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Based on interviews and document review the hospital's noncompliance with the requirements under EMTALA presented when the hospital failed to provide emergency services to Patient 50 when hospital staff observed him lying on the ground, in need of medical assistance, on the southwest perimeter of the hospital property.

Based on staff and independent contractors' interviews; clinical record, hospital and public documents review, the hospital failed to provide a medical screening examination (MSE) when Patient 50 was observed by hospital staff lying within 250 yards of the hospital's property. Staff observing Patient 50 reported the location to the security guards and the ED staff. The staff's initial responses had potentially delayed medical treatment for Patient 50, possibly contributing to Patient 50's death.

Findings:

During an interview with concurrent record review on 10/5/11 at 2 p.m., Licensed Nurse B stated Patient 50 was discharged and escorted outside the hospital through the ED on the evening of 9/19/11. The ED Summary Sheet indicated the ED disposition time to be 8:48 p.m. Licensed Nurse B stated, "I don't remember when he was discharged. Normal practice is for a patient to be discharged out of the computer as soon as he leaves the ED; however I wanted to see him walk before I took him out of the computer. I had him (Patient 50) do standby assist (the presence of another person in the event assistance is needed) with Unlicensed Staff M before he was discharged."

During an interview on 10/5/11 at 8 a.m., Unlicensed Staff M stated that on 9/19/11 he was asked to escort Patient 50 to the restroom and then to the outside (out of the ED) because he was discharged. Unlicensed Staff M mentioned that Patient 50 stated, "How do I get out of here?" and then said, "Thank you." Unlicensed Staff M further elaborated that he did not need to "help him" (physical support) (Patient 50) when he went to the restroom or when he left the ED.

During an interview on 10/5/11 at 7:20 a.m., Licensed Nurse D stated that during her shift on the evening of 9/19/11 at 9:45 p.m. Patient 50 was found in the main hospital sitting on the floor by the cafeteria. Licensed Nurse D stated that she and the security guard (unidentified) asked Patient 50, "What are you doing in here? Patient 50 replied, "I can't walk." Licensed Nurse D reported, "He could walk fine and he walked with the security guard out the main entrance (hospital)."

A document review during a survey extension on 12/28/11, indicated a signed statement by Security Guard K which showed, "I asked Patient 50 if he would follow me and I would take him to the sidewalk or the bus stop. He (Patient 50) said he wanted to go the bus stop. We walked outside and started toward the bus stop. He (Patient 50) stopped in the loop and said he was tired. He sat down on the curb and I let him rest. After a minute or so he got back up without being asked and we continued. We got in the ED parking lot and he said he needed to rest again and he sat down in the parking lot. He sat for a minute or so and got up again without being asked and he followed me the rest of the way to the bus stop and he sat on the bench." Security Guard K then left Patient 50 and returned to his scheduled duties.

During a document review on 10/5/11 of the security guards' report titled, "Daily Activity Record" dated 9/19/11, it indicated that at 9:45 p.m. Security Guard K "escorted discharged patient to bus stop."

Introduction to the Following Events:

On 9/20/11, staff (Licensed Staff C, Hospital Staff H, Hospital Staff J) were coming into work for the day shift. Following their usual routine of passing through the southwest corner of the hospital's property hospital staff observed a male (Patient 50) lying on the ground. In addition, Security Guard G observed Patient 50 when in followed-up on requests for assistance by hospital staff. Written and oral reports of the events are as follows:

During an interview on 10/5/11 at 11:40 a.m., Licensed Nurse C stated that while walking to work for the day shift, through the southwest corner of the hospital's property, on 9/20/11 she noticed a male, "awake, alert and moving." Licensed Nurse C asked the individual (Patient 50), "Are you ok?" Patient 50 stated, "Not really." Licensed Nurse C indicated Patient 50 did not appear to be in acute distress. "He was calm, not short of breath, and was lying on his side on the ground." Licensed Nurse C stated that she informed the security guard (name unknown) at the main entrance of the hospital that there was a male on the ground at the edge of the hospital property. Licensed Nurse C further explained that the security guard mentioned that he (Patient 50) could be drunk. There was a second unidentified security guard speaking with the first security guard. Licensed Nurse C stated, "I looked at the guy (first unidentified security guard) at the desk, he looked at me, we made eye contact and he said, "I will take care of that." Licensed Nurse C stated she felt he would take care of the man.

