HospitalInspections.org

Based on document review and staff interviews, the Acute Care Hospital (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 21 emergency patients reviewed (Patient #10, #20, and #21) with an appropriate medical screening exam (MSE) after presenting to the ED requesting emergency medical care. Failure to provide an appropriate MSE and stabilizing treatment places patients at risk for deterioration in their medical condition up to and including death.

The ACH's administrative staff identified an average of 2927 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Hospital policy number IPC005, "Transfer Emergency Medical Treatment and Labor Act (EMTALA) Policy ...," Last Reviewed 10/23, revealed in part:

a. " ...This policy applies to anyone who requests or requires care related to an emergency medical condition who presents on the Medical Center property ..."

b. " ...It is the policy of [ACH] to provide an appropriate medical screening examination to individuals presenting to the dedicated Emergency Department requesting examination or treatment of a medical condition, and to individuals presenting on hospital property requesting examination or treatment of an emergency medical condition. If an emergency medical condition exists, [ACH] will stabilize and treat the emergency condition or transfer the individual appropriately ..."

c. " ...Emergency Medical Condition --- acute symptoms of sufficient severity (including severe pain, psychiatric cdisturbances and/or symptoms of substance abuse) that without immediate medical attention could reasonably be expected to result in: placing health in serious jeopardy; serious impairment to body function; and/or serious dysfunction of any bodily organ or part. If an individual presents to the hospital expressing suicidal or homicidal thoughts or gestures, or if determined dangerous to self or others, they are considered to have an emergency medical condition ..."

d. "Medical Screening Examination: All individuals who come to [ACH's] Emergency Department for examination or treatment ... requesting examination or treatment of an emergency medical condition, shall receive an appropriate medical screening examination. The scope of the medical screening exam will provide all necessary testing and on-call services within the capability of the hospital to reach a diagnosis that excludes the presence of an emergency medical condition ... If the individual has an emergency medical condition, further examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition ..."

e. "Psychiatric patients are considered stable when they are protected and prevented from injury or harming self/others (i.e., initiation of 1:1 monitoring, seclusion, physical or chemical restraints, etc.), along with stabilizing of a medical condition as needed ..."
f. "Personnel qualified to perform an emergency medical exam include ... Practitioners - Any physician medical staff member or physician assistant or advanced practice nurse with appropriate privileges providing emergency services is authorized to perform medical screening examinations in any location on the Medical Center premises. Registered Nurses - Any registered nurse employed by [ACH] who has completed the competency-based orientation checklist for the Emergency Department is authorized to perform a nursing assessment which will form the basis for a medical screening examination. Upon completion of the nursing assessment, the registered nurse will describe the results to the appropriate physician who will determine whether the individual is in an emergency medical condition and will give orders for any further treatment. Treatment may include testing to exclude an emergency medical condition and use of on-call physicians as needed for diagnosis.

g. "Refusal of Examination/Treatment: If the individual, or a person acting on the individual's behalf, refuses further examination and treatment, the individual must be informed of the benefits of the examination and treatment and the risks of refusal of such examination and treatment. If consent to further examination and/or treatment is still withheld, an Against Medical Advice (AMA) form must be completed and placed in the medical record to document the individual's written informed refusal of examination and treatment. Documentation should include a description of the examination and/or treatment refused by or on behalf of the individual, and the fact that the individual has been informed of the benefits of the examination/treatment and risks of refusing examination, treatment or both ..."

2. Review of the policy "Emergency Department: Environmental Safety and Security ...," Last Reviewed 2/22, revealed in part:

a. "Purpose: The Emergency Department is committed to providing a safe environment for all staff, patients, and visitors ..."

b. " ...Behavioral Health area may be used per physician and staff discretion for patients who are belligerent, psychotic, exhibiting behavioral problems, suicidal, homicidal ..."

3. Review of Patient #10's medical record from the ACH revealed:

a. On 1/3/24 at 9:46 AM, Patient #10 presented to the ED by private vehicle for a chief complaint of an alcohol problem.

b. On 1/3/24 at 10:03 AM, an alcohol screening completed and revealed that Patient #10 drank ten or more units of alcohol daily or almost daily.

c. On 1/3/24 at 10:21 AM, Patient #10's neurological assessment completed by RN E revealed Patient #10 had tremors to both arms and legs.

d. On 1/3/24 at 10:26 AM, Patient #10 had a blood alcohol level of 163 (high; normal level is less than ten). Physician A noted Patient #10 had a drink since their report, of a day and a half ago. Physician A noted the hospital Social Worker (SW) would meet with Patient #10 to assist in looking for a "detox" facility for Patient #10's request.

e. On 1/3/24 at 11:38 AM, Social Worker (SW) L met with Patient #10 in the ED to discuss options of support for withdrawal management or treatment of acute alcohol intoxication. Patient #10 had returned from deployment overseas four months prior. Patient #10 had requested the hospital proceed in an attempt to secure a "detox" inpatient treatment option for them, and a referral was placed to a rehab facility.

f. On 1/3/24 at 2:22 PM, Physician A ordered Chlordiazepoxide (medication used to treat acute alcohol withdrawal) cap 25 milligrams (mg) for Patient #10.

g. On 1/3/24 at 2:25 PM, Patient #10 received Chlordiazepoxide cap 25 mg by mouth.

h. On 1/3/24 at 3:36 PM, Patient #10 left without their discharge paperwork, or having their discharge vital signs reassessed. Patient #10's diagnosed with chronic alcohol abuse.

4. The evidence in Patient #10's medical record showed the hospital failed to provide an appropriate MSE and stabilizing treatment as required by hospital policy number IPC005. The ED physician failed to reassess Patient #10 prior to discharge to determine if Patient #10 was no longer clinically intoxicated and/or experiencing signs and symptoms of alcohol withdrawal. ED staff failed to address why Patient #10 wanted to leave the hospital or determine if Patient #10 had the capacity to make an informed decision about leaving. Hospital staff failed to address the outcome of the referral sent to the inpatient treatment facility for Patient #10.

5. During an interview on 1/24/24 at 9:15 AM, RN E reported Patient #10 had been drinking heavily. Patient #10 had been seen a day or two before at another ED, but was sent home due to not being ready for "detox." Patient #10 received an order for medication, but didn't pick it up. RN E recalled Patient #10 had tremors.

6. During an interview on 1/24/24 at 10:10 AM, RN C recalled hospital staff trying to find placement for Patient #10 at a rehab center, but Patient #10 decided not to go due to "money issues." RN C recalled Patient #10 left the ED after talking with the SW. RN C recalled Patient #10 demonstrated symptoms of sweating, anxiety, and overall not feeling good.

7. During an interview on 1/24/24 at 10:40 AM, Physician A recalled Patient #10 being an alcohol abuser who left without getting placed in rehab. Physician A reported the ED SW was working on placement for Patient #10, was unaware if the SW found placement for Patient #10 prior to their discharge from the ED, and verbalized inpatient rehab placement can take days to find. Physician A recalled Patient #10 reported not being intoxicated, but Patient #10's blood alcohol level didn't support Patient #10's report. Physician A reported Patient #10 was "stable", had "stable" vital signs, and their potassium level was "stable", but denied seeing Patient #10 prior to their discharge from the ED. Physician A also reported Patient #10 left the ED prior to receiving their discharge instructions or having another full set of vital signs completed.

8. During an interview on 1/24/24 at 2:45 PM, SW L recalled sending a referral to a rehab facility for Patient #10. SW L reported they secured a bed for Patient #10 at a rehab facility, but Patient #10 left the ED. SW L reported Patient #10 had a blood alcohol level of 163, and recalled Patient #10 as being intoxicated, but able to have a conversation.

9. Review of Patient #21's ambulance report from the ACH revealed:

a. On 11/14/23 at 10:36 PM, emergency medical services (EMS) arrived on scene with Patient #21. Police reported to EMS, Patient #21 had an altercation with multiple people, and got struck in the head multiple times by a golf club. EMS noted Patient #21's had multiple assaults toward random public entities, and innocent bystanders. Patient #21 demonstrated uncooperative and combative behavior, and signs of extreme hostility toward EMS and law enforcement. Patient #21 sustained injuries to the left side of the head, with two lacerations, and swelling and contusions around the two lacerations. Patient #21 appeared to be in some form of hostile psychosis. Patient #21 demonstrated intermittent cooperativeness, along with unpredictable hostility and aggressive behaviors.

10. Review of Patient #21's medical record from the ACH revealed:

a. On 11/14/23 at 10:38 PM, Patient #21 presented to the ED by law enforcement for multiple facial lacerations, and medical clearance prior to being taken to jail. Upon Patient #21's arrival to the ED, physician P noted they were swearing and stated, "I refused medical care." Physician P attempted assess Patient #21's alertness and orientation when Patient #21 spit in Physician P's mouth, and kick Physician P in the face. ED staff applied a pressure dressing to Patient #21's facial lacerations and they were cleared to be taken to jail. Physician P asked ARNP (Advanced Registered Nurse Practitioner) I to assess and offer treatment to Patient #21.

b. On 11/14/23 at 10:54 PM, ARNP I offered medical attention to Patient #21, and they refused.

c. On 11/14/23 at 11:06 PM, RN O noted Patient #21 arrived at the ED by emergency medical services (EMS) with lacerations to their head. Patient #21 immediately reported they did not want to be at the ED, and refused care. Patient #21 allowed RN O to place a pressure dressing to their laceration.

d. On 11/14/23 at 11:11 PM, the ED staff discharged Patient #21.

