HospitalInspections.org

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital staff failed to comply with 42 CFR 489.24.

The Findings include:

~cross refer to 489.24(r) and 489.24(c) Medial Screening Examination - Tag A2406

Based on hospital policy review, closed medical record review, security log review, staff and physician interviews, and Company Policy Officer Incident/Investigation Report review, the hospital staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 2 of 41 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #39 and #41).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 08/22/2011 and 10/18/2011, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

1. Closed medical record review of Patient #39 revealed a 21 year-old female who presented to the hospital's DED via EMS (emergency medical services) on 10/18/2011 at 0839 with a chief complaint of abdominal pain. Record review revealed documentation of vital signs at 0824 (taken by EMS personnel prior to arrival) of blood pressure (BP) 110/74, pulse 88, and respirations 18. Record review revealed documentation at 0839 the patient reported a 10 of 10 abdominal pain severity (on a scale of 1 to 10, with 10 being the most severe). Record review revealed documentation of temperature of 97.6 at 0845. Record review revealed the patient was triaged by RN (registered nurse) #1 at 0842. Review of nursing documentation at 0842 revealed, "pt to triage with abd (abdominal) pain. pt will not answer all questions, pt hyperventilating, crying, states pain started sat (Saturday)." Review of the patient's past medical history obtained during triage revealed a history of non-insulin dependent diabetes, hypertension and ovarian cyst. Record review revealed RN #1 assigned an initial triage acuity level of 3 (on a 1 to 5 Emergency Severity Index, with 1 being the most acute). Review of nursing documentation by RN #2 revealed, "0855 pt rolling in wheelchair and panting, pt asked to remain still for BP. pt ask for BP cuff to be removed. BP cuff removed. pt ask to have seat in lobby and told that she would be seen shortly. pt began cursing calling this nurse a (expletive). pt ask to refrain from using that type of language. pt began saying (expletives). pt pushed to lobby in wheelchair still cursing. security at door. pt cursed at security. pt asked several times to refrain from using inappropriate language. pt escorted out of building. while typing this note pt back into lobby 2 times. pt saying (expletives) pt again escorted out of building. Lead charge nurse aware. 0923 LCN (lead charge nurse) in lobby with pt. pt continued to curse and threaten. LCN ask security to escort pt off property". Record review of nursing documentation by RN #3 (lead charge nurse) at 0922 revealed, "Eloped - w/out being seen." Record review failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified by hospital bylaws, rules and regulations, to determine whether or not Patient #39 had an emergency medical condition (EMC) after her presentation to the DED on 10/18/2011 at 0839 and before being escorted out of the DED lobby and off the hospital property at 0922 by security.

Further closed record review revealed Patient #39 returned to the hospital's DED 11/12/2011 at 0909 via EMS with a chief complaint of abdominal pain. Review revealed the patient was triaged at 0918 and assigned an initial acuity of Level 3. Record review revealed documentation at triage of blood pressure 148/116, pulse 107, respirations 22, and pain level of 10 of 10. Record review revealed Patient #39 was medically screened by the DED physician at 0933, labs were ordered, and Toradol (pain medication) and Zofran (anti-nausea medication) were given intravenously. Further review revealed the patient was admitted to the hospital at 1915. Review of the physician's dictated History and Physical dated 11/12/2011 at 1656 revealed , "...Assessment and Plan 1. Acute Pancreatitis, based on the history, the clinical findings and the elevated lipase level (610, with normal of 73-393)...2. Type 2 diabetes...3. Intractable vomiting...4. Abdominal pain...5. History of ovarian cyst...6. Obesity...7. ...admitted to the medical unit...." Review of the physician's dictated discharge summary dated 11/14/2011 at 1435 revealed, "...Discharge Diagnoses 1. Acute exacerbation of pancreatitis 2. Uncontrolled type 2 diabetes mellitus....Disposition The patient is being discharged home in stable condition...."

Review of hospital security's "Daily Journal & Operations Log" dated 10/18/2011 from 0800 to 1600 revealed a handwritten entry starting at 0910 and ending at 0919. Review of the entry revealed, "Company police, (#102) was notified to standby/escort checked in patient off (hospital's) property. Per lead charge nurse, (RN #3), verbal instructions to me, (Security Officer #1) and company police (#102). See Incident Report."

