HospitalInspections.org

Based on policy and procedure review, medical record review, observation, internal documents review, staff and physician interviews, the governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights for a safe environment; an organized nursing service to supervise and evaluate nursing care; an effective radiologic service for accurate diagnostic testing; an organized and effective quality assessment and performance improvement program for patient safety; and effective emergency services to meet care needs.

The findings include:

1. The hospital staff failed to ensure a safe environment for patient care by failing to provide an accurate diagnostic test per the physician's order for 1 of 3 CT patient's reviewed (Patient #8) and failing to prevent a male contract staff from visiting a female patient's room unattended with the door closed for 1 of 4 female inpatient behavioral health patients reviewed (Patient #28)

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. The hospital failed to communicate the final discharge plans with a patient's appointed guardian in 1 of 3 patients with a guardian or ward of the court (Patient #2).

~cross refer to 482.13 Patient Rights Standard: Tag 0117

3. The hospital's staff failed to analyze, track and take action to prevent errors for 1 of 2 significant patient incidents (Pt #8).

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0286

4. The facility's nursing staff failed to supervise and monitor patient care by allowing a male ED nurse to visit an IVC (involuntary committed) behavioral health female patient in her room with the door closed without supervision for 1 of 4 behavioral health female patients reviewed. (Patient #28)

~cross refer to 482.23 Nursing Services Standard: Tag 0395

5. The radiology staff failed to perform a CT scan without contrast as ordered by the physician for 1 of 3 patients with CT orders reviewed (Pt #8).

~cross refer to 482.26 Radiologic Services Standard: Tag 0535

6. The hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 7 of 20 sampled patiens that presented to the hospital's DED (dedicated emergency department) requesting medical treatment (Patients #12, 13 ,6, 14, 5, 4, 1); and failed to provide stabilizing treatment to 1 of 20 ED patients reviewed (Patient #14).

~cross refer to 482.55 Emergency Department Services Standard: Tag 1101

7. The hospital's emergency department staff failed to provide timely diagnostic testing for 5 of 20 patients presenting to the Emergency Department for care and treatment (Patients #12, 13, 6, 5, 4)

~cross refer to 482.23 Emergency Services Standard: Tag 1103

Based on policy review, medical record reviews and interviews, the hospital failed to protect and promote patient's rights by failing to provide a safe environment for diagnostic imaging and patient care.

The findings include:

1. The hospital staff failed to ensure a safe environment for patient care by failing to provide an accurate diagnostic test per the physician's order for 1 of 3 CT patient's reviewed (Patient #8); and failing to prevent a male staff from visiting a female patient's room unattended with the door closed for 1 of 4 female inpatient behavioral health patients reviewed (Patient #28)

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. The hospital failed to communicate the final discharge plans with a patient's appointed guardian in 1 of 3 patients with a guardian or ward of the court (Patient #2).

~cross refer to 482.13 Patient Rights' Standard: Tag 0117

Based on policy review, medical record review and patient and staff interviews, the hospital failed to communicate the final discharge plans with a patient's appointed guardian in 1 of 3 patients with a guardian or ward of the court (Patient #2).

The findings include:

Review of Hospital policy titled, Patient Rights & Responsibilities, 27 last revised 06/2021 revealed " ...Involvement in Care: The patient and/or representative have the right to be actively involved in developing, implementing and revising their plan of care ...Transfer and Continuity of Care: ...The patient has the right to expect reasonable continuity of care when appropriate to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate ..."

Review of Hospital policy titled, Guidelines for the Behavioral Health Patient in the Emergency Department and the Emergency Department Crisis Stabilization Unit (CSU) last revised 06/2022 revealed " ...PROCEDURE/ RESPONSIBILITIES ...m. For patients discharged to home from the behavioral health holding status, the behavioral health APP/psychiatrist will be solely responsible for managing this process ..."

Closed medical record review revealed Patient #2 was a 49-year-old female who presented to the hospital by way of law enforcement under Involuntary Commitment (IVC) on 09/29/2022 through 10/14/2022. Record review revealed the initial "Affidavit and Petition For Involuntary Commitment" paperwork on 09/29/2022 and 10/07/2022 included the name of the guardianship services and the (Interim Guardian) responsible for the care of Patient #2. Record review revealed the information of assigned guardian was not entered into the medical record during registration. Further review revealed on 09/29/2022 the Medical screening and Psychiatric evaluation was completed whereby Patient #2 was deemed to remain in the Emergency Department (ED) under IVC. Record review revealed on 09/29/2022 at 1643, ADM #6 notated, "This writer received a call from (Named guardian) a Rep with (Named Guardianship Services, telephone number). (Named Guardian) informed this writer that she is now the guardian of the patient ...She also stated if any other information is needed to give her a call." Further record review revealed Nursing note documentation on 10/13/2022 at 1119, whereby RN #7 had "Received a call from (Named Guardian) with (Named Guardianship Services) to check on patient's status. I informed her that patient's updated labs have all been faxed to our (Named) call center, as well as (Named) Hospital. Also let her know that it may be helpful if she and patient's outpatient providers (Named Outpatient psychiatrist) also reach out to (Named) Hospital to speak with someone to find out if patient admission can be expedited based on her acuity, and she tells me she will be happy to reach out to (Named) Hospital." Record review revealed Nursing note documentation on 10/13/2022 at 1522, RN #7 noted, "Informed psychiatric provider, (Named PA #5) that patient's IVC paperwork would expire sometime tomorrow morning (seven days from the date/time of issuance of custody order from the magistrate). Further review of Nursing note documentation revealed on 10/14/2022 at 1101, RN #3 notated "pt (patient) given Rx (prescription) for Haldol, pt calm and alert, all belongings returned to pt, pt got dressed, called cab and gave pt a voucher to take her home, liaison at ED entrance as voucher for cab driver to sign, pt walked out to ED entrance without any problems, co-operative." Medical record review revealed no further communication with the appointed guardian regarding final discharge plans and disposition for Patient #2.

Telephone interview with MD#1, Chairman of Psychiatry on 02/15/2023 at 1600 revealed he had worked at the hospital roughly 3 years. Interview revealed a plan of care discussion took place 0700 through 0900 with physicians, mid-level providers, nursing along with the ED physicians to address discharge needs of patients in the ED and CSU. Interview revealed MD #1 felt Patient #2 had reached " ...her baseline with fixed delusional thoughts ..." and it was felt Patient #2 no longer met criteria to recommend IVC whereby the Patient was discharged home. Interview revealed " ...we (psychiatry) are a consultation process while patient was in the ED, information provided to the staff in ED, communications would be through (Named) RN and (Named) Administrative Assistant." Interview revealed MD #1 did not recall any communication with the appointed guardian for Patient #2.

Interview with the CMO on 02/16/2023 at 1715 revealed it was the expectation of all hospital staff to convey communication to a patient's designated responsible family member/guardian to keep them well involved in plan of care and informed on the patient's discharge plans.

Based on review of hospital policy, closed medical record review, review of CT (computerized tomography) patient history form and staff and physician interviews, the hospital staff failed to ensure a safe environment for patient care by failing to provide an accurate diagnostic test per the physician's order for 1 of 3 CT patient's reviewed (Patient #8) and failing to prevent a male staff from visiting a female patient's room unattended with the door closed for 1 of 4 female behavioral health patients reviewed (Patient #28)

The findings include:

Review of hospital policy titled PRE/POST PROCEDURE CAT (COMPUTERIZED AXIAL TOMOGRAPHY) SCAN AND MRI(MAGNETIC RESONANCE IMAGING) revised 03/2018 revealed, "Purpose: To ensure a prompt and accurate exam for the patient. Pre-Procedure...Verify the physician order."

Review of hospital policy titled ADMINISTRATION OF IV (INTRAVENOUS) CONTRAST MATERIAL IN RADIOLOGY revised 12/2019 revealed, "Purpose: To identify guidelines that will ensure patient safety during the administration of IV contrast material...1. The following parameters will be used when assessing patients requiring IV iodinated contrast media: ... B. All patients greater than 60 years old require a serum creatinine (and/or eGFR [estimated glomerlar filtration rate]) performed within the last 30 days. D. Administration of intravenous contrast with serum creatinine greater than or equal to 2.0mg/dl (and/or eGFR less than or equal to 40) requires discussion with the ordering physician or radiologist. 2. Outpatients with the following conditions are considered "at risk" for contrast induced nephropathy (CIN) or CIN. A. 60 years of age or greater..."

A closed medical record review revealed Patient #8, an 80-year-old male referred for an outpatient CT scan without contrast on 12/28/2022 at 0800. Review of the physician's order dated 12/14/2022 revealed "CT Abdomen/ Chest/Pelvis...Test Reason: prostate cancer and weight loss, history of lung nodules...IV Contrast: Without. Oral contrast: Without..." Review of the H&P (History & Physical) dated 12/28/2022 at 2042 revealed a past medical history of prostate cancer, lung nodules, anemia, chronic kidney disease stage II, hypertension and auditory hallucinations. Further review of the H&P revealed "...order was for CT scan to be done without contrast, however imaging was obtained with contrast, repeat lab at the Oncology office revealed worsened creatinine at 5.4, patient baseline is 2.3, with a BUN of 53, and potassium of 5.2, due to worsened renal function oncologist called hospitalist team for direct admission..." Patient #8 was admitted to Hospital A's medical-surgical floor... "secondary to IV contrast." Further review of the H&P revealed a plan of care: "received 500ml (milliliters) of IV NS (normal saline) at the Oncology office, NS 100ml/hr (hour), renal ultrasound, BMP (basic metabolic panel) labs ordered daily, avoid nephrotoxic agent (drugs with potential to cause kidney damage) and nephrology consulted." On 12/28/2022 at 1954 the nursing note revealed the patient arrived to the unit via wheelchair at 1840 with his daughter at bedside. On 12/29/2022 at 1242 the physician note revealed "plan to continue to monitor renal function, electrolytes and avoid nephrotoxic agents." On 12/30/2022 at 1356 the physician note revealed "patient renal function unchanged...IV fluids resumed, add Dopamine, renal diet..." On 12/31/2022 at 1551 the physician note revealed "patient is non-oliguric (low urine output), continue IV fluids." On 01/02/2023 at 1321 the physician note revealed "Kidney function, weights and urine flow are acceptable. Agree with current therapy and monitoring." On 01/02/2023 at 1233 the physician note revealed "will proceed with HD (hemodialysis)... No significant change in renal function." On 01/03/2023 at 1017 the Radiology post procedure note revealed "...temporary dialysis catheter insertion into right internal jugular vein." On 01/03/2023 at 1236 the physician note revealed "HD for today..." On 01/05/2023 at 1338 the physician note revealed "Suspect New ESRD (end stage renal disease)." On 01/07/2023 at 1207 the physician note revealed "Patient is now dialysis dependent. Got tunneled dialysis catheter placement yesterday." On 01/07/2023 at 1703 the Discharge Summary revealed the patient was discharged home with self-care, stable.

Review of the form titled CT Patient History revealed it consists of 13 patient history questions; followed by "consent for contrast material injection" section to be signed by the patient and the radiology technician if contrast required; followed by documentation of IV site, gauge, contrast amount, time of contrast injection; creatinine drawn date, creatinine and GFR results (if needed); and radiology technician name.

Interview on 02/14/2023 at 1405 with CT technician (tech) #25 revealed she remembered the patient. CT tech #25 stated, "My eyes erroneously saw 'with contrast' when I looked at the order and his answers to certain questions during the patient history interview did not make me think twice about it. Had his answers triggered me I would've checked labs. Later that day I noticed the order clearly said 'without' and I remembered giving him contrast, so I called the ordering physician assistant and informed her. She informed me they would get the patient back into the Oncology office for rehydration..." Interview revealed CT tech #25 informed Radiology Manager #27 and put in an incident report.