11. Review of law enforcement bodycam video of Patient #21's ED visit at the ACH revealed:

a. On 11/14/23 at 10:36 PM, Patient #21 arrived at the ED by law enforcement. As law enforcement took Patient #21 out of the police car and placed them in a wheelchair, Patient #21 made threatening statements toward the officer, swearing, and referring to the officer's gun.

b. On 11/14/23 at 10:37 PM, upon entering the ED Patient #21 stood up from the wheelchair and became confrontational with paramedics and law enforcement, swearing, and making life threatening statements several times.

c. On 11/14/23 at 10:39 PM, Patient #21 transferred to an ED bed, remaining in police handcuffs with hands behind their back. Patient #21 stated "I'm refusing medical attention." Physician P attempted to ask Patient #21 for the day, and Patient #21 verbalized they were not going to answer any questions and spit Physician P's face. Physician P raised a fist at Patient #21, then turned to walk away, and Patient #21 kicked Physician P in the face. Physician P engaged in a physical altercation with Patient #21. Law enforcement, nursing staff, and paramedics were in the room, immediately responded, removed Physician P from Patient #21's exam room, and physically restrained Patient #21 down on the exam bed at the head, shoulders, and legs. Patient #21 remained handcuffed with both hands behind their back. Someone is then heard saying take him to jail. ED staff is heard saying Patient #21 is medically clear to go with discussion about Patient #21 being medically cleared for discharge, then RN O verbalized Patient #21 was not medically cleared.

d. On 11/14/23 at 10:40 PM, ED staff asked Patient #21 about letting staff clean them up, and putting sutures in the laceration. Patient #21 continued to talk and swear at ED staff.

e. On 11/14/23 at 10:41 PM, Patient #21 is heard asking law enforcement and ED staff to stop, as they are assessing Patient #21's injuries, and discussing treatment options.

f. On 11/14/23 at 10:42 PM, ED staff again are heard offering medical care, and Patient #21 is heard stating "I refuse medical attention." Then Patient #21 stated "if you want to put a towel on it, then fine, but I'm refusing medical attention." ED staff offered to wrap the lacerations, and Patient #21 verbalized they did not want anyone touching it. ARNP I is then seen at the foot of Patient #21's bed, just inside the exam room, and is heard introducing self to Patient #21, stating "sir, my name is [ARNP I], I am the nurse practitioner on, do you want medical treatment?" Patient #21 stated "no, I do not." ARNP I stated "okay," walked away from Patient #21's exam room with Physician P, and stated "he is refusing medical treatment."

g. On 11/14/23 at 10:43 PM, RN O told Patient #21 they had to help Patient #21 a little bit, and Patient #21 said, "no, I'm good, bud."

h. On 11/14/23 at 10:45 PM, Patient #21 allowed ED staff to assess the head lacerations. Patient #21 started talking to staff, asking if "we're good?" "You good, [random name]?" ED staff asked again about cleaning Patient #21 up, and they again refuse, but are heard asking "can you help me?" ED staff continued to assess, clean, and then bandaged Patient #21's head and facial lacerations.

i. On 11/14/23 at 10:51 PM, RN O applied a pressure dressing to Patient #21's head.

j. On 11/14/23 at 10:53 PM, law enforcement placed Patient #21 in the back of their patrol car, and Patient #21 continued to be verbally aggressive, making verbal threats.

12. During an interview on 1/30/24 at 8:45 AM, Paramedic N recalled Patient #21 being extremely agitated and aggressive, and demonstrated impaired judgment. Paramedic N reported ED staff didn't follow AMA policy with Patient #21, and Patient #21 should not have been allowed to leave AMA.

13. During an interview on 1/30/24 at 11:00 AM, RN O reported a potential for something very bad to happen. RN O didn't recall explaining the benefits of an examination and/or treatment, or the risks of refusing examination, treatment, or both.

14. During an interview on 1/30/24 at 11:00 AM, Physician P acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21. Physician P reported an interaction of 45 seconds with Patient #21, and after Patient #21 assaulted Physician P, they asked ARNP I to try and assess Patient #21. Physician P reported Patient #21 adamantly refused care multiple times, and explained Patient #21 had a Glasgow Coma Scale of 15 (13 to 15 means minor brain injury), spoke in full sentences, and felt Patient #21 was competent to make medical decisions and refuse medical treatment.

15. During an interview on 1/30/24 at 12:30 PM, ARNP I recalled Patient #21 being alert, aggressive, and screaming at ED staff. ARNP I recalled when attempting to assess Patient #21, they refused, and reported Patient #21 was able to sit up, look ARNP I in the face, and when asked if they wanted medical treatment, Patient #21 said no. ARNP I reported Patient #21 was medically competent to make medical decisions, but acknowledged ARNP I didn't do an assessment on Patient #21, and didn't know what Physician P did prior to ARNP I's attempt to assess Patient #21. ARNP I acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21.

16. During an interview on 1/30/24 at 2:30 PM, RN G acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21.

17. ED staff failed to follow hospital policy number IPC005 for individuals expressing homicidal thoughts or gestures, or determined to be dangerous to others, should be considered to have an emergency medical condition (EMC). The hospital policy also stated psychiatric patients are considered stable when they are protected and prevented from injuring or harming self or others. The hospital staff failed to complete an appropriate MSE to assure Patient #21 didn't have any head injuries other than the head lacerations. No laboratory testing or head imaging were obtained. The ED staff failed inform Patient #21 of the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. Patient #21 expressed violent thoughts and gestures toward hospital staff and law enforcement while in the ED from arrival to departure, but Patient #21 was allowed to leave AMA.

18. Review of Patient #20's medical record from the ACH revealed:

a. On 11/7/23 at 4:49 PM, Patient #20 presented to the ED by ambulance with law enforcement with a chief complaint of being physically and sexually assaulted. Patient #20 alleged being hit in the head numerous times. Upon Patient #20's arrival to the ED, ARNP I noted Patient #20 had a one-centimeter (cm) laceration to the scalp. Patient #20 had bleeding coming from the right ear, with a perforated eardrum, and scratches down the right side of the face. ARNP I noted Patient #21 rated her pain as a 10 out of 10 on the pain scale (tool used to help assess a patient's pain; 0 being no pain, and 10 being the worst possible pain) to the right side of the head and ear. ARNP I noted they cleansed and irrigated Patient #20's wounds, applied one staple to the one cm head laceration, and covered it with bacitracin (topical antibiotic ointment) and a dressing. ARNP I notified the sexual assault response team (SART), and diagnosed Patient #20 with a laceration of the scalp.

b. On 11/7/23 at 5:51 PM, Patient #20 became verbally aggressive and upset with RN H's questions about their injuries and reason for their ED visit. Patient #20 felt RN H was putting words in Patient #20's mouth, and didn't believed Patient #20. ED staff informed Patient #20 they notified the SART, and were awaiting their arrival.

c. On 11/7/23 at 5:56 PM, Patient #20 left against medical advice (AMA).

d. On 11/7/23 at 6:18 PM, Patient #20 returned to the ED accompanied by law enforcement for a chief complaint of seizures (a sudden, uncontrolled burst of electrical activity in the brain). Patient #20 held their breath until they turned purple in color and attempted to choke them self with the handcuffs. Patient #20 pulled out the staple from the scalp laceration which was placed approximately an hour prior. Patient #20 again reported pain as 10 out of 10 to the right ear, and right scalp laceration. ARNP I applied two staples to the laceration.

e. On 11/7/23 at 6:50 PM, Patient #20 discharged. Law enforcement came to transport Patient #20, and Patient #20 threw them self on the floor. Patient #20 attempted to take the new staples from the scalp laceration, and started hitting their head on the floor. ED staff lifted Patient #20 in handcuffs to a wheelchair, they were taken to the ambulance garage, and placed in the police car.

f. The hospital staff failed to provide any further assessment or treatment for Patient #20's complaints of pain. The hospital failed to complete an appropriate MSE to assure Patient #20 didn't have further head injuries other than the head laceration and rupture tympanic membrane. No laboratory testing or head imaging were obtained. The hospital also failed to address Patient #20's self-harm behaviors that could have resulted in further injuries, possible death of Patient #20. They also failed to obtain any imaging or testing to rule out the possibility of seizure activity.

19. During an interview on 1/24/24 at 8:30 AM, RN F recalled Patient #20 came into the ED twice on 11/7/23, once for an assault, and the second time by law enforcement for a possible seizure. RN F reported during Patient #20's second ED visit, they were observed choking them self with handcuffs.

