HospitalInspections.org

Based on interviews and record reviews, the facility failed to meet the Condition of Participation (CoP) for Patient Rights by failing to protect and promote each patient's rights as evidenced by the following:

1. The facility failed to facilitate written informed consent for 2 patients (P (patient) 4 & P12) out of 30 patients sampled prior to initiating a interfacility transfer. See Tag 131.

2. The facility failed to provide care in a safe setting for 3 patients by failing to ensure communication and intervention amongst treatment team members regarding At Risk Patients, and by failing to ensure skin protective interventions were maintained. See Tag 144.

3. The facility failed to implement interventions on 1 (P (patient) 18) out of 30 patients sampled that had concerning signs for neglect See Tag 145.

Based on record reviews and interviews, the facility failed to facilitate written informed consent for 2 patients (P (patient) 4 & P12) out of 30 patients sampled prior to initiating an interfacility transfer (transfer from one medical facility to a different medical facility usually due to a need of higher level of care.) This failed practice is likely to lead to lack of understanding of all risks and benefits by the patient prior to consenting.

The findings are:

A. Record Review of facility's "Patient Rights and Responsibilities" policy, effective 09/2014, revealed: "Except in emergencies, the patient may be transferred to another facility only with a full explanation of the reason for the transfer, provision for continuing care, and acceptance by the receiving institution."


B. Record Review of P4's Medical Record from 09/02/2021 revealed:

1. EMS (Emergency Medical Services) Preliminary PT (Patient) Care Report indicates P4 as a 16 year old patient presenting to the facility's Emergency Department for an overdose of 30 pills of melatonin (medication). Report states: "16yo (year old) called for SI (suicidal ideation)/ OD (overdose).

2. At 4:20 am, nursing note "Pt (P4) was brought in by EMS with no parent. Mom called from Denver (Colorado) and stated she is on her way.

3. P4's Grandmother was brought to the Emergency Department.

4. At 7:32 am, Provider note states: "Will work on transfer to an acute care facility in the morning. Discusses plan of transfer with grandmother who is in the room. Grandmother states understanding of plan." No documentation of mother made aware of need to transfer by provider. No documentation that grandmother is P4's legal decision maker.

5. P4's "Physician Standard Orders for Transfer" (Transfer consent form) from 09/02/2021 is unsigned at the area labeled "Patient Consent for Transfer"


C. Record Review of P12's Medical Record from 09/08/2021 revealed:

1. At 7:07 pm, Provider Note states: "Patient (P12) admits to trying to kill self with alcohol and Tylenol (medication). Patient states that they feel like nobody cares for them and they want to die. I (provider) believe that given this strong overdose intention patient needs a behavioral health unit."

2. P12 was transferred to another facility for psychiatric care.

3. P12's Physician Standard Orders for Transfer" (Transfer consent form) from 09/08/2021 is unsigned at the area labeled "Patient Consent for Transfer"


D. On 09/16/2021 at 10:00 am, interview with S (staff) 2 (Registered Nurse, Regulations Coordinator) confirmed the expected process to have signed informed consent for patients transferred to facilities. S2 indicates that for P4, the staff could have taken a telephone consent and documented it with 2 signatures on the transfer form.


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Based on observation, record review, and interview, the facility failed to provide care in a safe setting for 3P (patients), P2, P13, P24) out of 30 patients sampled, by failing to ensure communication and intervention amongst treatment team members regarding At Risk Patients, and by failing to ensure skin protective interventions were maintained. This failed practice is likely to lead to an increased risk of harm, adverse events, and extended length of stay.

The findings are:

Definitions:

Elopement: An event where a patient who is cognitively, physically, mentally, emotionally and/or chemically impaired (under the influence of a drug, medication, or alcohol which may cause loss of function and/or decision making abilities) wanders, walks away from, or escapes from the care of the facility unsupervised prior to discharge.

Left without being seen: The situation when a patient leaves [facility] before being seen by a [facility] provider but after registering in the Emergency Department.

