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

The findings included:

1. 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 determine whether or not an emergency medical condition existed for 1 of 5 sampled patients with a chief complaint of abdominal pain/swelling and 1 of 2 patients who left without treatment.

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

2. The hospital failed to ensure stabilization of a patient with an emergency medical condition for 1 of 5 sampled patients with a chief complaint of abdominal pain/swelling and 1 of 2 patients who left without treatment.

~cross refer to 489.24 (d)(1-3), Stabilizing Treatment - Tag A2407

Based on policy and procedure review, medical record review, and physician interviews, 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 determine whether or not an emergency medical condition existed for 1 of 5 patients with a chief complaint of abdominal pain/swelling (Patient #11) and 1 of 2 patients who left without treatment (Patient #9).

The findings included:

Review on 01/29/2020 of a policy titled "EMTALA Medical Screening Stabilization Policy" last reviewed 03/2019 revealed "...In general, when an individual comes, by himself or herself, with another person, or by EMS to the Dedicated Emergency Department of the Hospital and a request is made on the individuals' behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital...to determine whether an Emergency Medical Condition exists...4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition. 5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment. 6. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of their individual's ability to pay for medical care...7. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs..."

1. DED record review, on 01/28/2020 revealed Patient #11 arrived to the DED on 11/27/2019 at 1550 via private vehicle with a chief complaint of "abdominal swelling." Review of the triage notes performed at 1559 revealed " ...Husband states: states pt has hx of heavy etoh abuse and abd swelling. Risk considerations: patient denies pain radiation to back or syncopal episode. Care prior to arrival: None ...GI: Reports lower abdominal pain, nausea, Parent/caregiver reports the patient having bloating, intolerance off food, intolerance of fluids, nausea, vomiting. GU: Parent/caregiver report the patient having no problems with voiding ..." Vital signs were recorded as Pulse (P) 120, Blood Pressure (BP) 150/97, Respirations (R) 22, SpO2 94% on room air and a pain score of 5 out of 10 (on a scale of 0-10, with 10 being the worst pain). The patient was triaged as level 3, urgent. Further review of the triage notes revealed a past medical history of DVT, GERD, Osteoporosis, Cirrhosis, and Alcoholism. Review revealed an MSE was performed at 1630. Review of the MAR revealed Patient #11 received 4mg of Zofran IV at 1537, 1 liter of normal saline IV at 1701, 4mg of Zofran IV at 1701, and 1mg of Lorazepam IV at 1724. Review of a nursing note at 1750 revealed "Notified ED physician of LA 3.7." Review of laboratory results of Hematology, collected time 1653, revealed normal results with the exception of: Glucose 142 reference range 70-106, ALK PHOS 300 reference range 32-92, ALT 81 reference range 8-43, AST 188 reference range 16-40, Anion Gap 19.1 reference range 5-15, Lipase 346 reference range 7-58, Ethanol 212.8 reference range 0-10, Lactic acid 3.7 reference range 0.5-2.0, procalcitonin 0.09 reference range 0.10-0.50, MCV 106.7 reference range 83-96, and MCH 34.1 reference range 27-32.5. Review of the urinalysis results collected at 1807 revealed normal results with the exception of trace blood, 1+ urine protein, 3-5 white cells, trace bacteria, moderate epithelial cells, many yeast and few coarsely granular casts. Review of the radiology reports revealed a normal chest x-ray and a negative head CT. Review revealed no abdominal CT scan was ordered. Review of Physician documentation at 1830 revealed " ...This 39 yrs old Caucasian Female presents to ER via wheelchair with complaints of Abdominal Swelling. The patient presents with abdominal pain. Onset: The symptoms/episode began/occurred 5 day(s) ago. The symptoms do not radiate. Associated signs and symptoms: Pertinent negatives: fever. The symptoms are described as sharp. Modifying factors: The symptoms are alleviated by nothing, the symptoms are aggravated by nothing. Severity of pain: At its worst the pain was moderate in the emergency department the pain (as written). The patient has not recently seen a physician. HAS HX OF CIRRHOSIS AND CHRONIC ABD PAIN. RAN OUT OF HER PAIN MEDICINE. HAS STILL BEEN DRINKING ETOH HEAVILY AND THEREFORE IS NOT A CANDIDATE FOR LIVER TRANSPLANT ...Social history: ...Patient uses alcohol patient/guardian reports chronic longstanding heavy alcohol consumption ...1832 All other systems are reviewed and negative. Constitutional: Negative for fever. Abdomen/GI: Negative for black/tarry stool. Abdomen/GI: Inspections: distension, Bowel sounds: normal, Palpation: mild abdominal tenderness, in all quadrants, rebound tenderness, is not appreciated, voluntary guarding, is not appreciated, no appreciated organomegaly ...Differential diagnosis: appendicitis, bowel obstruction, cholecystitis, Cholelithiasis, Endometriosis, gastritis, gastroesophageal reflux disease, GI Bleed, Mesenteric ischemia or infarction, non-specific abd pain, Ovarian Torsion, pancreatitis, Peptic Ulcer Disease, Peritonitis, Pyelonephritis, Ureterolithiasis. Data reviewed: vital signs, nurses notes. Counseling: I had a detailed discussion with the patient and/or guardian regarding: the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, lab results, radiology results, the need for outpatient follow up, to return to the emergency department if symptoms worsen or persist or if there are any questions or concerns that arise at home. ED course: In summary This Is a 39-year-old Female with End-Stage Liver Disease and Continued Alcohol Abuse and Chronic Abdominal Pain. Tachycardia Is Appreciated, but Is Improving after IV Fluids. Repeat Abdominal Exam Reveals No Peritoneal Signs. She will Be Discharged Home to Follow up with Her GI Doctor with a Prescription of Zofran ..." Vital signs before discharge at 1836 were recorded as P 101, R 20, BP 139/84, SpO2 97% on room air and no other pain assessment documented. Review revealed Patient #11 was discharged home at 1844 to follow-up with her primary care provider and a prescription for ODT Zofran.

