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Based on the review of medical records, Policy and procedure review, Emergency Medical Services (EMS) ambulance report, Incident Report, Autopsy report, Police Report, review of the facility's video footage, and interviews, it was determined that the facility failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed for 1 (Patient #1) out of 20 Sampled Patients.

Refer to Findings in Tag A-2406

Based on the review of medical records, Policy and procedure review, Emergency Medical Services (EMS) ambulance report, Incident Report, Autopsy report, Police Report, review of the facility's video footage, and interviews, it was determined that the facility failed to ensure an appropriate medical screening examination that was within the capability of the hospital's Emergency Department (ED), including ancillary services routinely available to the ED, was provided to determine whether or not an emergency medical condition existed for 1 (Patient #1) out of 20 Sampled Patients. The patient presented to the hospital's emergency department on 4/17/2024, 4/18/24, 4/19/24, and 4/20/24 with presenting signs and symptoms on initial visit (4/17/2024) with elevated heart rate, and an abnormal heart rhythm QTc prolonged (a heart rhythm disorder that causes the fast heartbeats, irregular heartbeats) at 510ms (Normal QTc is >360 milliseconds, > 460 in women considered prolonged, potential fatal ventricular rhythm) on Electrocardiogram, complaining of weakness, fatigue, nausea vomiting and lightheadedness, and discharged. There was no documentation that a medical screening examination was performed. The patient returned to the ED 1.5 hours later after discharge on 4/17/24 complaining of not feeling well, the patient was escorted out of the hospital's emergency department via hospital police and did not receive a medical screening examination. The patient returned to the hospital's emergency department on 4/18/2024 (Day 2 visit) with an elevated heart rate of 132 beats per minute, elevated diagnostic laboratory tests of mild transaminitis (elevated liver enzymes), and an abnormal ECG with continued QTc prolonged, Tachycardia, and enlarged right atrium, the patient was discharged from the hospital ED. The patient returned to the hospital's ED on 4/19/2024 (Day 3 visit) and on 4/19/24 (Day 4 visit) with complaints of weakness, continued tachycardia critically high blood pressures, and subsequently discharged on 4/19/24 and 4/20/24. Patient #1 was known by the hospital employees to occupy an outside patio bench within the 250 yards of the main hospital building for the past 4 days was found on 4/21/2024 around 2:20 P.M. lying on the ground in the hospital's patio area unresponsive and in full cardiac arrest. The clinical staff was made aware, and the patient was taken into the hospital's ED for evaluation and treatment. During the resuscitation efforts "Exam shows ... there is blisters in the med torso area from the mid abdomen to the mid-thigh an area of dark discoloration what appears to be something like a second-degree burn with blistering and sloughing of the skin. There is also sloughing of the skin on the left upper extremity." Where the resuscitation efforts were unsuccessful, and Patient #1 expired at 2:38 P.M on 4/21/2024. The facility failed to ensure that on 4/17/24, 4/18/24, 4/19/24 and 4/20/24 appropriate medical screening examinations were provided for Patient #1 placed the health and safety of the patient in serious jeopardy.

Findings include:


Review of the facility's policy entitled (2) Administration Policy No. 209, Subject: Emergency Treatment and Patient Transfer Policy, Last Revised 08/22/2023 included but wasn't limited to:

I. Purpose
The purpose of this policy is to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA), its amendments, regulations, and reporting requirements. EMTALA requires that all patients who request medical treatment for an emergency medical condition or have such a request made on their behalf, receive certain basic threshold services and stabilizing treatment as necessary. ..To ensure the facility meets EMTALA's rules and requirements, including adherence to the 250-yard rule. This policy outlines the process for treating requests under EMTALA, as well as how to handle the transfer and acceptance of patients at Jackson Health System facilities ...III. Procedure: A. Requests for Emergency Treatment: All patients who request medical treatment for an EMC (Emergency Medical Condition) in any manner, or who have such a request made on their behalf, must receive an MSE by a QMP (Qualified Medical Professional-means a health practitioner acting within his or her scope if practice as defined in the medical staff bylaws or rules and regulations may perform a medical screening examination and in consultation with a physician) ... a. A patient may request such case anywhere on the hospital premises, within 250 yards of the main buildings, including any treatment areas, the parking lot, sidewalk or driveway ... 5. The medical screening examination must be documented in the patient's medical record."

