HospitalInspections.org

Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, facility oxygen Emergency Department (ED) protocol, facility ED Sepsis Triage Orders, receiving and transferring facility medical records (MRs), ambulance run report, ambulance event chronology, facility Patient Transfer Request Tracking Form, facility General Medical Surgical, post operative floor (floor 2200) bed census, ED and floor 2200 staffing house census and and staff interviews it was determined Springhill Memorial Hospital (SMH, Hospital A) failed to ensure:

1. To identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the ED in the facility bylaws or rules and regulations.

2. Patients and/or person acting on the individual's behalf who refused to consent to a MSE were informed of the risks and benefits to the individual of the examination and the facility took and documented steps to secure the individual's written informed refusal (or that of the person acting on his or her behalf).

3. Ensure a MSE was provided when notified of a patient's intent to leave without being seen.

4. Patient diagnosed with Psychosis with previous homicidal statements and agitation were reassessed to demonstrate capacity to sign out AMA.

5. The on-call Physician accepted Patient Identifier (PI) # 24, a patient with cervical spine fracture, when contacted by the transferring hospital (Hospital C) which had no available Neurosurgical consult, when SMH had the capability and capacity to treat the patient.

The findings include:

Refer to A2406, A2407 and A2411 for findings.

Based on review of the facility policy and procedure, Medical Staff Bylaws and Rules and Regulations, and interviews with staff it was determined the facility failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations.

2. Ensure a MSE was provided when notified of a patient's intent to leave without being seen.

3. Patient diagnosed with Psychosis with previous homicidal statements and agitation were reassessed to demonstrate capacity to sign out AMA.

The deficient practice affected 2 of 4 patients reviewed who LWBS (left without being seen) and 1 of 3 patients reviewed who left AMA (against medical advice), including Patient Identifier (PI) # 1, PI # 14, PI # 2 and had the potential to affect all patients served by the facility ED.

Findings include:

Policy: Cobra Policy on Responsibilities of Medicare Hospitals in Emergency Cases, Includes Transfers To and From Other Facilities (Pursuant to the Emergency Medical Treatment and Labor Act (EMTALA))
Revised: 3/12

Policy:
If any individual...comes by himself or herself or with another person to the ED and a request is made on the individual's behalf for examination or treatment of (a) medical condition by qualified medical personnel (as determined by the hospital in its Rules and Regulations), the hospital must provide for an appropriate MSE within the capability of the hospital's ED...

...A registered nurse (RN) may perform the MSE exams to ascertain emergency medical conditions..

...Medical Screening Examination Procedure

...A. A qualified medical person, either a RN or physician shall:
1) Conduct MSE upon arrival...

1. The facility bylaws and rules and regulations were received from Employee Identifier (EI) # 1, Director of Quality Improvement/Risk Management, on 8/18/2020 at 3:48 PM via email.

Review of the facility bylaws and rules and regulations on 8/19/2020 revealed no documentation to identify and approve the individual(s) qualified to perform the MSE in the ED, which is required by the regulation.

An interview was conducted with EI # 1 on 8/19/2020 at 6:03 PM who stated, "I reviewed our Bylaws and policies and we do not have it written. Only our physicians perform the Medical Screening Exam in our emergency department."

2. Patient Identifier (PI) # 1 presented to the ED on 7/7/2020 at 6:47 PM. Review of the MR revealed:

A triage was performed at 7:07 PM with a chief complaint of Altered Mental Status and the following vital signs: blood pressure (b/p) 73/51, temperature 98, pulse 76 and respirations 16. Patient oxygen saturation (O2 sat) was 96% on 2 liters of oxygen during the triage due to previously having the oxygen placed by Emergency Medical Services (EMS) for an O2 sat of 74%. A sepsis screening was performed with "yes" answered for does patient have a suspected infection and new onset altered mental status.

There was no documentation of nursing assessment or intervention from 6:48 PM until 7:51 PM. There was no documentation a blood culture, CBC (Complete Blood Count), Blood Gas/Lactate, CMP (comprehensive metabolic panel) , Sodium Chloride 0.9% bolus and Norepinephrine drip was ordered and no documentation the admitting MD (Medical Doctor) was notified per the ED sepsis triage orders.

At 7:52 PM, Nursing note documentation revealed "pt (patient) left with EMS (name identified) ambulance to go to (hospital B, receiving hospital identified)" with a disposition of "pt left without being seen by MD."

There was no documentation the patient was evaluated by a qualified medical provider and received an appropriate medical screening examination. The patient was not appropriately transferred utilizing a certificate of transfer but transported to the other hospital via EMS.

Ambulance Documentation:

Review of the Ambulance Run Report dated 7/7/2020 revealed:

The ambulance was dispatched at 5:12 PM to the home of PI # 1 for a chief complaint of weakness and altered level of conscious.

The ambulance arrived on scene at 5:38 PM.

Assessment findings of:
At 5:40 PM: mild upper lobe wheezing in lung fields, diminished breath sounds in lower lobes of lungs, PI # 1 was oriented to person, place, and time.
At 6:00 PM: b/p 74/45, pulse 82, respirations 16, and a O2 sat of 74% on room air (RA).
At 6:05 PM: b/p 74/45, pulse 82, respirations 16, and a O2 sat of 74% on 3 Liter of oxygen.
At 6:10 PM: b/p 74/45, pulse 82, respirations 16, and a O2 sat of 74% on 3 Liter of oxygen.
At 6:15 PM: b/p 74/47, pulse 83, respirations 16, and a O2 sat of 73% on 3 Liter of oxygen.
At 6:20 PM: b/p unable to complete, pulse 81, respirations 16, and a O2 sat of 93% on RA.
At 6:30 PM: b/p 114/89, pulse 81, respirations 16, and a O2 sat of 98% on RA.
At 6:40 PM: b/p 98/42, pulse 84, respirations 16, and a O2 sat of 91% on RA.
At 6:50 PM (arrived at Hospital A at 6:47 PM): b/p 97/67, pulse 82, and respirations 16. No O2 sat documented.
At 7:00 PM: b/p 73/51, pulse 81, respirations 16, and a O2 sat of 97% on RA.
At 7:10 PM: b/p 73/49, pulse 82, respirations 16, and a O2 sat of 97% on RA.
At 7:20 PM: b/p 70/47, pulse 79, respirations 16, and a O2 sat of 83% on RA.
At 7:30 PM: b/p 70/47, pulse 82, and respirations 16. No O2 sat documented.
At 7:40 PM: b/p unable to complete, pulse 76, respirations 16, and a O2 sat of 90% on RA.
At 7:50 PM: b/p unable to complete, pulse 76, respirations 16, and a O2 sat of 90% on RA.
At 8:00 PM: b/p 69/48, pulse 78, respirations 16, and a O2 sat of 90% on RA.

Narrative findings of:
..."...pt was A&O (alert and oriented) x (times) 3/4 with an adult GCS (Glasgow coma scale) of 14. Pt appeared to have slight alteration in her mental status...Auscultation upper lobes presented with mild exhibitory wheezing bilaterally, with diminished breath sounds present on lower lobes bilaterally. Pt SPO2 (oxygen level) was 74% on room air with a RR (respiratory rate) of 16. Pt did not state SOB (shortness of breath) despite low SPO2 levels...pt presented with altered mental status, low SPO2 levels, low b/p with associated weakness and general poor presentation. It was suspected pt may currently be septic based upon assessment...pt was initially transported emergent to (hospital A, SMH) emergency room, pt was then transported to (hospital B, receiving hospital)...Based upon patient presentation both (EMS identified) crew members...thought it was most appropriate to propose to both the family and pt the possibility of changing emergency room facilities. Pt's family member...was contacted...daughter/son agreed to said proposal. After a discussion with pt who presented with the ability to consciously answer questions appropriately, agreed to go to another facility...pt was successfully re-transported to (hospital B, receiving hospital) ER. Note- pt received no evaluation or treatment at (hospital A, SMH) during the entire stay."

Review of the Ambulance Event Chronology dated 7/7/2020 revealed PI # 1 arrived at Hospital A, SMH at 6:43 PM and departed at 7:45 PM.

Further review of the Ambulance Event Chronology dated 7/7/2020 revealed PI # 1 was transported from Hospital A, SMH at 7:45 PM to Hospital B, receiving hospital.

