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An unannounced EMTALA complaint survey was conducted to investigate complaint numbers NC00073360 and NC00073617.

Based on policy reviews, dedicated emergency department (DED) record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR 489.24.

The Findings include:

1. The hospital failed to provide an appropriate and ongoing medical screening examination (MSE) for 2 of 25 sampled patients (#9, #5) presenting to the hospital's DED with an emergency medical condition.

~Cross refer to 489.24(r) and 489.24(c), Medical Screening Exam - Tag A2406.

2. The hospital failed to provide stabilizing treatment within it's capacity for 1 of 5 sampled patients (#14) presenting to the hospital's DED that was transferred with an emergency medical condition and 1 of 1 sampled patient's (#5)presenting to the hospital's DED with a psychiatric emergency medical condition that eloped.

~Cross refer to 489.24(d)(1-3), Stabilizing Treatment - Tag A2407.

Based on policy review, emergency medical services (EMS) call reports, medical record review, physician and staff interviews, the hospital failed to provide an appropriate medical screening examination with ongoing monitoring for a patient with an emergency medical condition in 2 of 25 sampled patients (#9, #5) presenting to the hospital's dedicated emergency department (DED).

The findings include:

Review of current hospital policy PE-7, "SUBJECT: EMERGENCY MEDICAL SCREENING" dated 09/20/2010, revealed "POLICY The following policy is designed to ensure that (Hospital A name) provides emergency medical screening examinations to any individual for whom an exam or treatment is requested... POLICY DETAIL ...Procedure All emergency medical screenings must be conducted in a manner that is reasonably calculated to exclude the presence of an emergency medical condition. This may include the utilization of necessary tests, ancillary services, and/or on-call specialists when necessary. Examinations will be based on the patient's chief complaint and their medical condition... Should a patient refuse a medical screening examination...., treatment or transfer, hospital staff will take all reasonable steps to obtain informed written consent from the patient for refusing the examination, treatment or transfer. Staff will explain to the patient the hospital's legal obligations, the risks and benefits of refusing the examination, determine if the patient is competent to refuse, and will exercise every effort to obtain the patient's signature on the Refusal to Stay form (REFSTAY). The individual conducting the medical screening exam must be involved in this process. ..."

Review of current hospital policy PC-25, "SUBJECT: SUICIDE PRECAUTIONS/RISK LEVEL SYSTEM" dated 03/07/2011, revealed "PURPOSE To reduce the risk of harm to self or others for the patient with suspected or known suicidal ideation. ...IMPLEMENTATION This policy applies to....patients who are treated in the emergency department for an emotional or behavioral disorder.... In an effort to provide optimum protection, any patient deemed to be at risk for suicidal behaviors will be placed on suicide precautions. ...A. Suicide Precautions: 1. ...The psychiatric resource nurse....will be consulted to assist with the patient assessment. ...2. Any patient who verbalizes ideation-involving thoughts of self-harm or suicide will be placed on suicide precautions. ...5. In ED, ...discontinuation can only occur through a team decision of the ED PCC (Patient Care Coordinator) or Primary Nurse, and Psych Resource Nurse and then presented & approved by Suicide Prevention Team or Psychiatry PCC. ...the Psych Resource Nurse will utilize Psychiatry's suicide re-assessment scale to determine level of risk. ...the Psych Resource Nurse will also utilize Psychiatry's suicide re-assessment scale to determine risk level.... Suicidal Precautions/Risk Levels: ...C. 1:1 Suicidal Precautions: A 1:1 order may be implemented for constant observation of the patient if the patient is actively suicidal and/or attempting to inflict self-harm while hospitalized. A 1:1 order may also be necessary if the risk of injury, death, or elopement is too great to leave the patient alone for any period of time. ..."