Interview on 01/28/2020 at 1531 with MD #1 revealed he recalled Patient #11 and had reviewed Patient #11's medical record for 11/27/2019. Interview revealed Patient #11 arrived to the ED with abdominal pain and had a history of cirrhosis. Review revealed while reviewing Patient #11's lab work MD #1 stated Patient #11's lactic acid was 3.7 but her procalcitonin was normal, so he did not think she was septic. Interview revealed an increased lactic acid could be from Patient #11's continued alcohol abuse because her alcohol was 212. Interview revealed much of Patient #11's lab work was chronically elevated due to her cirrhosis and alcohol abuse. Interview revealed when reviewing Patient #11's lipase level of 346 he stated that chronic pancreatitis can cause elevated lipase due to alcohol abuse. Interview revealed when asked if Patient #11 needed a CT scan of her abdomen MD #1 stated that Patient #11's presentation was chronic, and he did not think a CT scan of the abdomen would help as far as "diagnosis or therapy." Interview revealed MD #1 was able to see that Patient #11 presented to another hospital the next day and was admitted for chronic pancreatitis and for a MRCP. Interview revealed MD #1 did not think Patient #11 needed admission when he saw her. Interview revealed Patient #11 was stable at discharge, had a through medical screening exam, and "the care provided here was appropriate."

In summary, a complete medical screening examination was not done for Patient #11 who arrived with 5 out of 10 abdominal pain, nausea and vomiting with an elevated lipase of 346. Another pain score was not completed prior to discharge. A CT abdomen and pelvis was not completed and Patient #11 was sent home to follow-up with an outpatient provider.

