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Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #21) clinical records reviewed regarding care planning, the hospital failed to ensure that Pt. #21's guardian participated in the development and implementation of Pt. #21's transfer to another hospital.

Findings include:

1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis (deviation from reality). The clinical record included:

- A document titled, "Order Appointing Limited Guardian of a Person with a Disability" (effective 9/2023) that indicated, " ... (Pt. #21) A Person with a Disability ... for the appointment of (Pt. #21's Mother) as Limited Guardian of the person of (Pt. #21 the Respondent) ... 6. The appointment of a Guardian ad litem (court-appointed legal advocate) WAS necessary for the protection of the Respondent or to make a reasonably informed decision..."

- The crisis worker's (E #20) progress note on 8/12/2024 at 9:30 AM, indicated, "... (Pt. #21) has now accepted that (Pt. #21) will be transferred to (psychiatric) unit, requesting to go to (Hospital B)..." At 12:34 PM, Pt. #21 was transferred to (Hospital B). However, there was no documentation that Pt. #21's mother/guardian was informed or participated in the transfer of Pt. #21 to another hospital.

2. On 4/09/2025, the hospital's document titled, "Your Patient Rights and Responsibilities" (undated) was reviewed and indicated, "... You have the right to... participate in your care plan..."

3. On 4/10/2025 at approximately 10:00 AM, an interview was conducted with MD #8 (ED Medical Director). MD #8 stated that patient's legal guardian should be informed and be allowed to participate in the discharge planning.

Based on document review and interview, it was determined that for 1 of 3 patients (Pt. #21) clinical records reviewed regarding use of restraints, the hospital failed to ensure that least restricve interventions were used before initiation of violent restraints.

Findings include:

1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis (deviation from reality). The clinical record indicated that Pt. #21 was placed in violent restraints on 8/09/2024 from 3:00 PM through 4:00 PM (one hour). There was no documentation that least restrictive interventions were used before initiation of violent restraints.

2. On 4/09/2025, the hospital's policy titled, "Restraint Management Policy" (3/2019) was reviewed and indicated, "... III. Policy: It is the objective of our hospitals to lmit and/or eliminate the use of restraint. Conversely, clnically and developmentally appropriate alternatives to restraint are to be attempted, documented and found to be ineffective prior ot use of restraint..."

3. On 4/09/2024 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that least restrictive intervention should be used before initiation of violent restraints.

Based on doucment review and interview, it was determined that for 1 of 3 patients' (Pt. #21) clinical records reviewed regarding use of restraints, the hospital failed to ensure that restriction of rights was provided to Pt. #21 and/or Pt. #21's guardian, in accordance with the hospital's policy.

Findings include:

1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis. The clinical record indicated that Pt. #21 was placed in violent restraints on 8/10/2024 from 3:14 PM through 3:39 PM (25 minutes). There was no restriction of rights provided to Pt. #21 or Pt. #21's guardian.

2. On 4/09/2025, the hospital's policy titled, "Restraint Management" (3/2019) was reviewed and included, "... V. Procedure... D. Violent, Self Destructive... 4. A Restriction of Rights form for the patient must be completed for each restraiont... with copies given to the patient's designated person... legal guardian, if applicable..."

3. On 4/09/2025 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that restriction of rights should be given to the patient and guardian.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #21) clinical records reviewed regarding restraints, the hospital failed to ensure a physician's order was obtained.

Findings include:

1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis. The clinical record indicated that Pt. #21 was placed in violent restraints on 8/10/2024 from 3:14 PM through 3:39 PM (25 minutes). There was no physician's order regarding use of restraints.

2. On 4/09/2025, the hospital's policy titled, "Restraint Management" (3/2019) was reviewed and included, "... V. Procedure: Each episode of restraint... must be ordered by a physician or an authorized licensed practitioner responsible for the patient's ongoing care..."

3. On 4/09/2025 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that a phyhsician's order should be obtained when a patient is placed in restraints.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #21) clinical records reviewed regarding use of restraints, the hospital failed to ensure that a physician or licensed practitioner conducted the required face-to-face evaluation.

Findings include:

1. On 4/08/2025, the clinical record for Pt. #21 was reviewed. On 4/08/2024, Pt. #21 was brought to the hospital due to worsening psychosis (deviation from reality). The clinical record indicated that Pt. #21 was placed in violent restraints on 8/10/2024 from 3:14 PM through 3:39 PM (25 minutes). There was no face-to-face evaluation by a physician or licensed practitioner within one hour after the application of restraints.

