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Based on document review and staff interviews, the CAH administrative staff failed to ensure the ED staff provided 1 of 20 emergency patients reviewed (Patient #1) with an MSE, and all available and appropriate stabilizing treatment after presenting to their ED seeking medical care. Failure to a provide an MSE, and all available and appropriate stabilizing treatment resulted in Patient #1, a type 1 diabetic patient with a history of noncompliance and self-induced DKA requiring hospitalization at another hospital 13 hours later, placing Patient #1's health in serious jeopardy, and may have resulted in Patient #1 causing further serious impairment or dysfunction to their bodily function or organs. The CAH's administrative staff identified an average of 477 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy " Emergency Medical Treatment and Labor Act (EMTALA) Transfer Policy and Procedure," Last approved 2/23, revealed in part:

a. " ...Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including ... psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical treatment could reasonably be expected to result in: Placing the health of the individual in serious jeopardy. Serious impairment of bodily functions. Serious dysfunction of any bodily organ or part ..."

b. " ...Stabilized: With respect to an emergency medical condition ..., that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur ..."

c. " ...Medical Screening Examination: Patients on [Hospital] premise seeking treatment will receive the appropriate medical screening examination with in the capabilities of [Hospital] to determine whether or not an emergency medical condition exists."

2. Review of the policy "Behavioral Health Evaluation Policy," Last approved 2/23, revealed in part:

a. " ...All patients presenting to the emergency room with complaints of depression ... or other signs of a mental health disorder will be given a qualified screening exam by the ER practitioner on call ..."

3. Review of the policy "Emergency Department Scope of Practice/Staffing," revealed in part:

a. " ...Behavioral health patients who present in crisis will be assessed, treated, and stabilize ..."

b. " ...If it is deemed the patient can be discharged with appropriate outpatient follow up care, these arrangements will be made, the patient will agree to a safety plan, and the patient will be educated regarding this during discharge planning ..."

4. Review of Patient #1's ambulance report revealed:

a. On 8/2/23 at 11:48 AM, EMS arrived at Patient #1's resident by ambulance for report of Patient #1 having a diabetic problem and high blood sugar. EMS found Patient #1 lying on the couch with their mother and law enforcement present.

5. During an interview on 9/18/23 at 2:35 PM, EMT M recalled transporting Patient #1 to the ED. EMT M reported that Patient #1 was being non-cooperative, non-compliant, and required law enforcement to get them uncovered, off the couch, and walking to the ambulance. EMT M recalled Patient #1 forcing them self to vomit by shoving their fingers down their throat.

6. Review of Patient #1's medical record revealed:

a. On 8/2/23 at 12:15 PM, Patient #1 presented to the ED by ambulance for a chief complaint of hyperglycemia and abdominal pain of unknown timeframe.

b. On 8/2/23 at 12:23 PM, Documentation by DO B in their progress report noted Patient #1 was unwilling to answer any questions for DO B, other than stating that they had abdominal pain everywhere. Patient #1 would not answer DO B as to why they were not eating or taking their insulin. DO B noted that prior to EMS arrival to Patient #1's home, Patient #1 "chugged large amount of water and vomited it up." DO B noted that Patient #1 had recently been hospitalized at their hospital, and had multiple other hospitalizations to other hospitals. DO B noted that "mom at one point had told EMS they were working on getting psychiatric services involved," but noted that it was unclear if this had been pursued or where they were with that process. Patient #1 was noted to have a past medical history of diabetes type 1 with a history of noncompliance, self-induced diabetic ketoacidosis, THC abuse, tobacco abuse, cyclical vomiting syndrome, and major depressive disorder.

c. On 8/2/23 at 12:36 PM, RN E noted that Patient #1 was fighting RN E physically to get out of bed, went over to the sink to drink water, and then Patient #1 would stick their fingers down their throat to make them self vomit. RN E noted that EMS came to assist with getting Patient #1 back into bed.

d. On 8/2/23 at 12:40 PM, law enforcement was contacted to assist with Patient #1 due to their non-compliance, not listening, fighting staff, and continuing to drink water and making them self vomit.

e. On 8/2/23 at 3:30 PM, RN E noted that Patient #1 has stuck his fingers down his throat multiple times to make them self vomit. Patient #1 was throwing their emesis bag on the floor, and then throwing up all over the floor, despite multiple staff reminders to use the emesis bags provided.

f. On 8/2/23 at 5:11 PM, DO B noted that Patient #1 was stable for discharge and they were instructed to follow up with their primary care provider and psychiatry. DO B also noted that there was a large psychiatric component for Patient #1's cyclical vomiting. DO B discussed Patient #1's safety in their home, and Patient #1 initially stated they were unsafe to be at home, but then verbalized that they just did not feel good, and they did not have any fear for their physical safety. It was then noted by DO B that they strongly advised Patient #1 to see a psychiatric provider, Patient #1 was interested in a psychiatric referral and counseling, and Patient #1 was provided with resource information for Infinity Health. DO B noted that Patient #1 was not suicidal or homicidal, and was not trying to kill them self, but could not tell DO B why Patient #1 had not been taking their insulin.

g. On 8/2/23 at 6:27 PM, RN E documented that Patient #1 ran into another ED room to drink from the faucet, and then stuck their fingers down their throat to make them self vomit.

h. On 8/2/23 at 6:28 PM, Patient #1 was discharged from the ED to home. Patient #1 was given discharge paperwork that included patient educational material on major depressive disorder and hyperglycemia. Patient #1's discharge instructions for follow up were to reach out to Infinity Health to schedule an appointment for psychiatric care, and return to ED for new or worsening symptoms. The discharge instructions provided to Patient #1 failed to include the contact information for Infinity Health. The discharge instructions also noted that Patient #1 did not have a primary care physician.

i. On 8/2/23 at 7:26 PM, DO A documented that Patient #1 was discharged prior to them coming on shift, but there was a delay in them leaving the facility due to nursing discharge process, and Patient #1 lacking a ride. DO A noted that Patient #1 was going into other ED patient rooms, drinking water, and self-inducing vomiting on the floors and counters despite being given multiple emesis bags, and at one-point Patient #1 almost vomited on another patient. DO A then noted that Patient #1 was removed from the ED and placed in the vestibule, and law enforcement was contacted to remove Patient #1 from the ED.

