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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to deterimine whether or not an emergency medical condition existed for 1 of 25 sampled patients (Patient #2).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on policy and procedure reviews, medical record reviews, Emergency Medical Services (EMS) report review, and staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was provided including ancillary service routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 (#2, #9) of 25 sampled patients medical record reviewed.


The findings included:


Review of the policy titled "LL.026. EMTALA - Medical Screening and Treatment of Emergency Medical Conditions", approved 08/30/2018, revealed "...The Hospital must provide for an appropriate Medical Screening Examination conducted by a physician or other Qualified Medical Professional, including to the extent necessary ancillary services within the Hospital's capabilities and on-call physician services, to determine whether or not an Emergency Medical Condition exists...."

Review of the policy "Behavioral Health Patients in ED [Emergency Department], and [Behavioral Health Unit Holding Area] {BHU} of the Emergency Department, D-50-ED-69", last revised 09/2019, revealed "...PURPOSE...To provide a safe environment with Behavioral Health complaints to ensure that they receive appropriate care and treatment based on their needs.... POLICY....Patients that are admitted to the Emergency Department with a Behavioral Health complaint will have a medical screening. A psychiatric consultation will occur.... Every time a provider.... rounds it needs to be documented.... Every time a referral goes out it needs to be documented, end [sic] every time follow up is completed it needs to be documented. ...L ... The medical screening examination is an ongoing process and the medical record must reflect continued monitoring based on the patients needs and must continue until the patient is either stabilized or transferred. Triage does not constitute a MSE "

Review of policy titled "Psychiatric Consults in the Emergency Room, D-50-ED124, D-50-PC261" revised 09/2019, revealed "...PROCESS: A. After the patient.... is medically cleared by the emergency department physician, the patient will then be moved to [BHU). B. The psychiatric nurse or LCSW (licensed Clinical Social Worker) is responsible for continuing the completion of the [Hospital Name] assessment form (RARF). C. Staff will then consults [sic] with the on call Psychiatric Physician/ Nurse Practitioner. The Psychiatric Physician/ Nurse Practitioner is solely responsible for the clinical judgments regarding admission and referring out to another facility. ..."


The facility's Policy titled "Treatment of Care in the ED , Policy ID stat:5629318, Origination 07/2016, Last revised 11/2018 was reviewed. The policy revealed in part, "Any patient arriving in the emergency department will have a triage screen completed and will be offered a Medical Screen by a provider ...the care and treatment plan will be decided upon based on chief complaint and general symptoms at time of presentation. Every patient that presents to the emergency department will have a set of vital signs including pain, sepsis, ...and suicide/homicide screen ...Patient needs to have vital signs reassessed every 2 hours ... Patients required to wait in the lobby need to have completed secondary assessment in 2 hours. They need to have reassessment of the compliant every 2 hours while waiting in the lobby."