1. Review on 06/22/2011 of an EMS call report dated 05/28/2011 (EMS Dispatch #1) revealed an ambulance was dispatched at 1901 to a residence where Patient #9 was located. Review of Paramedic documentation revealed the patient's chief complaint was "bleeding from throat" and "abdominal pain" onset 30 minutes prior to EMS arrival. Further review revealed "Arrived on the scene to find the patient sitting in the kitchen and he had a trash can between his legs and was spitting up large copious amounts of bright red blood and tissue. Large strands of tissue were accompanied with the blood. He was alert and oriented and very pale in color. Got the stretcher immediately prepared him for transport." Review of "History of Present Illness" revealed "The patient suffers from liver cirrhosis and ulcers and had been feeling fine all day and began bleeding from the throat. He was spitting copious amounts of blood and was having abdominal cramps." Review revealed an initial physical findings of distention, guarding, and tenderness to all quadrants of the abdomen. Further review revealed "Abdominal Comments: the patient complained of pain in his belly when I palpated...Abdominal Appearance: distended Abdominal palpation: hard and tender to touch." Further review revealed "Skin: clammy, pale Findings: pale and central cyanosis." Review revealed " Impression/Diagnosis...Bleeding..." Review revealed at 1912 the patient's vital signs were obtained: pulse rate of 96, blood pressure of 96 (systolic by palpated cuff), respirations 16, Pain 5/10 (0 pain free, 10 worst pain). Further review revealed "Placed the patient onto our stretcher and into our unit. Began preparing for emergency transport..." Review revealed at 1914 the patient was placed on 4 liters of oxygen via nasal cannula and "Prepared for 2 large bore IV (intravenous) due to the amount of blood loss in the house and the patient being on the verge of hypotension." Review revealed at 1915 a peripheral IV was initiated with 14 gauge IV catheter to the Right Antecubital. Repeat vital signs were obtained: pulse 94, blood pressure 104/64, respiration 16, oxygen saturation 99%, pain 5/10 (abdominal). Review revealed at 1916 IV fluids of Normal Saline was initiated at 100 milliliters per hour. Review revealed at 1917 a second peripheral IV was initiated with a 16 gauge IV catheter to the Left Forearm and IV fluids of Normal Saline was initiated at 100 milliliters per hour. Further review revealed "left the drip wide open during the entire transport (a fluid bolus)." Review revealed at 1920 repeat vital signs were obtained: Pulse 93, blood pressure 108/71, respirations 16, oxygen saturation 99%, pain 5/10. Review revealed at 1924 "Arrived at facility. The patient was still complaining of pain but had not spit up any more blood during the transport. He was still painful to palpation of the abdomen and his color was extremely pale. Placed him into ED #1. Gave report to the RN..."

Closed DED record review on 06/22/2011 for Patient #9 revealed a 50 year old male presented to the hospital's DED via ambulance on 05/28/2011 (DED Visit #1) at 1927. Review revealed the patient was triaged by a registered nurse (RN #7) at 1931. Review revealed a "chief complaint" of "GI Bleed" and a "stated complaint" of "Per EMS pt (patient) from home and c/o (complains of) vomiting large amounts of tissue and blood. Pt has HX (history) of cirrhosis and ulcers. Per EMS pt abdomen became distended and painful in route. Review revealed "General Appearance: Skin pale and yellow in color." Review revealed initial triage vital signs were obtained: blood pressure (BP) 122/69 (after fluid bolus enroute by EMS), Pulse (P) 81, Respirations (R) 18, Oxygen saturation (SpO2) 100%, and Temperature (T) 97.2. Review revealed a pain assessment was performed using a numerical pain scale of 0 (pain free) to 10 (worst pain) with a verbalized pain intensity score of 10 by Patient #9. Review revealed a pertinent past medical history of ulcers and cirrhosis. Further review revealed additional history of hypertension, alcohol abuse, anxiety depression, ulcerative colitis, and Chron's (Crohn's) disease. Review revealed the patient's home medications included Atenolol (for blood pressure) and Ambien (for sleep). The patient was assessed a triage level 2 (emergent). Review of a GI (gastrointestinal) Bleed assessment documented by RN #7 revealed a "Y (yes)" marked next to the following questions: Abdominal Pain? Epigastric? Review revealed "Description+ Sharp." Further review revealed "Amount of Blood Reported by Patient+" with a "Y (yes)" marked next to "Nausea or Vomiting Reported." Further review revealed "Description of Emesis: Pt reports vomiting blood and tissue." Review revealed "Precipitating Factors: Touching Alleviating Factors: None Constant? Y (yes)." Review revealed the following "Susp(ect) GI Bleed Standing Orders" were initiated by the nurse: complete blood count (CBC) with Differential, complete metabolic panel (CMP), PT/PTT (coagulation studies), Type & Screen, Orthostatic vital signs, cardiac monitor, continuous pulse oximetry and non invasive blood pressure monitoring. An EKG was obtained, normal sinus rhythm, pulse rate 86, abnormal EKG.

