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Based on interview, clinical record review, and hospital policy review, the hospital failed to ensure stabilizing treatment, and safety and security relevant to a psychiatric emergency medical condition (EMC) for 1 out of 36 sampled patients when a patient (Patient 25) was brought into the emergency department (ED) with suicidal ideations (thinking about or planning suicide). Patient 25 was able to go into the ED bathroom and take an overdose of a medication obtained from her purse.

This failure resulted in injury to Patient 25 and had the potential to cause additional serious harm and death to the patient.

Findings:

A review of Patient 25's ED clinical record revealed the following documents:

An ED provider note, dated 12/18/23 at 7:49 p.m., indicated, "SI [suicidal ideation] - plan to overdose on pills. EMS [emergency medical services] states patient has a plan to OD [overdose] on pills in her purse."

An ED assessment, dated 12/18/23 at 8:48 p.m., indicated, "Suicide Severity Rating: High" and "Suicide Prevention Interventions: Direct Observation, Secure Environment, Safety Attendant."

An ED provider note, dated 12/18/23 at 9:46 p.m., indicated, "Patient reportedly used the restroom here in the ED. Patient later reported to nurse that she overdosed on 60 tablets of [name of medication] while in the restroom. RN [registered nurse] reports patient's medication bottle is empty ...Patient had a witnessed generalized tonic-clonic seizure [uncontrolled shaking movements with loss of consciousness] in hallway. Seizure self-abated [decreased]. Patient was postictal [abnormal condition occurring between the end of a seizure and return to baseline condition]."

During an interview on 5/14/24 at 2:15 p.m., with ED Educator (EDE), EDE stated Patient 25 was left unobserved for a period of time and Patient 25's belongings were located under the head of the bed. Patient 25's belongings included medications.

During an interview on 5/16/24 at 1:05 p.m., with ED Director (EDD), EDD stated Patient 25's belongings should not have been put under the bed and Patient 25 should have been line of sight (a straight line along which an observer has unobstructed vision).

During an interview on 5/16/24 at 1:20 p.m., with registered nurse ED Staff (RN 1), RN 1 stated, "If a patient came in with SI and pills, I would remove these and keep them with me until security came. I would not leave the patient alone."

During a review of the facility's policy and procedure (P&P) titled, "Identifying and Assessing Patients at Risk of Suicide/Self harm," dated 2023, the P&P indicated, "Patients screened/assessed and found to be at HIGH risk will be monitored under a direct one-to-one (1:1) observation." The P&P further indicated, "Remove from the immediate patient environment any potentially harmful objects."

During a review of the facility's P&P titled, "EMTALA Patient transfer policy", dated 2022, the P&P indicated, "Rights to Treatment. Even if an individual cannot pay, does not have medical insurance, or is not entitled to Medicare or Medicaid, the Medical Center recognizes the right of the individual to receive, within the capabilities of the Medical Center's staff and facilities: b. Necessary stabilizing treatment for an Emergency Medical Condition."

Based on interview and document review, the hospital with capability and capacity failed to accept the transfer for 2 of 36 sampled patients (Patient 1 and 35) with emergency medical conditions (EMC) when:

1. Hospital B delayed Patient 1's transfer from Hospital A for eleven hours and Patient 1 developed a blood clot in the superior mesenteric vein (SMV- a life threatening condition that occurs when a blood clot forms in a large vein in your abdomen). Patient 1was transferred to the receiving facility (Hospital B) in severe septic shock requiring immediate intervention and treatment; and

2. Hospital B, with neurosurgical capabilities, declined to accept Patient 35 from Hospital A with a diagnosis of a subdural hematoma (collection of blood in the brain) and required transfer to another accepting facility.

These failures resulted in delay of treatment and stabilization of an EMC due to the receiving facility refusing to accept Patient 1 and Patient 35 for a higher level of care than the transferring facility could provide which contributed to Patient 1's medical deterioration and had the potential to result in a poor outcomes and death for Paitient 1 and 35.

Findings:

1. A review of Patient 1's medical record from Hospital A included a note titled, "Emergency Documentation - [MD]", which indicated Patient 1 presented to the emergency department on 7/28/23 at 3:13 a.m. with a family member. Patient 1 complained of a 4-5-day history of right upper quadrant abdominal pain with nausea and diarrhea. The note indicated "Pt [Patient 1] diaphoretic (clammy) upon arrival and c/o [complaint of] lightheaded."