Interview on 11/17/2011 at 1310 with Security Officer #1 revealed there was no security or police report related to Patient #39. Interview revealed, "I was asked by (RN #3) to escort the patient off the property. I walked her out and off the property. I noted that in my journal and filled out an incident report. I don't know what happened to the incident report." Interview further revealed, "My chain of command in the ED is the charge nurse. Once I step foot in the ED, the charge nurse is my supervisor."

Interview on 11/17/2011 at 1315 with the Director of Security revealed he could not locate an incident report completed for Patient #39. Interview revealed, "We were not sending police or security reports to quality or risk in October." Interview revealed now all incidents are forwarded to the Quality Department, the Risk Department, and the Vice President of Post Acute Care.

Interview on 11/17/2011 at 1115 with RN #1 revealed the nurse was a staff nurse in the DED on 10/18/2011 and remembered Patient #39. Interview revealed RN #1 was staffing Primary Triage on 10/18/2011. Interview revealed, "She (Patient #39) was brought in by EMS and came to triage in a wheelchair. She was loud, vulgar and uncooperative. She stated she wasn't going to answer any of my (expletive) questions. She was hyperventilating, crying and appeared to be in pain. EMS told me she was here the other day and didn't get her medicine filled. I moved her to the lobby. She continued cursing and walking around. She went to the bathroom a couple of times. I kept asking her to lower her voice because small children were around. She walked out. I called the charge nurse, (RN #3). She was pushing and slinging wheelchairs. (RN #3) went outside to talk with her. She came back in, balled her fist up and said to (RN #2), 'I'm going to cut you'. I told (RN #3) I wasn't going to stay in triage if they allow this to happen. I didn't hear (RN #3) tell her to leave but she left and didn't come back." Interview further revealed, "She didn't have a medical screening exam by a physician. I did the medical screening. I thought RNs in the ED could do medical screenings. Every patient should receive a medical screening." Interview further revealed the RN had received EMTALA training every 6 months. Interview revealed, "Here recently, we've had training more often." Interview further revealed, "I would never kick a patient out of the ED. If the situation escalates, I would contact my supervisor, in this case, the charge nurse, (RN #3)."

Interview on 11/17/2011 at 1045 with RN #2 revealed the nurse was working in Secondary Triage in the DED on 10/18/2011. Interview revealed, "She (Patient #39) was in a wheelchair, rolling around. I asked her to sit still so I could take her blood pressure. I told her I needed her vital signs so I could get her seen. She was cussing. I told her to have a seat in the lobby. I pushed her into the lobby in the wheelchair. She got up out of wheelchair several times. She went outside at least twice on her own. I called the charge nurse, (RN #3). He went out to talk with her. He brought her back in and when she came by triage, she jumped at the window and started cussing again." Interview further revealed, "She did not receive a medical screening exam prior to being escorted off the property. She absolutely should have received a medical screening. I saw her come back in a couple of hours later. It was after 9:30. I didn't triage her again because she never checked by in." Interview further revealed, "We get EMTALA training at least twice a year. With this patient, our EMTALA policy was not followed. This patient should have been offered a medical screening."

Interview on 11/17/2011 at 1320 with RN #3 revealed the nurse is a permanent charge nurse in the hospital's DED and was the charge nurse when Patient #39 presented to the DED on 10/18/2011. Interview revealed, "I saw her (Patient #39) at the EMS bay when she came in. She was alert and oriented and was sent to triage. I got a call from (RN #1). She said (Patient #39) was in the lobby cursing and they had removed her from the lobby and took her outside. I went outside, got the client, talked to her and de-escalated her. She told me she'd be cooperative and actually apologized. I brought her back in. She saw the nurse and became irate and started cursing again. I told her because of her violent nature, I would have her escorted off the property. I had her escorted off by security, can't remember his name." Interview further revealed, "I assessed her before asking her to leave the property. I didn't have a room to put her in. She was not asked to sign out AMA (against medical advice). I asked that she be removed from the property." Interview further revealed, "During the shift, the buck stops with me. I have had EMTALA training annually, here lately, everyday." Interview further revealed, "Our EMTALA policy was not followed."

Interview on 11/17/2011 at 1420 with MD #1 revealed the physician is the medical director of the hospital's DED. Interview revealed, "It's always concerning to me when a patient is moved to the lobby or outside prior to seeing a physician. (Patient #39) should have been seen by a physician or if her behavior was escalating she should have been moved to another area other than the lobby, probably not the security office which is not the best area to place a patient." Interview further revealed, "I was not aware of (Patient #39) being escorted off property prior to a MSE until today."