Gravely Disabled: Condition in which a person as a result of a mental illness; is in danger of serious physical harm due to his or her inability of failure to provide himself or herself with the essential human needs of food, clothing, shelter, and medical care; or lack judgement in the management of his or her resources and in the conduct of his or her social relations to the extent that his or her health or safety is significantly endangered and lacks the capacity to understand that this is a matter of importance; diagnosed by a professional person as suffering from: a major affective disorder (illness that affects the way you think or feel);is exhibiting a deteriorating course leading toward danger to self or others.

At Risk Patient (ARP): One whose thoughts or actions may lead to harm to themselves or others. Additionally a patient should be considered at risk if as a result of a variety of other conditions which may include but are not limited to mental illness, substance abuse-withdrawal, emotional stress or dementia; they are so impaired as to have lost contact with external reality.
Mental illness; a disorder of a person's emotional process, thoughts or cognition (condition that can cause people to have difficulty thinking clearly, can impair memory or judgement.)

Incapacitated Person: Any person who demonstrates over time either partial or complete functional impairment by reason of mental illness, physical illness or disability, chronic use of drugs, chronic intoxication, or other cause, to the extent the person is unable to manage the person's personal affairs or the person is unable to manage the person's estate or financial affairs or both.


Findings related to: Ensure communication and intervention amongst treatment team members regarding At Risk Patients.

A. Review of facility's "Requirements for Violent or Self-Destructive patients in the Emergency Department" policy dated 03/05/2019 revealed:

1. The Registered Nurse ensures the safety of the patient by performing an initial screening upon arrival to the Emergency Department and whenever there is a change in behavior to determine if a patient is at risk. The RN collaborates with Emergency Department providers to ensure the safety of the patient and others using the procedures in this policy.

2. Per Emergency Severity Index ((ESI) five level system that uses a flowchart to determine which patients need to be seen immediately versus those who's vital signs/injury/illness does not warrant immediate interventions by the medical staff) triage, at risk patients are categorized as ESI level risk 2, At risk patients will be placed in treatment areas that have been made safe.

3. The RN may place the patient on a temporary involuntary hold if they deem this to be necessary for the patient's safety or the safety of others. The treating Emergency provider should be made aware of at risk patients immediately. The Emergency Department provider, with the assistance of the Emergency Department staff is responsible for determining whether the patient: requires an involuntary hold, will remain as at risk patient status, and /or will require a 1:1 observer (staff member of the facility who is trained to provide direct supervision to a person who is deemed an at risk patient by Emergency Department medical staff.)

a. At risk patients must be escorted by qualified personnel anytime they are outside of their room, including travel to and from the rest room. This includes observation of the patient when using the restroom.


B. Record Review of facility's "Against Medical Advice, Leaving, Elopement or Refusing Treatment" policy dated 12/21/2020 revealed:

1. Documentation of Elopement requirement:

a. Time patient's absence was discovered.

b. Time patient was last seen.

c. Time of physician notification.

d. Document in Quantros (facility data management tracking software).

2. Additional Interventions for "At Risk" Patients:

a. All patients should be assessed for decision making capacity.


P13 Findings:
C. Record review of P13's medical record from 8/26/2021 revealed:

1. On 8/26/2021 documentation of "Emergency Medical Service Preliminary Patient Care Report (pre-hospital arrival ambulance report)" for P13 states:

a. P13 taken to [facility] by ambulance for Altered Mental Status ( AMS, change in behavior, can range from slight confusion to poor judgement, an inability to control emotions) and Suicidal Ideation (thoughts about killing oneself, often as a symptom of major depressive episodes) by saying "I want to die."

2. At 6:15 pm, P13 was registered in Emergency Department, the reason for visit is documented as, "Altered Mental Status, Alcohol Intoxication (temporary condition that occurs when a person drinks an excess of alcohol at one time) and Suicidal Ideation.

3. At 6:23 pm S7 (Registered Nurse) documented P13 was being seen for Altered Mental Status, and Alcohol Intoxication. No documentation of inclusion of suicidal ideation.