20. During an interview on 1/24/24 at 12:30 PM, ARNP I reported Patient #20 is seen frequently in the ED for alcohol abuse, drug abuse, and aggressive behavior. ARNP I recalled Patient #20 being hysterical, screaming, flailing around, being aggressive, and not letting anyone touch them during their first ED visit on 11/7/23. ARNP I reported being informed Patient #20 wanted leave after they agreed to wait for the SART. ARNP I reported Patient #20 pulled out the staple that had just been put in, and said they were leaving. ARNP I reported Patient #20 left multiple times before after the SART had been contacted, so they explained to Patient #20 the team was on the way, and Patient #20 needed to stay, but Patient #20 still left AMA. ARNP I reported law enforcement brought Patient #20 back to the ED, and reported they thought Patient #20 had a seizure. ARNP I replaced the staples to Patient #20's head laceration, and left the room. ARNP I then reported Patient #20 put them self on the floor, and began hitting their head on the floor. ARNP I didn't recall where Patient #20 was discharged to, because ARNP I didn't see Patient #20 before they left.

21. During an interview on 1/24/24 at 11:00 AM, RN G reported Patient #20 as someone that is seen in the ED frequently, had some serious medical issues, and serious substance abuse issues. RN G reported Patient #20 can be very volatile toward ED staff and other patients in the ED waiting room. RN G recalled triaging Patient #20 on 11/7/23 during their first ED visit, and notified the SART. RN G reported Patient #20 trying to rip out the staple to the scalp and wanting to leave AMA.

22. During an interview on 1/24/24 at 11:00 AM, RN H recalled Patient #20 coming to the ED twice on 11/7/23. RN H reported when they attempted to assess Patient #20 and ask question, Patient #20 immediately got upset. RN H reported attempting to explain to Patient #20 the SART had been notified and were on their way, but Patient #20 said they were leaving. RN H reported Patient #20 did not sign an AMA form. RN H then recalled law enforcement brought Patient #20 back to the ED for a possible seizure. RN H reported the ED provider went into see Patient #20, said Patient #20 didn't have a seizure, nothing changed from their previous ED visit, and Patient #20 could discharge. RN H recalled Patient #20 banging their head on the floor. RN H reported law enforcement was called back to the ED, Patient #20 was placed in handcuffs, discharged to law enforcement, and taken to jail.


Please refer to C-2406 for additional information.

Based on document review and staff interviews, the Acute Care Hospital (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 21 emergency patients reviewed (Patient #10, #20, and #21) with an appropriate medical screening exam (MSE) after presenting to their ED requesting emergency medical care. Failure to provide an appropriate MSE places all patients at risk of an undetected emergency medical condition and potential deterioration of their medical condition.

The ACH's administrative staff identified an average of 2927 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #10's medical record from the ACH revealed:

a. On 1/3/24 at 9:46 AM, Patient #10 presented to the ED by private vehicle for a chief complaint of an alcohol problem. Patient #10 reported drinking an 18 pack of beer and one pint of fireball daily since August, and had their last drink the previous morning.

b. On 1/3/24 at 10:00 AM, Patient #10's pulse was 87 (normal range 60-100), respirations were 18 (normal range 12-16), blood pressure (BP) was 139/88 (normal range less than 120/80), and pulse oximetry (SPO2) was 98% (normal range is usually 95% or higher).

c. On 1/3/24 at 10:03 AM, an alcohol screening revealed that Patient #10 drank ten or more units of alcohol daily or almost daily.

d. On 1/3/24 at 10:09 AM, Physician A evaluation noted Patient #10 as alert, nontoxic-appearing, calm and cooperative, and skin was warm and dry.

e. On 1/3/24 at 10:21 AM, Patient #10's neurological assessment completed by RN E revealed they were alert and oriented to time, place, person, and situation. Patient #10 had clear speech and could follow commands. Patient #10 had tremors to both arms and legs.

f. On 1/3/24 at 10:26 AM, Patient #10's abnormal lab results were noted as a white blood count of 4 (low; normal range 4.5-11.0); hemoglobin (Hgb - protein in the blood that carries oxygen) of 12.9 (low; normal range 13.5-17.5); platelets (cell found in the blood to help stop bleeding) were 108000 (low; normal range 150-400); potassium (helps nerves function and muscles contract, helps the heartbeat stay regular) of 2.8 (low; normal range 3.5-5.1); AST (test used to check for liver damage) of 181 (high; normal range 8-34); Bilirubin of 1.4 (high; normal range 0.3-1.2) (Higher levels may indicate different types of liver or bile duct problems). A blood alcohol level of 163 (high; normal level is less than 10). Patient #10 reported drinking a day and a half ago. Physician A noted the hospital Social Worker (SW) would meet with Patient #10 to assist in looking for a "detox" facility.

g. On 1/3/24 at 10:45 AM, Physician A ordered potassium chloride 40 Milliequivalents (mEq) by mouth for Patient #10.

h. On 1/3/24 at 10:57 AM, RN E administered potassium chloride 40 mEq to Patient #10.

i. On 1/3/24 at 11:38 AM, Social Worker (SW) L met with Patient #10 in the ED to discuss options of support for withdrawal management or treatment of acute alcohol intoxication. SW L questioned Patient #10 why they didn't pick up the prescription for withdrawal management given to them two days ago at Hospital B, and Patient #10 reported they were not aware of the prescription at their pharmacy. Patient #10 returned from deployment overseas four months prior. Patient #10 requested the hospital proceed in an attempt to secure a "detox" inpatient treatment option for them, and a referral was placed to a rehab facility.

j. On 1/3/24 at 12:54 PM, Patient #10's BP was 137/88, and SPO2 was 96%.

k. On 1/3/24 at 2:22 PM, Patient #10's pulse was 105, BP was 147/96, and SPO2 was 97%. Physician A ordered Chlordiazepoxide (medication used to treat acute alcohol withdrawal) cap 25 mg for Patient #10.

l. On 1/3/24 at 2:25 PM, Patient #10 received Chlordiazepoxide cap 25 mg by mouth.

m. On 1/3/24 at 2:45 PM, Patient #10's pulse was 107, BP was 142/89, and SPO2 was 96%.

n. On 1/3/24 at 2:45 PM, lab obtained a repeat basic metabolic panel (BMP) (test use to check fluid balance, electrolytes, and kidney function) from Patient #10.

o. On 1/3/24 at 3:13 PM, Patient #10's BMP resulted with a potassium level of 3.2 (low).

p. On 1/3/24 at 3:15 PM, Patient #10's BP was 152/95, and SPO2 was 97%.

q. On 1/3/24 at 3:36 PM, Patient #10 left without their discharge paperwork, or having their discharge vital signs reassessed. Patient #10's diagnosed with chronic alcohol abuse.

2. During an interview on 1/24/24 at 9:15 AM, RN E recalled caring for Patient #10 for about an hour, then passed care over to another RN. RN E reported Patient #10 had just returned from deployment a few months prior, and had been drinking heavily. Patient #10 had been seen a day or two before at another ED, but due to Patient #10 not being ready for "detox," they were sent home. RN E recalled Patient #10 received an order for medication, but didn't pick it up. RN E recalled Patient #10 having tremors during their ED visit.

3. During an interview on 1/24/24 at 10:10 AM, RN C recalled hospital staff trying to find placement for Patient #10 at a rehab center, but Patient #10 decided not to go due to "money issues." RN C recalled Patient #10 left the ED after talking with the SW. RN C reported encouraging Patient #10 to pick up the previously prescribed medication. RN C recalled Patient #10 demonstrated symptoms of sweating, anxiety, and overall not feeling good.

4. During an interview on 1/24/24 at 10:40 AM, Physician A recalled Patient #10 being an alcohol abuser who left without getting placed in rehab. Physician A reported Patient #10 had recently been evaluated at Hospital A, and given recommendations and a prescription for alcohol withdrawal, but didn't follow the treatment plan or pick up the prescription provided to them. Physician A reported the ED SW worked on placement for Patient #10, but wasn't aware if they found placement prior to discharging them from the ED, and verbalized inpatient rehab placement can take days to find. Physician A recalled Patient #10 reported not being intoxicated, but Patient #10's blood alcohol level didn't support their report. Physician A reported Patient #10 was "stable", had "stable" vital signs, and their potassium level was "stable", but denied seeing Patient #10 prior to their discharge from the ED. Physician A also reported Patient #10 left the ED prior to having another full set of vital signs completed.

5. During an interview on 1/24/24 at 2:45 PM, SW L recalled assessing Patient #10, and sending a referral to a rehab facility. SW L reported they secured a bed for Patient #10 at a rehab facility, but Patient #10 left the ED after talking with SW L. SW L reported Patient #10 had a blood alcohol level of 163, and described Patient #10 as being intoxicated, but able to have a conversation. SW L recalled Patient #10 reported drinking the morning before coming to the ED, almost 24 hours before coming in, but their blood alcohol level was still elevated.

6. Evidence from Patient #10's medical record showed the hospital failed to provide an appropriate MSE and stabilizing treatment. The ED physician failed to reassess Patient #10 prior to discharge to determine if Patient #10 was no longer clinically intoxicated and/or experiencing signs and symptoms of alcohol withdrawal. ED staff failed to address why Patient #10 wanted to leave the hospital or determine if Patient #10 had the capacity to make an informed decision about leaving. Hospital staff failed to address the outcome of the referral sent to the inpatient treatment facility for Patient #10.