DED record review for Patient #2, on 10/23/2019, revealed the 83-year old patient arrived to the DED via police on 10/14/2019 at 1643. Triage review, timed at 1647, revealed "PT [Patient] CAME IN VIA POLICE ON IVC [involuntary commitment] PAPERS]; PT [family member] TOOK IVC PAPER; PT STATES THAT SHE IS NOT SI OR HI [suicidal ideation or homicidal ideation]; PT STATES THAT SHE DOESN'T KNOW WHY SHE IS HERE ..." Triage review revealed Patient #2 was assigned a Priority level of 2 (Emergent)[on a scale of 1-5 with 1 being the most critical]. Review revealed the patient's vital signs were: Temperature [T] 98.1, Pulse [P] 90, Respirations [R] 17, Blood Pressure [BP] 128/70, and Pulse Oximetry 94% on room air. According to the Triage record, Patient #2 denied pain at the time of triage and the record noted there were no new or unexplained mental status changes. Review of an ED Record section labeled "Interventions" revealed a suicidal assessment at 1643 which showed negative responses to suicide related questions and at the end of the assessment noted " ...Suicide Risk Level NO SUICIDE RISK ...." A RN ED Psychiatric Assessment, started at 1643, revealed thought processes intact with no delusions or hallucinations noted, and noted Patient #2 as well groomed and without impairment in comprehension ability or oral expression ability. The Behavior Assessment noted the patient was cooperative, her mood was at baseline, and her affect was appropriate. Further assessment review revealed no risk of suicide or violence. DED record review revealed IVC paperwork which included the form "AFFIDAVIT AND PETITION FOR INVOLUNTARY COMMITMENT", signed by the magistrate on 10/14/2019 at 1405. Review of the IVC paperwork revealed a statement that " ...respondent family believes she has dementia, often does not know what day it is. Was involved in a head on collision about two months ago driving at night without lights on in the wrong direction. Since accident behavior has became [sic] increasingly worse. Two weeks ago walks out the house [sic] by herself and was later found by the police.. has violent tendencies toward others but especially her [family member], attempted to choke him yesterday. Made multiples [sic] statements about killing herself and now states she is going to kill her [family member]. refuses to go to the hospital. Respondent is a danger to herself. ..." IVC paperwork review revealed a "FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT" which indicated the following " ...Clear description of findings ....PT [patient] DOES NOT MEET CRITERIA FOR IVC. NOT SUICIDAL OR HOMICIDAL. NOT A DANGER TO SELF. ..." which was signed by MD #3 on 10/14/2019 at 1715. The document included a section called " ...SECTION III - RECOMMENDATION FOR DISPOSITION ..." which had the following statement marked "Release respondent and Terminate Proceedings... ." DED record review did not reveal any additional IVC paperwork.

Review of the ED Provider Note, dated and timed 10/14/2019 at 1655, revealed " ..HPI - Altered Mental Status ....Symtoms [sic] Started: Weeks Ago (Patient has become increasingly uncooperative at the house according to the family who did finally come to the ED. She has threatened family members with death and she would commit suicide. She does not speak much English so is difficult to communicate with her. With the family present we have been able to better delineate this story.) Symptoms Presented: Came on Gradually -History of Present Illness Quality: Change in Behavior, Confusion Severity: YES: Severe .... History of: Dementia. Denies: CVA (Cerebral Vascular Accident), Diabetes, Indwelling Foley .... Review of Systems - Adult ....10 Systems Reviewed: All systems are negative unless marked otherwise .... Psychiatric: Paranoia, Thoughts of Hurting Yourself or Others. negative: Visual Hallucinations, Auditory Hallucinations .... Physical Exam- Adult .... -Physical Exam Findings Unable to fully assess due to: Altered Mental Status Constitutional: Alert, No Acute Distress.... Talking with Visitors .... Neurological: Speech WNL (Within Normal Limits), Answering Questions WNL, No Gross Focal Deficits, CN (Cranial Nerve) Grossly Intact, Normal Extremity Strength Psychiatric: Calm Demeanor, Cooperative, Judgement/Insight Impaired, Depressed Mood MDM (Medical Decision Making) - Altered Mental Status - Differential Diagnosis .... Delirium, UTI (Urinary Tract Infection), Other (Dementia with behavioral disturbance). ..." DED record review of imaging studies revealed a Head CT without contrast and Chest X-ray were done and revealed laboratory studies were also done, which included among others, a urinalysis and urine culture. Review of the urinalysis results, at 1848, revealed abnormal results were: "NITRITES POSITIVE" [RR negative], "LEUKO ESTERASE TRACE" [RR negative], "WBC 6-10" [RR 0-2], "EPITHEL CELLS 6-10", and "BACTERIA LARGE" [RR none]. A urine culture, final result 10/16/2018 [after discharge] revealed "ESCHERICHIA COLI" (bacteria that commonly causes UTI'S). Record review revealed Patient #2 received both Keflex and Bactrim [antibiotics] in the ED, at 1939 and 2050 respectively. Further review of the ED Provider Note revealed " .... Reevaluation Time 1st Re-eval: 20:20 2nd Re-eval: Unchanged - Consultation: Psychiatrist - MDM Comments Plan for Disposition of Patient: Plan to Admit Date of Decision: 10/14/19 Time of Disposition: 20:20 .... Discharge Diagnosis (1) Dementia, unspecified, with behavioral disturbance Current Visit: Yes Status: Acute (2) Urinary tract infection .... site unspecified .... Current Visit: Yes Status: Acute.... Plan Disposition Type: Hospitalize Condition: Stable Admit To: Psychiatric Unit ...." Review of the Provider Note revealed it was signed 10/14/2019 at 2022.