4. No documentation of provider notification of P13 suicidal ideation statement.

5. No documentation of 1:1 observation for P13.

6. No documentation of S7 approaching S13 to assess decision making capacity.

7. At 7:11 pm, S7 describes P13 eloping from the Emergency Department by documenting the following, but this does not describe an elopement as per above facility's definition "patient seen walking out of ER (Emergency Room) after making a phone call for a ride home. Discharge orders not in placed by MD (Medical Doctor), pt (patient P13) was seen ambulating (to move from place to place: walk about) independently." No documentation of provider notification of P13 actively leaving the facility.

8. No documentation S7 intervened and asked P13 to stay until treatment has been provided.

9. No documentation S7 notified Security.


D. On 9/16/2021 at 2: 12 pm, interview with S14 (Emergency Department Nurse Manager) revealed:

1. If a Suicidal and alcohol intoxicated patient comes in from the lobby, the Emergency Medical Technician(EMT) tech will start the process to get the patient into gown, the EMT will communicate with the Charge Nurse who works on getting the patient into a room, they [EMT] take the patient's property, and get a urine sample. Once they get back to a room the doctor is in there shortly after, and does an assessment this determines voluntary (at will) or involuntary (against will) 1:1 observation. The patient is put in room designed for at risk patients, that have cameras in them, all of those cameras can be viewed by the unit secretary and [facility] security. If the patient comes in by ambulance, Emergency Medical Service notifies the Emergency Department by radio, and gives the Charge Nurse the preliminary report of what the patients chief complaint is. The Charge Nurse has access to the EMS radio, the Charge Nurse fills out the "Emergency Medical Service Preliminary Patient Care Report" writing down on the top portion what they hear over the radio, the Charge Nurse places the sheet on counter for EMS to finish filling out once ambulance personnel gives a verbal report to nurse, the Emergency Medical Technician (EMT) writes notes on the sheet, and it is given to unit secretary to scan into the medical chart." S14 confirmed that if P13's radio report indicated that they were presenting for suicidal ideation, the Charge Nurse should've communicated that with other members of the treatment team to ensure appropriate resources are utilized.


E. On 9/17/2021, at time interview with S32 (Director of Nursing) revealed:

1. When asked what are the expectations of staff if patient makes an attempt or does elope S32 (Director of Nursing) replied, "we would do our best to persuade the patient to stay. If they are causing harm to employees security should be called, if they are still combative we should make sure staff is safe, at that point we may even contact police officers for assistance if needed."


P2 Findings:
F. On 09/15/2021 at 10:45 am, observation of the care in Emergency Department provided to P2 revealed:

1. P2 was laying in hospital bed, in a multi-patient exam room alone appearing intoxicated as evidenced by delay in verbal response and tactile stimulation.

2. P2 was not connected to any monitor devices to assess blood pressure, heart rate, or oxygen saturation.

3. P2's room was located in a hallway on the other side of the Emergency Department, not near the nurse's station.


G. Record Review of P2's Medical Record from 09/15/2021 revealed:

1. At 9:30 am, P2 presented to facility's Emergency Department for the chief complaint (medical reason for encounter, or presenting problem) of "AMS (altered mental status) and Alcohol Intoxication."

2. At 10:55 am, no Glasgow Coma Scale (GSC scale measuring thinking skills, physical skills, and/or emotional skills) documentation upon discharge.


H. On 9/17/2021 at 11:00 am, interview with S4 (Registered Nurse) revealed:

1. "Patients who are in the Emergency Department that are here for alcohol intoxication are supposed to be placed with security, we take possession of the patient's belongings. The patient is to be put in a gown, and placed on the monitor so we can see the oxygen saturation level. The patient is placed in the Multi patient in exam room, there is a camera in there, the unit secretary can see the patient on, there is nobody that sits in that room with the patient. The monitor we put them on does not show on the central monitor station, however, the monitor will upload the vital signs on Cerner, that is our charting system." When S4 was asked if patients have fallen in the multi-patient room, S4 responded by saying, "there are sleigh beds (plastic platform placed on the floor as a make shift bed to reduce injury in case of fall) if they are getting up and falling. Yes, I have heard of patients being found on the floor, but not by me personally."


