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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for four of 20 patients (Patient 1, Patient 4, Patient 18, Patient 20) when:

1. Patient 1 did not receive an appropriate medical screen exam or stabilizing measures. Patient (Pt) 1 was admitted to the Emergency Department (ED) under 5150 hold (Welfare and Institutions code permitting 72-hour, involuntary detainment/hold of a patient who is danger to self, danger to others and/or gravely disabled, and are initiated by behavioral health professionals) on 9/11/23 at 7:17 a.m. for suicidal ideations. During the ED visit, Pt 1 was cleared of the 5150 hold but laboratory results for potassium (K-a mineral that is critical to the function of nerve and muscle cells (normal potassium levels are 3.5 to 5.2) resulted in a critical "low" value (a laboratory value that, if not acted upon quickly, may result in patient harm) of 2.9. Pt 1 left the hospital without being medically cleared and there was no staff follow up on the abnormal laboratory results despite having emergency contacts on file. Pt 1 was brought back by ambulance to the ED after having a fall on 9/12/23 at 12:50 p.m., approximately 18 hours after the 9/11/23 visit. Pt 1's behavior was noted to be erratic and a danger to himself and others. No neurological assessment or Columbia Suicide Severity Rating (CSSR- risk assessment tool that uses a series of simple, plain-language questions that anyone can ask. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs) were completed. A computed tomography (CT scan- used by ED physicians to view internal body parts and get an immediate assessment of a patient's condition) to rule out a medical emergency was not completed until 10:59 p.m., 10 hours after admission to the ED. (Refer to A2406)


2. Stabilizing measures were not provided to Patient 4. Patient 4 was brought to the Emergency Department (ED) on 5/24/23 by ambulance with a chief complaint of 9/10 (severe pain) pain on the "Numeric Pain Scale" [a simple pain scale that grades pain levels from 0 (no pain), 1,2, and 3 (mild), 4,5, and 6 (moderate), 7,8, and 9 (severe) to 10 (worst pain possible)] to her neck, left knee, and left foot after sustaining a fall at home. There was no documented evidence that Pt 4's pain (rated 9/10) was treated during the ED visit, vital signs (blood pressure [BP], heart rate [HR], respirations [R], temperature [T], and oxygen saturation [O2sats]) were not taken and pain level was not reassessed prior to Patient 4 being discharged home on 5/24/23. (Refer to A2407)

3. Patient 18 and Patient 20 were transferred to other facilities without written requests for transfer indicating the reason for, risks of, and benefits of the transfer, as well as documentation the patient consent or refusal of transfer. (refer to A2409)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for one of 20 patients (Patient 1) when Patient 1 was admitted to the Emergency Department (ED) under a 5150 hold (Welfare and Institutions code permitting 72-hour, involuntary detainment/hold of a patient who is danger to self, danger to others and/or gravely disabled, and are initiated by behavioral health professionals) on 9/11/23 at 7:17 a.m. for suicidal ideations. Although cleared of the psychiatric emergency by tele ("virtual visit" with a health care provider, through a phone call or video chat) mental health, Patient 1's laboratory results for potassium (K-a mineral that is critical to the function of nerve and muscle cells (normal potassium levels are 3.5 to 5.2) were noted to be 2.9. Patient 1 left the hospital in an unknown condition and there was no documented follow up on the low K level. Staff did not follow up with Patient 1 on the abnormal laboratory results despite having emergency contacts on file. Patient 1 was brought back by ambulance to the ED after having a fall and "bumping his head" on 9/12/23 at 12:50 p.m., approximately 18 hours after the 9/11/23 visit. Patient 1 was noted to exhibit unstable behavior, increased agitation, and aggressiveness and was placed on restraints (action or procedure that restricts freedom of movement of all or part of a person's body). A complete work up for an emergency medical condition was not done and determination of stabilizing measures not considered.

These failures resulted in an incomplete Medical Screening Exam (MSE), a delay in determining whether an emergency condition existed, and stabilization of Pt 1. These failures contributed to Pt 1 leaving the ED area unattended and fell from an elevated area of the hospital, sustaining injuries that required transport to a local trauma hospital.

Findings:

During a review of Patient 1's "ED Physician Notes," dated 9/11/23 at 8:24 a.m., the ED note indicated," ... [Patient 1] was brought to the ED by ambulance to be evaluated for suicidal ideation ... reports that he wants to commit suicide by cutting himself or "death by bullet" ... Laboratory studies in the emergency room: toxicology [a test conducted to check for presence of illicit substances in the body] negative serum potassium was low at 2.8 ... IV [intravenous- in a vein] therapy with KCL [potassium chloride-medication used to treat low levels of potassium] 10 mEq [milliequivalents- measure of fluid volume] x 2 and KCL 10 [milligrams- unit of measure] p.o. [by mouth] was ordered ... Diagnosis this visit ... profound hypokalemia (low level of potassium) ... Patient was signed out to on-coming physician ... I discussed with emergency room [Emergency Department Registered Nurse] we did need to complete infusion of potassium prior to patient medical clearance ..."