Interview on 11/17/2011 at 1530 with RN #4 revealed the nurse is the service line director for the hospital's DED. Interview revealed, "We had more EMTALA training here in October. I helped develop the training. The education was about transfers, not medical screening exams." Interview further revealed, "MSEs can be performed in our ED by physicians, PAs (physician assistants) and nurse practitioners. I don't know why the nurses think they can provide MSEs." Interview further revealed, " I was made aware of the incident with (Patient #39). I asked the staff to complete a QCC (incident report). I didn't follow up with staff to make sure a QCC was done. I reminded staff that an MSE needed to be done irregardless of behaviors. I had a verbal discussion with (RN #3)." Interview further revealed, "I didn't notify risk management or PI (performance improvement). The two incidents on October 18 got confused. I only knew about this one." Interview further revealed, "Our EMTALA policy was not followed because they failed to give the patient a MSE by a licensed, qualified practitioner."






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2. Closed medical record review for Patient #41 revealed a 28 year old female who presented to the hospital's Dedicated Emergency Department (DED) via Emergency Medical Services (EMS) ambulance on 10/18/2011 at 1358 (Presentation #1). Review revealed the patient was registered into the DED at 1402. Review of EMS documentation revealed the patient was transported to the DED for complaints of Right Flank Pain radiating in and towards the groin. Further review revealed the patient reported to EMS personnel "...AWOKE IN PAIN THIS MORNING ABOUT 0400 hrs (hours). CONTINUED TO GET WORSE INSTEAD OF BETTER. GOT NAUSEATED AND VOMITED. TRIED TO USE BATHROOM BUT COULD NOT...." Review of EMS assessment documentation revealed the patient was alert with guarding and tenderness in the right lower abdominal quadrant. Review of vital signs documented at 1345 revealed the following: Blood Pressure (BP) 132/80, Heart Rate (HR) 108, Respirations (R) 18. Review of EMS documentation revealed, "1420....AT THE DIRECTION OF THE CHARGE NURSE, PT (patient) WAS MOVED TO TRIAGE VIA WHEEL CHAIR, AND PT CARE WAS TRANSFERRED TO TRIAGE NURSE." Review of primary ("Frontline") triage nurse documentation revealed the patient was triaged at 1414 by a Registered Nurse (RN #1). Review revealed the patient complained of abdominal pain. Further review revealed at 1415 the patient's pain was assessed to be 9 out of 10 on a numerical pain scale (0 is pain free, 10 worse pain). Review revealed a past medical history of Asthma, Headache Migraine, Hypertension, and Urinary Tract Infections. Further review of "Primary Triage Info(rmation)" documented by RN #1 at 1417 revealed "....Note:~ pt to triage with RLQ (right lower quadrant) pain, states feels like pressure starting this am (morning) at 5. pt also states vomiting, denies diarrhea. Resp(irations) easy." Review revealed the patient was assigned "Initial Triage Acuity: 3 - Green (on a 1 to 5 Emergency Severity Index, with 1 being the most acute)." Review of documentation at 1427 by the secondary triage nurse (RN #2) revealed the patient's vital signs were assessed as Temperature (T) 100.0 (elevated) degrees Fahrenheit, BP 133/61, HR 107 (elevated), R 14, Pulse Oximetry 100% on room air. Review revealed "Orders: URINE-LAB PERFORMED U/A (urinalysis)" was ordered per DED protocol. Further review of RN #2's documentation at 1427 revealed, "....- Sepsis - (RN #2 name) Physician Notified: (MD #1 name) Sepsis Index of Suspicion: Unknown, Notify Physician/Provider." Review revealed at 1428 the patient was placed into the DED waiting room. Review of a "Triage Additional Note" documented by RN #3 (DED Charge Nurse on 10/18/2011 day shift) at 1552 revealed, "Note: Pt sitting at guest relations desk and will not move to have seat in lobby... pt ask to please have a seat in lobby and wait for available bed.. pt states she is not moving and began cursing at staff stating she has been waiting for 10 hours and patient has only been here 1.5 hours... Pt cursing still at staff, security notified and asked to escort pt out of lobby at this time. pt a (alert) and o (oriented) times 3 (person, place, time).. skin warm and dry.. resp(irations) even and non-labored and pt appears in no acute distress at this time.. pt refusing to cooperate and refrain from threatening behavior in triage... CPO (company police officer) notified and ask to remove patient from lobby..."

