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Based on facility policy review, medical record review, and staff and physician interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure organized and effective emergency services were in place to meet the needs of patients that presented to the Emergency Department.

The findings include:

The hospital's emergency department (ED) staff failed to ensure an organized and effective emergency services by failing to provide care and treatment including failing to evaluate, monitor and provide treatment to emergency department patients to prevent delays; failing to implement laboratory and EKG orders; and/or failing to explain the riks of leaving and benefits of staying to patients who were leaving the ED against medical advice for 7 of 21 sampled emergency department patients (#4, #9, #19, #7, #1, #14, and #13)

Cross refer to §482.55: Emergency Services Standard Tag A 1101.

Based on policy review, medical record review and staff interview the hospital staff failed to notify a patient's legal guardian of patient treatment decisions and discharge disposition.

Findings include:

Review of the hospital's policy "Patient Rights and Responsibilities, ECUH-PFE7" - PolicyStat ID 15129086, last revised 02/2024, revealed "Purpose ...All team members, medical team members and contracted agency team members shall observe these patient rights ...H. Be informed (or have your representative informed) about the outcome of your care ...Section E- Additional rights of mental health patients ...D. You are considered legally competent unless a court decides that you are incompetent ..."
Review of the hospital policy "Guardianship, ECUH-CS35" - PolicyStat ID 15213026, last revised 04/2024, did not address the procedure for involving a patient's legal guardian in their care. No specific hospital policy was provided by staff when requested that specifically addressed contact with an adult patient's legal guardian for treatment decisions or discharge disposition for an adult patient.

Review of family notification process education entitled "Family Notification, Go Live Date: 05/20/2024". Per education, " ...with the patient's consent, a family member or designated representative MUST be notified as this is a new requirement for Patient Access Services (registration) (PAS), Emergency Department (ED) nurse, and/or IP (Inpatient) Nurse. It is important to respect patient privacy and autonomy by seeking their approval before sharing any personal health information ...When PAS (registration staff) attempts to contact a patient's family or representative is unsuccessful, it is the responsibility of the ED Nurse to take over this task. The Family Notification section has been added to the Triage and ED Navigator". This new process was put in place after there were identified problems with family notifications.

Review of the closed medical record for Patient # 5 on 09/25/2024 revealed a 57-year-old male that presented to the ED on 06/02/2024 accompanied by law enforcement (LE). He was admitted at 1910 as an Involuntary Commitment (IVC) with a chief complaint of psychosis (a mental health disorder characterized by a disconnection from reality) and a history of schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves). Review of the medical record revealed Patient # 5 had a legal guardian with guardianship papers scanned into the system on 05/03/2024. Guardianship papers were dated 11/16/2023. Review of the EPIC system (electronic medical record) revealed a flag prominently displayed on the left side of the patient record showing that patient # 5 has a legal guardian. Per closed medical record review in regard to the 06/02/2024 admission, EPIC field "Notify Family or Rep on Admission?" the response was "unable to ask". The field "Family or Representative Notified" and "Family or Rep Contact Comments" are both blank. Patient # 5 remained in the ED until he was transferred to an inpatient psychiatric facility (without legal guardian notification) on 06/06/2024. Comprehensive review of closed medical record (including ED flowsheets, psychiatric consult and progress notes, psych triage notes, registration records and nursing and medical progress notes) did not reveal any documentation of contact with patient # 5's legal guardian from admission to discharge. Facility staff failed to notify legal guardian of treatment decisions, continuing care or discharge disposition. Patient #5 was accepted to the referring inpatient psychiatric facility on 06/05/2024 at 1302 and was subsequently discharged there on 06/06/2024 at 1040. There was no documentation of notification to the patient's legal guardian of the location where the patient was sent.

On 09/26/2024 at 1048, previous admission closed medical records were reviewed for patient # 5. He was admitted from 04/16/2024 to 04/19/2024 and no family contact (or legal guardian contact) was found in that record but there was a behavioral health triage note which stated, "Guardianship documents in Media tab".

An interview was conducted on 09/25/2024 at 1145 with ED Nursing Manager #3 in regard to notification of legal guardian for named
patient # 5. After thorough review of the record, she stated "It does not look like we called the guardian but it looks like we called the court". RN note dated 06/03/2024 revealed that the writer "called the clerk of the court office Halifax county & verified [ ...] is pt legal guardian, information given to registration @ this time, plan of care ongoing, charge nurse [ ...] made aware, interim ED director [ ...] made aware, plan of care ongoing." Writer was not able to be interviewed as they no longer work at the facility.

