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Based on observation, interview, medical record and document review, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) as evidenced by:

1. The facility failed to provide an adequate medical screening exam (MSE) for 1 of 25 sampled patients (Patient 3). (Refer to Tag 2406)

2. The facility failed to provide stabilizing and continued treatment for 2 of 25 sampled patients (Patients 1 and 3). (Refer to Tag 2407)

3. The facility failed to transfer 1 of 25 sampled patients to another facility in stable condition (Patient 1). (Refer to Tag 2409)

4. The facility failed to post required EMTALA signage in a conspicuous place in the patient waiting room (Refer to Tag 2402).

These failures potentially resulted in patients having delays in receiving needed treatment, stabilization and appropriate transfer which can result in adverse outcomes to patient's health and safety, up to and including death.

Based on observation and interview, the facility failed to conspicuously post a sign in the lobby area of the Emergency Department (ED) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA).

This failure resulted in the potential for patients to not know their rights under EMTALA.

Findings:

On 3/4/20 at 10:15 a.m., a tour of the Emergency Department (ED) lobby area revealed a wall containing nine information posters including a poster on EMTALA. The wall with the posters was located in a sectioned off work space which contained a large desk. Behind the desk was stored equipment, which included a standing scale, a vital signs monitor, a computer on wheels station, several office chairs, and wheelchairs. The area was not accessible to the public entering the ED or waiting in the ED lobby.

During an interview with the Emergency Department Director (EDD) on 3/4/20 at 10:20 a.m., the EDD confirmed the EMTALA poster in the work space area was the only EMTALA poster in the ED lobby. The EDD stated the work space was a nurse triage area that was used during busy periods. The EDD stated the posters were not moved once the desk was installed, and that they were not easily accessible for the public to read in their current location.

Based on interview, medical record, and document review the hospital failed to provide medical screening exams (MSEs) for 1 of 25 sampled patients (Patient 3) who presented to the Emergency Department (ED) with an emergency medical condition when Patient 3 complained of being suicidal and was allowed to voluntarily leave the ED prior to completion of the psychiatric screening evaluation.

This failure resulted in Patient 3's subsequent attempted suicide by walking into traffic.

Findings:

According to the admission record, Patient 3 presented to the ED on 11/9/19 at 2:01 a.m., complaining of seizures and suicidal thoughts. The 9:18 a.m., 11/9/19 "Initial Psychiatric Note" indicated the patient had a history of "severe bipolar disorder," had current and regular methamphetamine use, and had "many" psychiatric hospitalizations with the most recent being an inpatient stay on 10/12/19. The note reflected, "Prior suicide attempts and/or behaviors: Unknown." Patient 3 was discharged at 11:47 a.m., 11/9/19. Later that day, at 4:53 p.m., Patient 3 returned to the ED with the complaint of being suicidal.

Review of the facility document titled Self-Reported Adverse Event, dated 11/12/2019, included the following notation: "We had a patient in our Emergency Department who left AMA [against medical advice] and was struck by a car after he ran into the street. We believe this event meets the reporting criteria for patient attempted suicide under the adverse event reporting law. The patient was taken by ambulance to a trauma center where he is currently in stable condition."

Review of the clinical record for Patient 3 included:

Medical Doctor 1's (MD 1's) ED provider note dated 11/9/19 at 5:15 p.m. documented, "[Patient 3] seen in the ED for evaluation of feeling suicidal. He said he felt this way earlier today but he lied because he wanted to go home...He is thinking about cutting his wrists or walking out into traffic. He also mumbled about having a friend who he might try to get to shoot him." The assessment and plan for Patient 3 was, "Suicidal ideation. He denies any current alcohol or drug use. His exam is unremarkable. He has been seen by psychiatry earlier today and cleared, however he feels like he is worse now. Therefore he will be requested to have another psychiatry evaluation. He is medically clear for psychiatry evaluation at this time."

A physician's order, dated 11/9/19 at 5:11 p.m., for "Psychiatry - Initial inpatient consultation."

A physician's order, dated 11/9/19 at 5:11 p.m., "Place on mental health hold, 24-hour, 1799 [1799 hold: The person cannot be safely released from the hospital because, in the opinion of the
treating physician, the person, as a result of a mental disorder, presents a danger to himself or herself, or others, or is gravely disabled]."

A physician's order, dated 11/9/19 at 5:42 p.m., for discontinuation of 1799, mental health hold.

A nursing progress dated 11/11/19 (late entry) documented, "Call placed to the physician stating that patient had a history of malingering, do you still want to keep him on the 1799? 1799 ordered [sic] DC'd [discontinued] by [MD 1]. I informed break relief RN that I was just made aware of [Patient 3] being placed in treatment bed and needing a full assessment. Care handed off to [Registered Nurse] for break."

A nursing progress note dated 11/9/19 documented, "[RN 3] on phone with [MD 1] about pt [patient] 1799 status. No 1799 issued due to pt malingering in previous visit today. No contact with pt as pt eloping and becoming agitated and yelling insults walking to lobby. Pt began yelling again and walk [sic] through lobby close to other patients. Pt then left through lobby door into parking lot with security following. Elopement form filed with unit assistant."

A document titled, "Emergency Department (ED) Leaving Before Medical Evaluation/Treatment" indicated Patient 3 "eloped" on 11/9/19 at 6:00 p.m.

During an interview on 3/4/2020, at 11:18 a.m., with Emergency Department Registered Nurse (RN) 3, RN 3 stated that he was Patient 3's nurse on the early morning on 11/9/19. Patient 3 had come to the emergency department for suicidal ideation, but then denied being a danger to himself, and was subsequently discharged. RN 3 stated that Patient 3 had malingered in the emergency room for a couple hours after discharge, not wanting to leave. Patient 3 returned later in the day on 11/9/19. RN 3 stated he was told that his new admission had been placed in Hall 34 (assigned bed). RN 3 was then told by another nurse to take his break, and did not make contact with Patient 3. RN 3 then gave the break relief nurse an update on his previous encounter with Patient 3. RN 3 called MD 1 and was told that the 1799 hold was lifted.