During a review of Patient 1's "Tele Mental Health Consult Note", dated 9/11/23, at 5:41 p.m., the note indicated, " ... [Patient 1's] Behavior: cooperative ...Thought Process: linear, logical and goal directed ... no audiovisual hallucinations [seeing or hearing things that are not there] or overt paranoia [thinking or feeling like you are being threatened in some way]. Perception: Negative for auditory hallucinations [hearing voices], visual hallucinations. Orientation: Alert and oriented to time, place, person, and situation. Memory: Intact as evidenced by recollection of recent and remote events... Discharge: in my opinion; Outpatient care is the most appropriate and least restrictive option for this patient. Based on available evidence; This condition CAN be safely treated at a lower level of care..."

During a review of Patient 1's "ED Physician Notes," dated 9/11/23 at 6:01 p.m., the ED note indicated," ... Signed out patient pending potassium for med clearance and psychiatry. Psychiatry has evaluated and they do not believe he needs a hold and I agree. Awaiting repeat BMP [a blood test that measures eight different substances in your blood, including potassium level] and disposition ..."

During a review of Pt 1's "ED Nursing Note," dated 9/11/23, at 6:09 p.m., the note indicated, "... LEFT BEFORE PAPERWORK. EXPLAINED TO [Patient 1] THAT HE NEEDED TO WAIT UNTIL HIS LAB WAS BACK. [Patient 1] STATES HE JUST WANTED TO GO. EXPLAINED THAT WE DID NOT KNOW IF HIS K [potassium] WAS OK. STATED HE FEELS FINE GOT DRESSED AND LEFT..." The last set of vital signs (blood pressure [BP], heart rate [HR], respirations [R], temperature [T], and oxygen saturation [O2sats]) documented prior to Pt 1 leaving were BP 137/80, HR 80, R 18, 98% O2sats on room air (RA).

During a review of Patient 1's "[Laboratory] Result Details", dated 9/11/23, the document indicated, " ... Patient name and Critical test results read back for verification. Potassium critical value called to: [EDRN 1] ... at 09/11/2023 [6:43 p.m.] ...Potassium 2.9 mmol/L [millimoles per liter- number of molecules in the volume of fluid; normal range 3.5 mmol/L to 5.5mmol/l] ..." There was no documented evidence the ED physician was notified of the critical lab value. There was no evidence the hospital followed up with Patient 1 or his authorized emergency contact recorded in Patient 1's electronic medical record (EMR- patient health record in digital form).

During review of Patient 1's ambulance run sheet (medical record for ambulance services) document "Patient Care Record," dated 9/12/23, the document indicated, " ... Onset time 12:00 [pm] ... Chief Complaint ... Head Pain ... Duration ... 1 Hours ... Signs & Symptoms ... Hallucinations(Primary) ... Acute pain due to trauma ... Low back pain ... Strange and inexplicable behavior ... Injury ... Falls- Slip, trip, stumble ... 3 ft ... Mechanism of injury ... Blunt [any situation in which the victim's head collides with a surface or object which can easily result in a concussion, skull fracture, and/or penetrating injury that physically injures the brain] ... 12:38 [pm] BP [blood pressure] 174/ 123 ... Pulse [heart rate] 129 ... 12:51 [pm] BP 157/107 ... Pulse 138 ... Patient complains of lower back pain ... Patient ambulated into the ambulance ... Patient stated that he was throwing a football in the air when he tripped and fell. Patient denied LOC [loss of consciousness] but stated he hit his head and is now complaining of head pain and lower back pain. Patient requested transport to the hospital. Patient was transported to [name of hospital]. During transport patient was acting strange and appeared to be having hallucinations. Patient was talking and laughing to himself hysterically. Patient also began to fight the air in front of him. After arrival to the hospital patient was sent to the psych [psychiatric] ward in back of the emergency room. A full report was given to [Emergency Department Registered Nurse (EDRN) 3] ... At Destination 12:48 [p.m.] ..."

During a review of Patient 1's "ED Physician Notes," dated 9/12/23 at 1:38 p.m., the ED note indicated, " ... per EMS [emergency medical services] pt [Pt 1] stated he bumped his head [status post] throwing a football and falling ... Pt is laughing to himself and reaching for things, responding to internal stimuli. Denies [suicidal ideation (thinking about or planning suicide)] ... BP: 116/106 ... HR: 119, R: 20 ... Temperature (T) ... 98.9 ... GEN [general appearance]: erratic behavior ... Patient comes in secondary to erratic behavior. Patient is aggressive in talking to himself in the walls. Basic labs were ordered. Patient had to be treated with [olanzapine-antipsychotic that helps regulate mood, behaviors, and thoughts] IM [intramuscular- injected into a muscle], [lorazepam-antianxiety medication] and [diphenhydramine- sedating antihistamine] IM. Patient had to be placed on restraints (action or procedure that restricts freedom of movement of all or part of a person's body). Patient continues to have erratic behavior treated with [lorazepam] IM. Patients labs returned with low potassium and treated with potassium chloride. Otherwise labs returned with no acute significant findings. Patient is medically cleared discharge will be pending the psychiatric evaluation. Escalation of care considered: No ... Medical clearance for psychiatric evaluation ... 09/12/2023 [5:46 p.m.] ... Medically cleared. Awaiting psychiatric evaluation ..." There was no documented evidence in Patient 1's EMR that a neurological assessment was performed by the ED physician or nurse assigned to Patient 1.