2. On 4/09/2025, the hospital's policy titled, "Restraint Management" (3/2019) was reviewed and included, "... V. Procedure... D. Violent, Self-destructive, or Seclusion. 1... a. When restraint... is used for the emergency management of violent or self-destructive behaviors that jeopardize the immediate physical safety of the patient... the patient must be seen face-to-face within one hour after initiation of the intervention by a physician, authorized licensed practitioner, or a trained supervisory nurse..."

3. On 4/09/2025 at approximately 1:00 PM, an interview was conducted with E #29 (Nurse Manager, Medical Surgical Unit). E #29 stated that a face to face evaluation should be completed within one hour of placing the patient in restraints.

Based on document review and interview, it was determined that for 3 of 3 ED/Emergency Department RNs/Registered Nurses' (E #1, E #44, and E #45) and 4 of 4 ED Technicians' (E #7, E #41, E #42, and E #43) personnel files reviewed, the hospital failed to ensure that the ED staff had training regarding use of de-escalation techniques.

Findings include:

1. On 4/14/2025, the job description for ED RNs (undated) was reviewed. The job description indicated, "...Effectively delivers patient care through the nursing process of assessment, planning, intervention, implementation, and evaluation..."

2. On 4/14/2025, the job description for ED Technicians (undated) was reviewed. The job description indicated, "... Provides all services in accordance with established hospital/departmental policies and procedures..."

3. On 4/14/2025, the personnel files for E #1, E #7, E #41, E #42, E #43, E #44, and E #45, were reviewed. The personnel files lacked training/certification regarding use of de-escalation techniques/nonphysical intervention.

4. On 4/14/2025 at approximately 3:00 PM, findings were discussed with E #14 (Chief Nursing Officer). E #14 stated that ED nurses and technicians are supposed to be certified regarding use of de-escalation techniques for patients with aggressive behaviors. E #14 stated that the CPI (crisis prevention intervention/de-escalation) trainer no longer worked at the hospital since December 2024, and the hospital had not found someone to do the CPI training since that time.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #24) records reviewed regarding fall, the hospital failed to ensure care of Pt. #24 was supervised and evaluated by completing an incident report following a fall.

Findings include:

1. On 4/08/2025, the clinical record of Pt. #24 was reviewed. On 12/12/2024, Pt. #24 presented to the hospital's emergency department by ambulance due to chest pain. The clinical record indicated that while in the ED, Pt. #24 fell.

2. On 4/08/2025, the hospital's policy titled, "Fall Risk Assessment and Prevention" (3/2023) was reviewed and included, "... III... 7. An RN is responsible for implementation and oversight of individualized patient fall prevention..."

3. On 4/08.2025, the hospital's policy titled, "Event and Incident Reporting" (3/2021) was reviewed and included, "... IV... Examples of events to be reported... falls (patient)... V. A...1... Hospital Staff Members must complete and submit an event report as soon as possible..."

4. On 4/09/2025, the hospital's incident report/falls log for 12/2024 was reviewed. There was no event/incident report completed for Pt. #24.

5. On 4/14/2025 at approximately 1:00 PM, an interview was conducted with E #3 (ED Director). E #3 stated that there was no incident report completed for Pt. #24. E #3 stated that if the assigned nurse did not do an incident report, the charge nurse should have completed one.

Based on document review an interviews, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to maintain an accurate ED Log. Refer to A-2405.

2. The Hospital failed to ensure that a medical screening examination was completed to determine if a medical emergency existed. Refer to A-2406 A. and A-2406 B.

Based on audio recording, document review and interview, it was determined that for one patient (Pt #1) who presented to Emergency Department (ED) on 2/14/2025, the Hospital failed to ensure that the ED's central log included an individual who presented to the ED seeking treatment, as required.

Findings include:

1. The Hospital's policy titled, "The Hospital's policy titled, "EMTALA" (Emergency Medical Treatment and Labor Act), dated 1/2025, was reviewed, and required, " ...C. Central Log. 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE [medical screening examination]..."