7. During an interview on 9/11/23 at 11:00 AM, RN E recalled Patient #1 going into another ED room, downed a bunch of water, then stuck their fingers down their throat to self-induce vomiting. RN E recalled providing Patient #1 with numerous emesis bags, but they would still vomit on the bed and floor. RN E reported having the water turned off to Patient #1's ED room, and after receiving their discharge papers, Patient #1 went into another patient's room, again gulped down a bunch of water, and almost vomited on another ED patient. RN E reported that Patient #1 was not suicidal or cutting them self, but was not demonstrating self-help behavior, and RN E did not feel like Patient #1 was taking care of them self at home.

8. During an interview on 9/11/23 at 10:10 AM, DO B recalled Patient #1 had recently been admitted to their hospital for DKA, which was self-induced. DO B reported while Patient #1 was in the ED, they forced past the tech to get to the sink, drank a bunch of water, and then forced them self to vomit. DO B recalled having maintenance shut off the water to Patient #1's room. DO B reported Patient #1 denied being a risk to them self, denied wanting to harm them self, and was not suicidal. DO B acknowledged Patient #1 had psychiatric concerns, and had previous hospitalizations in inpatient behavioral health (BH) facilities, and they were previously on a waitlist for an inpatient BH facility 2 weeks prior, but when Patient #1 was medically stable, they no longer met inpatient psychiatric requirements, and was cleared for discharge. DO B acknowledged that they did not have a psychiatric provider assess Patient #1 while in the ED, but they provided Patient #1 with the phone number for an outpatient psychiatric provider, and DO B felt they addressed Patient #1 psychiatric needs. Finally, DO B reported that Patient #1 was dismissed from "our clinic" (Patient #1's primary care provider) the same day they were in the ED, and was unable to provide Patient #1 with a social worker or case manager to assist him with resources or setting up follow up at time of discharge.

9. During an interview on 9/11/23 at 2:50 PM, RN G confirmed the hospital ED has mental health services available to ED patients, and reported Patient #1 was provided with information on services provided, but was not assessed by a psychiatric provider. RN G reported the hospital has a list of resources that the hospital case manager has available for patients if needed.

10. During an interview on 9/11/23 at 12:00 PM, RN F recalled Patient #1 gulped down a bunch of water, and then violently started throwing up. RN F recalled Patient #1 sticking two fingers down their throat to self-induce vomiting. RN F reported that Patient #1 was in the ED for their blood sugars, not for their mental health issues.

11. During an interview on 9/11/23 at 12:00 PM, PCT (patient care tech) H recalled Patient #1 being in the ED and they were throwing up everywhere, and running into other patients' rooms. PCT H reported that the nurses working thought Patient #1 had some psychiatric issues besides the medical issues that he presented for.

12. During an interview on 9/11/23 at 1:00 PM, DO A recalled Patient #1's behaviors escalated after their discharge. DO A reported Patient #1 had been previously evaluated at another hospital for mental health and self-induced vomiting. DO A reported Patient #1 was in another patient room vomiting. DO A reported when they entered the other patient's room, Patient #1 was standing over the other patient, and was going to vomit on their head. DO A reported Patient #1 then went into the bathroom, chugged water, and vomited all over. DO A reported when law enforcement arrived they transported Patient #1 home. DO A reported Patient #1 certainly did not need a mental health evaluation while in the ED, they were free to make their own decision, and if Patient #1 chooses to do this behavior, they [hospital staff] cannot stop Patient #1. DO A reported DO B assessed Patient #1's mental health while in the ED. DO A explained the hospital did not have psychiatry available in the hospital, and they utilize a remote telehealth service, where a social worker or a mid-level provider would have evaluated Patient #1, asking them the same assessment questions that DO B asked Patient #1, and would have said Patient #1 was okay to follow up on an outpatient basis. DO A reported that Patient #1 was "one hundred thousand percent" appropriate for discharge, and would not have met requirements inpatient psychiatric treatment.

13. During an interview on 9/11/23 at 1:50 PM, ED Medical Director acknowledged that staff from Knoxville Hospital have communicated with providers at other hospitals previously on Patient #1's mental health and self-induced vomiting behaviors, but Patient #1 has not met admission criteria for inpatient BH. ED Medical Director reported that Patient #1's actions are behavioral, and does not meet the admission criteria for mental health.

14. During an interview on 9/18/23 at 4:15 PM, CNO acknowledged that the behaviors demonstrated by Patient #1 while in the ED is not typical behavior, and a lay person would think they were really sick, and would be confused by Patient #1's behaviors. CNO reported they did not think of non-compliance or not following your medication regimen as self-harm. CNO also reported that Patient #1 was not in their ED for mental health, their behaviors were baseline, and Patient #1 was being evaluated and treated for their abdominal pain and high blood sugars.

15. The critical access hospital failed to provide Patient #1 with an appropriate MSE and stabilizing treatment within its capabilities, including completing an oral diet challenge to determine if the patient was able to tolerate food and liquids, or determine if the patient needed additional anti-nausea medication or further hydration to ensure no material deterioration of an emergency medical condition prior to discharge.

16. Review of Patient #1's medical record from Hospital B revealed: a. On 8/3/23 at 6:55 AM, just under 13 hours after discharge from Knoxville Hospital ED. Patient #1 arrived at Hospital B by private vehicle, accompanied by their mother, for a chief complaint of diabetes and vomiting since Tuesday (8/1/23). Patient # 1's BP was elevated at 201/143, pulse was 140, initial temperature was 99.9 F with a high of 100.8 F while in the ED, and blood sugar was elevated at 479 (normal range 70 - 110). MD K noted Patient # 1 presented with nausea, vomiting, and high blood pressure and had multiple hospital admissions previously for DKA.

b. On 8/3/23 at 3:07 PM, Hospital B admitted Patient # 1 as an inpatient for treatment to stabilize an emergency medical condition.