Review of the facility's video footage captured Patient #1 at various times while in the ED foyer/ED Registration area on 04/17/2024, 04/18/2024, 04/19/2024, and 04/20/2024. Patient #1 was seen in the ED on 4 consecutive days prior to expiring. At no time did Patient #1 leave the facility's property within the four days preceding her death.

The Police Report dated 4/21/2024 at 6:17 P.M. was reviewed. The Police Report revealed in part, "Narratives ... On Sunday, April 24, 2024, ...dispatched to (Jackson Memorial Hospital) in reference to a death. Upon arrival contact was made with reporting person/nurse ...who advised (Pt#1) was pronounced deceased ...at approximately 2:38 P.M ...Contact was then made via phone with Security Guard ...who advised at approximately 2:10 P.M ...Upon his arrival to the picnic area he noticed (Pt.#1) on the ground laying on her right side and appeared unresponsive. He then called for medical assistance to where (Patient #1) was transported inside of the hospital."

The facility's incident report dated 4/28/2024 for Patient #1 was reviewed. The section of the report titled "GENERAL INFORMATION ABOUT THE DIAGNOSIS/TREATMENT EVENT; Specific event type: Diagnosis issue ... Severity Level (Reported) X. Person's Death Due to Admitting Diagnosis or Unrelated disease." The report revealed in part, "GENERAL INFORMATION ABOUT THE DIAGNOSIS/TREATMENT EVENT: ...Brief Factual Description: On Wednesday April 17, 2024, unknown black female patient was observed in the Emergency Room and later discharged. However, the patient complained about having continued pain she couldn't describe her pain to medical staff, The female patient checked herself in again to emergency room over a four (4-day period) and discharged. On Sunday April 21, 2024, at 2:10 the patient was found on the Emergency Room Patio location, it was discovered that the female patient had marks on her leg and stomach area that appeared to be burn marks."

(3) Review of Patient #1's medical records revealed the following documentation:

Emergency Department Visit #1

The EMS ambulance report dated 4/17/2024 at 1:36 P.M. was reviewed. The section of the report titled, "Narrative Treatment Summary" revealed in part, Pt. (patient) stated she has been experiencing flu like symptoms and requested transport to the hospital. Vitals WNL (within normal limits). The patient was oriented to person, place, time an event, The patient was transferred to Jackson North Medical Center, Emergency Department on 4/17/2024 at 1:44 P.M.

Review of the medical record dated 4/17/2024 revealed that patient #1 registered into the Emergency Department at 2:10 P.M. Review of the "ED Note -Physician" revealed the patient was seen by ED Physician Staff P on 4/17/2024 at 2:26 P.M. The patient's complaint was listed as "Weakness or Fatigue." Documentation by the ED physician Staff P revealed, in part "History of Present Illness: Patient #1 who denies any chronic medical conditions presenting to the emergency department for evaluation of nausea vomiting. The patient says over the last 2 (two) days she has had multiple episodes of nonbloody, nonbilious emesis that has resulted in her feeling weak. She also feels lightheaded and some spinning whenever she stands ... Patient #1 reports to smoking marijuana, has not done this in a couple days. Plan to treat Patient #1 with a Liter of IV fluids and IV Zofran (medication for nausea). If her symptoms do not resolve will administer Haldol and today, she is suffering from cannabinoid hyperemesis syndrome (a condition that leads to repeated and severe bouts of vomiting). Electrocardiogram (EKG) ordered to monitor QTc (Stands for heart rate corrected QT interval-on EKG measures efficiency of the repolarization of the left ventricle). Electrocardiogram: 04/17/2024 at 3:26 PM, heart rate 101 (normal heart rate- 60-100), QTc prolonged (a heart rhythm disorder that causes the fast heartbeats, irregular heartbeats) at 510ms, otherwise intervals within normal limits. The abnormal laboratory tests resulted on 4/17/2024 T 5:34 P.M. and 6:10 P.M. were reviewed: Glucose: 110 High (Normal 60-100); Potassium:3.1 low (mineral keeps heartbeat regularly and blood pressure stable. Normal value 3.5 to 5.2); Total Protein 9.1 High (test performed to help diagnose nutritional problems, kidney, and liver disease- Normal value- 6.0 to 8.3); Total Bilirubin 1.8 High (test ordered if suspect liver or gallbladder problems. Normal level between 0.1 to 1.2); AST- 89 High (Aspartate Transferase- test measures potential damage to liver or muscles. Normal range 8 to 33); ALT-101 Hi (Alanine Transaminase- helps to assess liver health. Normal Range: 7 to 56). The patient was triaged as an ESI (emergency severity index- prioritize patients according to their illness and injury, severity or acuity) acuity 3 (urgent-abdominal pain, dehydration, and fractures).