During an interview on 3/4/2020 at 2:30 p.m., with MD 1, MD 1 stated he placed a 1799 hold on Patient 3 and ordered a psychiatric evaluation when Patient 3 told him he was suicidal. After discussing Patient 3 with RN 3 and reviewing the notes from Patient 3's ED visit from the morning of 11/9/2020, MD 1 felt Patient 3 did not have an emergency medical condition and was stable. MD 1 stated he felt Patient 3 had a psychiatric problem but it was not an emergency. MD 1 stated Patient 3 made a request to speak to someone about his psychiatric problems. For those reasons, MD 1 decided to lift the 1799 hold but keep the psychiatric consult. MD 1 stated he felt competent to make a clinical decision on whether a patient was having a psychiatric emergency, and did not need to rely on the psychiatric evaluation to make that determination. He did not think Patient 3 was an elopement risk; he walked by Patient 3 several times and noticed he appeared calm and was speaking to someone next to him. MD 1 confirmed he did not write a note to indicate the patient no longer had an emergency medical condition.

During an interview on 3/4/2020 at 3:05 p.m., the Licensed Marriage and Family Therapist (LMFT) stated she started her shift on 11/9/2019 at 3 p.m., and between 5:00 p.m. and 5:45 p.m., the ED received five new psychiatric consult requests. LMFT stated she reviewed the medical record of Patient 3, but before she could make contact with Patient 3, the security officer assigned to watch Patient 3 asked if the patient was able to leave. LMFT told the security officer she was unable to make that decision, but, according to the order list, MD 1 had discontinued the 1799 hold. At that moment, Patient 3 got up and started walking out of the ED, while cursing and making threats, such as, "I'm going to burn the hospital down." LMFT felt uncomfortable and told a security officer the patient was making threats. LMFT stated her manager instructed her not to write a progress note in Patient 3's chart because she had not started her psychiatric evaluation.

Review of a July 2019 facility policy titled, "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)" indicated that, "Emergency Medical Condition (EMC): means as a medical condition manifesting itself by acute symptoms of sufficient severity, including ...psychiatric disturbances ...such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy ..." The policy also included, "Medical Screening Examination (MSE) means the process required to determine within reasonable clinical confidence whether or not an emergency medical condition exists. It is an ongoing process, including monitoring of the patient until the patient is either stabilized or transferred...[and]...The medical record will reflect the [MSE]."

Review of a November 2018 facility policy titled, "Treatment and Transfer," indicated that, "When it is determined that the individual does not have an EMC, the individual may be referred to outpatient services, discharged, transferred to another health care facility, or remain in the Emergency Department. The medical record will contain the basis for the determination."




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Based on interview, record review, and hospital policy review, the hospital failed to ensure stabilizing treatment and continuous monitoring relevant to the emergency medical condition (EMC) to 2 patients (Patient 1 and 3) out of 25 sampled patients and ensure no material deterioration of the condition would likely occur, when;

1. Patient 1 was not provided adequate treatment and continuous monitoring for an unstable airway and possible delivery.

2. Patient 3 complained of being suicidal and was allowed to voluntarily leave the emergency department, and subsequently attempted suicide by walking into traffic.

This failure caused Patient 1 to be at high risk for developing respiratory failure, fetal demise (dead baby), and death; and caused Patient 3 to be at high risk for attempting and committing suicide.

Findings:

1. Review of Patient 1's emergency department's (ED's) electronic medical record (EMR), dated 10/19/19 reflected the following:

At 5:36 p.m., upon admission, Patient 1 had a Glasgow Coma Scale of 7 (GCS, a scale used to report a person's level of consciousness with less than 8 as severe) and was receiving oxygen by a non-rebreather mask (high concentration of oxygen) while Medical Doctor (MD) 4 ordered a chest x-ray, labs, and medication, but no arterial blood gas (lab used to determine oxygen exchange in the lungs). The chest x-ray results were hazy with mild atelactisis (the collapse or closure of a lung). Lab results included a high lactic acid level (acid build up in the body due to a lack of oxygen, which may indicate severe infection) of 14.8 millimoles per liter (a unit of measurement, normal range, 0.5-1 mmol/L), an elevated white blood cell count (part of the body's immune system) of 32,000 per microliter (a unit of measurement, normal range, 4,300 - 10.800 per microliter, also a possible indicator of infection), and there was protein detected in the urine at a level above 500 milligrams per deciliter (a unit of measurement, normal range, 0-14 mg/dl, which could have indicated the development of preeclampia, a pregnancy complication).

At 5:39 p.m., the EMR reflected a head to toe assessment document completed by Registered Nurse (RN) 1 which Patient 1 and 2 were an Emergency Severity Index of 1 (ESI, a five level triage tool utilized by the ED with 1 meaning the most urgent patients). The EMR vital sign sheet indicated Patient 1's initial vital's upon arrival to the ED were: Blood Pressure at 174/108 (normal range, 130/85), Heart Rate at 173 (normal range, 60-90), respirations at 32, and temperature at 101.3 (normal range, 98.7). The assessment document indicated Patient 1 was receiving oxygen through a face mask at 100% (maximum amount of oxygen). The document indicated Patient 1 was incontinent of urine, and a Foley catheter (tube that collects urine from the bladder) was inserted by the nurse. The document further indicated Patient 1 was intermittently agitated, combative, non-verbal, lethargic, stuporous (sluggish and confused), vomiting, snoring, incontinent, skin hot, flushed and clammy, and precautions were taken for seizures and aspiration.

At 6:01 p.m., restraints were ordered for Patient 1, and the restraint documentation reflected Patient 1 was place in soft restraints until she was transferred to the accepting hospital.

At 6:15 p.m., medications were ordered for intubation (placement of a breathing tube into the lungs) by MD 4. Patient 1 and 2's primary Registered Nurse 1 (RN 1) wrote in her progress notes, "Plan to intubate."

At 6:18 p.m., an entry by discharge planner included "MD states fetal demise and patient needs removed stat ....[the accepting hospital's] labor and delivery charge [nurse] was on the phone [with MD 2]".

At 6:23 p.m., Medical Doctor (MD) 2 canceled Patient 1's intubation.

