 a.m. actual time. The CAO stated the effort was to try to get Patient 1 to the bus stop on Grant Road. When asked if Patient 1 said anything to them at this time, the DSS stated no. The DSS stated Patient 1 took off running and made a left on North Drive, then across the street in and out of traffic. The DSS stated they were hoping Patient 1 would go right because that would take him away from all the other buildings. The DSS stated they needed to make sure Patient 1 didn't enter another building. The DSS stated, at that time, they thought this was a dangerous situation for Patient 1 so they called 911. The DSS stated Patient 1 tried to get into another hospital building, then ran down Hospital Drive and into the main lobby of the Sobrato building.

For Video Seven, the footage showed 8/26/22 at 10:39 a.m. The DSS stated this was the actual time. The DSS stated the footage was from the lobby of the Sobrato Pavillion. Patient 1 was observed running down the street and walking into the lobby of the Sobrato Pavillion. Patient 1 was observed walking around the lobby and speaking to the screener and other visitors, then walking off camera at 10:41 a.m. The DSS stated they were following the patient, and their goal was to keep Patient 1 from entering another building. The DSS stated he, the Security Account Manager, and Security Guard G came on camera at 10:41 a.m.

For Video Eight, the footage showed 8/26/22 at 10:34 a.m. The DSS stated the actual time was 10:42 a.m. The DSS stated this was the third floor of the Sobrato parking garage. Patient 1 was observed pushing a button on the blue emergency pillar at 10:42 a.m. actual time, then entering the elevator at 10:43 a.m. actual time. The CAO stated the blue emergency pillar is an emergency phone to speak with security, and Patient 1 did not stay to speak with security.

For Video Nine, the footage showed 8/26/22 at 10:35 a.m. The DSS stated the actual time was 10:43 a.m. Patient 1 was observed exiting the elevator and going up stairs and off camera. The CAO stated the elevator was on the fourth floor of the parking garage. The DSS stated Patient 1 went up the stairwell to the fifth floor of the parking garage.

For Video Ten, the footage showed 8/26/22 at 10:42 a.m. The DSS stated the actual time was 10:44 a.m. Patient 1 was observed trying to enter glass doors into a building but was unsuccessful. The CAO stated these doors were to the Fogarty Institute. The DSS stated the doors were locked.

For Video Eleven, the footage showed 8/26/22 at 10:44 a.m. The DSS stated the actual time was 10:46 a.m. Patient 1 was observed standing by the glass doors to the Fogarty Institute. The DSS stated the Security Account Manager was standing near the top of the camera. Patient 1 was observed running on and off camera. The DSS stated he was positioned off camera to the right, and was speaking with Patient 1. The DSS stated he told Patient 1 that 911 was called and police were on the way. The DSS stated the Security Account Manager was trying to get Patient 1 to calm down. The CAO stated the DSS called him at 10:45 a.m. saying Patient 1 was acting out and a little out of control.

For Video Twelve, the footage showed 8/26/22 at 10:52 a.m. The CAO stated the actual time was 10:54 a.m. Patient 1 was observed straddling a white beam, one leg on each side of the beam and grating, at the top of the parking garage and police were present. The CAO stated he went up to the fifth floor of the parking garage around 10:50 a.m., where he saw Patient 1 walking on a white steel beam four inches wide. The CAO stated he told Patient 1 he was there to help him. The CAO stated Patient 1 made his way down off the beam and was looking around the garden area, but when Patient 1 heard sirens, Patient 1 ran back to the beam. The CAO stated the grating was decorative and not heavy duty. The CAO stated Patient 1 fell about 58 feet to the ground.