Further review revealed, "Reevaluation Time: 04/17/2024 at 4:28 PM. Patient #1 feels some improvement. Stated she is currently experiencing homelessness. Spoke to population health or social worker for disposition help. She declined to give urine sample though on questioning has no Urinary Tract Infection (UTI) symptoms, so it was canceled. Repeat Reevaluation Time: 04/17/2024 at 6:15 PM Patient #1 has tolerated the turkey sandwich, apple sauce and juices given. No witnessed vomiting so no Haldol was ordered especially since her QTc is prolonged. She is otherwise non-toxic appearing. No admission criteria based on her exam, vitals and labs. Stated she called 911 from her hotel. Spoke with the bedside nurse to see if we can help her with transportation back to her hotel. .. Notes: The bedside nurse stated Patient #1 was still mildly tachycardic [114] (Fast heart rate), likely still mildly dehydrated (a condition where the body does not have enough fluids to function properly) however she is trying multiple things of juice and water. She has no chest pain, no dyspnea, no vomiting, no diarrhea, no other acute process that will warrant admission at this time based solely on her mild tachycardia. Patient #1 was stable for discharge." The section of the medical record titled "Physical Examination" revealed no documentation that a medical screening examination was performed by ED physician Staff P. Additionally, there was no repeat of an ECG prior to discharge, given the patient's initial ECG showing prolonged QTc abnormally high at 510. Documentation in the Physical Examination section were vital signs and body measurements." The section titled, "Impression and Diagnosis" revealed the patient's discharge diagnoses were homelessness, hypokalemia and mildly dehydrated. Patient #1 was discharged on 4/17/2024 at 6:21 P.M. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a physical examination was documented for Patient #1 on 4/17/2024, to determine whether or not an EMC existed.

Further review of the medical record the section titled "Assessments and Treatments" revealed that on 4/17/2024 at 8:00 P.M., "Nursing Note 1- Patient was advised that they were discharged and patient denied to go and kept stating that they felt bad. Security was called and escorted patient out of the ER (emergency room). Patient #1 returned to the hospital's ED 1.5 hours later after being discharged from the hospital's ED, requesting to be evaluated because she was feeling bad. Instead, the patient was escorted out of the hospital's ED by security. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that a medical screening examination was provided for Patient #1 when she presented to the hospital's ED again on 4/17/24 at 8:00 P.M. requesting a medical evaluation.