2. Closed DED record review, on 01/29/2020, revealed Patient #9 arrived to the DED via EMS on 10/02/2019 at 2024 with a chief complaint of "Overdose". Review of triage notes at 2025, revealed, " ...patient overdosed 2 times in 4 days. Patient denies harming self. Sheriff states that mother is taking out IVC papers to his drug use. Patient denies wanting to harm his life and states he just wanted to get high". Vital signs taken at 2025 were recorded as Blood Pressure 116/73; Pulse 116; Temperature 98.2; Pulse Ox 96% on Room Air. At 2042 Respirations of 17 were recorded. The patient was triaged as Acuity: ESI Level 2. The nursing assessment at 2027 revealed, "Pain: Denies pain ...Neuro: Level of Consciousness is awake, alert, obeys commands, oriented to person, place and time ...Cardiovascular: Rhythm is regular. Respiratory: Breath sounds are clear". The suicide screening at 2028 revealed " ...Columbia Suicide Risk Assessment: 1.) Have you wished you were dead or wished you could go to sleep and never wake up? No 2.) Have you actually had any thoughts of killing yourself? No 6.) Have you ever done anything, started to do anything, or prepared to do anything to your life? No. Highest Assessed Suicide Risk Level: Low suicide risk ...PMHx: Anxiety and Substance Abuse. PSHx: None ..." Review revealed Patient #9 had a MSE at 2032. Review of Physician notes at 2042 revealed, " ...this 23-yr. old Caucasian Male presents to ER via (County Name) EMS Ground with complaints of Overdose ...a result of recreational substance abuse ...the OD/poisoning occurred at home, mom found patient on the bathroom floor after overdosing on heroin. She gave him Narcan ...Pertinent positives: Chest Pain ...The EMS care prior to arrival includes: none ...in the emergency department the symptoms have improved. The patient experienced similar episodes in the past, a few times ... Cardiovascular: Positive for chest pain. Respiratory: Negative for cough, shortness of breath. Neuro: Positive for loss of consciousness ...Constitutional: This is a well-developed, well-nourished patient who is awake, alert, and in no acute distress. Eyes: Pupils equal, round and reactive to light... Conjunctiva and sclera are non-icteric and not injected. Head/Face: Noted is abrasion(s), that are mild, of the top of head. Cardiovascular: Rate: normal, Rhythm: regular ...Respiratory: the patient does not display signs of respiratory distress. Respirations: normal, Breath sounds: are normal, clear throughout ...Chest/Axilla: Inspection: abrasion, that is mild, of the mid-sternal area. Palpation: tenderness, that is mild, of the anterior aspect of right upper chest and anterior aspect of left upper chest ...Neuro: Orientation: to person, place and time. Cranial nerves: CN II-XII are normal as tested, Motor: moves all fours, strength is normal, strength is 5/5 in all extremities, Sensation: no obvious gross deficits. Glasgow Coma Score ...Total 15 ..." Orders at 2040 included a " ...CBC w/Diff (Interpretation: Normal except: WBC 13.8; HGB 13.2; HCT 40.8.), CMP (Interpretation: Normal except: Glucose 108), IV saline lock, EKG (Rate 99 beats/min. Rhythm is regular, Normal Sinus Rhythm. QRS Axis is Normal. PR interval is normal. QRS interval is normal. QT interval is normal. No Q waves. T waves are Normal). Chest AP/PA Single view (Interpretation: No acute disease. CONCLUSION: Single view of the chest was obtained. Cardiac silhouette within normal limits. No focal consolidation or failure. No pneumothorax or pleural effusions) ..." Review of dispensed medications revealed Patient #9 received Toradol 30 mg via IV at 2059. Further review of Physician Documentation at 2130 revealed, " ...Data reviewed: vital signs, nurses notes, lab test result(s), EKG, radiologic studies. Counseling: I had a detailed discussion with the patient and/or guardian regarding: the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, lab results, radiology results. ED course: Patient pulled his IV out and left the Emergency Department. I had a discussion with him and his mother. His mother is concerned that he is trying to hurt himself with his multiple overdoses. She states he did make threatening statements about 'going out.' He states that he does not want to kill himself. He states that he does not want to die. I recommended that he get treatment. Unfortunately, at this time I do not feel he meets involuntary commitment criteria ..." Review of the Nurse's Note at 2131 revealed, " ...General: Pt mother left room stating that she was going to leave. Pt walked out of room after his mom stating that he was going to leave because his mom is his only ride home. Pt was asked by nurse to return to room so we could at least get discharge paperwork completed after he was evaluated. Pt stated that he is 'discharging himself' and that he 'doesn't have to stay here'. RN made sure that Pt IV had been taken out prior to him leaving. Pt notified RN that he had ripped out his IV. There is no bleeding present from IV site. Pt was escorted out of hospital security". Review revealed Patient #9 left the ED on 10/02/2019 at 2135.