Hospital B, Receiving Hospital Documentation:

PI # 1 arrived at Hospital B, Receiving Hospital via EMS at 8:00 PM on 7/7/2020. A triage was completed upon arrival at 8:00 PM with the following vital signs: b/p 87/57, pulse 80 and respirations 20. There was no documentation of an O2 sat. PI # 1 was evaluated by the Hospital B, ED physician at 8:08 PM for a chief complaint of altered mental status, hypotension (low b/p), and low O2. The ED physician documented PI # 1 was not altered upon assessment, alert and oriented x 4 (person, place, time, and situation), and had wheezing in the bilateral lung lobes. PI # 1 had the following abnormal labs at Hospital B: Arterial Blood Gases were performed at 8:19 PM showed pH (potential hydrogen) arterial 7.34, PO2 (partial pressure of oxygen) 109, Base Excess/Deficit -4, a Urinalysis (UA) was completed at 9:14 PM and showed UA Protein 2+, UA Glucose trace, UA Ketones trace, UA bili (bilirubin) 1+, UA blood 1+, UA WBC (white blood cells) 5-10, UA RBS (red blood cells) 5-10, UA Bacteria 1+, a CBC (Complete Blood Count) was completed 9:50 PM and showed the following abnormal findings: WBC 13.7, Hematocrit 43.5, BUN 44, Creatine 5.83, Total CK (Creatine Kinase) 177, Troponin was completed at 9:50 PM and showed 0.019.

On 7/7/2020 at 10:53 PM, PI # 1 was admitted to inpatient to the Intensive Care Unit for acute renal insufficiency with condition documented as guarded.

Interviews:

An interview was conducted via phone on 8/20/2020 at 2:05 PM with EI # 3, Registered Nurse (RN), who verbalized PI # 1, "came in by ambulance and I triaged her/him. Her/His BP (blood pressure) was low and EMS had an IV (intravenous) going already. There wasn't a room available at that time and I told them it would be a few minutes and they could wait. They said okay. While they were waiting they were in the ambulance bay and there was no other initial conversation." EI # 3 was asked how he/she was made aware PI # 1 was leaving the ED by EMS and being taken to Hospital B, receiving hospital. EI # 3 stated, "the EMS called (hospital B identified) and they accepted her. I went to the ambulance bay EMS told me they were leaving." EI # 3 was then asked what his/her response to EMS was after being told the patient was being transported to another facility. EI # 3, stated "I believe I just said okay." EI # 3 was then asked if the risk and benefits of leaving without the MSE were explained to the patient and/or caregiver. EI # 3 stated, PI # 1 "was altered and not capable of understanding. She/He had no family with her."

An interview was conducted via phone on 8/20/2020 at 4:15 with EI # 4, ED Director, who verbalized the process when a patient is brought into the ED via ambulance is "they come in from the ambulance entrance and at that point they are in the middle of the ED. A nurse greets them and they are triaged. We then look at the diagnosis board and if a bed is available we take them to the area needed." EI # 4 verbalized if an ED bed is not available at the time, "We leave them in front of the nurse's station until a bed is available..." EI # 4 verbalized he/she was told of the situation with PI # 1 the next day by EI # 6, ED Nurse Manager." EI # 4 verbalized he/she was told, "basically, EMS brought the patient in and the patient was triaged. EMS waited 20 minutes and EMS decided they were not going to wait any longer, so they rolled her/him out on the stretcher and put her/him in the ambulance and took her/him to (Hospital B identified)..." EI # 4 was asked if the risks and benefits of having a medical screening exam (MSE) explained to the patient and/or caregiver who intends to LWBS? EI # 4 stated, "if we knew they were leaving it is usually written in the disposition of the flow sheet."

An interview was conducted via phone on 8/21/2020 at 1:10 PM with EI # 5, Paramedic, who verbalized PI # 1 was found to have a low B/P, altered mental status with mild confusion to circumstance on assessment, low O2 saturation, an intravenous line (IV) was initiated to administer lV fluids to see if that was the problem with the low BP. EI # 5 verbalized during the transfer to Springhill, PI # 1 assessment findings "did not change much" but the Oxygen saturation did increase to "70's to 80's." EI # 5 stated, "...was giving... IV fluids to increase...BP. We only got about 300 ml (milliliters) in her/him which is not as much as we would have liked. At Springhill she/he was on our stretcher and we got her/him out of the ambulance and her/his BP was 70's over 40's...We took the patient in and ...Springhill...said we needed to roll around the corner to wait. We rolled the patient around the corner and kept her/him on our monitor and O2 the entire time. EI # 5 was then asked, the ambulance run report documented the patient was placed on 3 Liters of Oxygen but later the oxygen saturations were on room air. Was the oxygen removed? No not to my knowledge...I would bet...made a mistake and hit the wrong thing. There is no way (second EMS staff identified) took her/him off... even had her/him on the portable O2 tank when we took her/him off the ambulance. EI # 5 was asked, do you know approximately what time you left Springhill? "We left at 1842 (6:42 PM)." EI # 5 was asked, what happened while waiting at Springhill? "We monitored her/him and kept the O2 on...continuously, admissions came and verified name and put name band on her/him. The ER (Emergency Room) staff...got a base line VS (vital signs)... (second EMS staff identified) concentrated on the patient because her/his b/p was still 70's/40's. (second EMS staff identified) told the young lady/gentleman who took the base line. I thought this would help out the patient would get back faster since BP continued to be low..." EI # 5 verbalized he/she contacted the EMS supervisors "at about 7:30 PM we had been there 48 minutes", ...explained what was going on..." EI # 5 verbalized he/she was "asked if the patient and/or family was willing to go somewhere else...I called the daughter/son and explained the situation and ...I told her... (Hospital B, receiving hospital) was available. The daughter/son thanked me, and I called dispatch told them I talked to the family and we were leaving Springhill to go to Hospital B as a Code 3 (lights and siren). We headed to Hospital B...arrived at Hospital B at 2005 (8:05 PM) and they were already waiting on us when we arrived. They got her/him a bed right away and gave immediate attention." EI # 5 was asked did you notify anyone you were leaving Springhill? EI # 5 responded, "...told the young lady/gentleman who took the VS... I remember saying we were leaving and going to (Hospital B identified). ...I said out loud we were going to (Hospital B identified)." EI # 5 was asked, did the Springhill staff person try to communicate with the patient after being told you were leaving? EI # 5 responded, "no...No one talked to the patient except when the ID (identification) band was put on her/him."

An interview was conducted via phone on 8/21/2020 at 2:00 PM with EI # 6, ED Nurse Manger. EI # 6 was asked, if the ED does not have an available bed for a patient brought in by ambulance what is the facility practice/policy? EI # 6 stated, "the patient remains on the stretcher with EMS and sometimes we do labs until a bed is available." EI # 6 was then asked if she/he recalled PI # 1. EI # 6 stated, "I was not working then but my nurse called the next morning to give me a heads up. (EI # 3, RN identified) was the nurse and...said ER was full and waiting on a bed...and EMS got mad and took the patient to another facility." EI # 6 was asked if the nurse identified how she/he was aware the EMS was leaving? EI # 6 stated, "she/he (nurse) stepped out of ER to triage another patient and she saw then loading her up, so...asked them (EMS)." EI # 6 was asked, what the facilities policy was when a patient and/or caregiver lets a staff member know they are intending to LWBS? EI # 6 stated, "yes, we would tell the patient the risks and benefits of leaving without being seen and document it in the nurse notes in the ED flow sheet." EI # 6 was asked, do you recall if the risks/benefits of having a MSE were explained to PI # 1? EI # 6 sated, "no, (employee identified) did not know she/he was leaving. She/He was already being loaded onto the ambulance."

An interview was conducted via phone on 8/21/2020 at 3:15 PM with EI # 7, Paramedic. EI # 7 was asked to describe the circumstances surround PI # 1. EI # 7 stated, "generalized weakness and a low BP and low 02 Sat. We transported to Springhill and we had an extended stay there. After contacting the family...we decided to transport her/him to Hospital B." EI # 7 was asked what happened after arrival at Springhill? EI # 7 stated, "arrived in the ED and brought the patient to the nurse ' s desk. They triaged the patient and got VS and registered the patient. When we arrived this time, no one contacted us we were just told abruptly to go back to the ambulance area and we continued to monitor the patient. My partner delivered the information the admissions. The nurse came to get VS on the patient and a brief summary of the patient....registration placed a band on the patient and we received a paper from the hospital to say she/he was registered. After that we waited about 50 to 55 minutes and there was no other contact." EI # 7 was asked what prompted you to call your supervisors? EI # 7 respond, "after 60 minutes or 1 hour we have the right to explain to the patient she/he could go to another facility. What we could and did provide while waiting. We helped her/him some, but we recognized she/he was deteriorating, and...needed higher level of care she/he was not receiving, so we contacted higher ups and determined she/he needed to be transported elsewhere...I told my patient and she/he consented and... the daughter/son who consented. So, we took our patient and loaded her/him up in the ambulance." EI # 7 was asked if PI # 1 was able to comprehend transferring to another facility? EI # 7 stated, PI # 1 "...was presenting a low-level alteration and...before transfer she/he was able to understand why she/he was being transferred." EI # 7 was asked if PI # 1 was on oxygen for the duration of the EMS transport? EI # 7, "yes..." EI # 7 was asked, if a staff member at Springhill ED attempted to speak or spoke with PI # 1 following being told the EMS was transporting the patient to Hospital B? EI # 7 stated, "the only interaction with staff at Springhill was when she/he was triaged and registered. One other ambulance came in toward the time we were leaving and at one time there were 3 ambulances in the corner. The staff just did the initial VS on the others and they had to walk directly past us to go do the VS and then return past us to the nurse's station."