Interview on 02/14/2023 at 1430 with Director #26 revealed she was familiar with the incident. Director #26 stated, "The CT tech saw the order as with and not without contrast. She followed procedure by calling the provider...Standard procedures tell us when to use contrast or not but it's all up to the physician's order, so staff should double check the order to confirm. No specific changes were made after the incident..." Interview revealed Director #26 signed off on the incident report and acknowledged an error was made by staff but did not take any other actions.

Interview on 02/14/2023 at 1447 with Radiology Manager #27 revealed she remembered the incident. She stated, "The CT tech called and told me what happened and that she had already informed the provider. I then told her to put in the incident report. I discussed with her to verify orders and she confirmed she would..." Interview revealed no education had been reiterated with other staff and no other actions were taken since the incident.

Interview on 02/15/2023 at 0830 with Medical Doctor (MD) #28 revealed the CT scan was ordered without contrast. He stated, "I got the call 12/28/2022 at 1610 that the patient had been given IV contrast...The patient has chronic kidney disease, so the safe thing for staff to do is always check creatinine on every patient. The patient's creatinine was 5.4 in the office following the CT scan with contrast..." Interview revealed the patient was directly admitted due to elevated creatinine level after the contrast was received.

Interview on 02/15/2023 at 0840 with Physician Assistant (PA) #29 revealed "The CT scan was ordered for unexplained weight loss. The scan without contrast was due to his renal function. I got the call at 1435 from the CT tech informing me of the error. I then called the patient and got him in the office to hydrate him... The patient was in the office by 1500... We gave IV NS fluid from 1510-1645. The patient creatinine level was checked in office and was 5.4. I spoke with hospitalist and then called his daughter to have her take the patient to the hospital to be directly admitted." Interview revealed the patient is now on dialysis as a result of the contrast.

Interview with 02/15/2023 at 1105 with CT tech #30 revealed "...for scans and MRI we only look at patient labs if they are diabetic, take metformin, or have kidney disease/failure. If patients answer yes to those questions, then we do a stat creatinine."

Follow up interview on 02/16/2023 at 0933 with the Radiology Manager #21 revealed "We have one CT patient history form that staff fill out for all patients, whether they are receiving contrast or not. If the patient is getting contrast, then they would sign the consent portion of the form." Interview revealed all patient's history is assessed via the CT Patient History form prior to imaging.



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2. Review of facility policy "Visiting Hours" last reviewed 06/2022 revealed "POLICY: ...B. No patient visitor will be allowed on the Unit without a written and/or verbal release from the patient/guardian ... F. Unless clinically contraindicated, each patient may have visitors according to the following Unit rules: 1. Visitors must adhere to the visiting hours posted, unless previously approved in writing by the attending physician, Administrative Director, or Nurse Manager ... 3. Visitors and patients on the adult unit meet only in the common dinning areas of the units and visiting is supervised at all times by staff. 4. Physical contact between patient(s) and visitors will be limited to acceptable public behavior. Sexual activity is prohibited on the Unit ..."

Review of facility policy "Visiting Hours" last reviewed 06/2022 revealed "POLICY: ...B. No patient visitor will be allowed on the Unit without a written and/or verbal release from the patient/guardian ... F. Unless clinically contraindicated, each patient may have visitors according to the following Unit rules: 1. Visitors must adhere to the visiting hours posted, unless previously approved in writing by the attending physician, Administrative Director, or Nurse Manager ... 3. Visitors and patients on the adult unit meet only in the common dining areas of the units and visiting is supervised at all times by staff. 4. Physical contact between patient(s) and visitors will be limited to acceptable public behavior. Sexual activity is prohibited on the Unit ..."

Closed medical record review on 02/15/2023 of Patient #28 revealed a 27-year-old presented to the facility via EMS on 01/13/2023 with a complaint of "Overdose." Review of the medical record revealed Patient #13 was served with IVC (involuntary commitment petition) paperwork on 01/13/2023 at 2203. Throughout Patient #28's ED stay, Patient #28 was having flight of ideas, hyperverbal, hypersexual, restless, trying to leave, and demanding to leave. Patient #28 was transported to the inpatient behavioral health unit on 01/16/2023 at 1333. Review of the Psychiatric Evaluation signed 01/16/2023 at 1215 revealed "Chief Complaint: Patient presented to the hospital ED after an intentional overdose of 18 tablets of 100 mg (milligram) Lamotrigine (medication to treat seizures and bipolar disorder), Patient has a history of bipolar disorder; off off (sic) psychiatric medication for 5-6 months, reporting auditory and visual hallucinations and was paranoid of her ex-boyfriend trying to kill her resulting in overdose on medications with the intent to calm her auditory and visual hallucinations and was not trying to kill her (sic) ... Medical Necessity: psychosis/ manic - OD on Lamotrigine... 1/16/23: Per nursing report patient was not able to sleep well yesterday. Was making hand gestures to the behavior health staff members... 1/15/23: Patient use worker language (sic) and sexually hyper focused, Patient thought process was very disorganized ..." Review of the "Level of Observation" form dated 01/16/2023 revealed "Time: 2200 Bx (behavior or activity code)/Location: 12/R" Review of the ---box "12" means "lying down" and "R" means "Patient Room." Continued review of the "Level of Observation" form revealed "Time: 2215; Bx/Location: 13/R (13 means Sitting); Time 2230: 13/R; and Time: 2245; Bx/Location:1-/R (unable to read the second number beside the 1). Review of the Provider note signed 01/17/2023 at 1342 revealed ... Patient was also asked about altercation that occurred last night and stated that it occurred due to the fact that she could not leave AMA (against medical advice) and was forced to stay. She admits to acting out which lead (sic) to the verbal altercation that occurred ..." Patient #28 was discharged 01/19/2023 at 0941

Observation during tour of the Behavioral Health Unit on 02/21/2023 at1243 revealed 1 Facility Security Officer, 1 (Name of County) PD (Police Department) Officer, and 1 new admit behavioral health patient entered on unit. Observation revealed after the Nurse and the (Name of County) PD Officer complete paperwork, the Facility Security Officer and the (Name of County) PD exited the unit. While the Officers were exiting the unit a lab technician entered the unit. Observation revealed the lab technician did not call in to get permission to enter the locked behavior health unit.

Interview on 02/15/2023 at 0847 with Certified Nursing Assistant (CNA) #31 revealed she remember the incident that happened on 01/16/2023. Interview revealed about 2200 a Registered Nurse (RN) brought another patient up to the unit with Facility Security. Interview revealed the RN asked the Charge Nurse (CN) about a female patient (identified as Patient #28), stated he had a good rapport with her in the ED. Interview revealed the ED RN started walking the hall toward female patient's (Patient #28) room. Interview revealed about thirty (30) minutes had passed and the CNA had not seen the ED RN leave the unit. Interview revealed CNA #31 went to Patient #28's room, the door was closed so CNA #31 peeped in through the middle door (a door within the door that opens outward allowing staff to enter a room if a patient was to barricade themselves in the room). Interview revealed CNA #31 saw the male ED RN and Patient #28 sitting on the bed with the female Patient #28's head on the male ED RN's left shoulder. Interview revealed both the male ED RN and Patient #28 looked startled and jumped up. Interview revealed CNA #31 reported this information to the CN, who went to Patient #28's room and talked with them. Interview revealed the male ED RN did not leave at that time. Interview revealed a second incident was observed by another staff member during the fifteen minute rounding. Interview revealed ED RNs do not typically go into other patient rooms when they bring a patient to the behavioral health unit.

Interview on 02/15/2023 at 0908 with LPN #32 revealed she remembered the incident that occurred on 01/16/2023. Interview revealed LPN #32 was still on orientation during this event. Interview revealed a patient was brought to the behavioral health unit by hospital security and a male ED RN. Interview revealed LPN #32 observed the male ED RN ask the CN a question then saw him (the male ED RN) walk down the hall. Interview revealed LPN #32 was approached by a CNA that reported the male ED RN was in a female patient's room (identified as Patient #28) sitting with shoulder's touching and the female patient's head on the male ED RN's shoulder. Interview revealed LPN #32 reported this information to the CN who went to Patient #28's room. Interview revealed when the CN returned she said the male ED RN was standing not sitting and that she had spoken to him. Interview revealed the CN went back to complete the admission. Interview revealed the techs on the hallway were still uneasy and called the house supervisor. Interview revealed the house supervisor notified them the male ED RN should not be in the room. Interview revealed LPN #32 went to Patient #28's room instantly, Patient #28's head was face down in the lap of the male ED RN. Interview revealed Patient #28 jolted her head up out of the male ED RN's lap and the male ED RN did not move or say anything. Interview revealed LPN #32 immediately went down the hall and notified the CN. Interview revealed the CN immediately went down the hall to Patient #28's room. Interview revealed shortly after the CN went to the room, the male ED RN and the CN were seen walking down the hall away from Patient #28's room. Interview revealed the Director sent out an email (unsure of date) stating that "nobody should be in the rooms, no external staff on the unit period except to bring admits up or are from EVS (environmental services - housekeeping). Interview revealed "not sure if it is a change or not, but the techs are not allowed to use the inside door to do their checks anymore."

Interview on 02/15/2023 at 0932 with RN #33 revealed she was the Charge Nurse (CN) on 01/16/2023 and remembered the incident. Interview revealed a male ED RN brought another patient up being admitted on the behavioral health unit. Interview revealed the male ED RN said he had a good rapport with a female patient on the unit. (identified as Patient #28) and when she was downstairs she wasn't doing good. Interview revealed RN #33 notified the male ED RN the patients were getting ready for bed and that if she (Patient #28) was asleep to not bother her. Interview revealed the male ED RN stated he was only going to say 'hey' and leave. Interview revealed RN #33 started with the admission of the new patient. Interview revealed RN #33 was interrupted by CNA #31 and RN #33 went to Patient #28's room. Interview revealed when RN #33 arrived to the room the male ED RN was standing against the wall and was "talking therapeutically" to the patient. Interview revealed RN #33 told the male ED RN it was "getting late, to wrap it up, and that she (Patient #28) needed to get ready for bed." Interview revealed RN #33 returned to her admission patient. Interview revealed RN #33 was notified by LPN #32 that she (LPN #32) saw Patient #28's head in the male ED RN's lap. Interview revealed RN #33 went back to Patient #28's room where the male ED RN was sitting at the head of the bed and Patient #28 was sitting midway down the bed. Interview revealed RN #33 told the male ED RN that it looked inappropriate, and he had to leave the floor. Interview revealed the male ED RN said ok and left. Interview revealed RN #33 contacted the Nurse Administrator on Call (NAC) to notify her and to get guidance of what needed to be done. Interview revealed the NAC instructed RN #33 to enter the incident in the RL solutions (the facilities incident reporting system) and to send an email to the Director. Interview revealed there has been a sign posted with specific visitation times and the techs are not allowed to use the middle door for their checks any longer. They have to open the big door. Interview Patient #28's medical provider was notified the following morning.