The CAO showed twelve pictures but said he could not verify if the timestamps were accurate. Picture One was at 10:47 a.m. showing the Security Account Manager near the garden area. Picture Two was at 10:58 a.m. showing Patient 1 up on the white metal beam, with police present. Picture Three was at 11:10 a.m. The CAO stated police were speaking with Patient 1. Picture Four was at 11:22 a.m. showing Patient 1 up on the white metal beam. The CAO stated they tried to bring lunch and water to Patient 1. Picture Five was at 11:34 a.m. showing Patient 1 kneeling on the white metal beam. The CAO stated Patient 1 did not believe the police were real police. The CAO stated the city behavioral specialist was speaking to Patient 1. Picture Six was at 11:58 a.m. showing Patient 1 up on the white metal beam. The CAO stated ED Physician was present and Patient 1 did not believe he was a real physician. Picture Seven was at 11:58 a.m. showing Patient 1 up on the white metal beam. The CAO stated he wore a white coat and told Patient 1 he was a physician, that they brought food and would make sure Patient 1 was safe. Picture Eight was at 12:09 p.m. showing Patient 1 further to the right on the white metal beam. The CAO stated police were still speaking to Patient 1. Picture Nine was at 12:21 p.m showing Patient 1 up on the white metal beam. The CAO stated Patient 1 was in a more precarious position, the white metal beam was twelve feet above the parking ramp. The CAO stated they brought a hospital stretcher to the parking garage. Picture Ten was at 12:33 p.m. showing Patient 1 up on the white metal beam. The CAO stated Patient 1 had taken off his backpack. Picture Eleven was at 12:45 p.m. The CAO stated Patient 1 had already fallen off the parking garage at that point. Picture Twelve was at 12:57 p.m. Patient 1 was not observed in the picture.

The CAO stated Patient 1 fell between 12:42 p.m. and 12:45 p.m. The CAO stated it appeared as if Patient 1 was trying to climb down the grating. The CAO showed a picture he took of the thin aluminum metal grating that broke off when Patient 1 fell. The CAO stated Patient 1 was screaming help, you're not real cops, you're not real doctors. The CAO stated Patient 1 clearly was not listening, that Patient 1 kept saying I'm not going to jump but was screaming help at the top of his lungs.

During a concurrent observation and interview on 9/6/22 at 10:50 a.m. with the Associate Chief Nursing Officer and Director of Safety and Security (DSS), the DSS provided a tour of the Sobrato parking garage. The DSS stated he and the Security Account Manager went up to the fifth floor of the parking garage, where Patient 1 saw them and was afraid of them. The DSS stated Patient 1 wanted them to call the police; the DSS stated Patient 1 said they were not real cops and were not going to help him. The DSS stated they told Patient 1 the police were on the way. The DSS stated as he and the Security Account Manager got closer to Patient 1, the patient became more paranoid so they stayed back. The DSS stated Patient 1 then jumped onto the parking garage ledge, and a few minutes later the police arrived and took over. The DSS stated Patient 1 told the police they weren't real police and he wanted the real police and a doctor. The DSS stated the police were trying to talk Patient 1 down. The DSS stated hospital doctors and nurses, the hospital behavioral health team, the city police and city behavioral team were at the parking garage. The DSS stated Patient 1 climbed from the parking garage ledge up five feet onto a beam. The DSS stated the patient tied a belt to the grating on the side of the parking garage, thinking he could lower himself but he was unable to hold on and fell to the ground. The DSS stated when the patient fell, an ambulance was nearby already.

During an interview on 9/6/22 at 2:35 p.m. with the Director of Quality (DOQ), the DOQ stated the ambulance staff attempted to do CPR but Patient 1 was pronounced dead inside the ambulance on 8/26/22 at 12:44 p.m.