At 6:24 p.m., a diagnosis entry by MD 2 indicated Patient 1's diagnosis as "eclampsia (a severe complication in pregnancy which includes high blood pressure and seizures), third trimester". No assessment of Patient 1 or 2 was documented in the EMR.

At 6:30 p.m., the physician assessment and transfer note indicated MD 2 marked the Patient 1 as being stable.

At 6:37 p.m., the physician's note by MD 2 diagnosed Patient 1 with intrauterine fetal demise (baby dead while still inside of mother). No assessment of Patient 1 or 2 was in the EMR, such as an ultrasound reading, fetal heart tone monitoring, fetal heart tone strip, and/or an assessment or treatment by an OB.

At 6:47 p.m. the chart reflected a note filed and signed by RN 1 which indicated Patient 1 was 8 months pregnant, Russian speaking, had non-purposeful body movements, a swollen tongue, incontinent, loud respirations, swelling in both lower extremities, partially digested food on her face and shirt, and febrile. RN 1's note included "No fetal heart tones on bedside ultrasound," and "MD on phone with (accepting hospital)" as Patient 1 and 2 are to be transported emergently.

A review of Patient 1's Medication Administration Record (MAR), dated 10/19/19, indicated Patient 1 received lorazepam (a sedation medication) IV (Intravenously) multiple times between 5:45 p.m. through 7:22 p.m..

During an interview with the Assistant Medical Group Administrator (AMGA), on 3/3/2020 at 9:36 a.m., she stated "Anesthesia can intubate and is available 24/7, and ER MDs can intubate 24/7." She further stated, "There is a difficult airway kit available." She further stated if a pregnant patient needs to deliver and delivery is imminent (near approaching) or the patient has delivered, the sister facility will send a team to the ED. She stated their hospital can do emergency Caesarean sections in the Operating Room (OR). The ED has an obstetrician (OB, a physician who provides medical care to pregnant patients) consultant available to the ED. The transport team includes: NICU team (also known as neonatal intensive care unit team; a team of nurses and doctors that care for premature infants), and there is a delivery team in the ED.

During a concurrent interview with the Emergency Department Manager (EDM) and a review of Patient 1's EMR on 3/4/2020 at 10:12 a.m., she stated when a pregnant patient needs care in the ED, an OB will be called from two other sister facilities, one across the street and another 30 minutes away. EDM explained that the ED doctor will communicate with OB, and the OB will come to the ED.

During a concurrent interview with the Assistant Physician-in-Charge (APIC) and EDM and a review of Patient 1's EMR on 3/4/2020 at 11:22 a.m., APIC referred to RN 1's nursing note at 6:47 p.m. which indicated "No fetal heart tones or heart beat noted on bedside ultrasound". APIC stated the patient was critically ill with fetal demise, and "The baby needed to be delivered to treat [eclampsia]". APIC acknowledged the ED had the capacity and capability to admit and care for Patient 1 and deliver Patient 2. APIC stated, "We can deliver [Patient 2] and place her [Patient 1] in the ICU if she [Patient 1] had lost the baby already." She further stated, the hospital could treat the high lactic acid level and call the on-call OB team to care for the patient. APIC stated, at 7:26 p.m., the chart indicated Patient 1's heart rate was 163 (normal range, 60 to 100), temperature 101.5 (normal range, 98.6), respiratory rate 36 (normal range, 12 to 20), and she was septic.

During a concurrent interview with Emergency Department Physician Director (EDPD) and APIC and review of Patient 1's EMR on 3/4/20 at 3:10 p.m., MDPD stated a "Delivery Alert" is called for pregnant patients greater than 27 weeks pregnant. EDPD stated, "Focus on the mother first, stabilize her, then the fetus." "When you call OB, you need info. So, [perform a] fetus ultrasound." He stated he will look for fetal heart tones, movement, pelvic exam, as possible pending delivery. He states that a delivery alert includes: overhead call, team and in-house staff. EDPD explained emergency room doctors know "even before vital signs, know if [the patient] is in extremis [he point of death]", and know the priority is resuscitation (life sustaining efforts), airway, breathing, and circulation. EDPD explained that ED physicians will consult with OB on the phone to receive advice for stabilization. He stated the ED will stabilize patients always, and if there is distress or difficulty transferring the patient, the hospital will keep the patient without exception and will send to the patient to the sister facility. He further stated, when the NICU and OB get called, they get to the hospital right away. He again stated "Airway and breathing" come first with stabilization. He stated the rule of thumb is to intubate when the patient has a GCS of 8. When he was asked if he would intubate a patient with a GCS of 7 and a lactic acid of 14, he stated "Yes".

During a concurrent interview with MD 2 and review of Patient 1's EMR on 3/4/20 at 3:44 p.m., MD 2 confirmed his only note for Patient 1 and 2 note was completed at 11:54 p.m. because he "busy taking care" of patient 1 and 2. MD 2 stated he was at the bedside and completed a fetal ultrasound and pelvic exam on Patient 1. MD 2 stated the fetal ultrasound showed, "Low fluid, no heartbeat, no activity". MD 2 stated Patient 1 was given lorazepam in the ED twice for questionable seizure activity, but she was not having constant seizures. Additional doses of lorazepam were given after 6 p.m. were for delirium and agitation. MD 5 acknowledged lorazepam can potentially affect respirations of Patient 1. The chart reflected that Patient 1 was not intubated on arrival to Facility 1 resuscitation room 6 at 5:36 p.m. When MD 2 was asked why Patient 1 was not intubated on admission or during the stay in the ED, he stated Patient 1 was critical and one of the "sickest" of patients and "required resuscitation". MD 2 further stated he was skilled at intubating patients and could intubate within 2 to 3 minutes. MD 2 stated he canceled the intubation at 6:23 p.m. because it would have delayed care and didn't feel it was beneficial for Patient 1. "We were ready to send the patient to the floor [the accepting hospital's labor and delivery unit]". MD 2 further stated Patient 1 and 2 were being transferred to the accepting hospital with 2 paramedics and RN 1. He stated the head of the bed was up the entire transfer to help with Patient 1's breathing. He stated the transferring paramedics could intubate Patient 1 in route if an airway was necessary.