Interview on 02/15/2023 at 1530 with Nursing Administrative Supervisor (NAS) #34 revealed a male ED RN took a behavioral health patient upstairs from the behavioral health area in the ED. Interview revealed the male ED RN asked if he could visit with another female patient up there and the behavioral health RN said "Yeh go ahead." Interview revealed the NAS #34 was notified on one of the rounds the female patient had her head on the male ED RN's shoulder and on the second round the patient had her head in the male ED RN's lap. Interview revealed the behavioral health nurse called the NAS #34 and NAS #34 advised the behavioral health RN to have the ED RN leave. Interview revealed the behavioral health RN checked the patient and their were no changes that NAS #34 was aware of. Interview revealed NAS #34 instructed the behavioral health RN to go ahead an email her director what had happened, and NAS #34 notified the ED Director and the behavioral health director what information she knew. Interview revealed the NAS did not talk with the male ED RN nor the behavioral health female patient about what had happened. Interview revealed the male ED RN did not come back to work after that shift and the NAS #34 had not seen any policy changes related to this incident.

Interview on 02/16/2023 at 1453 with CNA #35 revealed she called the house supervisor as she was not comfortable with a male ED RN in a female behavioral health patient's room. Interview revealed the house supervisor said the male ED RN did not need to be there and that the nurse went to the room and told him he had to leave. Interview revealed the staff cannot use the middle doors to do the checks anymore.

Interview on 02/17/2023 at 0847 with Security Officer (SO) # 36 revealed he escorted the new behavioral health admission patient, (Name of County) PD Officer, and the male ED RN to the behavioral health unit on 01/16/2023. Interview revealed the male ED RN asked the behavioral health unit RN if a patient was still there and if he could go see her. Interview revealed the male ED RN notified the RN that he had a good rapport with the patient. Interview revealed while on the unit SO #36 was asked to speak with another patient about their behavior. When walking to the other patients room, SO #36 saw the male ED RN sitting at the head of the bed and the female patient sitting at the other end of the bed. Interview revealed after talking with the other patient and ready to exit the unit, the female patient's door was closed when SO #36 walked past the door. Interview revealed SO #36 did not see the male ED RN and thought he had left prior to the SO #36 leaving. Interview SO #36 got the (Name of County) PD Officer and they left the unit together.

Based on review of hospital policies and procedures, hospital incident reports, medical record review, and staff interviews, the hospital failed to maintain an effective, ongoing data-driven quality assessment and performance improvement program by failing to analyze and take action to prevent significant adverse events.

The findings include:

The hospital's staff failed to analyze, track and take action to prevent errors for 1 of 2 significant patient incidents (Pt #8).

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard - Tag 0286

Based on review of hospital policies and procedures, hospital incident reports, medical record review, and staff interviews, the hospital's staff failed to analyze, track and take action to prevent errors for 1 of 2 significant patient incidents (Pt #8).

The findings include:

Review on 02/21/2023 of the hospital policy titled, Risk and Sentinel/Serious Event Management Plan, 41.0" last revised 06/2021 revealed " The purpose of the Risk and Sentinel/Serious Event Management Plan at (Facility Name) is to outline the on-going process for providing an environment that is safe and of minimal risk to patients, medical staff, employees and visitors ... Loss Prevention and Reduction: ... E. Follow-up Action: All incidents will be trended and analyzed ... For a 'near miss' or sentinel events, a root cause analysis will be completed ..."

Review of a hospital incident report dated 12/28/2022 (not timed) revealed the radiology technician read the order wrong and gave the patient contrast. The test was ordered to be done without contrast. The radiology technician contacted her manager and the ordering provider of the error.

A closed medical record review revealed Patient #8, an 80-year-old male referred for an outpatient CT scan without contrast on 12/28/2022 at 0800. Review of the physician's order dated 12/14/2022 revealed "CT Abdomen /Chest/Pelvis...Test Reason: prostate cancer and weight loss, history of lung nodules...IV Contrast: Without. Oral contrast: Without..." Review of the H&P (History & Physical) dated 12/28/2022 at 2042 revealed a past medical history of prostate cancer, lung nodules, anemia, chronic kidney disease stage II, hypertension and auditory hallucinations. Further review of the H&P revealed "...order was for CT scan to be done without contrast, however imaging was obtained with contrast, repeat lab at the Oncology office revealed worsened creatinine at 5.4, patient baseline is 2.3, with a BUN of 53, and potassium of 5.2, due to worsened renal function oncologist called hospitalist team for direct admission..." Patient #8 was admitted to Hospital A's medical-surgical floor..."secondary to IV contrast." On 01/02/2023 at 1233 the physician note revealed "will proceed with HD (hemodialysis)... No significant change in renal function." On 01/03/2023 at 1017 the Radiology post procedure note revealed "...temporary dialysis catheter insertion into right internal jugular vein." On 01/05/2023 at 1338 the physician note revealed "Suspect New ESRD (end stage renal disease)". On 01/07/2023 at 1207 the physician note revealed "Patient is now dialysis dependent. Got tunneled dialysis catheter placement yesterday." On 01/07/2023 at 1703 the Discharge Summary revealed the patient was discharged to home.

Interview on 02/14/2023 at 1430 with Director #26 revealed she "signed off" on the RL (facilities incident reporting system). Interview revealed the radiology technician read the order as "with" contrast but the order actually was for "without" contrast. Interview revealed the technician followed procedure by calling the provider. Interview revealed the standard procedure is for the Provider order to tell us when to use contrast and when not to. Interview revealed no changes have been put in placed from this incident. Interview revealed there had been no counseling of staff that Director #26 was aware of. Interview revealed Director #26 was unsure how often the contrast is given when not ordered or not given when ordered. Interview revealed this is only tracked through the RL system when reported. Interview revealed it is not something that is actively tracked or monitored.

Interview on 02/14/2023 at 1447 with Radiology (Rad) Manager #27 revealed the radiology technician notified her of the error and had notified the ordering provider of the error. Interview revealed the Rad Manager instructed the Rad Tech to enter the error in the RL system. Interview revealed she told the tech she should be verifying accurately but no education was provided to other staff nor was any other action taken.

Based on facility policy review, medical record review, and staff interview, the facility's nursing staff failed to have an effective nursing service providing oversight of day-to-day operations by failing to ensure systems were in place to provide oversight and supervision of care to behavioral health patients.

The findings include:

The facility's nursing staff failed to supervise and monitor patient care by allowing a male ED nurse to visit an IVC (involuntary committed) behavioral health female patient in her room with the door closed without supervision for 1 of 4 behavioral health female patients reviewed. (Patient #28)

~ cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on policy and procedure review, medical record review, observation, and staff interview, the facility's nursing staff failed to supervise and monitor patient care by allowing a male ED nurse to visit an IVC (involuntary committed) behavioral health female patient in her room with the door closed without supervision for 1 of 4 behavioral health female patients reviewed. (Patient #28)

The findings include:

Review of facility policy "Visiting Hours" last reviewed 06/2022 revealed "POLICY: ...B. No patient visitor will be allowed on the Unit without a written and/or verbal release from the patient/guardian ... F. Unless clinically contraindicated, each patient may have visitors according to the following Unit rules: 1. Visitors must adhere to the visiting hours posted, unless previously approved in writing by the attending physician, Administrative Director, or Nurse Manager ... 3. Visitors and patients on the adult unit meet only in the common dining areas of the units and visiting is supervised at all times by staff. 4. Physical contact between patient(s) and visitors will be limited to acceptable public behavior. Sexual activity is prohibited on the Unit ..."

Closed medical record review on 02/15/2023 of Patient #28 revealed a 27-year-old presented to the facility via EMS on 01/13/2023 with a complaint of "Overdose." Review of the medical record revealed Patient #13 was served with IVC (involuntary commitment petition) paperwork on 01/13/2023 at 2203. Throughout Patient #28's ED stay, Patient #28 was having flight of ideas, hyperverbal, hypersexual, restless, trying to leave, and demanding to leave. Patient #28 was transported to the inpatient behavioral health unit on 01/16/2023 at 1333. Review of the Psychiatric Evaluation signed 01/16/2023 at 1215 revealed "Chief Complaint: Patient presented to the hospital ED after an intentional overdose of 18 tablets of 100 mg (milligram) Lamotrigine (medication to treat seizures and bipolar disorder), Patient has a history of bipolar disorder; off off (sic) psychiatric medication for 5-6 months, reporting auditory and visual hallucinations and was paranoid of her ex-boyfriend trying to kill her resulting in overdose on medications with the intent to calm her auditory and visual hallucinations and was not trying to kill her (sic) ... Medical Necessity: psychosis/ manic - OD on Lamotrigine... 1/16/23: Per nursing report patient was not able to sleep well yesterday. Was making hand gestures to the behavior health staff members... 1/15/23: Patient use worker language (sic) and sexually hyper focused, Patient thought process was very disorganized ..." Review of the "Level of Observation" form dated 01/16/2023 revealed "Time: 2200 Bx (behavior or activity code)/Location: 12/R" Review of the ---box "12" means "lying down" and "R" means "Patient Room." Continued review of the "Level of Observation" form revealed "Time: 2215; Bx/Location: 13/R (13 means Sitting); Time 2230: 13/R; and Time: 2245; Bx/Location:1-/R (unable to read the second number beside the 1). Review of the Provider note signed 01/17/2023 at 1342 revealed ... Patient was also asked about altercation that occurred last night and stated that it occurred due to the fact that she could not leave AMA (against medical advice) and was forced to stay. She admits to acting out which lead (sic) to the verbal altercation that occurred ..." Patient #28 was discharged 01/19/2023 at 0941

Observation during tour of the Behavioral Health Unit on 02/21/2023 at1243 revealed 1 Facility Security Officer, 1 (Name of County) PD (Police Department) Officer, and 1 new admit behavioral health patient entered on unit. Observation revealed after the Nurse and the (Name of County) PD Officer complete paperwork, the Facility Security Officer and the (Name of County) PD exited the unit. While the Officers were exiting the unit a lab technician entered the unit. Observation revealed the lab technician did not call in to get permission to enter the locked behavior health unit.

Interview on 02/15/2023 at 0847 with Certified Nursing Assistant (CNA) #31 revealed she remember the incident that happened on 01/16/2023. Interview revealed about 2200 a Registered Nurse (RN) brought another patient up to the unit with Facility Security. Interview revealed the RN asked the Charge Nurse (CN) about a female patient (identified as Patient #28), stated he had a good rapport with her in the ED. Interview revealed the ED RN started walking the hall toward female patient's (Patient #28) room. Interview revealed about thirty (30) minutes had passed and the CNA had not seen the ED RN leave the unit. Interview revealed CNA #31 went to Patient #28's room, the door was closed so CNA #31 peeped in through the middle door (a door within the door that opens outward allowing staff to enter a room if a patient was to barricade themselves in the room). Interview revealed CNA #31 saw the male ED RN and Patient #28 sitting on the bed with the female Patient #28's head on the male ED RN's left shoulder. Interview revealed both the male ED RN and Patient #28 looked startled and jumped up. Interview revealed CNA #31 reported this information to the CN, who went to Patient #28's room and talked with them. Interview revealed the male ED RN did not leave at that time. Interview revealed a second incident was observed by another staff member during the fifteen minute rounding. Interview revealed ED RNs do not typically go into other patient rooms when they bring a patient to the behavioral health unit.