During a review of Patient 1's "ED Nursing Note", dated 9/12/23, at 2:16 p.m., the note indicated, " ... At [2 p.m.] pt [Patient 1] became agitated and while laying on the floor grabbed onto a sitter's [in-room trained staff for patients that need supervision/observation] leg and would not let go. Security and sitters then had to physically restrain pt [due to] not letting go of sitter. [Patient] combative and not redirecting. [Patient] assisted to standing and then placed back in gurney and restrained [with] restraints. [Patient] medicated for agitation per MD order ..."

During a review of Patient 1's "ED Nursing Note", dated 9/12/23, at 4:09 p.m., the note indicated, " ... [Patient] still agitated and fidgeting w/ his restraints..."

During a review of Patient 1's "ED Nursing Note", dated 9/12/23, at 5:03 p.m., the note indicated, " ... [Patient] medicated for continued agitation ..."

During a review of Patient 1's "ED Nursing Note", dated 9/12/23, at 6:28 p.m., the note indicated, " ... [ED Physician] notified of patients continued agitation, patient now diaphoretic (excessive sweating). Continues to be delusional (an unshakable belief in something that's untrue) ..."

During the review of Patient 1's "[Restraints] Flowsheet" dated 09/12/23, 5 p.m. through 9:30 p.m., the flowsheet indicated Patient 1 remained agitated, combative, restless, and irritable until 8:54 p.m. when the restraints were removed.

During a review of Pt 1's "Patient Summary Report," dated 9/12/23, the report indicated, "Orders Information ... Start [date] 9/12/23 [9:50 p.m.] CT Head [computed tomography (CAT scan) of the head without contrast (no dye)- the test of choice for detecting bleeding in the brain for patients with central nervous system symptoms or a traumatic head injury] ... completed [10:59 p.m.] ..." The CT scan resulted at 10:30 p.m., "Impression:1. No acute large vessel distribution infarction (obstruction), hemorrhage (loss of blood from a damaged blood vessel), mass or mass- effect. However, if there is continued clinical suspicion, follow up CAT scan or MRI [magnetic resonance imaging] with diffusion weighted imaging (sensitive test for detecting obstructions) should be obtained ..." The test was ordered and completed 10 hours after Pt 1's arrival to the ED on 9/12/23.

During a concurrent interview and record review of Patient 1's EMR on 10/25/23, at 2 p.m., with the Interim Emergency Department Director (IEDD), the IEDD validated the sequence of events during Pt 1's visits to the ED on 9/11/23 and 9/12/23. Upon further review, the IEDD stated there was no physical assessment performed by the ED nurse during Patient 1's ED visit on 9/11/23 and the EDRN did not follow hospital policy and procedure for abnormal laboratory values and patient follow up. The IEDD stated the Emergency Department Registered Nurse should have notified the ED physician and patient of the abnormal laboratory value that resulted after the patient left on 9/11/23 and documented it in the EMR. The IEDD also stated there was no neurological (an evaluation of a person's nervous system) assessment or Columbia-Suicide Severity Rating Scale (C-SSR- suicide risk assessment toolrisk assessment tool that uses a series of simple, plain-language questions that anyone can ask. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs) performed during Patient 1's ED visit on 9/12/23. The IEDD stated the expectation was for nursing to complete an assessment as it related to the patient's chief complaint during triage (the sorting of patients in the emergency room according to the urgency of their need for care) to help the physicians prioritize patient care in the ED and implement stabilizing measures. The IEDD stated assessment, reassessment, and complete vital signs were not consistently monitored during Patien 1's ED visits.

During an interview on 10/25/23, at 2:08 p.m., with the Emergency Department Registered Nurse (EDRN) 1, EDRN 1 stated she was assigned to Patient 1 on 9/11/23. EDRN 1 stated Patient 1 was admitted to the ED on a 5150 hold (72-hour, involuntary detainment/hold of a patient who is danger to self, danger to others and/or gravely disabled, and are initiated by behavioral health professionals) for suicidal ideation. EDRN 1 stated tele mental health cleared Pt 1 of his psychiatric emergency but he had low potassium level that needed to be rechecked before being medically cleared for discharge. EDRN 1 stated she notified ED Physician (EDP) 1 that Patient 1 wanted to leave, and Patient 1 was no longer on 5150 hold. EDRN 1 stated Patient 1 left before the laboratory results were completed. EDRN 1 stated she thought Patient 1 pulled his IV out before he eloped (when a patient leaves a healthcare facility against medical advice), but she was not sure. EDRN 1 stated she did not find a telephone number to call in Patient 1's EMR. EDRN 1 stated she notified EDP 1 and did not notify the charge nurse. EDRN 1 stated in the past she had called the police to do a welfare check (when police stop by a person's home to make sure they are okay) on a emergency department patient with abnormal laboratory results, however she did not for Patient 1 on 9/11/23. EDRN 1 stated she did not notice anything out of the ordinary with Patient 1 and was uncertain if EDP 1 followed up with Patient 1.