A review of the hospital's policy titled, "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)," effective 7/11/19, indicated when an individual has an emergency medical condition, the hospital will provide further medical treatment required to stabilize the emergency medical condition within its capability and capacity. The policy further indicated, "If the individual requires services of a consultant in order to provide stabilizing treatment, an on-call physician will be contacted and will be available to evaluate and treat the individual within a reasonable period of time to meet the medical needs of the individual." This policy included the hospital will provide the necessary medical care and services for females to deliver a baby and/or stabilize any emergency medical condition.

Review of the hospital's policy titled, "Treatment and Transfer", effective 11/13/18, indicated an emergency medical condition is "stabilized" when the condition is resolved. A women experiencing contractions is in true labor, unless a physician or other qualified medical person acting within his or her scope of practice as defined in the medical staff bylaw and State law, certifies that, after a reasonable time of observation the woman is in false labor.

Review of the hospital policy titled, "Imminent Delivery-Care of Mother and Infant", effective 8/18/17, indicated any pregnant patient over 20 weeks gestation that presents with symptoms possibly related to labor or trauma related complaints will be triaged as emergent, which will facilitate rapid deployment of needed resources. The physician must determine preterm labor, contractions onset, duration, bag of water intact, vaginal bleeding, fetal movement, fetal heart tones (normal range is 120-160), mother's vitals and temperature, immunizations, and signs and symptoms of impending birth. If a delivery is imminent, the ED MD is to notify OB on-call, neonatologist (a physician who provides medical care to infants) on-call, laboratory, anesthesia, NICU, respiratory therapy, and ED managers/directors.


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2. According to the admission record, Patient 3 presented to the ED on 11/9/19 at 2:01 a.m., complaining of seizures and suicidal thoughts. The 9:18 a.m., 11/9/19 "Initial Psychiatric Note" indicated the patient had a history of "severe bipolar disorder," had current and regular methamphetamine use, and had "many" psychiatric hospitalizations with the most recent being an inpatient stay on 10/12/19. The note reflected, "Prior suicide attempts and/or behaviors: Unknown." Patient 3 was discharged at 11:47 a.m., 11/9/19. Later that day, at 4:53 p.m., Patient 3 returned to the ED with the complaint of being suicidal.

Review of the facility document titled Self-Reported Adverse Event dated 11/12/2019 included the following notation: "We had a patient in our Emergency Department who left AMA [against medical advice] and was struck by a car after he ran into the street. We believe this event meets the reporting crtiteria for patient attempted suicide under the adverse event reporting law. The patient was taken by ambulance to a trauma center where he is currently in stable condition."

Review of the clinical record for Patient 3 included:

Medical Doctor 1's (MD 1's) ED provider note dated 11/9/19 at 5:15 p.m. documented, "[Patient 3] seen in the ED for evaluation of feeling suicidal. He said he felt this way earlier today but he lied because he wanted to go home...He is thinking about cutting his wrists or walking out into traffic. He also mumbled about having a friend who he might try to get to shoot him." The assessment and plan for Patient 3 was, "Suicidal ideation. He denies any current alcohol or drug use. His exam is unremarkable. He has been seen by psychiatry earlier today and cleared, however he feels like he is worse now. Therefore he will be requested to have another psychiatry evaluation. He is medically clear for psychiatry evaluation at this time."

A physician's order, dated 11/9/19 at 5:11 p.m., for "Psychiatry - Initial inpatient consultation."

A physician's order, dated 11/9/19 at 5:11 p.m., "Place on mental health hold, 24-hour, 1799 [1799 hold: The person cannot be safely released from the hospital because, in the opinion of the
treating physician, the person, as a result of a mental disorder, presents a danger to himself or herself, or others, or is gravely disabled]."

A physician's order, dated 11/9/19 at 5:42 p.m., for discontinuation of 1799, mental health hold.

A nursing progress dated 11/11/19 (late entry) documented, "Call placed to the physician stating that patient had a history of malingering, do you still want to keep him on the 1799? 1799 ordered [sic] DC'd [discontinued] by [MD 1]. I informed break relief RN that I was just made aware of [Patient 3] being placed in treatment bed and needing a full assessment. Care handed off to [Registered Nurse] for break."

A nursing progress note dated 11/9/19 documented, "[RN 3] on phone with [MD 1] about pt [patient] 1799 status. No 1799 issued due to pt malingering in previous visit today. No contact with pt as pt eloping and becoming agitated and yelling insults walking to lobby. Pt began yelling again and walk [sic] through lobby close to other patients. Pt then left through lobby door into parking lot with security following. Elopement form filed with unit assistant."

A document titled, "Emergency Department (ED) Leaving Before Medical Evaluation/Treatment" indicated Patient 3 "eloped" on 11/9/19 at 6:00 p.m.

During an interview on 3/4/2020, at 11:18 a.m., with Emergency Department Registered Nurse (RN) 3, RN 3 stated that he was Patient 3's nurse on the early morning on 11/9/19. Patient 3 had come to the emergency department for suicidal ideation, but then denied being a danger to himself, and was subsequently discharged. RN 3 stated that Patient 3 had malingered in the emergency room for a couple hours after discharge, not wanting to leave. Patient 3 returned later in the day on 11/9/19. RN 3 stated he was told that his new admission had been placed in Hall 34 (assigned bed). RN 3 was then told by another nurse to take his break, and did not make contact with Patient 3. RN 3 then gave the break relief nurse an update on his previous encounter with Patient 3. RN 3 called MD 1 and was told that the 1799 hold was lifted.

During an interview on 3/4/2020 at 2:30 p.m., with MD 1, MD 1 stated he placed a 1799 hold on Patient 3 and ordered a psychiatric evaluation when Patient 3 told him he was suicidal. After discussing Patient 3 with RN 3 and reviewing the notes from Patient 3's ED visit from the morning of 11/9/2020, MD 1 felt Patient 3 did not have an emergency medical condition and was stable. MD 1 stated he felt Patient 3 had a psychiatric problem but it was not an emergency. MD 1 stated Patient 3 made a request to speak to someone about his psychiatric problems. For those reasons, MD 1 decided to lift the 1799 hold but keep the psychiatric consult. MD 1 stated he felt competent to make a clinical decision on whether a patient was having a psychiatric emergency, and did not need to rely on the psychiatric evaluation to make that determination. He did not think Patient 3 was an elopement risk; he walked by Patient 3 several times and noticed he appeared calm and was speaking to someone next to him. MD 1 confirmed he did not write a note to indicate the patient no longer had an emergency medical condition.