Interview on 02/15/2023 at 0908 with LPN #32 revealed she remembered the incident that occurred on 01/16/2023. Interview revealed LPN #32 was still on orientation during this event. Interview revealed a patient was brought to the behavioral health unit by hospital security and a male ED RN. Interview revealed LPN #32 observed the male ED RN ask the CN a question then saw him (the male ED RN) walk down the hall. Interview revealed LPN #32 was approached by a CNA that reported the male ED RN was in a female patient's room (identified as Patient #28) sitting with shoulder's touching and the female patient's head on the male ED RN's shoulder. Interview revealed LPN #32 reported this information to the CN who went to Patient #28's room. Interview revealed when the CN returned she said the male ED RN was standing not sitting and that she had spoken to him. Interview revealed the CN went back to complete the admission. Interview revealed the techs on the hallway were still uneasy and called the house supervisor. Interview revealed the house supervisor notified them the male ED RN should not be in the room. Interview revealed LPN #32 went to Patient #28's room instantly, Patient #28's head was face down in the lap of the male ED RN. Interview revealed Patient #28 jolted her head up out of the male ED RN's lap and the male ED RN did not move or say anything. Interview revealed LPN #32 immediately went down the hall and notified the CN. Interview revealed the CN immediately went down the hall to Patient #28's room. Interview revealed shortly after the CN went to the room, the male ED RN and the CN were seen walking down the hall away from Patient #28's room. Interview revealed the Director sent out an email (unsure of date) stating that "nobody should be in the rooms, no external staff on the unit period except to bring admits up or are from EVS (environmental services - housekeeping). Interview revealed "not sure if it is a change or not, but the techs are not allowed to use the inside door to do their checks anymore."

Interview on 02/15/2023 at 0932 with RN #33 revealed she was the Charge Nurse (CN) on 01/16/2023 and remembered the incident. Interview revealed a male ED RN brought another patient up being admitted on the behavioral health unit. Interview revealed the male ED RN said he had a good rapport with a female patient on the unit. (identified as Patient #28) and when she was downstairs she wasn't doing good. Interview revealed RN #33 notified the male ED RN the patients were getting ready for bed and that if she (Patient #28) was asleep to not bother her. Interview revealed the male ED RN stated he was only going to say 'hey' and leave. Interview revealed RN #33 started with the admission of the new patient. Interview revealed RN #33 was interrupted by CNA #31 and RN #33 went to Patient #28's room. Interview revealed when RN #33 arrived to the room the male ED RN was standing against the wall and was "talking therapeutically" to the patient. Interview revealed RN #33 told the male ED RN it was "getting late, to wrap it up, and that she (Patient #28) needed to get ready for bed." Interview revealed RN #33 returned to her admission patient. Interview revealed RN #33 was notified by LPN #32 that she (LPN #32) saw Patient #28's head in the male ED RN's lap. Interview revealed RN #33 went back to Patient #28's room where the male ED RN was sitting at the head of the bed and Patient #28 was sitting midway down the bed. Interview revealed RN #33 told the male ED RN that it looked inappropriate, and he had to leave the floor. Interview revealed the male ED RN said ok and left. Interview revealed RN #33 contacted the Nurse Administrator on Call (NAC) to notify her and to get guidance of what needed to be done. Interview revealed the NAC instructed RN #33 to enter the incident in the RL solutions (the facilities incident reporting system) and to send an email to the Director. Interview revealed there has been a sign posted with specific visitation times and the techs are not allowed to use the middle door for their checks any longer. They have to open the big door. Interview Patient #28's medical provider was notified the following morning.

Interview on 02/15/2023 at 1530 with Nursing Administrative Supervisor (NAS) #34 revealed a male ED RN took a behavioral health patient upstairs from the behavioral health area in the ED. Interview revealed the male ED RN asked if he could visit with another female patient up there and the behavioral health RN said "Yeh go ahead." Interview revealed the NAS #34 was notified on one of the rounds the female patient had her head on the male ED RN's shoulder and on the second round the patient had her head in the male ED RN's lap. Interview revealed the behavioral health nurse called the NAS #34 and NAS #34 advised the behavioral health RN to have the ED RN leave. Interview revealed the behavioral health RN checked the patient and their were no changes that NAS #34 was aware of. Interview revealed NAS #34 instructed the behavioral health RN to go ahead an email her director what had happened, and NAS #34 notified the ED Director and the behavioral health director what information she knew. Interview revealed the NAS did not talk with the male ED RN nor the behavioral health female patient about what had happened. Interview revealed the male ED RN did not come back to work after that shift and the NAS #34 had not seen any policy changes related to this incident.

Interview on 02/16/2023 at 1453 with CNA #35 revealed she called the house supervisor as she was not comfortable with a male ED RN in a female behavioral health patient's room. Interview revealed the house supervisor said the male ED RN did not need to be there and that the nurse went to the room and told him he had to leave. Interview revealed the staff cannot use the middle doors to do the checks anymore.

Interview on 02/17/2023 at 0847 with Security Officer (SO) # 36 revealed he escorted the new behavioral health admission patient, (Name of County) PD Officer, and the male ED RN to the behavioral health unit on 01/16/2023. Interview revealed the male ED RN asked the behavioral health unit RN if a patient was still there and if he could go see her. Interview revealed the male ED RN notified the RN that he had a good rapport with the patient. Interview revealed while on the unit SO #36 was asked to speak with another patient about their behavior. When walking to the other patients room, SO #36 saw the male ED RN sitting at the head of the bed and the female patient sitting at the other end of the bed. Interview revealed after talking with the other patient and ready to exit the unit, the female patient's door was closed when SO #36 walked past the door. Interview revealed SO #36 did not see the male ED RN and thought he had left prior to the SO #36 leaving. Interview SO #36 got the (Name of County) PD Officer and they left the unit together.

Based on policy review, medical record review, hospital document review and staff and physician interviews the hospital failed to provide effective radiologic services for patient care and safety.

The findings include:

Based on review of hospital policy, closed medical record review, review of CT (computerized tomography) patient history form and staff and physician interviews, the radiology staff failed to perform a CT scan without contrast as ordered by the physician for 1 of 3 patients with CT orders reviewed (Pt #8).

~cross refer to 482.26 Radiologic Services Standard: Tag 0535

Based on review of hospital policy, closed medical record review, review of CT (computerized tomography) patient history form and staff and physician interviews, the radiology staff failed to perform a CT scan without contrast as ordered by the physician for 1 of 3 patients with CT orders reviewed (Patient #8).

The findings include:

Review of hospital policy titled PRE/POST PROCEDURE CAT (COMPUTERIZED AXIAL TOMOGRAPHY) SCAN AND MRI(MAGNETIC RESONANCE IMAGING) revised 03/2018 revealed, "Purpose: To ensure a prompt and accurate exam for the patient. Pre-Procedure...Verify the physician order."

Review of hospital policy titled ADMINISTRATION OF IV (INTRAVENOUS) CONTRAST MATERIAL IN RADIOLOGY revised 12/2019 revealed, "Purpose: To identify guidelines that will ensure patient safety during the administration of IV contrast material...1. The following parameters will be used when assessing patients requiring IV iodinated contrast media: ... B. All patients greater than 60 years old require a serum creatinine (and/or eGFR [estimated glomerlar filtration rate]) performed within the last 30 days. D. Administration of intravenous contrast with serum creatinine greater than or equal to 2.0mg/dl (and/or eGFR less than or equal to 40) requires discussion with the ordering physician or radiologist. 2. Outpatients with the following conditions are considered "at risk" for contrast induced nephropathy (CIN) or CIN. A. 60 years of age or greater..."

A closed medical record review revealed Patient #8, an 80-year-old male referred for an outpatient CT scan without contrast on 12/28/2022 at 0800. Review of the physician's order dated 12/14/2022 revealed "CT Abdomen/ Chest/Pelvis...Test Reason: prostate cancer and weight loss, history of lung nodules...IV Contrast: Without. Oral contrast: Without..." Review of the H&P (History & Physical) dated 12/28/2022 at 2042 revealed a past medical history of prostate cancer, lung nodules, anemia, chronic kidney disease stage II, hypertension and auditory hallucinations. Further review of the H&P revealed "...order was for CT scan to be done without contrast, however imaging was obtained with contrast, repeat lab at the Oncology office revealed worsened creatinine at 5.4, patient baseline is 2.3, with a BUN of 53, and potassium of 5.2, due to worsened renal function oncologist called hospitalist team for direct admission..." Patient #8 was admitted to Hospital A's medical-surgical floor... "secondary to IV contrast." Further review of the H&P revealed a plan of care: "received 500ml (milliliters) of IV NS (normal saline) at the Oncology office, NS 100ml/hr (hour), renal ultrasound, BMP (basic metabolic panel) labs ordered daily, avoid nephrotoxic agent (drugs with potential to cause kidney damage) and nephrology consulted." On 12/28/2022 at 1954 the nursing note revealed the patient arrived to the unit via wheelchair at 1840 with his daughter at bedside. On 12/29/2022 at 1242 the physician note revealed "plan to continue to monitor renal function, electrolytes and avoid nephrotoxic agents." On 12/30/2022 at 1356 the physician note revealed "patient renal function unchanged...IV fluids resumed, add Dopamine, renal diet..." On 12/31/2022 at 1551 the physician note revealed "patient is non-oliguric (low urine output), continue IV fluids." On 01/02/2023 at 1321 the physician note revealed "Kidney function, weights and urine flow are acceptable. Agree with current therapy and monitoring." On 01/02/2023 at 1233 the physician note revealed "will proceed with HD (hemodialysis)... No significant change in renal function." On 01/03/2023 at 1017 the Radiology post procedure note revealed "...temporary dialysis catheter insertion into right internal jugular vein." On 01/03/2023 at 1236 the physician note revealed "HD for today..." On 01/05/2023 at 1338 the physician note revealed "Suspect New ESRD (end stage renal disease)." On 01/07/2023 at 1207 the physician note revealed "Patient is now dialysis dependent. Got tunneled dialysis catheter placement yesterday." On 01/07/2023 at 1703 the Discharge Summary revealed the patient was discharged home with self-care, stable.

Review of the form titled CT Patient History revealed it consists of 13 patient history questions; followed by "consent for contrast material injection" section to be signed by the patient and the radiology technician if contrast required; followed by documentation of IV site, gauge, contrast amount, time of contrast injection; creatinine drawn date, creatinine and GFR results (if needed); and radiology technician name.

Interview on 02/14/2023 at 1405 with CT technician (tech) #25 revealed she remembered the patient. CT tech #25 stated, "My eyes erroneously saw 'with contrast' when I looked at the order and his answers to certain questions during the patient history interview did not make me think twice about it. Had his answers triggered me I would've checked labs. Later that day I noticed the order clearly said 'without' and I remembered giving him contrast, so I called the ordering physician assistant and informed her. She informed me they would get the patient back into the Oncology office for rehydration..." Interview revealed CT tech #25 informed Radiology Manager #27 and put in an incident report.

Interview on 02/14/2023 at 1430 with Director #26 revealed she was familiar with the incident. Director #26 stated, "The CT tech saw the order as with and not without contrast. She followed procedure by calling the provider...Standard procedures tell us when to use contrast or not but it's all up to the physician's order, so staff should double check the order to confirm. No specific changes were made after the incident..." Interview revealed Director #26 signed off on the incident report and acknowledged an error was made by staff but did not take any other actions.

Interview on 02/14/2023 at 1447 with Radiology Manager #27 revealed she remembered the incident. She stated, "The CT tech called and told me what happened and that she had already informed the provider. I then told her to put in the incident report. I discussed with her to verify orders and she confirmed she would..." Interview revealed no education had been reiterated with other staff and no other actions were taken since the incident.

Interview on 02/15/2023 at 0830 with Medical Doctor (MD) #28 revealed the CT scan was ordered without contrast. He stated, "I got the call 12/28/2022 at 1610 that the patient had been given IV contrast...The patient has chronic kidney disease, so the safe thing for staff to do is always check creatinine on every patient. The patient's creatinine was 5.4 in the office following the CT scan with contrast..." Interview revealed the patient was directly admitted due to elevated creatinine level after the contrast was received.

