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

Findings include:

1. The Hospital failed to conduct a thorough re-assessment as required and medical screening examination by the licensed medical practitioner to determine if an emergency medical condition existed. (A-2406)

The Immediate Jeopardy began on 05/29/2023 due to the hospital's failure to conduct a complete a medical screening examination to determine if an emergency medical condition existed. Subsequently the patient was found unresponsive and died. The IJ was identified on 12/8/2023 at 42 CFR 489.24 (a) (c). The IJ was announced on 12/08/2023 at 10:30 AM during a meeting with the Director of Regulatory, Clinical Services Administrator, Chief Medical Officer, Chief Quality Officer, Chief Executive Officer, and Risk Manager. The IJ was not removed by the survey exit date of 12/08/2023.

Based on document review and interviews, it was determined that for 1 of 25 (Pt. #1) clinical records reviewed for emergency medical services, the hospital failed to complete an appropriate medical screening exam to determine whether or not an emergency medical condition existed prior to discharge. Subsequently Pt.#1 expired.

1. On 12/05/23, the hospital's policy titled, "Emergency Medical Treatment (EMTALA)" (revised 5/2021) was reviewed and required, " ... all persons seeking emergency care at hospital shall receive an appropriate medical examination and evaluation ('screening to determine whether an emergency condition exists ...') If the patient has an emergency medical condition, the patient will receive treatment within the hospital's capabilities until the condition is stabilized ..."

2. On 12/05/23, the hospital's policy titled, "Emergency Management of Narcotic Overdose/Substance Abuse: Guidelines" (revised 05/2021) was reviewed and included, "Substance Abuse, signs & symptoms: A. Examples ...1. Opiates (Heroin) ... 5. Cocaine, Amphetamines ... Clinical Manifestations -acute intoxication/overdose ... 1. Slurred speech ... 3. Decreased Vital signs ... 6. Tachycardia ... Emergency Management per Physician Order: 1. Monitor vital signs, cardiac and respiratory monitoring ... 3. Send urine for urinalysis with toxicology screen ... Opioid Withdrawal - Signs and Symptoms 1. Lethargy ... 4. Irritability/Agitation ... Emergency Management ... 1. Intravenous fluids. 2. Assess for Associated Medical problems and comorbidities. 3. Place patient in protective environment under proper medical supervision. 4. Continuous Monitoring of Vital Signs and Reassessment ..."

3. On 12/05/23, the hospital's policy titled, "Reporting Critical or Panic or there Results" (revised 3/8/23) was reviewed and required, "A. Critical Values: Denoting a morbid condition in which death is possible. Critical or Panic Values: A=Urgent Action-notify the ordering physician or designated service immediately, all hours ... Troponin - I POS > 0.03 (positive greater than) = Urgent Action required ... It is the responsibility of the technologist who performs the test to initiate notification of such results to physicians or RNs ..."

4. Pt. #1's clinical record was reviewed and indicated that on 05/29/2023 Pt. #1 was brought to the Emergency Department (ED) by ambulance with a chief complaint of drug ingestion. The clinical record included the following:


-Ambulance Care Report, dated 5/29/23 at 12:30 PM, included "Called for overdose." Pt. #1 was found on the porch stating that Pt. #1 had been "on a weeklong crack binge".

-Triage Note dated 5/29/23 at 12:34 PM, vital signs were the following: Temperature 98.5 (normal 95.9-99.6); Blood Pressure 96/62 (normal systolic 100-140); Pulse 95 (normal 60-90); Respirations 15 (12-24); O2 Sat 93% (normal oxygen saturation 95-100); ... Psychosocial History: Schizophrenia; Substance use: Yes Cocaine, heroin ... Triage Acuity Level: ESI-3 (emergency severity level-1 requiring immediate care; 3-emergency care)."

-EKG (electrocardiogram/shows electrical activity of the heart) report dated 05/29/23 at 1:47 PM, included, "Ventricular rate 113 bpm (beats per minute/normal range 60 - 100) Sinus tachycardia."

- History and physical (entered by MD #1) dated 05/29/23 at 12:59 PM, " ... Chief Complaint: Drug ingestion ... Mentioned cocaine use heavily. Physical Exam: Conscious (appears drowsy) ...cardiovascular/Chest: Sinus tachycardia (irregular rapid heartbeat at 110 beats per minute/normal 60-90) ... (Pt. #1) is more alert, (Pt. #1) is refusing all further treatment and evaluation in their workup, noncooperative, will be discharged home, the nurse, and the ER (emergency room) physician both tried to encourage him to allow evaluation and treatment and/or observation (Pt. #1) is refusing everything. Disposition: Discharge to home, self-care at 12:59 PM. Clinical Impression: cocaine abuse. Condition: Fair."

-Nursing note (E #10/Registered Nurse) dated 05/29/23 at 2:53 PM, "(Pt. #1) becomes angry and screams at staff stating (Pt. #1) does not want any more services. Security is called, (Pt. #1) is d/c'd (discharged) after showing (Pt. #1) is stable for d/c, security wheels pt to waiting area to wait for bus card."