During an interview on 10/26/23, at 2:50 p.m., with EDRN 3, EDRN 3 stated she was the primary nurse for Patient 1 on 9/12/23. EDRN 3 stated Patient 1 was a behavioral health (refers to patients who has mental health and substance use disorders, life stressors and crises, and stress-related physical symptoms) patient that was brought in by ambulance with the chief complaint of falling on his back and hitting his head, hallucinating, laughing to self, responding to internal stimuli, and not answering questions appropriately. EDRN 1 stated she heard Pt 1 was seen in the ED and was admitted to the psych (psychiatric) section the day before on 9/11/23. EDRN 3 stated she planned to assess Patient 1 upon her return from lunch but did not. EDRN 1 stated on 9/12/23, she was notified by the relief nurse that Patient 1 attacked a security guard and sitter. EDRN 3 stated she returned to Patient 1 pinned down (to make somebody unable to move by holding them with a lot of force) on the floor by staff, EDRN 3 stated Patient 1 was transferred back to bed and placed in four-point restraints (both arms and both legs are restrained). EDRN 3 stated she did not perform a focused assessment on Patient 1 on 9/12/23, while Patient 1 was in her care. EDRN 3 stated she notified Patient 1's ED physician of his continued agitation. EDRN 3 also stated Patient 1's physician was aware Patient 1 had sustained a fall and "bumped" his head. EDRN 3 stated the physician did not order any procedures or diagnostic studies other than routine laboratory studies. EDRN 3 stated Pt 1's potassium was "low."

During a review of Pt 1's "ED Physician Notes," dated 9/12/23 at 1:38 p.m., the ED note indicated, " ... ED Labs (last two resulted values within 24 hours) ... potassium 2.9 ..."

During an interview at 10:26, at 4:05 p.m., with the Laboratory Services Director (LABD), the LABD stated a critical lab value required immediate attention and could potentially place a patient in danger if the value was not addressed and interventions to correct the cause were not implemented. The LABD stated it was the laboratory's practice to rerun all tests that resulted as "critical" high or low to ensure accurate results and immediately notify the attending nurse, charge nurse, and or physician of the abnormal "critical" results. The LABD stated "critical lab values" were established per facility and presented to the hospital's Medical committee, Policy committee, Chief Medical Officer, Quality, and Chief Nursing Officer (CNO) for approval. The LABD stated list of "critical lab values" were posted in the laboratory for the laboratory scientists' awareness. The LABD stated a normal potassium level for this hospital was 3.5 to 4.5. The "critical lab value" limit was any number that resulted less than 3.0 or higher than 6.0. The LABD stated potassium level of 2.9 was "critical" as established by this hospital.

During concurrent interviews on 10/27/23, at 9:15 a.m., with the Emergency Department Chairman & Medical Director (EDMD) and IEDD, the EDMD stated for purposes of EMTALA (Emergency Medical Treat and Labor Act), the ED was responsible to evaluate and treat all patients who presented to the ED requesting an examination. The EDMD stated the MSE, and initial set of vital signs were necessary to determine if an emergency medical condition existed. The EDMD stated the MSE should be started within 30 minutes of a patient's arrival to the ED, and it was ongoing until the patient was stabilized and discharged within the capacity of the hospital or transferred to a higher level of care. The EDMD stated EMTALA was "a huge deal" and taken very seriously. The EDMD stated a "critical" lab value did not mean a patient was not medically cleared, rather it depended on the entire presentation of a patient. The EDMD stated a potassium level of 2.9 would not necessarily be critical if the patient was treated and agreed to follow up as outpatient. The EDMD stated the expectation was that ED staff follow up with the patient if they left before knowing their results. The EDMD stated, "I would hear about it [a potential EMTALA violation] within 24 hours." The EDMD stated he reviewed all potential EMTALA cases as "they came up." The IEDD stated the ED did not have a process in place to capture potential EMTALA violations (e.g., left without being seen and elopement cases).

During an interview on 10/27/23 at 9:28 p.m. with Security Officer (SO) 1, SO 1 stated while she was in the hallway, she observed RN 9 following Patient 20 asking him where he was going. SO1 stated she proceeded to follow them out of the emergency department. SO 1 stated patient 20 stopped by the rails near the ambulance entrance and she attempted to redirect Patient 20 to return to the emergency department by offering gelatin. SO 1 stated Patient 20 appeared off balance while walking and stated he needed rest while placing his hands on the rail. SO1 stated she told RN 9 to get a wheelchair for patient 20. SO 1 stated Patient 20 placed one of his legs over the rail and at that point she called for backup. SO 1 stated she told Patient 20 not to go over the rail and grabbed his shirt by his shoulders. SO 1 stated she held Patient 20 by hugging his shoulders but eventually let go because she felt that she was going to fall with him. SO1 stated Patient 20 fell by the time back up arrived.

During a review of Patient 20's "ED Nursing Note", dated 9/13/23, the "ED Nursing Note" indicated, " ...fall greater than 25 feet. Trauma to head and body. Left leg pain, shortening, and deformity. Right leg abrasion and bruising. Multiple abrasion to bilateral upper extremities. Multiple facial lacerations. Abdominal distention. Possible LOC [Loss of Consciousness]. GCS 15 [alert and oriented to person, place, time, event and obeys commands] ..."

During a review of Patient 20's "Emergency Department Physician Note (EDPN)" from local trauma hospital, dated 9/13/23 was reviewed. The EDPN indicated, " ...Comminuted fracture of left intertrochanteric and subtrochanteric femur [hip fracture] ...Fracture of left iliac bone [hip fracture] ...Fracture of left anterior orbital rim [eye socket fracture] ...Fracture of left frontal bone [forehead fracture] ...Fracture of anterior wall of left maxillary sinus [left cheek bone] ..."