7. Review of Patient #10's medical record from Hospital B revealed:

a. On 1/3/24 at approximately 4:40 PM, Patient #10 presented to Hospital B's ED. Documentation showed patient #10 reported feeling very shaky, tremulous, nauseous, and anxious. Vital signs were documented as temperature 98.3 F, pulse 110, respiration rate 18, BP 162/118, SpO2 97. Patient #10 tested positive for COVID-19. Patient #10's white blood cell count increased to 4.2, Hgb increased to 13.1, platelet count increased to 118,000, potassium increased to 3.6, AST decreased to 152, Bilirubin increased to 1.9.

b. On 1/3/24 at 6:29 PM, Patient #10 became more tremulous and hypervigilant. BP was 154/109.

c. On 1/3/24 at 7:02 PM, Patient #10's BP was 145/119. The ED provider ordered Valium (medication used to treat anxiety, seizures, muscle spasms, and twitches) IV for Patient #10.

d. On 1/3/24 at 7:15 PM, ED staff noted Patient #10 received IV Valium.

e. On 1/3/24 at 9:45 PM, Patient #10 was admitted to Intensive Care Unit for stabilizing treatment.

8. Review of Patient #21's ambulance report from the ACH revealed:

a. On 11/14/23 at 10:36 PM, emergency medical services (EMS) arrived on scene with Patient #21. Police reported to EMS, Patient #21 had an altercation with multiple people, and got struck in the head multiple times by a golf club. The EMS documented Patient #21 had multiple assaults toward random public entities, and innocent bystanders. EMS noted Patient #21 as uncooperative and combative, showing signs of extreme hostility toward EMS and law enforcement. Patient #21 sustained injuries to the left side of the head, with two lacerations, and swelling and contusions around the two lacerations. EMS noted Patient #21 appeared to be in some form of hostile psychosis. Law enforcement transport Patient #21 to the ED for further evaluation and care due to unsafe probability of Patient #21 toward EMS. It was unknown whether Patient #21 had taken any illicit drugs or alcohol. EMS documented Patient #21 demonstrated intermittent cooperativeness, along with unpredictable hostility and aggressive behaviors.

9. Review of Patient #21's medical record from the ACH revealed:

a. On 11/14/23 at 10:38 PM, Patient #21 presented to the ED by law enforcement for multiple facial lacerations, and medical clearance prior to being taken to jail. Upon Patient #21's arrival to the ED, they were swearing, and stated, "I refused medical care." Physician P attempted to assess Patient #21's alertness and orientation, but Patient #21 spit at Physician P, and kick Physician P in the face. Physician P noted Patient #21 had a pressure dressing applied to their facial lacerations, and they were cleared to be taken to jail. Physician P asked ARNP (Advanced Registered Nurse Practitioner) I to assess and offer treatment to Patient #21.

b. On 11/14/23 at 10:54 PM, ARNP I noted blood to Patient #21's face. ARNP I offered medical attention to Patient #21, and Patient #21 refused. ARNP documented Patient #21 would be arrested, and leave by law enforcement for assaulting medical staff.

c. On 11/14/23 at 11:06 PM, RN O documented Patient #21 arrived at the ED with a laceration to the top of the left side of their head. Patient #21 immediately stated "I don't know why I'm here, I don't want to be here," and they did not want anyone to touch them. Patient #21 allowed RN O to place a pressure dressing to their laceration.

d. On 11/14/23 at 11:11 PM, the ED staff discharged Patient #21 with law enforcement.

10. Review of law enforcement bodycam video of Patient #21's ED visit at the ACH revealed:

a. On 11/14/23 at 10:36 PM, Patient #21 arrived at the ED by law enforcement, taken out of the patrol car by law enforcement in the ambulance garage, and placed into a wheelchair. Patient #21's face, and clothes were covered with blood. Patient #21 made threatening statements to law enforcement as they were assisted to a wheelchair. Patient #21 is heard swearing and talking about the officer's gun.

b. On 11/14/23 at 10:37 PM, upon entering the ED Patient #21 stood up from the wheelchair, became confrontational with paramedics and law enforcement swearing, and made life threatening statements several times before three officers got Patient #21 to sit back down in the wheelchair to be escorted into an ED exam room.

c. On 11/14/23 at 10:39 PM, Patient #21 transferred from the wheelchair to an ED exam bed. Patient #21 remained in police handcuffs with hands behind their back. Physician P presented to Patient #21's bedside, and asked "what happened to you?" Patient #21 stated "I'm refusing medical attention," while swearing at ED staff. DO P then attempted to ask Patient #21 for the day, and Patient #21 verbalized they were not going to answer any questions and spit in Physician P's face. Physician P raised a fist at Patient #21, then turned to walk away, and Patient #21 kicked Physician P in the face. Physician P engaged in a physical altercation with Patient #21. Law enforcement, nursing staff, and paramedics were in the room, immediately responded, removed Physician P from Patient #21's exam room, and physically restrained Patient #21 down on the exam bed at the head, shoulders, and legs. Patient #21 remained handcuffed with both hands behind their back. Patient #21 continued talking, and swearing at ED staff and law enforcement. Someone is then heard saying take him to jail. ED staff is heard saying Patient #21 is medically clear to go, discussion continued about Patient #21 being medically cleared for discharge, then RN O verbalized Patient #21 was not medically cleared.

d. On 11/14/23 at 10:40 PM, ED staff asked Patient #21 about letting them clean them up, and putting sutures in the laceration. Patient #21 continued to talk to ED staff, talking about them hitting him some more, and they might like it.

e. On 11/14/23 at 10:41 PM, Patient #21 told RN O to let go of their face, as RN O applied pressure to Patient #21's facial laceration. RN O explained to Patient #21, they were bleeding. ED staff were heard asking for medication for Patient #21, but told by another ED staff they didn't think the provider would. ED staff were then heard asking about the lacerations to Patient #21's face and head. Law enforcement reported a golf club being involved, and Patient #21 verbalized that is what they got hit with. Patient #21 then asked police and ED staff to stop, as they are assessing Patient #21's injuries, and discussing treatment options.

f. On 11/14/23 at 10:42 PM, ED staff again are heard offering medical care, and Patient #21 is heard stating "I refuse medical attention." Then Patient #21 stated "if you want to put a towel on it, then fine, but I'm refusing medical attention." ED staff offered to wrap the lacerations, and Patient #21 verbalized they did not want anyone touching it. ARNP I is then seen at the foot of Patient #21's bed, just inside the exam room, and is heard introducing self to Patient #21, stating "sir, my name is [ARNP I], I am the nurse practitioner on, do you want medical treatment?" Patient #21 stated "no, I do not." ARNP I stated "okay," walked away from Patient #21's exam room with Physician P, and stated "he is refusing medical treatment."

g. On 11/14/23 at 10:43 PM, RN O told Patient #21 they had to help Patient #21 a little bit, and Patient #21 said, "no, I ' m good, bud."

h. On 11/14/23 at 10:45 PM, Patient #21 allowed ED staff to assess the head lacerations. Patient #21 started asking if "we're good?" "You good, [random name]?" ED staff asked Patient #21 if they could clean off around Patient #21's face, and Patient #21 stated "I don't want you touching me." Then Patient #21 asked "can you help me?" ED staff explained they were trying to help Patient #21, and are heard continuing to assess, clean, and bandage Patient #21's head and facial lacerations.

i. On 11/14/23 at 10:48 PM, Patient #21 allowed the ED staff to clean some of the dried blood off their face, but is heard saying "there is no blood." ED staff are also heard reporting a tear in Patient #21's ear.

j. On 11/14/23 at 10:51 PM, RN O applied a pressure dressing to Patient #21's head.

k. On11/14/23 at 10:52 PM, ED staff and law enforcement assisted Patient #21 to a sitting position, as Patient #21 asked "are you done?" Law enforcement responded, informing Patient #21 they were done, and Patient #21 stated "alright just making sure." As law enforcement escorted Patient #21 back toward the ambulance garage, Patient #21 reached for law enforcement's gun. Patient #21 remained handcuffed.

l. On 11/14/23 at 10:53 PM, law enforcement placed Patient #21 in the back of their patrol car, and Patient #21 continued to be verbally aggressive, making verbal threats.

11. During an interview on 1/30/24 at 8:45 AM, Paramedic N recalled Patient #21 being extremely agitated and aggressive, and demonstrated impaired judgment, but aware of their name and where they were. Paramedic N reported Patient #21 would become agitated then de-escalate, but nothing triggered them. Paramedic N reported when a patient has violent mood swings like Patient #21, something else is going on, and a CT is needed to rule out potential causes. Paramedic N reported Patient #21 attempted to reach for the officer's gun as they were being escorted from the ED. Paramedic N reported Patient #21 didn't have an appropriate assessment. Paramedic N recalled the ED staff mindset as getting Patient #21 out of the ED.

12. During an interview on 1/30/24 at 11:00 AM, RN O recalled Physician P attempted to ask Patient #21 questions, but Patient #21 didn't allow Physician P to ask anything. RN O couldn't recall what questions ARNP I asked Patient #21. RN O reported seeing Patient #21 reaching for the officer's gun as they were walking Patient #21 out of the ED, and a potential for something very bad to happen. RN O didn't recall explaining the benefits of an examination and/or treatment, or the risks of refusing examination, treatment, or both.