An interview was conducted via phone on 8/31/2020 at 3:45 PM with EI # 1 who was asked to provide the ED Sepsis Protocol. EI # 1 verbalized she/he would have the protocol emailed to the surveyor. On 8/31/2020 at 11:30 AM the surveyor received the following ED Sepsis Triage orders for the facility ED Sepsis Protocol via email from EI # 2, Chief Nursing Officer:
Lab: Blood Culture, Completed Blood Count (CBC), Blood Gas/Lactate, Comprehensive Metabolic Panel (CMP)
IV (Intravenous) orders: Sodium Chloride 0.9% Bolus volume 1905 rate 999 ml (milliliters)/hr (hour), Norepinephrine Drip Volume 8 Rate 3.8 ml/hr
Nursing Orders: Notify Admitting MD (Medical Doctor)...

An interview was conducted via email on 9/1/2020 at 2:48 PM with EI # 2 who was asked, on the order set protocols for triage, would each of these orders be placed following the completion of triage by the nurse? EI # 2 stated, "the triage nurse would initiate the order set upon completion of triage..."

3. PI # 14 presented to the SMH ED on 5/26/2020 at 1:39 PM by private vehicle.

Review of the MR revealed at 2:01 PM the patient was triaged and assessed by EI # 12, RN. PI # 14 complained of back pain from a MVC (Motor Vehicle Collision).

Vital signs (VS) were taken and temperature was 97.5, Pulse 89 respirations 18 Oxygen Saturation 100% on room air. The pain assessment was documented as comfortably manageable. PI # 14 was alert and oriented to person, place and time and ambulatory.

Further review of the MR revealed at 2:55 PM, EI # 12 documented a note stating "PI # 14 asked the security guard for a diaper and the security guard called Labor and Delivery (L&D). L&D did not have the size diaper needed. PI # 14 began to yell and take pictures of the security guard stating she was going to tell the news we did not give her a diaper. The patient left before being seen by an MD. The patient was ambulatory to her vehicle and stood beside the vehicle and continued to take pictures of the security officers".

At 2:55 PM, EI # 12 documented patient left the ED without being seen by the MD (Medical Doctor.)

There was no documentation the patient was evaluated by a qualified medical provider and received an appropriate medical screening examination prior to elopement which was watched by a member of the facility security department.

Interviews:

An interview was conducted on 8/19/2020 at 1:47 PM with EI # 1 who stated "There was no further documentation and the patient had not been seen by a healthcare provider before the patient eloped. The physician did not get the opportunity to explain the risks and benefits"

An interview was conducted on 9/1/2020 at 2:35 PM with EI # 12, RN who was asked in your nursing documentation you noted at 2:55 PM you documented the patient requested a diaper from security and after the patient was told L&D did not have a diaper the patient began to yell, take pictures, and left ambulatory while taking pictures. Can you tell me how you found out about the previous? EI # 12 stated, "Security came to me and told me about the diaper and labor and delivery did not have one to fit. I saw her/him standing in the parking lot with a child on her/his hip and the phone out." EI # 12 was asked were you aware at that time PI # 14 was leaving? "Yes, and she/he was saying she/he was telling the news we would not give her/him a diaper. She/He was all the way out in the parking lot and did not try to come back." EI # 12 was asked how were you made aware of the patient leaving? "Security came and got me and told me she/he left. I went to assess the situation and she/he was way out in the parking lot already she/he was too far out." EI # 12 was asked did you attempt to tell PI # 14 about the LWBS risks and benefits? EI # 12 stated, "I don't remember talking with her/him, she/he was already way out in the parking lot. EI # 12 was asked what is the facilities policy when a patient and/or caregiver lets a staff member know they are intending to LWBS? "We go talk to the patient and find out why they want to leave, see if we can resolve the issue and assess the situation to improve what is wrong. This patient was way out in the parking lot and I could not leave the ED to go out there."

4. PI # 2 presented to the ED on 6/12/2020 at 12:50 AM. Review of the MR revealed:

Review of the Physician ER Note dated 6/12/2020 at 1:26 AM revealed the following assessment: "Chief complaint: psychosis...PD (police department) was called to Burger King where patient was reportedly 'walking around.' PD noted pt (patient) to be yelling and belligerent, so EMS (Emergency Medical Services) was called. Pt complained to EMS that he/she had leg pain from walking. On arrival to ER, pt was reportedly yelling and spitting. Security was involved and PD tased patient. On my evaluation, he/she now c/o (complains of) 'pain all over.' He/She refuses to answer further questions. 'I plead the fifth' to most questions. Pt later notes he/she has previously been at (Psychiatric (Psych) Hospital identified) and was previously taking 'some shot' for an unknown diagnosis....Psych: reported hallucinations... Neuro (Neurological): oriented to person only. speech clear but confused. moves all extremities w/ (with) good strength. Psych: rambling incoherently, intermittent outbursts...The differential diagnosis for the patient's symptoms includes but is not limited to 1. psychosis 2. drug intoxication 3. malingering... Final Diagnostic Impression: Acute Psychosis, Chronic Renal Disease..."

Further review of the Physician ER Note dated 6/12/2020 revealed the following documentation of follow up assessments (recheck) without a time documented: "pt more cooperative once in ED bed. Remains poor historian and does not appropriately answer questions....d/w (discussed with)...Hospitalist NP (Nurse Practitioner) re (in reference of) admission."

Review of the ED Assessment Flowsheets dated 6/12/2020 revealed the following documentation:

At 1:30 AM, documentation of "Nursing Note: Upon arrival to ED, pt becomes increasingly agitated and combative towards nursing staff. Pt begins attempting to spit on triage nurse and surrounding nursing staff. Pt begins to cuss out nursing staff, 'fuck you bitch. I will kill you. Come closer and just see,' pt instructed that he can't talk that way to the nursing staff. Pt continues to be combative and attempting to hurt nursing staff. This RN (Registered Nurse) calls...security to triage to assess situation. Pt begins cussing at...with hospital security. 'Fuck you, you think your something. I will fucking kill you bitch, I will kill you,' ...security informs this RN to call 911 for police back up."

At 1:31 AM, documentation of "Nursing note: ...EMT (Emergency Medical Technician) and Medic (Paramedic) remove patient via stretcher from triage area to a more secluded part of the ER as to minimize threats to nursing staff. (Facility Security guard identified) with security and two other security officer(s) escort the patient and (EMS company identified) team to await police back up in the ambulance bay. Pt still being combative and threating all staff members nearby at this time", neurological assessment findings of alert, MAEW (Moves All Extremities Well), oriented to person, confused, agitated.

At 1:32 AM, documentation of "Nursing note: patient arrived to ED screaming, cussing, and spitting. Patient erratic and agitated at staff. Patient stated, 'I will kill you bitch.' Making inappropriate comments to everybody around and acting like he/she is spitting at triage nurse. (Police Department Identified) on scene. Patient was tased, (Police Department and EMS company identified) and ED staff witnessed situation."

At 1:35 AM, documentation of "Nursing note: (police department identified) arrives on scene to assess situation. Pt is removed from stretcher and handcuffed by two...officers. Pt is still being uncooperative and combative. Pt states, 'hear ye, hear ye, I will fucking kill you.' Pt restrained per...police dept (department) at this time."

At 1:36 AM, documentation of "Nursing note: Pt becoming increasingly agitated at this time and is attempting to break free of (police department identified) custody....officers taze patient. Vitals signs taken after and are stable."

At 1:37 AM, documentation of "Nursing note: Pt brought inside for MD assessment and treatment."

At 1:45 AM, documentation of the MD was at bedside and an intravenous (IV) catheter line was placed in the right upper arm. The nurse documented instructing the patient to call for problems with IV and "...pt pulls out penis and states, 'yeah you like that. You looking at my balls. I bet you are and you want that don't you.' Pt instructed not to talk to nursing staff that way. Pt stays silent."

Review of the Laboratory Results Report dated 6/12/2020 at 1:47 AM revealed documentation of the following abnormal lab results: White Blood count 15.4, Red Blood Cell Count 5.66, Hematocrit 49.6, Absolute Neutrophils 10.01, Absolute Lymphocytes 3.85, Absolute Monocytes 1.18, BUN 30, Creatine, Blood 1.90, Albumin, Blood 5.2, urine Protein +1, trace amount of urine Ketones, few urine mucous, 3-5 urine hyaline casts, Creatine phosphokinase (CPK) 352, Urine drug screen positive for amphetamines and THC (Cannabinoid).

