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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:

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 and on-call services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 27 sampled patients (Patient #19 [visits 1 &2] and Patient #27).

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

2. The hospital failed to ensure stabilizing treatment was provided as required to stabilize an emergency medical condition for 2 of 27 sampled patients (Patient #19 [visits 1 & 2] and Patient #27).

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

Based on policy and procedure review, medical record reviews and staff and provider 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 and on-call services routinely available to determine whether or not an emergency medical condition existed for 2 of 27 sampled patients [Patient #19 {visits 1 &2} and Patient #27].

The findings included:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA)...", last revised 10/2020, revealed "...DEFINITIONS: ....5. Medical Screening Examination (MSE)...The screening process required to determine with reasonable clinical confidence whether an emergency medical condition [EMC] does or does not exist....11. Within the capability: Those services available at [Hospital Initials], as well as on-call specialists and .... ancillary services routinely available....EMTALA PROVISIONS OVERVIEW....5. Medical Screening Exam....The scope of the MSE must be reasonable calculated to exclude the presence of an Emergency Medical Condition....including utilizing necessary tests, ancillary services and on-call specialists, where appropriate. ..."

1. a. DED medical record review, on 04/28/2021, revealed Patient #19 was an 81 year old who arrived by private vehicle to the DED on 04/12/2021 at 0932 [Visit #1] with a stated complaint of stroke-like symptoms. Review revealed Patient #19 had numbness in the right arm since 0600 and that a neighbor stated her speech sounded slurred. The patient was assigned an ESI of 2 [on a scale of 1 to 5, with 1 being the most emergent and 5 being least acute]. The ED Provider Note, time seen 0942, indicated "...HPI (History of Present Illness) - Stroke - Timing of Symptoms Time of Onset: 06:00 Symptoms Started: Hours ago (3) Onset of symptoms: Gradually Since Onset, Symptoms are: Improved ....Other History: Patient....complaining of slurred speech and right-sided weakness since 6:00 a.m. This morning. Patient is awake and alert x3 [to person, place, time]. Patient's family, which lives next door brought her in, patient normally lives on her own.... Patient continues to have right hand and right foot weakness and numbness with slurred speech. Patient is sent to CT [Computed Tomography - type of imaging] for code stroke upon arrival....PMH [Past Medical History]....Hypertension [High blood pressure], Hyperlipidemia [high concentration of fats in the blood].... TIA [Transient Ischemic Attack - brief stroke-like attack].... Diabetes....Review of Systems ....Abnormal Speech, Weakness Physical Exam Findings Constitutional Alert, Moderate Distress....Cardiovascular: Normal Rate, Regular Rhythm. negative: Murmur Respiratory: Normal Rate, Lung Sounds Clear. negative: Respiratory Distress.... Neurological: Oriented x 3. negative: Speech WNL [within normal limits] (Patient has slurred speech at this time,), Answering Questions WNL, No Gross Focal Deficits (Patient is having weakness on the right side of face, right hand, and right foot.), CN (Cranial Nerves) Grossly Intact....MDM - Stroke ....Differential Diagnosis: Bell's Palsy [sudden weakness in the muscles of half of the face], CVA [Cerebral Vascular Accident-stroke], Hypoglycemia [low blood sugar], TIA ....Have antithrombotics been Ordered? If NO, why?: No (Symptoms had resolved.).... Reevaluation Time of 1st Reeval: 10:12 1st Reeval: Improved (Patient's symptoms have dissipated at this time, patient no longer has slurred speech, patient is moving all extremities well states she feels much better. CT negative for acute CVA.).... Consultation: Hospitalist Called: 12:37....Plan to Admit.... Diagnostic Results ....EXAMINATION: CT HEAD CODE STROKE, 4/12/2021.... IMPRESSION: Negative noncontrast head CT. No intracranial hemorrhage [bleed in the brain], mass or acute infarct [small area of dead tissue from failure of blood supply] ....Electronically Signed.... 9:55 EDT [Eastern Daylight Time]....Discharge Diagnosis (1) TIA .... Plan ....Hospitalize. ..." Review of the History and Physical, dated 04/12/2021 at 1240, revealed "...Patient is a pleasant, high functioning 81-year-old female....She presents the emergency department today after noticing severe balance issues at about 6:00 a.m. this morning....Per the emergency department nurse practitioner, the patient was very dysarthric [slurred speech] when she presented....By the time I evaluated the patient, the patient's NIH [stroke scale] scale was 0. The patient had a head CT done which was negative for acute intracranial abnormality.... Assessment and Plan (1) Stroke-like symptoms ....NIHSS [stroke scale] 6 on admission, 0 - Thrombolytic therapy not indicated, symptoms resolved, out of time window - Cause: Unknown - Order MRI brain [Magnetic Resonance Imaging - a type of imaging used to visualize organs, tissues] without contrast - Order CTA [CT Angiography] head and neck to assess Intra and extracranial circulation - Order ECHO [Echocardiogram- diagnostic test on the heart]....Watch rhythm on telemetry....Aspirin ....PT/ST [Physical Therapy/Speech Therapy] consult - Frequent neuro checks - VTE [venous thromboembolism - blood clot] prophylaxis [prevention] with Lovenox.... Disposition: Place in observation. ..." Medical record review revealed Patient #19 was admitted under observation. Review of the "Physician Discharge Summary", electronically signed 04/13/2021 at 1453, revealed Patient #19 was discharged from observation 04/13/2021. Discharge Summary review revealed "...Echocardiogram (without bubble study was done given the patient's age)....A CT angiogram was done.... The patient refused MRI, even when offered sedation.... The patient was started on aspirin 81 mg. [milligrams] daily and discharged home on this. She was started on high-intensity statin with Lipitor 40 mg. at bedtime....I saw the patient myself on the day of discharge. The patient was eating and drinking okay. Vital Signs were stable at the time my evaluation. They reported feeling back to baseline and were eager to be discharged home....It was felt that the maximum benefit of hospitalization was obtained. The patient should follow up with their PCP [Primary Care Provider] within 1 week. The patient was discharged in a stable condition on 04/13/ 2021....New medications for discharge....For TIA: Aspirin 81 mg daily Lipitor 40 mg q.h.s. [every bedtime]. Medical record review revealed Patient #19 was discharged from Observation status without being seen by a neurologist, or if neurology service was not available, without being transferred to a hospital with Neurology services, which delayed a sufficient thorough medical screening.