Interview on 02/15/2023 at 0840 with Physician Assistant (PA) #29 revealed "The CT scan was ordered for unexplained weight loss. The scan without contrast was due to his renal function. I got the call at 1435 from the CT tech informing me of the error. I then called the patient and got him in the office to hydrate him... The patient was in the office by 1500... We gave IV NS fluid from 1510-1645. The patient creatinine level was checked in office and was 5.4. I spoke with hospitalist and then called his daughter to have her take the patient to the hospital to be directly admitted." Interview revealed the patient is now on dialysis as a result of the contrast.

Interview with 02/15/2023 at 1105 with CT tech #30 revealed "...for scans and MRI we only look at patient labs if they are diabetic, take metformin, or have kidney disease/failure. If patients answer yes to those questions, then we do a stat creatinine."

Follow up interview on 02/16/2023 at 0933 with the Radiology Manager #21 revealed "We have one CT patient history form that staff fill out for all patients, whether they are receiving contrast or not. If the patient is getting contrast, then they would sign the consent portion of the form." Interview revealed all patient's history is assessed via the CT Patient History form prior to imaging.

Based on policy review, medical record review, EMS (Emergency Medical Services) Patient Care reports and provider and staff interviews, the hospital failed to meet the emergency needs of patients.

The findings include:

1. The hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 7 of 20 sampled patiens that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #12, 13 ,6, 14, 5, 4, 1 ) and failed to provide stabilizing treatment to 1 of 20 ED patients reviewed (Patient #14).

~cross refer to 482.55 Emergency Services Standard: Tag 1101

2. The hospital's emergency department staff failed to provide timely diagnostic testing for 5 of 20 patients presenting to the Emergency Department for care and treatment (Patients #12, 13, 6, 5, 4)

~cross refer to 482.55 Emergency Services Standard: Tag 1103

Based on hospital policy review, medical record review, emergency department staff and provider interviews, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 7 of 20 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #12, 13 ,6, 14, 5, 4, 1 ) and failed to provide stabilizing treatment for 1 of 20 ED patients reviewed (Patient #14).

The findings include:

Review of the EMTALA policy, last revised 04/2020, revealed "...All individuals who seek emergency treatment....will receive a Medical Screening Examination to determine if an Emergency Medical Condition exists. This screening will include the use of any services routinely available to the Emergency Department....Refusal of Medical Screening Exam If a patient or person acting on the patient's behalf refuses further exam and treatment, the qualified medical personnel should... offer exam and treatment...inform the patient....of the risks and benefits of the exam and treatment....document in the medical record a description of exam, treatment, or both if applicable, refused by the patient....take reasonable steps to obtain the patient's written and informed refusal...document what steps were taken to obtain a written refusal, if the patient refuses to sign a written refusal. ..." The EMTALA policy further revealed "...If the medical screening exam reveals that an emergency medical conditiom exists, (Hospital) will then provide all such patient with treatment necessary to stabilize this condition. ..."

A. 1. Closed medical record review on 02/14/2023 of Patient #12 revealed a 45-year-old female who presented to the ED via EMS on 02/08/2023 at 0839 with a complaint of "Chest Pain." Review revealed Patient #12 was triaged at 0858 and assigned a priority 3. An ECG (electrocardiogram- measures the heart's electrical activity) performed at 0858 revealed "Normal sinus rhythm; Minimal voltage criteria for LVH (left ventricular hypertrophy - heart's left pumping chamber that has thickened and may not be pumping efficiently), may be normal variant; Borderline ECG." Review revealed the ECG was signed by a Medical Provider at 0905. Review of the electronic medication administration report (eMAR) revealed Aspirin 324 mg po (by mouth) was ordered at 0945 and signed off as administered at 1203. Review of the Provider Orders revealed blood work to include Troponin levels were ordered at 0943. Troponin blood test was also timed for 1243 and 1543. Review of the Chest X-ray at 1008 revealed "IMPRESSION: 1. Minimal streaky opacities the lung bases, most likely atelectasis." Review of the blood lab test completed at 1159 included a normal Troponin level. Continued review of the blood lab test revealed a second normal Troponin level at 1515. Review of the ED MSE Provider Note at 1235 revealed "Medical Screening Exam; Time Seen by Provider in MSE: 12:35; (3 hours, 56 minutes after arrival) Med Screening Eval Performed?: Yes' Subjective: ...evaluation of left-sided chest pain. Patient arrives via EMS. Aspirin administered by EMS. Patient states had symptoms diarrhea and headache yesterday. Patient states diarrhea improved. She developed left-sided chest pain which comes in waves of pain in the left anterior chest with associated malaise. No shortness of breath cough or wheezing. No palpitations. No lower extremity pain swelling or edema. No cough. No known sick contacts. No pleuritic pain. Patient does have a significant past medical history consistent with PVC (premature ventricular contractions - extra heartbeats), Hashimoto (autoimmune condition that causes underactive thyroid), cervical cancer. (sic) ... Assessment: This patient was greeted and a Medical Screening Exam was performed in triage... Due to no available ED beds, the patient has been directed back to the waiting room to wait for an available ED bed. This patient is not being managed by me. I alerted nursing and other ED staff that I recommend the patient go back to a room in the ED. Plan: To Main ED. Review of the Nurse Note at 1354 revealed "ASA that was charted as given was not given due to the fact the patient received it by EMS." Review of the ED Summary Report revealed Patient #12 was placed in an ED room at 1657 (8 hours, 18 minutes later). Review revealed disposition was set to "Discharge" at 1726. Review of the medical record revealed Patient #12 was discharged home at 1740.

Interview on 02/15/2023 at 1441 with Physician Assistant (PA) #20 revealed it is not normal for orders to be placed at 0944 and not drawn until 1159. Interview revealed due to staffing and other needs, staff resources are pulled to other areas of the ED. Interview revealed patients are sick and when there are no rooms available in the ED, PA #20 talks with the Charge RN and the Triage RN to try to get a bed. Interview revealed PA #20's "job is to do the MSE, put in the orders, not to manage every pt in the waiting room." Interview revealed any critical or abnormal test result that came back that PA #20 ordered; he would get notified of the result. Interview revealed if the pt has stable chest pain, not ideal, but ok to put them in the ED waiting until a bed is available. Interview revealed stable chest pain means "EKG is normal and labs are normal." Interview revealed last week there were Level 2 and Level 3 priority patients in the ED waiting room awaiting a bed. Interview revealed the call outs, holds for admission, and behavioral health patients were the reason.

Telephone interview on 02/16/2023 at 1143 with Medical Doctor (MD) #2 confirmed it was his signature on the ECG. Interview revealed any patient that comes into the ED complaining of chest pain gets an ECG. Interview revealed MD #2 looks at the ECG to determine if the patient is having an acute STEMI (ST elevated myocardial infarction - a heart attack) or not. Interview revealed the ECG will go along with what is going on with the patient, if they are diaphoretic (sweaty), ill looking, fatigue (tired), and if their vital signs are abnormal. Interview revealed MD #2 does not review the patient's medical history when reviewing the ECG. Interview revealed if the patient is "not actively dying, they will sit in the lobby at (Facility Name) due to the holds in the ED and staffing" throughout the facility. Interview revealed there is not always a tech or nurse available to draw labs while the patients are waiting for a room in the ED. Interview revealed when there is not a tech or nurse the patient has to wait until they get into the ED room for the labs to be drawn or the orders to be fulfilled.

Telephone interview on 02/16/2023 at 1628 with RN #22 revealed she remembered writing the note regarding not giving the aspirin. Interview revealed RN #22 had already scanned and documented the aspirin prior to Patient #12 notifying she had the medication from EMS. Interview revealed RN #22, still being new to the facility, did not know how to correct the documented administrated time for the medication and that is why she wrote the note. Interview revealed RN #22 was the MSE RN and fulfilled the provider orders within comfort level and scope. Interview revealed RN #22 would perform ECG, administer certain medications, and draw blood for lab tests. Interview revealed RN #22 remembered 02/08/2023 was a very busy day and typically patients complaining of chest pain do not wait that long for their lab work to be drawn.

Interview on 02/17/2023 at 1109 with RN #21 revealed she did not remember Patient #12. Interview revealed when a patient comes in complaining of chest pain, the triage nurse initiates the chest pain protocol. Interview revealed the chest pain protocol includes vital signs and ECG within ten minutes. Interview revealed the ECG has to be given to the MD within ten minutes and if there is no life time threatening problem, the patient can go into the waiting room. Interview revealed protocol blood labs are ordered. Interview revealed priorities 2 and 3's have been placed in waiting room due to no bed available in the ED due to holding pts. Interview revealed when a patient with a complaint of chest pain and a cardiac history is placed in the waiting room due to no beds available in the ED, RN #21 does her very best to place the patient in her line of vision until a bed becomes available.

Interview on 02/17/2023 at 1129 with RN #12 revealed he was not aware of an incident involving Patient #12. Interview revealed "Physicians are not screening patients upon arrival via EMS." Interview revealed it does not mean pts do not need to go directly back, it means they are stable enough to go to the lobby.

2. Closed medical record review on 02/16/2023 of Patient #13 revealed a 57-year-old female who presented to the ED on 02/07/2023 at 0957 with a chief complaint of "Chest Pain." Review of the Nursing Triage Assessment at 1020 revealed vital signs of blood pressure (BP): 133/72; pulse (P): 96; respirations (R): 20; oxygen saturation: 98%; temperature (T): 98.7; and pain 8 out 10 on the numerical 0-10 pain scale (0 is no pain and 10 is severe pain). Review of the Nurse Triage note revealed "Pt reports sob (shortness of breath) since last year. Pt states she is suspicious of copd (chronic obstructive pulmonary disease - progressive lung disease) and had increased sob and cough in the last moth (sic). ..." Review of the ED MSE Provider Note at 1205 revealed "Medical Screening Exam; Time Seen by Provider in MSE: 12:05; MED Screening Eval Performed?: Yes' Subjective: ... ongoing cough with dyspnea and intermittent chest pain. Developed midsternal chest pain last night which has been unrelieved by gasx and antacids. Described as heaviness sensation. Dyspnea exacerbated with exertion and has been present for about 6 months, gradually worsening. Cough is dry, nonproductive and has been present for one month. Tobacco user. Hx (history) DM (diabetes mellitus - the body does not produce enough insulin to deal with the amount of blood sugar in the body) ... Assessment: 1- chest pain 2-chronic dyspnea; Plan: To Main ED." Review of the Chest X-ray at 1257 revealed IMPRESSION: 1. Low volumes with interstitial thickening which may represent fibrosis, edema or infection. Further evaluation with chest CT may be useful as clinically indicated." Review of the ECG performed at 1443 revealed "Normal sinus rhythm; Possible Left atrial enlargement; Septal infarct, age undetermined; Abnormal ECG; When compared with ECG of 23-JUN-2018 11;17, Septal infarct is now Present." Review revealed the ECG had not been signed by a medical provider. Review of the medical record revealed blood lab work were performed at 1440 to include a Troponin which resulted a normal value. Review of the medical record revealed at 2038 "Disposition Type: AMA (against medical advice) ... Recognized Date Patient Left: 02/07/2023 Recognized Time Patient Left: 1909 (approximatley 9 hours after arrival) AMA Sheet: Signed ... Review of the medical record revealed no signed AMA form."