Review of the ED Assessment Flowsheet dated 6/12/2020 at 2:33 AM revealed vital signs of temperature 98.3, pulse 94, respirations 18, oxygen saturation 94%, and blood pressure 122/83.

Review of the ED Nursing Triage Note dated 6/12/2020 at 2:35 AM revealed documentation of the chief complaint as "altered mental status...EMS states patient took unknown substance and is altered now. Pt states they are a psych patient." Associated symptoms included "agitated, confusion." The assessment finding were documented as "...Glasgow Coma Scale: Verbal response: Disoriented...Neurological assessment: alert, MAEW, orient to person, confused, agitated..."

Review of the ED Assessment Flowsheet dated 6/12/2020 at 3:08 AM revealed documentation of "Nursing note: pt resting in bed occasionally waking up and yelling out curse words..." and the patients was stable.

Review of the ED Assessment Flowsheet dated 6/12/2020 at 4:04 AM revealed documentation of "Nursing note: pt laying in bed awake. Calm. Given sheet to cover self. Vitally stable..."

Review of the Physician ER Note dated 6/12/2020 at 5:45 AM revealed the following recheck documentation: "pt again became agitated with violent outbursts and threats against staff, he/she was placed in physical restraints, broke through them and had to be chemically restrained, first w/ Haldol/Benadryl. He/She then ripped out IV and was given IM (intramuscular) Ketamine. Pt appears acutely psychotic...there is renal disease of unclear duration. Do not suspect acute medical illness. Pt is stable for psych evaluation."

Review of the Medication Administration Record dated 6/12/2020 revealed at 6:10 AM, Haldol 5 mg (milligrams) and Benadryl 50 mg were administered IV to the patient and at 6:18 AM Ketamine 400 mg was administered IM to the patient.

Further review of the ED Assessment Flowsheet dated 6/12/2020 revealed:

At 6:30 AM, documentation of "Nursing note: ...pt medicated as per EMAR (electronic medical record). Tolerated well...pt combative and threatening us saying 'I will beat your ass...'

At 9:33 AM, documentation of "Nursing note: patient asleep in bed..."

At 9:48 AM, documentation of "Nursing note: patient found walking in the hallway with restraints still around wrists and ankles. Security called and patient back to room, into restraints and IV restarted..."

At 9:58 AM, documentation of "Nursing note: Spoke with...NP. Diet order received."

At 10:00 AM, documentation of "Nursing note: meal tray ordered."

At 10:07 AM, documentation of "Nursing note: patient screaming 'I want fucking food!!!!!' I informed patient that we have already ordered his/her meal tray. Patient broke bilateral wrist restraints. Security and department assistant manager called. Hospitalist called and on the way down. Patient stating that he/she wants to leave. Patient alert and oriented x (times) 4."

At 10:13 AM, documentation of "Nursing note: Police and security at bedside. Patient signed AMA (against medical advice) form. Hospitalist NP at bedside. IV removed. Shoes given to patient. Escorted out by security" with a discharge disposition documented as "...pt wheeled to ramp; pt left AMA. Escorted out by security..."

Review of the MR revealed the patient did not receive an examination by a psychiatrist and the Hospitalist concluded the patient being alert and oriented x 4 was enough to demonstrate capacity to sign out AMA without a reassessment of the patient's previous homicidal statements and agitation which continued at the time of discharge by screaming "I want fucking food." The patient was permitted to leave prior to the necessary psychiatric and renal insufficiency workups which would be part of the MSE.

Based on review of the facility policies and procedure, facility oxygen Emergency Department (ED) protocol, facility ED Sepsis Triage Orders, medical records (MRs), ambulance run report, ambulance event chronology and staff interviews it was determined the facility failed to ensure:

1. Patients and/or person acting on the individual's behalf who refused to consent to a Medical Screening Examination (MSE) were informed of the risks and benefits to the individual of the examination and the facility took and documented steps to secure the individual's written informed refusal (or that of the person acting on his or her behalf).

2. A patient diagnosed with Psychosis with previous homicidal statements and agitation were reassessed to demonstrate capacity to sign out AMA.

The deficient practice affected 2 of 4 patients reviewed who LWBS (left without being seen) and 1 of 3 patients reviewed who left AMA (against medical advice), including Patient Identifier (PI) # 1, PI # 2, PI # 14 and had the potential to affect all patients served by the facility ED.

Findings include:

Policy: Cobra Policy on Responsibilities of Medicare Hospitals in Emergency Cases, Includes Transfers To and From Other Facilities (Pursuant to the Emergency Medical Treatment and Labor Act (EMTALA))
Revised: 3/12

Policy:
If any individual...comes by himself or herself or with another person to the ED and a request is made on the individual's behalf for examination or treatment of (a) medical condition by qualified medical personnel (as determined by the hospital in its Rules and Regulations, the hospital must provide for an appropriate MSE within the capability of the hospital's ED...

...MSE Procedure:

...B. Consent for screening and/or

1. Inform the patient or person acting on the individual's behalf of the risks of refusal of the proposed examination or treatment and of the potential benefits.

2. Document steps taken to secure written refusal in the MR or on the Against Medical Advice (AMA) form or on the Transfer to Acute Care Specialty Facility Summary form. Obtain signature of patient or representative...

Policy: Discharge of Patients
Revised: 8/1999

Purpose: To establish guidelines and protocol for the discharge of patient's from the ED.

...2. Each patient presenting to the ED for treatment must see a physician for a MSE or sign a refusal form stating that they refuse a MSE...

Oxygen Therapy Protocol
Revised: 9/2017

I. Subject: Oxygen Therapy Protocol

II. Purpose: To provide adequate oxygenation for patients, the respiratory care practitioner will utilize the following protocol to evaluatetreat (evaluate, treat) and monitor appropriate oxygen administration.

...VII. Overview: Oxygen Therapy order received, assess patient, select appropriate oxygen device, re-evaluate

VIII. Protocol: The following guidelines will be followed in determining the indications for oxygen therapy and for selection of appropriate oxygen therapy delivery devices.

A. Indications for oxygen therapy include:

1. Documented hypoxemia (low oxygen) -...SpO2 (oxygen saturation) less than 90%...

...D. Assessment of Outcome:

1. Absence of clinical signs of symptoms of hypoxia.
a. SpO2 is greater than or equal to 90%...

...X. Guidelines/Warning:
Monitor patient's vital signs and evaluate patient's clinical status...

Hospital A, Springhill Memorial Hospital (SMH) documentation:

1. PI # 1 presented to the ED on 7/7/2020 at 6:47 PM. Review of the MR revealed:

A triage was performed at 7:07 PM with a chief complaint of Altered Mental Status and the following vital signs: blood pressure (b/p) 73/51, temperature 98, pulse 76 and respirations 16. Patient oxygen saturation (O2 sat) was 96% on 2 liters of oxygen during the triage due to previously having the oxygen placed by Emergency Medical Services (EMS) for an O2 sat of 74%. A sepsis screening was performed with "yes" answered for does patient have a suspected infection and new onset altered mental status.

There was no documentation of nursing assessment or intervention from 6:48 PM until 7:51 PM. There was no documentation a blood culture, CBC (Complete Blood Count), Blood Gas/Lactate, CMP (comprehensive metabolic panel) , Sodium Chloride 0.9% bolus and Norepinephrine drip was ordered and no documentation the admitting MD (Medical Doctor) was notified per the ED sepsis triage orders.

At 7:52 PM, Nursing note documentation revealed "pt (patient) left with EMS (name identified) ambulance to go to (hospital B, receiving hospital identified)" with a disposition of "pt left without being seen by MD."

There was no documentation the patient, caregiver and/or EMS staff were informed of the risks of refusal of MSE and treatment and of the potential benefits and no documentation steps were taken to secure written refusal with the patient's and/or representatives signature in the MR.

Ambulance Documentation:

Review of the Ambulance Run Report dated 7/7/2020 revealed:

The ambulance was dispatched at 5:12 PM to the home of PI # 1 for a chief complaint of weakness and altered level of conscious.

The ambulance arrived on scene at 5:38 PM.