During an interview on 10/27/23, at 12:00 p.m., with EDP 1, EDP 1 stated he was the physician assigned to Patient 1 on 9/11/23. EDP 1 stated he assumed the care of Patient 1 when he came on shift and was tasked to reevaluate and follow up on Patient 1's medical stability and mental health evaluation. EDP 1 stated Patient 1 was calm, cooperative and had received potassium replacement during his ED visit. EDP 1 stated he was alerted by the EDRN that Patient 1 eloped and did not want to stay. EDP 1stated Patient 1 had been cleared by mental health. EDP 1 stated he identified a few "lab abnormalities" but no immediate concerns and Patient 1 could be managed as outpatient. EDP 1 stated he reviewed the results, Patient 1's ED visit determined treatment was complete and Patient 1 was medically stable. EDP 1 stated he evaluated potential risks for Patient 1 such asnausea, vomiting, diarrhea which Pt 1 did not have. EDP 1 stated a "low" potassium could manifest as weakness, muscle cramps, electrocardiogram (EKG- measures electrical activity of the heart) changes, and/or risk for cardiac arrythmia (abnormal heart rhythm). EDP 1 stated if potassium continued to decrease below 2.5 it would have been more concerning. EDP 1 stated Patient 1 potassium of 2.9 resulted after he left the ED. EDP 1 stated he looked through Patient 1's chart, psychiatric recommendation, trends over last several months at that time, and evaluated no further treatment was needed. EDP 1 stated staff attempted to reach the patient. EDP 1 stated he did not task anyone with further follow up. EDP 1 stated staff could have called the police to do a welfare check, welfare checks had been done by staff in the past.

During concurrent interviews on 10/27/23, at 2:05 p.m., with the Chief Nursing Officer (CNO) and Chief of Medical Staff (CMS), the CMS stated EMTALA as he understood it was that any person who presented to the ED with a chief complaint or emergency should be immediately screened to determine the emergency medical condition, prioritize care, and stabilize patients before they were discharged, admitted, or transferred. The CNO stated EMTALA was to ensure all patients were medically treated regardless of their ability to pay, with no discrimination within the capabilities of the hospital, and the patient was given information about their care before being transferred, admitted, or discharged. Both the CMS and CNO stated a MSE started at triage when a patient walked into the ED seeking care and ended when the patient was determined within reasonable clinical confidence that the patient was stable. The CNO stated vital signs were built into triage and crucial for helping physicians determine care and safe discharge or transfer. The CMS stated Patient 1 was brought to the ED on 9/11/23 by the police department under a 5150 hold and mental health cleared Patient 1's psychiatric emergency. CMS stated Patient 1 had laboratory studies done while in the ED and his potassium resulted "critical" low, 2.8. CMS stated Patient 1 received IV and oral potassium and his level was rechecked, then eloped around 5 p.m. that evening before the physician received the lab results and reevaluated Patient 1. The CMS stated Patient 1's potassium had increased to 2.9 on the recheck. The CMS stated a potassium level of 2.9 may not be cause for alarm if the clinical presentation of Patient 1 was stable and he did not have underlying factors that would cause the potassium to continue to decrease. The CMS stated his expectation would be for the physician to follow up with Patient 1. The CMS stated he could not say with certainty that Patient 1 was stable since no assessment and vital signs were documented. The CMS also stated that he could not say with certainty that Patient 1's fall and return to ED on 9/12/23 was not caused Patient 1's low potassium because low potassium could potentially cause cardiac arrythmias, muscle weakness and no follow up was done after he eloped on 9/11/23. Both the CMS and CNO stated the delay in ordering Patient 1's CT scan was of concern since Pt 1 had sustained a traumatic head injury and a scan could help identify potential life-threatening injuries. The CNO acknowledged Patient 1's erratic behavior could have been a symptom of underlying injuries to the brain that could not be detected by visual assessment. The CMS and CNO stated Patient 1 should have been sedated to complete the CT scan upon arrival to the ED on 9/12/23. CMS stated, a timely, consistent neurological assessment and reassessment should had been performed to capture acute changes in Patient 1's condition.

During a review of the hospitals' policy and procedure (P&P) titled, "[name of hospital] Emergency Medical Care/ Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," dated 9/25/18, indicated, " ... The purpose of this policy is to describe and comply with the requirements of EMTALA (Emergency Medical Treatment and Labor Act) and to establish [name of hospital] policies and procedures for compliance with EMTALA obligations... "Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/ or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in... placing the health of the individual... in serious jeopardy... "Medical Screening Examination" means the process of examination and evaluation of the individual required to determine, within the capabilities (services and staff) if an individual who comes to the dedicated emergency department has an emergency medical condition or is in labor ... medical screening examinations depend on the individuals presenting symptoms, and an ongoing process that may include vital signs, history and physical examination of affected or potentially affected symptoms, consideration of known chronic conditions, or testing needed to determine the presence of an emergency medical condition, documented in the record and reflect continued monitoring according to the individual's needs until it is determined that the individual does not have an Emergency Medical Condition...This policy applies to anyone who requests or requires care who presents on hospital property specifically including the main emergency department, obstetrical units, on campus or off campus DED's [Dedicated Emergency departments]... The hospital shall not delay in providing a medical screening examination or necessary stabilizing treatment ... Scope of examination. A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists. The scope of the examination must be tailored to the presenting complaint and the medical history of the individual. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include laboratory tests, diagnostic imaging, lumbar punctures, other diagnostic tests and procedures and the use of an on-call physician specialists. A medical record documenting the history and physical examination, and any special reports such as consultations, clinical laboratory, diagnostic imaging, and the like, will be created to document the screening exam..."