2. On 4/7/2025, the ED Director (E #3) presented an EMS run sheet for Pt #1 (dated 2/14/2025 at 7:10 AM), which was reviewed. The EMS Run Sheet for Pt #1 indicated that Pt #1 was transported to Hospital A's ED via ambulance. The EMS Run Sheet included, "Possible Injury: Yes: Car driver injured in collision with sport utility vehicle in traffic accident. Summary, crew dispatched to the scene for the accident. Upon arrival crew found patient ambulatory on scene, patient is alert X3 [person, place, time] and complains of head pain after being involved in a low impact MVC [motor vehicle crash] ...Patient was restrained and no airbag deployment ...Patient secured inside ambo and performed secondary assessment without further findings noted. [Hospital A] contacted with pre notification. Patient transported with ongoing assessment enroute without incident or change in condition. Patient transferred to ER Triage Area [Hospital A] per charge flow nurse and report given to receiving RN [registered nurse] ..."

- The EMS Run Sheet indicated that Pt #1 arrived at Hospital A on 2/14/2025 at 7:15:59 AM. The EMS Run Sheet was signed and dated by the 2 EMS crew members and by Pt #1, confirming the time of arrival to Hospital A's ED.

3. The ED Centralized log from 2/14/2025 was reviewed. The ED Centralized log did not include Pt #1.

4. On 4/8/2025 at approximately 10:30 AM, an interview was conducted with the ED Director (E #3). E #3 reviewed the ED Centralized log and acknowledged that Pt #1 was not on the log on 2/14/2025.

5. On 4/8/2025 at approximately 11:30 AM, a phone interview was conducted with a Patient Access Clerk (E #8/assigned on 2/14/2025 day shift). E #8 stated that any patient that comes in from EMS or walks in and wants to be seen, should be registered and are put on the tracking board and log.

A. Based on document review, audio recording review, and interview, it was determined that for 1 of 4 (Pt #1) patients presenting with obstetrical issues/pregnancy (of a total ED record sample of 22 patients), the Hospital failed to ensure an appropriate medical screening exam was performed to determine if an emergency medical condition existed.

Findings include:

1. The Hospital's policy titled, "EMTALA" (Emergency Medical Treatment and Labor Act), dated 1/2025, was reviewed, and required, "If an individual comes to the Emergency Department: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists ...Triage and Registration. 1a. As soon as practical after arrival, individuals who come to the Emergency Department should be triaged in order to determine the order in which they will receive a medical screening examination ..."

2. The Hospital's "ED Labor Patient Assessment" form (undated) was reviewed on 4/7/2025 and included fillable lines to enter date, time, patient name, date of birth, primary care physician/obstetrician, due date, gestational age, arrival mode, vital signs. The form included the following directives: "[arrival by] Ambulance: Admitting RN - If patient is pregnant and/or states has recently delivered (within the last 3 months): After taking VS [vital signs] and brief history call OB Charge Nurse at [extension] and inform ED doctor at the same time to decide on next step; Fellow/OB Charge [nurse]; If patient stable will bring up to OB ED triage; If patient unstable fellow will come to see patient in the ED ..."

3. A "Care Point Radio" recorded audio EMS call (Emergency Medical Services Call System/alerts inbound patient transfers), from 2/14/2025 at 7:14 AM, was reviewed with the ED Director (E #3) on 4/8/2025 at approximately 10:10 AM. The call was made by the local fire department's EMS crew to Hospital A's ED (emergency department). The call was regarding the anticipated arrival of a patient (Pt #1) to Hospital A's ED. The call indicated that Pt #1 was enroute to the Hospital and the chief complaint was that Pt #1 was a 6-month pregnant patient who was involved in a motor vehicle accident. The Hospital staff (could not determine which staff) who received the call, verbally acknowledged the EMS crew's report prior to ending the call.

4. On 4/7/2025, the ED Director (E #3), presented an EMS run sheet for Pt #1 (dated 2/14/2025 at 7:10 AM). The EMS Run Sheet for Pt #1 indicated that Pt #1 was transported to Hospital A's ED via ambulance. The EMS Run Sheet included, "Possible Injury: Yes: Car driver injured in collision with sport utility vehicle in traffic accident. Summary, crew dispatched to the scene for the accident. Upon arrival crew found patient ambulatory on scene, patient is alert X3 [person, place, time] and complains of head pain after being involved in a low impact MVC [motor vehicle crash] ...Patient was restrained and no airbag deployment ...Patient secured inside ambo and performed secondary assessment without further findings noted. [Hospital A] contacted with pre notification. Patient transported with ongoing assessment enroute without incident or change in condition. Patient transferred to ER Triage Area [Hospital A] per charge flow nurse and report given to receiving RN [registered nurse - no name documented] ..." The EMS Run Sheet indicated that Pt #1 arrived at Hospital A on 2/14/2025 at 7:15:59 AM. The EMS Run Sheet was signed and dated by the 2 EMS crew members and by Pt #1, confirming the time of arrival to Hospital A at 7:15 AM on 2/14/2025. [The EMS run sheet did not include that Pt #1 was 6 months pregnant as stated on the recorded/received EMS call.]