Telephone interview with RN # 3 on 01/30/2020 at 1600 revealed she recalled Patient #9, "I remember he wanted to leave and go home with his mom because he didn't have another way home." RN #3 stated that she did attempt to get him to stay, but Patient #9 kept coming up to the nurse's station saying he wanted to leave. Interview revealed that Patient #9 was being loud and disruptive. RN #3 stated "he ripped out his IV and said he was going to leave, since security was close by, they just walked him out." Interview revealed MD #3 was aware of Patient #9's intentions to leave the ED before being discharged. RN #3 stated that Patient #9 did not seem suicidal and "he was absolutely awake and alert."

Telephone interview with MD #3 on 01/29/2020 at 1617 revealed, MD #3 did remember Patient #9 "a little bit." Interview revealed MD #3 was "pretty sure I saw Patient #9 leave the Emergency Department." MD #3 stated that the MSE had been completed, but "I was not ready to discharge yet ...with overdoses I usually like to have a period of observation of at least 2 hours to make sure the patient is staying awake and their Sats are not dropping, his O2 had been fine and he was awake the whole stay." MD #3 stated that Patient #9 was not suicidal and that he adamantly denied wanting to harm himself. Interview revealed MD #3 did not attempt to have Patient #9 sign AMA (against medical advice) paperwork as "usually the nurses get this signed." MD #3 stated that Patient #9 was safe to leave, "otherwise, I would've called the cops."

Based on policy and procedure review, medical record review, and staff and physician interviews, the hospital failed to ensure stabilization of a patient with an emergency medical condition for 1 of 5 patients with a chief complaint of abdominal pain/swelling (Patient #11) and 1 of 2 patients who left without treatment (Patient #9).

The findings included:

Review on 01/29/2020 of a policy titled "EMTALA Medical Screening Stabilization Policy" last reviewed 03/2019 revealed "...In general, when an individual comes, by himself or herself, with another person, or by EMS to the Dedicated Emergency Department of the Hospital and a request is made on the individuals' behalf for a medical examination or treatment, the Hospital must provide an appropriate Medical Screening Examination within the capability of the Hospital...to determine whether an Emergency Medical Condition exists...4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition. 5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment. 6. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital's Dedicated Emergency Department with those signs and symptoms, regardless of their individual's ability to pay for medical care...7. Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs..."