Assessment findings of:
At 5:40 PM: mild upper lobe wheezing in lung fields, diminished breath sounds in lower lobes of lungs, PI # 1 was oriented to person, place, and time.
At 6:00 PM: b/p 74/45, pulse 82, respirations 16, and a O2 sat of 74% on room air (RA).
At 6:05 PM: b/p 74/45, pulse 82, respirations 16, and a O2 sat of 74% on 3 Liter of oxygen.
At 6:10 PM: b/p 74/45, pulse 82, respirations 16, and a O2 sat of 74% on 3 Liter of oxygen.
At 6:15 PM: b/p 74/47, pulse 83, respirations 16, and a O2 sat of 73% on 3 Liter of oxygen.
At 6:20 PM: b/p unable to complete, pulse 81, respirations 16, and a O2 sat of 93% on RA.
At 6:30 PM: b/p 114/89, pulse 81, respirations 16, and a O2 sat of 98% on RA.
At 6:40 PM: b/p 98/42, pulse 84, respirations 16, and a O2 sat of 91% on RA.
At 6:50 PM (arrived at Hospital A at 6:47 PM): b/p 97/67, pulse 82, and respirations 16. No O2 sat documented.
At 7:00 PM: b/p 73/51, pulse 81, respirations 16, and a O2 sat of 97% on RA.
At 7:10 PM: b/p 73/49, pulse 82, respirations 16, and a O2 sat of 97% on RA.
At 7:20 PM: b/p 70/47, pulse 79, respirations 16, and a O2 sat of 83% on RA.
At 7:30 PM: b/p 70/47, pulse 82, and respirations 16. No O2 sat documented.
At 7:40 PM: b/p unable to complete, pulse 76, respirations 16, and a O2 sat of 90% on RA.
At 7:50 PM: b/p unable to complete, pulse 76, respirations 16, and a O2 sat of 90% on RA.
At 8:00 PM: b/p 69/48, pulse 78, respirations 16, and a O2 sat of 90% on RA.

Narrative findings of:
..."...pt was A&O (alert and oriented) x (times) 3/4 with an adult GCS (Glasgow coma scale) of 14. Pt appeared to have slight alteration in her mental status...Auscultation upper lobes presented with mild exhibitory wheezing bilaterally, with diminished breath sounds present on lower lobes bilaterally. Pt SPO2 was 74% on room air with a RR (respiratory rate) of 16. Pt did not state SOB (shortness of breath) despite low SPO2 levels...pt presented with altered mental status, low SPO2 levels, low b/p with associated weakness and general poor presentation. It was suspected pt may currently be septic based upon assessment...pt was initially transported emergent to (hospital A, SMH) emergency room, pt was then transported to (hospital B, receiving hospital)...Based upon patient presentation both (EMS identified) crew members...thought it was most appropriate to propose to both the family and pt the possibility of changing emergency room facilities. Pt's family member...was contacted...daughter/son agreed to said proposal. After a discussion with pt who presented with the ability to consciously answer questions appropriately, agreed to go to another facility...pt was successfully re-transported to (hospital B, receiving hospital) ER. Note- pt received no evaluation or treatment at (hospital A, SMH) during the entire stay."

Review of the Ambulance Event Chronology dated 7/7/2020 revealed PI # 1 arrived at Hospital A, SMH at 6:43 PM and departed at 7:45 PM.

Further review of the Ambulance Event Chronology dated 7/7/2020 revealed PI # 1 was transported from Hospital A, SMH at 7:45 PM to Hospital B, receiving hospital.

Hospital B, Receiving Hospital Documentation:

PI # 1 arrived at Hospital B, Receiving Hospital via EMS at 8:00 PM on 7/7/2020. A triage was completed upon arrival at 8:00 PM with the following vital signs: b/p 87/57, pulse 80 and respirations 20. There was no documentation of an O2 sat. PI # 1 was evaluated by the Hospital B, ED physician at 8:08 PM for a chief complaint of altered mental status, hypotension (low b/p), and low O2. The ED physician documented PI # 1 was not altered upon assessment, alert and oriented x 4 (person, place, time, and situation), and had wheezing in the bilateral lung lobes. PI # 1 had the following abnormal labs at Providence: Arterial Blood Gases were performed at 8:19 PM showed pH (potential hydrogen) arterial 7.34, PO2 (partial pressure of oxygen) 109, Base Excess/Deficit -4, a Urinalysis (UA) was completed at 9:14 pm and showed UA Protein 2+, UA Glucose trace, UA Ketones trace, UA bili (bilirubin) 1+, UA blood 1+, UA WBC (white blood cells) 5-10, UA RBS (red blood cells) 5-10, UA Bacteria 1+, a CBC (Complete Blood Count) was completed 9:50 PM and showed the following abnormal findings: WBC 13.7, Hematocrit 43.5, BUN 44, Creatine 5.83, Total CK (Creatine Kinase) 177, Troponin was completed at 9:50 PM and showed 0.019.

On 7/7/2020 at 10:53 PM, PI # 1 was admitted to inpatient to the Intensive Care Unit for acute renal insufficiency with condition documented as guarded.

Interviews:

An interview was conducted via phone on 8/20/2020 at 2:05 PM with EI # 3, Registered Nurse (RN), who verbalized PI # 1, "came in by ambulance and I triaged her/him. Her/His BP (blood pressure) was low and EMS had an IV (intravenous) going already. There wasn't a room available at that time and I told them it would be a few minutes and they could wait. They said okay. While they were waiting they were in the ambulance bay and there was no other initial conversation." EI # 3 was asked how he/she was made aware PI # 1 was leaving the ED by EMS and being taken to Hospital B, receiving hospital. EI # 3 stated, "the EMS called (hospital B identified) and they accepted her. I went to the ambulance bay EMS told me they were leaving." EI # 3 was then asked what his/her response to EMS was after being told the patient was being transported to another facility. EI # 3, stated "I believe I just said okay." EI # 3 was then asked if the risk and benefits of leaving without the MSE were explained to the patient and/or caregiver. EI # 3 stated, PI # 1 "was altered and not capable of understanding. She/He had no family with her."

An interview was conducted via phone on 8/20/2020 at 4:15 with EI # 4, ED Director, who verbalized the process when a patient is brought into the ED via ambulance is "they come in from the ambulance entrance and at that point they are in the middle of the ED. A nurse greets them and they are triaged. We then look at the diagnosis board and if a bed is available we take them to the area needed." EI # 4 verbalized if an ED bed is not available at the time, "We leave them in front of the nurse ' s station until a bed is available..." EI # 4 verbalized he/she was told of the situation with PI # 1 the next day by EI # 6, ED Nurse Manager." EI # 4 verbalized he/she was told, "basically, EMS brought the patient in and the patient was triaged. EMS waited 20 minutes and EMS decided they were not going to wait any longer, so they rolled her/him out on the stretcher and put her/him in the ambulance and took her/him to (Hospital B identified)..." EI # 4 was asked if the risks and benefits of having a medical screening exam (MSE) explained to the patient and/or caregiver who intends to LWBS? EI # 4 stated, "if we knew they were leaving it is usually written in the disposition of the flow sheet."

An interview was conducted via phone on 8/21/2020 at 1:10 PM with EI # 5, Paramedic, who verbalized PI # 1 was found to have a low B/P, altered mental status with mild confusion to circumstance on assessment, low O2 saturation, an intravenous line (IV) was initiated to administer lV fluids to see if that was the problem with the low BP. EI # 5 verbalized during the transfer to Springhill, PI # 1 assessment findings "did not change much" but the Oxygen saturation did increase to "70's to 80's." EI # 5 stated, "...was giving... IV fluids to increase...BP. We only got about 300 ml (milliliters) in her/him which is not as much as we would have liked. At Springhill she/he was on our stretcher and we got her/him out of the ambulance and her/his BP was 70 ' s over 40 ' s...We took the patient in and ...Springhill...said we needed to roll around the corner to wait. We rolled the patient around the corner and kept her/him on our monitor and O2 the entire time. EI # 5 was then asked, the ambulance run report documented the patient was placed on 3 Liters of Oxygen but later the oxygen saturations were on room air. Was the oxygen removed? No not to my knowledge...I would bet...made a mistake and hit the wrong thing. There is no way (second EMS staff identified) took her/him off... even had her/him on the portable O2 tank when we took her/him off the ambulance. EI # 5 was asked, do you know approximately what time you left Springhill? "We left at 1842 (6:42 PM)." EI # 5 was asked, what happened while waiting at Springhill? "We monitored her/him and kept the O2 on...continuously, admissions came and verified name and put name band on her/him. The ER (Emergency Room) staff...got a base line VS (vital signs)... (second EMS staff identified) concentrated on the patient because her/his b/p was still 70 ' s/40 ' s. (second EMS staff identified) told the young lady/gentleman who took the base line. I thought this would help out the patient would get back faster since BP continued to be low..." EI # 5 verbalized he/she contacted the EMS supervisors "at about 7:30 PM we had been there 48 minutes", ...explained what was going on..." EI # 5 verbalized he/she was "asked if the patient and/or family was willing to go somewhere else...I called the daughter/son and explained the situation and ...I told her... (Hospital B, receiving hospital) was available. The daughter/son thanked me, and I called dispatch told them I talked to the family and we were leaving Springhill to go to Hospital B as a Code 3 (lights and siren). We headed to Hospital B...arrived at Hospital B at 2005 (8:05 PM) and they were already waiting on us when we arrived. They got her/him a bed right away and gave immediate attention." EI # 5 was asked did you notify anyone you were leaving Springhill? EI # 5 responded, "...told the young lady/gentleman who took the VS... I remember saying we were leaving and going to (Hospital B identified). ...I said out loud we were going to (Hospital B identified)." EI # 5 was asked, did the Springhill staff person try to communicate with the patient after being told you were leaving? EI # 5 responded, "no...No one talked to the patient except when the ID (identification) band was put on her/him."