Review of nursing documentation at 1935 by RN #7 revealed "MD in room and states to get blood and give Protonix 40 mg (milligrams). Asked MD for a CT (computed tomography) Abdomen....states (Physician #4) ''that is not indicated at this time.'"

Review revealed at 1939 the patient was administered Aspirin 324 milligrams by mouth; at 1944 Protonix 40 milligrams IV push; at 2000 Morphine 4 milligrams IV push and Phenergan 12.5 milligrams IV push.

Review revealed repeat vital signs were obtained at 2000 (time Morphine and Phenergan were administered): BP 131/63, P 83, R 18, SpO2 100%, Pain Intensity of 10; at 2058 (58 minutes after Morphine and Phenergan administered): BP 136/78, P 78, R 18, SpO2 99%, Pain Intensity of 6; and at 2129 (89 minutes after Morphine and Phenergan were administered) orthostatic vital signs were obtained with a BP 100/58 (decreased), P 78, R 18, SpO2 98% while lying supine and a BP 103/57 (decreased), P 89 while standing, and a Pain Intensity of 6. (Note: the orthostatic BP obtained at 2129, after treatments, returned to baseline within 4-7 points systolic when compared to the baseline BP (96 Systolic by palpation) obtained upon EMS arrival at the residence before treatment was initiated.)

Review revealed documentation "MD to Eval(uate)" at 1936 and "MD Signup" documented at 2008. Review of an emergency department report dictated at 2133 revealed a medical screening examination (MSE) was performed by Physician #4. Review revealed a chief complaint of "Stomach hurting." Further review revealed a "History of Present Illness: This 50-year-old man began vomiting this evening. He vomited blood x2. He describes it as bright red. After the vomiting, he began having some crampy upper abdominal pain. He does have a history of ulcer disease. He also carries the diagnosis of ulcerative colitis and Crohn's disease. He has had a history of episodic alcohol abuse in the past. He tells me that he has been sober for 7-8 months. Further review revealed "Social History: ...He tells me that he has been followed by Dr. (name) for GI. I have no history of whether or not anything showed with upper GI endoscopy that he has had sometime within the last year." Review of "Review of Systems: He did note some black, tarry stool a couple weeks ago. This has cleared and the stool has been brown. He has not had any diarrhea. He had vomiting x2 with some blood in his vomitus tonight. He has had some mild tightness in his chest after vomiting as well as the crampy upper abdominal pain. All other systems are reviewed and are negative. He does carry a diagnosis of cirrhosis." Review of "Physical Examination: General: The patient is uncomfortable with crampy upper abdominal pain. He is not pale or jaundiced. He looks to have some muscle wasting, possibly from cirrhosis of the fatty nutritional variety. Vital Signs: His initial vital signs were quite stable, with a pulse of 80, blood pressure 120/70, pulse oximetry 100% on room air. ...Abdomen: Soft. He does have some mild tenderness to deep palpation in the epigastrium. There is absolutely no involuntary guarding or rebound tenderness. Bowel sounds are increased. ...Rectal: Brown stool, which is weakly positive for blood." Review revealed "Emergency Department Course: The patient was given normal saline at 200 ml per hour. I am examining him again at 2017. He is quiet comfortable. His abdominal exam is benign. I am also doing an abdominal series. At this point, I am awaiting laboratory studies. Abdominal series shows nonspecific small bowel gas. There is no evidence of perforation. Comprehensive metabolic profile showed an SGOT (liver enzyme) of 55, total bilirubin 2.5. His albumin is 3.8. The patient continues to be comfortable as of 2130. He is to take Protonix 40 mg every 12 hours. He needs to return if he is vomiting blood or dizzy while standing. At this point, I have a low index of suspicion of serious bleeding, but he will be instructed to return if he vomits red blood or is dizzy while standing. Also, his parents are in attendance at this time and they feel like he also has not been drinking for 7-8 months. The mother says that he knows if he drinks, it will kill him. Postural checks are pending. If these are insignificant, he will be allowed to go home at this point. I have written a prescription for Protonix 40 mg to take every 12 hours with some Phenergan to take for nausea and/or pain."

Review of physician's orders revealed the following diagnostic studies were ordered in addition to the "Susp GI Bleed Standing orders" initiated by the nursing staff: Abdominal Series and Lipase.