Findings related to: ensure skin protective interventions were maintained

I. Record Review of facility's "Pressure Ulcers (sore/injury to skin and underlying tissue, primarily caused by prolonged pressure on the skin, primarily caused by prolonged pressure on the skin from laying in a bed, or sitting in a wheelchair for long periods of time.) Prevention" policy, effective 01/2019, revealed:

1. "Physician will be notified of any pressure injuries."


P24 Findings:
J. Record Review of P24's Medical Record from 05/20/2021 to 06/03/2021 revealed:

1. On 4/29/2021, P24 was admitted to facility after seeking medical treatment for COVID 19 (respiratory illness caused by the corona virus) symptoms.

2. On 5/06/2021, P24 was placed on ventilator due to hypoxemic respiratory failure (insufficient oxygen in blood to supply lungs, and body organs) secondary to COVID 19 infection.

3. On 05/18/2021, Pressure Injury Investigation Form indicates P24 formed a Deep Tissue Injury on their back. The investigator reports it's due to "potentially be from a cable, wrinkles in sheet."Investigator also reports that P24 developed, Deep Tissue Injuries to their buttocks secondary to critical illness and COVID 19. For both, recommendation is "Turning Q1-2H (every one to two hours)."

2. On 05/18/2021, second Pressure Injury Investigation Form indicates P24 formed a left upper arm stage I pressure ulcer on the area under the blood pressure cuff. "When removing BP (blood pressure) cuff skin with red linear scattered areas of non-blanchable redness." Investigator indicates that a stockinette (protective cover) was not documented as applied from 05/02/2021 to 05/18/2021.

3. Provider notes from 05/18/2021 and 05/19/2021 do not mention formation of pressure ulcer to left upper arm or Deep Tissue Injury

K. On 09/17/2021 at 10:40 am, interview with S(staff) 33 (Registered Nurse) confirmed that when there's a concern for a potential new pressure ulcer, a wound care team assesses the patient, implements orders, reports it, and notifies the provider. Additionally, S33 confirmed that if wound care team does not notify the provider, the bedside nurse caring for the patient is expected to.

Based on record reviews and interviews, the facility failed to implement interventions on 1 (P (patient) 18) out of 30 patients sampled that had concerning signs of neglect. This failed practice is likely to lead to increased risk of patient harm and continuation of the neglect cycle.

A. Review of facility's "Abuse, Neglect, or Exploitation Screening and Reporting" policy, effective 08/2020, revealed:

1. Neglect is defined as: "failure of a caretaker, parent, or guardian to provide basic needs which are necessary to avoid physical harm, mental anguish, or mental illness."

2. All incidents must be reported to Children, Youth, Families Division (CYFD).


B. Record Review of facility's "Abuse, Neglect, and Exploitation Review" undated, revealed:

1. "All states require providers to report suspected child abuse and neglect."


C. Record Review of P18's Medical Record from 08/23/2021, revealed:

1. P18 is a 4 month old patient.

2. At 4:21 pm, P18 was brought in by Emergency Medical Services (EMS) for evaluation of a heart murmur (sounds such a whooshing or swishing made by turbulent blood in or near your heart) and respiratory distress. Additionally, the sending clinic requested a cardiology consult and transfer to a third healthcare facility, specializing in pediatric cardiology services.

3. At 4:34 pm, Chief Complaint as stated by P18's parent was: "They [P18] had a chest x-ray at their doctors and they needed to come here so you [the facility] could run test on their heart."

4. At 7:32 pm, P18 was documented as Left Without Being Seen (LWBS, situation when a patient leaves a facility before being seen by a provider, but after registering in a facility's Emergency Department.)

5. No documentation of follow up made to P18's parent regarding LWBS.

6. No documentation of report filed with CYFD for possible neglect.


D. On 09/17/2021 at 11:55 am, interview with S32 (staff) (Director of Nursing) confirmed the existence of a policy on child abuse, neglect, and exploitation and that all nursing staff are mandated reporters. Additionally, S32 DON confirmed that if a parent removes a patient or withholds care from them, that is a neglectful act and should be reported to CYFD.