An interview was conducted via phone on 8/21/2020 at 2:00 PM with EI # 6, ED Nurse Manger. EI # 6 was asked, if the ED does not have an available bed for a patient brought in by ambulance what is the facility practice/policy? EI # 6 stated, "the patient remains on the stretcher with EMS and sometimes we do labs until a bed is available." EI # 6 was then asked if she/he recalled PI # 1. EI # 6 stated, "I was not working then but my nurse called the next morning to give me a heads up. (EI # 3, RN identified) was the nurse and...said ER was full and waiting on a bed...and EMS got mad and took the patient to another facility." EI # 6 was asked if the nurse identified how she/he was aware the EMS was leaving? EI # 6 stated, "she/he (nurse) stepped out of ER to triage another patient and she saw then loading her up, so...asked them (EMS)." EI # 6 was asked, what the facilities policy was when a patient and/or caregiver lets a staff member know they are intending to LWBS? EI # 6 stated, "yes, we would tell the patient the risks and benefits of leaving without being seen and document it in the nurse notes in the ED flow sheet." EI # 6 was asked, do you recall if the risks/benefits of having a MSE were explained to PI # 1? EI # 6 sated, "no, (employee identified) did not know she/he was leaving. She/He was already being loaded onto the ambulance."

An interview was conducted via phone on 8/21/2020 at 3:15 PM with EI # 7, Paramedic. EI # 7 was asked to describe the circumstances surround PI # 1. EI # 7 stated, "generalized weakness and a low BP and low 02 Sat. We transported to Springhill and we had an extended stay there. After contacting the family...we decided to transport her/him to Hospital B." EI # 7 was asked what happened after arrival at Springhill? EI # 7 stated, "arrived in the ED and brought the patient to the nurse ' s desk. They triaged the patient and got VS and registered the patient. When we arrived this time, no one contacted us we were just told abruptly to go back to the ambulance area and we continued to monitor the patient. My partner delivered the information the admissions. The nurse came to get VS on the patient and a brief summary of the patient....registration placed a band on the patient and we received a paper from the hospital to say she/he was registered. After that we waited about 50 to 55 minutes and there was no other contact." EI # 7 was asked what prompted you to call your supervisors? EI # 7 respond, "after 60 minutes or 1 hour we have the right to explain to the patient she/he could go to another facility. What we could and did provide while
waiting. We helped her/him some, but we recognized she/he was deteriorating, and...needed higher level of care she/he was not receiving, so we contacted higher ups and determined she/he needed to be transported elsewhere...I told my patient and she/he consented and... the daughter/son who consented. So, we took our patient and loaded her/him up in the ambulance." EI # 7 was asked if PI # 1 was able to comprehend transferring to another facility? EI # 7 stated, PI # 1 "...was presenting a low-level alteration and...before
transfer she/he was able to understand why she/he was being transferred." EI # 7 was asked if PI # 1 was on oxygen for the duration of the EMS transport? EI # 7, "yes..." EI # 7 was asked, if a staff member at Springhill ED attempted to speak or spoke with PI # 1 following being told the EMS was transporting the patient to Hospital B? EI # 7 stated, "the only interaction with staff at Springhill was when she/he was triaged and registered. One other ambulance came in toward the time we were leaving and at one time there were 3 ambulances in the corner. The staff just did the initial VS on the others and they had to walk directly past us to go do the VS and then return past us to the nurse ' s station."

An interview was conducted via phone on 8/31/2020 at 3:45 PM with EI # 1 who was asked to provide the ED Sepsis Protocol. EI # 1 verbalized she/he would have the protocol emailed to the surveyor. On 8/31/2020 at 11:30 AM the surveyor received the following ED Sepsis Triage orders for the facility ED Sepsis Protocol via email from EI # 2, Chief Nursing Officer:
Lab: Blood Culture, Completed Blood Count (CBC), Blood Gas/Lactate, Comprehensive Metabolic Panel (CMP)
IV (Intravenous) orders: Sodium Chloride 0.9% Bolus volume 1905 rate 999 ml (milliliters)/hr (hour), Norepinephrine Drip Volume 8 Rate 3.8 ml/hr
Nursing Orders: Notify Admitting MD (Medical Doctor)...

An interview was conducted via email on 9/1/2020 at 2:48 PM with EI # 2 who was asked, on the order set protocols for triage, would each of these orders be placed following the completion of triage by the nurse? EI # 2 stated, "the triage nurse would initiate the order set upon completion of triage..."

2. PI # 2 presented to the ED on 6/12/2020 at 12:50 AM. Review of the MR revealed:

Review of the Physician ER Note dated 6/12/2020 at 1:26 AM revealed the following assessment: "Chief complaint: psychosis...PD (police department) was called to Burger King where patient was reportedly 'walking around.' PD noted pt (patient) to be yelling and belligerent, so EMS (Emergency Medical Services) was called. Pt complained to EMS that he/she had leg pain from walking. On arrival to ER, pt was reportedly yelling and spitting. Security was involved and PD tazed patient. On my evaluation, he/she now c/o (complains of) 'pain all over.' He/She refuses to answer further questions. 'I plead the fifth' to most questions. Pt later notes he/she has previously been at (Psychiatric (Psych) Hospital identified) and was previously taking 'some shot' for an unknown diagnosis....Psych: reported hallucinations... Neuro (Neurological): oriented to person only. speech clear but confused. moves all extremities w/ (with) good strength. Psych: rambling incoherently, intermittent outbursts...The differential diagnosis for the patient's symptoms includes but is not limited to 1. psychosis 2. drug intoxication 3. malingering... Final Diagnostic Impression: Acute Psychosis, Chronic Renal Disease..."

Further review of the Physician ER Note dated 6/12/2020 revealed the following documentation of follow up assessments (recheck) without a time documented: "pt more cooperative once in ED bed. Remains poor historian and does not appropriately answer questions....d/w (discussed with)...Hospitalist NP (Nurse Practitioner) re (in reference of) admission."

Review of the ED Assessment Flowsheets dated 6/12/2020 revealed the following documentation:

At 1:30 AM, documentation of "Nursing Note: Upon arrival to ED, pt becomes increasingly agitated and combative towards nursing staff. Pt begins attempting to spit on triage nurse and surrounding nursing staff. Pt begins to cuss out nursing staff, 'fuck you bitch. I will kill you. Come closer and just see,' pt instructed that he can't talk that way to the nursing staff. Pt continues to be combative and attempting to hurt nursing staff. This RN (Registered Nurse) calls...security to triage to assess situation. Pt begins cussing at...with hospital security. 'Fuck you, you think your something. I will fucking kill you bitch, I will kill you,' ...security informs this RN to call 911 for police back up."

At 1:31 AM, documentation of "Nursing note: ...EMT (Emergency Medical Technician) and Medic (Paramedic) remove patient via stretcher from triage area to a more secluded part of the ER as to minimize threats to nursing staff. (Facility Security guard identified) with security and two other security officer(s) escort the patient and (EMS company identified) team to await police back up in the ambulance bay. Pt still being combative and threating all staff members nearby at this time", neurological assessment findings of alert, MAEW (Moves All Extremities Well), oriented to person, confused, agitated.

At 1:32 AM, documentation of "Nursing note: patient arrived to ED screaming, cussing, and spitting. Patient erratic and agitated at staff. Patient stated, 'I will kill you bitch.' Making inappropriate comments to everybody around and acting like he/she is spitting at triage nurse. (Police Department Identified) on scene. Patient was tased, (Police Department and EMS company identified) and ED staff witnessed situation."

At 1:35 AM, documentation of "Nursing note: (police department identified) arrives on scene to assess situation. Pt is removed from stretcher and handcuffed by two...officers. Pt is still being uncooperative and combative. Pt states, 'hear ye, hear ye, I will fucking kill you.' Pt restrained per...police dept (department) at this time."

At 1:36 AM, documentation of "Nursing note: Pt becoming increasingly agitated at this time and is attempting to break free of (police department identified) custody....officers taze patient. Vitals signs taken after and are stable."

At 1:37 AM, documentation of "Nursing note: Pt brought inside for MD assessment and treatment."

At 1:45 AM, documentation of the MD was at bedside and an intravenous (IV) catheter line was placed in the right upper arm. The nurse documented instructing the patient to call for problems with IV and "...pt pulls out penis and states, 'yeah you like that. You looking at my balls. I bet you are and you want that don't you.' Pt instructed not to talk to nursing staff that way. Pt stays silent."