On 09/26/2024 at 1048, closed medical record was reviewed (including previous admissions) with Quality RN #13. Pt #5 was admitted from 04/16/2024 to 04/19/2024 and no family contact (or legal guardian contact was found). In regard to admissions in April 2024 and June 2024, per Quality RN #13, "I don't see where anyone was talked to". "If they did, they aren't documenting".

An interview was conducted with Corporate Quality Manager #19 on 09/26/2024 at 1610 in which she was asked for the policy that addresses notification of legal guardian in regard to care and treatment. Policies that were provided were "Informed Consent", ECUH-CS4- PolicyStat ID 15998577, last revised 09/2024 and "Family Presence and Visitor Policy and Guidelines", ECUH-PFE2- PolicyStat ID 15693199. Per Corporate Quality Manager #19, "I think what you are looking for is a combination of these". Neither policy addressed notification of guardian with treatment decisions or discharge disposition. Both policies were in effect after patient #5's admission.

An interview with Psych ED (locked section of ED for psychiatry patients) RN #19 on 09/27/2024 at 0845 revealed that "it was the RN's responsibility to contact the POA upon presentation to the Psych ED, especially if IVC'd". He stated that he would confirm with the provider and/or charge RN first to make sure there were no legal reasons (suspected abuse, etc.) that would preclude him from contacting first. Once the patient was to be admitted and/or ready for transfer "the water gets a little muddy" and he usually leaves that up to the CM (Case Manager) working the case to complete all those calls.

An interview was conducted with Quality Director #12 on 09/27/2024 at 1042 in regard to family notification process education. Per Quality Director #12, "new process (family notification) go live was 05/20/2024 systemwide. Now we have Patient Access Screen (PAS). They (registration) verify legal guardian is accurate. Goes to ED triage nurse automatically. They are still asking permission to contact the guardian. The nurse would pick up off the list that there is a guardian." "If there is a guardian, they are supposed to notify them." If patient is in the ED, the ED nurse would go into the record. "It should be documented in the nurse's note who they talked to and information they gave." "Guardian should be kept up with everything going on." When asked if patient's legal guardian should be informed of disposition and if it should be documented, Quality Director #12 stated, "Yes, the primary nurse would need to hand off to the facility and to the guardian".

An interview was conducted with Patient Access Services Manager #14 with Patient Access Services Manager #15 present on 09/27/2024 at 1145. When asked when the legal guardian flag on the left side of the EPIC screen was added, he stated, "It does not tell you". In regard to the person that completes registration when a patient presents to the ED, he stated "They (registration) should notify the legal guardian, the registrar would have to notify them to verify the registration information."

A telephone interview was conducted with Risk Management Manager #16 on 09/27/2024 at 1318 who stated that "I don't have any record of a (risk management) consult with this patient's name, I don't have anything for a (risk management) consult on that date from North (named hospital)" when asked if risk management was consulted about this patient for his admission on 06/02/2024 through 06/06/2024. When asked about the protocol for a psychiatric patient under IVC with a legal guardian transferred to an outside facility she stated, "In general terms, IVC or not, before we transfer a patient anywhere, typically we notify the legal next of kin". When asked who would take ownership of notifying the legal next of kin, she stated, "It may be case management, ED should have someone who supports".

An interview was conducted with Corporate Quality Manager #17 on 09/27/2024 at 1343 in regard to documentation on patient #5's record showing that patient's legal guardian was contacted during his admission. She states, "I don't think we had one in here". "I can't find anything". "I am not saying we didn't do it". When asked who is responsible for notifying a patient's legal guardian of admission, ongoing care and disposition she stated, "It is supposed to be the bedside people". She stated that she had received an email from the System Administrator for Behavioral Health who told her it's at the local level to do the notification.

A telephone interview was conducted on 09/27/2024 at 1418 with Behavioral Health Triage Manager #18. When asked about the procedure from patient consult to disposition she stated, "My team (Behavioral Health Triage) does not do the actual assessment. They call the hospitals (they cover) each morning. They are asked can they locate a bed. They will make referrals to facilities. Once they get an acceptance and the accepting physician's name, they let the team (inpatient hospital team) know who the facility is and the number to call report. They are done with the case." "The nurse and the doctor arrange transport, contact guardians, whatever they need to do to get them transferred". When asked if they speak to the patient she stated "no, typically the nurse will let them know if they (the patient) say that don't want to go somewhere".