Requests to interview the ED NP [Nurse Practitioner] and discharging DO [Doctor of Osteopathy] from Visit #1 revealed they were not available for interview.

1. b. Medical Record review revealed Patient #19 returned to the DED [Visit #2] on 04/14/2021. Triage started at 0928 and stated "...pt arrived via private vehicle with c/o [complaint of] stroke like symptoms, not able to talk and weakness. ..." Review revealed Patient #19 was given an ESI of 3 and had a pain intensity of 0 [no pain]. Vital signs were documented as Temperature [T] 98.2, Pulse [P] 63, Respirations [R] 16, Blood pressure [BP] 164/65, and Pulse Oximetry 98% on room air. Review of "ED Physician Documentation", time seen 0940, revealed "...Stated Complaint: POSS STROKE....HPI - Altered Mental Status - Timing of Symptoms ...Hours Ago (Patient again woke up this morning with symptoms similar to stroke with some dysarthria generalized weakness there were no localizing symptoms. CT a [as written] done 2 days ago did not show any obstruction. She did not get an MRI during that hospitalization.) Symptoms Presented: Came on suddenly Duration: Since onset....Review of Systems: ....Neurological: Abnormal Speech, Confusion, Weakness. negative: Headache.... MDM - Altered Mental Status - Differential Diagnosis ....CVA, Mass Lesion....Reevaluation Time 1st Reeval: 12:55 1st Reeval: Improved ....MDM Comments Plan for Disposition of Patient: Plan to Discharge Date of Decision: 04/14/2021 Time of Decision: 14:53. ..." A study labeled "...CT HEAD WITHOUT CONTRAST...", electronically signed at 0959, revealed "IMPRESSION: 1. No acute intracranial pathology." Review of a MRI of the Brain, electronically signed at 1408, revealed "...MRI BRAIN WITHOUT AND WITH IV CONTRAST ....IMPRESSION: 1. Small left ventral pontine ischemic infarct. [stroke] No hemorrhage. ..." Further record review revealed "...Discharge Diagnosis (1) CVA....CVA mechanism: thrombosis....Current Visit: yes Status: Acute - Plan Disposition Type: Discharge Condition: Stable.... Referrals: [Name] MD....2-3 Days. ..." Record review revealed Patient #19 was discharged home on 04/14/2021 at 1520. Review did not reveal a neurology consult or consideration of transfer for neurologic services. .