1. DED record review, on 01/28/2020 revealed Patient #11 arrived to the DED on 11/27/2019 at 1550 via private vehicle with a chief complaint of "abdominal swelling." Review of the triage notes performed at 1559 revealed " ...Husband states: states pt has hx of heavy etoh abuse and abd swelling. Risk considerations: patient denies pain radiation to back or syncopal episode. Care prior to arrival: None ...GI: Reports lower abdominal pain, nausea, Parent/caregiver reports the patient having bloating, intolerance off food, intolerance of fluids, nausea, vomiting. GU: Parent/caregiver report the patient having no problems with voiding ..." Vital signs were recorded as Pulse (P) 120, Blood Pressure (BP) 150/97, Respirations (R) 22, SpO2 94% on room air and a pain score of 5 out of 10 (on a scale of 0-10, with 10 being the worst pain). The patient was triaged as level 3, urgent. Further review of the triage notes revealed a past medical history of DVT, GERD, Osteoporosis, Cirrhosis, and Alcoholism. Review revealed an MSE was performed at 1630. Review of the MAR revealed Patient #11 received 4mg of Zofran IV at 1537, 1 liter of normal saline IV at 1701, 4mg of Zofran IV at 1701, and 1mg of Lorazepam IV at 1724. Review of a nursing note at 1750 revealed "Notified ED physician of LA 3.7." Review of laboratory results of Hematology, collected time 1653, revealed normal results with the exception of: Glucose 142 reference range 70-106, ALK PHOS 300 reference range 32-92, ALT 81 reference range 8-43, AST 188 reference range 16-40, Anion Gap 19.1 reference range 5-15, Lipase 346 reference range 7-58, Ethanol 212.8 reference range 0-10, Lactic acid 3.7 reference range 0.5-2.0, procalcitonin 0.09 reference range 0.10-0.50, MCV 106.7 reference range 83-96, and MCH 34.1 reference range 27-32.5. Review of the urinalysis results collected at 1807 revealed normal results with the exception of trace blood, 1+ urine protein, 3-5 white cells, trace bacteria, moderate epithelial cells, many yeast and few coarsely granular casts. Review of the radiology reports revealed a normal chest x-ray and a negative head CT. Review revealed no abdominal CT scan was ordered. Review of Physician documentation at 1830 revealed " ...This 39 yrs old Caucasian Female presents to ER via wheelchair with complaints of Abdominal Swelling. The patient presents with abdominal pain. Onset: The symptoms/episode began/occurred 5 day(s) ago. The symptoms do not radiate. Associated signs and symptoms: Pertinent negatives: fever. The symptoms are described as sharp. Modifying factors: The symptoms are alleviated by nothing, the symptoms are aggravated by nothing. Severity of pain: At its worst the pain was moderate in the emergency department the pain (as written). The patient has not recently seen a physician. HAS HX OF CIRRHOSIS AND CHRONIC ABD PAIN. RAN OUT OF HER PAIN MEDICINE. HAS STILL BEEN DRINKING ETOH HEAVILY AND THEREFORE IS NOT A CANDIDATE FOR LIVER TRANSPLANT ...Social history: ...Patient uses alcohol patient/guardian reports chronic longstanding heavy alcohol consumption ...1832 All other systems are reviewed and negative. Constitutional: Negative for fever. Abdomen/GI: Negative for black/tarry stool. Abdomen/GI: Inspections: distension, Bowel sounds: normal, Palpation: mild abdominal tenderness, in all quadrants, rebound tenderness, is not appreciated, voluntary guarding, is not appreciated, no appreciated organomegaly ...Differential diagnosis: appendicitis, bowel obstruction, cholecystitis, Cholelithiasis, Endometriosis, gastritis, gastroesophageal reflux disease, GI Bleed, Mesenteric ischemia or infarction, non-specific abd pain, Ovarian Torsion, pancreatitis, Peptic Ulcer Disease, Peritonitis, Pyelonephritis, Ureterolithiasis. Data reviewed: vital signs, nurses notes. Counseling: I had a detailed discussion with the patient and/or guardian regarding: the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, lab results, radiology results, the need for outpatient follow up, to return to the emergency department if symptoms worsen or persist or if there are any questions or concerns that arise at home. ED course: In summary This Is a 39-year-old Female with End-Stage Liver Disease and Continued Alcohol Abuse and Chronic Abdominal Pain. Tachycardia Is Appreciated, but Is Improving after IV Fluids. Repeat Abdominal Exam Reveals No Peritoneal Signs. She will Be Discharged Home to Follow up with Her GI Doctor with a Prescription of Zofran ..." Vital signs before discharge at 1836 were recorded as P 101, R 20, BP 139/84, SpO2 97% on room air and no other pain assessment documented. Review revealed Patient #11 was discharged home at 1844 to follow-up with her primary care provider and a prescription for ODT Zofran.