Emergency Department Visit #2

Review of the medical record revealed that Patient #1 registered into the ED on 4/18/2024 at 6:30 A.M. At 6:35 the patient's abnormal heart rate was listed as 132 (high) beats per minute. The section of the medical record titled "Emergency/Trauma Documentation, revealed documentation by the ED physician Staff Q revealed, on 04/18/2024 at 7:18 AM, "History of present illness: The patient presents with nausea and vomiting. The onset was 5 days ago. The course / duration of symptoms is constant ... Additional history ... Patient with significant past medical history of schizophrenia, bipolar disorder presented to the hospital for evaluation of nausea vomiting and severe weakness. Patient was seen and evaluated yesterday in the hospital for similar complaints ...She admitted being using marijuana ...Patient was given fluids and Zofran, and she was able to tolerate foot (food). Patient was discharged home ...Review of Systems: Constitutional symptoms: Weakness, fatigue ...Gastrointestinal symptoms: Nausea, vomiting ...
Physical Examination: General: Alert, mild distress; Skin: Dry and pink.
Review of the Radiology results reveled that an Ultrasound was completed on 4/18/24 on 12:41 P.M. The reason for the exam was for right upper quadrant pain. The findings of the Ultrasound were "Findings::Limited evaluation right arm. Liver not well seen. No definitive gallstones appreciated. Common bile duct not seen ... IMPRESSION: Limited exam. Liver and gallbladder poorly visualized. No obvious pathology." The resulted abnormal Labs for 4/18/2024 at 11:19 A.M., and 11:43 A.M. were reviewed: Glucose -110; Sodium: 136 9 Low; Sodium-136 Low; Potassium- 3.3 low; Chloride-93 Low (electrolyte help maintain body fluid and acid base balance); Osmolality Calculated -273 Low (test measures electrolyte helps maintain body fluids and acid base balance); Total Protein- 8.4 Hi; AST-79; AST- 89 Hi; ALT 79 Hi-
Reexamination/ Reevaluation Time: 04/18/2024 at 1:04 PM. Labs with mild transaminitis (elevated liver enzymes), hypokalemia (low potassium) noted that was replaced. Right upper quadrant ultrasound was done to rule out cholecystitis, difficult study, no evidence of acute pathology. Patient #1 able to tolerate oral intake. Patient #1 was evaluated yesterday for similar complaints and was discharged. Patient #1 will be discharged home to follow up with primary care physician (PCP). Impression and Plan: Diagnosis: Cannabinoid hyperemesis syndrome, history of psychiatric disorder, nausea and vomiting. Condition: Stable. Prescriptions: ondansetron 4 mg oral tablet every 8 hours, for 3 day(s), as needed for nausea/vomiting.
The section titled, "Certification of Emergency Condition", on 4/18/2024 at 1:07 P.M. the Advanced Practice Registered Nurse documented, yes Patient #1 met criteria for an emergency condition. Further review revealed the patient was triaged as an ESI -3 (URGENT). The section of the medical record titled, "Cardiology Procedures dated, 4/18/24 at 8:34 A.M. the results of the status of the 12 lead EKG (Electrocardiogram- test that records the electrical activity of the heart, including abnormal heart rhythms) was reviewed. The review revealed the finding of the 12-lead electrocardiogram, sinus tachycardia, right atrial enlargement (a condition in which the right atrium of the heart is enlarged), Prolonged QT interval. The EKG was interpreted as an abnormal ECG on 4/18/2024 at 9:58 P.M. There was no documentation in the medical to indicate the ED physician was notified of the abnormal ECG. Patient #1 had an identified emergency medical condition and required further evaluation and treatment of the abnormal ECG on 4/18/2024.

Emergency Department Visit #3

Review of the medical record revealed that Patient #1 registered into the ED on 4/19/2024 at 7:43 A.M. The section of the medical record titled, "Emergency/Trauma Documentation" revealed the patient was seen by a Physician Assistant Staff R, on 4/19/2024 at 8:30 A.M.
Review of the "History of Present Illness" revealed in part, " ...female presents to the ED secondary to weakness. Patient has been seen here the past 2 days and discharged ...back for a 3rd (third) day straight. Patient states she has a history of bipolar schizophrenia and has not been taking her medications. Patient is a poor historian, barely speaking or answering questions. Patient denies cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, headache.
Review of the Physical Examination revealed in part, "General: No acute distress ...Cardiovascular: Regular rate and rhythm, No Murmur, Normal peripheral perfusion ...Gastrointestinal: Soft, nontender, Obesity ...Psychiatric: Not very cooperative, Not aggressive." Review of the patient's Vital Signs: Peripheral Pulse Rate: 102 to 126 beats per minute; Blood Pressure at 7:55 AM and at48 A.M.: 151/123. Blood Pressure at 8:48 AM: 150/79. Further review revealed the patient was triaged as an ESI acuity -3 (URGENT).
Labs positive for Cannabinoid. Radiology results updated Chest X-ray, 1 View 4/19/2024 11:07 AM. Reason For Exam: Elevated Blood Pressure, Nausea and Vomiting. Impression: No radiographic evidence of acute cardiopulmonary disease.
Reexamination/ Reevaluation Time: 04/19/2024 at 2:20 PM
Course: Improving. Pain status.
Impression and Plan: Diagnosis: Depression, Chronic bipolar disorder
Calls-Consults - 04/19/2024 at 1:04 PM, recommends to follow-up with outpatient psychiatry. Condition: Improved. Stable. Disposition: Medically cleared, Discharged: 04/19/2024 at 2:32 PM.to home. There was no documentation in the medical record to indicate that an EKG was ordered given Patient #1's presenting signs and symptoms weakness, Tachycardia 126, and elevated blood pressures 150/79 to 152/126 as this resulted in an inappropriate medical screening examination. The patient was again discharged to home.