During a review of the hospital's Incident Details report, created 8/29/2022 at 3:35 p.m., indicated Security Guard C received a call from ED Charge Nurse E on August 26, 2022 at approximately 10:18 a.m. The report noted ED Charge Nurse E requested Security Guard C escort Patient 1, "... who was lingering in the ED waiting area ..." to the Grant Road bus stop. Security Guard C asked Patient 1 to leave but the patient stated he forgot his identification at the nursing station. The ED staff stated they did not have Patient 1's identification and he did not give them one. Security Guard C again asked Patient 1 to leave. The report noted "... The discharged patient was about to go through the South entrance but was stopped and redirected to the parking lot. The individual was acting paranoid, hallucinating, and started screaming and asking for help aloud. He was saying "they were after him and someone wanted to kill him." [Security Guard C] told the individual he is safe and asked him to step outside in order to escort him to the bus stop. [Security Guard C] then radioed to the Security team that he would perform an escort from the Emergency Department waiting area to Grant rd. bus stop across from parking Lot 1B. [Security Guard G] heard the radio call and responded ... At approximately 10:20 am [Security Guard C] escorted the discharged patient through parking Lot 1B to the bus stop on Grant Rd. To make sure the discharged patient was going to remain at the bus stop until he was picked up, the two officers stood by for a few minutes. After a few minutes, the patient ran away on the sidewalk of Grant Road screaming and asking for help at passing vehicles on the road. While running on the sidewalk of Grant road he took a left turn up North Drive and ran straight towards the Main entrance of the Hospital. [Security Guard C and Security Guard G] followed ... the individual made his way inside the main entrance of the Hospital lobby at approximately 10:27 am. Once in the main lobby the discharged patient started running back and forth as both officers continuously tried to calm him down. The individual was screaming, acting paranoid, hallucinating, and kept repeating that he needed help, wanted to call 9-1-1 and wanted real cops. [Security Guard G] phoned [Security Account Manager] for backup, who along with [Director of Safety and Security] arrived on the scene within 2 minutes. [Security Account Manager] asked the discharged patient what kind of help he needed to which he replied to leave him alone and began to repeat that he needed help and to call 9-1-1. After about 5 minutes, at approximately 10:34 am, the responding officers were able to persuade him to exit the Hospital via the front entrance. Once outside the Hospital the discharged patient ran towards the YMCA building screaming aloud and asking for help. The discharged patient then started running through the YMCA Parking lot and approached moving vehicles and anyone passing by on foot for help. The discharged patient continued running followed by Security personnel ... [Security Guard G] then called [city police department] and informed them of the situation. The discharged patient continued running on Hospital Dr. screaming for help, then crossed the street towards the Sobrato Pavilion and at approximately 10:40 am he briefly entered the Sobrato main lobby. A minute later, at approximately 10:41 am, he quickly exited out of the Sobrato main lobby, and ran up the exterior staircase of the Sobrato Garage. At approximately 10:42 am, while heading up the staircase the discharged patient activated the emergency call box on the 3rd floor. The discharged patient then entered the elevator on the 3rd floor and exited it on the 4th floor at approximately 10:43 am. The discharged patient then took the staircase to the 5th floor where at approximately 10:44 am he tried to enter the Fogarty suite but the doors were locked. At about 10:46 am [Security Account Manager] and [Director of Safety and Security] arrived on the fifth floor of the parking garage and tried to connect verbally with the discharged patient. The discharged patient was now pacing back and forth on the fifth floor near the edge of the parking garage ... A minute or so later at approximately 10:48 am, an ambulance with sirens on passed by the parking garage and that caused the discharged patient to panic. He then climbed up onto the ledge of the parking garage, stood up and screamed for help asking for "real police officers" to show up. Shortly thereafter [Chief Administrative Officer] arrived on the fifth floor and tried to speak with the discharged patient and calm him down ... [city police department] arrived on scene to the fifth floor and took over the situation. [City police department] Officers and many Hospital staff made every effort for about two hours to convince the discharged patient to come down but were unsuccessful. The discharged patient eventually fell at approximately 12:42 pm from the fifth floor of the Sobrato parking garage ...".