Interview on 02/21/2023 with RN #12 revealed he had reviewed the medical record for Patient #13. Interview revealed there was no AMA form in the medical record. Interview revealed RN #12 spoke with RN #19 and determined Patient #13 did not leave AMA. Interview revealed Patient #13 left prior to treatment being completed. Interview revealed RN #19 did not document in the electronic medical record calling Patient #13 three times and did not fill out the paper copy to be scanned into the system as listed as part of the POC. Interview revealed RN #19 was not available for interview.

3. Closed medical record review on 02/14/2023 of Patient #6 revealed a 70-year-old male who presented to the ED via EMS on 11/28/2023 at 1546 with a complaint of "Chest Pain." Review of the Triage Note at 1656 revealed "Pt with reproducable (sic) R (right) sided chest pain x (times) 5 days. Hx (history) HTN (hypertension- high blood pressure). More painful on inspiration. " Vital signs at 1656 were Blood Pressure (BP): 144/82; Pulse (P): 94; Respirations (R): 20; oxygen saturation: 97%; temperature (T): 100.2; and pain 5 out 10 on the numerical 0-10 pain scale (0 is no pain and 10 is severe pain). Patient # 6 was assigned a "Priority 3." Review of the ED Summary revealed Patient #6 was seen by a Provider at 1919, however there is no provider note documented in the medical record. Review of the Chest X-ray at 2017 revealed IMPRESSION: Elevated left hemidiaphragm and mild basilar atelectasis without consolidation. Review of the ECG performed at 2020 (4 hours, 34 minutes) revealed "Atrial fibrillation with rapid ventricular response; T wave abnormality, consider lateral ischemia; Abnormal ECG; When compared with ECG of 20-Aug-2018 0957; Atrial fibrillation has replaced Sinus rhythm; Nonspecific T wave abnormality now evident in Inferior leads; T wave inversion more evident in Lateral leads." Review of medical record revealed blood lab work was performed at 2032 to include a Troponin level that was normal. Vital Signs at 2032 were BP: 125/59; P: 105; R: 16; and oxygen saturation: 99%. Vital Signs on 11/29/2022 at 0301 revealed BP:119/67; P: 106; T: 99; oxygen saturation: 100% and vital signs at 0615 revealed BP: 101/62; P: 65; R: 18; oxygen saturation: 100%. Review revealed Patient #6 left AMA on 11/29/2022 at 0721 (15 hours and 21 minutes after arrival). Review failed to reveal an MSE documented.

Interview on 02/15/2023 at 1105 with PA#18 revealed he did not remember Patient #6. Interview confirmed after PA #18 reviewed the medical record for Patient #6, there was no MSE note. Interview revealed PA #18 "must have gone to the next room to see next pt and forgot to put in note."

Interview on 02/16/2023 at 1522 with MD #24 revealed he did not remember Patient #6. Interview revealed the MSE has been started and the EKG has been performed by the time MD #24 sees the patient in the back.

5. DED Medical Record review, on 02/14/2023, revealed Patient #5 was a 54-year-old male who arrived to the hospital's DED via EMS on 11/28/2022 at 1408. Review of the EMS report for Patient #5 revealed "History of Present Illness ....stroke call. Upon arrival ...made contact with the patient and his wife ....She stated that she heard him call for her and when she walked back there he was on the floor and was not alert ... shortly after ...she was able to get him up.... On initial assessment...Vital signs.... were unremarkable except for his BGL (blood glucose level) which was high at 302 ....Once assessed medic 1 (with EMS) assisted the patient out of the bathroom and into the stair chair and during that time some severe lower extremity weakness was noted.... IV access was then established and a 500 ml bolus of LR (lactated ringers) was started....Upon arrival to the ER the patient was taken inside via stretcher to the nurses station. The charge nurse and ER doc stated that they wanted to check his BP after the fluid bolus finished and see if he could go to triage. Once finished vital signs were reassessed and the nurse and ER doc were informed of the updated VS. The patient was then taken to the triage hallway where he was assisted off of the stretcher and into a wheelchair ....report was given to the triage nurse. ..." ED record review revealed Patient #5 was in the waiting room at 1408. Review of the "Rapid Initial Screening" at 1533 (1 hour, 25 minutes later) revealed a stated complaint that "Per family pt with no hx (history) of seizure, had a seizure lasting appx (approximately) 5 minutes with some foaming from his mouth." Record review revealed a past medical history that included among other things, Moyamoya (progressive cardiovascular disorder caused by blocked arteries in the base of the brain), diabetes, and hypertension. Review of the ED MSE Provider Note, time seen 1632 (approximately 2 ½ hours after arrival), revealed "...presents to the emergency department via.... EMS from home ...for evaluation possible stroke-like symptoms versus seizures symptoms that occurred today around 1:30 p.m....Assessment: Possible seizure activity versus stroke-like symptoms ....Unenhanced Head CT, CT Angiogram of the Head and Neck Vessels, 12-lead EKG, Continuous Cardiac Monitoring, CMP, Cardiac Profile, PT/INR/PTT, CBC (lab tests) were ordered....This patient was MSE/greeted by me in triage. I have initiated this patients work up. Due to no available ED beds the patient has been directed back to the waiting room to wait for an available ED bed. This patient is not being managed by me. I alerted nursing and other ED staff that I recommend the patient go back to a room in the ED. Plan: To Main ED. ..." Review revealed a Chest X-ray was completed and signed at 1758. Review failed to reveal the Head CT, CT Angiogram, the EKG, any cardiac monitoring or any ordered lab work was done. Review failed to reveal any additional vital signs or follow-up with Patient #5 after the provider saw the patient. At 1945, over 5 ½ hours after arrival by EMS, Patient #5 was noted to have left AMA. A note in the record indicated that "AMA Sheet Refused", however, no AMA document was located in the medical record and no written note documented if the patient was encouraged to stay or had been explained the risks of leaving. In the "Disposition" section of the DED record was the statement "IV Fluids continue on Depart?" with the answer "N". No notation was documented to indicate when or by whom the IV (started by EMS) was discontinued.

Request for interview with the Triage Nurse revealed the nurse no longer worked at the hospital and was not available for interview.

Interview on 02/15/2023 at 1105 with PA #18, the PA who did the initial screening on Patient #5 revealed he was the provider who did the quick MSE. In relation to the statement about initiating the work up but not managing the patient, PA #18 stated he did a quick exam and orders, the initial medical screening, but "it is not a patient I am actively managing". Interview revealed the provider doing the quick MSE did not follow patients in the waiting room, that someone else would follow the patient once they got back into the main ED. Interview revealed the facility sometimes had a tech or nurse to help carry out the orders placed but sometimes not. If there was not one to assist, the patient would wait. The PA's role, interview revealed, was to keep seeing patients, do screenings and place the orders, then move to the next patient and wait for someone else to carry out the orders. Interview revealed the orders for diagnostic testing should have been done more rapidly but there had to be someone to carry out the orders. Interview revealed Moyamoya increased the risk of both strokes and seizures. Interview revealed there was "absolutely" there was a delay for Patient #5. Interview revealed the patient should have been in the main ED but there were only 20 beds plus 6 hallway beds.

6. DED medical record review, on 02/14/2023, revealed Patient #4, an 81-year-old male, was taken to the DED on 10/05/2022 at 1724 after a fall on the premises. Review of a "Rapid Initial Screening" at 1740 revealed "... Stated Complaint Details PATIENT PRESENTS TO ED AFTER A FALL, TRIP AND FELL, MEDICAL ALERT UPSTAIRS. PATIENT WAS BLEEDING FROM NOSE AND MOUTH WITH LACERATION TO LOWER LIP. PATIENT ALSO REPORT SPAIN (sic - reports pain) TO HEAD, AND BILATERAL HANDS. DENIES LOC (loss of consciousness), NOT ON BLOOD THINNERS. NOSE CLAMPS APPLIED, EPISTAXIS (nose bleed) CONTROLLED AT THIS TIME. ..." Review revealed vital signs of BP 146/81, Pulse 102, Respirations 17, Temperature 97.1 and pulse oximetry 98% on room air. Record review did not reveal a documented pain score. At 1739, DED record review revealed "ED MSE Provider Note....Time Seen by Provider in MSE: 17:39 MED Screening Eval Performed?: Yes Subjective: ...(Last Name) is an 81 year-old male who presents to the emergency department as an MR T (hospital's response team.... The patient states he fell face forward and injured his nose. The patient tells me he 'bled profusely' after. No LOC. GCS (Glasgow Coma Scale) of 15 (normal) per my evaluation. Objective: .... HENT - Facial injury with nasal injury and associated epistaxis. Nasal clamp applied by me. Oropharynx is moist. Voice is normal. No facial swelling. OPHTHALMIC - PERRLA (Pupils equal, round, reactive to light and accommodation) EOMI b (extraocular motion intact bilateral) Sclera (whites of the eyes) anicteric (not jaundiced or yellow). NECK - Supple. Non-tender. Full ROM (range of motion) .... EXTREMITIES.... warm and non-tender. Full ROM. NEUROLOGIC - Non-focal examination. Assessment: Trip and fall with facial injury and epistaxis Plan: Fast Track. ..." Review of the "Status Event History" revealed "10/05/22....1950 Elopement 10/10/22 1533 Record Closed." Review revealed that on 10/10/2022 at 1531 was a note that "patient left on board" and a "Departure Assessment" was noted which indicated "...Disposition Type: AMA ....Recognized Date Patient Left 10/05/2022 Recognized Time Patient Left 1950 Comment based on chart. ..." Review of the printed DED medical record did not reveal any orders for diagnostic testing nor any results of testing.

Review of an "Order Audit Trail" on 02/20/2023 revealed an order for "CT MAXILLOFACIAL WO (without)/CONTRAST" was placed 10/05/2022 at 1747 and was cancelled at 2155 (after Patient #4 departed the DED).

Interview on 02/17/2023 at 1030 with RN #23, on 02/17/2023 at 1030 revealed RN #23 saw and spoke with Patient #4 as he was coming down a hall, then turned and heard a noise. Interview revealed Patient #4 was on the ground face down. Interview revealed "His nose was busted, his lip was busted, there was a lot of blood, but he was talking, responsive, appropriate and helping hold the gauze (to his face)." Interview revealed Patient #4 was placed in a wheelchair and taken to the ED.

Interview with PA #18 on 02/15/2023 at 1105 revealed if the PA was scheduled as the provider to do a quick MSE the PA #18 saw patients, did a quick screening, wrote orders, indicated whether the patient should go to fast track or to a bed in the main ED and entered basic notes on what was done. Interview revealed that per his notes, Patient #4 was able to tell the story of what happened. Interview revealed PA#18 ordered a maxillofacial CT "stat". Interview revealed PA #18 was mainly concerned about the facial bones but stated a facial CT would show if there was excess fluid, which would show evidence of intracranial hemorrhage. Interview revealed Patient #4 was placed in the waiting room to wait for the CT. Interview revealed patients generally may have to wait 15-20 minutes for a CT. Interview revealed the PA thought the CT and results would happen quickly and the patient could then go to Fast Track to have his wounds evaluated, cleaned and sutured, and also to have a more thorough evaluation should that have been needed. PA #18 stated he tried to address the imminent needs first, which was the facial CT. Interview revealed there was a delay in getting the stat CT done for ongoing medical screening.

7. DED medical record review, on 02/14/2023, revealed Complaint Patient #1 arrived to the DED on 10/17/2022 at 0944 with a stated complaint of "FALL." Review revealed Patient #1 was not triaged and did not have a medical screening examination. Review revealed the recognized time that Patient #1 left was 1000 (16 minutes after arrival) and noted the record was closed at 1144. DED record review did not reveal any vital signs, any discussion of the patient's chief complaint or any medical information other than she came to the DED because of a fall. Record review failed to reveal any documentation of attempting to get the patient to stay or explaining the risks of leaving without screening thus potentially delaying medical screening for presence of an emergency medical condition. .