Review of the Laboratory Results Report dated 6/12/2020 at 1:47 AM revealed documentation of the following abnormal lab results: White Blood count 15.4, Red Blood Cell Count 5.66, Hematocrit 49.6, Absolute Neutrophils 10.01, Absolute Lymphocytes 3.85, Absolute Monocytes 1.18, BUN 30, Creatine, Blood 1.90, Albumin, Blood 5.2, urine Protein +1, trace amount of urine Ketones, few urine mucous, 3-5 urine hyaline casts, Creatine phosphokinase (CPK) 352, Urine drug screen positive for amphetamines and THC (Cannabinoid).

Review of the ED Assessment Flowsheet dated 6/12/2020 at 2:33 AM revealed vital signs of temperature 98.3, pulse 94, respirations 18, oxygen saturation 94%, and blood pressure 122/83.

Review of the ED Nursing Triage Note dated 6/12/2020 at 2:35 AM revealed documentation of the chief complaint as "altered mental status...EMS states patient took unknown substance and is altered now. Pt states they are a psych patient." Associated symptoms included "agitated, confusion." The assessment finding were documented as "...Glasgow Coma Scale: Verbal response: Disoriented...Neurological assessment: alert, MAEW, orient to person, confused, agitated..."

Review of the ED Assessment Flowsheet dated 6/12/2020 at 3:08 AM revealed documentation of "Nursing note: pt resting in bed occasionally waking up and yelling out curse words..." and the patients was stable.

Review of the ED Assessment Flowsheet dated 6/12/2020 at 4:04 AM revealed documentation of "Nursing note: pt laying in bed awake. Calm. Given sheet to cover self. Vitally stable..."

Review of the Physician ER Note dated 6/12/2020 at 5:45 AM revealed the following recheck documentation: "pt again became agitated with violent outbursts and threats against staff, he/she was placed in physical restraints, broke through them and had to be chemically restrained, first w/ Haldol/Benadryl. He/She then ripped out IV and was given IM (intramuscular) Ketamine. Pt appears acutely psychotic...there is renal disease of unclear duration. Do not suspect acute medical illness. Pt is stable for psych evaluation."

Review of the Medication Administration Record dated 6/12/2020 revealed at 6:10 AM, Haldol 5 mg (milligrams) and Benadryl 50 mg were administered IV to the patient and at 6:18 AM Ketamine 400 mg was administered IM to the patient.

Further review of the ED Assessment Flowsheet dated 6/12/2020 revealed:

At 6:30 AM, documentation of "Nursing note: ...pt medicated as per EMAR (electronic medical record). Tolerated well...pt combative and threatening us saying 'I will beat your ass...'

At 9:33 AM, documentation of "Nursing note: patient asleep in bed..."

At 9:48 AM, documentation of "Nursing note: patient found walking in the hallway with restraints still around wrists and ankles. Security called and patient back to room, into restraints and IV restarted..."

At 9:58 AM, documentation of "Nursing note: Spoke with...NP. Diet order received."

At 10:00 AM, documentation of "Nursing note: meal tray ordered."

At 10:07 AM, documentation of "Nursing note: patient screaming 'I want fucking food!!!!!' I informed patient that we have already ordered his/her meal tray. Patient broke bilateral wrist restraints. Security and department assistant manager called. Hospitalist called and on the way down. Patient stating that he/she wants to leave. Patient alert and oriented x (times) 4."

At 10:13 AM, documentation of "Nursing note: Police and security at bedside. Patient signed AMA (against medical advice) form. Hospitalist NP at bedside. IV removed. Shoes given to patient. Escorted out by security" with a discharge disposition documented as "...pt wheeled to ramp; pt left AMA. Escorted out by security..."

Review of the MR revealed the patient did not receive an examination by a psychiatrist and the Hospitalist concluded the patient being alert and oriented x 4 was enough to demonstrate capacity to sign out AMA without a reassessment of the patient's previous homicidal statements and agitation which continued at the time of discharge by screaming "I want fucking food." The patient was permitted to leave prior to the necessary psychiatric and renal insufficiency workups to stabilize the Emergency Medical Condition.



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2. PI # 14 presented to the SMH ED on 5/26/2020 at 1:39 PM by private vehicle.

Review of the MR revealed at 2:01 PM the patient was triaged and assessed by EI # 12, RN. PI # 14 complained of back pain from a MVC (Motor Vehicle Collision).

Vital signs (VS) were taken and temperature was 97.5, Pulse 89 respirations 18 Oxygen Saturation 100% on room air. The pain assessment was documented as comfortably manageable. PI # 14 was alert and oriented to person, place and time and ambulatory.

Further review of the MR revealed at 2:55 PM, EI # 12 documented a note stating "PI # 14 asked the security guard for a diaper and the security guard called Labor and Delivery (L&D). L&D did not have the size diaper needed. PI # 14 began to yell and take pictures of the security guard stating she was going to tell the news we did not give her a diaper. The patient left before being seen by an MD. The patient was ambulatory to her vehicle and stood beside the vehicle and continued to take pictures of the security officers".

At 2:55 PM, EI # 12 documented patient left the ED without being seen by the MD (Medical Doctor.)

There was no documentation the patient was informed of the risks of refusal of MSE and treatment and of the potential benefits and no documentation steps were taken to secure written refusal with the patient's and/or representatives signature in the MR.

An interview was conducted on 8/19/2020 at 1:47 PM with EI # 1 who stated "There was no further documentation and the patient had not been seen by a healthcare provider before the patient eloped. The physician did not get the opportunity to explain the risks and benefits"

An interview was conducted on 9/1/2020 at 2:35 PM with EI # 12, RN who was asked in your nursing documentation you noted at 2:55 PM you documented the patient requested a diaper from security and after the patient was told L&D did not have a diaper the patient began to yell, take pictures, and left ambulatory while taking pictures. Can you tell me how you found out about the previous? EI # 12 stated, "Security came to me and told me about the diaper and labor and delivery did not have one to fit. I saw her/him standing in the parking lot with a child on her/his hip and the phone out." EI # 12 was asked were you aware at that time PI # 14 was leaving? "Yes, and she/he was saying she/he was telling the news we would not give her/him a diaper. She/He was all the way out in the parking lot and did not try to come back." EI # 12 was asked how were you made aware of the patient leaving? "Security came and got me and told me she/he left. I went to assess the situation and she/he was way out in the parking lot already she/he was too far out." EI # 12 was asked did you attempt to tell PI # 14 about the LWBS risks and benefits? EI # 12 stated, "I don't remember talking with her/him, she/he was already way out in the parking lot. EI # 12 was asked what is the facilities policy when a patient and/or caregiver lets a staff member know they are intending to LWBS? "We go talk to the patient and find out why they want to leave, see if we can resolve the issue and assess the situation to improve what is wrong. This patient was way out in the parking lot and I could not leave the ED to go out there."

Based on review of the facility policy and procedure, transferring Hospital C and receiving Hospital D medical records (MR), facility Patient Transfer Request Tracking Form, facility General Medical Surgical post-operative floor (floor 2200) bed census, Emergency Department (ED) and floor 2200 staffing house census and interviews, it was determined Springhill Memorial Hospital (SMH, Hospital A) failed to ensure the on-call physician for Neurosurgery accepted a patient with cervical spine fracture, when contacted by the transferring hospital (Hospital C) which had no available Neurosurgical consult, when SMH had the capability and capacity to treat the patient.

This deficient practice affected 1 of 4 declined transfer request reviewed, including Patient Identifier (PI) # 24.

Findings include:

Policy: Process For Handling and Documenting Transfer Requests
Revised: 3/12

Statement of Purpose:

In order to properly handle and track transfer requests to Springhill Medical Center and perform on-going quality assurance for appropriateness, the House Supervisor is responsible for documenting transfer requests using a transfer request form.

Procedure:

1. When a request is received for transfer of a patient from another hospital to Springhill Medical Center, the House Supervisor will record on the Transfer Request Form the information provided by the requesting facility about the patient and need for the transfer.

2. The House Supervisor will validate the information with the representative from the requesting hospital. The House Supervisor will also advise the individual that there may be additional requests for medical information about the patient, such as physician notes, lab work, radiology reports, etc, if requested by the ER (Emergency Room) physician or on-call physicians.

3. The House Supervisor will review the information to determine whether the transfer is accepted or denied. The House Supervisor may consult with the ER physician and/or on-call physician(s) to assist in determining whether the transfer will be accepted or refused that will be reviewed by case management.

4. In compliance with the Emergency Medical Treatment and Labor Act (EMTALA), as long as Springhill has the capacity to treat, including appropriate specialists, personnel, beds, and equipment, Springhill will accept emergency department patients who have an emergency medical condition and who require Springhill ' s specialized capabilities to stabilize the patients ' emergency medical condition. If there is doubt or disagreement, the administrator-on-call can be involved to help facilitate the process.