Interview with DO #4 on 04/28/2021 at 1605 revealed the physician was a Hospitalist and was on duty 04/14/2021. Interview revealed MD #5 contacted him about Patient #19 regarding admission. Interview revealed the information DO #4 got was that the stroke was in the Pons region and it had been going on for 2-3 days. Interview revealed the patient had a CTA and was not a candidate for thrombectomy [removal of blood clot]. Interview revealed he told MD #5 if they did not want rehab, the workup was already done. Interview revealed a CT, ECHO and carotid studies had been done, the MRI was done on the current visit, and the patient had been started on Aspirin on the 12th. DO #4 stated Pons posterior strokes were complicated, there was not much to intervene on. Interview revealed if the patient had been admitted she would have been started on heparin as DVT prophylaxis, not a treatment related to the stroke. The DO stated he did not do a physical exam on the patient, it was not a formal consult, but a conversation. DO #4 indicated he would have been happy to admit if needed, and stated the workup was done and the patient did not need /want rehab at that time.

Telephone interview on 04/28/2021 at 1630, with MD #5,revealed MD #5 was away from the hospital and did not have access to the patient's medical records at the time of the interview. Interview revealed MD #5 thought he recalled the patient. Interview revealed Patient #19 had been in with a stroke or TIA two days before. Interview revealed Patient #19's symptoms went away. Interview revealed MD #5 talked with the hospitalist who did not think the patient needed to be admitted. Further interview revealed MD #5 told the patient/family to immediately return to the ED if any symptoms returned.

1. c. DED record review revealed Patient #19 returned by ambulance 04/15/2021 at 0441 [Visit 3]. Review of "ED Physician Documentation", date/time seen 04/15/2021 at 0442 [13 hours, 22 minutes after previous ED discharge], revealed "...Patient has worsening for stroke-like symptoms since yesterday morning....This morning patient work up with increasing right-sided weakness and slurred speech as well as right facial droop. Patient reports this time the symptoms are not resolving or improving. ..." Review of the "Physician Discharge Summary", electronically signed at 1922, revealed Final Discharge Diagnoses of "...Left Pontine Stroke....Anemia....B 12 deficiency....Stroke due to stenosis of posterior cerebral artery....Hospital Course: ....She came into the [Name] ER on the early AM of 4/15 c/o resumption of right sided weakness and worsening right leg weaknes [sic] with gait ataxia that was reportedly worse than what she's had all week. Her new onset neurological issues began within this last week. Initially she was admitted through the ER from 4/12-4/13....Patient then returned to the ER....on 4/14 on the late morning c/o again of waking up in the early AM with dysarthria and generalized weakness....The ER was able to obtain MRI which showed left pons CVA....she was taken home again with referral to [Name] of local neurology. Patient presented back to the ER at [Hospital Name] today on 4/15 around 0800 c/o waking up at 0300 with more severe right leg deficits than she'd previously had, resumption of right arm weakness, and worse slurred speech than typical....repeat MRI showed slight expansion of past pons area of CVA. The patient's family is very concerned by the waxing and waning nature of her symptoms.... They request neurology evaluation. I have called [outside hospital] and discussed case with....neurology who graciously accepted the patient. Further review revealed a Nurses Note, created 04/15/2021 at 2059, which indicated "Patient transferred to [outside hospital name] at this time via EMS for treatment of CVA. ;;;"

In summary, Patient #19 did not receive appropriate medical screening exams on Visits 1 and 2. No neurologist was consulted on either visit. On Visit #1, by discharging Patient #19 without a neurology consult the medical screening examination was delayed. On Visit #2, the patient's continuing medical screening examination was not sufficient when the patient was again discharged without a neurology consult. If a neurologist or neurology service was not available, Patient #19 should have been transferred to a facility with neurology services to prevent delay in appropriate medical screening.