Based on facility policy review, medical record review, and staff and physician interviews, the facility staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department.

The findings included:

The hospital's emergency department (ED) staff failed to ensure an organized and effective emergency services by failing to provide care and treatment including failing to evaluate, monitor and provide treatment to emergency department patients to prevent delays; failing to implement laboratory and EKG orders; and/or failing to explain the riks of leaving and benefits of staying to patients who were leaving the ED against medical advice for 7 of 21 sampled emergency department patients (#4, #9, #19, #7, #1, #14, and #13)

Cross refer to §482.55 Emergency Services Standard: Tag 1101.

Based on policy review, medical record reviews and staff and provider interviews, the hospital's emergency department (ED) staff failed to ensure an organized and effective emergency services by failing to provide care and treatment including failing to evaluate, monitor and provide treatment to emergency department patients to prevent delays; failing to implement laboratory and EKG orders; and/or failing to explain the riks of leaving and benefits of staying to patients who were leaving the ED against medical advice for 7 of 21 sampled emergency department patients (#4, #9, #19, #7, #1, #14, and #13)

The findings include:

1. Review of the EMTALA policy, effective 11/2022, revealed "...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who 'comes to the emergency department' an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ..."

The "Refusal of Care Leaving the Hospital AMA Leaving the Hospital ED WOT...", effective 10/2022, revealed "...Definitions...B. AMA....1. Patient who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ..."

Closed medical record review on 09/25/2024 revealed Patient #4 (Pt#4) was a 59-year-old-female who presented to the Emergency Department (ED) on 07/28/2023 at 1618 with complaints of a possible kidney infection. The triage vital signs at 1735 revealed temperature 98.7, heart rate 117, respirations 18, blood pressure 110/69, room air pulse oximetry 98%, pain rated 9, severe pain. Triage documentation revealed Pt#4 was assigned an Emergency Severity Index (ESI) level of 3 (scale of 1 - 5 with 1 the most emergent). The medical record revealed that lab tests were ordered by the triage nurse at 1738 and Pt#4 was placed in the lobby waiting room. Review of the Patient Care Timeline revealed the laboratory staff called RN#8 (ED nurse) at 1933 to report a critical Potassium level of 2 (normal 3.5 to 5.1) which was reported to MD #6 (ED physician) at 1933. Pt #4 remained in the lobby waiting room with no orders for potassium supplement until Pt #4 was seen by the PA #7 (Physician Assistant) at 0147. Review of the Patient Care Timeline revealed PA #7 ordered Potassium chloride (KLOR-CON) 40 mEq (milliequivalents) tablet PO (orally) and a fluid bolus of sodium chloride 0.9% 1,000 ml (milliliters) at 0151. Record review revealed Pt #4 was placed on a cardiac monitor around 0217 and the RN documented the cardiovascular assessment was within defined limits. Review of the Patient Care Timeline revealed the nurse initiated the IV (intravenous) bolus and medications [Zofran (medication for nausea) 4 mg (milligrams) IV, Cefepime (antibiotic) 1 gram IV, and Klor-Con 40 mEq orally] around 0254 (Potassium replacement administered 7 hours and 21 minutes after critical lab was reported). Medical record review revealed MD #11 (Hospitalist) was consulted to complete a H&P (history and physical) for admission at 0338 and wrote an inpatient admission order at 0431. Record review revealed MD #11 wrote an order for an additional dose of Klor-Con 40 mEq tablet orally at 0434 and a nursing note that the medication wasn't administered at 0535 because Pt #4 was complaining of nausea. Review of the medical record revealed MD #11 wrote an order for an EKG (electrocardiogram) at 0553. Review of the medical record failed to review completion of the EKG order at Hospital A. Medical record revealed a dose of Flagyl 500 mg IV was ordered at 0806. Record review revealed a second dose of oral Klor-Con 40 mEq tablet administered at 0927 and the Flagyl 500mg IV was administered at 0955. Review of the Patient Care Timeline revealed a repeat potassium level was reported to be 2.1 at 1055. Review of the Patient Care Timeline revealed a downward trend in Pt #4's blood pressure and Pt#4 subsequently received an additional 1,500 ml of sodium chloride 0.9% fluid bolus and 3 doses of albumin human 25% infusion 12.5 g (grams) IV. The medical record revealed an IV infusion of Levophed (life-threatening low blood pressure medication) 4 mg/250 ml at 16 mcg/ml (micrograms per milliliter) for low blood pressures (79/47 to 102/63) was initiated at 1351. Record review revealed an IV dose of potassium chloride in water 10 mEq/100 ml was administered at 1425. Review of the medical record revealed that Pt #4 was transferred to an outside tertiary care center (Hospital B) on 07/29/2023 at 1540 where she was treated for sepsis from a complicated UTI (urinary tract infection) with severe hydronephrosis (excess urine in the kidneys), hydroureter (blockage of one or both tubes that carry urine from the kidneys to the bladder) and possible colitis (inflammation of the colon).

