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Based on the review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that one Patient (P) #1 of 20 sampled patients reviewed for stabilizing treatment. Specifically, a review of P#1's medical records and staff interviews revealed that P#1 was discharged home because he refused to be stuck again with a needle in order to gain an Intravenous (IV) line access to get more blood work and further treatment.

Cross refer to A-2407 as it relates to the facility's failure to provide a stabilizing treatment to P#1.

Based on the review of facility policy and procedures, medical records, and interviews with staff it was determined that the facility failed to provide one patient (P) (#1) of 20 sampled patients with stabilizing treatment within the capabilities of the facility.

P#1 presented to the facility's emergency department (ED) on 2/27/25 at 6:10 a.m. with complaints of chest pain and dizziness. P#1 used inappropriate language toward staff when staff were unable to maintain a functioning intravenous line (IV) (small catheter inserted in a vein to administer medications and/or fluids). P#1 was discharged to home at 8:12 a.m. without further medical treatment. P#1 was treated at Facility B from 1:37 p.m. on 2/27/25 through 3/3/25 for gastrointestinal bleeding and alcohol withdrawal.

Findings included:

A review of the facility's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) PROCEDURE, Clinical A-5000P", Policy #17258304, last revised 12/11/24, stated that "6. Refusal of Consent to Examination or Treatment. If an individual who has decision making capacity is unwilling to continue with the MSE and Stabilizing treatment (as indicated), the situation must be handled the same as any refusal of care and documented as such. The practitioner informs the individual of the risks and benefits of such examination and treatment, and of the risks and benefits of withdrawal prior to receiving such examination and treatment and takes reasonable steps to secure the individual's documented informed refusal of such examination and treatment in the medical record."

Facility A
A review of Patient (P) #1's medical record revealed that P#1 was admitted to the facility's Emergency Department (ED) on 2/27/25 at 6:10 a.m. with the chief complaint of chest pain and dizziness and was diagnosed with Acute Chest Pain (a sudden onset or change in chest pain, pressure, or discomfort that could indicate a serious medical condition, requiring immediate medical attention). Documentation revealed that P#1's means of arrival was via a car, accompanied by the spouse.

P#1's blood pressure on arrival (during triage by Registered Nurse HH) was 204/109 mmHg (normal was 120/80) and the heart rate was 115 beats per minute (bpm) (normal was 60-100 bpm). A repeat blood pressure was done by RN II at 6:26 a.m. and P#1's blood pressure reading was 178/104 mmHg, and the heart rate was 112 bpm.

Documentation under the 'ED Care Timeline' revealed that a peripheral IV was inserted on 2/27/25 at 6:34 a.m. by RN II and P#1 tolerated the procedure well. Documentation also revealed that the IV was removed due to occlusion (blockage) on 2/27/25 at 7:12 a.m. by RN EE.

Documentation under the 'ED Notes' by RN DD on 2/27/25 at 7:45 a.m. revealed P#1 refused to have an IV inserted anywhere except his lower arm. Documentation revealed that upon inserting the needle by RN DD to access the vein in the right forearm, P#1 yelled out and cussed her (RN DD) telling her to take the needle out, or he would rip it out himself. Documentation also revealed that P#1 told RN DD to stick the needle where the previous INT (intermittent needle therapy - a capped-off IV cannula for later use) was located, but she (RN DD) left the room and notified DO KK of P#1's actions and foul statements.

A continued review of P#1's medical record revealed documentation by DO KK under the 'ED Course' on 2/27/25 at 7:45 a.m. that P#1 was refused further lab draws and asked to be discharged shortly after IV attempt (at a patient-selected site). Documentation revealed that P#1 began to speak expletives toward the charge nurse and told her to take the needle out. Documentation revealed that P#1 was discharged home with self-care on 2/27/25 at 8:15 a.m.

Facility B
A review of P#1's medical record from Facility B revealed that P#1 was transferred to Facility B from Facility C as a transfer to a higher level of care on 2/27/25 with a request and acceptance time of 1:42 p.m., and a presenting problem of hematemesis (vomiting of stomach contents mixed with blood, or the regurgitation of blood only) and was discharged on 3/3/25 with a primary discharge diagnosis of ETOH (Alcohol) withdrawal and a secondary discharge diagnosis of possible GIB (Gastro Intestinal Bleeding - bleeding that occurs within the gastrointestinal tract, from the mouth to the anus).

An interview took place in the facility's conference room on 3/17/25 at 4:30 p.m. with Registered Nurse (RN) DD, who was also the ED Charge Nurse. RN DD stated that she took over P#1's care in the morning and he (P#1) was very anxious and agitated. RN DD stated that P#1 talked non-stop and refused the ultrasound-guided intravenous line insertion after the IV line placed earlier was occluded. RN DD stated that when she tried to stick the needle, it hit a nerve, and P#1 started cussing. RN DD stated that she had to step out because P#1 started making derogatory comments, which she (RN DD) reported to the doctor, and the doctor told her (RN DD) that she was going to discharge P#1 anyway. RN DD stated that P#1 was discharged to the lobby, and he (P#1) said he was going to call an Uber.

An interview took place in the facility's conference room on 3/18/25 at 12:05 p.m. with ED Nursing Director/Director of Nursing (DON) AA who stated that she worked with the multidisciplinary team to help ensure the facility's staff followed policies/procedures, up to date with the required education, and she also oversees the implementation of any action plan. DON AA stated that the ED staff at the facility under investigation reported to her directly; however, there was no report of any incident to her (DON AA) regarding P#1.

A telephone interview took place on 3/18/25 at 6:20 p.m. with Registered Nurse (RN) II who stated that P#1 was very anxious about his blood pressure when he presented to the ED and had stated that his heart was racing. RN II stated that she was able to calm P#1 and had no issues with him (P#1), so she (RN II) was very surprised when she later heard what happened between P#1 and the other staff. RN II also stated that she would usually not discharge a patient with a systolic blood pressure higher than 160; however, it also depended on the patient's clinical symptoms and if the patient was alert and oriented. RN II further stated that if a patient was alert and oriented and was waiting for an Uber or a family member, the patient would be left in the lobby alone until the ride or family member arrived.

A telephone interview took place on 3/20/25 at 11:30 a.m. with Doctor of Osteopathy (DO) KK who stated that P#1 came in with complaints of chest pain, and a staff member had taken the initial laboratory blood work, which showed that P#1's ETOH (alcohol) level was slightly elevated. DO KK stated that P#1 had to get a new IV line to get more blood work but P#1 got very agitated, and he (P#1) stated that everyone should get away from him. DO KK stated that she explained the risks and benefits of not getting the additional blood work, but P#1 stated that he did not want to be stuck again. DO KK also stated that she did not think of an AMA (Against Medical Advice) form because the discussion she (DO KK) had with P#1 was not an adversarial conversation and P#1 was clinically stable based on her (DO KK) observations.

The hospital did not take secure written informed refusal as the patient was discharged and was not considered leaving against medical advice.