2. DED Medical Record review on 04/29/2021 revealed Patient #27, a 24 year old, arrived to the DED on 01/23/2021 at 1624. Review of an ED Triage Assessment, start time 1624, revealed a chief complaint of "Psych Eval" and a "Description of Symptoms" as "Pt (Patient) brought in by law enforcement for IVC (Involuntary Commitment)." Vital signs at 1630 were noted as Temperature 97.7, Pulse 96, Respirations 18, Blood Pressure 135/95 and Pulse Oximetry 100%. Patient #27 was assigned an ESI (priority level) of 2 (on a scale of 1-5, with 1 being the most emergent). Review of "Interventions" revealed a "C-SSRS (Columbia Suicide Severity Rating Scale) Safe T Triage Screening", at 1631, which indicated "...1. In the past month, have you wished you were dead or wished could go to sleep and not wake up? No 2. In the past month, have you actually had any thoughts of killing yourself? No C-SSRS Suicidal Behavior 6. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life? ....Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. was it within the past 3 months? No...Suicide Risk Level NO SUICIDE RISK .... pt denies suicidal ideation or making statements regarding the same. ..." Review of "ED Physician Documentation" notes, time seen 1632 and electronically signed by a NP on 01/24/2021 at 1311, revealed "...History of Present Illness. Presents with: Depression .... Associated Symptoms:...brought in by police with IVC papers that were petition by his [Family member] for threatened suicide. On the IVC form it states patient threatened to light his bed on fire. Patient states he has girlfriend of 10 years have recently broken up he had a child with said girlfriend. States he feels depressed but denies suicidal and homicidal ideation. States his [family member] has pulled IVC papers on him previously for depression. Patient denies said statements on IVC form....Review of Systems....Psychiatric: Depression, Other...Reported SI by family member....Physical Exam....Psychiatric: Calm Demeanor, Cooperative, Flat Affect. negative: Suicidal Thoughts, Homicidal.... 01/23/21 16:40 Reviewed and discussed case with Dr. [Name] 17:44 Patient eloped from ER. charge nurse and ER MD aware....Discharge Diagnosis (1) Suicidal ideation.... (2) Eloped from Emergency Department....(3) Depression. ..." Review of "Patient Notes", revealed an "ED Nurses Note", at 1747 which stated "pt now (?sic) in room. security notified, overhead page called at 1746." At 1754 another Nurses Note revealed "Patient eloped main ED.... Code was called. ED Provider contacted IVC petitioner. ED3 RN called 911 and reported elopement." "Patient Notes" review revealed a note at 1830 which indicated "pt appeared missing from room 7....around 1545, missing person from ED was called by registration at 1545; pt has not returned to the ER and we have not found him as of 1832" and an Addendum was added at 1841 that indicated "The entered time was wrong. It should be 1743 and 1745 respectively." Further review indicated "01/23/21 19:45.... SPOKE WITH GUARDIAN....PERMITS RN TO LET PT LEAVE HOSPITAL WITH [Family Member]. BELONGINGS RETURNED WITH PT." DED record review revealed a "Discharge" section which stated "...Emergency Discharge Date/Time 01/23/21 19:45....Disposition of Patient....Discharge....Discharge Instructions Given To....PT AND FAMILY. ..." Details of the elopement and return were not clearly evident in the medical record. Record review did not reveal evidence of a Psychiatry consult.