Please see C-2406 and C-2407 for additional information.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #1) with an appropriate medical screening exam (MSE) after presenting to their ED by ambulance requesting medical care. Failure to provide an appropriate MSE resulted in Patient #1, a type 1 diabetic (chronic condition typically starting in childhood, and is insulin dependent) patient with a history of noncompliance and self-induced diabetic ketoacidosis (DKA) (a serious complication of diabetes that can be life-threatening), having a delay in stabilizing treatment resulting in hospitalization at another hospital 13 hours later, placing Patient #1's health at risk, and may have resulted in Patient #1 causing further impairment or dysfunction to their bodily function or organs. The CAH's administrative staff identified an average of 477 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's ambulance report revealed:

a. On 8/2/23 at 11:48 AM, emergency medical services (EMS) arrived at Patient #1's resident for report of Patient #1 having a diabetic problem and high blood sugar. EMS found Patient #1 lying on the couch with their mother and law enforcement present. Patient #1's mother reported Patient #1 hadn't eaten much the last couple of days, and they gave Patient #1 some short acting insulin (medication used to treat diabetes for approximately two to four hours) around 3:00 AM, but couldn't report when Patient #1 had last taken their insulin prior to that time.

b. On 8/2/23 at approximately 11:50 AM, Patient #1 walked to the ambulance with EMS staff.

c. On 8/2/23 at 11:56 AM, Patient #1's blood pressure (BP) was 177/125 (high blood pressure is considered to be 140/90 or higher) and pulse was 144 (normal range 60-90).

d. On 8/2/23 at 12:05 PM, Patient #1's BP was 167/120 and pulse was 132.

e. On 8/2/23 at 12:15 PM, Patient #1's BP was 159/116 and pulse was 130.

2. During an interview on 9/18/23 at 2:35 PM, EMT M recalled transporting Patient #1 to the ED. EMT M reported that Patient #1 was alert and talking to their mother and law enforcement when EMS arrived. EMT M reported that Patient #1 was being non-cooperative, non-compliant, and required law enforcement to get them uncovered, off the couch, and walking to the ambulance. EMT M recalled Patient #1 forcing them self to vomit by shoving their fingers down their throat, and reported that every time they take care of Patient #1, they do the exact same stuff. EMT M recalled taking Patient #1's blood sugar during transport to the ED, and that the blood sugar was high, but could not recall what the exact result was.

3. Review of Patient #1's medical record revealed:

a. On 8/2/23 at 12:15 PM, Patient #1 presented to the ED by ambulance for a chief complaint of hyperglycemia and abdominal pain of unknown timeframe.

b. On 8/2/23 at 12:23 PM, Patient #1 blood sugar was 437 (normal range 70-100). DO B saw Patient #1, and noted Patient #1 wasn't willing to answer questions, other than stating they had abdominal pain everywhere. Patient #1 wouldn't answer DO B as to why they weren't eating or taking their insulin. DO B noted that prior to EMS arrival to Patient #1's home, Patient #1 "chugged large amount of water and vomited it up," and vomited one additional time after EMS arrived. DO B noted Patient #1 had recently been hospitalized at their hospital, and had multiple other hospitalizations at other hospitals. DO B noted that "mom at one point had told EMS they were working on getting psychiatric services involved," but noted that it was unclear if this had been pursued or where they were with that process. Patient #1 had abdominal tenderness. Patient #1 had a medical history of diabetes type 1 with a history of noncompliance, self-induced diabetic ketoacidosis, THC (marijuana) abuse, tobacco abuse, cyclical vomiting syndrome (a disorder that causes sudden, repeated episodes of severe nausea and vomiting), and major depressive disorder (mental health disorder causing significant impairment in daily life).

c. On 8/2/23 at 12:25 PM, RN E triaged Patient #1, and noted a temperature of 99.3 F (normal range 97 F - 99 F), BP of 185/118, and pulse of 127. Patient #1's had a blood sugar of 386. RN E assessed Patient #1's pain level and noted abdominal pain of "2" or "hurts a little bit" using the FACES Pain Scale (the patient chooses the face that best depicts the pain they are experiencing). RN E completed a Suicide assessment, and noted Patient #1 answered no to all the suicide questions, indicating a low risk for suicide. RN E noted Patient #1 had abdominal tenderness, nausea, and vomiting.

d. On 8/2/23 at 12:36 PM, RN E noted Patient #1 fought RN E physically to get out of bed, went to the sink, drank water, and then Patient #1 stuck their fingers down their throat to make them self-vomit. RN E noted EMS came to assist with getting Patient #1 back into bed.

e. On 8/2/23 at 12:40 PM, law enforcement was contacted to assist with Patient #1 due to their non-compliance, not listening, fighting staff, and continuing to drink water and making them self vomit. Abnormal labs were noted as followed: chloride 97 (low - normal range 98-107), glucose level 387 (high - normal range 70-199), blood urea nitrogen (BUN) 35.0 (high - normal range 7.0-18.0), creatinine 1.85 (high - normal range 0.51-1.17), calcium 11.10 (high - normal range 8.5-10.10), protein total 8.60 (high - 6.40-8.20), C-reactive protein (CRP, protein made by the liver) 0.00 (low - normal range 0.05-0.90), white blood count (WBC) 17.92 (high - normal range 4.4-13.0), red blood count (RBC) 3.98 (low - normal range 4.6-6.20), hemoglobin (Hgb) 10.60 (low - normal range 14.00-18.00), and hematocrit (Hct) 31.70 (low - normal range 40.00-54.00). Lactic acid was 1.76 which was in normal range of 0.40-2.00. Ketone Serum were negative. Abnormal blood gases were noted as pCO2 was 33 (low - normal range 41-51), and pH was 7.5 (high - normal range 7.32-7.42). No anion gap (check acid-base balance in the blood) was obtained.

f. On 8/2/23 at 12:42 PM, Patient #1 blood sugar was 387.

h. On 8/2/23 at 12:50 PM, law enforcement left the ED.

i. On 8/2/23 at 1:30 PM, Patient #1 pulse was 131.

j. On 8/2/23 at 2:00 PM, Patient #1 BP was 199/73.

k. On 8/2/23 at 2:37 PM, Patient #1's medical records note they were dismissed from the clinic (primary care provider) due to no shows.