Review on 11/16/2011 of a CPO Incident/Investigation Report (NC02626249P, OCA1110-025) completed by CPO #1 and dated 10/18/2011 at 1550 revealed, "...Narrative Continued On or about 10/18/2011 15:50 hrs, Security Officer (SO) [name of SO #1] requested assisted in reference to a black female patient that Lead Charge Nurse (RN #3's name) wanted escorted out of the ED (emergency department) due to her refusing to cooperate with staff. I responded to same. I spoke with Officer (SO #1 name) who stated that the suspect, (Patient #41's name) was being disruptive with staff and refused to leave the ED. I requested Ms. (Patient #41's name) to leave and she refused. I advised her that if she didn't leave the ED she would be arrested for trespassing. Ms. (Patient #41's name) then left the ED and was walking toward the Tobacco store. Officer (SO #1's name) advised me that (RN #3's name) wanted her escorted off of the property. I advised Ms. (Patient #41's name) of same who had 2 white blankets that belonged to (name of Hospital). As we approached the edge of the property line, I advised Ms. (Patient #41's name) to give me the blankets. Ms (Patient #41's name) stated, 'No, I'm not giving you nothing, I'm cold.' I advised her that they belong to the hospital and she could be charged with larceny. Ms. (Patient #41's name) stated, 'No, I'm not giving them to you!' I tried to get the blankets from Ms. (Patient #41's name) who then pulled the blankets away from me. Ms. (Patient #41's name) continued to refuse to give me the blankets. I managed to get one blanket away from Ms. (Patient #41's name) who then started walking away off of property with the other blanket. Ms. (Patient #41's name) stated, 'There, you can have that one but I'm keeping this one. I advised (Patient #41's name) that she was under arrest and to put her hands behind her back. Ms. (Patient #41's name) refused to put her hands behind her back and continued to resist by trying to get her hands free from my hold. Officer (SO #1's name) arrived and assisted me so I could place handcuffs on Ms. (Patient #41's name). Officer (SO #1's name) and I escorted Ms. (Patient #41's name) to the CPO office (located adjacent to, but outside of the DED) to complete paperwork. I searched Ms. (Patient #41's name) and started the paperwork. Ms. (Patient #41's name) was very uncooperative and argumentative. Ms. (Patient #41's name) began to breath heavy, and stated that she has asthma. I asked her if she had her inhaler. Ms. (Patient #41's name) stated no. Ms. (Patient #41's name) stated that her chest felt tight. I called Lead Charge Nurse (RN #5's name) and requested him to check on Ms. (Patient #41's name). As I was on the phone with (RN #5's name) Ms. (Patient #41's name) began to vomit. I advised (RN #5's name) of same. (RN #5's name) checked Ms. (Patient #41's name) and stated that her lungs sound fine. (RN #5's name) advised me that she could be taken to room 31. I escorted Ms. (Patient #41's name) to room 31 and advised her that I wouldn't take her to jail but would charge her by citation (C 1713351-9)." Further review revealed Patient #41 was charged with Larceny and Resist, Delay, Obstruction.

Further medical record review for Patient #41 failed to reveal any available documentation the patient was provided an appropriate medical screening examination (MSE) within the capability of the hospital's ED by an individual who was determined qualified (QMP) by hospital bylaws, rules and regulations, to determine whether or not Patient #41 had an emergency medical condition (EMC) after her initial presentation to the DED on 10/18/2011 at 1358 and before being escorted out of the DED lobby and off the hospital property at 1552 by a SO and CPO.