DED record review of "Interventions", dated 10/15/2019 at 1028 revealed " ...Regional Asst [Assessment] & Referral Form [RARF] .... Referral Information .... Spoke w/ pt. [with patient] via interpretation computer.... Pt. is an 83 y/o female who presents to the ED under IVC by her [family member]. Per IVC paperwork, 'Respondent family believes she has dementia, often does not know what day it is. Was involved in a head on collision about 2 months ago driving at night w/o [without] lights on in the wrong direction. Since accident behavior has become increasingly worse. 2 weeks ago walks [sic] out of the house by herself and was later found by the police. Has violent tendencies toward others but especially her [family member], attempted to choke him yesterday. Made multiple statements about killing herself and now states she is going to kill her [family member]. Refuses to go to hospital. Respondent is a danger to herself'. Upon exam, pt. denies any SI, HI, or A/VH [audio/visual hallucinations]. When asked if she is having any thoughts of wanting to harm herself in any way, pt. states 'No'. When asked if she knows why she is here she says per interpreter, 'I don't know. I'm just waiting for my [family member] to take me home'. Pt. asked how her life at home and her relationship w/ [with] her family are, she replies 'Good'. She denies any psych hx [history] or taking any meds. Pt has been calm and cooperative since arrival to the unit and is pleasant during interpretation.... Staff Taking Referral [First and Last Name] RN Date 10/15/19 Time 10:24.... Care Status Voluntary Yes Involuntary No.... Risk Assessment Risk Factor: Suicidality None .... Risk Factor: Violence None.... Mental Status Exam....Thought Content Goal Oriented Delusions None Hallucinations/ Illusions None....Consciousness Alert....Judgment Intact Current Diagnostic and Level of Care Impressions...Recommendations Pending. ..." At 1124, record review revealed a RN Note which stated "Pt. evaluated by on call psychiatric provider who agrees that pt. is ready for d/c [discharge]." DED record review did not reveal any notation/ documentation of the evaluation by the psychiatric provider. Review of an ED Provider Note by a Nurse Practitioner [NP], on 10/15/2019 at 1204, revealed "Progress Note Patient....presented from home with anger and being less cooperative with family. Patient is awake and alert x3 patient able to answer all questions, a online translator service was used during interview. [Name] the psychiatric practitioner interviewed patient as well, patient is to follow up with [outpatient behavioral health organization] if it is noted that she has increased confusion. Patient has no complaints of pain or discomfort at this time, patient denies suicidal and homicidal ideation." DED record review revealed, on 10/15/2019 at 1217, a Nursing Note which stated "Pt's [family member] notified of d/c." Further DED record review revealed Patient #2 was discharged home with family around 1417. Vital signs prior to Discharge, revealed T 98.3, P 68, R 17, BP 132/74, and Pulse Ox 99%. Review of Discharge instructions did not reveal any evidence of a prescription for antibiotics to treat the urinary tract infection.

Interview with MD #3, on 10/24/3019 at 1730, revealed he did the initial medical screening on Patient #2. Family was not present when Patient #2 arrived and did not come until 2-3 hours later. Interview revealed they used an interpreter to speak with the patient. Interview revealed t he Patient's story was very different than what he heard later from the family. Interview revealed that initially when speaking with the patient, MD #3 thought Patient #2 could be discharged because she was alert, oriented and responsive. Interview revealed MD #3 did not uphold the IVC at that time. MD #3 stated though, that as time went on, he could see Patient #2 was not "totally with it". Interview revealed he had put an evaluation in the computer but "didn't trust it" and wanted information from the family, and when the family arrived and he got additional information he reinstated the IVC. Interview revealed there should be two sets of IVC paperwork, the original that he overturned and a new one he took out. MD #3 stated he started new IVC paperwork which was to go the the magistrate. Interview revealed with MD #3 signed off his shift, his plan was to admit Patient #2. Further interview revealed Patient #2's labs came back with a UTI and he initiated medication.