Patient 1's initial vital signs were a temperature 36.7 Celsius (98.1 Fahrenheit), blood pressure 113/81 (BP is the amount of force blood uses to get through arteries- normal approximately 120/80), pulse of 98 (the beating of blood through body- normal 60-100 beats per minute [bpm]), respiratory rate of 18, ([RR] is the rate of breaths per minute- normal 12-18 per minute), and SPO2 of 98% (a measurement of how much oxygen your blood is carrying).

A review of a document from Hospital A titled, "Medical Decision Making", dated 7/28/23 at 5:26 a.m., "CT"( a medical technique used to obtain detailed images of the bodies internal organs) results, "SMV thrombus with likely infarcted jejunum, (narrowing or blockage of one or more arteries that supply blood to the small intestine) likely more bowel at risk." The document continued, "Heparin (medication used to prevent harmful clots) ... ordered .... Rocephin and Flagyl (antibiotics used to stop the growth of bacteria) ordered for intra-abdominal coverage." During a further review of the same document indicated "there is/was a high probability of imminent or life-threatening deterioration in the patient's condition due to cardiopulmonary, [heart and lungs], GI [gastro-intestinal, stomach and gut] compromise without immediate intervention." The document also indicated, "No IR (Interventional Radiology- a surgical procedure to treat conditions like clots) at [Hospital A Name] until 8 am".

During a review of the document from Hospital A, "Laboratory Results", dated 7/28/23 at 5:26 a.m., the following was noted:

WBC: 16.6 k/uL (per cubic milliliter- unit of measure), white blood cells- normal range is 4.5 to 11.00, part of the immune system to fight infections, which is elevated indicating a potential infection);

Anion Gap: 23 mEq/L (milliequivalents per liter- unit of measure, Normal range 4mEq/L-12mEq/L a measurement of the acid base balance of blood, levels increase during severe infection)

Glucose: 154 mg/dL (milligrams per deciliter- unit of measure, normal range 125mg/dL or lower, sugar found in blood, when fighting infection, the body responds by increasing the glucose);

Lactic Acid: 2.3 mg/dL (greater than 2mg/dL indicates there is not sufficient oxygen at the cellular level, high levels are common in sepsis or severe shock) Repeat Lactic acid results at 11:41 a.m.: 9.2 mg/dL with a note, "Critical value called to and read back by RN in ED at [12:40 p.m.] 7/28/23."

During a review of a document from Hospital A titled, "Hemodynamics and Vitals", dated 7/28/23 from 3:13 a.m. through 2:25 p.m., revealed Patient 1's systolic blood pressure (measures the pressure in millimeters of mercury [mmHg- a unit of measure] in the arteries when the heart beats) was as high as 158 and as low as 56. Patient 1's diastolic blood pressure (measures the pressure in mmHg in the arteries when your heart relaxes between beats) was as high as 104 and as low as 38. Patient 1's pulse was as low as 58 bpm and as high as 140 bpm. Patient 1's respiratory rate was as low as 15 RR and as high as 29 RR.

A review of Patient 1's medical record note from Hospital A titled, "Respiratory", dated 7/28/23 at 1:49 p.m., noted, "Bi-Level Positive Airway Pressure (BIPAP) "BIPAP per protocol" ... (Used to support breathing through a face mask). The document further indicated at 2:00 p.m., "transferred airway care management to EMS transport team without complications." The note continues, "At 2:11 p.m., "unable to obtain ABG (Arterial Blood Gas- measures how much oxygen, carbon dioxide and the pH, level of acidity or basicity, is in the blood) at this time, transport here to pick up patient."