Review of IVC paperwork revealed Patient #27 presented to the hospital for first examination on 01/23/2021 at 1630. Review of the "AFFIDAVIT AND PETITION..." Revealed "...RESPONDENT....HAS BEEN VERY DEPRESSED. IN THE LAST FEW DAYS HE HAS THREATENED SUICIDE. HE TOLD HIS [Family member] TODAY THAT HE WAS GOING TO SET HIS BED HIS FIRE [as written]....GOES DAYS WITHOUT EATING AND SLEEPS ALL DAY SOMETIMES. ..." Review of the "FIRST EXAMINATION OF INVOLUNTARY COMMITMENT" revealed the first examination was noted to be conducted on 01/23/2021 at 1700 at the hospital and "Criteria for Commitment" were marked as "An individual with a mental illness" and "Dangerous to... Self" and a written note that documented "Patient depressed, suicidal with plan to set his bed on fire." Further review revealed the "RECOMMENDATION FOR DISPOSITION" was marked as "Inpatient Commitment... ." Review of further documentation received from the facility 04/29/2021 revealed the IVC was terminated on 01/23/2021. Review revealed documentation there was no criteria for commitment and the patient denied suicidal or homicidal ideation.

Interview with NP #6, on 04/29/2021 at 1155, revealed the NP did not recall Patient #27. Interview revealed the NP had reviewed the record. NP #6 stated she did not know how Patient #27 eloped and did not think the patient returned to the ED. Interview revealed NP #6 documented discharged once the patient eloped, stated the patient was not an AMA [against medical advice] and elopement was not a documentation choice, so the NP indicated discharged. Interview revealed if the NP was aware Patient #27 returned, she would have opened the record back up and documented. Interview revealed Patient #27 denied SI and HI.

Interview with Administrative Staff #7, on 04/29/2021 at 1430 revealed none of the nurses requested for interview for Patient #27 were available for interview.

Interview with the physician who released the IVC, MD #3, on 04/29/2021 at 1500, revealed he did not recall the patient and did not know if Patient #27 returned to the facility after he eloped. Interview revealed the providers were changing shifts at that time. As far as signing the IVC paperwork to release the patient, MD #3 stated NPs cannot sign off, the physicians have to do so. Interview revealed the handwritten note was not MD #3's handwriting but the signature was. Interview revealed MD #3 was "guessing" they realized the patient was not there and asked MD #3 to signoff the IVC since the patient expressed no SI in the ED. Interview revealed it was common for a midlevel to bring the paperwork, discuss that the patient wasn't suicidal, and ask the physician to sign the IVC paperwork. Further interview revealed the IVC would sometimes be upheld initially but once the provider talked /evaluated the patient it would be overturned Further interview revealed psychiatry might not be involved - if patients said they were not actively suicidal, providers might not get psych involved.

In summary, Patient #27 did not receive an appropriate medical screening. Although Patient #27 denied suicidal ideations while in the Emergency Department, the patient had reported suicidal ideations with a specific plan prior to his arrival. The discrepancies should have been resolved more thoroughly with the help of psychiatry prior to discharge but no psychiatry consult was obtained.

Based on policy and procedure review, medical record reviews and staff and provider interviews the hospital failed to ensure stabilizing treatment was provided as required to stabilize an emergency medical condition for 2 of 27 sampled patients [Patient #19 {visits 1 & 2} and Patient #27].

The findings included:

Review of the "Emergency Medical Treatment and Labor Act (EMTALA)...", last revised 10/2020, revealed "...DEFINITIONS: ....7. To stabilize or stabilized: A. With respect to an emergency medical condition, the patient is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the patient, or....C. The emergency medical condition has resolved...EMTALA PROVISIONS OVERVIEW....1...B....Provide necessary stabilizing treatment to an individual with an EMC (Emergency Medical Condition)....within the hospitals capacity and capability...."