During an interview on 3/4/2020 at 3:05 p.m., the Licensed Marriage and Family Therapist (LMFT) stated she started her shift on 11/9/2019 at 3 p.m., and between 5:00 p.m. and 5:45 p.m., the ED received five new psychiatric consult requests. LMFT stated she reviewed the medical record of Patient 3, but before she could make contact with Patient 3, the security officer assigned to watch Patient 3 asked if the patient was able to leave. LMFT told the security officer she was unable to make that decision, but, according to the order list, MD 1 had discontinued the 1799 hold. At that moment, Patient 3 got up and started walking out of the ED, while cursing and making threats, such as, "I'm going to burn the hospital down." LMFT felt uncomfortable and told a security officer the patient was making threats. LMFT stated her manager instructed her not to write a progress note in Patient 3's chart because she had not started her psychiatric evaluation.

Review of a July 2019 facility policy titled, "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)" indicated that, "Emergency Medical Condition (EMC): means as a medical condition manifesting itself by acute symptoms of sufficient severity, including ...psychiatric disturbances ...such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy ..." The policy also included, "To Stabilize means: In the care of an individual with a psychiatric or behavioral condition, the individual is protected and prevented from injuring himself or herself or others."

Review of a November 2018 facility policy titled, "Treatment and Transfer," indicated that, "When it is determined that the individual does not have an EMC, the individual may be referred to outpatient services, discharged, transferred to another health care facility, or remain in the Emergency Department. The medical record will contain the basis for the determination."

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Based on interview, medical record and document review, the Emergency Department (ED) failed to restrict the transfer of 1 of 25 sampled patients (Patient 1) when it had the capacity and capability to first stabilize and treat:

- A stable airway was not established for Patient 1 on arrival to the ED, i.e. intubation (placing a breathing tube into the throat to assist breathing), ,
- Around-the-clock in-house services such as specialty providers to assist as needed for intubation, Operating Room to deliver an infant, and an adult ICU were not used to treat and stabilize; and
- Patient 1 was transferred to another hospital with an unstable airway and required immediate intubation upon arrival.

The failure to continuously assess and treat, and stabilize before transfer, resulted in delay of treatment and stabilization of an EMC.

Findings:

Review of the ED electronic medical record (EMR), dated 10/19/19, reflected the following timeline:

At 5:28 p.m. Patient 1 arrived at the ED.

At 5:36 p.m., upon admission, Patient 1 had a Glasgow Coma Scale of 7 (GCS, a scale used to report a person's level of consciousness with less than 8 being severe impairment) and was receiving oxygen by a non-rebreather mask (high concentration of oxygen) while Medical Doctor (MD) 4 ordered a chest x-ray, laboratory tests, and medication, but no arterial blood gas (laboratory test used to determine oxygen exchange in the lungs). The chest x-ray results noted a mild collapse of a lung. Lab results included a high lactic acid level (acid build up in the body due to a lack of oxygen, which may indicate severe infection) of 14.8 millimoles per liter (normal range, 0.5-1 mmol/L), an elevated white blood cell count (part of the body's immune system) of 32,000 per microliter (normal range, 4,300 - 10.800 per microliter, also a possible indicator of infection). There was protein detected in the urine at a level above 500 milligrams per deciliter (normal range, 0-14 mg/dl) which could have indicated the development of preeclampia (high blood pressure and salt in the urine, a medical complication of pregnancy).

A 5:39 p.m. nursing progress note reflected a head-to toe-assessment of Patient 1 completed by Registered Nurse 1 (RN 1). An Emergency Severity Index level of "1" (ESI, five level ED patient categorization based on illness severity and resource needs with "1" indicating the most urgent patients) was assigned. Patient 1's vital signs included a blood pressure of 174/108 millimeters of mercury (normal average blood pressure 120/ 80 mm Hg), heart rate of 173 beats per minute (normal range is 60-100 BPM), respirations of 32 per minute (normal is 10 - 18 per minute), and temperature of 101.3 (normal body temperatures is 98.6 F). The assessment indicated Patient 1 was receiving oxygen through a face mask at 100% (maximum amount of oxygen). A Foley catheter (tube that collects urine from the bladder) was inserted by the nurse. Patient 1 was intermittently agitated, combative, non-verbal, lethargic, stuporous (sluggish, sleepy and confused), vomiting, snoring, incontinent (unable to control bladder), skin hot, flushed and clammy. Precautions were taken for seizures and aspiration (swallowing vomit into the lungs). Patient 1's labor status was not documented.

Starting at 5:45 p.m. through 7:22 p.m., the Medication Administration Record (MAR) indicated Patient 1 received the sedative lorazepam (Ativan) intravenously (IV, through a tube into a vein) multiple times.

At 6:01 p.m., the restraint documentation reflected Patient 1 was placed in soft restraints until she was transferred to the accepting hospital.

At 6:15 p.m., the chart reflected MD 4's medication orders in preparation for intubation (breathing tube placed in throat to breathe). The chart reflected that RN 1 wrote, "Plan to intubate".

At 6:18 p.m., the chart reflected an entry by discharge planner registered nurse, "MD states fetal demise [death of unborn baby] and patient needs removed stat [immediately]...[accepting hospital] labor and delivery charge [nurse] was on the phone [with MD 2]".

At 6:23 p.m. the chart indicated that Patient 1's intubation was cancelled. No MD assessment of Patient 1 was documented in the EMR at this time.

At 6:24 p.m., the chart reflected a diagnosis entry by MD 2, Patient 1 diagnosis of "eclampsia [high blood pressure and siezures during pregnancy], third trimester". No MD assessment of Patient 1 was documented in the EMR at this time.