A review of a document titled, "Patient Care Report" (ambulance transport note), dated 7/28/23 at 2:41 p.m., approximately 13 hours after presenting to the ED, indicated the following:

"Dispatched to ... [Hospital A] for a 52 YOM [year old male] who presented to the ED with generalized, worsening abdominal pain x 3 days, CT revealed full occlusion of superior messentric [sic] artery. While in ED patient had multiple episodes of hypotension (low blood pressure), which were treated with a total of 3L NS (normal saline). Patient then became dyspneic (shortness of breath) and was placed on Bipap for ventilator support" and, "Arrived to find patient hypotensive (low blood pressure) ...pale/cool/diaphoretic, on Bipap ... 9/10 abdominal pain (a numeric scale used to determine a patient's level of pain with 0 being no pain and 10 being worst pain ever) not relieved by pain meds ... ST [rapid heart rate] on monitor ...".

"Enroute to receiving facility patient began to decompensate requiring Levophed (IV medication used to treat life threatening low blood pressure, maybe referred to as a 'pressor') and CPAP (CPAP provides a positive pressure of air through a mask and into the airway which helps keep the airway open) to be started".

A review of a document titled, "Patient Care Report" (ambulance transport note), dated 7/28/23 at 2:41 p.m., included the following vital signs during transport:
2:51 p.m.: 65/31 (BP), 125 pulse, pain- 9/10
2:54 p.m.: 75/59 (BP), 124 pulse, pain- 9/10
3:03 p.m.: 86/63 (BP), heart rate not documented, pain- 9/10
3:05p.m.: 76/51 (BP), 133 pulse, pain- 9/10
3:07p.m.: 81/56 (BP), 131 pulse, pain- 9/10

A review of a document from the receiving hospital, Hospital B, titled, "Final Report, Emergency Documentation," dated 7/28/24 at 3:40 p.m., indicated the following:

Patient 1 arrived at Hospital B complaining of 8/10 abdominal pain and was started on "Levophed and CPAP shortly before arrival". Patient 1's vital signs were documented as blood pressure of 117/97, pulse 125, and respiratory rate of 25, SPO2 97%.

A review of the same document under "Procedures" the following was documented:
"Given the patient's presentation with abdominal pain, there is/was a high probability of imminent or life-threatening deterioration (becoming progressively worse) in patients condition due to cardiovascular, metabolic compromise (failure of the heart and other internal organs) without immediate intervention." Further review of the document dated 7/28/24 at 3:19 p.m., included, "Direct Laryngoscopy/Intubation was performed for airway protection (placement of a flexible plastic tube into the windpipe to maintain an open airway) and Central Venous Catheter (a thin flexible catheter that is inserted into a large, central vein usually below the collar bone to give intravenous fluids, blood, and drugs) was placed for "emergent access for fluid and drug administration".

Review of the same document under "Laboratory Results", at 3:33 p.m., the following abnormal laboratory results were documented:

WBC: 29.2 k/uL, increasing WBC indicated infection.

Anion Gap: 31 mEq/L, levels increase during severe infection.

Glucose: 396 mg/dL, levels increase with severe infection.

Creatinine: 2.85mg/dl (normal range 0.7 -1.3mg/dl- may indicate an acute kidney injury).

Lactic Acid: 16.1 mg/dL, levels increase with severe infection.

Troponin: 101 mg/mL (normal range 0-0.04mg/ml, elevation is an indicator of heart damage related to shock).

The document revealed a second, "CT Angio Abdomen and Pelvis" was performed at 5:33 p.m., and indicated the following, "Patient has known thrombus (blood clot) within the jejunal veins (carry blood to large arteries in the intestines) and thrombosis (blood clot) of entire superior mesenteric vein to its confluence with the splenic vein with thrombus now also extending into the proximal portal vein (more clotting and loss of blood flow) ... Increasing length of involvement of jejunal loops (intestine) as well as also extending towards the proximal ileal loop (intestine) ... The terminal ileum (intestine) is "now collapsed" and "worsening mesenteric fat stranding and edema (swelling) and free fluid in the central mesentery suggesting venous congestion as well as increasing free fluid around the liver and spleen and right lower quadrant."