l. On 8/2/23 at 3:00 PM, Patient #1 BP was 166/70 and pulse was documented as 133 and 75.

m. On 8/2/23 at 3:20 PM, Patient #1 blood sugar was 426.

n. On 8/2/23 at 3:27 PM, Patient #1 BP was 149/121 and pulse was 126.

o. On 8/2/23 at 3:30 PM, RN E noted Patient #1 had stuck their fingers down their throat multiple times to make them self vomit. Patient #1 threw their emesis bag on the floor, and then threw up all over the floor, despite multiple staff reminders to use the emesis bags provided.

p. On 8/2/23 at 4:00 PM, Patient #1 BP was 210/69 and pulse was 66.

q. On 8/2/23 at 4:03 PM, Patient #1 blood sugar was 294.

r. On 8/2/23 at 4:30 PM, Patient #1 BP was 173/81 and pulse was 63.

s. On 8/2/23 at 5:00 PM, Patient #1 BP was 172/67 and pulse was 127.

t. On 8/2/23 at 5:11 PM, Patient #1 blood sugar was 237. DO B noted that Patient #1 was stable for discharge and they were instructed to follow up with their primary care provider and psychiatry. DO B noted Patient #1 diagnosis as type 1 diabetes with hyperglycemia (high blood sugar) with long-term current use of insulin, and borderline acute kidney injury (AKI), but it was not significant enough to warrant an admission. DO B noted that Patient #1 was not in DKA. Patient #1 was given two 1-liter boluses of normal saline IV fluid, 7 units of regular insulin subcutaneous (under the skin, in fatty tissue), and 4 mg of Zofran (medication to treat nausea/vomiting) IV while in the ED. DO B also noted that there was a large psychiatric component for Patient #1's cyclical vomiting. DO B discussed Patient #1's safety in their home, and Patient #1 initially stated they were unsafe to be at home, but then verbalized that they just did not feel good, and they did not have any fear for their physical safety. It was then noted by DO B that they strongly advised Patient #1 to see a psychiatric provider, Patient #1 was interested in a psychiatric referral and counseling, and Patient #1 was provided with resource information for Infinity Health (healthcare for psychiatric care). DO B noted that Patient #1 was not suicidal or homicidal, and was not trying to kill them self, but could not tell DO B why Patient #1 had not been taking their insulin.

u. On 8/2/23 at 5:30 PM, Patient #1 BP was 174/68 and pulse was 64.

v. On 8/2/23 at 6:27 PM, RN E documented that Patient #1 ran into another ED room to drink from the faucet, and then stuck their fingers down their throat to make them self vomit. RN E noted that RN F and DO A ran into the room, and put Patient #1 back into their ED room.

w. On 8/2/23 at 6:28 PM, Patient #1 discharged from the ED to home. Patient #1 received discharge paperwork that included patient educational material on major depressive disorder and hyperglycemia. Patient #1's discharge instructions for follow up were to reach out to Infinity Health to schedule an appointment for psychiatric care, and return to ED for new or worsening symptoms. RN E noted that Patient #1 attempted to stay in the ED room, and DO A reinforced to Patient #1 that they needed to leave the ED, as they were discharged, and the family was notified to pick them up. The discharge instructions provided to Patient #1 failed to include the contact information for Infinity Health. The discharge instructions also noted that Patient #1 did not have a primary care physician.

x. On 8/2/23 at 7:26 PM, DO A documented that Patient #1 was discharged prior to them coming on shift, but there was a delay in them leaving the facility due to nursing discharge process, and Patient #1 lacking a ride. DO A noted that Patient #1 was going into other ED patient rooms, drinking water, and self-inducing vomiting on the floors and counters despite being given multiple emesis bags, and at one-point Patient #1 almost vomited on another patient. DO A then noted that Patient #1 was removed from the ED and placed in the vestibule, and law enforcement was contacted to remove Patient #1 from the ED.

4. During an interview on 9/11/23 at 11:00 AM, RN E recalled Patient #1 coming to the ED, and right after arriving, Patient #1 went to another ED room, downed a bunch of water, then stuck their fingers down their throat to self-induce vomiting. RN E recalled providing Patient #1 with numerous emesis bags, but they would still vomit on the bed and floor. RN E reported having the water turned off to Patient #1's ED room, and after receiving their discharge papers, Patient #1 went into another patient's room, again gulped down a bunch of water, and almost vomited on another ED patient. RN E reported asking Patient #1 questions to assess them, but they would sometimes refuse to answer, and when they did answer it was with one-word responses. When asked about Patient #1 being a harm to them self, RN E reported that Patient #1 was not suicidal or cutting them self, but they were not demonstrating self-help behavior, and RN E did not feel like Patient #1 was taking care of them self at home.

5. During an interview on 9/11/23 at 10:10 AM, DO B recalled Patient #1 coming into the ED by ambulance. DO B reported that Patient #1 had recently been admitted to their hospital for DKA, which was self-induced. DO B reported Patient #1 had complaints of vomiting and abdominal pain, and they worked Patient #1 up for things that would cause the reported complaints. DO B recalled Patient #1 was slightly hypertensive (abnormal, high BP) and tachycardic (abnormal, fast heart rate), but was at baseline for them at discharge. DO B reported while Patient #1 was in the ED, they forced past the tech to get to the sink, drank a bunch of water, and then forced them self to vomit. DO B recalled having maintenance shut off the water to Patient #1's room. DO B explained that Patient #1 had very concentrated blood due to their vomiting, which had affected their lab values, and reported Patient #1's Hgb, Hct, creatinine, calcium, and platelets were all higher than Patient #1's normal. When asked about Patient #1's elevated WBC, DO B explained that this was due to Patient #1's vomiting, demargination (movement away from the vascular walls of a blood vessel), and the rest of Patient #1's blood being concentrated. DO B reported that Patient #1's CRP was negative, they did not have any fevers, and their lactic acid was negative, which showed Patient #1 did not have an infection. DO B also reported that patient #1 was given 2 liters of IV fluids and insulin while in the ED, Patient #1's symptoms had improved, and their arterial blood gases (ABG), ketones, and anion gap levels did not show Patient #1 was in DKA. DO B reported Patient #1 denied being a risk to them self, denied wanting to harm them self, and was not suicidal. DO B reported they felt Patient #1 was safe for discharge home. DO B acknowledged Patient #1 had psychiatric concerns, and had previous hospitalizations in inpatient behavioral health (BH) facilities, and they were previously on a waitlist for an inpatient BH facility 2 weeks prior, but when Patient #1 was medically stable, they no longer met inpatient psychiatric requirements, and was cleared for discharge. DO B acknowledged that they did not have a psychiatric provider assess Patient #1 while in the ED, they provided Patient #1 with the phone number for an outpatient psychiatric provider, and DO B felt they addressed Patient #1 psychiatric needs. Finally, DO B reported that Patient #1 was dismissed from "our clinic" (Patient #1's primary care provider) the same day they were in the ED, and was unable to provide Patient #1 with a social worker or case manager to assist him with resources at time of discharge.