At 6:30 p.m., indicated MD 2 completed an English version of the "Physician Assessment and Certification Patient Transfer under EMTALA/COBRA" form for Patient 1: Diagnosis "antepartum eclampsia [severe high blood pressure and seizures occurring not long before childbirth]", condition was marked "Stable" and reason for transfer was "higher level of care, additional time delay in receiving treatment, deterioration of medical condition". The chart reflected vital signs recorded by RN 1. The form reflected that MD 2 certified he examined and explained to the risks and benefits of being transferred to Patient 1. No MD assessment of Patient 1 was documented in the EMR at this time.

At 6:37 p.m., the chart reflected a diagnosis entry by MD 2, Patient 1 diagnosis of history of fetal demise. No MD assessment of Patient 1 was documented in the EMR at this time

At 6:47 p.m. the chart reflected a note filed and signed by RN 1: Patient eight months pregnant, Russian speaking, postictal (confusion and sleepy after a seizure) on arrival, swollen tongue, incontinent, sonorous respirations, pitting edema (very swollen legs), emesis (vomit) on face and shirt, febrile. No fetal heart tones noted on bedside ultrasound (pregnant women imaging of an unborn infant). MD on phone with accepting hospital and Patient 1 to be transported emergently to accepting hospital. No MD assessment of Patient 1 was documented in the EMR at this time.

At 6:52 p.m. the chart reflected Patient 1's heart rate was 156 and respiratory rate was 39. No MD assessment of Patient 1 was documented in the EMR at this time.

At 6:56 p.m., the chart reflected a filed (entered) and signed by RN 1, "L&D [Labor and Delivery at accepting hospital], reports unable to take patient due to lactic elevated. Pending bed placement at [accepting hospital]."

At 7:09 p.m., a note by RN 1 read, "Pending ICU [Intensive Care Unit] bed at [accepting hospital]". The chart indicated RN 1 gave report to an ICU RN at the accepting hospital.

At 7:26 p.m. the chart reflected, Patient 1's vital signs were heart rate 163, temperature 101.5, and respiratory rate 36. No MD assessment of Patient 1 was documented in the EMR at this time.

At 7:38 p.m., Emergency Medical System Advance Life Support (also known as EMS ALS, transport of critical patient and a paramedic is required) records reflected Patient 1 was accompanied by RN 1 and a paramedic, and was transported to accepting hospital via EMS ALS with light and sirens. The initial vital signs taken during transfer reflected in the chart were a blood pressure 148/80 mm Hg, heart rate 157, respiratory rate 30, temperature 103.9, oxygen 96% on 15 liters of oxygen via face mask (maximum oxygen deliverable by face mask), and GCS score of 7.

A review of the accepting hospital's transfer timeline, dated 10/19/19 at 7:58 p.m., indicated, "Call back to [nurse], asked to hold transport as bed is not ready until 8:30 p.m., [accepting facility] needs to move patient. Advised transport has already left with patient". The chart also reflected the accepting physician was OB and not an ICU physician.

At 8:08 p.m., Patient 1 arrived at the accepting hospital directly to the ICU. There was no available bed for the patient.

1) During an interview with the Assistant Medical Group Administrator (AMGA), on 3/3/2020 at 9:36 a.m., she stated "Anesthesia can intubate and is available 24/7, and ER MDs can intubate 24/7." She further stated, "There is a difficult airway kit available." She further stated if a pregnant patient needs to deliver and delivery is imminent (near approaching) or the patient has delivered, the sister facility will send a team to the ED. She stated their hospital can do emergency Caesarean sections in the Operating Room (OR). The ED has an obstetrician (OB, a physician who provides medical care to pregnant patients) consultant available to the ED. The transport team includes: NICU team, and there is a delivery team in the ED.

During a concurrent interview with the Emergency Department Manager (EDM) and a review of Patient 1's EMR on 3/4/2020 at 10:12 a.m., she stated when a pregnant patient needs care in the ED, an OB will be called from two other sister facilities, one across the street and another 30 minutes away. EDM explained that the ED doctor will communicate with OB, and the OB will come to the ED.

During a concurrent interview with the Assistant Physician-in-Charge (APIC) and EDM and a review of Patient 1's EMR on 3/4/2020 at 11:22 a.m., APIC referred to RN 1's nursing note at 6:47 p.m. which indicated "No fetal heart tones or heart beat noted on bedside ultrasound". APIC stated the patient was critically ill with fetal demise, and "The baby needed to be delivered to treat [eclampsia]". APIC acknowledged the ED had the capacity and capability to admit and care for Patient 1 and deliver the fetus (unborn infant). APIC stated, "We can deliver [the baby] and place her [Patient 1] in the ICU, if she [Patient 1] had lost the baby already." She further stated, the hospital could treat the high lactic acid level and call the on-call OB team to care for the patient. APIC stated, at 7:26 p.m., the chart indicated Patient 1's heart rate was 163 beats per minute normal range is 60 to 100 BPM), temperature 101.5 (normal range, 98.6), respiratory rate 36 (normal range, 12 to 20), and she was septic.

During a concurrent interview with Emergency Department Physician Director (EDPD) and APIC and review of Patient 1's EMR on 3/4/20 at 3:10 p.m., MDPD stated a "Delivery Alert" is called for pregnant patients greater than 27 weeks pregnant. EDPD stated, "Focus on the mother first, stabilize her, then the fetus." "When you call OB, you need info. So, [perform a] fetus ultrasound." He stated he will look for fetal heart tones, movement, pelvic exam, as possible pending delivery. He states that a delivery alert includes: overhead call, team and in-house staff. EDPD explained emergency room doctors know "even before vital signs, know if [the patient] is in extremis", and know the priority is resuscitation - airway, breathing, and circulation. EDPD explained that ED physicians will consult with OB on the phone to receive advice for stabilization. He stated the ED will stabilize patients always, and if there is distress or difficulty transferring the patient, the hospital will keep the patient without exception and will send to the patient to the sister facility. He further stated, when the NICU and OB get called, they get to the hospital right away. He again stated "Airway and breathing" come first with stabilization. He stated the rule of thumb is to intubate when the patient has a GCS of 8. When he was asked if he would intubate a patient with a GCS of 7 and a lactic acid of 14, he stated "Yes".