5. On 4/7/2025, Pt #1's clinical record from Hospital A was requested. The Hospital was unable to provide a clinical record for 2/14/2025, as there was no encounter history or registration for Pt #1 in the Hospital's EMR (electronic medical record) system. There was no documentation indicating that after Pt #1's arrival to Hospital A's ED, Pt #1 received a triage assessment, vital signs taken, or received a medical screening examination to determine if an emergency medical condition existed for an OB patient with twins, status post a motor vehicle accident.

6. The clinical record for Pt #1, from Hospital B (receiving Hospital) was obtained, and reviewed on 4/9/2025, and included:
Pt #1's OB Triage Notes (dated 2/14/2025 at 9:53 AM), included, "Patient brought by EMS to [Hospital A] where [Pt #1] waited several hours in the waiting room to be seen. [Pt #1's spouse] then drove [Pt #1] to Hospital B."
OB Triage Notes included the following on 2/14/2025 at:
-10:00 AM: "Pain in lower back after MVA [motor vehicle accident]. MVA around 730 this am. Patient was driving 25-30 mph when t-boned by a car who was turning slowly. Patient reported intermittent pain primarily on [Pt #1] left lower back. Patient reports feeling a couple of cramps around 7:50 [AM], but currently denies feeling any cramping or contractions. Patient denies any other injuries during the car accident, denies losing consciousness, and denies any bumps or direct injury to her abdomen. Patient was initially brought to [Hospital A] and was waiting in the waiting room for several hours, so her husband brought her to [Hospital B]. In between [Hospital A] and [Hospital B], patient stopped for food. Patient stated that she debated whether or not she should come to the hospital because she and her babies "felt fine" Patient reports slight cramping around 07:50 after the car accident, but currently denies contractions; Rupture of membranes: Denies; Vaginal bleeding: None; Vaginal Discharge: Denies; Recent Sexual Intercourse: Denies; Abdominal Trauma: Motor Vehicle Accident, Annotation: Abdomen soft to palpation; Patient Complaints: Back Pain; Triage Level: Priority 3 require evaluation (within 30 minutes) by the Healthcare Provider ..."
- 10:18 AM (Per external ultrasound/monitor) - Fetus B Comments: Inconsistent tracing baby B during possible variable for baby A ..."
- 10:45 AM - "Fetal Assessment A ... FHR Baseline Rate: 155 ... Decelerations: none ... Fetal Assessment B ... FHR Baseline Rate: 145 ... Decelerations: none ..."
- 11:00 AM - "Fetus B Comments: deceleration x2 noted, unspecified due to absence of contractions."
- 11:10 AM - "Provider [MD/Pt #1's OB] at Bedside"
- 11:14 AM - "[MD] performing bedside ultrasound"
- 11:24 AM, "RN at bedside; RN reviewed strip; Provider at bedside. Provider at bedside discussing potential need for c-section. Patient visibly distressed about discussion and asking if babies are viable at 24 weeks. [MD] told patient the risks of injury after car accident and potential need for c-section."
- 11:29 AM, included, "[MD] verbalized need for c-section."
- 11:40 AM - "Patient signed consents for emergency c-section."
The Delivery Summary (dated 2/14/2025), included, "[Pt #1] at 24.1/7 wks [gestational age] iup [intrauterine pregnancy] who was in a serious car accident where [Pt #1] was T-boned and the car hit [Pt #1] on [Pt #1] side of the car as [Pt #1] was the driver and after the accident the ambulance took [Pt #1] to the nearest hospital [Hospital A] and [Pt #1] sat there for 4 hours and [Pt #1] came to the hospital [Hospital B] because [Pt #1] is my patient from the clinic. When Pt #1 was in triage [MD] noted that [Pt #1] was having late decels [abnormal low fetal heart rate] for baby B and baby B is the one moving less ...[MD] spoke to the patient quickly and detailed and [Pt #1's spouse] consented for a C/S [cesarean section] due to concern for an abruption [placenta detaches from uterus] ...Classical C/S ...Baby A delivered ... Delivery Date: 2/14/2025 at 12:03 PM ...Apgars 5/8 [quick assessment of newborn at birth at 1 and 5 minutes of birth/normal 1 minute is 7 or above] ... Baby B: Delivery Date: 2/14/2025 at 12:04 PM ...Baby B delivered Apgars 5/8 ..." Baby A and Baby B were transferred to NICU (neonatal intensive care unit)." There is no further documentation in Pt #1's clinical record regarding Baby A and Baby B.