During a review of the hospital's document titled " Emergency Department Services Agreement," dated 9/1/22, indicated, " ... Groups shall comply, and shall cause each Group Provider and Group Agent to comply, with any and all federal, state and local laws, rules and regulations (collectively, "Laws"), including the Emergency Medical Treatment and Labor Act and the rules and regulations thereunder ("EMTALA") ... Group represents and warrants that Group has adopted policies and procedures consistent with the Hospital Rules as necessary and appropriate to ensure compliance with EMTALA...Group shall ensure that each additional group provider (including locum tenens physicians) receives EMTALA compliance training in accordance with such policies and procedures prior to providing any of the services under this Agreement, and that all Group providers receive continued training and education on not less than an annual basis and as otherwise necessary and appropriate to ensure compliance with them EMTALA..."

During a review of the hospitals document titled "[name of hospital] Medical Staff Bylaws," dated 12/6/18, indicated, " ... Except for the honorary staff, each member of the Medical Staff and each practitioner granted clinical privileges shall... Provide patients with efficient and high quality of care meeting the professional standards of the Medical Staff of this hospital... Abide by the Medical Staff Bylaws, Medical Staff rules and regulations, and policies as well as applicable hospital policies to ensure the safety of patients' visitors and staff and efficient hospital operations..."

During a review of the hospital's P&P titled " Standards of Practice- Emergency Department," dated 2/22, indicated, " ... the emergency registered nurse collects pertinent data and information relative to the patient's health or situation... contribute to determination of patient acuity or classification (ESI triage level system)... the patient will be continually assessed for changes and progress towards meeting outcome goals and discharge objectives... discharge assessments are completed by the registered nurse (RN)... Significant changes in assessments or critical data values will be reported to the physician/ LIP [Licensed independent practitioner] in compliance with hospital policy..."

Based on interview and record review, the facility failed to stabilize the Emergency Medical Condition (EMC) for one of twenty patients (Patient 4) when Patient 4 was brought to the Emergency Department (ED) on 5/24/23 by ambulance with a chief complaint of 9/10 (severe) pain on the "Numeric Pain Scale" [a simple pain scale that grades pain levels from 0 (no pain), 1,2, and 3 (mild), 4,5, and 6 (moderate), 7,8, and 9 (severe) to 10 (worst pain possible)] to her neck, left knee, and left foot after sustaining a fall at home. There was no documented evidence that Patient 4's pain rated 9/10 was treated during the ED visit nor were vital signs (blood pressure [BP], heart rate [HR], respirations [R], temperature [T], and oxygen saturation [O2sats]) and pain level reassessed prior to Patient 4 being discharged home on 5/24/23.

This failure resulted in the inappropriate discharge of Patient 4 without stabilizing treatment.

Findings:

During a review of Patient 4's "ED Physician Notes," dated 5/24/23 at 11:37 a.m., the ED note indicated," ... [Patient 4] [brought in by ambulance] presenting to the emergency department [status post] fall. Patient was walking home when she tripped and fell. She endorses neck pain, [left] knee pain, and foot pain ... First vitals Heart Rate 66 ... Respiratory Rate 20 ... Temperature ... 36.4... Radiology result date 5/24/23 12:08 [p.m.] ... [x-ray- pictures of the inside of the body] C- spine [cervical spine- neck region] The odontoid process [a bony structure on the cervical spine] is obscured by the overlying hard palate [roof of the mouth] on the open mouth view. Therefore, it is not fully evaluated by plain film... [x-ray] foot ... There is soft tissue swelling of the 1st digit. There is a hairline non-displaced fracture [bone cracks or breaks but stays in place] of the base of the first distal phalanx [tip of the big toe on the foot] ... disposition... After bedside reassessment the patient was seen in no acute distress and with an improved level of comfort ... discharged home... condition... stable..."

During a concurrent interview and record review on 10/26/23, at 10:45 a.m., with the Emergency Department Charge Nurse (EDCN) 1, EDCN 1 validated Patient 4 reported 9/10 pain to neck after she fell at home. EDCN 1 stated Patient 4's workup included x-rays of Patient 4's cervical spine, knees, and feet and a fracture to Patient 4's great toe was identified. EDCN 1 stated Patient 4 was not administered pain medication and there was no documented evidence the Patient 4's pain level was reassessed in the electronic medical record (EMR- patient health record in digital form). EDCN 1 stated Patient 4's vitals signs were not taken prior to being discharged home. EDCN 1 stated Patient 4's blood pressure was not taken during Patient 4's entire ED stay on 5/24/23. EDCN 1 stated the expectation was that a complete set of vital signs, including pain levels were taken upon a patient's arrival and discharge from the ED, and a reassessment at minimum to ensure patients were stable before discharge.