Medical record review of the tertiary care hospital revealed that a repeat potassium level at 1804 was still 2.1. Record review of the EKG completed at the tertiary care hospital at 1747 revealed HR (heart rate) 96, PR 141, QRSD 83, QT 429, and an interpretation of "Sinus rhythm, prolonged QT, and nonspecific repol (repolarization) abnormality." The record revealed with further treatment of the low potassium, on 07/30/2023 at 0436 the potassium level was reported as 2.7 and then at 1758 the level was reported to be 5.0.

Medical record review of Hospital A failed to reveal treatment of a critical potassium level of 2.0 for over 7 hours and 21 min (reported time 1933 to administration time of a potassium supplement at 0254) while Pt #4 was sitting in the lobby waiting area. Medical record review failed to reveal completion of an EKG order during Pt #4's stay with Hospital A (from order at 0553 to transfer at 1540).

The Triage RN was unavailable for interview.

Interview on 09/26/2024 at 1025 with MD #6 revealed no recollection of Pt #4. MD #6 revealed no recollection of being told of the critical potassium level for Pt #4. MD #6 revealed "there were many times over the summer of 2023 where the ED was full and there were multiple patients with no treatment rooms available and patients were waiting in the lobby." MD #6 revealed the decision to move a patient to the treatment area was left up to the charge nurse and the nurse in the triage area. MD #6 revealed that he was unsure of the delay in getting Pt #4 into a treatment room. MD #6 revealed the potassium level of 2.0 would be something to treat, typically with IV potassium. MD #6 revealed that the patient volumes and wait time were much better currently.

Interview on 09/26/2024 at 1050 with the admitting Hospitalist (MD #11) revealed no recollection of Pt #4, but a review of the H&P had been completed prior to the interview. MD #11 revealed there were a large number of patients during the summer of 2023, "especially at night." "As the Hospitalist on call, there were many times where the patient needed to go to another hospital, but there were no beds to send them to so we had to admit them and hold them in the ED." MD #11 revealed that the ED physicians would contact the hospitalist to admit and assume care of patients and then the ED MD's would go back to focusing on the ED patients. MD #11 revealed feeling "overwhelmed at times," but that "everyone was doing the best they could." MD #11 revealed that while she may still have admit privileges at Hospital A, MD #11 hasn't worked or admitted a patient in over six months.

Interview 09/26/2024 at 1645 with PA #7 (Physician Assistant - Certified) revealed Pt #4 was a "hot potato" that was picked up on 07/29/2023 after having been in the lobby for many hours. PA #7 revealed that upon examination the priority of care was treating the patient's sepsis with fluid resuscitation and IV antibiotics. PA #7 revealed P t#4 was stable from a cardiac standpoint, "yes there was tachycardia (rapid heart rate), but the bigger concern was for the sepsis." When asked about potassium supplementation being given orally, PA #7 revealed staff having "issues with IV access" and "with a stable cardiac view, the priority needed to be on fluid resuscitation." Once the fluids were infusing, "the next avenue to deliver the potassium was orally so the order was placed." PA #7 revealed that Pt #4 needed a transfer out to a tertiary care facility, but there were no beds available so a consultation was placed for the hospitalist to see the patient and admit at Hospital A until transfer could be completed. PA #7 revealed no issues with nursing staff completing orders or getting things done and if it was emergent, PA #7 reported getting the charge nurse to perform the duty. PA #7 revealed there was "no question" in her mind that "sepsis was the primary concern for Pt #4 at the time of assuming care and there were no questions" in her mind that the care provided was the "right care."



16369

2. The "Refusal of Care / Against Medical Advice.../ Leaving the Clinical Setting" policy, effective 03/2024, revealed "...Definitions...B. AMA....1. Patients who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ..."