6. During an interview on 9/11/23 at 2:50 PM, RN G recalled Patient #1, but reported they were working as House Supervisor the day that Patient #1 was in the ED, and they were not Patient #1's primary nurse. RN G reported that Patient #1 has been in the hospital numerous times and usually presents due to their blood sugars. RN G confirmed the hospital ED has mental health services available to ED patients, and reported Patient #1 was provided with information on services provided, but was not assessed by a psychiatric provider. RN G reported the hospital has a list of resources that the hospital case manager has available for patients if needed.

7. During an interview on 9/11/23 at 12:00 PM, RN F recalled Patient #1. RN F reported Patient #1 went into another patient's room while in the ED, gulped down a bunch of water, and then violently started throwing up. RN F recalled being at the desk when they heard a commotion, and when they walked into the room Patient #1 had two fingers down their throat. Patient #1 was given an emesis bag, and escorted back to their ED room. RN F reported that Patient #1 was in the ED for their blood sugars, not for their mental health issues.

8. During an interview on 9/11/23 at 12:00 PM, PCT (patient care tech) H recalled Patient #1 being in the ED and they were throwing up everywhere, and running into other patients' rooms. PCT H reported that the nurses working thought Patient #1 had some psychiatric issues besides the medical issues that he presented for.

9. During an interview on 9/11/23 at 1:00 PM, DO A recalled Patient #1 was discharged from the ED prior to their shift, but was still in the ED waiting for a ride. DO A reported that Patient #1's behaviors escalated after their discharge. DO A reported Patient #1 had been previously evaluated at another hospital for mental health and self-induced vomiting. DO A recalled they were extremely busy in the ED that day, and they were trying to free up beds for other patients, and Patient #1 was already discharged, so they told Patient #1 he needed to go to the waiting area. DO A reported a PCT ran out and said Patient #1 was in another patient room vomiting. DO A reported when they entered the other patient's room, Patient #1 was standing over the other patient, and was going to vomit on their head. DO A recalled they escorted Patient #1 out of the other patient's room, and called law enforcement to come and assist with Patient #1. DO A reported Patient #1 then went into the bathroom, chugged water, and vomited all over. DO A reported when law enforcement arrived they transported Patient #1 home. DO A reported Patient #1 certainly did not need a mental health evaluation while in the ED, they were free to make their own decision, and if Patient #1 chooses to do this behavior, they [hospital staff] cannot stop Patient #1. DO A reported DO B assessed Patient #1's mental health while in the ED. DO A explained the hospital did not have psychiatry available in the hospital, and they utilize a remote telehealth service, where a social worker or a mid-level provider would have evaluated Patient #1, asking them the same assessment questions that DO B asked Patient #1, and would have said Patient #1 was okay to follow up on an outpatient basis. DO A reported that Patient #1 was "one hundred thousand percent" appropriate for discharge, and would not have met requirements inpatient psychiatric treatment.

10. During an interview on 9/11/23 at 1:50 PM, ED Medical Director acknowledged that staff from Knoxville Hospital have communicated with providers at other hospitals previously on Patient #1's mental health and self-induced vomiting behaviors, but Patient #1 has not met admission criteria for inpatient BH. ED Medical Director reported that Patient #1's actions are behavioral, and does not meet the admission criteria for mental health. ED Medical Director also reported that Patient #1 bounces between hospitals and has demonstrated self-induced vomiting behaviors for at least over a year.

11. During an interview on 9/18/23 at 4:15 PM, CNO acknowledged that the behaviors demonstrated by Patient #1 while in the ED is not typical behavior, and a lay person would think they were really sick, and would be confused by Patient #1's behaviors. CNO reported that if labs were within their normal range then they were not in danger. CNO also reported that Patient #1 was non-compliant and they didn't want to take their meds, then they run the risk of Patient #1 returning to the ED. CNO explained they always run a risk of patients bouncing back to the ED, and Patient #1 would be at risk for this also. CNO reported when they think of self harm, they think of suicidal thoughts, or running out into the street. CNO reported they did not think of non-compliance as self-harm or not following your medication regimen as self-harm. CNO also reported that Patient #1 was not in their ED for mental health, their behaviors were baseline, and Patient #1 was being evaluated and treated for their abdominal pain and high blood sugars, which were back to baseline prior to discharge from the ED.

12. During an interview on 9/18/23 at 2:35 PM, Deputy L recalled transporting Patient #1 from Knoxville Hospital to their home. Deputy L recalled when they arrived to the ED, Patient #1 was lying outside of the ED entrance on the ground with 2 law enforcement officers. Deputy L reported that Patient #1 was quiet during transport, had an emesis bag with them, but did not vomit during transport, and did not verbalize any complaints or concerns.

13. The critical access hospital failed to provide Patient #1 with an appropriate MSE within its capabilities, including completing an oral diet challenge to determine if the patient was able to tolerate food and liquids, or determine if the patient needed additional anti-nausea medication or further hydration prior to discharge.