1. a. Dedicated Emergency Department (DED) medical record review, on 04/28/2021, revealed Patient #19 was an 81 year old who arrived by private vehicle to the DED on 04/12/2021 at 0932 [Visit #1] with a stated complaint of stroke-like symptoms. Review revealed "...MDM - Stroke ....Differential Diagnosis: Bell's Palsy [sudden weakness in the muscles of half of the face], CVA [Cerebral Vascular Accident-stroke], Hypoglycemia [low blood sugar], TIA [Transient Ischemic Attack -brief stroke-like attack] ....Have antithrombotics been Ordered? If NO, why?: No (Symptoms had resolved.).... Reevaluation Time of 1st Reeval: 10:12 1st Reeval: Improved (Patient's symptoms have dissipated at this time, patient no longer has slurred speech, patient is moving all extremities well states she feels much better. CT negative for acute CVA.).... Consultation: Hospitalist Called: 12:37....Plan to Admit.... Diagnostic Results ....EXAMINATION: CT HEAD CODE STROKE, 4/12/2021.... IMPRESSION: Negative noncontrast head CT. No intracranial hemorrhage [bleed in the brain], mass or acute infarct [small area of dead tissue from failure of blood supply] ....Electronically Signed.... 9:55 EDT [Eastern Daylight Time]....Discharge Diagnosis (1) TIA .... Plan ....Hospitalize. ..." Review of the History and Physical, dated 04/12/2021 at 1240, revealed "...She presents the emergency department today after noticing severe balance issues at about 6:00 a.m. this morning....Per the emergency department nurse practitioner, the patient was very dysarthric [slurred speech] when she presented....By the time I evaluated the patient, the patient's NIH scale was 0. The patient had a head CT done which was negative for acute intracranial abnormality.... Assessment and Plan (1) Stroke-like symptoms ....NIHSS 6 on admission, 0 - Thrombolytic therapy not indicated, symptoms resolved, out of time window - Cause: Unknown - Order MRI brain [Magnetic Resonance Imaging - another type of imaging used to visualize organs, tissues] without contrast - Order CTA [CT Angiography] head and neck to assess Intra and extracranial circulation - Order ECHO [Echocardiogram- diagnostic test on the heart]....Watch rhythm on telemetry....Aspirin ....PT/ST [Physical Therapy/Speech Therapy] consult - Frequent neuro checks - VTE [venous thromboembolism - blood clot] prophylaxis [prevention] with Lovenox.... Disposition: Place in observation. ..." Record review revealed Patient #19 was placed in observation but did not reveal a neurology consult was ordered. Review of the "Physician Discharge Summary", electronically signed 04/13/2021 at 1453, revealed Patient #19 was discharged from observation 04/13/2021. Discharge Summary review revealed "...Echocardiogram (without bubble study was done given the patient's age)....A CT angiogram was done.... The patient refused MRI, even when offered sedation.... The patient was started on aspirin 81 mg. [milligrams] daily and discharged home on this. She was started on high-intensity statin with Lipitor 40 mg. at bedtime.... They reported feeling back to baseline and were eager to be discharged home....It was felt that the maximum benefit of hospitalization was obtained. The patient should follow up with their PCP [Primary Care Provider] within 1 week. The patient was discharged in a stable condition on 04/13/ 2021....New medications for discharge....For TIA: Aspirin 81 mg daily Lipitor 40 mg q.h.s. [every bedtime]. Review failed to reveal a neurologist was involved in management of Patient #19's care prior to discharge from observation, or if neurology services were not available, that transfer was considered. .

1. b. Medical Record review revealed Patient #19 returned to the DED [Visit #2] on 04/14/2021. Triage started at 0928 and stated "...pt arrived via private vehicle with c/o [complaint of] stroke like symptoms, not able to talk and weakness. ..." MDM - Altered Mental Status - Differential Diagnosis ....CVA, Mass Lesion....Reevaluation Time 1st Reeval: 12:55 1st Reeval: Improved ....MRI of the brain was ordered... MDM Comments Plan for Disposition of Patient: Plan to Discharge Date of Decision: 04/14/2021 Time of Decision: 14:53. ..." Review of a MRI of the Brain, electronically signed at 1408, revealed "...MRI BRAIN WITHOUT AND WITH IV CONTRAST .... IMPRESSION: 1. Small left ventral pontine ischemic infarct. No hemorrhage. ..." Further record review revealed "...Discharge Diagnosis (1) CVA....CVA mechanism: thrombosis....Current Visit: yes Status: Acute - Plan Disposition Type: Discharge Condition: Stable.... Referrals: [Name] MD....2-3 Days. ..." Record review revealed Patient #19 was discharged home. Review did not reveal a neurologist was consulted or involved in the management of Patient #19's care prior to discharge, or if neurology services were not available, consideration of transfer for stabilization.