Medical record review on 09/25/2024 of Patient #7 revealed a 70-year-old-male that presented to the hospital's emergency department on 03/29/2024 at 1747 with a chief complaint of suicide intentions. Review of a triage note at 1757 recorded vital signs that included a blood pressure of 116/71, temperature 98.4, pulse 103, respirations 18, oxygen saturation of 96% on room air, and a pain level of 6, moderate pain. Review of the triage note revealed the patient reported suicide ideations with a plan of walking out in front of oncoming traffic and abdominal pain that started around one hour ago. The patient denied nausea, vomiting or diarrhea. Review revealed the patient was triaged with an Emergency Severity Index (ESI) level of 2 (scale of 1 - 5 with 1 the most emergent). Review of the record revealed the patient was roomed at 1809 with a patient safety observer in place for safety monitoring beginning at 1810. Review revealed laboratory studies were ordered and completed. At 1847 a Columbia Suicide Severity Rating Suicide Risk Assessment was completed with a total score of 7 or moderate risk identified. Review of nursing notes recorded at 1936 stated the patient endorsed suicide ideations but denied homicidal ideations or audio or visual hallucinations. Review revealed the patient had a plan to walk out in front of traffic. The patient stated he had some stomach pain on the right side and reported he was hungry. Review of a medical screening examination initiated on 03/29/2024 at 1947 revealed the patient presented to the DED with complaints of suicide ideations and abdominal pain. Review revealed the patient had a past medical history of depression, substance abuse, and suicide ideations. Review of the note stated that the patient had a plan to walk into traffic due to his depression. Review revealed the patient reported a momentary abdominal pain which he believed was due to being hungry. A review of systems was done and positive for suicide ideations. A physical exam was completed showing the patient was alert and oriented with no acute distress. The patient's attention and perception were recorded as normal, mood and speech were normal, with cooperative behavior. "... Medical Decision Making 70-year-old M (male) with significant psychiatric history presenting for SI (suicide ideations) with plan. Labs ordered and reviewed, unremarkable. Patient medically cleared for tele psych consultation for further evaluation and treatment of psychiatric problems. ED COURSE Clinical Impressions as of 03/30/2024 at 0029 Suicidal ideation, Depression, unspecified depression type, Cannabis use disorder." A tele psych consult was requested at 1950. Record review revealed hourly rounding by nursing staff was documented beginning on 03/30/2024 at 0121 showing the patient was resting at that time. Review of the DED record revealed ongoing safety monitoring and review of vital signs. A Suicide Assessment was recorded by nursing at 0719 that documented a low suicide risk level. Review of a tele psych consult electronically signed on 03/30/2024 at 1421 revealed, "... RECOMMENDATIONS Assessment and Plan 70 yo (year old) male with SI and plan to walk into traffic. Lives with his son and states they were arguing yesterday and this made him have thoughts of killing himself. He states he gets lonely and depressed at his son's house. He has been to the ED several times recently for the same complaint. He was recently at (name of outpatient facility) for the same complaint. He continues to state that if he is discharged he will hurt himself. Currently calm and cooperative, no psychomotor agitation or retardation, speech wnl (within normal limits), good eye contact. Thoughts appear linear and directable. No SI/HI (suicidal ideations/homicidal ideations) or AVH (audio visual hallucinations), and no obvious paranoia or delusions were noted. Mood and affect appropriate. Insight and judgement appear fair, and age-appropriate. Recommend IVC (involuntary commitment) be continued and inpatient hospitalization ... IVC Status Recommended Initiate IVC ... ADDENDA Mr. (patient name) was reporting SI. In the note, it says that he was reporting SI but at the end of the note it says No SI/HI noted. The note should have read No HI noted but reporting SI." Review of a nursing note at 1715 revealed, "TELE PSYCH RECOMMENDED PT (patient) BE IVC'd (involuntarily committed) & WRITER REPORTED TO MD THE RECOMMENDATIONS & MD SAID THAT IS NOT NECESSARY BECAUSE THE PT IS AGREEING TO STAY & RECEIVE TREATMENT VOLUNTARY (sic)." Review of a nursing note at 2024 revealed, HALIFAX COUNTY MAGISTRATE REFUSES TO IVC THIS PATIENT. (name) STATES "HE MUST BE PROVIDED WITH OUTPATIENT DOCUMENTS FOR DRUG REHAB AND FURNISH HIS OWN TRANSPORTATION TO DRUG REHAB..." Review of a psychosocial assessment note documented by nursing at 2349 recorded the patient appears depressed and "verbalizes suicidal thoughts." Review of a nursing note at 2352 documented a Suicide Assessment with a risk score of 2 indicating a low risk. Review revealed an emergency department provider was notified of the suicide risk score. Review revealed the patient had hourly rounding done and was calm and cooperative. Vital signs remained stable. Review of a nursing Suicide Assessment documented on 03/31/2024 at 0722 revealed a suicide risk score of 2, low risk and an emergency department provider was notified of the low risk. Review of a nursing note at 1406 revealed, "Patient stated that he was no longer suicidal and no longer wanted to be at the hospital. Patient asking to leave AMA (against medical advice). (Emergency department physician MD #6) notified and patient signed AMA form. Review of the "Notice of Treatment and Implications for Care Eligibility Act (NOTICE Act) Leaving Against Medical Advice (AMA)" form revised 10-22 revealed, "As a result of being notified of my rights under the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) I, _______________, a patient at (name of hospital system), at my own insistence and without the authority of and against advice of my personal physician(s) am informing you that I am refusing to be admitted as an observed patient. I have been fully counseled of the risks to my health due to my refusal of examination and/or treatment and unadvised discharge. ... I hereby release (hospital system name), its officers, agents, employees, and my personal physician(s) from any responsibility for all consequences caused as a result of me leaving the hospital." Review of the form revealed it was signed by Patient #7 on 03/31/2024 at 1400 and signed by a nurse as the witness. There was no signature of a provider on the form. Review of a nursing note recorded the patient left ambulatory by himself on 03/31/2024 at 1413. Review of the DED record revealed no discharge instructions were documented in the medical record. Review of the DED record revealed no documentation of a discussion of the risks of leaving or the benefits of staying. Review of the record revealed the only provider notes were documented on 03/29/2024 at 1947 when the medical screening examination was initiated and on 03/30/2024 at 1421 when the tele psych evaluation was completed. Review revealed no provider documentation of a reassessment of the patient's condition and no documentation of risks and benefits.