During a concurrent interview with MD 2 and review of Patient 1's EMR on 3/4/20 at 3:44 p.m., MD 2 confirmed his only note for Patient 1 was completed at 11:54 p.m. because he "busy taking care" of Patient 1. MD 2 stated he was at the bedside and completed a fetal ultrasound and pelvic exam on Patient 1. MD 2 stated the fetal ultrasound showed, "Low fluid, no heartbeat, no activity". MD 2 stated Patient 1 was given lorazepam in the ED twice for questionable seizure activity, but she was not having constant seizures. Additional doses of lorazepam were given after 6 p.m. were for delirium and agitation. MD 5 acknowledged lorazepam can potentially affect respirations of Patient 1. The chart reflected that Patient 1 was not intubated on arrival to at 5:36 p.m. When MD 2 was asked why Patient 1 was not intubated on admission or during the stay in the ED, he stated Patient 1 was critical and one of the "sickest" of patients and "required resuscitation". MD 2 further stated he was skilled at intubating patients and could intubate within 2 to 3 minutes. MD 2 stated he cancelled the intubation at 6:23 p.m. because it would have delayed care and didn't feel it was beneficial for Patient 1. "We were ready to send the patient to the floor [the accepting hospital's labor and delivery unit]". MD 2 further stated Patient 1 was being transferred to the accepting hospital with two paramedics and RN 1. He stated the head of the bed was up the entire transfer to help with Patient 1's breathing. He stated the transferring paramedics could intubate Patient 1 in route if an airway was necessary.

During a concurrent phone interview and chart review, on 10/13/2020 at 10:12 a.m. with RN 3, Director of Medical ICU. stated received multiple complaints regarding the Patient 1 critical status and stability during transfer, and the ICU was not ready not ready for the patient and the bed was not assigned yet.

During a concurrent phone interview and chart review, on 10/13/2020 at 10:46 a.m. with RN 3 and RN 4, the Interim Clinical Nurse Manager for Nursing Administration, stated she was present when Patient 1 arrived to ICU, and described Patient 1 as "super sick". She further stated the ICU team had to stabilize and intubate Patient 1 on arrival, and manage multiple critical tasks at once, including the delivery of the baby, brain scans for brain injury due to eclampsia, labs, exam and so forth.

2) During a concurrent interview and record review on 3/4/2020 at 11:22 a.m., with Emergency Room Manager (EDM) and Assistant Physician in Charge (APIC). APIC stated Patient 1 was not hospital members (HMO insurance holders). "[We] would have had to bring the OB team in [to the hospital] to deliver [the fetus]". The hospital could deliver a baby in operating room (OR) or the intensive care unit (ICU), but would have preferred to have Patient 1 cared for at a sister facility. APIC stated it would take "less time to transport Patient 1 elsewhere than to wait for [hospital OB] team to deliver ...We can deliver and place her [Patient 1] in the ICU, if she had lost the baby already... a code-C [Cesarean Sections], bring OB team] here....We can do it here with the labor and delivery team." However, APIC stated Patient 1 was "critical" and it would "delay care" because it usually took 15 to 30 minutes, and sometimes up to 60 minutes to get the patient to the operating room. Patient 1 arrived at the ED at 5:28 p.m. in "critical" condition and was in the ED until 7:38 p.m. APIC stated, at 7:26 p.m. the chart reflected, Patient 1's heart rate was "163 (normal 60 to 100), temperature 101.5 (normal 98.6), respiratory rate 36 (normal 10 to 16), and septic (life threatening body infection), [necessary to] get the baby out".

During an interview and concurrent chart review with MDPD and APIC, MDPD stated, NICU [neonatal intensive care team] was 15 to 30 minutes here [Facility 1] ...Delivery alert for [pregnancy] greater than 27 weeks". MDPD explained ED doctors will "consult with [the on-call] OB on the phone for advice for stabilization ...always will stabilize patients... in distress or if difficulty transferring... [We] will keep patient without exception and will send to the patient [to sister facility]... transferred intubated... with medications... after vital signs are stable... when [it is] safe for the patient".

During a 3:44 p.m., 3/4/20 concurrent interview and record review, MD 2 stated Patient 1 needed to be transferred to another facility to control seizures and for birth. His progress note indicated Patient 1 was a "critically ill patient" and was "stabilized effectively...breathing...required restraints for delirium because of eclampsia (severe high blood pressure and seizures during pregnancy), septsis (blood infection) and acidosis (increased acid levels in blood), and needed resuscitation... had GCS of 8 the whole time... sonorous (loud snoring) respiration, snoring was sign of soft tissue obstruction".

MD 2 stated, the ED called the accepting hospital to "take her" because she was "stable". MD 2 stated accepting hospital, labor and delivery unit was "taking too long", so he called Patient 1's regular obstetrician at the accepting hospital who accepted the transfer. MD 2 acknowledged labor and delivery would not accept Patient 1 due to the high lactate level (high blood acid levels), and instead Patient 1 needed to go to an intensive care unit (ICU) for treatment of eclampsia and seizures. MD 2 stated he gave an "up to date summary of the Patient 1's status" to accepting hospital intensive unit care (ICU) physician, and stated he relayed Patient 1 was "stable" and "no longer seizing...stabilized...labs...updated vitals...Ativan for agitation...blood pressure controlled...breathing on own."

MD 2 was asked why Patient 1 was not intubated on admission or during the stay at the ED. MD 2 stated he "didn't feel it was beneficial. It would delay care." MD 2 stated he cancelled the intubation at 6:23 p.m. because "it would delay care", and "lose 20 minutes", so "didn't intubate". "We were ready to send the patient to the floor [ a non ICU bed at the accepting hospital]"

MD 2 stated a note for Patient 1's transfer documentation was completed before the transfer. MD 2 referred to the documentation on the "Physician Assessment and Certification Patient Transfer under EMTALA/COBRA" form completed at 6:30 p.m. MD 2 indicated from 5:45 p.m. until transfer time at 7:38 p.m., Patient 1 was given several additional doses of lorazepam for agitation and delirium. MD 2 stated Patient 1 required restraints for delirium because of eclampsia, sepsis and acidosis and needed resuscitation...had GCS of 8 whole time ...sonorous respiration and snoring was sign of soft tissue obstruction ... and critical". MD 2 continued, Patient 1 was being transferred to the accepting hospital via ALS (Emergency Medical System, Advance Life Support ambulance) with a paramedic and RN 1, an ED employee, and "911, EMS could intubate if needed, to and from facilities".