During concurrent interviews on 10/27/23, at 2:05 p.m., with the Chief Nursing Officer (CNO) and Chief of Medical Staff (CMS), the CMS stated EMTALA as he understood it was that any person who presented to the ED with a chief complaint or emergency should be immediately screened to determine the emergency medical condition, prioritize care, and stabilized before the patient was discharged, admitted, or transferred. Both the CMS and CNO stated a MSE started at triage (the sorting of patients according to the urgency of their need for care) when a patient walked into the ED seeking care and ended when the patient was determined to within reasonable clinical confidence that the patient was stable. The CNO stated vital signs were built into triage and crucial for helping physicians determine care and safe discharge or transfer. The CNO stated she expected staff to collect a last set of vital signs at most one hour before discharge to ensure patients were stable. The CNO and CMS stated a patient who comes into the ED with a chief complaint of 9/10 pain must be reassessed prior to discharge to ensure the patient was stable for discharge. The CNO stated the hospital did not have a policy and procedure that outlined expectations.

During a review of the hospitals' policy and procedure (P&P) titled, "[name of hospital] Emergency Medical Care/ Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," dated 9/25/18, indicated, " ... The purpose of this policy is to describe and comply with the requirements of EMTALA (Emergency Medical Treatment and Labor Act) and to establish [name of hospital] policies and procedures for compliance with EMTALA obligations... "Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain ... "To Stabilize" means, with respect to an emergency medical condition, to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result ..."

During a review of the hospital's P&P titled " Standards of Practice- Emergency Department," dated 2/22, indicated, " ... the emergency registered nurse collects pertinent data and information relative to the patient's health or situation... contribute to determination of patient acuity or classification (ESI triage level system)... the patient will be continually assessed for changes and progress towards meeting outcome goals and discharge objectives... discharge assessments are completed by the registered nurse (RN)..."

Based on interview and record review, the facility failed to provide required documentation of transfers for two of 20 patients (Patients 18 and 20), when Patient 18 and Patient 20 were transferred to mental health facilities without written requests for transfer indicating the reason for, risks of, and benefits of the transfer, as well as documentation of the patient's consent or refusal of transfer.

These failures resulted in a violation the Patient 18, and Patient 20's rights to participate in and make decisions regarding their care.

Findings:

During a review of the "Emergency Department Log (EDL)", dated 3/1/23 to 6/23/23, the "EDL" indicated Patient 18 was transferred on 6/1/23 and Patient 20 was transferred on 10/5/23.

During a concurrent interview and record review on 10/25/23 at 1:50 p.m. with the Interim Emergency Department Manager (IEDM), Patient 18's Electronic Medical Record (EMR) ", dated 6/1/23, was reviewed. The "EMR" indicated Patient 18 was brought to the Emergency Department (ED) by ambulance for a psychiatric (relating to mental illness) evaluation. The IDEM stated Patient 18 was under a 5150 hold (72-hour involuntary detainment/hold of a patient who is danger to self, danger to others and/or gravely disabled that are initiated by behavioral health (BH) professionals).

During a review of Patient 18's "ED Physician Progress Note (EDPPN)", dated 6/1/23, the "EDPPN" indicated, " ... Upon evaluation patient is agitated and aggressive but cooperative. Basic labs were obtained. Patient is dehydrated (condition caused by excessive loss of water from the body) and able to tolerate [oral] fluids. Patient labs returned with no significant acute findings. Patient is otherwise medically cleared and discharged with pending psychiatric evaluation ... Diagnosis ... Acute psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality] ... Dehydration ..."

During a review of Patient 18's "Discharge Instructions (DI)", dated 6/1/23, the "DI" indicated, " ... Follow up instructions ... follow up with your provider ... within 1 to 3 days ... Follow up with [receiving facility] ... within 1 to 3 days ... Call for follow up appointment ..."

During a concurrent interview and record review on 10/25/23 at 2:25 p.m. with the IEDM, Patient 18's "EMR", dated 6/1/23, was reviewed. The IEDM stated he did not know why the electronic medical record had no documentation of consent to transport or explanation of risks and benefits of transport signed by Patient 18, a responsible party (individual[s] acting on behalf of a patient) or the physician that transferred Patient 18. The IEDM stated transport consent documentation should be in the medical record. The IEDM stated the Patient 18's "EMR" presents as if Patient 18 was discharged rather than a transferred patient.

During a concurrent interview and record review on 10/25/23 at 2:55 p.m. with the IEDM, the IEDM reviewed Patient 20's "EMR", dated 10/3/23. The IEDM stated Patient 20 was brought to the ED by law enforcement on 10/3/23 at 8:01 p.m. as a 5150 hold. The IEDM stated Patient 20 was seen by Emergency Department Physician (EDP) 2 at 8:05 p.m. and diagnostic laboratory tests were ordered. The IEDM stated an emergency medical condition was ruled out for Patient 20 by EDP 2 on 10/3/23 at 8:35 p.m.