Interview with RN #5, on 10/25/2019 at 1355, revealed she triaged and cared for Patient #2 on 10/14/2019. Interview revealed the patient was nervous and did not know why she was in the hospital. Interview revealed Patient #2 seemed agitated, and the nurse was not sure why so she asked the patient if she felt safe and if her [family member] was nice, and the patient said yes. Interview revealed she knew the doctor was talking about taking the IVC off but wanted to be sure it was okay with the (family member).

Interview with RN #6, the discharging nurse, on 10/23/2019 at 1455, revealed Patient #2 had been IVC'd by her family and spoke very little English. Interview revealed the family member who took out the IVC was not present when RN #6 was there. Interview revealed Patient #2 was not IVC'd, that the ED doctors had not upheld the IVC, that the patient did not meet criteria. Interview revealed Patient #2 was calm and cooperative. Interview revealed RN #6 did a psych assessment (called a RARF) using an interpreter. Interview revealed she had special training from behavioral health to do the assessment. RN #6 stated she recalled speaking with NP #8 and gave him information on what she had gathered in her assessment. RN #6 stated she called the patient's family to let them know Patient #2 was being discharged. Interview revealed RN #6 was there at the patient's discharge and Patient #2 was fine, no behaviors, no aggression, no SI, and was happy to go home. Follow-up interview at 1630 revealed RN #6 did not believe she gave any antibiotic prescriptions to Patient #2.

Interview with Nurse Practitioner [NP] #8, on 10/23/2019 at 1415, revealed he saw Patient #2 but did not write any assessment notes. Interview revealed the ED physician determined if there was a primary psychiatric issue. Interview revealed that NP #8 or a psychiatrist rounded in the DED behavioral health holding area and did psych consults on the phone or in person. NP #8 indicated he would review the case and make recommendations. Interview revealed NP #8 did not write discharge orders but did say if patients were stable for discharge. NP #8 stated he did not write notes on all patients he saw, sometimes he wrote them and sometimes he did not. NP #8 stated when they (psych providers) walked through the ED it was more informal than psych consults on the inpatient units. On the inpatient units, NP #8 stated, they always wrote notes. Interview revealed that in the ED BH holding area, ED providers made rounds daily and the psych providers went as needed. Interview revealed NP #8 recalled seeing Patient #2. Interview revealed NP #8 did not know enough Spanish to really talk with the patient. Interview revealed he may have spoken with her but there was not a translator available at the time and he did not know enough Spanish to do an assessment. Interview revealed the nurse in the ED BH area had done her assessment and used a translator to do it. The nurse, NP #8 stated, then "processed" with him about that assessment and from what he learned, his recommendation was outpatient. Interview revealed if Patient #2 needed inpatient care they would have made the appropriate referral, but it did not appear she met criteria. Interview revealed NP #8 did not speak with the family and did not know if the nurse did. Interview revealed the family did not always give the full picture. Interview revealed IVC's were frequently overturned in the ED, that the obligation was to protect a patient's civil rights. Interview revealed the patient was presenting as oriented, was able to answer the orientation questions in the assessment the nurse completed. Interview revealed after a recommendation was made the ED provider made the disposition decision and NP #8 stated if the ED provider disagreed they could take a different approach.

Interview with NP #7, on 10/24/2019 at 1600, revealed he saw Patient #2 and spoke with her in Spanish and had an interpreter. Interview revealed NP #7 discharged Patient #2. Interview revealed he would not discharge a patient without psychiatry seeing the patient and would not overturn an IVC without a psychiatric provider assessment. Interview revealed NP #7 believed NP #8 had completed a psychiatric assessment of Patient #2. Interview revealed NP #7 could not recall if he continued antibiotics at discharge or not. Interview revealed he usually continued antibiotics, but if he did not, then 48 hours later when the culture returned the patient should have been called back. Further interview revealed NP #7 thought Patient #2 was safe/ stable to go home.