Emergency Department Visit #4
Review of the medical record revealed that Patient #1 registered into the ED on 4/20/2024 at 7:02 A.M. The patient's Vital Signs were taken at 7:15 A.M. and listed as: Temperature Oral: 98.0; Peripheral Pulse Rate: 124 beats per minute; Respiratory Rate: 18 breaths per minute; Blood Pressure: 144/110. The section of the medical record titled "Emergency/Trauma Documentation revealed the patient was seen by ED Physician Staff O at 7:59 A.M. Staff C documented "History of Present Illness: Patient #1 is a 32-year-old with past medical history of schizophrenia, bipolar, anxiety presents to the ED for generalized weakness. This is her third visit for this month. Patient #1 was evaluated by psych yesterday and did not meet inpatient criteria. Her case management came to see her. According to her case manager, Patient #1 received money monthly. She is currently homeless. Shelter resources provided yesterday."
Further review revealed, the patient's "Active Problem" list included: Agitation, Bipolar 1 disorder, current or most recent episode manic, sever, Cannabis dependence, abuse GAD (generalized anxiety disorder). There was no mention of the patient's persistent elevated heart rate since 4/17/2024, elevated blood pressure on this visit and 4/19/24 visit, and the abnormal ECG. Continued review revealed "Impression and Plan: Diagnosis: Homeless / Condition: Stable. Disposition: Discharged 8:36 AM Saturday morning." There was no documentation in the medical record that diagnostic laboratory tests were ordered, or that an ECG was ordered to evaluate the patient's abnormal elevated heart rate and critically high blood pressure on 4/20/2024. As this resulted in an inappropriate medical screening examination.

The facility failed to ensure that their policy and procedure was followed o ensure that an appropriate medical screening was provided as evidenced failing to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to address the patient's presentation to the ED of persistent tachycardia for 4 days ,and progressed to critically high blood pressure determine whether or not an emergency medical condition existed for patient #1on 4/17/2024, 4/18/2024, 4/19/24 and 4/20/2024.

Emergency Department Visit #5

A review of the medical record revealed that on 4/21/2024 Patient #1 was registered into the ED on 4/21/2024 at 2:23 P.M. EDMD Staff N documented in part on the "Emergency/Trauma Documentation" form "Cardiac-Respiratory Arrest *ED. Further review of the ED note dated 04/21/2024 at 2:53 P.M. revealed in part, "Emergency Trauma documentation" History of Present illness Patient #1 presents in cardio-respiratory arrest. The onset was unknown. Witnessed arrest no. Initial cardiac rhythm Asystole (no heartbeat). Preceding symptoms unknown. Patient #1 32-year-old female was found unresponsive outside in the sitting area, security apparently saw her laying on her right side she was unresponsive and medical staff was called. Upon their evaluation the Patient #1 was pulseless and was immediately brought to the resuscitation Bay doing Cardiopulmonary Resuscitation (CPR). Once in the resuscitation Bay, CPR continued, an Intraosseous (IO-medical procedure involves inserting a hollow needle into the bone to deliver fluids and medications) was attempted on the left shoulder however secondary to body habitus it was not a acceptable placement, a right tibia IO was placed. Epinephrine calcium bicarb were given, multiple rounds of CPR, bedside evaluation with bedside ultrasound shows cardiac standstill with poor windows. Exam shows central cyanosis on the mucosal membrane, pupils are fixed dilated, the body is warm, there is blisters in the mid- torso area from the mid-abdomen to the mid-thigh with an area of dark discoloration of what appears to be something like a second-degree burn with blistering and sloughing of the skin. There is also sloughing of the skin on the left upper extremity. Patient #1 was also intubated during CPR. After multiple rounds Patient #1 remained asystole with no cardiac activity on ultrasound resuscitative efforts were discontinued". Physician N documented "Disposition: Time 4/21/2024 at 2:38 P.M. Expired."