13. During an interview on 1/30/24 at 11:00 AM, Physician P recalled Patient #21 as uncooperative, speaking in full sentences, and being neurologically intact (nervous system is working, which involves things like balance, memory, and strength). Physician P reported Patient #21 refused medical treatment to law enforcement prior to being brought to the ED. Physician P reported if a violent patient is brought to their ED, they are typically assessed for competency, and there are numerous opportunities for treating a patient depending on their competency. Physician P acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as Physician P was "just kicked in the head." Physician P reported an interaction of 45 seconds with Patient #21, and after Patient #21 assaulted Physician P, they asked ARNP I to try and assess Patient #21. Physician P reported Patient #21 assaulted other people prior to coming to the ED, had a laceration to their head, adamantly refused care multiple times, and explained Patient #21 had a Glasgow Coma Scale (GCS) of 15 (13 to 15 means minor brain injury), spoke in full sentences, and felt Patient #21 was competent to make medical decisions and refuse medical treatment. Physician P then reported they were comfortable discharging Patient #21 to jail, because nurses were available to monitor Patient #21 at the jail.

14. During an interview on 1/30/24 at 12:30 PM, ARNP I recalled Patient #21 being alert, aggressive, and screaming at ED staff. ARNP I recalled when attempting to assess Patient #21, they refused, and reported Patient #21 was able to sit up, look ARNP I in the face, and Patient #21 said no. ARNP I reported ED staff attempted to do a medical screening on Patient #21, but Patient #21 refused. ARNP I reported Patient #21 was medically competent to make medical decisions, but acknowledged ARNP I didn't do an assessment on Patient #21, didn't know what Physician P did prior to ARNP I's attempt to assess Patient #21, and ARNP I didn't even get close to Patient #21. ARNP I acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21.

15. During an interview on 1/30/24 at 2:30 PM, RN G recalled Patient #21 called them by a random name, and would ask for help, but then said no when ED staff tried to help. RN G reported Patient #21 wouldn't let ED staff suture the laceration, but did allow ED staff to clean it, and apply a dressing. RN G recalled three or four law enforcement officers, two paramedics, two nurses, and a tech caring for Patient #21 during their ED visit, and Patient #21 being held down for ED staff to treat them. RN G recalled it being reported to them that Patient #21 reached for law enforcement's gun when they were leaving the ED, and prior to Patient #21 arrived at the ED, they had been attacking people in the community. RN G acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as they were not Patient #21's primary nurse.

16. The hospital failed to provide an appropriate MSE to Patient #21 while in their ED to fully assess Patient #21 for concern of a closed head injury, or the cause of Patient #21's combativeness, which if not related to a head injury could have been from a countless number of causes. The ED staff failed to inform Patient #21 of the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. Patient #21 expressed violent thoughts and gestures toward hospital staff and law enforcement while in the ED from arrival to departure, but Patient #21 was allowed to leave against medical advice (AMA).

17. Review of Patient #20's medical record from the ACH revealed:

a. On 11/7/23 at 4:49 PM, Patient #20 presented to the ED by ambulance with law enforcement with a chief complaint of being physically and sexually assaulted. Patient #20 alleged being hit in the head numerous times. Upon arrival to the ED, ARNP I assessed Patient #20, and noted they had a one-centimeter (cm) laceration to their scalp. Patient #20 denied loss of consciousness, lightheadedness, dizziness, vision change, nausea, vomiting, or fainting. Patient #20 had bleeding coming from the right ear, with a perforated eardrum, and scratches down the right side of the face. ARNP I noted Patient #21 rated their pain as a 10 out of 10 on the pain scale (tool used to help assess a patient's pain; 0 being no pain, and 10 being the worst possible pain) to the right side of the head and ear. ARNP I cleansed and irrigated Patient #20's lacerations, applied one staple to the one cm head laceration, and covered it with bacitracin (topical antibiotic ointment) and a dressing. ARNP I notified the sexual assault response team (SART) and diagnosed Patient #20 with a laceration of the scalp.

b. On 11/7/23 at 4:49 PM, ARNP I ordered an antibiotic for Patient #20 for the ruptured tympanic membrane, and sent a prescription to Patient #20's pharmacy. ARNP I educated Patient #20 on the medication prescribed and wound care.

c. On 11/7/23 at 5:12 PM, Patient #20 received the antibiotic. Patient #20's GCS assessment was 15.

d. On 11/7/23 at 5:51 PM, Patient #20 became verbally aggressive and upset with RN H's questions about their injuries and reason for their ED visit. Patient #20 felt RN H was putting words in Patient #20's mouth, and didn't believed Patient #20. ED staff informed Patient #20 that they notified the SART, and were awaiting their arrival.

e. On 11/7/23 at 5:56 PM, Patient #20 left AMA.

f. On 11/7/23 at 6:18 PM, Patient #20 returned to the ED accompanied by law enforcement for a chief complaint of seizures (a sudden, uncontrolled burst of electrical activity in the brain). ARNP I assessed Patient #20 upon their arrival to the ED. Patient #20 held their breath until they turned purple in color and attempted to choke them self with their handcuffs. Patient #20 pulled the staple out of the scalp laceration placed approximately an hour prior. Patient #20 again reported pain as 10 out of 10 to the right ear, and right scalp laceration. ARNP I cleansed and irrigated the laceration, applied two staples, and covered it with antibiotic ointment and a dressing.

g. On 11/7/23 at 6:22 PM, RN H assessed Patient #20's GCS, which remained 15.

h. On 11/7/23 at 6:24 PM, Patient #20 told RN H "it feels better to not breathe."

i. On 11/7/23 at 6:35 PM, Patient #20 pulled their pants down, and intentionally peed through the bedrails onto the floor.

j. On 11/7/23 at 6:50 PM, Patient #20 discharged. When law enforcement came to transport Patient #20, and Patient #20 threw them self on the floor, attempted to take out the new staples from the scalp laceration, and started hitting their head on the floor. ED staff lifted Patient #20 in handcuffs to a wheelchair, took Patient #21 to the ambulance garage, and place them in the police car.

k. The hospital staff failed to provide further assessment or treatment for Patient #20's complaints of pain. The hospital failed to complete an appropriate MSE to rule out Patient #20 didn't have any significant head injuries other than the head laceration and rupture tympanic membrane. No laboratory testing or head imaging were obtained. The hospital also failed to address Patient #20's self-harm behaviors that could have resulted in further injuries, or possible death of Patient #20. Hospital staff failed to obtain any imaging or testing to rule out the possibility of seizure activity.

18. During an interview on 1/24/24 at 8:30 AM, RN F recalled Patient #20 coming to the ED often, and had a history of alcohol and drug abuse. RN F recalled Patient #20 came to the ED twice on 11/7/23, once for an assault, and the second time by law enforcement for a possible seizure. RN F reported ED staff notified SART during Patient #20's first ED visit, but Patient #20 became upset with another nurses' questions, and decided to leave. RN F reported Patient #20's second ED visit, they were reported as not breathing well by law enforcement, and were observed choking them self with their handcuffs. RN F recalled Patient #20's skin color being a different color. RN F reported when ARNP I presented to Patient #20's room, RN F left because they were not the primary nurse for Patient #20.

19. During an interview on 1/24/24 at 12:30 PM, ARNP I recalled Patient #20, and reported they are seen frequently in the ED for alcohol abuse, drug abuse, and aggressive behavior. ARNP I recalled Patient #20 being seen in the ED twice on 11/7/23. ARNP I reported Patient #20 being hysterical, screaming, failing around, being aggressive, and not letting anyone touch them during their first ED visit on 11/7/23. ARNP I recalled barely being able to get staples into Patient #20's laceration ARNP I reported being informed Patient #20 wanted to leave after they agreed to wait for SART. ARNP I reported Patient #20 pulled out the staple they had just been put in, and said they were leaving. ARNP I reported Patient #20 left multiple times before after SART had been contacted, so they explained to Patient #20 the team was on the way, and Patient #20 needed to stay, but Patient #20 still left AMA. ARNP I reported law enforcement brought Patient #20 back to the ED, and reported they thought Patient #20 had a seizure. ARNP I reported replacing the staples Patient #20 had removed from the head laceration, and left the room. ARNP I reported Patient #20 wanted to leave. ARNP I then reported Patient #20 urinated and defecated on the floor, put them self on the floor, and began hitting their head on the floor. ARNP I was unable to recall where Patient #20 was discharged to, or what happened to Patient #20, because ARNP I didn't see Patient #20 before they left.

20. During an interview on 1/24/24 at 11:00 AM, RN G reported Patient #20 as someone that is seen in the ED frequently. RN G reported Patient #20 had some serious medical and substance abuse issues. RN G reported Patient #20 being very volatile toward ED staff and other patient in the ED waiting room, and there being complaints about Patient #20 assaulting people in the ED waiting room. RN G recalled triaging Patient #20 on 11/7/23 during their first ED visit, and notifying SART. RN G reported Patient #20 trying to rip out the staple to the scalp and wanting to leave AMA. RN G denies seeing Patient #20 during their second ED visit on 11/7/23.