Interview with DO #4 on 04/28/2021 at 1605 revealed the physician was a Hospitalist and was on duty 04/14/2021. Interview revealed MD #5 contacted him about Patient #19 in relation to admission. Interview revealed the information DO #4 got was that the stroke was in the Pons region and it had been going on for 2-3 days. Interview revealed the patient had a CTA and was not a candidate for thrombectomy. Interview revealed he told MD #5 if they did not want rehab, the workup was already done. Interview revealed a CT, ECHO and carotid studies had been done, the MRI was done on the current visit, and the patient had been started on Aspirin on the 12th. DO #4 stated Pons posterior strokes were complicated, there was not much to intervene on. Interview revealed if the patient had been admitted she would have been started on heparin as DVT prophylaxis, not a treatment related to the stroke. The DO stated he did not do a physical exam on the patient, it was not a formal consult, but a conversation. DO #4 indicated he would have been happy to admit if needed, and stated the workup was done and the patient did not need /want rehab at that time.

Telephone interview on 04/28/2021 at 1630, with MD #5, the physician who saw Patient #19 on the second visit revealed MD #5 was away and did not have access to the patient's medical records at the time of the interview. Interview revealed MD #5 thought he recalled the patient. Interview revealed Patient #19 had been in with a stroke or TIA two days before. Interview revealed Patient #19's symptoms went away. Interview revealed MD #5 talked with the hospitalist who did not think the patient needed to be admitted. Further interview revealed MD #5 told the patient/family to immediately return to the ED if any symptoms returned.

1. c. DED record review revealed Patient #19 returned by ambulance 04/15/2021 at 0441 [Visit 3]. Review of "ED Physician Documentation", date/time seen 04/15/2021 at 0442 [13 hours, 22 minutes after previous ED discharge], revealed "...Patient has worsening for stroke-like symptoms since yesterday morning....This morning patient work up with increasing right-sided weakness and slurred speech as well as right facial droop. Patient reports this time the symptoms are not resolving or improving. ..." Review of the "Physician Discharge Summary", electronically signed at 1922, revealed Final Discharge Diagnoses of "...Left Pontine Stroke....Stroke due to stenosis of posterior cerebral artery....Hospital Course: ....Patient presented back to the ER at [Hospital Name] today on 4/15 around 0800 c/o waking up at 0300 with more severe right leg deficits than she'd previously had, resumption of right arm weakness, and worse slurred speech than typical....repeat MRI showed slight expansion of past pons area of CVA. The patient's family is very concerned by the waxing and waning nature of her symptoms.... They request neurology evaluation. I have called [outside hospital] and discussed case with....neurology who graciously accepted the patient. Further review revealed a Nurses Note, created 04/15/2021 at 2059, which indicated "Patient transferred to [outside hospital name] at this time via EMS for treatment of CVA. ;;;"

In summary, Patient #19 came to the DED with stroke-like symptoms, with confirmation of a stroke on the second visit. There was no neurology consult ordered or obtained. With no Neurologist involved in the management of Patient #19's care the Emergency Medical Condition was not stabilized prior to discharge. If no neurologist or neurological services were available Patient #19 should have been transferred to a facility with those services to prevent delay in stabilization.