During an interview on 9/9/22 at 11:02 a.m. with the Main Lobby Screener (MLS), the MLS stated he was a contractor and had been working at the hospital for about one-and-a-half years. The MLS stated his duties are to monitor hospital entrances, to ensure every person entering is asked COVID-19 [viral illness that can cause breathing problems and other symptoms] screening questions, and to check for proof of COVID-19 vaccination or testing. The MLS confirmed he had no medical background. The MLS confirmed he was working on 8/26/22 as the main hospital lobby screener. The MLS recalled Patient 1 running in through the main hospital lobby doors, shouting that he was being chased and someone was trying to murder him. The MLS recalled Patient 1 wanted people to call the police and said why is everyone staring at me, why are people standing around. The MLS stated he then called security, and the security guard who answered said security personnel were on the way. The MLS stated security personnel kept trying to calm Patient 1 down, while Patient 1 said the security personnel were the people trying to murder him. The MLS stated security was asking Patient 1 to calm down, that they weren't trying to hurt him and they were trying to get him the help he needed. The MLS stated as security personnel got closer to Patient 1, Patient 1 kept backing away from them. When asked what bystanders were saying, the MLS stated bystanders were saying Patient 1 needed help and mental health help. The MLS stated they could tell Patient 1 was "authentically scared and paranoid" and they could tell Patient 1 was "out of his mind." When asked who was saying this, the MLS stated it was himself and two hospital volunteers. The MLS stated a visitor bystander said they hoped Patient 1 would get the help he needed and everything would calm down. When asked if he felt Patient 1 needed help right then and there, the MLS stated he did but security personnel were right there so he was hoping security would cover it. The MLS stated he has had patients come in with mental health crises before and they were able to direct these patients to the ED. The MLS stated Patient 1's case was more extreme. When asked what screeners are able to do when patients come in for mental health help, the MLS stated the best thing he can do is direct patients to a place where they can see a physician. When asked if the hospital trained him on how to deal with people coming in with mental health issues, the MLS said there was no specific training but that if people are coming into the hospital, they are likely trying to see a physician. The MLS said his training was to send patients to where they could see a physician. When asked if he felt from his training he should send Patient 1, who appeared to have a mental health issue, to see a physician, the MLS said yes. When asked what prevented him from sending Patient 1 to see a physician, the MLS stated Patient 1 was extremely uncooperative, was "super panicking" and was not listening to anything anyone was saying. The MLS stated he left it to security personnel because he figured they would deal with it better than him. When asked if he has had EMTALA training, the MLS stated no but he has been told if a patient comes with a serious medical situation, to call the Rapid Response Team [group of clinical staff summoned to immediately evaluate a patient whose condition is deteriorating] or hospital supervisor.

During an interview on 9/7/22 at 2:03 p.m. with Security Guard C (SG C) and the DSS, SG C stated he was working on 8/26/22 at the security station in the ED lobby, next to the registration desk and screener nurse desk. SG C stated he recalled Patient 1. SG C stated he received a telephone call from ED Charge Nurse E saying there was a discharged patient lingering in the ED lobby and he needed to escort the patient to the bus stop. SG C stated he and Patient 1 stepped outside the ED lobby, and Patient 1 started running around parking lots 1A and 1B by the ED. SG C stated Patient 1 crossed Grant Road then returned to the main hospital lobby entrance. SG C stated, on Grant Road, Patient 1 ran across the street and back and was screaming to cars for help. SG C stated he and Security Guard G were following Patient 1, and then the Security Account Manager and DSS met them in the main hospital lobby. SG C stated Patient 1 said he wanted to make a call to the police. SG C said it seemed like Patient 1 was paranoid and scared and hallucinating. When asked if Patient 1 was like this in the ED lobby, SG C stated no the paranoia started when Patient 1 was in the parking lot, before Patient 1 went into the main hospital lobby. SG C stated in the ED lobby, Patient 1 was just talking a lot to nurses and bystanders. When asked if he was worried about Patient 1, SG C stated yes but Patient 1 was discharged, that he was wondering what was wrong with Patient 1 but he couldn't put hands on the patient. SG C confirmed he had no medical background. SG C stated he was dismissed from the main hospital lobby and returned to the ED security station. When asked who he calls for help if he sees a patient who may need help on hospital grounds, SG C said he calls his supervisor and they call 911.