During an interview on 10/5/11 at 5 p.m., Security Guard G stated, "At around 7:20 a.m., on 9/20/11, a lady came into the hospital lobby and said someone was lying on the fire lane. I drove the van to the scene. The man was shaking, lying down, reaching out with his arms, breathing, and I saw his hospital armband and read his name. I called out Patient 50's first name, his eyes opened. That was his only response." Security Guard G went on to explain that he drove back to the ED, went to registration and spoke with someone in registration (unidentified) who in turn called a nurse (unidentified). The nurse took me to the lead nurse. Security Guard G stated that the lead nurse told him, "We did not see it. This is your problem. I ran into Security Guard L and he took over the situation."

On 12/27/11, during a survey extension, record review of Security Guard G's written statement indicated, "At approximately 7:15 a.m. a hospital employee- white female...came to the lobby and told me a person was laying down at the fire lane exit. At approximately 7:20 a.m. ...I saw the person laying down and alive. Not knowing exactly what to do I went to the E.R. (Emergency Room) for assistance. I talked to the E.R. [staff] and she got ahold of a RN. The RN got ahold of the Lead Nurse. I explained the situation to her and I suggested the paramedics. She didn't think that was necessary and that it was my problem, not theirs. I put the van back in the garage and returned to the lobby. My supervisor was there and took over the situation. At approximately 8 a.m., a fireman came to the lobby and reported the man was dead."

During an interview on 10/5/11 at 10:35 a.m., Hospital Staff I stated that at 7:25 a.m. (on 9/20/11), Security Guard G came to the ED and said there was a male down in the parking lot by the fire gate. "He is down, talking, mumbling, shaking." Hospital Staff I stated, "I told Licensed Nurse E. A few minutes later I told her to tell the lead nurse. Licensed Nurse F (Lead Nurse) told me not to go out in the parking lot, not our policy...".

During an interview on 10/4/11 at 3:30 p.m. Licensed Nurse E stated that on 9/20/11 at 7-7:30 a.m. a security guard (unidentified) came to the emergency room seeking assistance from the ED staff for a man down. The security guard did not give exact location. Licensed Nurse E stated she told the guard, "I will grab a wheelchair and go with you. I also told the guard I had to tell my lead nurse." Licensed Nurse E reported the situation to Licensed Nurse F, her Lead Nurse. Licensed Nurse F stated, "if concerned call 911." Licensed Nurse E stated, "I felt uncomfortable, impeded and yet I know I have to follow my lead nurse's directions." She went on to say, the visual look on the security guard's face told me he needed assistance. He was told by the ED staff, "You need to take responsibility for this." Licensed Nurse E said the security guard responded, "We are working on this."

During an interview on 10/5/11 at 9 a.m., Licensed Nurse F stated Licensed Nurse E, Hospital Staff I, and an unidentified security guard were in the ED the morning of 9/20/11. The unidentified guard was describing a male who had wet himself and he couldn't understand what he was saying... Licensed Nurse F confirmed that security should call 911 if not comfortable with the situation. Licensed Nurse F stated, "if the medics came he would get medical attention if he required it or the police would respond and he would be escorted off if necessary."

During an interview on 10/4/11 at 4:40 p.m. and a subsequent phone interview on 10/12/11 at 10:50 a.m., Hospital Staff J stated she saw a male lying on the ground when coming to work on 9/20/11 around 7:40 a.m. She stated she stopped to watch and described his (Patient 50's) breathing as "funky, arrhythmic (without rhythm or regularity) and saw spaces between breaths." Hospital Staff J also described the male with his eyes open, "glossy" [glassy]. Hospital Staff J called out, "Hello, can you hear? Do you need help? He would not respond." Hospital Staff J went on to say that she saw the security guard (unidentified) sitting in the van at the hospital's main entrance. She stated, I asked the security guard if the ED knew about the individual and he said "yes". She added, "I can't believe they're not doing something." Hospital Staff J stated the following- I went to the ED. There were two nurses (unidentified) discussing the incident related to Patient 50. I told them that was why I am here. One of the nurses said, "It's not that we don't care. He has been here the last two to three days. He has probably got drugs at the creek and is sleeping it off."
During an interview on 10/4/11 at 3 p.m., Hospital Staff H stated she was on her way to work (day shift) on 9/20/11, when she saw someone on the ground, on their back, with their hands extended out and their head facing the street. She yelled out, "Are you ok?" A male passer-by stayed with me. (I wanted to be safe because I wasn't sure of the situation.) Hospital Staff H went on to say, "I touched him, he was cold, I couldn't see his face. I told the guy with me, I think he is dead. I stared at his chest, no respirations. I checked his other arm and neck, no pulse. I told the male passer-by he is dead. I remembered my cell phone was 'dead' so I told the male passer-by to call 911. I walked fast to the main hospital and told the security guard (unidentified) a man outside is dead. He asked me if this is about the male by the emergency gate."