In summary, Patient #2's family took out an IVC on the patient believing she was a danger to herself and others. On the initial medical screening MD #3 overturned the IVC and considered discharge of Patient #2, but after further evaluation and family discussion, MD #3 intended to resume the IVC and admit Patient #2 for inpatient psychiatric care. No IVC paperwork was found on the record and the discharging nurse who did the RARF assessment stated the patient was voluntary and did not meet IVC criteria. Patient #2 spoke very little English, the psychiatric NP did not speak much Spanish, and there was no interpreter at the time he saw the Patient. The psychiatric NP stated he did not complete a psychiatric evaluation, instead gathered his information from the RN who did the RARF. The ED NP, recommended discharge without a complete psych evaluation. The ED NP who discharged Patient #2 did so because he believed the Psychiatric NP had completed a psych assessment prior to his outpatient recommendation. Further there is no evidence whether the discharging ED NP prescribed discharge antibiotics. The discharging nurse did not think she gave any prescriptions to the patient. Antibiotics were given in the ED and after discharge the urine culture came back positive for E-coli. The facility failed to ensue that Patient #2, received an appropriate medical screening examination from a qualified medical provider (Psychiatrist) during the first visit.



Closed DED record review revealed Patient #9, a 78-year-old, arrived to the DED as a "walk-in" on 08/18/2019 at 1735. Review of the Triage Assessment, documented at 1745, revealed"... Description of Symptoms GROWTH ON LEFT TESTICLE NOTICED IT LAST NIGHT CAUSING LARGE AMOUNT OF PAIN...." Triage assessment review revealed Patient #9 had a normal airway assessment, was breathing without difficulty, skin was pink, warm, and dry, and the patient was noted to be alert and oriented times three [to person, place, time]. Pain intensity was documented as 10 on a scale of 0-10 where 10 equals the worst pain. Review of vital signs at 1745 revealed Temperature was [T] 98.1, Pulse [P] 128 (Normal Pulse rate 60-100-), Respirations [R] 20, Blood Pressure [BP]102/66, and Pulse Oximetry 95% on room air. Triage review revealed there were no new or unexplained mental status changes. Review did not reveal any further documentation on Patient #9 except for "Emergency Discharge Date/Time: 08/18/19 22:40" and a "Status" listed as "Discharged".

Interview with Administrative Staff [AS] #9, on 10/23/2019, revealed Patient #9's record should not have indicated discharge. Interview revealed that was incorrect, it should have been documented as a walk-out A [left without being seen].


Review of EMS trip report, dated and timed 08/19/2019 at 0039 (2 hours after timed sign out from visit #1) revealed "EMS was dispatched out for a sick call. Upon arrival male pt.(patient) found lying supine on his couch stating he had severe groin pain. The patient stated he had went [sic] to the hospital earlier in the day and was there for several hours and was never seen by a Dr (Doctor) so he left. The pt stated the groin pain has just gotten worse since he had been home. The pt. stood up from the couch and placed himself on the stretcher in the semi fowlers position.... EMS began transport .... Pt was a & o x4....Lower extremities normal with unremarkable motor sensory function and strong distal pulses.... Pt stated while en route that his groin pain was the main problem and it had just started earlier in the day.... The pt. was taken to the ED....The pt. then removed himself from the stretcher and sat down on a hospital type bed...."Review of vital signs at 0038 were BP 122/76, P 100, R 16, Pulse oximetry 95% on room air. The patient's pain score was noted as 10.