Review of a document titled, "Patient Placement Note", dated 7/28/23 at 05:31 a.m., indicated the following:

"52-year-old male, [diagnosis] Thrombosis, [complaint of] 4-5 days [history] of ...[abdominal] pain associated with nausea and diarrhea. Denies vomiting. [Patient] diaphoretic upon arrival and ...lightheaded ..." and, "BED: Med. Tele (indicating a heart monitored bed in a unit at Hospital B), REASON: HLOC [higher leve lof care] Vascular Services (the specialty accepting Patient 1) ... Stable for transfer...";

At 5:52 a.m., "[MD# 4], [Hospital B] Vascular talked to sending physician and stated "it is General Surgery";

At 7:30 a.m., "Presented case to [Hospital B] ANS (Administrative Nursing Supervisor- ANS 2) states "this is the same [patient] that was declined by Vascular MD earlier because [patient] needs tertiary care. Has there been a change?";

At 8:00 a.m., "Presented updated information to [ANS 2. [ANS 2] agreed to proceed to present and if accepted bed available pending [discharges] Present to IR and if accepted circle back after 1500 (3:00 p.m.) for bed";

At 10:49 a.m., "[MD #4] at [Hospital B] is willing to see pt at [Hospital B] if vascular and hospitalist agree to accept ...";

At 11:08 a.m., [MD #6] "Vascular surgery not available for this issue but I'll see the patient if IR has problems during intervention ...";

At 11:39 a.m., "[MD #7] hospitalist accepted to MedTele. Waiting on bed ...";

At 12:31 p.m., "Call from unit clerk at [Hospital A] asking for update-advised pending BR (Bed Request)";

At 1:39 p.m., "[Hospital A] requesting bed update, [patient] needs to transfer immediately> (sic) [patient] is scheduled for IR procedure today";

At 1:46 p.m., "[Hospital A] "requesting bed update, informed MD I just reached out to PP (patient placement) re (regarding) this transfer request";

At 2:03 p.m., "Call to 6TN at [Hospital B] (nursing unit within the hospital) CN (Charge Nurse) to discuss bed assignment, advised that she is staffing down and can no longer accept [patients]..."

At 2:42 p.m., "[Patient] LOC (level of care) has changed to ICU (Intensive Care Unit- high level of care)...".

During an interview on 5/15/24 at 4:20 p.m., with ANS 1, ANS 1 indicated the process to accept a patient begins when the "call center bed placement person calls the ANS to request a bed.". ANS 1 indicated "trauma and neuro (brain) are the priority; we will make a bed for those patients." ANS 1 further indicated she will ask the staffer to have nurses come in early or may have a nurse on call who can come in early to care for a transfer patient." ANS 1 stated, "we never stop trying ... I do whatever I can to get a bed for a patient who needs to be admitted or transferred to this hospital." ANS 1 further indicated, "charge nurses may not decline a patient." ANS 1 indicated when she needs additional beds to accept transfers for admission she will round on the floors, involve leadership, check for discharges that have not yet been discharged see if she can expedite the discharge and encourages early discharges. ANS 1 stated the facility does not have an expected discharge time for patients to leave the facility and stated, "discharges happen all day, but mostly in the afternoon."

During a concurrent interview and document review of the document titled "Patient Placement" with ANS 2 on 5/16/24 at 9:22 a.m., ANS 2 indicated the ANS "oversees the entire house (hospital)". ANS 2 indicated when the transfer center calls and requests a bed, even if no beds [available], she would call a physician, if a physician accepts, we will give window of bed availability. ANS 2 stated she declined Patient 1 because "the surgeon declined". ANS 2 indicated she does not keep records of calls for bed requests indicating, "the call center does." ANS 2 further stated she did not accept Patient 1 because Patient 1 needed "tertiary care" which the hospital does not provide. ANS 2 stated she did have a discussion with call center personnel and indicated the hospital only provided "tertiary care for neuro and trauma". ANS 2 stated she did not remember having a conversation with the surgeon regarding Patient 1. ANS 2 stated she did not remember involving the AOC (administrator on call) regarding Patient 1. ANS 2 further indicated a transfer patient can be placed in any one of the hospital's six ICU's or the med/tele floors and it, "just requires an open bed."

During an interview and concurrent document review with Medical Staff Director (MSD) on 5/16/24 at 8:56 a.m., the MSD provided the physician call schedule for 7/28/23 which indicted a vascular surgeon, general surgeon, and IR (Interventional Radiology) were on call for Hospital B. MSD further indicated the on-call physician is expected to be in the hospital within 20 minutes of being called for a case.