Patient #1's autopsy report dated 4/23/2024 at 9:15 A.M. The section of the report titled "evidence of injury' revealed in part, "Areas of the skin sloughing with underlying erythema and surrounding drying are on the left cheek, abdomen, anterior aspects of the thighs, and posterior aspect of the left arm." Patient #1's "CAUSE OF DEATH: Cannabinoid Hyperemesis Syndrome. CONTRIBUTORY CAUSE: Hot Weather."

The facility failed to ensure that an appropriate medical screening was provided as evidenced by failing to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for patient #1 on 4/17/2024, 4/18/2024, 4/19/24 and 4/20/2024.

Security/Staff Interviews - Documented in chronological order of interviews.

Interview with Staff D (Security Specialist #1) and Staff E (Security Specialist #2) on 09/16/2024 at 12:20 PM. Staff D (Security Specialist #1) stated that because it was very hot on 04/21/2024, he and a co-worker Staff F (Security Specialist #3) were taking Patient #1 Gatorade and snacks. Patient #1 was found lying down on an outdoor ED patio bench on her side. She was very still. Staff D (Security Specialist #2) stated, I touched her to see if she was asleep. She did not respond. I radioed dispatch that a patient was down. Staff D stated another security specialist was standing between the registration desk and the front door. Staff F (ED Patient Care Technician) was standing nearby and overheard what was going on, she went and got other medical staff to come and assist. Staff D stated he did not write a report, and the information was passed on to the oncoming 2nd shift. Staff I (Security Specialist #4) who is in charge sometimes may have written the report. Staff D stated shift hours are from 6:00 AM - 2:30 PM and they get relieved around 2:15 PM.

Staff E (Security Specialist #2) interviewed during the same time stated that they were dealing with Patient #1 over several days. On one of the days, a social worker was called to speak with Patient #1 and they were told there was nothing they could do (something about her funding). Staff E stated that it was tricky because Patient #1 was discharged and brought back in for several days. We had almost a week of that. Staff E stated the outdoor patio is checked during building checks anywhere from every 30 to 45 minutes and the focus is the outside and interior. Staff E stated they round for maybe 20 -30 minutes, then they do the outside of the ED. If there is an issue, they let the staff know inside. Staff E stated they are only allowed to move from the registration desk to where visitor passes are made.

Interview with Staff G (Emergency Medical Technician) conducted on 09/16/2024 at 1:05 PM. Staff G stated she is unable to recall the date or time of the incident; When the overhead page was made, she grabbed some gloves and walked outside. Patient #1 was lying on her side. A sternal rub was done, checked and there was no pulse. Security was asked to go inside to get help because she didn't have her radio with her. Security helped get the patient on the ground and cardiopulmonary resuscitation (CPR) was started.

Interview with Staff H (ED Registered Nurse) on 09/16/2024 at 1:15 PM revealed she observed Patient #1 sitting on the patio bench when coming into work on the morning of 04/21/2024 and Patient #1 was not in distress. Staff H stated during the code she was involved with triaging and assisting in the Resuscitation room.

Interview with Staff I (Security Specialist #4) conducted on 09/16/2024 at 2:37 PM. Staff I stated when coming in on Sunday (04/21/2024), they gave me a number to call the family because Patient #1 had been here for days. While getting report in front of the ED, Staff D (Security Specialist #1) was walking by with water. A little while later, heard Staff D (Security Specialist #1) say, she's down, throwing up. Staff I stated after that he ran to the ED and got Staff G (Emergency Medical Technician) to come and called for security back up to come. Staff G (Emergency Medical Technician) started compressions and went to get more help. Patient #1 was put on stretcher and taken inside.

Interview with Staff J (Security Manager) conducted on 09/16/2024 at 2:53 PM. Staff J stated he was a Lieutenant at the time of the incident; the previous manager retired. He is predominately responsible for doing the schedule for all 3 shifts. Staff J stated every time one of the security guards spoke to Patient #1, she stated she was not feeling well, and that was why she was not escorted off the premises. The facility's practice is to have the patient check back into the ED to see the physician again. If the person is not feeling well, we're supposed to have them check back in.