7. On 4/7/2025 at approximately 12:00 PM, an interview was conducted with Attending Physician (MD #2) stated that every patient should receive a medical screening exam. MD #2 stated that when a pregnant patient presents to the ED, who was in a motor vehicle accident, the patient should be medically cleared in the ED before going to the OB unit. MD #2 stated that at minimum if the patient hits her head during the collision, CT (cat scan imaging) will be done to rule out head trauma. MD #2 stated that also, the ED will get fetal heart tones via ultrasound to check on the well-being of the fetus. MD #2 stated that the other usual course of treatment for the OB patient in the ED, would include obtaining blood work, doing a full comprehensive assessment, and administering Tylenol for pain if needed.

8. On 4/8/2025 at approximately 10:10 AM, an interview was conducted with the ED Charge RN (E #12). E #12 stated the E #12 was the dayshift Charge RN on 2/14/2025. E #12 stated that E #12 does not recall Pt #1. E #12 stated that if a pregnant patient who was in a motor vehicle accident, presents to the ED, she should be triaged right away. E #12 stated that more than likely, the patient would be triaged as an ESI 2 (high risk situation/scale 1-5). E #12 stated that patients triaged as ESI 2, should be taken to the back (ED treatment area), and not placed in the waiting room if possible. E #12 stated that these patients would be considered as high priority to be seen. E #12 stated that the ED doctor would look at the OB patient first to determine if they need to stay in the ED or get sent to the OB department (if over 16 weeks gestation). E #12 stated that the RN would get an abdominal ultrasound on the patient to check fetal well-being. E #12 stated that the OB triage sheet [ED Labor Patient Assessment] should be completed on arrival for all pregnant patients presenting to the ED, and the ED Charge Nurse will contact the OB Charge Nurse.

9. On 4/8/2025 at approximately 10:10 AM, an interview was conducted with the ED Director (E #3). E #3 stated that when any OB patient presents to the ED, the OB triage sheet should be completed, and an assessment should be done right away. E #3 stated that the ED Charge RN will contact the L & D (Labor and Delivery) Charge RN to inform them of the pregnant patient in the ED. E #3 stated that if the patient was in a motor vehicle accident, the patient would be assessed to see if their belly was hit by the steering wheel or feeling dizzy. E #3 stated that if the mother is complaining of symptoms related to the baby, then the pregnant patient goes straight up to OB. E #3 confirmed that there was no documentation indicating that Pt #1 received a medical screening exam.

10. On 4/10/2025 at 10:23 AM, a phone interview was conducted with the Director of Women's Health Physician (MD #3). MD #3 stated that if a pregnant patient presents to the ED following a motor vehicle accident, and is conscious and stable, the patient should come straight up to OB. MD #3 stated that the ED should call the OB unit even prior to the mother arriving to make the OB unit aware. MD #3 stated that the priority once knowing that the mother is stable, is to put fetal monitoring on the babies. MD #3 stated that the baby/babies should remain on the monitor for at least 6 hours to assure fetal well-being. MD #3 stated that even if the mother was in a "fender bender" (minor car accident), there is still a possibility of placenta abruption. MD #3 stated that assessment timing is critical in this scenario, as 24-week babies are viable, and an emergency C-section could be done if warranted. MD #3 stated that this patient scenario should be at the top of the list, as far as priority in being seen.

B. Based on document review and interview, it was determined that for 1 of 3 (Pt #24) patients presenting with chest pain (of a total ED record sample of 22 patients), the Hospital failed to ensure an appropriate medical screening exam was performed to determine if an emergency medical condition existed.

Findings include:

1. On 4/09/2025, the hospital's policy 'Triage Process for Patients in the Emergency Department' (reviewed 3/2023) included, " ...V. Procedure: ...2. If a bed is not immediately available ...the triage nurse will evaluate each patient in the order determined by a quick look triage process based on age and presenting complaint ...Test ordering: ...3. EKGs will be done using "STAT" EKG protocol for patient with chest pain ...".