5. The House Supervisor is responsible for contacting the requesting hospital and accepting or refusing the transfer.

Hospital C, Transferring Hospital documentation:

Review of the MR dated 5/26/2020 revealed:

PI # 24 presented to Hospital C ED at 4:50 AM with a chief complaint of pain to neck, which was worse with movement due to tripping on his/her flip flops the prior evening and falling face first onto the brick patio.

At 4:52 AM a triage was performed which revealed the following vital signs and assessment findings: Blood pressure (BP) 102/87, Pulse (P) 121, Respirations (R) 18, Temperature (T) 97.6, Pain scale 6/10. Sharp pain to neck with limited Range of Motion (ROM), bruising to the orbits, and small laceration to forehead.

At 4:58 AM the ED physician assessed PI # 24, which revealed no numbness or tingling in extremities and the patient was moving normally except for tightness in the neck.

At 5:19 AM a Computerized Tomography (CT) Scan of the cervical spine was performed and revealed acute non-displaced fractures of the posterior arch of C 1 (Cervical 1) bilaterally and an acute type 2 dens fracture.

At 5:55 AM, the ED physician documented SMH, Hospital A, was contacted to request transfer to a higher level of care due to Hospital C not having neurosurgical consult for a C 1 fracture.

At 5:57 AM, the ED physician documented EI # 8, Neurosurgeon would like for the patient to be transferred to SMH, Hospital A.

At 6:48 AM, The ED physician documented "patient is accepted" at SMH.

At 7:15 AM, The ED nurse documented EI # 11, nursing supervisor at SMH, was contacted to inquire about the continued wait. He/she verbalized EI # 8, SMH on-call neurosurgery physician, was contacted "...and informed that (his/her) administrator does not allow transfer with (EI # 8) accepting from ED to ED."

At 9:09 AM, the ED supervisor documented a call to EI # 9, Nursing Supervisor at SMH, and was told he/she was trying to find an accepting physician.

At 9:25 AM, the ED supervisor documented a call to EI # 8's office to inquire about the delay in transfer and was told the office staff would contact SMH to find out what could be done.

At 10:14 AM, the ED supervisor at Hospital C documented a call from EI # 8's office staff who verbalized SMH does not accept ED to ED transfers and they will not be able to accept patient anymore.

At 10:46 AM, the ED supervisor documented a call to Hospital D, receiving hospital, who accepted the patient as an ED to ED transfer.

Review of the Transfer to Acute Facility Summary-Consent revealed the patient was transferred at 12:25 PM. PI # 24 was discharged from Hospital C and transported via ambulance to Hospital D.

Hospital A, SMH documentation:

Review of the Patient Transfer Request Tracking Form revealed:

At 6:10 AM EI # 11, Nursing Supervisor, documented a call was received from Hospital C, transferring hospital, with a request to transfer PI # 24 with a diagnosis of a Cervical Spine fracture related to a fall.

At 6:49 AM EI # 11 documented he/she contacted EI # 8, on-call neurosurgery for SMH.

At 7:05 AM EI # 11 documented EI # 8 was not accepting the transfer. EI # 8 wanted the patient PI # 24 to be an ED to ED transfer and have the ED doctors see and evaluate. EI # 11 documented he/she contacted EI # 2, SMH Chief Nursing Officer, and was informed SMH ED doctors do not see ED to ER transfers.

At 9:05 AM EI # 9, Nursing Supervisor, documented EI # 8's office was called. There was no documentation of the conversation.

At 9:07 AM EI # 9 documented a call was received from Hospital C at 9:07 AM requesting an updated and EI # 9 responded with documented he/she was working on obtaining an accepting physician.

At 9:19 AM EI # 9 documented a call to EI # 8's nurse. There was no documentation of the conversation.

At 10:04 AM EI # 9, Nursing Supervisor, documented he/she spoke with EI # 8's nurse who stated EI # 8 again refuses to accept patient PI # 24 as a direct admit/transfer. Hospital C was to send the patient elsewhere.

Review of the bed census dated 5/26/2020 for SMH Unit 2200, General medical surgical post-op, which per EI # 1, Director of Quality Improvement/Risk Management, would have been where PI # 24 was admitted, revealed Unit 2200 had 1 of 12 beds available at 6:10 AM and continued to have 1 bed available when the transfer request was declined at 10:05 AM.

Review of the hospital staffing schedules for unit 2200 revealed the floor had 2 nurses, 2 care techs, and 1 unit secretary on 5/26/2020, which per EI # 1 on 8/ 27 /2020 at 3:06 PM via email was sufficient staffing.

Review of the ED bed census report dated 5/26/2020 revealed the ED had 23 open beds at 6:00 AM, 18 open beds at 7:00 AM, and 16 open beds at 10:00 AM.

Review of the ED staffing schedule dated 5/26/2020 revealed the ED had 6 nurses, 1 care technician, and 1 secretary on 5/26/2020,


Ambulance Run Report documentation:

Review of the Ambulance Run Report dated 5/26/2020 revealed:

The ambulance was dispatched to Hospital C, transferring hospital at 11:23 AM.

At 12:17 PM, the ambulance arrived at Hospital C and documented the following assessment findings: Patient alert, sitting upright in bed wearing hard cervical collar. The vital signs were as follows; BP 110/69, P 84, R 20, Pulse oximetry 93 %, pain scale 3/10.

At 12:30 PM, the ambulance left Hospital C enroute to Hospital D, receiving hospital.

At 1:29 PM, the ambulance documented arrival at Hospital D.

Hospital D, Receiving Hospital documentation:

Review of the MR dated 5/26/2020 revealed:

PI # 24 arrived via ambulance at 1:25 PM with a chief complaint of fall.

At 1:27 PM, a triage assessment was completed and revealed; BP 98/76, P 87, R 16, T 98.6, Pulse oximetry 96%.

At 1:27 PM, the ED physician assessed PI # 24 and documented range of motion and sensation was normal throughout.

CT scans of the head, neck, chest, abdomen, and pelvis were performed at 3:16 PM with the impression documented as Cholelithiasis and Cervical Spine fracture of C1 and C2.

At 3:41 PM the ED physician consulted Neurosurgery who recommended at 3:41 PM to maintain rigid cervical collar for 12 weeks and to discharge home with outpatient follow up.

At 6:07 PM PI # 24 was discharged home with diagnosis of Cholelithiasis and Cervical Spine Fracture-stable. Instructions to follow up with neurosurgery on 6/23/20.

Interviews:

An interview was conducted via phone with EI # 4, ED Director, on 8/20/2020 at 4:15 PM who stated SMH generally does not accept ED to ED transfers. EI # 4 further stated "if we accept the transfer, then we would wait for the other hospital to call report. The MD who requested ED to ED transfer that MD would have to accept the patient. If he/she does not, then that we would have to have an accepting physician." When asked what is SMH responsibility under EMTALA laws for when a hospital requests a transfer into SMH EI # 2 responded "to find an accepting physician."

An interview was conducted via phone with EI # 6, ED Nurse Manager, on 8/21/2020 at 2:00 PM. EI # 6 was asked what was the facility's policy for another hospital ED requesting a transfer into the facility? EI # 6 responded "it goes through the house supervisor and need an accepting doctor. We do not do ED to ED transfers."

An interview was conducted via phone with EI # 8, Neurosurgeon, on 8/24/2020 at 1:00 PM. EI # 8 was asked how do you decide to accept or decline the transfer? EI # 8 responded "depends on ...the facilities capability to handle situation. Patient needs to be evaluated first ...We rarely accept general medical patients to ED. When EI # 8 was asked what he remembered about PI # 24 transfer request he/she responded "I agreed to consult on patient and agreed to see patient and agreed to send them to supervisor to see if hospitalist decided to accept patient. I do not know what the hospitalist decided."

An interview was conducted via phone on 8/27/2020 at 2:45 PM with EI # 9, Supervisor, who was asked if SMH does ED to ED transfers. EI # 9 responded, "no, we do not because the patients get double billed for ED services. When asked who told you the facility does not accept ED to ED transfers, EI # 9 responded "its just always been that way. I always tell people we do not do ED to ED transfers."

An interview was conducted via phone on 8/27/2020 at 4:25 PM with EI # 2, Chief Nursing Officer. EI # 2 was asked what was the facility policy on accepting ED to ED transfers EI # 2 responded, "we accept the patient according to availability and ability to accept the patient. If the MD does refuse, I have to explain to the MD it is the facility's responsibility to accept the patient." When asked why PI # 24 was not accepted from Hospital C, EI # 2 responded, (he/she) "was a C spine fracture and I do not know why he/she wouldn't accept. We do ED to ED transfers."

An interview was conducted via email with EI # 1, Director of Quality Management, Risk Management, on 8/27/2020 at 3:06 PM who confirmed SMH was not on diversion on 5/26/2020, Unit 2200 and the ED had sufficient staffing, SMH did have the capability and capacity to receive PI # 24 for transfer and does accept ED to ED transfers.