Based on record review and interviews, the facility failed to ensure the communication of nursing care plans between all prospective members of the treatment team for 3 (P (patient) 24, P25, & P26) out of 30 patients sampled. This failed practice is likely to lead to inconsistent care for the patient and disconnection between the transferring facility.

The findings are:

A. Review of the facility's "Case Management-Nursing Home Admission/Transfer" policy, approve 12/2016, revealed:

1. "The Case Management Department will work with the interdisciplinary team in identifying the need for nursing home management."

2. "The Case Management Department will assist with the transportation arrangements to the accepting facility."

3. "When the patient is discharged should be documented."


B. Record Review of facility's "Case Management/Discharge Planning" policy, approved 03/2018, revealed:
1. "Documentation will include referrals/ communications with other agencies when applicable"


C. Record Review of P 24's Medical Record from 09/02/2021 revealed:

1. Case Management note indicates that P24 was to be discharged to a skilled nursing facility and that P24's bedside nurse was made aware of need for report to be given to the receiving facility.

2. No documentation of report given prior to discharge.


D. Record Review of P25's Medical Record from 06/11/2021 revealed:

1. Case Management note indicates that P25 was to be discharged to a skilled nursing facility and that P25's bedside nurse was made aware of need for report to be given to the receiving facility.

2. No documentation of report given prior to discharge.


E. Record Review of P26's Medical Record from 09/02/2021 revealed:

1. Case Management note indicates that P26 was to be discharged to a skilled nursing facility and that P26's bedside nurse was made aware of need for report to be given to the receiving facility.

2. No documentation of report given prior to discharge.


F. On 09/17/2021 at 10:40 am, interview with S4 (Registered Nurse) confirmed that the facility's discharge process for nursing home discharges includes Case Management notifying the patient's nurse about the expected time for pick up. S4 continued and stated that nurses must call to report to the nursing homes and document it in the patient's medical record.


G. On 09/17/2021 at 10:20 am, interview with S5 (Registered Nurse) confirmed that the process for a nursing home discharge patient is to be notified by Case Management and given the accepting nursing home's phone number to call report. S5 acknowledged that there is an expectation to document report being given.

Based on interviews and record reviews, the facility failed to meet the Condition of Participation (CoP) for Discharge Planning by failing to provide a safe discharge plan for identified high risk patient as evidenced by the following:

1. Based on observation, record reviews, interviews, the facility failed to provide a safe discharge plan for 2 (P (patient) 1 & P16) out of 30 patients sampled, that were identified as having a circumstance placing them at a higher likelihood to suffer adverse health consequences upon discharge. See Tag 800.

Based on observation, record reviews, interviews, the facility failed to provide a safe discharge plan for 2 (P (patient) 1, & P16) out of 30 patients sampled, that were identified as having a circumstance (a fact or condition connected with or relevant to an event or action) placing them at a higher likelihood to suffer adverse health consequences upon discharge. This failed practice is likely to lead to ineffective discharge planning and an increased risk of readmission to the facility.


The findings are:

A. Record Review of facility's "Case Management/Discharge Planning" policy, effective 03/05/2018, revealed:

1. The Case Manager department staff member will review the medical record and interview patients, (and or family member) that are an inpatient or an outpatient receiving observation services. The interview will assist to identify any post hospital care needs, and explain the role of case management in setting up services for a smooth transition. The Case Management department staff member will work with the multi-displinary team to identify the appropriate referrals, both within the hospital and outside the hospital setting. Documentation will include the initial discharge plan, ongoing reassessment of the discharge plan, the patient's progress towards discharge, communication with patient/family, multi--disciplinary discussions, and referrals/communications with other agencies when applicable.