Telephone interview on 09/26/2024 at 1450 with the DED physician (MD #6) that was notified of Patient #7's request to leave AMA on 03/31/2024 revealed he remembered this patient as Patient #7 was in the emergency department frequently. He stated if he sent a patient out AMA he usually included the risks and benefits in the discharge instructions. The physician stated he had seen this patient multiple times within the last year. He stated he is not suicidal. MD #6 stated "He was not suicidal at the time he left."

Interview on 09/27/2024 at 0850 with RN #7 revealed there were no discharge instructions or after visit summary found in Patient #7's DED record for the visit on 03/29/2024. Interview revealed there was no documentation of a discussion with Patient #7 of the risks of leaving AMA.



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3. Review of the EMTALA policy, effective 01/2024, revealed "...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who 'comes to the emergency department' an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ..."

The "Refusal of Care / Against Medical Advice.../ Leaving the Clinical Setting" policy, effective 05/2024, revealed "...Definitions...B. AMA....1. Patient who leave an inpatient or outpatient setting or any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ..."

DED medical record review, on 09/25/2024, revealed Patient #9 arrived to the emergency department by private vehicle on 09/01/2024 at 1720. The ED Care Timeline noted that triage started at 1724. Vital signs at 1936 were blood pressure (BP) 108/69, temperature 97.5, pulse 81, respirations 16 and oxygen saturation of 100% on room air. A pain score of 10 was documented (on a scale of 0-10, with 10 indicating severe pain). A Triage Note at 1737 documented "Pt is G1P0 (first pregnancy), 12 wks. Was told at 8wks that pregnancy was not viable. Two days ago she started bleeding and this afternoon bleeding became heavy w/ (with) clots. Having severe pelvic pain." A physical assessment at 1737 noted respiratory, cardiovascular, peripheral vascular and neurological systems as within defined limits. There was no physical assessment noted related to the pregnancy bleeding. Patient #9 was assigned a triage acuity of 3 (on a scale of 1-5, with 1 being most severe). The following lab tests were collected: CBC with Differential, CMP, Type and Screen. The CBC resulted at 1747 with the following abnormal results: White Blood Count (WBC) 11.29 (Reference Range [RR] 4.50-11.0), Absolute Neutrophils 9.53 (RR 1.80-7.70) and Absolute Immature Granulocytes 0.05 (RR 0). The CMP resulted at 1806, with abnormal results of low CO2 of 20 (RR 22-29) and elevated glucose of 111 (RR 70-105). Review of the ED Care Timeline revealed at 1827 (1 hour 7 minutes after arrival) " ...Patient and significant other (SO) demanded that her IV be taken out so they could leave. The patient and SO was adamant about leaving because they had not been brought to the back yet. An AMA form was obtained. The patient was advised that by leaving she could continue to bleed up to the point of death and by signing the AMA form she takes responsibility for anything that happens after she leaves the hospital. The patient stated that she was going to go somewhere else. The patient signed the AMA form witnessed by RN. IV removed." At 1908 the ED Care Timeline indicated "Patient dismissed." Record review failed to reveal any physical evaluation of Patient #'s bleeding and failed to reveal a repeat pain evaluation prior to departure after an initial pain score of 10 on arrival.

