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Based on video surveillance review, document review, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to provide a medical screening examination (MSE) by a qualified practitioner, to determine if an emergency medical condition existed. (A-2406)

The Immediate Jeopardy (IJ) began 10/16/2022 due to the Hospital's failure to conduct a medical screening and examination by the licensed medical practitioner to determine if any emergency medical condition existed when patient was initially brought to the Emergency Department (ED) via ambulance by the paramedics. Subsequently, the patient was brought back a second time the same day to the ED by the paramedics after cardiac arrest and was DOA (Dead on Arrival), and was identified on 1/5/2023, at 42 CFR 489.24, Compliance with 489.24-489.20(l). The IJ was announced on 1/5/2023 at 5:00 PM during a meeting with the President of the Hospital, Assistant Chief Nursing Officer, Chief Nursing Officer, Chief Medical Officer, Director of Collaborative Care, and Regulatory/Compliance Specialist. The IJ was not removed by the survey exit date of 1/5/2023.

Based on video surveillance review, document review, and interview, it was determined that for 1 of 20 patients (Pt. #2) that presented to the Emergency Department (ED) seeking emergency services, the Hospital failed to ensure the patient was listed in the central log.

Findings include:

1. On 12/27/2022 at 11:00 AM, the video surveillance for ED - Triage and Waiting Area dated 10/16/2022 beginning from 1:00 AM was reviewed along with Manager of Public Safety (E #11). The video footage on 10/16/2022 showed:

-1:02:00 AM (hour/minutes/seconds) - One female paramedic (Z #1) brought Pt. #2 to the front triage area on a wheelchair.

- 1:04:11 AM, Pt. #2 was escorted out of the ED by two public safety officers (E #2 and E #4).

- From 1:04 AM through 1:29 AM, Pt. #2 was outside the Hospital's ED. At 1:29:41 AM, Pt. #2 was taken by CPD (Chicago Police Department) officers and left the Hospital's ED.

2. On 12/27/2022 at 10:05 AM, the ED central log from 10/15/2022 to 10/16/2022 was reviewed. The log did not indicate that Pt. #2 was brought to the ED by the paramedics on 10/16/2022 at 1:02 AM.

3. On 12/27/2022 at 1:50 PM, the Hospital's CFD (Chicago Fire Department) EMS (emergency medical services) run sheet for Pt. #2 dated 10/16/2022 at 12:53 AM, was reviewed and included, " ... (Pt. #2) was taken to [the Hospital] ...chief complaint abdominal distress and ETOH (alcohol) intoxication ... and when (Pt. #2) arrived, (Pt. #2) became combative ..."

4. On 12/28/2022 the Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) dated 11/2022 was reviewed and included, " ...C. Central Log: 1. The Hospital must maintain a central log of individuals who come to the emergency department and include in such central log whether such individuals refused treatment ...the central log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ..."

5. On 12/27/2022 at 1:20 PM, the Director of ED (E #8) and Assistant Chief Nurse Officer (E #9) were interviewed. E #8 stated that any patient that presents to the ED should have been registered. E #9 stated that they should have logged Pt. #2 when he was brought to the ED.

6. On 12/27/2022 at 1:51 PM, the Lead Logistics Technician/Registration Staff (E #10) was interviewed. E #10 stated that she was the greeter at the front desk and should have checked-in Pt. #2 when he was brought in by the paramedics. E #10 stated that she asked the patient his name but he did not tell her. E #10 stated, "This patient (Pt. #2) was not registered, in hindsight, the patient should have been registered. Every patient that comes to the ED must be registered. If they did not tell their name, I should have documented as 'name unknown' with the date, time, and chief complaint."

Based on video surveillance review, document review, and interview it was determined that for 1 of 20 patients (Pt.#2) reviewed for emergency medical services, the Hospital failed to conduct a medical screening and examination by the licensed medical practitioner to determine if any emergency medical condition existed when patient was initially brought to the Emergency Department (ED) via ambulance by the paramedics. Subsequently, the patient was brought back a second time the same day to the ED by the paramedics after cardiac arrest and was DOA (Dead on Arrival).

Findings include:

1. On 12/27/2022 at 11:00 AM, the video surveillance for the emergency department (ED) - Triage and Waiting Area dated 10/16/2022 beginning from 1:00 AM was reviewed along with Manager of Public Safety (E #11). The video footage of 10/16/2022 showed:

-1:02:00 AM (hour/minutes/seconds) - One female paramedic (Z #1) brought Pt. #2 to the front triage area on a wheelchair. Pt. #2 did not have his shirt on. Behind Z #1 and Pt. #2 were a male paramedic (Z #2) and two (E #2 and E #4) Hospital's Public Safety Officers.

-1:04:10 AM - Pt. #2 gets up again from the wheelchair, pushes his wheelchair back, points finger at E #2 and E #4 (public safety officers), and one more public safety officer was seen walking to the scene. The Triage Nurse (E #1) was watching from the triage room.

-1:04:11 AM - E #2 stood by Pt. #2's left side and held Pt. #2 at the back of the neck. E #4 stood by Pt. #2's right side, held Pt #2's right shoulder and upper arm, walked Pt. #2 out to the ED main entrance, and closed the automatic door. An unidentified public safety officer was seen placing his foot by the ED door, preventing the automatic door from opening.