During an interview on 9/7/22 at 1:13 p.m. with Security Guard G (SG G), SG G confirmed he was working on 8/26/22 as the on-duty security supervisor. SG G stated he heard Security Guard C on the radio saying Patient 1 was being escorted from the ED lobby to the bus stop. SG G stated he was free at the time, so he went to check on Security Guard C. SG G stated he caught up to them in the parking lot across from the main ED entrance, two minutes after Security Guard C called. SG G stated, by the time he stepped into the parking lot, he could see Patient 1 was walking all over the place and Security Guard C was trying to direct Patient 1 to the bus stop. SG G stated Patient 1 then bolted on Grant Road and made a left onto North Drive. SG G stated he and Security Guard C cut across the parking lot toward the main hospital lobby entrance, and saw Patient 1 entering the main hospital lobby. SG G stated the main hospital lobby screener called him directly on his Vocera [wearable device for hospital staff to communicate with each other] for assistance with a man who ran by and was acting erratic. SG G stated, when he and Security Guard C arrived in the main hospital lobby, he saw Patient 1 running back and forth in the lobby yelling they're after me, they're going to kill me, call 911. When asked what he did then, SG G stated he approached Patient 1 trying to tell him to calm down and that he wasn't in any danger. SG G stated anytime they got close to Patient 1, the patient would just run away to another area of the main hospital lobby. SG G stated when he realized he couldn't calm Patient 1 down, he called the Security Account Manager. SG G stated Patient 1 seemed very erratic, and the security staff was worried about making sure other people weren't too close to Patient 1 and at risk for getting hit. When asked if he thought Patient 1 needed medical help at that moment, SG G stated he thought Patient 1 was recently discharged so the patient had been seen by a doctor and if the ED was willing to discharge Patient 1 given the patient's behavior, their main focus was to simply get Patient 1 off hospital property. SG G confirmed he had no medical background. When asked if he thought Patient 1 needed someone with a medical background to see him, SG G stated he couldn't say and those things weren't really going through his head at the time. SG G stated, even if he felt like Patient 1 needed help, it's not common practice where they can pull ED staff out to come see the patient because Patient 1 had already been discharged. When asked if he tried to call the ED staff, SG G stated no it's something they have never done. SG G stated, when the Security Account Manager and the DSS arrived, the Security Account Manager told Patient 1 to calm down because the patient was yelling. SG G stated Patient 1 kept saying he needed to call 911, and the Security Account Manager told Patient 1 they would call 911 outside. SG G stated they then walked Patient 1 outside, and Patient 1 bolted toward North Drive. SG G stated Patient 1 ran around the YMCA parking lot and to another hospital building. SG G stated the DSS told him to call 911, so he told 911 a patient who was just discharged was acting manic, causing scenes and trying to break into doors. When asked if Patient 1 seemed ill, SG G said no just disoriented because Patient 1's movements were erratic and Patient 1 was looking around like he was being chased. SG G said they then felt like Patient 1 needed medical help, they could tell Patient 1 wasn't fully there and they noticed Patient 1 was under the influence of some sort of substance. SG G stated Patient 1 then went up to the Sobrato parking garage and started yelling help, they're chasing me, they're trying to kill me. SG G stated, by the time he, the Security Account Manager, and the DSS got to the patient, Patient 1 was in front of the Fogarty doors hiding in a corner. SG G stated, when Patient 1 saw them, he started running toward the edge of the parking structure. SG G stated the CAO arrived to speak with Patient 1, and the patient did come down from the ledge for a brief moment but then got back on the ledge. SG G stated he then went to the first floor to do crowd control.

During an interview on 9/7/22 at 2:30 p.m. with the Security Account Manager (SAM) and the DSS, the SAM stated he has worked at the hospital for ten years as a security guard and started as the security account manager three months ago. The SAM confirmed he was working on 8/26/22 and recalled Patient 1. The SAM stated Security Guard G called him saying there was a discharged ED patient acting erratic, asking for help and wanting the police. The SAM stated he and the DSS went to the main hospital lobby, where Patient 1 was circling around. The SAM stated Patient 1 said he needed help, he needed real cops. The SAM stated Patient 1 wanted them to call the real cops, so the DSS told Patient 1 to calm down and go outside and they would call the real cops. The SAM stated they walked Patient 1 out of the main lobby and he asked Patient 1 what kind of help the patient needed. The SAM stated Patient 1 said leave me alone, and they told Patient 1 if he went to the bus stop no one will bother him. The SAM stated Patient 1 appeared to be high on something and was acting erratic. When asked if, in the main lobby, Patient 1