14. Review of Patient #1's medical record from Hospital B revealed:

a. On 8/3/23 at 6:55 AM, just under 13 hours after discharge from Knoxville Hospital ED. Patient #1 arrived at Hospital B by private vehicle, accompanied by their mother, for a chief complaint of diabetes and vomiting since Tuesday (8/1/23). Patient # 1's BP was elevated at 201/143, pulse was 140, initial temperature was 99.9 F with a high of 100.8 F while in the ED, and blood sugar was elevated at 479 (normal range 70 - 110). MD K noted Patient # 1 presented with nausea, vomiting, and high blood pressure and had multiple hospital admissions previously for DKA.

b. On 8/3/23 at 3:07 PM, Hospital B admitted Patient # 1 as an inpatient for treatment to stabilize an emergency medical condition.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Emergency Department (ED) staff provided 1 of 20 emergency patients reviewed (Patient #1) with all available and appropriate stabilizing treatment after presenting to the ED seeking medical care. Failure to provide all available and appropriate stabilizing treatment resulted in Patient #1, a type 1 diabetic patient with a history of noncompliance and self-induced diabetic ketoacidosis (DKA) requiring hospitalization at another hospital 13 hours later, placing Patient #1's health in serious jeopardy, and may have resulted in Patient #1 causing further serious impairment or dysfunction to their bodily function or organs. The CAH's administrative staff identified an average of 477 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's ambulance report revealed:

a. On 8/2/23 at 11:48 AM, emergency medical services (EMS) arrived at Patient #1's resident for report of Patient #1 having a diabetic problem and high blood sugar. EMS found Patient #1 lying on the couch with their mother and law enforcement present. Patient #1's mother reported Patient #1 hadn't eaten much the last couple of days, and they gave Patient #1 some short acting insulin (medication used to treat diabetes for approximately two to four hours) around 3:00 AM, but couldn't report when Patient #1 had last taken their insulin prior to that time.

b. On 8/2/23 at approximately 11:50 AM, Patient #1 was able to walk out to the ambulance with EMS staff.

c. On 8/2/23 at 11:56 AM, Patient #1's BP was 177/125 and pulse was 144.

d. On 8/2/23 at 12:05 PM, Patient #1's BP was 167/120 and pulse was 132.

e. On 8/2/23 at 12:15 PM, Patient #1's BP was 159/116 and pulse was 130.

2. During an interview on 9/18/23 at 2:35 PM, EMT M recalled transporting Patient #1 to the ED. EMT M reported that Patient #1 was alert and talking to their mother and law enforcement when EMS arrived. EMT M reported that Patient #1 was being non-cooperative, non-compliant, and required law enforcement to get them uncovered, off the couch, and walking to the ambulance. EMT M recalled Patient #1 forcing them self to vomit by shoving their fingers down their throat, and reported that every time they take care of Patient #1, they do the exact same stuff. EMT M recalled taking Patient #1's blood sugar during transport to the ED, and that the blood sugar was high, but could not recall what the exact result was.

3. Review of Patient #1's medical record revealed:

a. On 8/2/23 at 12:15 PM, Patient #1 presented to the ED by ambulance for a chief complaint of hyperglycemia and abdominal pain of unknown timeframe.

b. On 8/2/23 at 12:23 PM, Patient #1 blood sugar was 437. Patient #1 was seen by DO B. Documentation by DO B in their progress report noted Patient #1 was unwilling to answer any questions for DO B, other than stating that they had abdominal pain everywhere. Patient #1 would not answer DO B as to why they were not eating or taking their insulin. DO B noted that prior to EMS arrival to Patient #1's home, Patient #1 "chugged large amount of water and vomited it up," and vomited one additional time after EMS arrived. DO B noted that Patient #1 had recently been hospitalized at their hospital, and had multiple other hospitalizations to other hospitals. DO B noted that "mom at one point had told EMS they were working on getting psychiatric services involved," but noted that it was unclear if this had been pursued or where they were with that process. It was noted that Patient #1 had abdominal tenderness. Patient #1 was noted to have a past medical history of diabetes type 1 with a history of noncompliance, self-induced diabetic ketoacidosis, THC abuse, tobacco abuse, cyclical vomiting syndrome, and major depressive disorder.

c. On 8/2/23 at 12:25 PM, Patient #1 was triaged by RN E, and their temperature was 99.3 F, BP was 185/118, and pulse was 127. Patient #1's blood sugar was 386. Pain assessment by RN E noted Patient #1's abdominal pain level as a "2" or "hurts a little bit" using the FACES Pain Scale. Suicide assessment was completed and Patient #1 answered no to all the suicide questions, indicating a low risk for suicide. RN E noted Patient #1 was having abdominal tenderness, nausea, and vomiting.

d. On 8/2/23 at 12:36 PM, RN E noted that Patient #1 was fighting RN E physically to get out of bed, went over to the sink to drink water, and then Patient #1 would stick their fingers down their throat to make them self vomit. RN E noted that EMS came to assist with getting Patient #1 back into bed.

e. On 8/2/23 at 12:40 PM, law enforcement was contacted to assist with Patient #1 due to their non-compliance, not listening, fighting staff, and continuing to drink water and making them self vomit. Abnormal labs were noted as followed: chloride 97 (low), glucose level 387 (high), BUN 35.0 (high), creatinine 1.85 (high), calcium 11.10 (high), protein total 8.60 (high), CRP 0.00 (low), WBC 17.92 (high), RBC 3.98 (low), Hgb 10.60 (low), and Hct 31.70 (low). Lactic acid was 1.76 which was in normal range. Ketone Serum was negative. Abnormal blood gases were noted as pCO2 was 33 (low), and pH was 7.5 (high). No anion gap was obtained.

f. On 8/2/23 at 12:42 PM, Patient #1 blood sugar was 387.

g. On 8/2/23 at 12:50 PM, law enforcement left the ED.

h. On 8/2/23 at 1:30 PM, Patient #1 pulse was 131.

i. On 8/2/23 at 2:00 PM, Patient #1 BP was 199/73.

j. On 8/2/23 at 2:37 PM, it was noted in Patient #1's medical records that they were dismissed from the clinic (primary care provider) due to no shows.

k. On 8/2/23 at 3:00 PM, Patient #1 BP was 166/70 and pulse was documented as 133 and 75.

l. On 8/2/23 at 3:20 PM, Patient #1 blood sugar was 426.