Interview on 01/28/2020 at 1531 with MD #1 revealed he recalled Patient #11 and had reviewed Patient #11's medical record for 11/27/2019. Interview revealed Patient #11 arrived to the ED with abdominal pain and had a history of cirrhosis. Review revealed while reviewing Patient #11's lab work MD #1 stated Patient #11's lactic acid was 3.7 but her procalcitonin was normal, so he did not think she was septic. Interview revealed an increased lactic acid could be from Patient #11's continued alcohol abuse because her alcohol was 212. Interview revealed much of Patient #11's lab work was chronically elevated due to her cirrhosis and alcohol abuse. Interview revealed when reviewing Patient #11's lipase level of 346 he stated that chronic pancreatitis can cause elevated lipase due to alcohol abuse. Interview revealed when asked if Patient #11 needed a CT scan of her abdomen MD #1 stated that Patient #11's presentation was chronic, and he did not think a CT scan of the abdomen would help as far as "diagnosis or therapy." Interview revealed MD #1 was able to see that Patient #11 presented to another hospital the next day and was admitted for chronic pancreatitis and for a MRCP. Interview revealed MD #1 did not think Patient #11 needed admission when he saw her. Interview revealed Patient #11 was stable at discharge, had a through medical screening exam, and "the care provided here was appropriate."

In summary, Patient #11 was not stabilized prior to discharge. Patient #11 arrived to the DED with 5 out of 10 abdominal pain, nausea and vomiting with an elevated lipase of 346. Another pain score was not completed prior to discharge. A CT abdomen and pelvis was not completed and Patient #11 was sent home to follow-up with an outpatient provider.