-Pt. #1 was escorted to warming area (area adjacent to the emergency department [ED] where people come to warm up or to cool down from the weather) at 2:59 PM.

-Laboratory report dated 05/29/23 at 14:00 (2:00 PM), included the following: K level (potassium) at 6.2 high (normal range is 3.5-5.1; high levels-can cause heart problems that require immediate medical attention); Troponin at 0.170/high (normal level 0.000-0.034/value greater than 0.120 has a 95% positive predictive value for positive acute myocardial infarction). Pt. #1's clinical record lacked documentation regarding the abnormal lab results being reviewed, reported, or assessed by laboratory staff, ED physician, and ED registered nurse.

5. Pt. #1 was readmitted to the ED on 5/29/2023 at 7:43 PM (4 hours and 44 minutes after first ED visit). The clinical record included the following: History dated 05/29/23 at 8:12 PM, "(Pt. #1) ...was sitting in the waiting area and (Pt. #1) was found to be unresponsive and was brought to the main ED ..." At 7:43 PM Cardiopulmonary resuscitation (CPR) was initiated, and emergency medication were administered. CPR was discontinued and patient was pronounced dead at 8:09 PM.

6. On 12/05/23, the hospital provided a "Quality Management Occurrence Report (QMOR)" dated 05/30/23 at 3:02 PM and included, "Date of Occurrence; Time 14:25 PM (2:25 PM) ... with (Pt.#1), Security reported; the ED physician (MD#1) on duty and nurse (E#10) requested to have the patient mentioned escorted out of the building, stating the patient refused care. When public safety officers arrived, (Pt. #1) appeared to be unstable, (Pt. #1) was unable to stand or walk and his eyes were rolling different directions per responding officers. (MD #1) was very adamant directing security to escort (Pt. #1) out of the building. Security informed the nurse and doctor of the patient's current state, however, instructed security to escort (Pt. #1) outside. Security did not feel comfortable escorting (Pt. #1) out of the building therefore they assisted (Pt. #1) into a wheelchair and allowed (Pt. #1) to wait in the waiting area. At approximately 20:25 (8:25 PM) hours, it was reported the (Pt. #1). in question was found without a pulse ... What Caused this Occurrence? (MD#1) ended treatment and requested to have patient escorted out of the building."

7. On 12/05/2023 at 2:00 PM, the hospital's quality department timeline for the sentinel event was reviewed and included, Staff members (anonymous) stated: The [Pt. #1] stated (Pt. #1) could not walk and complained of chest pains ..."

8. On 12/05/23 at 12:45 PM, an interview was conducted with a Security Officer (E #7), E #7 stated a nurse (E #10) called E #7 to the back to take a patient out of the ED because the patient wanted to leave. E #7 stated that the patient (Pt.#1) did not look well and needed help getting up from the bed because he could not stand or walk, (Pt.#1) stated his legs were wobbly. The patient was calm and cooperative when speaking with E #7. E #7 and another Security Officer helped (Pt.#1) into a wheelchair and took him out to the warming center. (Pt.#1) had to be assisted out of wheelchair to another chair. The patient stated (Pt. #1) needed a few minutes to get self together. E #7 stated that the nurse and physician were present when the patient stated (Pt. #1) could not walk and had to be assisted to the wheelchair.

9. On 12/05/23 at 2:15 PM, an interview was conducted with the Chief Medical Officer (MD #2). MD #2 stated that a patient can be discharged before stat (immediately) lab results are obtained, based on their clinical presentation. In the case of (Pt.#1) it was the right of the patient to refuse treatment. However, if a patient is unresponsive, we will proceed with the necessary care and interventions. MD #2 was asked if based on the RCA findings, was (Pt.#1) safe to be discharged from the ED. MD #2 stated that the RCA findings indicated that (Pt.#1) was not wanting to stay, (Pt.#1) was belligerent and did not want any treatment and did not want to be there, this patient was not safe to discharge. MD #2 stated that the RCA should have identified other concerns such as the lab results were not reported or followed up, and if there was a concern that the patient was not adequate for discharge, (Pt.#1) should have been reassessed.

10. On 12/06/23 at 2:05 PM, an interview was conducted with MD #1 (ED Physician/ED Medical Director). MD #1 stated that any patient in the ED with a change in condition should be re-evaluated prior to discharge. MD #1 stated that based on his evaluation (Pt.#1) did not have a change in medical condition and was appropriate for discharge. MD #1 stated that MD #1 did not recall any staff voicing concern about escorting the patient (Pt.#1) off the premises. MD #1 stated that he ordered cardiac enzymes and other labs because the patient reported cocaine and heroin abuse. The patient was discharged before these lab results were reported. MD #1 stated that the laboratory did not call on any abnormal lab results and that he did not look at the lab results because the patient was already discharged.