-1:05:43 AM - While inside the ED, an unidentified public safety officer was still seen holding the automatic entrance door from opening. Pt. #2 was still laying on the floor outside the ED without his shirt.

-1:08:10 AM - Pt. #2 was seen getting up from the floor and tried to open the glass door to enter the ED. The unidentified public safety officer from inside the ED blocked the automatic door from opening by using his leg.

-1:08:47 AM - Pt. #2 seen trying to force open the door again using both his hands.

Two public safety officers (E #2 and E #4) escorted Pt. #2 outside of ED without the input or assessment by the Triage Nurse (E #1) or Team Lead/Charge Nurse (E #3). The ED physician was not made aware of Pt. #2's arrival to the ED. Pt. #2 did not receive medical-screening examination to determine if Pt. #2 had an emergency medical condition.

2. On 12/27/2022 at 10:05 AM, the ED log dated 10/16/2022 was reviewed. The log included, "Time: 0600 (6:00 AM) ... (Name of Pt. #2) ...(age) ...(sex) ...complaint: Cardiac Arrest ...Arrival: CFD [Chicago fire department] ...Disposition: EXP. DOA [expired/ Dead on arrival] ...Disposition Date/time: 10/16/2022 -10:00 AM."

3. On 12/28/2022 the Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) dated 11/2022 was reviewed and included, " ...If an individual comes to the Emergency Department: A. The Hospital will provide an appropriate medical screening examination within the capability of the Hospital's Dedicated Emergency Department ...to determine whether or not an emergency medical condition exists... Qualified Medical Person or Qualified Medical Personnel... to perform Medical Screening Examination. In the Hospital, qualified medical personnel are limited to physicians, physician assistant, and nurse practitioners..."

4. On 12/27/2022 during the observation of the video footage, at 11:10 AM, the Manager of Public Safety (E #11) was interviewed. E #11 stated that they (public safety officers E #2 and E #4) put the patient outside the ED because he (Pt. #2) was making threats to the staff and was using profanity. E #11 stated that the security staff thought of keeping the patient (Pt. #2) outside the ED would be safe until the CPD (Chicago Police Department) arrived. E #11 stated that the video footage did not indicate if the triage nurse or the charge nurse advised the security officers to walk the patient outside of the ED and put him outside.

5. On 12/27/2022 at 12:38 PM, the Senior Manager of Patient Safety and Patient Relations (E #7) was interviewed. E #7 stated that he reviewed the MIDAS (occurrence report) sheet on 10/16/2022 regarding Pt. #2 and brought it to the attention of the Director of ED (E #8). E #7 stated that a root cause analysis was done and several plan of correction items were put together since 11/01/2022. E #7 stated that on the day of the event (10/16/2022) at 1:00 AM, the triage area was not crowded, there was only one (1) patient in the triage room. E #7 stated that he was not sure why the paramedics brought the patient through the front door instead of bringing the patient (Pt. #2) through the ambulance bay. E #7 stated that there were rooms available in the ED and the patient (Pt. #2) could have been accommodated, ED was not full. E #7 stated that he was not sure why the ED physician was not notified regarding the patient (Pt. #2). E #7 stated that the security officers should not have put the patient (Pt. #2) outside the ED, they should have de-escalated the situation and handled it better. E #7 stated that they should have provided the medical screening and examination for the patient (Pt. #2).

6. On 12/27/2022 at 1:20 PM, the Director of ED (E #8) and Assistant Chief Nurse Officer (E #9) were interviewed. E #9 stated that they did not make the best decision of leaving the patient outside the ED without doing a medical screening examination or triaging. E #8 stated that they should have called a Code BERT (Behavioral Emergency Response Team) and the team would have responded including the clinicians to make a better judgement. E #9 stated that the security officers did not wait for the triage nurse or the charge nurse to intervene instead walked the patient out of the ED and blocked the door not allowing Pt. #2 to enter the ED. That was not the right thing to do.

7. On 12/27/2022 at 2:02 PM, the Manager of Public Safety (E #11) was interviewed. E #11 stated that it was not okay for the security officers to have put the patient (Pt. #2) outside the ED. E #11 stated that he suspended five (5) security officers immediately after reviewing the video footage on 10/16/2022 and terminated them on 10/21/2022. E #11 stated that he was appalled watching the video and how the security officers treated the patient (Pt. #2) without any orders or advice from nursing or ED physician.

8. On 12/27/2022 at 2:17 PM, the ED Physician (MD #1) was interviewed. MD #1 stated that, he was not the physician when the patient was brought initially by the paramedics at 1:00 AM. MD #1 stated that he first saw the patient (Pt #2) at 6:00 AM, when brought in by the paramedics with chief complaint as cardiac arrest and DOA. MD #1 stated that he was pronounced dead on 10/16/2022 at 6:14 AM. MD #1 stated that when the paramedics brought him to the ED initially at around 1:00 AM, they should have notified the Triage Nurse or the ED physician. MD #1 stated that abdominal distress and alcohol intoxication was the initial reason for the paramedics bringing in the patient and would have treated him accordingly in ED room immediately.