B. Review of facility's "Requirement for Violent or Self-Destructive Patients in the Emergency Department" policy, effective 03/2019, revealed:

1. At Risk Patient (ARP) is defined as: "one whose thoughts or actions may lead to harm to themselves or others. Additionally, a patient should be considered at risk if as a result of a variety of other conditions which may include but are not limits to mental illness, substance abuse-withdrawal, or emotional stress."


P1 Findings:
C. On 09/13/2021 at 12:00 pm, video observation of news broadcasting from 09/02/2021 titled "Elderly woman left outside overnight outside [name of city where facility is located] hospital" shows P1 being wheeled in a wheelchair off the facility's property line by facility security and left across the street with the brakes engaged.


D. Record Review of P1's Medical Record from 08/31/2021 to 09/01/2021 revealed:

1. On 08/31/2021 at 9:16 pm, P1 presented to the facility's Emergency Department with the chief complaint stated as "I'm going to kill myself by taking the rest of my pills."

2. P1 was deemed an "At Risk Patient" with pertinent interventions including: one to one safety watch, suicide screening, and involuntary hold placed.

3. On 08/31/2021 at 9:31 pm, provider note for P1 indicated plan to transfer for psychiatric services by stating "Unclear if patient is suicidal as they [P1] state they are not now but seem slightly altered. Will have social work evaluate in the morning when they [P1] are more evaluable for transfer for psychiatric evaluation."

4. On 09/01/2021 at 11:11 am, P1 was discharged from the facility's Emergency Department to the care of "self." No documentation of a reassessment by the provider determining if P1 was no longer suicidal, no documentation of specific discharge plan or follow up referrals.


E. On 09/16/2021 at 1:00 pm, interview with S(staff) 1 (Vice President of Accreditation) confirmed that after the media video of P1 was viewed, the facility conducted a swift investigation and determined that P1 was discharged by the facility and refused multiple assistive resources. P1 was trespassed (being on someone else's property without permission) by local law enforcement and removed from the grounds. S1 states they were not aware at the time the investigation was conducted that P1's reason for presentation to the Emergency Department on 08/31/2021 was suicidal ideation. S1 confirmed they could not find documentation regarding the physician indicating P1 was safe to discharge and not actively suicidal.


F. On 09/17/2021 at 12:30 pm, S33 (Chief Medical Officer) confirmed they were not involved in the facility's investigation into the discharge of P1, nor were they informed that P1 was suicidal.


P16 Findings:
G. Record Review of P16's Medical Record from 08/22/2021 revealed:

1. At 12:38 pm, P16 presented to the facility's Emergency Department with the chief compliant stated as "I don't want to be here anymore."

2. At 12:44 pm, provider note states: "Presents to the Emergency Department for suicidal ideation. Patient states they have a lot of 'self-hate' for the past 4 days after an argument with their husband, has been contemplating suicide without a plan. They feel unstable with their bipolar (disorder causing extreme mood swings that include emotional highs and lows.) They are not currently taking any medications and does not see a psychiatrist or therapist. They also state they "have been abusing alcohol recently."

a. Medical Decision Making states: "They are increasingly depressed, suicidal without plan. They are requesting help and stabilization. No BHU (Behavioral Health Unit) beds available, have discussed with social work will evaluate for transfer."

3. At 12:57 pm, Suicide Risk Screen confirmed that P16 answered yes to the following:

a. Feeling Down, Depressed, or Hopeless

b. Little interest or pleasure in doing things

c. Wish to be dead

d. Nonspecific active suicide thoughts (thoughts of suicide, but no concrete plan with active steps taken to facilitate)
e. Lifetime attempt (has the patient attempted suicide ever in their lifetime)

4. At 12:57 pm, nursing note states: "Pt (patient, P16) crying and in distress, states they 'doesn't want to be here anymore.' Has a history of being diagnosed with depression and bipolar disorder when they were a teenager but currently not on anything. Pt also admits to using alcohol as a coping mechanism and isn't happy with that fact about herself. Pt also self-medicates with marijuana. Pt amiable (Friendly and agreeable) to care or transfer if that is what the MD (medical doctor) decides with their plan of care."