During a concurrent interview and record review on 10/25/23 at 3:10 p.m. with the IEDM, the IEDM reviewed Patient 20's "EMR", dated 10/5/23. The IEDM stated, Patient 20 was transferred to the receiving behavioral health facility and " ... there is no transfer paperwork [transfer summary, consent for transport, or explanation of risks and benefits of transport] that I can locate ..."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Care/ EMTALA (EMC)", dated 1/2021, the P&P indicated, " ... DEPARTMENTS: Hospital-Wide ... ASSOCIATED DOCUMENTS: ... Patient Request for Transfer or Discharge ... Physician Certification to Transfer and Consent to Transfer ... Patient transfer Acknowledgement ... Patient Refusal of transfer ... [Facility name] will adopt and follow the [Corporate name] policy "Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA)' ..."

During a review of the facility's policy and procedure (P&P) titled, "[Corporate Name] Governance Policy and Procedure ", dated 9/25/16, the P&P indicated, " ... Subject ... EMTALA corporate Policy ... PROCESS ... Transfer of Individuals with an Emergency Medical Condition ... Requirements an appropriate Transfer ... the hospital sends to the receiving facility all medical records ... the individual's informed written consent to transfer or the physician certification ... Refusal to Consent to Examination, Treatment or Transfer ... The hospital may transfer any individual with an unstabilized Emergency Medical Condition, including ....a psychiatric disturbance or symptoms of substance abuse, if the individual so requests the transfer and the hospital does all of the following: ...Offers the individual further medical examination and treatment ...Informs the individual of the risks and benefits of such an examination and treatment, and the risk and benefits of withdrawal prior to receiving such examination and treatment ... Takes all reasonable steps to secure the individual's written informed consent to refuse such examination and treatment; and ...Documents in the medical record a description of the examination, treatment, or both if applicable that was refused ..."

During a review of the facility's "Physician Certification to Transfer and Consent to Transfer (PCTCT)", dated 11/2007, the "PCTCT" indicated, "I, (name of physician), _____________, the undersigned physician, have examined and evaluated (name of patient) __________________ Based on this examination, the information available to me at this time, and the reasonable risks and benefits to the patient, I have concluded for the reasons which follow that, as of the time of transfer, the medical benefits reasonably expected from the provision of treatment at another facility outweigh any increased risks to the patient ... from the effecting the transfer. I believe, within reasonable medical probability, the transfer will not create a material deterioration in, or jeopardy to, the medical condition or expected chances for recovery of the patient ... Reasons for transfer, including summary of risks and benefits:_______________ Updated status of patient's condition:_______________ Date:_______ Time:_________ AM/PM ... Signature: ___________ (physician) ... CONSENT TO TRANSFER ... I hereby consent to transfer to another medical facility. I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risks and benefits upon which this transfer is being made. I have considered these risks and benefits and consent to transfer ... Signature of Patient or Patient's legal Representative: ___________ Date: _______ Time: _________ Witness: ________________ ... COPY MUST BE SENT WITH PATIENT ..."

During a review of "Patient Refusal of Transfer (PRT)", date 9/2012, the "PRT" indicated, " ... I acknowledge that I have been offered a transfer to another medical facility for medical treatment and that I refuse this transfer. I have been informed of the risks and consequences potentially involved in this refusal, the possible benefits of transfer to another medical facility, and any alternatives to my decision to refuse the transfer ... I refuse this transfer because ________________ I hereby release the attending physician, any physicians involved in my care, the hospital, and its agents and employees, from all responsibility for any ill effects which may result from my refusal of further medical examination and treatment. I understand that the physicians involved in my care are not employees or agents of the hospital. They are independent medical practitioners ... Date: _____ Time: _____ AM/PM ... Signature: ____________ (patient/legal representative) ... If signed by someone other than patient, indicate relationship: ________ Print name: __________ (legal representative) ... COPY MUST BE SENT WITH PATIENT ..."

During a review of "Patient Request for Transfer or Discharge (PRTD)", dated 3/2009, the "PRTD" indicated, " ... I have been informed of the risks and consequences potentially involved in the transfer discharge, which are _______ and the possible benefits of continuing treatment at this hospital, which are _______ and the alternatives, if any, to the transfer or discharge I am requesting, and the obligation of this hospital to provide further examination and treatment, within its available staff and facilities, as to stabilize my medical condition. I request this transfer or discharge because _________ __.... Date: ___ Time: _____ Signature: _________ (patient/legal representative) ... If signed by someone other than patient, indicate relationship: _________ Print Name: ____________... COPY MUST BE SENT WITH PATIENT ...."

During a review of Patient Transfer Acknowledgement (PTA)", dated 10/2012, the "PTA" indicated, " ... I understand that I have a right to receive medical screening, examination, and evaluation by a physician (or other appropriate personnel), without regard to my ability to pay, prior to any transfer from this hospital. I also have the right to be informed of the reasons for any transfer. I acknowledge that I have received medical screening, examination, and evaluation by a physician (or other appropriate personnel), and that I have been informed of the reasons for my transfer ...Date: ____ Time: _____ Signature: _____ (patient/legal representative) If signed by someone other than patient, indicate relationship: ______ Print name: ______ ... Copy must be sent with patient ..."

During an interview on 10/27/23 at 2:04 p.m. with the Chief Nursing Officer (CNO), the CNO stated the facility currently did not have 5150 hold patients sign a consent for transfer. .

During an interview on 10/27/23 at 2:10 p.m. with the Chief of Staff (COS), the COS stated a patient that was a 5150 hold had the right to be explained the risks and benefits of transport.