Record review during a survey extension on 12/27/11, Security Guard L wrote in his report, dated 9/20/11, the following statement: ... On 9/20/11, I started my shift at approximately 08:08 hours and Hospital Staff H came to the (hospital's) front desk to inform Security Guard G of a man laying down in the valet parking lot and that she needed help. I (Security Guard L) started to go out to investigate, as Hospital Staff H was trying to explain what she had found. Security Guard G said, "you mean the guy in the parking lot by the metal gate?" Hospital Staff H said 'Yes'.

Security Guard L also wrote in his 9/20/11 report that Security Guard G stated, "Yes, I know about him. I am trying to give Security Guard L the pass down (report prior shift activities to oncoming staff), at that point I (Security Guard L) stopped and stayed to get the pass down from Security Guard G. Security Guard G informed me there was a man that was laying down in the valet parking lot and he was incoherent. I also asked Security Guard G if the person was asleep or if he needed medical attention. Security Guard G reported, "He has had about five people complain about him. ... At approximately 8:14 hours a Santa Rosa fire fighter came into the main lobby to let us know that there was a deceased man...".

During a review of the security guards' "Daily Activity Report" the following entries were made:
- Security Guard K wrote on 9/19/11 at 9:45 p.m., "Escorted discharged patient to bus stop."
- Security Guard L wrote on 9/20/11 at 8:14 a.m., "Called out to the valet parking lot to assist with a deceased male subject."

During record review on 10/12/11, EMS (Emergency Medical Services) provider's narrative for Patient 50 on 9/20/11 at 8:01 a.m. stated, "...Pt (Patient) found supine at ground, pulseless, apneic, unresponsive. 911 by passerby who noted pt (patient) lying on the ground, unwitnessed arrest (cardiac/respiratory)...".

An interview during a survey extension on 12/28/11 at 2:25 p.m., the Chief Nursing Officer was asked by the surveyor why during the interviews hospital staff stated they were not to assist and should call 911 when responding to a concern for an individual needing medical assistance on the hospital property? Chief Nursing Officer responded, "The policy was not as clear as it should have been. The ED [staff] was not to leave the department if on the outside. EMS was typically to respond if there was a need a distance away. Somewhere along the way staff must have been told...miscommunicated. The policy is not as strong as it should have been."

A record review during a survey extension on 12/28/11 of an agreement entered into and effective on 4/1/08 between the hospital and the contractor providing the hospital's security needs read, "...Contractor shall endeavor to provide Services such that a cooperative team spirit conducive to quality patient care and a quality working environment is evident."

During a review of the hospital's policy titled, "Visitor Accident or Injury on Hospital Campus" located in the Administrative Policy/Procedure Manual with the last revised date of 4/11 indicated under 'Policy'- "When there is an accident or injury to any visitor on any hospital campus, the person is to be stabilized and transported to the Emergency Department as appropriate.

Covered in the same title under "Procedure" indicated the following:
I. Main Hospital Campus- 1165 Montgomery Drive
The first employee on the scene is to take the following steps.
A. Stabilize the person. Call for ED assistance if indicated.
B. Transport the person to the ED for evaluation by an ED physician. Always accompany the person to the ED.
C. Notify the ED registration secretary that this person is a visitor and requires assessment for injury... .

In addition, under Section III of "Visitor Accident or Injury on Hospital Campus", Procedure:
III. All off campus sites other than Urgent Care locations:
A. Stabilize the patient. Call "911" if emergency medical assistance is indicated.
Request transport to Santa Rosa Memorial Hospital's ED... .