5. At 6:56 pm, Provider note states: "Patient [P16] is now much less intoxicated. They are not tearful, remorseful saying any kind of suicidality. They actually want help for their drinking. Patient would like to see a therapist, have recommended they start going to AA (Alcoholics Anonymous) meetings, social work will come provide them with these resources. Will discharge home, patient is no longer suicidal.

6. At 7:20 pm, nursing note states: "dr (Doctor, P16's provider) canceled transfer sent pt [P16] home with etoh (alcohol) resources."

7. No resources given regarding establishing psychiatric care or suicidal ideation.


H. On 09/17/2021 at 12:30 pm, S33 (Chief Medical Officer) confirmed that there is an expected process for a provider to document assessments of patients concerning for suicidal ideation and that those providers effectively enact a safe discharge plan. S33 indicates that there is no set protocol on revaluating a patient's blood alcohol level, such as for P16, but that providers should effectively document that the patient has capacity to state if they are or are not suicidal.

Based on interviews and record reviews, the facility was not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) by failing to provide an appropriate Medical Screening Examination and determination of a medical emergency as evidenced by the following:

A. The facility failed to provide an appropriate Medical Screening Examination. See tag 2406.

Based on observation, record reviews, and interviews, the facility failed to comply with requirements under the Emergency Medical Treatment and Labor Act by delaying the medical screening exam for 3 (P (patient) 1, P7, & P9) out of 30 patients sampled. This failed practice is likely to lead to delay in medical treatment and an increased risk of deterioration.

The findings are:
A. Record Review of the facility's "EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions" guidelines, effective 06/2016, revealed:

1. "[The facility] shall not delay the provision of a Medical Screening Examination."

B. Record Review of facility's "Patient Rights and Responsibilities" policy, effective 09/2014, revealed:

1. "Patient shall be treated with consideration, respect, and recognition of their individuality, including the need for privacy in treatment."

C. Record Review of facility's "ED (Emergency Department) Comprehensive Triage" policy, effective 12/2019, revealed:

1. Purpose: "To provide timely, and accurate assessment for every patient entering the Emergency Department (ED) either through the triage area or ambulance entrance."

2. All patients who present to the Emergency Department are to receive "timely, complete, and accurate" sorting.

P1 Findings:
D. On 09/16/2021 at 4:00 pm, video observation of facility's Emergency Department security cameras on 09/01/2021 from 10:45 pm to 11:07 pm , revealed:

1. At 10:45 pm, P1 is wheeled into the facility and is seen speaking with registration to present to be seen.

2. At 10:46 pm, P1 is seen being removed from the facility's Emergency Department by security staff. Two other security staff members encircle P1 at the entrance to the Emergency Department's waiting room, preventing P1 to present to registration for admittance to the Emergency Department.

3. At 11:07 pm, security staff disband and permit P1 to continue visit to seek care.

E. Record Review of facility's "Security Daily Report" from 09/01/2021 revealed:

1. At 10:40 pm security officer's report states "called dispatch for individuals that was previously discharged and trespassed." After this documentation, officer states "Charge Nurse instructed to check them (P1) in."

F. Record Review of P1's Medical Record from 09/01/2021 revealed:

1. P1 was registered as entering the facility at 11:07 pm.

G. On 09/16/2021 at 4:30 pm, interview with S (staff) 18 (Security Manager) reviewed the security camera footage with New Mexico State Surveyors and confirmed that P1 had already trespassed earlier on 09/01/2021. S18 confirmed that security officers are trained in compliance with EMTALA and that trespassed patients are still able to present to receive care and that when that visit is over they must vacate the premises immediately. S18 stated that trespassed patients are tracked with a "Trespass Incident Report" form that correlates their trespass warning or charge with a police incident number and that for P1, S18 could not present such form to New Mexico State Surveyors.

H. Record Review of facility's "Trespass Incident Report" form, effective 08/2018, revealed:

1. "EMTALA compliance will supersede any trespass violation and no enforcement action will be taken. You [trespassed individuals] can still come on [facility's name] property for emergency treatment."