21. During an interview on 1/24/24 at 11:00 AM, RN H reported Patient #20 comes to the ED frequently. RN H reported Patient #20 comes into the ED drunk, aggressive, and abusive. RN H recalled Patient #20 coming to the ED twice on 11/7/23. RN H reported attempting to assess Patient #20, asking questions, and Patient #20 immediately got upset, thinking RN H didn't believe them. RN H reported attempting to explain to Patient #20 the SART had been notified and were on their way, but Patient #20 said they were leaving. RN H reported Patient #20 did not sign an AMA form. RN H then recalled law enforcement bringing Patient #20 back to the ED for a possible seizure. RN H recalled the ED provider went to see Patient #20, said Patient #20 didn't have a seizure, nothing changed from their previous ED visit, and Patient #20 could discharge. RN H recalled Patient #20 banging their head on the floor. RN H reported law enforcement was called back to the ED, Patient #20 was placed in handcuffs, discharged to law enforcement, and taken to jail.

Based on document review and staff interviews, the Acute Care Hospital (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 21 emergency patients reviewed (Patient #10, #20, and #21) with an appropriate stabilizing treatment for their emergency medical condition (EMC) after presenting to the ED requesting emergency medical care. Failure to provide appropriate stabilizing treatment places all patients at risk for deterioration of their emergency medical condition up to and including death.

The ACH's administrative staff identified an average of 2927 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #10's medical record from the ACH revealed:

a. On 1/3/24 at 9:46 AM, Patient #10 presented to the ED by private vehicle for a chief complaint of an alcohol problem. Patient #10 reported drinking an 18 pack of beer and one pint of fireball daily since August, and had their last drink the previous morning.

b. On 1/3/24 at 10:00 AM, Patient #10's pulse was 87 (normal range 60-100), respirations were 18 (normal range 12-16), blood pressure (BP) was 139/88 (normal range less than 120/80), and pulse oximetry (SPO2) was 98% (normal range is usually 95% or higher).

c. On 1/3/24 at 10:03 AM, an alcohol screening revealed that Patient #10 drank ten or more units of alcohol daily or almost daily.

d. On 1/3/24 at 10:09 AM, Physician A evaluation noted Patient #10 as alert, nontoxic-appearing, calm and cooperative, and skin was warm and dry.

e. On 1/3/24 at 10:21 AM, Patient #10's neurological assessment completed by RN E revealed they were alert and oriented to time, place, person, and situation. Patient #10 had clear speech and could follow commands. Patient #10 had tremors to both arms and legs.

f. On 1/3/24 at 10:26 AM, Patient #10's abnormal lab results were noted as a white blood count of 4 (low; normal range 4.5-11.0); Hgb of 12.9 (low; normal range 13.5-17.5); platelets were 108000 (low; normal range 150-400); potassium of 2.8 (low; normal range 3.5-5.1); AST of 181 (high; normal range 8-34); Bilirubin of 1.4 (high; normal range 0.3-1.2). A blood alcohol level of 163 (high; normal level is less than 10). Patient #10 reported drinking a day and a half ago. Physician A noted the hospital Social Worker (SW) would meet with Patient #10 to assist in looking for a "detox" facility.

g. On 1/3/24 at 10:45 AM, Physician A ordered potassium chloride 40 mEq by mouth for Patient #10.

h. On 1/3/24 at 10:57 AM, RN E administered potassium chloride 40 mEq to Patient #10.

i. On 1/3/24 at 11:38 AM, Social Worker (SW) L met with Patient #10 in the ED to discuss options of support for withdrawal management or treatment of acute alcohol intoxication. SW L questioned Patient #10 why they didn't pick up the prescription for withdrawal management given to them two days ago at Hospital B, and Patient #10 reported they were not aware of the prescription at their pharmacy. Patient #10 returned from deployment overseas four months prior. Patient #10 requested the hospital proceed in an attempt to secure a "detox" inpatient treatment option for them, and a referral was placed to a rehab facility.

j. On 1/3/24 at 12:54 PM, Patient #10's BP was 137/88, and SPO2 was 96%.

k. On 1/3/24 at 2:22 PM, Patient #10's pulse was 105, BP was 147/96, and SPO2 was 97%. Physician A ordered Chlordiazepoxide (medication used to treat acute alcohol withdrawal) cap 25 mg for Patient #10.

l. On 1/3/24 at 2:25 PM, Patient #10 received Chlordiazepoxide cap 25 mg by mouth.

m. On 1/3/24 at 2:45 PM, Patient #10's pulse was 107, BP was 142/89, and SPO2 was 96%.

n. On 1/3/24 at 2:45 PM, lab obtained a repeat basic metabolic panel (BMP) (test use to check fluid balance, electrolytes, and kidney function) from Patient #10.

o. On 1/3/24 at 3:13 PM, Patient #10's BMP resulted with a potassium level of 3.2 (low).

p. On 1/3/24 at 3:15 PM, Patient #10's BP was 152/95, and SPO2 was 97%.

q. On 1/3/24 at 3:36 PM, Patient #10 left without their discharge paperwork, or having their discharge vital signs reassessed. Patient #10's diagnosed with chronic alcohol abuse.

2. During an interview on 1/24/24 at 9:15 AM, RN E recalled caring for Patient #10 for about an hour, then passed care over to another RN. RN E reported Patient #10 had just returned from deployment a few months prior, and had been drinking heavily. Patient #10 had been seen a day or two before at another ED, but due to Patient #10 not being ready for "detox," they were sent home. RN E recalled Patient #10 received an order for medication, but didn't pick it up. RN E recalled Patient #10 having tremors during their ED visit.

3. During an interview on 1/24/24 at 10:10 AM, RN C recalled hospital staff trying to find placement for Patient #10 at a rehab center, but Patient #10 decided not to go due to "money issues." RN C recalled Patient #10 left the ED after talking with the SW. RN C reported encouraging Patient #10 to pick up the previously prescribed medication. RN C recalled Patient #10 demonstrated symptoms of sweating, anxiety, and overall not feeling good.

4. During an interview on 1/24/24 at 10:40 AM, Physician A recalled Patient #10 being an alcohol abuser who left without getting placed in rehab. Physician A reported Patient #10 had recently been evaluated at Hospital A, and given recommendations and a prescription for alcohol withdrawal, but didn't follow the treatment plan or pick up the prescription provided to them. Physician A reported the ED SW worked on placement for Patient #10, but wasn't aware if they found placement prior to discharging them from the ED, and verbalized inpatient rehab placement can take days to find. Physician A recalled Patient #10 reported not being intoxicated, but Patient #10's blood alcohol level didn't support their report. Physician A reported Patient #10 was "stable", had "stable" vital signs, and their potassium level was "stable", but denied seeing Patient #10 prior to their discharge from the ED. Physician A also reported Patient #10 left the ED prior to having another full set of vital signs completed.

5. During an interview on 1/24/24 at 2:45 PM, SW L recalled assessing Patient #10, and sending a referral to a rehab facility. SW L reported they secured a bed for Patient #10 at a rehab facility, but Patient #10 left the ED after talking with SW L. SW L reported Patient #10 had a blood alcohol level of 163, and described Patient #10 as being intoxicated, but able to have a conversation. SW L recalled Patient #10 reported drinking the morning before coming to the ED, almost 24 hours before coming in, but their blood alcohol level was still elevated.

6. Acute alcohol intoxication can lead to altered mental status which can lead to hypoventilation (breathing too shallow and too slow to meet the bodies oxygen need) and excessive drowsiness, leading to airway compromise. Acute alcohol withdrawal can lead to electrolyte abnormalities, and life-threatening seizures. Treatment for acute alcohol intoxication and acute alcohol withdrawal are metabolizing, hydration, rechecking the blood alcohol level, admission to the hospital, and medications. Evidence in Patient #10's medical record showed the ED physician failed to reassess Patient #10 prior to discharge to determine if Patient #10 was no longer clinically intoxicated and/or experiencing signs and symptoms of alcohol withdrawal. ED staff failed to address why Patient #10 wanted to leave the hospital or determine if Patient #10 had the capacity to make an informed decision about leaving. Hospital staff failed to address the outcome of the referral sent to the inpatient treatment facility for Patient #10.

7. Review of Patient #10's medical record from Hospital B revealed:

a. On 1/3/24 at approximately 4:40 PM, Patient #10 presented to the ED with their mother for an unknown complaint. Patient #10 reported feeling very shaky, tremulous, nauseous, and anxious. Vital signs were documented as temperature 98.3 F, pulse 110, respiration rate 18, BP 162/118, SpO2 97. Patient #10 tested positive for COVID-19. Patient #10's white blood cell count increased to 4.2, Hgb increased to 13.1, platelet count increased to 118,000, potassium increased to 3.6, AST decreased to 152, Bilirubin increased to 1.9.

b. On 1/3/24 at 6:29 PM, Patient #10 became more tremulous and hypervigilant. BP was 154/109.

c. On 1/3/24 at 7:02 PM, Patient #10's BP was 145/119. The ED provider ordered Valium (medication used to treat anxiety, seizures, muscle spasms, and twitches) IV for Patient #10.

d. On 1/3/24 at 7:15 PM, Patient #10 received IV Valium.

e. On 1/3/24 at 9:45 PM, Patient #10 was admitted to Intensive Care Unit for stabilizing treatment.