Interview with Administrative Staff (AS) #16 on 02/14/2023 at 1500 revealed the video was reviewed by hospital staff and a nurse was observed assisting the patient into the car to leave the premises. Interview revealed the video was no longer available. Interview revealed the hospital was never able to identify the nurse who assisted the patient into the vehicle.

Telephone interview on 02/14/2023 at 1500 with RN #17, the Charge Nurse on the day Patient #1 arrived, revealed she recalled Patient #1. Interview revealed Patient #1 was brought in by EMS after a fall and the facility received a quick report. The rooms in the ED were full so the RN #17 thought it would be appropriate to triage the patient then place her in the waiting room. The patient, she stated came in with a complaint of pain, she did not know the specific patient needs. Interview revealed RN #17 went out to the "front", the patient's husband was requesting to speak to the Charge Nurse. Interview revealed the husband stated Patient #1 had a procedure at another hospital and could not be in a seated position. RN #17 stated she understood the patient may have had a broken pelvis, which she had been unaware of at the time of arrival. Interview revealed RN #17 asked the husband to "let me go in the back and try to find a bed for you ....Give me a few minutes let me see what I can find out and I will get back with you." Interview revealed RN #17 went back into the ED, got a place to put the patient and got a bed ready, then went back to the waiting room and told the gentleman she had found a place. RN #17 stated he said he did not want the bed, he now wanted to take her to another hospital. Interview revealed "I offered a room again ....that we will see them ....he wanted to leave." Interview revealed it was very hectic in the ED that day, but she tried to address his concerns but he was adamant to leave. RN #17 stated the hospital had always had AMA forms, but she had only used the forms to document after a patient was checked in, not when they left before they checked in. Interview revealed RN #17 did not ask the patient/spouse to sign anything. Interview revealed after they were determined to leave, RN #17 went back into the ED and did not see them leave. Interview revealed she did not know who assisted the patient into the vehicle to leave.

B. Review of the EMTALA policy, last revised 04/2020, revealed "...If the medical screening exam reveals that an emergency medical conditiom exists, (Hospital Initials) will then provide all such patient with treatment necessary to stabilize this condition. ..."

ED record review, on 2/14/2023, revealed Patient #14 arrived to the DED on 02/06/2023 at 1337 via EMS from home and was checked in to an ED room. Review of a Rapid Initial Screening by a RN at 1524 revealed Patient #14 was brought in for suicidal ideation. Review revealed Patient #14 had a past medical history that included "Parkinsons (progressive disorder of the Central Nervous System affecting movement), schizoaffective /bipolar (chronic mental illnesses)" and had been discharged from the hospital psychiatry unit that morning. Review of an Emergency Provider Record, signed 02/06/2023 at 1626, revealed "...Time Seen By Provider: 16:21.... Chief Complaint: Suicidal ....This is a 60-year-old male with a known history of schizophrenia, was just discharged from hospital today this a.m..... patient states that he still wants to kill himself and that he has been having auditory hallucinations....Discussed with..... Psychiatry.... Decision regarding hospitalization was made ....Diagnosis: 1. Schizophrenia exacerbation.... Primary Impression: Chronic schizophrenia Disposition Type: Hospitalize. ..." Review of Involuntary Commitment paperwork revealed a "FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT" which documented the first-level examination and evaluation for Patient #14 was conducted 02/06/2023 at 1600. Review revealed it showed the patient needed Inpatient commitment because the patient was "...An Individual with a mental illness" and "Dangerous to: ... Self or...Others." The findings listed were "Schizophrenic with Auditory hallucinations & S.I. ..." Review of a "Provider Progress Note" by a psychiatrist, electronically signed 02/08/2023 at 0912, revealed"...Date Seen: 2/8/23 Interval History: ....male with schizoaffective disorder and significant behavioral challenges continues to have mood lability and is adamant about wanting to be in a different hospital IVC paperwork was filled out and he is waiting to be transferred to another hospital no side effects reported on current medication .... Anticipated Discharge Date: Feb 22, 2023 .... Mental Status .... alert oriented x 3 mood is okay affect is constricted thought process is labile denies any current suicidal homicidal thoughts .... insight and judgment limited ... Problems List (1) Schizoaffective disorder....Will continue current medications he is waiting to be transferred to another hospital.... Current Suicide Risk: Medium....Expected Length of Stay ....6-8 Days....Clinical Pain (sic) /Reasoning Based on direct contact with the patient, I certify in my best clinical judgement that continued care in an Inpatient is warranted. Evidence for continue care is: Abnormal MSE. ..." On 02/08/2023 at 1537, an Emergency Department Note indicated "Pt became upset when he saw another pt (patient) leaving and said we should find him a place before we find someone else a place.... He said that we were not trying. I told him that was not true but he has to understand that him coming back to back to hospital make people suspect he is homeless and maligering (sic) so they may not think he really want (sic) help. Pt said he will just die in here then. He said yall (sic) aren't giving me the help I need. I told him that we are and have treated him for what he tell (sic) us is the problem and he is better when we discharge him .... Pt yelled and stomped off to his room, saying I would rather kill myself than be here." At 1641, an Emergency Department note documented "Pt is adament (sic) that he no longer want to be here. He want to go to another facility. I called (where pt lived) owner and informed her of pt request to be sent to another hospital. I told her we had referred him out but there are no takers at this time. I told her we would continue to refer him out and has continued to offer pt further treatment here and will continue to but he is adament (sic) he don't want help from here and we are not helping him. I told her the pt want to know if she will come pick him up and take him to (hospital name). She said she would not unless she knew they were going to keep him....I asked her did pt have money left for him to take a cab to another facility if he requested to go. She said yes. He was grown, his on (sic) guardian and she was not going to spend her time taking him to another hospital I told her I would inform the pt. I also advised Dr. (Name)." Review of another note, timed as 1707, revealed "Safety Cab called and asked for an estimate for transport to (Hospital name). Pt and ...owner (Name) informed of estimate....We continued to encourage pt to be patient. He continued to refuse care at this facility. Dr. (Name) talked to pt again and again tried to get pt to stay until he could be accepted at another facility. Pt said no he was ready to leave and leave right now. He continued to say we were not doing anything for him here." Review revealed at 1741 another note that stated "Pt discharged AMA (against medical advice) by charge nurse. Pt was given his belongings and let off of unit by myself." Review of IVC Status "NOTICE OF COMMITMENT CHANGE", signed on 02/08/2023 (no time documented), revealed Patient #14's name was listed as the Respondent. The form included a listing of reasons that the involuntary commitment might be changed with a box to be checked by the appropriate reason(s) for the change. Review of the document revealed none of the boxes were checked but beside the last box which was labelled "Other (Specify)" were the handwritten words "AMA discharge" signed by a provider.

Interview on 02/17/2023 at 1515 with Paramedic #14 revealed Patient #14 had just been discharged from the inpatient psychiatric unit that day. Interview revealed the patient "signed himself back in" but did not want to be treated at this hospital. Interview revealed the plan was to refer him out to another hospital and treat him while he awaited the transfer. Paramedic #14 stated the patient wanted to know why other facilities were

Based on review of policy and procedures, medical record reviews and staff and physician interviews, the hospital's emergency department staff failed to provide timely diagnostic testing for 5 of 20 patients presenting to the Emergency Department for care and treatment (Patients #12, 13, 6, 5, 4)

The findings include:

Review of the EMTALA policy, last revised 04/2020, revealed All individuals who seek medical treatment according to this policy will receive a Medical Screening Examination to determine if an Emergency Medical Condition exists. This screening will include the use of any services routinely available to the Emergency Department ... ."

Review of the CP (chest pain)/ACS (acute coronary syndrome) Evaluation (NUR [nursing]), not dated, revealed "General; Nurse to initiate these orders if patient presents with chest pain suspicious of being cardiac; OR the patient presents with chest pain and has a prior cardiac history; OR the patient has chest pain and has cardiac risk factors (age over 50, hypertension, diabetes, history of tobacco or cocaine use, or high cholesterol); or the patient has chest pain that is not reproduced by palpitation or respiration ... Laboratory: Comprehensive Metabolic Panels (LAB) STAT (immediately) Today Now; Complete Blood Count (LAB) STAT Today Now; Partial Thromboplas (thromboplasty) Time - PTT (LAB) STAT Today Now; Prothrombin Time - PT/INR (LAB) STAT Today Now; Troponic I (LAB) STAT Today Now; Troponin I (LAB) Timed Today @1024 -Q3H (every three hours) - Count 2; ... Radiology: Portable Chest X-Ray (CXR) (RAD) - STAT Today Now; Diagnostic Tests - Cardiology; EKG* (CARD) STAT (immediately) Today Now ..."

Review of the ACS Clinical Pathway ECG Pathway, not dated, revealed "... Patient complaint of ACS signs/symptoms ... Perform STAT 12 Lead ECG (electrocardiogram); 12 Lead completed/interpreted by provider <= 10 min (minutes); *ECG performed in triage if no immediate bed available ..."

1. Closed medical record review on 02/14/2023 of Patient #12 revealed a 45-year-old female who presented to the ED via EMS on 02/08/2023 at 0839 with a complaint of "Chest Pain." Review revealed Patient #12 was triaged at 0858 and assigned a priority 3. Review of the Provider Orders revealed blood work to include Troponin levels were ordered at 0943 for a total of 3 troponins. The Troponin 2nd and 3rd tests were timed 1243 and 1543. Review of the blood lab test completed at 1159 (2 hours, 16 minutes after ordered) included a normal Troponin level. Continued review of the blood lab tests revealed a second normal Troponin level at 1515 (was timed for 1243). Review of the ED MSE Provider Note at 1235 revealed "Medical Screening Exam; Time Seen by Provider in MSE: 12:35; (3 hours, 56 minutes after arrival) Med Screening Eval Performed?: Yes' Subjective: ...evaluation of left-sided chest pain. Patient arrives via EMS. Aspirin administered by EMS. Patient states had symptoms diarrhea and headache yesterday. Patient states diarrhea improved. She developed left-sided chest pain which comes in waves of pain in the left anterior chest with associated malaise. No shortness of breath cough or wheezing. No palpitations. No lower extremity pain swelling or edema. No cough. No known sick contacts. No pleuritic pain. Patient does have a significant past medical history consistent with PVC (premature ventricular contractions - extra heartbeats), Hashimoto (autoimmune condition that causes underactive thyroid), cervical cancer. (sic) ... Assessment: This patient was greeted and a Medical Screening Exam was performed in triage... Due to no available ED beds, the patient has been directed back to the waiting room to wait for an available ED bed. This patient is not being managed by me. I alerted nursing and other ED staff that I recommend the patient go back to a room in the ED. Plan: To Main ED. Review revealed disposition was set to "Discharge" at 1726. Review of the medical record revealed Patient #12 was discharged home at 1740.

Interview on 02/15/2023 at 1441 with Physician Assistant (PA) #20 revealed it is not normal for orders to be placed at 0944 and not drawn until 1159. Interview revealed due to staffing and other needs, staff resources are pulled to other areas of the ED.

Telephone interview on 02/16/2023 at 1143 with Medical Doctor (MD) #2 revealed there is not always a tech or nurse available to draw labs while the patients are waiting for a room in the ED. Interview revealed when there is not a tech or nurse the patient has to wait until they get into the ED room for the labs to be drawn or the orders to be fulfilled.