Review of Laboratory Results dated 05/28/20011 at 1945 revealed a Hematocrit of 37.8 L(ow) (reference range 41.0 - 53.0%); Hemoglobin 13.3 L(ow) (reference range 13.5 - 17.5 gm/dl); White Blood Count 13.7 H(igh) (reference range 4.5 - 11.0 K/ul); and Red Blood Count 3.84 L(ow) (reference range 4.69-6.13 M/ul).

Review of nursing documentation at 2150 by RN #8 revealed "Pt asking for more pain medication prior to discharge. Dr. (Physician #4) notified. Family remains at bedside. Pt P.W.D. (pink, warm, dry), A&O (alert and oriented) Resp(irations) even and unlabored."

Review of nursing documentation at 2153 by RN #8 revealed Dr. (Physician #4) gave RX (prescription) for Percocet. Pt given RX and D/C (discharge) paperwork and informed to return to ED if symptoms worsen or new symptoms develop."

Review of the "Discharge Home Med(ication) List" revealed the patient was discharged home on Protonix 40 milligrams by mouth every 12 hours and Phenergan 50 milligrams by mouth every four hours as needed for nausea.

Review of Discharge Assessment documentation by RN #8 at 2215 revealed the patient was discharged with a BP of 100/58 (decreased from triage baseline of 122/69), P 78, R 18, SpO2 98%, T 97.1, and a Pain Intensity of 6.

Record review revealed a diagnosis of Alcoholism by History. Further review revealed the patient was given instructions for Family Practice List, Phenergan, Alcohol Abuse, and Alcoholism. The patient was given additional instructions for a Light Diet, Return if vomiting blood or passing red blood clots or black stool. Follow up with your regular doctor for a recheck. The patient departed the DED at 2215.

Review on 06/22/2011 of an EMS call report dated 05/29/2011 (EMS Dispatch #2) revealed an ambulance was dispatched at 0302 to a residence where Patient #9 was located. Review of Paramedic documentation revealed the patient's chief complaint was "bleeding" onset 15 minutes prior to EMS arrival. Further review revealed "Arrived on the scene to find the patient in the bathroom on his knees. There was extremely large amounts of blood on the patient, the floor, the toilet and walls of the bathroom. The patient had a large blood soaked towel underneath him. There was blood coming from his nares and his mouth and his anus. He was begging us to save him. His mother and father were hysterical. Review of a history of present illness revealed "The patient had been released from the hospital earlier for bleeding ulcers. The patient began vomiting blood again and also anal bleeding also. The mother dialed 911." Review revealed the patient was Alert with bleeding noted from mouth and anus. Review of "Initial Physical Findings" revealed ...Abdominal Appearance: distended Abdominal Palpation: hard and tender Pelvis: Bleeding, Heavy Findings: copious amounts of bright red blood coming from the anus....Skin: Cold, Cyanotic, Pale..." Review of a "Impression/Diagnosis ....Bleeding..." Review revealed at 0312 "Got the patient onto our stretcher and he then displayed projectile vomiting of blood. Copious amounts of blood and tissue was running out of his mouth and his anus. ...The patient continued to vomit copious amounts of blood. The patient displayed a feeling of impending doom." Review revealed at 0319 a BP of 80 systolic by palpated cuff was obtained, R 20, Pain 10/10. Further review revealed the patient was placed on high flow oxygen via non-rebreather mask. An IV was established via 18 gauge catheter and normal saline was initiated at 300 milliliter bolus. Review revealed at 0323 a BP 106/64 and P 107 was obtained. Review revealed at 0327 "The patient was loosing large amounts of blood and kept begging for us to save him. There was blood flowing off of the stretcher onto the floor of the unit." Review revealed at 0329 "Arrived on the scene of the Hospital and placed him into ED #18. He was still vomiting profusely copious amounts of blood upon our arrival. ..."

Closed DED record review on 06/22/2011 for Patient #9 revealed a 50 year old male presented to the hospital's DED via ambulance on 05/29/2011 (DED Visit #2) at 0333. Review revealed the patient was triaged by a registered nurse (RN #9) at 0340. Review revealed a "chief complaint" of "GI Bleed, Esophageal Varacises (Varices)" and a "stated complaint" of "Per EMS: Pt from home, was here earlier tonight with coughing up/vomiting blood, Recently tonight has been having increased vomiting of blood ('Projectile') and copious rectal bleeding, also weak." Review revealed "General Appearance: Appears lethargic, skin pale/cool/dry, cap refill on toes 5 secs (seconds), oriented to person/place, garbled speech noted. Maintaining airway, no work of breathing noted." Review revealed initial triage vital signs were obtained: BP 36/29 (hypotensive), P 112 (tachycardia), R 16, SpO2 94%. Review revealed a pain assessment was performed using a numerical pain scale of 0 (pain free) to 10 (worst pain) with a verbalized pain intensity score of 5 by Patient #9. Review revealed a pertinent past medical history of Esophageal Varices. Further review revealed additional history of hypertension, alcohol abuse, anxiety depression, ulcerative colitis, and Chron's (Crohn's) disease, and Esophageal Varices. The patient was assessed a triage level 2 (emergent).