DED record review revealed Patient #9 arrived back to the ED on 08/19/2019 at 0048 (2 hours, 8 minutes after being signed out of the ED. Triage was started at 0051 and Patient #2 had a pain score of 10 and was assigned a priority level of 2. Vital signs at that time were T 97.1, P 92, R 17, BP 136/77, Pulse Oximetry 96% on room air, and a pain score of 10. Review of the ED Physician Note, time seen 0054, revealed "Patient is a 78-year-old male who presents to the emergency department with the bilateral testicle pain. He states the looks [sic] like his testicles are bruised. He denies any anticoagulation. He has a history hypertension, hyperlipidemia, COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) status post intracoronary stenting. He states he has had testicle pain for several days as noticed a been [sic] increasingly bruised like is bleeding into his testicles. He denies any abdominal complaints, flank pain, chest pain, shortness of breath, hematuria, dysuria, frequency, urgency. Pain described as moderate to severe, dull, constant for several days now with increasing pain and swelling. Denies any previous prostate issues. Denies any other palliative, provocative factors or associated symptoms .... Physical Exam Findings .... Genitourinary: Other (Ecchymotic right ilioinguinal area with bilateral ecchymotic hemiscrotums. Also, with ecchymosis of the penis.) .... MDM....Differential Diagnosis: The patient presents with bilateral scrotal erythema, ecchymosis. Without history of trauma I am quite concerned about a leaking abdominal aneurysm. The patient went emergently for a CT angio of the chest abdomen pelvis. This showed a saccular aneurysm of the ascending arch without leak. Also, a complex infrarenal abdominal aortic aneurysm without leak. There is diffuse aortoiliac atherosclerosis and small saccular aneurysms of the common iliac arteries. The patient was placed in room 11 when he came back from CT imaging. The patient suddenly became bradycardic and went into cardiac arrest. The patient was initially bradycardic. He was apneic. He was emergently intubated by me.... CPR was initiated.... received 2 amps ofIV epinephrine ....received IV amiodarone placed on amiodarone drip. We were notified the patient's potassium was 6.5 and he had low calcium. He received multiple rounds of IV sodium bicarb IV calcium. Also received D50 and 10 units of IV regular insulin. After minutes of return of spontaneous circulation, the patient suddenly became bradycardic and went into asystole. The asystole was work [sic] for more than 20 minutes without return of spontaneous circulation...."Further review revealed Patient #9 expired at 0303.


Interview with RN #10, on 10/23/2019, revealed she was the triage nurse for Patient #9. Interview revealed the patient stated he had a "knot in his testicle" and it had been there for a day or so. Interview revealed RN #10 did not generally assess a site unless it was clearly visible, such as on the arm. Interview revealed there were windows all the way around the triage room.


Interview revealed patients were assessed when they got back inside the ED. Interview revealed the only complaint the patient expressed was the knot. In response to the pain assessment score, RN #10 stated patients had to see a provider before being given pain medication. Interview revealed Patient #9 was in the waiting room because it was "full in the back", there were no beds available at the time. RN #10 indicated the charge nurse was trying to move patients. At about 1845, the RN stated, Patient #9 went to the bathroom and then came up to her and stated he thought he would just go home and try some ointment. RN #10 stated she encouraged the patient to stay and he agreed. RN #10 went off duty at 1900, she stated, and at that time Patient #9 was still in the waiting room. RN #10 stated he was walking around. Further interview revealed vital signs in the waiting room should be checked by the triage nurse every two hours. They were not due, because it had not been two hours since he arrived. As far as how busy the waiting room was, RN #10 stated there were probably 4-5 people "in the rack" waiting to go back. Interview revealed RN #10 was not aware of staffing in the back because she was busy with triage.


Interview on 10/24/2019 at 1445 with RN #2, the day charge nurse, revealed the RN did not recall having any conversations with the triage nurse about Patient #9. Interview revealed that in seeing the triage vital signs a heart rate of 128 was "concerning" and stated she would want to investigate more about it. Interview revealed they never wanted a patient to leave prior to being seen, and stated if she was aware of someone potentially leaving she would ask about bed availability and talk with a provider. Interview revealed RN #2 felt there was not adequate staffing on 08/18/19. Interview revealed the hospital would "flex people off' and on that day two staff members were flexed off. Fast track, RN #2 stated, was not open. As the volumes increased one staff member was called back. Then after 1500 a staff member who was supposed to come in called out. Also, per RN #2, there was a code blue on an inpatient unit and at the time, the ED responded to codes, which added to the issue. Interview revealed that after Patient #9 left and returned, RN #2 and another RN met with the Chief Nursing Officer to discuss the situation. Now, RN #2 stated, things were improved, staffing was better, leadership rounded in the ED more, and ED RNs are no longer required to go to code blues outside the ED.