Telephone interview on 02/16/2023 at 1628 with RN #22 revealed 02/08/2023 was a very busy day and typically patients complaining of chest pain do not wait that long for their lab work to be drawn.

Interview on 02/17/2023 at 1109 with RN #21 revealed she did not remember Patient #12. Interview revealed when a patient comes in complaining of chest pain, the triage nurse initiates the chest pain protocol. Interview revealed protocol blood labs are ordered.

2. Closed medical record review on 02/16/2023 of Patient #13 revealed a 57-year-old female who presented to the ED on 02/07/2023 at 0957 with a chief complaint of "Chest Pain." Review of the Nurse Triage note at 1020 revealed "Pt reports sob (shortness of breath) since last year. Pt states she is suspicious of copd (chronic obstructive pulmonary disease - progressive lung disease) and had increased sob and cough in the last moth (sic). ..." Review of the ED MSE Provider Note at 1205 revealed "Medical Screening Exam; Time Seen by Provider in MSE: 12:05; MED Screening Eval Performed?: Yes' Subjective: ... ongoing cough with dyspnea and intermittent chest pain. Developed midsternal chest pain last night which has been unrelieved by gasx and antacids. Described as heaviness sensation. Dyspnea exacerbated with exertion and has been present for about 6 months, gradually worsening. Cough is dry, nonproductive and has been present for one month. Tobacco user. Hx (history) DM (diabetes mellitus - the body does not produce enough insulin to deal with the amount of blood sugar in the body) ... Assessment: 1- chest pain 2-chronic dyspnea; Plan: To Main ED." Review of the Chest X-ray at 1257 revealed IMPRESSION: 1. Low volumes with interstitial thickening which may represent fibrosis, edema or infection. Further evaluation with chest CT may be useful as clinically indicated." Review of the ECG performed at 1443 revealed "Normal sinus rhythm; Possible Left atrial enlargement; Septal infarct, age undetermined; Abnormal ECG; When compared with ECG of 23-JUN-2018 11;17, Septal infarct is now Present." Review revealed the ECG had not been signed by a medical provider. Review of the medical record revealed blood lab work were performed at 1440 to include a Troponin which resulted a normal value. Review of the medical record revealed at 2038 "Disposition Type: AMA (against medical advice) ... Recognized Date Patient Left: 02/07/2023 Recognized Time Patient Left: 1909 (approximatley 9 hours after arrival) AMA Sheet: Signed ... Review of the medical record revealed no signed AMA form."

Interview on 02/21/2023 with RN #12 revealed he had reviewed the medical record for Patient #13. Interview revealed there was no AMA form in the medical record. Interview revealed RN #12 spoke with RN #19 and determined Patient #13 did not leave AMA. Interview revealed Patient #13 left prior to treatment being completed. Interview revealed RN #19 did not document in the electronic medical record calling Patient #13 three times and did not fill out the paper copy to be scanned into the system as listed as part of the POC. Interview revealed RN #19 was not available for interview.

3. Closed medical record review on 02/14/2023 of Patient #6 revealed a 70-year-old male who presented to the ED via EMS on 11/28/2023 at 1546 with a complaint of "Chest Pain." Review of the Triage Note at 1656 revealed "Pt with reproducable (sic) R (right) sided chest pain x (times) 5 days. Hx (history) HTN (hypertension- high blood pressure). More painful on inspiration. " Vital signs at 1656 were Blood Pressure (BP): 144/82; Pulse (P): 94; Respirations (R): 20; oxygen saturation: 97%; temperature (T): 100.2; and pain 5 out 10 on the numerical 0-10 pain scale (0 is no pain and 10 is severe pain). Patient # 6 was assigned a "Priority 3." Review of the ED Summary revealed Patient #6 was seen by a Provider at 1919, however there is no provider note documented in the medical record. Review of the Chest X-ray at 2017 revealed IMPRESSION: Elevated left hemidiaphragm and mild basilar atelectasis without consolidation. Review of the ECG performed at 2020 (4 hours, 34 minutes) revealed "Atrial fibrillation with rapid ventricular response; T wave abnormality, consider lateral ischemia; Abnormal ECG; When compared with ECG of 20-Aug-2018 0957; Atrial fibrillation has replaced Sinus rhythm; Nonspecific T wave abnormality now evident in Inferior leads; T wave inversion more evident in Lateral leads." Review of medical record revealed blood lab work was performed at 2032 to include a Troponin level that was normal. Vital Signs at 2032 were BP: 125/59; P: 105; R: 16; and oxygen saturation: 99%. Vital Signs on 11/29/2022 at 0301 revealed BP:119/67; P: 106; T: 99; oxygen saturation: 100% and vital signs at 0615 revealed BP: 101/62; P: 65; R: 18; oxygen saturation: 100%. Review revealed Patient #6 left AMA on 11/29/2022 at 0721 (15 hours and 21 minutes after arrival). Review failed to reveal an MSE documented.

Interview on 02/15/2023 at 1105 with PA#18 revealed he did not remember Patient #6. Interview confirmed after PA #18 reviewed the medical record for Patient #6, there was no MSE note. Interview revealed PA #18 "must have gone to the next room to see next pt and forgot to put in note."

Interview on 02/16/2023 at 1522 with MD #24 revealed he did not remember Patient #6. Interview revealed the MSE has been started and the EKG has been performed by the time MD #24 sees the patient in the back.

4. DED Medical Record review, on 02/14/2023, revealed Patient #5 was a 54-year-old male who arrived to the hospital's DED via EMS on 11/28/2022 at 1408. Review of the EMS report for Patient #5 revealed "History of Present Illness ....stroke call....Once assessed medic 1 (with EMS) assisted the patient out of the bathroom and into the stair chair and during that time some severe lower extremity weakness was noted.... IV access was then established and a 500 ml bolus of LR (lactated ringers) was started....Upon arrival to the ER the patient was taken inside via stretcher to the nurses station....The patient was then taken to the triage hallway where he was assisted off of the stretcher and into a wheelchair ....report was given to the triage nurse. ..." ED record review revealed Patient #5 was in the waiting room at 1408. Review of the "Rapid Initial Screening" at 1533 (1 hour, 25 minutes later) revealed a stated complaint that "Per family pt with no hx (history) of seizure, had a seizure lasting appx (approximately) 5 minutes with some foaming from his mouth." Record review revealed a past medical history that included among other things, Moyamoya (progressive cardiovascular disorder caused by blocked arteries in the base of the brain), diabetes, and hypertension. Review of the ED MSE Provider Note, time seen 1632 (approximately 2 ½ hours after arrival), revealed "...presents to the emergency department via.... EMS from home ...for evaluation possible stroke-like symptoms versus seizures symptoms that occurred today around 1:30 p.m....Assessment: Possible seizure activity versus stroke-like symptoms ....Unenhanced Head CT, CT Angiogram of the Head and Neck Vessels, 12-lead EKG, Continuous Cardiac Monitoring, CMP, Cardiac Profile, PT/INR/PTT, CBC (lab tests) were ordered.... Review revealed a Chest X-ray was completed and signed at 1758. Review failed to reveal the Head CT, CT Angiogram, the EKG, any cardiac monitoring or any ordered lab work was done. Review failed to reveal any additional vital signs or follow-up with Patient #5 after the provider saw the patient. At 1945, over 5 ½ hours after arrival by EMS and over 3 hours since testing was ordered), Patient #5 was noted to have left AMA. A note in the record indicated that "AMA Sheet Refused", however, no AMA document was located in the medical record and no written note documented if the patient was encouraged to stay or had been explained the risks of leaving. In the "Disposition" section of the DED record was the statement "IV Fluids continue on Depart?" with the answer "N". No notation was documented to indicate when or by whom the IV (started by EMS) was discontinued.

Interview on 02/15/2023 at 1105 with PA #18, the PA who did the initial screening on Patient #5 revealed he was the provider who did the quick MSE. PA #18 stated he did a quick exam and orders, the initial medical screening. Interview revealeed in that role the PA did not follow patients who were in the waiting room, that someone else followed them once they got back into the main ED. Interview revealed the facility sometimes had a tech or nurse to help carry out the orders placed but sometimes not. If there was not one to assist, the patient would wait for orders to be carried out. Interview revealed the orders for diagnostic testing should have been done more rapidly but there had to be someone to carry out the orders. Interview revealed Moyamoya increased the risk of both strokes and seizures. Interview revealed there was "absolutely" there was a delay for Patient #5.

5. DED medical record review, on 02/14/2023, revealed Patient #4, an 81-year-old male, was taken to the DED on 10/05/2022 at 1724 after a fall on the premises. Review of a "Rapid Initial Screening" at 1740 revealed "... Stated Complaint Details PATIENT PRESENTS TO ED AFTER A FALL, TRIP AND FELL, MEDICAL ALERT UPSTAIRS. PATIENT WAS BLEEDING FROM NOSE AND MOUTH WITH LACERATION TO LOWER LIP. PATIENT ALSO REPORT SPAIN (sic - reports pain) TO HEAD, AND BILATERAL HANDS. DENIES LOC (loss of consciousness), NOT ON BLOOD THINNERS. NOSE CLAMPS APPLIED, EPISTAXIS (nose bleed) CONTROLLED AT THIS TIME. ..." At 1739, DED record review revealed a ED MSE Provider Note. Review of the Note indicated "...Assessment: Trip and fall with facial injury and epistaxis Plan: Fast Track. ..." Review revealed that on 10/10/2022 at 1531 was a note that "patient left on board" and a "Departure Assessment" was noted which indicated "...Disposition Type: AMA ....Recognized Date Patient Left 10/05/2022 Recognized Time Patient Left 1950 (2 hours 26 minutes after falling on the premises and taken to the ED) Comment based on chart. ..." Review of the printed DED medical record did not reveal any orders for diagnostic testing nor any results of testing.

Review of an "Order Audit Trail" on 02/20/2023 revealed an order for "CT MAXILLOFACIAL WO (without)/CONTRAST" was placed 10/05/2022 at 1747 and was cancelled at 2155 (after Patient #4 departed the DED).

Interview on 02/17/2023 at 1030 with RN #23, on 02/17/2023 at 1030 revealed RN #23 saw and spoke with Patient #4 as he was coming down a hall, then turned and heard a noise. Interview revealed Patient #4 was on the ground face down. Interview revealed "His nose was busted, his lip was busted, there was a lot of blood, but he was talking, responsive, appropriate and helping hold the gauze (to his face)." Interview revealed Patient #4 was placed in a wheelchair and taken to the ED.

Interview with PA #18 on 02/15/2023 at 1105 revealed if the PA was scheduled as the provider to do a quick MSE the PA #18 saw patients, did a quick screening, wrote orders, indicated whether the patient should go to fast track or to a bed in the main ED and entered basic notes on what was done. Interview revealed that per his notes, Patient #4 was able to tell the story of what happened. Interview revealed PA#18 ordered a maxillofacial CT "stat". Interview revealed PA #18 was mainly concerned about the facial bones but stated a facial CT would show if there was excess fluid, which would show evidence of intracranial hemorrhage. Interview revealed Patient #4 was placed in the waiting room to wait for the CT. Interview revealed patients generally may have to wait 15-20 minutes for a CT. Interview revealed the PA thought the CT and results would happen quickly and the patient could then go to Fast Track to have his wounds evaluated, cleaned and sutured, and also to have a more thorough evaluation should that have been needed. Interview revealed there was a delay in getting the stat CT done for ongoing medical screening.