2. On 4/10/2025, the hospital's 'General Approach to ED Chest Pain' (revised/reviewed 9/23) included, " ...start ECG in Triage by ED staff or immediately upon placement on ED cart. < (less than) ten minutes (STAT ECG may be initiated at any time) ...ECG immediately shown to ED attending who interprets, signs and times ECG ..."

3. On 04/08/2025, the clinical record of Pt. #24 was reviewed. On 12/12/2024 at 6:01 PM, Pt. #24 presented to the hospital's emergency department by ambulance for prolonged chest pain. The medical record included:

The 'ED Triage- Part 1 and 2' documents on 2/12/2024 indicated that triage was performed at 6:39 PM and included, " ...chief complaint: chest pain ...Tracking Acuity: 3-Urgent ...Pain location: Chest ...Numeric Pain Score: 8 (out of 10) ...Falls Risk: Not a fall risk ...Assessment: ...Level of Consciousness: Alert ...Orientation: Oriented x4 (person, place, time, and situation) ...".

The Registered Nurse's (E #38) 'ED Nursing Note' timeline on 12/12/2024 as follows:
-At 6:18 PM included, " ...[Pt. #24] received from CFD (Chicago Fire Department) with complaints of chest pain. [Pt. #24] attached to monitor (cardiac monitoring) and EKG (also called ECG/test to record the heart's electrical activity/heart rhythms) completed. [Pt. #24] immediately asked to be removed from the monitor to use the restroom. [Pt. #24] ambulated to restroom with stand by assist. [Pt. #24] in NAD (no acute distress) at this time ..."
-At 6:28 PM included, " ...[Pt. #24] ambulated back to room with standby assist. [Pt. #24] positioned in bed and reattached to the monitor ..."
-At 6:30 PM included, " ...[Pt. #24] states need to use the restroom again. [Pt. #24] ambulated to restroom ..."
-At 6:42 PM included, " ...[Pt. #24] ambulated back to restroom with standby assist. [Pt. #24] positioned in bed, reattached to the monitor ..."
-At 6:45 PM included, "[Pt. #24] requesting to use the restroom again. [Pt. #24] removed self from monitor leads and ambulated to restroom ..."
-At 6:50 PM included, " ...[Pt. #24] ambulated back to room unassisted. [Pt. #24] states no further needs at this time ...".
-At 9:29 PM included, " ...ME (medical examiner) office notification of [Pt. #24] death. Spoke with (medical examiner) ...[medical examiner] states [Pt. #24] manner of death is concurrent with medical history and are releasing the body to the family ..."

The ED Physician's Orders indicated that the following were ordered on 12/12/2024 at 6:22 PM and 6:23 PM: EKG-stat, B-type Natriuretic Peptide (blood test to measure the BNP level that could indicate heart function), Troponin (blood test to indicate heart muscle damage), CBC (complete blood count/blood test looked at for one's overall health and or conditions) and CMP (Comprehensive Metabolic Panel/blood test that measure your liver, kidney, and electrolyte functions). The Diagnostic Tests-Procedures on 12/12/2024 at 6:22 PM included, " ...Cardiology procedures: ...routine ECG 12 lead/15 lead tracing only." The clinical record did not contain results for any of the orders.

The 'EKG Documentation' section of the record, dated 12/12/2024 at 6:22 PM, indicated that an EKG was recorded by the ED Technician (E #7) and (MD #4) was notified. However, the clinical record did not include a copy of the EKG that was performed, printed, reviewed by physician/MD #4, and signed by MD #4.