8. Review of Patient #21's ambulance report from the ACH revealed:

a. On 11/14/23 at 10:36 PM, emergency medical services (EMS) arrived on scene with Patient #21. Police reported to EMS, Patient #21 had an altercation with multiple people, and got struck in the head multiple times by a golf club. The EMS documented Patient #21 had multiple assaults toward random public entities, and innocent bystanders. EMS noted Patient #21 as uncooperative and combative, showing signs of extreme hostility toward EMS and law enforcement. Patient #21 sustained injuries to the left side of the head, with two lacerations, and swelling and contusions around the two lacerations. EMS noted Patient #21 appeared to be in some form of hostile psychosis. Law enforcement transport Patient #21 to the ED for further evaluation and care due to unsafe probability of Patient #21 toward EMS. It was unknown whether Patient #21 had taken any illicit drugs or alcohol. EMS documented Patient #21 demonstrated intermittent cooperativeness, along with unpredictable hostility and aggressive behaviors.

9. Review of Patient #21's medical record from the ACH revealed:

a. On 11/14/23 at 10:38 PM, Patient #21 presented to the ED by law enforcement for multiple facial lacerations, and medical clearance prior to being taken to jail. Upon Patient #21's arrival to the ED, they were swearing, and stated, "I refused medical care." Physician P attempted to assess Patient #21's alertness and orientation, but Patient #21 spit at Physician P, and kick Physician P in the face. Physician P noted Patient #21 had a pressure dressing applied to their facial lacerations, and they were cleared to be taken to jail. Physician P asked ARNP (Advanced Registered Nurse Practitioner) I to assess and offer treatment to Patient #21.

b. On 11/14/23 at 10:54 PM, ARNP I noted blood to Patient #21's face. ARNP I offered medical attention to Patient #21, and Patient #21 refused. ARNP documented Patient #21 would be arrested, and leave by law enforcement for assaulting medical staff.

c. On 11/14/23 at 11:06 PM, RN O documented Patient #21 arrived at the ED with a laceration to the top of the left side of their head. Patient #21 immediately stated "I don't know why I'm here, I don't want to be here," and they did not want anyone to touch them. Patient #21 allowed RN O to place a pressure dressing to their laceration.

d. On 11/14/23 at 11:11 PM, the ED staff discharged Patient #21 with law enforcement.

10. Review of law enforcement bodycam video of Patient #21's ED visit at the ACH revealed:

a. On 11/14/23 at 10:36 PM, Patient #21 arrived at the ED by law enforcement, taken out of the patrol car by law enforcement in the ambulance garage, and placed into a wheelchair. Patient #21's face, and clothes were covered with blood. Patient #21 made threatening statements to law enforcement as they were assisted to a wheelchair. Patient #21 is heard swearing and talking about the officer's gun.

b. On 11/14/23 at 10:37 PM, upon entering the ED Patient #21 stood up from the wheelchair, became confrontational with paramedics and law enforcement swearing, and made life threatening statements several times before three officers got Patient #21 to sit back down in the wheelchair to be escorted into an ED exam room.

c. On 11/14/23 at 10:39 PM, Patient #21 transferred from the wheelchair to an ED exam bed. Patient #21 remained in police handcuffs with hands behind their back. Physician P presented to Patient #21's bedside, and asked "what happened to you?" Patient #21 stated "I'm refusing medical attention," while swearing at ED staff. DO P then attempted to ask Patient #21 for the day, and Patient #21 verbalized they were not going to answer any questions and spit in Physician P's face. Physician P raised a fist at Patient #21, then turned to walk away, and Patient #21 kicked Physician P in the face. Physician P engaged in a physical altercation with Patient #21. Law enforcement, nursing staff, and paramedics were in the room, immediately responded, removed Physician P from Patient #21's exam room, and physically restrained Patient #21 down on the exam bed at the head, shoulders, and legs. Patient #21 remained handcuffed with both hands behind their back. Patient #21 continued talking, and swearing at ED staff and law enforcement. Someone is then heard saying take him to jail. ED staff is heard saying Patient #21 is medically clear to go, discussion continued about Patient #21 being medically cleared for discharge, then RN O verbalized Patient #21 was not medically cleared.

d. On 11/14/23 at 10:40 PM, ED staff asked Patient #21 about letting them clean them up, and putting sutures in the laceration. Patient #21 continued to talk to ED staff, talking about them hitting him some more, and they might like it.

e. On 11/14/23 at 10:41 PM, Patient #21 told RN O to let go of their face, as RN O applied pressure to Patient #21's facial laceration. RN O explained to Patient #21, they were bleeding. ED staff were heard asking for medication for Patient #21, but told by another ED staff they didn't think the provider would. ED staff were then heard asking about the lacerations to Patient #21's face and head. Law enforcement reported a golf club being involved, and Patient #21 verbalized that is what they got hit with. Patient #21 then asked police and ED staff to stop, as they are assessing Patient #21's injuries, and discussing treatment options.

f. On 11/14/23 at 10:42 PM, ED staff again are heard offering medical care, and Patient #21 is heard stating "I refuse medical attention." Then Patient #21 stated "if you want to put a towel on it, then fine, but I'm refusing medical attention." ED staff offered to wrap the lacerations, and Patient #21 verbalized they did not want anyone touching it. ARNP I is then seen at the foot of Patient #21's bed, just inside the exam room, and is heard introducing self to Patient #21, stating "sir, my name is [ARNP I], I am the nurse practitioner on, do you want medical treatment?" Patient #21 stated "no, I do not." ARNP I stated "okay," walked away from Patient #21's exam room with Physician P, and stated "he is refusing medical treatment."

g. On 11/14/23 at 10:43 PM, RN O told Patient #21 they had to help Patient #21 a little bit, and Patient #21 said, "no, I ' m good, bud."

h. On 11/14/23 at 10:45 PM, Patient #21 allowed ED staff to assess the head lacerations. Patient #21 started asking if "we're good?" "You good, [random name]?" ED staff asked Patient #21 if they could clean off around Patient #21's face, and Patient #21 stated "I don't want you touching me." Then Patient #21 asked "can you help me?" ED staff explained they were trying to help Patient #21, and are heard continuing to assess, clean, and bandage Patient #21's head and facial lacerations.

i. On 11/14/23 at 10:48 PM, Patient #21 allowed the ED staff to clean some of the dried blood off their face, but is heard saying "there is no blood." ED staff are also heard reporting a tear in Patient #21's ear.

j. On 11/14/23 at 10:51 PM, RN O applied a pressure dressing to Patient #21's head.

k. On11/14/23 at 10:52 PM, ED staff and law enforcement assisted Patient #21 to a sitting position, as Patient #21 asked "are you done?" Law enforcement responded, informing Patient #21 they were done, and Patient #21 stated "alright just making sure." As law enforcement escorted Patient #21 back toward the ambulance garage, Patient #21 reached for law enforcement's gun. Patient #21 remained handcuffed.

l. On 11/14/23 at 10:53 PM, law enforcement placed Patient #21 in the back of their patrol car, and Patient #21 continued to be verbally aggressive, making verbal threats.

11. During an interview on 1/30/24 at 8:45 AM, Paramedic N recalled Patient #21 being extremely agitated and aggressive, and demonstrated impaired judgment, but aware of their name and where they were. Paramedic N reported Patient #21 would become agitated then de-escalate, but nothing triggered them. Paramedic N reported when a patient has violent mood swings like Patient #21, something else is going on, and a CT is needed to rule out potential causes. Paramedic N reported Patient #21 attempted to reach for the officer's gun as they were being escorted from the ED. Paramedic N reported Patient #21 didn't have an appropriate assessment. Paramedic N recalled the ED staff mindset as getting Patient #21 out of the ED.

12. During an interview on 1/30/24 at 11:00 AM, RN O recalled Physician P attempted to ask Patient #21 questions, but Patient #21 didn't allow Physician P to ask anything. RN O couldn't recall what questions ARNP I asked Patient #21. RN O reported seeing Patient #21 reaching for the officer's gun as they were walking Patient #21 out of the ED, and a potential for something very bad to happen. RN O didn't recall explaining the benefits of an examination and/or treatment, or the risks of refusing examination, treatment, or both.

13. During an interview on 1/30/24 at 11:00 AM, Physician P recalled Patient #21 as uncooperative, speaking in full sentences, and being neurologically intact (nervous system is working, which involves things like balance, memory, and strength). Physician P reported Patient #21 refused medical treatment to law enforcement prior to being brought to the ED. Physician P reported if a violent patient is brought to their ED, they are typically assessed for competency, and there are numerous opportunities for treating a patient depending on their competency. Physician P acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as Physician P was "just kicked in the head." Physician P reported an interaction of 45 seconds with Patient #21, and after Patient #21 assaulted Physician P, they asked ARNP I to try and assess Patient #21. Physician P reported Patient #21 assaulted other people prior to coming to the ED, had a laceration to their head, adamantly refused care multiple times, and explained Patient #21 had a Glasgow Coma Scale (GCS) of 15 (13 to 15 means minor brain injury), spoke in full sentences, and felt Patient #21 was competent to make medical decisions and refuse medical treatment. Physician P then reported they were comfortable discharging Patient #21 to jail, because nurses were available to monitor Patient #21 at the jail.