m. On 8/2/23 at 3:27 PM, Patient #1 BP was 149/121 and pulse was 126.

n. On 8/2/23 at 3:30 PM, RN E noted that Patient #1 has stuck his fingers down his throat multiple times to make them self vomit. Patient #1 was throwing their emesis bag on the floor, and then throwing up all over the floor, despite multiple staff reminders to use the emesis bags provided.

o. On 8/2/23 at 4:00 PM, Patient #1 BP was 210/69 and pulse was 66.

p. On 8/2/23 at 4:03 PM, Patient #1 blood sugar was 294.

q. On 8/2/23 at 4:30 PM, Patient #1 BP was 173/81 and pulse was 63.

r. On 8/2/23 at 5:00 PM, Patient #1 BP was 172/67 and pulse was 127.

s. On 8/2/23 at 5:11 PM, Patient #1 blood sugar was 237. DO B noted that Patient #1 was stable for discharge and they were instructed to follow up with their primary care provider and psychiatry. DO B noted Patient #1 diagnoses as type 1 diabetes with hyperglycemia with long-term current use of insulin, and borderline AKI, but it was not significant enough to warrant an admission. DO B noted that Patient #1 was not in DKA. Patient #1 was given two 1-liter boluses of normal saline IV fluid, 7 units of regular insulin subcutaneous, and 4 mg of Zofran IV while in the ED. DO B also noted that there was a large psychiatric component for Patient #1's cyclical vomiting. DO B discussed Patient #1's safety in their home, and Patient #1 initially stated they were unsafe to be at home, but then verbalized that they just did not feel good, and they did not have any fear for their physical safety. It was then noted by DO B that they strongly advised Patient #1 to see a psychiatric provider, Patient #1 was interested in a psychiatric referral and counseling, and Patient #1 was provided with resource information for Infinity Health. DO B noted that Patient #1 was not suicidal or homicidal, and was not trying to kill them self, but could not tell DO B why Patient #1 had not been taking their insulin.

t. On 8/2/23 at 5:30 PM, Patient #1 BP was 174/68 and pulse was 64.

u. On 8/2/23 at 6:27 PM, RN E documented that Patient #1 ran into another ED room to drink from the faucet, and then stuck their fingers down their throat to make them self vomit. RN E noted that RN F and DO A ran into the room, and put Patient #1 back into their ED room.

v. On 8/2/23 at 6:28 PM, Patient #1 was discharged from the ED to home. Patient #1 was given discharge paperwork that included patient educational material on major depressive disorder and hyperglycemia. Patient #1's discharge instructions for follow up were to reach out to Infinity Health to schedule an appointment for psychiatric care, and return to ED for new or worsening symptoms. RN E noted that Patient #1 attempted to stay in the ED room, and DO A reinforced to Patient #1 that they needed to leave the ED, as they were discharged, and the family was notified to pick them up. The discharge instructions provided to Patient #1 failed to include the contact information for Infinity Health. The discharge instructions also noted that Patient #1 did not have a primary care physician.

w. On 8/2/23 at 7:26 PM, DO A documented that Patient #1 was discharged prior to them coming on shift, but there was a delay in them leaving the facility due to nursing discharge process, and Patient #1 lacking a ride. DO A noted that Patient #1 was going into other ED patient rooms, drinking water, and self-inducing vomiting on the floors and counters despite being given multiple emesis bags, and at one-point Patient #1 almost vomited on another patient. DO A then noted that Patient #1 was removed from the ED and placed in the vestibule, and law enforcement was contacted to remove Patient #1 from the ED.

4. During an interview on 9/11/23 at 11:00 AM, RN E recalled Patient #1 coming to the ED, and right after arriving, Patient #1 went to another ED room, downed a bunch of water, then stuck their fingers down their throat to self-induce vomiting. RN E recalled providing Patient #1 with numerous emesis bags, but they would still vomit on the bed and floor. RN E reported having the water turned off to Patient #1's ED room, and after receiving their discharge papers, Patient #1 went into another patient's room, again gulped down a bunch of water, and almost vomited on another ED patient. When asked about Patient #1 being a harm to them self, RN E reported that Patient #1 was not suicidal or cutting them self, but they were not demonstrating self-help behavior, and RN E did not feel like Patient #1 was taking care of them self at home.

5. During an interview on 9/11/23 at 10:10 AM, DO B recalled Patient #1 coming into the ED by ambulance. DO B reported that Patient #1 had recently been admitted to their hospital for DKA, which was self-induced. DO B reported Patient #1 had complaints of vomiting and abdominal pain, and they worked Patient #1 up for things that would cause the reported complaints. DO B recalled Patient #1 was slightly hypertensive and tachycardic, but was at baseline for them at discharge. DO B reported while Patient #1 was in the ED, they forced past the tech to get to the sink, drank a bunch of water, and then forced them self to vomit. DO B recalled having maintenance shut off the water to Patient #1's room. DO B explained that Patient #1 had very concentrated blood due to their vomiting, which had affected their lab values, and reported Patient #1's Hgb, Hct, creatinine, calcium, and platelets were all higher than Patient #1's normal. When asked about Patient #1's elevated WBC, DO B explained that this was due to Patient #1's vomiting, demargination, and the rest of Patient #1's blood being concentrated. DO B reported that Patient #1's CRP was negative, they did not have any fevers, and their lactic acid was negative, which showed Patient #1 did not have an infection. DO B also reported that patient #1 was given 2 liters of IV fluids and insulin while in the ED, Patient #1's symptoms had improved, and their ABG, ketones, and anion gap levels did not show Patient #1 was in DKA. DO B reported Patient #1 denied being a risk to them self, denied wanting to harm them self, and was not suicidal. DO B reported they felt Patient #1 was safe for discharge home. DO B acknowledged Patient #1 had psychiatric concerns, and had previous hospitalizations in inpatient BH facilities, and they were previously on a waitlist for an inpatient BH facility 2 weeks prior, but when Patient #1 was medically stable, they no longer met inpatient psychiatric requirements, and was cleared for discharge. DO B acknowledged that they did not have a psychiatric provider assess Patient #1 while in the ED, but they provided Patient #1 with the phone number for an outpatient psychiatric provider, and DO B felt they addressed Patient #1 psychiatric needs. Finally, DO B reported that Patient #1 was dismissed from "our clinic" (Patient #1's primary care provider) the same day they were in the ED, and was unable to provide Patient #1 with a social worker or case manager to assist him with resources at time of discharge.