The Physician's (MD #4) 'ED Note Physician' on 12/12/2024 included: 6:30 PM, " ...[MD #4] seen: 12/12/2024 6:21 PM ...History of present illness: ...includes HFrER (heart failure with reduced ejection fraction/heart pumps less blood than normal) LV EF 35-40% (left ventricle ejection fraction-normal 55% to 70%) ...[Pt. #24] underwent ptca (percutaneous transluminal coronary angioplasty/minimally invasive procedure that opens blocked coronary arteries to improve blood flow) earlier this month due to cardiomyopathy (disease of heart muscle) and positive stress test (test to show how the heart works during physical activity) ...[Pt. #24] here with 1-2 hours of central chest squeezing/pressure ...slight sob (shortness of breath) with pain ...asa (aspirin) and nitroglycerin (medication to treat chest pain) en route (by EMS/emergency medical services) with no change in discomfort ...Procedure: ekg from ambulance. Poor quality, question changes in III (lead 3), no stemi (severe type of heart attack) ...Medical Decision Making: chest pain with burning in the throat. Cath within the past days with no critical stenosis (narrowing of the artery, blocking blood flow) ...question (differential diagnosis): gi (gastrointestinal), msk (musculoskeletal), pna (pneumonia), acs (acute coronary syndrome/heart condition with blocked blood flow) doubt pe (pulmonary embolism/blood clot in the lungs), dissection (tear in wall of heart artery) ...plan: ekg, labs, xray (test to image a part of the body), gi(gastrointestinal) cocktail, re-evaluation, asa already given ...(addendum) at 8:31 PM: ...ekg was done on the room monitor but was not able to be printed, per nursing read on monitor was NOT stemi (acute ST-segment elevation myocardial infarction/a type of heart attack). [E #38] was attempting to print the ekg and settle [Pt. #24] and [Pt. #24] took off all leads and monitoring off and insisted that [Pt. #24] go to the bathroom against [E #38] trying to convince [Pt. #24] not to ...[E #38] saw [Pt. #24] go into the room and then shortly after heard [Pt. #24] fall. [MD #4] was called to the room. [Pt. #24] was bleeding from where [Pt. #24] struck her face in the fall directly into the ground. [Pt. #24] was moved to the bed and noted to have agonal respirations ...[Pt. 24] looked to be in v-tach (ventricular tachycardia/fast, irregular heartbeat) ...ACLS (advanced cardiac life support) initiated ...[pt. #24] lost pulse and remined in vtach that showed no response to several shocks ...after several sequential shocks [Pt. #24] went into asystole (without pulse) with epi (epinephrine) reinitiated. ...[pt. #24] went into sinus brady (low heart rate) with a rate in the 40's ...[Pt. #24] degraded into asystole despite these measures ...after close to an hour twenty minutes the efforts were stopped ..."
The 'Code Resuscitation' document indicated that a code was called at 7:07 PM and CPR (Cardiopulmonary Resuscitation) and life saving measures were performed, however (Pt. #24) remained with PEA (pulseless electrical activity/without a pulse) and death was pronounced.
The 'Record of Death' document included, " ...Date of death: 12/12/24 ...Time of Death: 8:19 PM ...Is patient's death reportable to Medical Examiner: Yes ...Does Medical Examiner (ME) want the patient: No ...Time ME called: 9:15 PM ..."
- Although not included in Pt #24's medical record, on 4/14/2025 at approximately 1:25 PM, the ED Director (E #3) presented an EKG printout for Pt #24, dated 12/12/2024 at 6:21 PM. The EKG printout was reviewed, yet did not include the cardiac rhythm readings nor a physician signature to indicate that the EKG had been read by the physician.

4. On 4/8/2025 at approximately 3:30 PM, an interview with the ED Attending Physician (MD #4) was conducted. MD #4 stated (Pt. #24) presented to the hospital via EMS with reported chest pain. MD #4 stated that an EKG was not provided to or reviewed by (MD #4) prior to (MD #4's) assessment of (Pt. #24). MD #4 stated that orders for an EKG and lab work were entered post assessment. MD #4 stated that (MD #4) was called to another patient emergency when (MD #4) was called and notified of (Pt. #24's) fall and subsequent code blue.

5. On 4/10/2025 at approximately 10:30 AM, an interview with the ED Technician (E #7) was conducted. E #7 stated that all ED rooms have cardiac monitoring which can be printed. E #7 stated that if the monitor is not printing or working, then an EKG should be performed on a portable EKG machine. E #7 stated all chest pain patients receive a stat EKG which should be performed within ten minutes and provided to an attending physician within one minute of printing. E #7 stated there should be no delay in providing the EKG results to the physician.

6. On 4/14/2025 at approximately 1:25 PM, an interview was conducted with the ED Director (E #3). E #3 stated, after review of the EKG within (Pt. #24's) record, that an EKG should have been performed and included the rhythm readings and presented to the ED physician for review and signature and confirmed that (Pt. #24's) EKG did not include either component.

7. On 4/10/2025 at approximately 11:15 AM, an interview with the ED Medical Director (MD #8) was conducted. MD #8 stated that it is hospital protocol for an EKG to be performed on a patient with reported chest pain in less than ten minutes from time of arrival as part of the medical screening.