14. During an interview on 1/30/24 at 12:30 PM, ARNP I recalled Patient #21 being alert, aggressive, and screaming at ED staff. ARNP I recalled when attempting to assess Patient #21, they refused, and reported Patient #21 was able to sit up, look ARNP I in the face, and Patient #21 said no. ARNP I reported ED staff attempted to do a medical screening on Patient #21, but Patient #21 refused. ARNP I reported Patient #21 was medically competent to make medical decisions, but acknowledged ARNP I didn't do an assessment on Patient #21, didn't know what Physician P did prior to ARNP I's attempt to assess Patient #21, and ARNP I didn't even get close to Patient #21. ARNP I acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21.

15. During an interview on 1/30/24 at 2:30 PM, RN G recalled Patient #21 called them by a random name, and would ask for help, but then said no when ED staff tried to help. RN G reported Patient #21 wouldn't let ED staff suture the laceration, but did allow ED staff to clean it, and apply a dressing. RN G recalled three or four law enforcement officers, two paramedics, two nurses, and a tech caring for Patient #21 during their ED visit, and Patient #21 being held down for ED staff to treat them. RN G recalled it being reported to them that Patient #21 reached for law enforcement's gun when they were leaving the ED, and prior to Patient #21 arrived at the ED, they had been attacking people in the community. RN G acknowledged they didn't explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as they were not Patient #21's primary nurse.

16. The hospital failed to provide an appropriate MSE to Patient #21 while in their ED to fully assess Patient #21 for concern of a closed head injury, or the cause of Patient #21's combativeness, which if not related to a head injury could have been from a countless number of causes. The ED staff failed to inform Patient #21 of the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. Patient #21 expressed violent thoughts and gestures toward hospital staff and law enforcement while in the ED from arrival to departure, but Patient #21 was allowed to leave against medical advice (AMA) without being explained the benefits of an examination/treatment and the risks of refusing examination, treatment, or both.

17. Review of Patient #20's medical record from the ACH revealed:

a. On 11/7/23 at 4:49 PM, Patient #20 presented to the ED by ambulance with law enforcement with a chief complaint of being physically and sexually assaulted. Patient #20 alleged being hit in the head numerous times. Upon arrival to the ED, ARNP I assessed Patient #20, and noted they had a one-centimeter (cm) laceration to their scalp. Patient #20 denied loss of consciousness, lightheadedness, dizziness, vision change, nausea, vomiting, or fainting. Patient #20 had bleeding coming from the right ear, with a perforated eardrum, and scratches down the right side of the face. ARNP I noted Patient #21 rated their pain as a 10 out of 10 on the pain scale (tool used to help assess a patient's pain; 0 being no pain, and 10 being the worst possible pain) to the right side of the head and ear. ARNP I cleansed and irrigated Patient #20's lacerations, applied one staple to the one cm head laceration, and covered it with bacitracin (topical antibiotic ointment) and a dressing. ARNP I notified the sexual assault response team (SART) and diagnosed Patient #20 with a laceration of the scalp.

b. On 11/7/23 at 4:49 PM, ARNP I ordered an antibiotic for Patient #20 for the ruptured tympanic membrane, and sent a prescription to Patient #20's pharmacy. ARNP I educated Patient #20 on the medication prescribed and wound care.

c. On 11/7/23 at 5:12 PM, Patient #20 received the antibiotic. Patient #20's GCS assessment was 15.

d. On 11/7/23 at 5:51 PM, Patient #20 became verbally aggressive and upset with RN H's questions about their injuries and reason for their ED visit. Patient #20 felt RN H was putting words in Patient #20's mouth, and didn't believed Patient #20. ED staff informed Patient #20 that they notified the SART, and were awaiting their arrival.

e. On 11/7/23 at 5:56 PM, Patient #20 left AMA.

f. On 11/7/23 at 6:18 PM, Patient #20 returned to the ED accompanied by law enforcement for a chief complaint of seizures (a sudden, uncontrolled burst of electrical activity in the brain). ARNP I assessed Patient #20 upon their arrival to the ED. Patient #20 held their breath until they turned purple in color and attempted to choke them self with their handcuffs. Patient #20 pulled the staple out of the scalp laceration placed approximately an hour prior. Patient #20 again reported pain as 10 out of 10 to the right ear, and right scalp laceration. ARNP I cleansed and irrigated the laceration, applied 2 staples, and covered it with antibiotic ointment and a dressing.

g. On 11/7/23 at 6:22 PM, RN H assessed Patient #20's GCS, which remained 15.

h. On 11/7/23 at 6:24 PM, Patient #20 told RN H "it feels better to not breathe."

i. On 11/7/23 at 6:35 PM, Patient #20 pulled their pants down, and intentionally peed through the bedrails onto the floor.

j. On 11/7/23 at 6:50 PM, Patient #20 discharged. When law enforcement came to transport Patient #20, and Patient #20 threw them self on the floor, attempted to take out the new staples from the scalp laceration, and started hitting their head on the floor. ED staff lifted Patient #20 in handcuffs to a wheelchair, took Patient #21 to the ambulance garage, and place them in the police car.

k. The hospital staff failed to provide further assessment or treatment for Patient #20's complaints of pain. The hospital failed to complete an appropriate MSE to rule out Patient #20 didn't have any significant head injuries other than the head laceration and rupture tympanic membrane. No laboratory testing or head imaging were obtained. The hospital also failed to address Patient #20's self-harm behaviors that could have resulted in further injuries, or possible death of Patient #20. Hospital staff failed to obtain any imaging or testing to rule out the possibility of seizure activity. Hospital staff also failed to provide prophylaxis treatment for the sexual assault or behavioral health treatment for the self-harm behaviors.

18. During an interview on 1/24/24 at 8:30 AM, RN F recalled Patient #20 coming to the ED often, and had a history of alcohol and drug abuse. RN F recalled Patient #20 came to the ED twice on 11/7/23, once for an assault, and the second time by law enforcement for a possible seizure. RN F reported ED staff notified SART during Patient #20's first ED visit, but Patient #20 became upset with another nurses' questions, and decided to leave. RN F reported Patient #20's second ED visit, they were reported as not breathing well by law enforcement, and were observed choking them self with their handcuffs. RN F recalled Patient #20's skin color being a different color. RN F reported when ARNP I presented to Patient #20's room, RN F left because they were not the primary nurse for Patient #20.

19. During an interview on 1/24/24 at 12:30 PM, ARNP I recalled Patient #20, and reported they are seen frequently in the ED for alcohol abuse, drug abuse, and aggressive behavior. ARNP I recalled Patient #20 being seen in the ED twice on 11/7/23. ARNP I reported Patient #20 being hysterical, screaming, failing around, being aggressive, and not letting anyone touch them during their first ED visit on 11/7/23. ARNP I recalled barely being able to get staples into Patient #20's laceration ARNP I reported being informed Patient #20 wanted to leave after they agreed to wait for SART. ARNP I reported Patient #20 pulled out the staple they had just been put in, and said they were leaving. ARNP I reported Patient #20 left multiple times before after SART had been contacted, so they explained to Patient #20 the team was on the way, and Patient #20 needed to stay, but Patient #20 still left AMA. ARNP I reported law enforcement brought Patient #20 back to the ED, and reported they thought Patient #20 had a seizure. ARNP I reported replacing the staples Patient #20 had removed from the head laceration, and left the room. ARNP I reported Patient #20 wanted to leave. ARNP I then reported Patient #20 urinated and defecated on the floor, put them self on the floor, and began hitting their head on the floor. ARNP I was unable to recall where Patient #20 was discharged to, or what happened to Patient #20, because ARNP I didn't see Patient #20 before they left.

20. During an interview on 1/24/24 at 11:00 AM, RN G reported Patient #20 as someone that is seen in the ED frequently. RN G reported Patient #20 had some serious medical and substance abuse issues. RN G reported Patient #20 being very volatile toward ED staff and other patient in the ED waiting room, and there being complaints about Patient #20 assaulting people in the ED waiting room. RN G recalled triaging Patient #20 on 11/7/23 during their first ED visit, and notifying SART. RN G reported Patient #20 trying to rip out the staple to the scalp and wanting to leave AMA. RN G denies seeing Patient #20 during their second ED visit on 11/7/23.

21. During an interview on 1/24/24 at 11:00 AM, RN H reported Patient #20 comes to the ED frequently. RN H reported Patient #20 comes into the ED drunk, aggressive, and abusive. RN H recalled Patient #20 coming to the ED twice on 11/7/23. RN H reported attempting to assess Patient #20, asking questions, and Patient #20 immediately got upset, thinking RN H didn't believe them. RN H reported attempting to explain to Patient #20 the SART had been notified and were on their way, but Patient #20 said they were leaving. RN H reported Patient #20 did not sign an AMA form. RN H then recalled law enforcement bringing Patient #20 back to the ED for a possible seizure. RN H recalled the ED provider went to see Patient #20, said Patient #20 didn't have a seizure, nothing changed from their previous ED visit, and Patient #20 could discharge. RN H recalled Patient #20 banging their head on the floor. RN H reported law enforcement was called back to the ED, Patient #20 was placed in handcuffs, discharged to law enforcement, and taken to jail.