2. DED Medical Record review on 04/29/2021 revealed Patient #27, a 24 year old, arrived to the DED on 01/23/2021 at 1624. Review of an ED Triage Assessment, start time 1624, revealed a chief complaint of "Psych Eval" and a "Description of Symptoms" as "Pt (Patient) brought in by law enforcement for IVC (Involuntary Commitment)." Review of "ED Physician Documentation" notes, time seen 1632 and electronically signed by a NP on 01/24/2021 at 1311, revealed "...History of Present Illness. Presents with: Depression .... Associated Symptoms:...brought in by police with IVC papers that were petition by his [Family member] for threatened suicide. On the IVC form it states patient threatened to light his bed on fire....States he feels depressed but denies suicidal and homicidal ideation. States his [family member] has pulled IVC papers on him previously for depression. Patient denies said statements on IVC form....17:44 Patient eloped from ER....Discharge Diagnosis (1) Suicidal ideation.... (2) Eloped from Emergency Department....(3) Depression. ..." Review of "Patient Notes", revealed an "ED Nurses Note", at 1747 which stated "pt now (?sic) in room. security notified, overhead page called at 1746." At 1754 another Nurses Note revealed "Patient eloped main ED.... Code was called. ED Provider contacted IVC petitioner.... RN called 911 and reported elopement." "Patient Notes" review revealed a note at 1830 which indicated "pt appeared missing from room 7....around 1545, missing person from ED was called by registration at 1545; pt has not returned to the ER and we have not found him as of 1832" and an Addendum was added at 1841 that indicated "The entered time was wrong. It should be 1743 and 1745 respectively." Further review indicated "01/23/21 19:45.... SPOKE WITH GUARDIAN....PERMITS RN TO LET PT LEAVE HOSPITAL WITH [Family Member]. BELONGINGS RETURNED WITH PT." DED record review revealed a "Discharge" section which stated "...Emergency Discharge Date/Time 01/23/21 19:45....Disposition of Patient....Discharge....Discharge Instructions Given To....PT AND FAMILY. ..." Details of the elopement, potential return and discharge were not clear in the medical record. There was no evidence Psychiatry was consulted or evaluated Patient #27.

Review of IVC paperwork revealed Patient #27 presented to the hospital for first examination on 01/23/2021 at 1630. Review of the Review of the "FIRST EXAMINATION OF INVOLUNTARY COMMITMENT" revealed it was conducted on 01/23/2021 at 1700 at the hospital and "Criteria for Commitment" were marked as "An individual with a mental illness" and "Dangerous to... Self" and a written note that documented "Patient depressed, suicidal with plan to set his bed on fire." Further review revealed the "RECOMMENDATION FOR DISPOSITION" was marked as "Inpatient Commitment... ." Review of further documentation received 04/29/2021 revealed the IVC was terminated on 01/23/2021. Review pf the documentation revealed there was no criteria for commitment and the patient denied suicidal or homicidal ideation.

Interview with NP #6, on 04/29/2021 at 1155, revealed the NP did not recall Patient #27. Interview revealed the NP had reviewed the record. NP #6 stated she did not know how Patient #27 eloped and did not think the patient returned to the ED. Interview revealed NP #6 documented discharged once the patient eloped, stated the patient was not an AMA [against medical advice] and elopement was not a documentation choice, so the NP indicated discharged. Interview revealed if the NP was aware Patient #27 returned, she would have opened the record back up and documented. Interview revealed Patient #27 denied SI and HI.

Interview with the physician who released the IVC, MD #3, on 04/29/2021 at 1500, revealed he did not recall the patient and did not know if Patient #27 returned to the facility after he eloped. Interview revealed the providers were changing shifts at that time. As far as signing the IVC paperwork to release the patient, MD #3 stated NPs cannot sign it, the physicians have to do so. Interview revealed the handwritten note was not MD #3's handwriting but the signature was his signature. Interview revealed MD #3 was "guessing" they realized the patient was not there and asked MD #3 to signoff the IVC since the patient expressed no SI in the ED. Interview revealed it was common for a midlevel to bring the paperwork, discuss with the physician that the patient wasn't suicidal, and ask the physician to sign the IVC paperwork. Further interview revealed the IVC would sometimes be upheld initially but once the provider talked /evaluated the patient it would be overturned. Further interview revealed if patients said they were not actively suicidal, providers might not get psychiatry involved.

In summary, Patient #27 eloped, potentially returned to the DED and was then allowed to leave with family without Psychiatry being consulted. Although the patient denied suicidal ideation in the ED when a risk assessment was done, he had reported suicidal ideation with a specific plan prior to arrival. Psychiatry was needed to resolve the discrepancy more thoroughly. By not involving Psychiatry in the management of Patient #27 prior to discharge, stabilization was delayed.