Interview with Staff K (ED Director) conducted 09/16/2024 at 3:08 PM. Staff K stated Patient #1 is known to us. Unfortunately, this is not an unusual occurrence. We frequently have homeless patients coming in asking for juice or complaining of abdominal pain. Chest pain protocol is done, the physician is notified and labs, chest x-ray is done. Staff K stated many patients coming in with cannabis hyperemesis syndrome. Reviewed labs on 04/17/2024. Potassium level 3.1, if the patient is not symptomatic there is no reason to treat a low potassium. Patient #1 was discharged at 8:24 PM and was taken out to the foyer. My understanding was that she walked around the campus and came back. Patient #1 was registered at 6:35 AM the next morning. EKG. Labs, ultrasound of the abdomen. Dx: cannabinoid hyperemesis syndrome. Reviewing the medical record, Patient #1 received 40 milliequivalents of potassium on 04/17/2024 and 04/18/2024, however additional review revealed no documentation that the staff administered additional milliequivalents of potassium to Patient #1 on 4/20/2024 and 4/21/2024.

Interview with Staff J (Security Manager) revealed Staff F (Security Specialist #3) was in charge on 04/20/2024 and 04/21/2024. Staff J stated that security specialists are assigned to zones within the campus. Staff J stated the Rover Patrol zones include the ED patio area, and the expectation is for each shift to make observations twice a day.

Interview with Staff F (Security Specialist #3) on 09/17/2024 at 1:34 PM revealed Staff F was in charge on Saturday 4/20/2024 and Sunday 4/21/2024. Staff F stated she first made contact with Patient #1 on Thursday (04/18/2024). A code grey was called in the fast-track area. Upon arrival me and Staff E (Security Specialist #2) told Patient #1 to move from the area. We took her to the foyer in the ED, and told Staff E (Security Specialist #2) to call the case manager. Patient #1 started crying. I did not see her on Friday. Upon return to work on Saturday, I noticed the same [ ____ ] female still sitting inside. Miami-Dade police was contacted. The Police arrived on the premises and attempted a conversation with Patient #1. The only thing she said was the word "pain". Patient #1 was assisted to the police car and was leaning on the hood. The police stated if Patient #1 continued to complain of pain, there is nothing they could do. Patient #1 was taken back into the ED via wheelchair by the police officer to be seen. I went to the security office to complete the shift summary report. The Chief Operating Officer (COO) stepped into the office, and I informed him about Patient #1 and he took a picture of my summary report and stated he would send it to Staff K (ED Director).

Upon return to work at 5:45 AM on Sunday 04/21/2024, I noticed same the [ ____ ] female was no longer on the foyer bench but was sitting ED patio area. Again, I contacted the social worker. Staff L (Social worker #2) was on duty for the ED and stated that if the person is not in the ED, she could not offer any assistance. I brought to her attention that Patient #1 was discharged and has been here for a couple of days. I also informed her that I spoke with the COO regarding Patient #1, and he stated he would send the information to Staff K (ED Director).

Interview with the COO conducted on 09/17/2024 at 2:30 PM. The COO stated Patient #1 had multiple visits and was discharged multiple times. Received phone call on weekend from security. The ED was called, and I spoke to Staff K (ED Director), he was asked to check on Patient #1. Staff K (ED Director) called back from the ED to say Patient #1 was okay and was being discharged. The next day I received a call that Patient #1 was dead. The Risk Manager probably followed up with the clinical team. In August, approximately 3 weeks ago, we placed an armed police officer in the ED. The officer rides around the campus for visibility. The incident sort of escalated the decision because we were contemplating the idea because of the violence staff encounters. The officer attends ED huddles, and there are improved feelings of security for the staff. We want the staff to know that we listened to them and responded to their concerns.

Interview with the Risk Manager conducted on 09/17/2024 at 3:10 PM. Provided with the Risk Manager's investigation notes for review. The Risk Manager stated the records, and the video were reviewed and did not feel it was necessary to interview security staff or investigate any further.

Interview with Staff K (ED Director) conducted on 09/17/2024 at 3:18 PM. Staff K stated he does not recall receiving a call from the COO on the morning of 04/20/2024 asking him to check on Patient #1.

Interview with Staff L (Social Worker #2) conducted on 09/18/2024 at 1:50 PM revealed she does not recall speaking with anyone requesting assistance for a patient outside of the ED.