6. During an interview on 9/11/23 at 2:50 PM, RN G recalled Patient #1, but reported they were working as House Supervisor the day that Patient #1 was in the ED, and they were not Patient #1's primary nurse. RN G reported that Patient #1 has been in the hospital numerous times and usually presents due to their blood sugars. RN G confirmed the hospital ED has mental health services available to ED patients, and reported Patient #1 was provided with information on services provided, but was not assessed by a psychiatric provider. RN G reported the hospital has a list of resources that the hospital case manager has available for patients if needed.

7. During an interview on 9/11/23 at 12:00 PM, RN F recalled Patient #1. RN F reported Patient #1 went into another patient's room while in the ED, gulped down a bunch of water, and then violently started throwing up. RN F recalled being at the desk when they heard a commotion, and when they walked into the room Patient #1 had two fingers down their throat. Patient #1 was given an emesis bag, and escorted back to their ED room. RN F reported that Patient #1 was in the ED for their blood sugars, not for their mental health issues.

8. During an interview on 9/11/23 at 12:00 PM, PCT H recalled Patient #1 being in the ED and they were throwing up everywhere, and running into other patients' rooms. PCT H reported that the nurses working thought Patient #1 had some psychiatric issues besides the medical issues that he presented for.

9. During an interview on 9/11/23 at 1:00 PM, DO A recalled Patient #1 was discharged from the ED prior to their shift, but was still in the ED waiting for a ride. DO A reported that Patient #1's behaviors escalated after their discharge. DO A reported Patient #1 had been previously evaluated at another hospital for mental health and self-induced vomiting. DO A recalled they were extremely busy in the ED that day, and they were trying to free up beds for other patients, and Patient #1 was already discharged, so they told Patient #1 he needed to go to the waiting area. DO A reported a PCT ran out and said Patient #1 was in another patient room vomiting. DO A reported when they entered the other patient's room, Patient #1 was standing over the other patient, and was going to vomit on their head. DO A recalled they escorted Patient #1 out of the other patient's room, and called law enforcement to come and assist with Patient #1. DO A reported Patient #1 then went into the bathroom, chugged water, and vomited all over. DO A reported when law enforcement arrived they transported Patient #1 home. DO A reported Patient #1 certainly did not need a mental health evaluation while in the ED, they were free to make their own decision, and if Patient #1 chooses to do this behavior, they [hospital staff] cannot stop Patient #1. DO A reported DO B assessed Patient #1's mental health while in the ED. DO A explained the hospital did not have psychiatry available in the hospital, and they utilize a remote telehealth service, where a social worker or a mid-level provider would have evaluated Patient #1, asking them the same assessment questions that DO B asked Patient #1, and would have said Patient #1 was okay to follow up on an outpatient basis. DO A reported that Patient #1 was "one hundred thousand percent" appropriate for discharge, and would not have met requirements inpatient psychiatric treatment.

10. During an interview on 9/11/23 at 1:50 PM, ED Medical Director acknowledged that staff from Knoxville Hospital have communicated with providers at other hospitals previously on Patient #1's mental health and self-induced vomiting behaviors, but Patient #1 has not met admission criteria for inpatient BH. ED Medical Director reported that Patient #1's actions are behavioral, and does not meet the admission criteria for mental health. ED Medical Director also reported that Patient #1 bounces between hospitals and has demonstrated self-induced vomiting behaviors for at least over a year.

11. During an interview on 9/18/23 at 4:15 PM, CNO acknowledged that the behaviors demonstrated by Patient #1 while in the ED is not typical behavior, and a lay person would think they were really sick, and would be confused by Patient #1's behaviors. CNO reported that if labs were within their normal range then they were not in danger. CNO also reported that Patient #1 was non-compliant and they didn't want to take their meds, then they run the risk of Patient #1 returning to the ED. CNO explained they always run a risk of patients bouncing back to the ED, and Patient #1 would be at risk for this also. CNO reported when they think of self harm, they think of suicidal thoughts, or running out into the street. CNO reported they did not think of non-compliance as self-harm or not following your medication regimen as self-harm. CNO also reported that Patient #1 was not in their ED for mental health, their behaviors were baseline, and Patient #1 was being evaluated and treated for their abdominal pain and high blood sugars, which were back to baseline prior to discharge from the ED.

12. During an interview on 9/18/23 at 2:35 PM, Deputy L recalled transporting Patient #1 from Knoxville Hospital to their home. Deputy L recalled when they arrived to the ED, Patient #1 was lying outside of the ED entrance on the ground with 2 law enforcement officers. Deputy L reported that Patient #1 was quiet during transport, had an emesis bag with them, but did not vomit during transport, and did not verbalize any complaints or concerns.

13. The critical access hospital failed to provide Patient #1 with the treatment necessary to assure Patient #1 had no material deterioration of an emergency medical condition (EMC). The CAH failed to determine Patient #1 demonstrated tolerance of an oral diet. If Patient #1 were unable to tolerate an oral diet, they would have needed further treatment including additional anti-nausea medication and possible hospital admission for ongoing hydration.

14. Review of Patient #1's medical record from Hospital B revealed:

a. On 8/3/23 at 6:55 AM, just under 13 hours after discharge from Knoxville Hospital ED. Patient #1 arrived at Hospital B by private vehicle, accompanied by their mother, for a chief complaint of diabetes and vomiting since Tuesday (8/1/23). Patient # 1's BP was elevated at 201/143, pulse was 140, initial temperature was 99.9 F with a high of 100.8 F while in the ED, and blood sugar was elevated at 479 (normal range 70 - 110). MD K noted Patient # 1 presented with nausea, vomiting, and high blood pressure and had multiple hospital admissions previously for DKA.

b. On 8/3/23 at 3:07 PM, Hospital B admitted Patient # 1 as an inpatient for treatment to stabilize an emergency medical condition.