I. On 09/17/2021 at 12:30 pm, interview with S33 (Chief Medical Officer) confirmed that any patient that presents to the facility's Emergency Department is expected to receive care without delay. S33 confirmed that the Emergency Department is able to conduct blood draws and would be an appropriate setting to manage a potential overdose. S33 reported that trespassed patients may seek care.

P7 Findings:
J. Record Review of Grievance Letter sent to P7 dated 09/03/2021 revealed:

1. On 08/06/2021 P7 expressed a grievance to the facility that they presented to the facility's Emergency Department to have blood drawn and that they were told by staff to go to another area.

2. "You (P7) stated that you told them (Emergency Department staff) you needed blood drawn for a possible OD (overdose) and your behavioral health provider told you to go to the ED (Emergency Department). You felt that you didn't need to share that you were suicidal to the registration staff and felt you didn't get the help you needed."

K. On 09/15/2021 at 11:00 am, interview with S3 (Patient Experience Manager) confirmed that they led the grievance investigation for P7. S3 reported that there were multiple registration staff working on 08/06/2021 and that it was impossible to determine which staff member deferred them. S3 endorsed that P7 presented for a blood draw from their behavioral health and that the Emergency Department doesn't always see patients just for blood draws and directed P7 to an outpatient lab. "They [P7] did not tell anyone from registration that they were suicidal. If they did, then the team would've been able to make sure they stayed."

L. On 09/17/2021 at 11:30 am, interview with S4 (Registered Nurse, Emergency Department) confirmed that the facility's Emergency Department does see patients needing blood draws. Additionally, S4 reported that it is normal for patients with suicidal ideation to not disclose that with registration. "They sometimes will just tell us (nursing) during the triage or once they're comfortable in the room and feel safe."

P9 Findings:
M. Record Review of P9's Grievance Intake reported on 09/01/2021 revealed:

1. Intake comments state that on 08/23/2021 "Patient waited over 3 hours without talking to provider. Tech advised them they should go home and come back in the morning between 7:00 am - 8:00 am."

2. "Patient's [P9] daughter states that tech [technician] suggested they leave and come back in the morning. Tech states 'they [P9] aren't not a high priority and could be here all night without being seen."

3. During facility's interview with P9 states: "Confirm all information and states they went back for a second set of vitals and begged the RN [Registered Nurse] to let them see a doctor or to give them something for the pain. The RN stated 'you [P9] should go home and try to sleep it off. Try to come back in the morning."

N. Record Review of P9's Medical Record from 08/23/2021 to 08/24/2021 revealed:

1. On 08/23/2021 at 10:43 pm, P9 presented to the facility's Emergency Department for evaluation of upper abdominal pain.

2. On 08/24/2021 at 2:01 am, P9 was discharged from the facility's Emergency Department listed as "Left without Treatment."

3. On 08/24/2021 at 5:39 am, P9 represents to the facility's Emergency Department for upper abdominal pain with the following documented: "Have abd [abdominal] pain that feels like a bowel obstruction, I have had them before."
4. On 08/24/2021 at 6:13 am, provider note states "Concerning for small bowel obstruction and possible metastatic (spreading, potentially due to cancer) lesions. NG Tube (Nasogastric Tube) a tube inserted through the nose, down the throat and esophagus, and into the stomach. It can be used to give medications, liquids, and liquid foods, or used to remove substances from the stomach) and admit for monitoring and possible surgery."

O. Record Review of Grievance Letter sent to P9, undated, revealed:

1. On 09/01/2021 P9 expressed a grievance to the facility that they presented to the facility's Emergency Department on 08/23/2021 for abdominal pain and was directed by the facility's staff to leave and come back later.

2. "After hearing your formal complaint, reviewing your [P9] medical chart and conducting interviews with the staff that cared for you, it was determined we [the facility] could have been better communicators."

P. On 09/15/2021 at 11:00 am, interview with S3 (Patient Experience Manager), when asked about P9, S3 confirmed that no patient should be deferred from seeking treatment or be discouraged by wait times.