ED record review revealed a form titled "Leaving AMA-Discontinue Tx-Refuse Tx". This form noted " ...This is to certify that I (Name of Patient #9), a patient at Unknown Department at my own insistence and without the authority of and against the advice of my personal physician(s) (First and Last Name), RN demand to leave the hospital. ..." The form included a section labeled "To be completed by a physician: [space] A. The examination and/or treatment recommended and refused: [space] B. The likely dangers of refusal of such examination and/or treatment may include, but are not limited to the following: [space]. ..."These two sections left spaces to document the exam or treatment refused and also the likely dangers of refusal. Both sections were left blank, nothing was written on the form in either of those two areas. The form then indicated " ...I have been fully counseled of the risk to my health, including, but not limited to, those listed above, due to my refusal of examination and/or treatment and unadvised discharge. I acknowledge that follow-up care with my regularly treating physician has been advised and it is my sole responsibility to seek such follow-up care and a treatment. I hereby release (System name), it's officers, agents, employees, and my personal physician(s) from any responsibility for all consequences caused by my leaving said hospital. ..." After that last statement, there were lines for the patient to sign, a witness to sign, and a physician to sign as well as a place for date and time. Over the line for the Patient's Signature was a handwritten statement "too long a wait" with no patient signature noted. There were handwritten signatures over the witness and physician signature lines. The date and time were not filled in. Form review revealed the form was not populated or completed accurately; it inserted "Unknown Department", inserted the name of a hospital nurse where a physician name was to have been inserted and indicated the patient's personal provider gave advice to the patient not to refuse the care/treatment even though the patient was in the hospital ED, not in a provider office. The sections for documenting the exam or treatment refused and the likely dangers of refusal were not filled in, nothing was written in either section. The date and time the form was signed was not completed.

Telephone interview with RN #21, on 09/26/2024 at 1345, revealed the nurse remembered Patient #9. Interview revealed at the time of the patient's arrival, "we were pretty backed up." Interview revealed Patient #9 said "we called ahead and thought you would be ready." Interview revealed Patient #9 was brought in and triaged but "...all of our rooms were full ...there was no room to put her in .... she was stable." Interview revealed RN #21 talked with the charge nurse and discussed the situation to see if they could get her out of the waiting room into the back but the Charge Nurse thought there might not be adequate staff to keep fast track open during the night. In asking how Patient #9 looked in the car, RN #21 stated "(she) looked like she was in pain, she was not diaphoretic, was not pale. When asked how the RN evaluated the patient, RN #21 indicated she asked the patient how much bleeding there was, the patient was still in the car and the nurse could not assess her in the car. In response to a question about visible blood in the car, the RN stated there was not obvious blood visible in the car. As they got into the waiting area, RN#21 stated the patient's husband went to registration and RN#21 thought there was another patient in triage so the RN went back to finish that triage. Interview revealed "there is always 1 nurse in triage plus I had a new grad nurse ... was there to learn, not to do tasks." In triage, the RN indicated, she asks patients what brought them in, checks vital signs, looks at the computer record to check for ultrasound history. The RN stated she did not usually physically evaluate for bleeding, she asked patients how much bleeding they had, were they soaking through a large pad every hour or so; in this specific case RN#21 indicated she did not recall what was asked of this patient. When asked if it would be documented if the nurse asked the amount of bleeding, RN#21 stated "I'm not sure I would write that down ... can't write everything down." Patient #9, the RN stated, was "tearful, crying, very emotional, seemed very frustrated, thought she would go from the vehicle to a private room. ..." RN #21 stated she started an IV and drew labs and went back and spoke to the Charge Nurse again to see if she could get the patient back. RN #21 stated the patient and husband wanted the IV out, wanted to leave and agreed to sign the AMA form. "They said they were going to another hospital." Interview revealed RN #21 did not go over the AMA form, the RN in orientation (RN #22) was the one who physically signed the AMA form and wrote a note about it. When asked what happened when patients stated they wanted to leave, RN #21 indicated they tell them about the form acknowledging they are leaving AMA.... That they haven't seen a doctor ....encourage them to stay and see the doctor ....if they leave it is at their own risk." Interview revealed physicians were not involved in the AMA process if they had not seen the patient.