During the interview at 3:44 p.m., MD 2 was unable to locate any additional written documentation of Patient 1's exam, additional GCS scores, ultrasound (a machine that documentation and pictures, vaginal (birth canal) exam, MSE on arrival for EMC, continuous status exam, transfer note before discharge, and communication with other physicians. MD 2 stated, his note filed and signed at 11:54 p.m. was "incomplete".

Review of records from accepting hospital dated 10/19/2019 and concurrent interview on 3/10/2020 at 4:36 p.m. with MD 5. The chart indicated that MD 5 was contacted by Patient 1's obstetrician and was informed Patient 1 had a fetal demise, and Patient 1 was transferred due to insurance reasons, the elevated lactic acid level. In addition, the records reflected the following: MD 5, an ICU lung disease specialist at the accepting hospital, wrote an 8:08 p.m. progress note that Patients 1 was admitted directly to an ICU. MD 5 stated, he was informed by the Patient 1's OB physician that because of insurance reasons, Patient 1 was being transferred and Patient 1 "might arrive" in the ICU. MD 5 stated the patient arrived in the ICU unexpectantly via EMS ambulance, and "had to scramble to get ready for the patient... the nurses didn't know and had to find a bed." MD 5 further stated that the only knowledge he had of Patient 1 was from the accepting OB's report, history in EMR, and the husband, through a translator. MD 5 stated the ED transferring physician did not contact him to accept the patients. MD 5 stated "I'm upset" and "I saved her life." MD 5's note reflected Patient 1 was not stable for transfer and presented to ICU with acute hypoxic respiratory failure (unable to breathe on own and not getting enough oxygen), severe sepsis, eclampsia and suspected fetal demise. The chart indicated Patient 1 was confused, agitated, not following commands, snoring, had high blood pressure, a fast heart rate, and pre-term labor (early labor) and rupture of membranes (a sign of labor). Patient 1 was intubated on arrival to the ICU. Examination of the fetus on 10/19/19 at 9:36 p.m. reflected fetal demise via fetal heart tracing and bedside ultrasound. The fetus was vaginally delivered in the ICU. An MRI (detailed picture of the brain) completed on 10/21/2019 at 9:32 p.m. reflected non-specific findings which were but "concerning for PRES [Posterior reversible encephalopathy [brain damage] syndrome, also called the acute hypertensive [high blood pressure] encephalopathy (brain damage)], hypertension in the setting of eclampsia."

Review of the hospital policy titled "Emergency Medical Screening Examination, Treatment and Transfer (EMTALA)," effective 7/11/19, indicated the following: the hospital may not transfer any patient with an unstabilized emergency medical condition unless the patient requests the transfer or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the patient from the transfer. The hospital provided medical treatment within its capacity to minimize the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child. Once the emergency medical condition is stabilized, the individual may be admitted to the hospital for further care, be discharged, or be transferred to another facility. The transfer process: The transfer may pose a threat to the health and safety of the woman or unborn child or a physician determines the transfer is medically necessary. Prior to transfer, the patient's condition will be reassessed just before transfer. The medical record or transfer form #02494, will reflect the exam (form 3 2494, titled physician Assessment and Certification- Patient Transfer under EMTALA/Cobra). The transferring physician will contact a physician at the receiving facility, obtain his/her agreement to accept the transfer, and document the receiving physician's acceptance on the transfer form (Physician Assessment and Certification-Patient Transfer under EMTALA/COBRA). The receiving facility will be contacted to obtain acceptance of the transfer, confirmation that the appropriate bed is available, and that appropriate medical treatment will be provided. The transferring physician will inform the patient (or legal representative) of the reasons for the transfer, including risks and benefits of the transfer. The physician will document the reason for the transfer, including risks and benefits, in the medical record. The transferring physician will complete the transfer form certifying that for unstable patients, the medical benefits of receiving treatment at another facility outweigh the risks to the patient (or if pregnant, unborn child) from effecting the transfer.

Review of the hospital's policy titled, "Treatment and Transfer", effective 11/13/18, indicated an emergency medical condition is "stabilized" when the condition is resolved. A women experiencing contractions is in true labor, unless a physician or other qualified medical person acting within his or her scope of practice as defined in the medical staff bylaw and State law, certifies that, after a reasonable time of observation the woman is in false labor.

Review of the hospital policy titled, "Imminent Delivery-Care of Mother and Infant", effective 8/18/17, indicated any pregnant patient over 20 weeks gestation that presents with symptoms possibly related to labor or trauma related complaints will be triaged as emergent, which will facilitate rapid deployment of needed resources. The physician must determine preterm labor, contractions onset, duration, bag of water intact, vaginal bleeding, fetal movement, fetal heart tones (normal range is 120-160), mother's vital signs and temperature, immunizations, and signs and symptoms of impending birth. If a delivery is imminent, the ED MD is to notify OB on-call, neonatologist (a physician who provides medical care to infants) on-call, laboratory, anesthesia, NICU, respiratory therapy, and other managers and directors.

Review of hospital policy titled, Qualified Interpreter Services for Limited English Proficient Persons, effective 11/1/19, reflected the following: individuals who need spoken language assistance: When an interpreter encounter is complete, use of an interpreter is documented in the medical record or health plan file.

Review of a 12/20/13 publication from CPDH and the California Maternal Quality Care Collaborative titled "Airway Management In Pregnant or Postpartum Women Having Seizures" reflected the following: "A seizure is a frightening and uncommon occurrence in Labor and Delivery and the visceral response of many providers is to immediately administer magnesium sulfate to stop the abnormal movement associated with the seizure. However, even more important than stopping the seizure, which usually stops on its own after 1-2 minutes, is maintaining and protecting the airway. Seizures do not directly cause death, but intracranial hemorrhage [bleeding inside the brain] and hypertensive encephalopathy [brain injury due to high blood pressure]. Therefore, the airway is the first priority in seizure management, even before administration of magnesium sulfate." https://www.cmqcc.org/resource/airway-management-pregnant-or-postpartum-women-having-seizures-toolkit-pdf. Accessed 3/11/2020.