Telephone interview, on 10/24/2019 at 1530, with RN #11 revealed she worked nights on 08/18- 19/2019. Interview revealed RN #11 was the triage nurse and remembered Patient #9 being in the ED. Interview revealed he was standing at the doorway, just standing there, the first time she saw him. RN #11 stated it was not uncommon for patients to stand there when the ED was full. In this case, there were in excess of 15 people waiting to be seen with a 2-3 hour wait time.


Interview revealed RN #11 was not aware of the particulars of the night, but stated the ED was "slammed" and patients were in hallway beds. Interview revealed the ED census had been lower for a while and the hospital was placing people on call during low census times, and that was what happened that day. Staff members were put on call, then it got so busy and it took time to get them back. Interview revealed because of that they were sunk. RN #11 stated she knew Patient #9 was still standing there about an hour into her shift, and further stated she thought he probably was there about 3 hours. "I knew he had been there a long time", she stated. Interview revealed she did not know when Patient #9 left, that he did not come up to her to tell her he was leaving. Interview revealed she did not realize which patient he was until he came back in and she recognized him. Interview revealed RN #11 did not recall a conversation with the previous triage RN about the patient potentially wanting to leave. There were about 15 reports to receive (on patients waiting) she stated. RN #11 stated the standard was to reassess patients in the waiting room every hour and then stated maybe he was not there an hour since nothing was documented. Interview revealed it is hard enough to keep up with new triage patients and on that night the triage nurse was also trying to cover the "ancillary room". RN #11 stated the "ancillary room" is a room behind triage where patients could be taken for an immediate EKG or something simple like suture removal. "It was a perfect storm", RN #11 stated. Further interview revealed that unless they know for sure a patient has left the ED (i.e. watch them leave), the nurses are to call the patient back three times and document it. Interview revealed that even though they call at different times, they may document all at once. Interview revealed she did not know how long the patient was there, but after his return, she recalled thinking that he had been there a long time and that there was a big difference between how he was when he was there the first time and when he came back in a later that night. "I blame us for that", the RN stated.


Telephone interview with the night shift Charge Nurse from 08/18-19/2019, RN #12, revealed she recalled the situation. Interview revealed it was a high-volume day and patients were being cared for in the hallway. RN #12 stated she was not sure what staffing was like. Interview revealed patients in the waiting room should be rounded on and receive vital signs every hour. If a patient says he/she wants to leave, then they try to get a provider to talk with the patient and encourage the patient to stay. Interview revealed a patient should be called back from the waiting room three separate times. On the discharge screen, RN #12 stated, there is a place to document the calls as left without being seen. Interview revealed RN #12 was very involved in Patient #9's care when he came back in via EMS. Interview revealed she also reviewed the patient record.


Interview revealed the patient had a high heart rate and 10:10 pain. Interview revealed she went
to administration the next morning to discuss concerns and the back log of patients and felt like she was heard and issues addressed.

Interview with MD #2, on 10/24/2019 at 1430, revealed the MD was on duty the night Patient #9 was in the ED. MD #2 stated Patient #9 was in the ED over 4 hours. Interview revealed 12 patients had signed in in one hour. Interview revealed Patient #12's chief complaint of a lesion on the testicle was different than a complaint of testicular pain. In discussion of the pain score of 10, MD #2 stated he did not hear of a patient in the waiting room with a 10:10 pain. Interview revealed testicular pain of 10 would be concerning. Interview revealed when Patient #9 returned to the ED he was seen immediately, and the area was ecchymotic, CT scans were done, the scan was initially read as negative for a leak [which he discussed with the radiologist because of the clinical picture]. MD #2 stated Patient #9 rapidly deteriorated. In regards to ED throughput and wait time, MD #2 stated "throughput here is pretty good" and indicated many patients who left were in the ED less than an hour. Interview revealed if the providers were aware a patient is about to leave, one of them would go out and try to talk with the patient.


Interview with the Chief Nursing Officer [CNO], on 10/25/2019 at 1315, revealed that on 08