Further medical record review revealed Patient #41 was placed into DED treatment room Blue 31 South (Presentation #2) on 10/18/2011 at 1637 (45 minutes after being escorted off of hospital property). Review of the patient's vital signs documented at 1645 revealed the following: T 102.6 degrees Fahrenheit (2.6 degrees higher than on initial presentation), HR 122 (25 beats higher than on initial presentation), and R 32 (18 cycles higher than on initial presentation #1). Record review revealed the DED physician (MD #2) evaluated the patient at 1637. Review of documentation by MD #2 of the MSE performed on Patient #41 (after placement in room 31 - Presentation #2), dated 10/18/2011 (not timed), revealed Patient #41's complaint of abdominal pain, flank pain, and brief chest pain was described as constant and still present upon exam. Review revealed documentation the patient described the pain as sharp, stabbing with associated nausea and vomiting. Further review revealed the patient's pain severity was documented as severe. Review revealed documentation the patient had a past medical history of polycystic kidney disease. Review of physician documentation revealed the patient was assessed as being in moderate distress. Further review of physician documentation revealed the patient had tachycardia (elevated heart rate) and was awake and alert, but disoriented to place and time. Review revealed documentation the patient's abdomen was soft and non-tender. Record review revealed the patient was started on the "sepsis bundle" (sepsis treatment protocol). Review revealed MD #2 ordered multiple diagnostic blood, urine, and radiological studies and prescribed multiple medications, including pain medications, antibiotics, and intravenous fluids for the patient. Record review revealed diagnoses of Severe Sepsis, Acute Pyelonephritis, Altered Mental Status, Chest Pain, Abdominal Pain, Fever, and Tachycardia. Further record review revealed the patient was admitted to the hospital's intensive care unit for further treatment and was subsequently discharged on 10/25/2011 (7 days later) with final diagnoses of "1. Escherichia coli septicemia 2. Acute Pyelonephritis 3. History of polycystic kidney disease 4. Elevated blood pressure with a prior history of hypertension 5. Anemia (required blood transfusion) 6. Iron-deficiency anemia 7. Hypokalemia 8. Hypomagnesemia".

Interview on 11/17/2011 at 0945 with SO #1 revealed he was the security officer on duty in the DED lobby on 10/18/2011 when Patient #41 presented to triage via wheelchair with EMS personnel. Interview revealed his post is approximately 10 feet from the triage nursing station in the DED lobby. Interview revealed the check-in nurse (RN #1) called him over to make him aware of the patient's (Patient #41) behavior and that she was using profanity. Interview revealed the patient was already in the lobby area when he was informed of the patient's behavior. Interview revealed the patient came up to the check-in station (triage) then went back into the lobby. Interview revealed the patient returned to the patient information desk (guest services desk) in a wheelchair. Interview revealed the patient started using profanity and became loud enough for the SO to hear the patient. Interview revealed RN #1 told him that the patient needed to move away from the guest relations desk. Interview revealed the SO spoke with the patient and told her she needed to move back. Interview revealed the SO went behind the patient's wheelchair to move the patient back into the lobby when the patient got up out of the wheelchair and sat down in a chair in front of the patient information desk. Interview revealed the patient was using profanity and said she was not leaving until she spoke with someone to find out why she was waiting in the lobby and having pain. Interview revealed RN #1 was checking in another patient and did not come over to reassess the patient. Interview revealed the SO assumed someone called the charge nurse (RN #3) because he came out to speak with the patient. Interview revealed while RN #3 spoke with the patient, he called the CPO to put them on stand-by if "it became a trespass issue" when the patient was asked to leave. Interview revealed when ever a person displays hostility and uses profanity they may be asked to leave the property. Interview revealed it may be patients, visitors, or family members. Interview revealed, "It may happen twice per day or go weeks at a time and not happen." Interview revealed when the SO is asked to escort a patient out of the DED lobby or off the hospital property he is unsure if they have or have not had a medical screening examination by a QMP. Interview revealed the practice of SO or CPO escorting patients/visitors/family members out of the DED lobby or off hospital property has been in place since he has worked at the hospital (at least 7 years). Interview revealed he asks individuals to leave the DED lobby or property under the direction of clinical staff such as doctors and nurses. Interview revealed on 10/18/2011 RN #3 came out and spoke with the nurse who called him and then he talked to Patient #41. Interview revealed afterwards he told him (SO #1) "She (Patient #41) can leave." Interview revealed the patient was verbally hostile, loud, and using profanity but he did not observe her being a danger to herself or others. Interview revealed he did not witness RN #3 reassess the patient, but he (RN #3) just walked back through the double doors into the DED treatment area. Interview revealed the SO called the CPO for assistance. Interview revealed CPO #1 arrived to the DED lobby and he (SO #1) discussed the patient (#41) with the CPO. Interview revealed CPO #1 asked the patient to leave. Interview revealed the patient stated she would not leave until waited upon. Interview revealed the patient was using profanity. Interview revealed the patient then got up and said she was going to leave and not wait for her ride. Interview revealed the patient had two hospital blankets in which the CPO told her she could take outside. Interview revealed the patient then went out the door with the CPO and himself following. Interview revealed another SO was outside of the DED and SO #1 asked that SO to keep an eye on the CPO and patient. Interview revealed SO #1 then returned back inside the DED lobby. Interview revealed he last viewed the patient stepping up on the curb in the DED parking lot by the fire hydrant with the CPO. Interview revealed after returning into the DED lobby he received a radio call from the base operator requesting him to go out and assist CPO #1. Interview revealed he went outside and saw CPO #1 and Patient #41 at the corner of the Tobacco Shop building (a private commercial establishment adjacent to hospital's DED parking lot). Interview revealed the CPO was struggling with the patient and holding her left arm. Interview revealed the patient was up against the fence (property line) facing towards the tobacco store parking lot. Interview revealed he assisted the CPO place Patient #41 into handcuffs. Interview revealed he escorted the CPO and patient back to the hospital entrance. Interview revealed the CPO and patient went to the CPO office adjacent to the DED and he went back into the DED lobby.