2. Closed DED record review, on 01/29/2020, revealed Patient #9 arrived to the DED via EMS on 10/02/2019 at 2024 with a chief complaint of "Overdose". Review of triage notes at 2025, revealed, " ...patient overdosed 2 times in 4 days. Patient denies harming self. Sheriff states that mother is taking out IVC papers to his drug use. Patient denies wanting to harm his life and states he just wanted to get high". Vital signs taken at 2025 were recorded as Blood Pressure 116/73; Pulse 116; Temperature 98.2; Pulse Ox 96% on Room Air. At 2042 Respirations of 17 were recorded. The patient was triaged as Acuity: ESI Level 2. The nursing assessment at 2027 revealed, "Pain: Denies pain ...Neuro: Level of Consciousness is awake, alert, obeys commands, oriented to person, place and time ...Cardiovascular: Rhythm is regular. Respiratory: Breath sounds are clear". The suicide screening at 2028 revealed " ...Columbia Suicide Risk Assessment: 1.) Have you wished you were dead or wished you could go to sleep and never wake up? No 2.) Have you actually had any thoughts of killing yourself? No 6.) Have you ever done anything, started to do anything, or prepared to do anything to your life? No. Highest Assessed Suicide Risk Level: Low suicide risk ...PMHx: Anxiety and Substance Abuse. PSHx: None ..." Review revealed Patient #9 had a MSE at 2032. Review of Physician notes at 2042 revealed, " ...this 23-yr. old Caucasian Male presents to ER via (County Name) EMS Ground with complaints of Overdose ...a result of recreational substance abuse ...the OD/poisoning occurred at home, mom found patient on the bathroom floor after overdosing on heroin. She gave him Narcan ...Pertinent positives: Chest Pain ...The EMS care prior to arrival includes: none ...in the emergency department the symptoms have improved. The patient experienced similar episodes in the past, a few times ... Cardiovascular: Positive for chest pain. Respiratory: Negative for cough, shortness of breath. Neuro: Positive for loss of consciousness ...Constitutional: This is a well-developed, well-nourished patient who is awake, alert, and in no acute distress. Eyes: Pupils equal, round and reactive to light... Conjunctiva and sclera are non-icteric and not injected. Head/Face: Noted is abrasion(s), that are mild, of the top of head. Cardiovascular: Rate: normal, Rhythm: regular ...Respiratory: the patient does not display signs of respiratory distress. Respirations: normal, Breath sounds: are normal, clear throughout ...Chest/Axilla: Inspection: abrasion, that is mild, of the mid-sternal area. Palpation: tenderness, that is mild, of the anterior aspect of right upper chest and anterior aspect of left upper chest ...Neuro: Orientation: to person, place and time. Cranial nerves: CN II-XII are normal as tested, Motor: moves all fours, strength is normal, strength is 5/5 in all extremities, Sensation: no obvious gross deficits. Glasgow Coma Score ...Total 15 ..." Orders at 2040 included a " ...CBC w/Diff (Interpretation: Normal except: WBC 13.8; HGB 13.2; HCT 40.8.), CMP (Interpretation: Normal except: Glucose 108), IV saline lock, EKG (Rate 99 beats/min. Rhythm is regular, Normal Sinus Rhythm. QRS Axis is Normal. PR interval is normal. QRS interval is normal. QT interval is normal. No Q waves. T waves are Normal). Chest AP/PA Single view (Interpretation: No acute disease. CONCLUSION: Single view of the chest was obtained. Cardiac silhouette within normal limits. No focal consolidation or failure. No pneumothorax or pleural effusions) ..." Review of dispensed medications revealed Patient #9 received Toradol 30 mg via IV at 2059. Further review of Physician Documentation at 2130 revealed, " ...Data reviewed: vital signs, nurses notes, lab test result(s), EKG, radiologic studies. Counseling: I had a detailed discussion with the patient and/or guardian regarding: the historical points, exam findings, and any diagnostic results supporting the discharge/admit diagnosis, lab results, radiology results. ED course: Patient pulled his IV out and left the Emergency Department. I had a discussion with him and his mother. His mother is concerned that he is trying to hurt himself with his multiple overdoses. She states he did make threatening statements about 'going out.' He states that he does not want to kill himself. He states that he does not want to die. I recommended that he get treatment. Unfortunately, at this time I do not feel he meets involuntary commitment criteria ..." Review of the Nurse's Note at 2131 revealed, " ...General: Pt mother left room stating that she was going to leave. Pt walked out of room after his mom stating that he was going to leave because his mom is his only ride home. Pt was asked by nurse to return to room so we could at least get discharge paperwork completed after he was evaluated. Pt stated that he is 'discharging himself' and that he 'doesn't have to stay here'. RN made sure that Pt IV had been taken out prior to him leaving. Pt notified RN that he had ripped out his IV. There is no bleeding present from IV site. Pt was escorted out of hospital security". Review revealed Patient #9 left the ED on 10/02/2019 at 2135.

Telephone interview with RN # 3 on 01/30/2020 at 1600 revealed she recalled Patient #9, "I remember he wanted to leave and go home with his mom because he didn't have another way home." RN #3 stated that she did attempt to get him to stay, but Patient #9 kept coming up to the nurse's station saying he wanted to leave. Interview revealed that Patient #9 was being loud and disruptive. RN #3 stated "he ripped out his IV and said he was going to leave, since security was close by, they just walked him out." Interview revealed MD #3 was aware of Patient #9's intentions to leave the ED before being discharged. RN #3 stated that Patient #9 did not seem suicidal and "he was absolutely awake and alert."

Telephone interview with MD #3 on 01/29/2020 at 1617 revealed, MD #3 did remember Patient #9 "a little bit." Interview revealed MD #3 was "pretty sure I saw Patient #9 leave the Emergency Department." MD #3 stated that the MSE had been completed, but "I was not ready to discharge yet ...with overdoses I usually like to have a period of observation of at least 2 hours to make sure the patient is staying awake and their Sats are not dropping, his O2 had been fine and he was awake the whole stay." MD #3 stated that Patient #9 was not suicidal and that he adamantly denied wanting to harm himself. Interview revealed MD #3 did not attempt to have Patient #9 sign AMA (against medical advice) paperwork as "usually the nurses get this signed." MD #3 stated that Patient #9 was safe to leave, "otherwise, I would've called the cops."