Interview with the orienting nurse, RN #22, on 09/26/2024 at 1530, revealed the RN recalled Patient #9. Interview revealed the patient arrived with vaginal bleeding and was pregnant. Interview revealed "day was very busy, had a lot of people in the waiting room at that time ...hadn't stopped triaging patients all day ... all the beds in the back were full and no one was moving at the time." There were "holds for placement" the RN stated. When asked if the RN saw Patient #9 when she first came in, RN #22 stated "yes". When asked how she appeared, the RN answered "normal skin tone, not pale, believe in pain, did not appear to be in severe distress." Interview revealed RN #21 triaged Patient #9, and after triage the patient sat right outside the triage door the whole time, in a wheelchair, most waiting room chairs were full. Interview revealed the patient and significant other were both upset that they were not going to the back yet. The RN stated they were informed multiple times that beds were not available, when they were available they would be taken back. When asked if RN#22 thought the patient needed to be in the back, the answer was "yes, with bleeding she is at higher risk." Interview revealed Patient #9's vital signs were in normal range and this RN never saw bleeding/blood on the patient. Further interview revealed RN #22 took the patient out to the car and did not remember any blood on the wheelchair. Interview revealed the RN thought he would have remembered because he would have needed to wipe the wheelchair down with bleach wipes rather than regular wipes. The RN stated Patient #9 wrote too long a wait on the form and did not sign her name. Interview revealed the form used with Patient #9 was printed out of the computer system, possibly by the Charge Nurse, for the RN to use with this patient. Interview revealed RN #22 had not been taught to use that form, stating "It is not the one we usually use." RN #22 stated "They said multiple times if they didn't get a bed in the back were going to leave. We advised them multiple times that it was not recommended ... needed to be seen by a doctor ... leaving could continue to bleed up until death." Interview revealed Patient #9's significant other stated "If we continue to sit here would bleed out anyway." RN #22 stated they reiterated they were trying to get a bed in the back as soon as possible and again the risks of bleeding/death. The RN stated "I felt she needed to be seen but due to circumstances could not bring her back yet." RN #22 did not recall if anyone spoke to a physician about Patient #9.

Request to interview the Charge Nurse on duty when Patient #9 was in the ED revealed the Charge Nurse was not available for interview.

Telephone interview on 09/27/2024 at 1030 with MD #23 revealed MD #23 did not see Patient #9. Interview revealed blood work and IV were done while the patient was waiting on a room. Interview revealed the MD would not go out to talk with a patient in triage who wanted to leave, stating "... I haven't seen the patient." MD #23 indicated nursing did the right thing, started labs and IV, discussed the risks or leaving and got the AMA form. "If a patient in triage wants to leave and not see a doctor, think it's very appropriate to get the paperwork and explain the risks/ you might die."

4. DED medical record review revealed Patient #19 arrived to the emergency department on 05/07/2024 at 0003. Review revealed an arrival complaint of "possible miscarriage." Vital signs at 0008 were blood pressure 123/82, temperature 98.3, pulse 93, respirations 20, SpO2 98% on room air with abdominal pain pain score of 8 - severe pain. Review of the ED Triage Note at 0009 revealed "Pt c/o abd pain, cramping, and vaginal bleeding. Pt had OB urine confirmed pregancy (sic) ....EDD 1/3/25 ....Pt states bleeding started today but states abd pain and cramping started after she was hit in the stomach yesterday around 1330." Review of the ED Provider Note, service time 0157, revealed " ...HPI [space] 27-year-old female with no medical history presents to the ED with a chief complaint of threatened labor and vaginal bleeding that started at 11PM on 5/6/2024. Patient reports that she was assaulted yesterday and points to her belly. She reports that her ex-boyfriend assaulted her and he is now along. She denies any dizziness chest pain shortness of breath but reports abdominal cramping and vaginal bleeding. She has tissue noted in his (sic) lower back and it shows some