During an interview on 5/16/24 at 11:35 a.m., the Intensive Care Unit Manager (Mgr.2) stated he manages the ANS's. The Mgr. 2 stated it was the expectation the ANS "shuffles patients around to make an open bed for a patient who needs to be transferred." Mgr.2 further indicated it is the expectation the ANS will not refuse a transfer but will discuss with the physician and AOC how to accommodate the patient needing transfer into the hospital for a higher level of care.

A review of an untitled document dated 7/28/23 presented by the Quality Director (QD) which QD indicated was the census for 6TN Unit on 7/28/23. The document reflected an inpatient census of 26 patients with staffing for 27 patients as well as a charge nurse "who could take patients if needed" according to the QD. The document further reflected on 7/28/23, the 6TN Unit had 11 discharges and 5 admits. Per the QD 6TN has 30 beds for patients.

Review of the Hospital policy titled, "[Organization Name] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", effective 9/25/2018, directed, "... It is also the policy [Organization Name] to accept emergency transfers from other facilities if the individual being transferred requires Specialized Capabilities that are not offered or not immediately available at the transferring hospital provided that the [Organization Name] hospital has the Capacity and Capability to treat the individual." The policy defined, "...Capability means the physical space, equipment, supplies, and services including ancillary services available at the hospital", and, "...Capacity means the ability of the hospital to accommodate an individual requesting examination or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, and equipment and the hospital's past practices of accommodating additional patients in excess of its occupancy limits."

Review of the Hospital policy titled,"Inter-Facility Transfer", approval date 1/27/22, stipulated, "...Inter-facility transfers are necessary to provide patient's access to specialized providers or higher level of care/services at an appropriate unit/facility ....When a patient requires a higher level of care other than that available/provided at the sending facility, a receiving facility with capability and capacity to provide a higher level of a care may not refuse the request for transfer."

Review of the Hospital document titled, "Memorandum of Understanding for Transfers Between [Hospital A and Hospital B]," dated 3/29/2019, indicated ... "[Hospital B] provides certain emergency, trauma and other clinical services ... which may be required by, or suited for patients at [Hospital A]; and because of either a lack of available personnel ... or services ... [Hospital A] from time to time request the transfer of patients to [Hospital B] to receive appropriate care."

2. Review of Patient 35's medical record from Hospital A titled, "Emergency Documentation - MD", dated 4/21/2024, at 6:49 p.m., indicated the following:

"Medical Decision Making...Patient is an 83-year-old male [with] history of falls who sustained a ground-level fall shortly prior to arrival. Patient has a right parietal [middle part of the brain] occipital [back of head] hematoma [collection of blood] present on exam. CT [Computed Tomography, x-ray images] scan was obtained which shows a large mixed attenuation [reduction of signal] left holohemispheric [entire] subdural hematoma measuring up to 3.6 cm [centimeter, unit of measure]. Immediately following the CT results I asked for a transfer case to be open with [Hospital Name] transfer center. I was contacted back by [name] RN [Registered Nurse] stating that [Medical Doctor (MD) 2 at Hospital B] had reviewed imaging and stated [Patient 35] was a nonsurgical candidate, thus recommend transfer to another facility. I asked to speak with [MD 2] directly which he was agreeable. [MD 2] states in his opinion patient is not an emergent neurosurgical candidate. He recommends that I call another neurosurgeon to obtain their opinion. I did ask [MD 2] if he would be able to speak peer-to-peer, i.e., neurosurgeon to neurosurgeon regarding imaging recommendations, however he declines. I spoke with [MD 8 at Hospital C] as above who states patient is not an emergent neurosurgical candidate...I contacted [Hospital D]... who recommends emergent transfer to [Hospital D]...EMS is planned for pickup at [1:00 a.m.]".

Review of Patient 35's medical record from the receiving hospital, Hospital D, titled, "Emergency Department Nursing Transfer", dated 4/22/24 at 1:10 a.m., indicated Patient 35 had a subdural hematoma, a right elbow abrasion (scrape). Patient 35 had a history of stroke, speech deficits, facial droop, and right arm flaccid (limp) at baseline.

Review of Hospital D document titled, "Op [Operative] Note", dated 4/22/24 at 3:09 p.m., indicated Patient 35 underwent a left-sided craniotomy (removing bone from the skull) for drainage of acute (severe sudden onset) on chronic (over extended period of time) subdural hematoma.