Interview on 11/17/2011 at 1100 with CPO #1 revealed she was the company police officer on duty 10/18/2011 when Patient #41 was escorted out of the DED lobby and arrested. Interview revealed SO #1 called for assistance in the DED lobby. Interview revealed when she arrived Patient #41 was sitting in a chair in front of the visitors' information desk (guest services desk). Interview revealed the patient was acting out, using profanity, and was disruptive. Interview revealed SO #1 stated RN #3 wanted the patient escorted off of the property because she would not move out from in front of the guest services desk and was cursing. Interview revealed when the CPO arrived the patient was not appearing suicidal, homicidal or a danger to self or others. Interview revealed the patient was verbally abusive, using profanity, and being loud. Interview revealed, "If the Lead Charge Nurse wants a patient escorted off of the property then we do what the Charge Nurse requests regardless of medical treatment and condition." Interview revealed she approached the patient while on her cell phone and she advised the patient she was going to have to leave because the hospital was requesting her to leave. Interview revealed the patient continued to talk on the cell phone telling someone "they are kicking me out of the hospital. Can you come and pick me up". Interview revealed the patient ignored the officer's request to leave 3-4 times. Interview revealed the CPO informed Patient #41 if she did not leave she (CPO #1) would have to arrest her for trespassing. Interview revealed the patient continued to ignore the CPO until she unsnapped her handcuff case to remove her handcuffs. Interview revealed the patient then stood up and walked out of the DED lobby without assistance. Interview revealed when the patient walked towards the exit doors the patient stated she was cold and was advised by her (CPO#1) that she (Patient #41) could hold onto the two blankets she had wrapped around her for right then. Interview revealed, "(SO #1) stated, 'He (RN #3) wants the patient off the property.'" Interview revealed CPO #1 advised the patient that she was to be escorted off hospital property. Interview revealed as she escorted the patient off the property the patient was very argumentative and "venting." Interview revealed the CPO and patient walked towards the smoking area where the patient wanted to wait for her ride. Interview revealed the patient was informed she could not wait at the smoking area because it was still hospital property. Interview revealed the patient was instructed by the CPO that she could wait at the bus stop or on the tobacco store property (not on hospital property). Interview revealed the patient requested to wait at the tobacco store. Interview revealed the CPO requested the patient to give back the two hospital blankets and the patient became argumentative. Interview revealed the patient refused to give the blankets back. Interview revealed the officer advised the patient if she did not give the blankets back she would be charged with larceny. Interview revealed the patient refused to give back the blankets and the CPO grabbed for the blankets and retrieved one. Interview revealed the patient refused to give her the second blanket. Interview revealed the CPO reached for the other blanket and the patient went to grab for the CPO's hands. Interview revealed the CPO then advised the patient she was under arrest. Interview revealed she (CPO #1) struggled with the patient to get her into handcuffs. Interview revealed SO #1 arrived and assisted with placing the patient into handcuffs. Interview revealed the patient was escorted back to the CPO office. Interview revealed the CPO initiated paperwork for the magistrate in preparation to take Patient #41 to jail. Interview revealed the patient was searched and was being very difficult and verbally abusive. Interview revealed while completing the paperwork for the magistrate, the patient started breathing heavy and complained of chest tightness. Interview revealed the CPO called the Lead Charge Nurse desk and requested the charge nurse (R