Review of Hospital D document titled, "Hospital Discharge Summary", dated 4/30/24 at 4:02 p.m., indicated Patient 35 was discharged home on 4/30/24.

During a concurrent telephone interview and record review on 5/15/2024 at 1:05 p.m. with the Director of the Clinical Command Center (CCC), the untitled transfer transcript for Patient 35, dated 4/21/24 at 7:40 p.m., was reviewed. The transfer communication transcript indicated that a request was made by Hospital A for neurosurgery services for Patient 35 with a subdural hematoma and included the following:

At 8:19 p.m. the transcript indicated a bed was available at Hospital B and the neurosurgeon (MD 2) would review the CT and call back. The notes further indicated at 9:03 p.m., MD 2 called back and stated "there is nothing he would do surgically but if family wants second opinion that is there (sic) decision."

At 9:49 p.m., indicated a Hospital C neurosurgeon agreed that Patient 35 was not a surgical candidate.

At 10:08 p.m. indicated Hospital B's president was notified and stated "given no surgical intervention needed recommend to admit to [Hospital A] by hospitalist and neurology consult. If they won't admit transfer to [Hospital B] with hospitalist with neurology consult ..."

At 11:02 p.m., [MD 1] [Hospital B] "says this patient should be a potential surgical candidate. States he cannot except (sic) [to] Hospital B, then without neurosurgery support. He spoke with [MD 2] (Hospital B) himself and [MD 2] is unwilling to change his opinion."

At 11:38 p.m., the transcript indicated Hospital D accepted Patient 35.

During a telephone interview on 5/16/2024 at 10:55 a.m., with MD 1, MD 1 stated Patient 35 had a massive left subdural hematoma with left midline shift (brain pushed to one side). Patient 35 met guidelines for surgical interventions. MD 1 did not feel appropriate to admit a patient without surgical support to offer or be available for Patient 35 needs.

During a telephone interview on 5/16/2024 at 1:30 p.m., with MD 2, MD 2 indicated Patient 35 had a dominant hemisphere (controls language) stroke, and a subdural hematoma. Because of his dominant hemisphere stroke, Patient 35 was not a surgical candidate. MD 2 felt ethically it would not be appropriate to operate on Patient 35. Additionally, felt Patient 35 had a poor prognosis and a poor outcome. Patient 35 would likely be left with language problems and already had a hemispheric stroke. MD 2 stated he "would not have surgery done to any of my family member if they had this injury". MD 2 further stated he was not rejecting the patient and stated, "It was an easy surgery....It was an ethical dilemma."

Review of the Hospital policy titled, "[Organization Name] Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy", effective 9/25/2018, directed, "... It is also the policy [Organization Name] to accept emergency transfers from other facilities if the individual being transferred requires Specialized Capabilities that are not offered or not immediately available at the transferring hospital provided that the [Organization Name] hospital has the Capacity and Capability to treat the individual." The policy defined, "...Capability means the physical space, equipment, supplies, and services including ancillary services available at the hospital", and, "...Capacity means the ability of the hospital to accommodate an individual requesting examination or treatment of the transferred individual. Capacity encompasses such things as numbers and availability of qualified staff, beds, and equipment and the hospital's past practices of accommodating additional patients in excess of its occupancy limits."

Review of the Hospital policy titled,"Inter-Facility Transfer", approval date 1/27/22, stipulated, "...Inter-facility transfers are necessary to provide patient's access to specialized providers or higher level of care/services at an appropriate unit/facility ....When a patient requires a higher level of care other than that available/provided at the sending facility, a receiving facility with capability and capacity to provide a higher level of a care may not refuse the request for transfer."

Review of the Hospital document titled, "Memorandum of Understanding for Transfers Between [Hospital A and Hospital B]," dated 3/29/2019, indicated ... "[Hospital B] provides certain emergency, trauma and other clinical services including but not limited to neuro-surgery ... which may be required by, or suited for patients at [Hospital A]; and because of either a lack of available personnel ... or services ... [Hospital A] from time to time request the transfer of patients to [Hospital B] to receive appropriate care."