Review of nursing documentation at 0343 by RN #9 revealed "Pt has been vomiting copious amts (amounts) blood, projectile, going about 2 feet." Review of nursing documentation at 0351 by RN #9 revealed "Pt states he stopped drinking a week ago." Review of nursing documentation at 0410 by RN #9 revealed "...Pt intermittently moaning/yelling/grimacing. Verbalizes that he would want to have all measures taken to save his life if needed...."

Review of an emergency department report dictated at 0508 revealed a medical screening examination (MSE) was performed by Physician #4 upon the patient's arrival via EMS. Review revealed a chief complaint of "This is a 50-year-old white male brought in by EMS with a chief complaint of vomiting blood, as well as bright red blood per rectum." Further review revealed a "History of Present Illness: The patient was apparently seen here in the emergency department earlier this evening with history of vomiting blood. At that time he did not appear to be actively bleeding. He was discharged home. After discharge, early this morning, he began profusely vomiting apparently dramatic amounts of blood at home, passed bright and dark red blood per rectum as well. EMS was called. Upon their arrival he had initial blood pressure of 80/palp(ation). He was tachycardic. He was transported here for further evaluation and management. Reviewing the patient's dictation from earlier this evening, as well as other past medical history on the Meditech medical records reveals that on CT scan of the abdomen and pelvis late 2010, the patient was noted to have large esophageal varices. He does have a history of alcohol abuse in the past, although he apparently also has a history of peptic ulcer disease, ulcerative colitis, and Crohn disease. Review revealed "Review of Systems: Unable to be obtained secondary to the patient's critical illness."

Review revealed "Physical Examination: General: This is a well-nourished, thin white male in extremis. He is pale, clammy, actively vomiting bleeding, covered in blood essentially from head to toe. HEENT (head, ears, eyes, nose, throat): ...Conjunctivae exceedingly pale. Oropharynx is clear with pale mucous membranes. Blood throughout the oropharynx. ...Cardiovascular: Tachycardic. Weakly palpable radial pulses and central pulses. Abdomen: Soft, flat, tender in the epigastrium. No rebound or guarding. Extremities: ...Delayed capillary refill time. Skin: Cool, pale, moist. Dark and bright red blood, predominantly nonclotted with some clots covering the patient's entire body. Neurologic: Awake, alert, anxious, nonfocal. ...Assessment: 1. Acute, severe gastrointestinal bleed secondary to #2. 2. History of esophageal varices. 3. Shock. 4. Acute blood loss anemia. Plan: The patient has been transfused with 2 units of packed red blood cells stat, as well as normal saline 2 L (Liter) bolus started stat. He was also treated with Protonix 40 mg IV, Octreotide 100 mcg (micrograms) bolus and 50 mcg per hour drip has been started on the patient. After 2 units of packed red blood cells and starting a second pair of 2 units of packed red blood cells, the patient's blood pressure still is in the 50s systolic. He remains tachycardic. He is becoming less responsive. Given this, he was started on Levophed drip titrating to a systolic blood pressure of 80 mmHg (millimeters mercury). It is felt that the patient requires endotracheal intubation and mechanical ventilation secondary to his shock and lack of adequate airway protective reflexes with his active vomiting.

Laboratory Evaluation: ...CBC: He has a white count of 15.4 , H&H (hemoglobin and Hematocrit) of 8.0 and 22.6 and this is significantly down form 13.3 and 37.8 earlier this evening (DED Visit #1)..." Further review revealed "The patient had multiple large IV lines placed. A central line was placed by anesthesiologist. The patient is receiving massive transfusion. Upon noting his PT/INR of 2.4, fresh frozen plasma 2 unites IV has been ordered stat as well. The case has been discussed with Dr. (Physician #6), hospitalist on call, who has admitted the patient to the intensive care unit for further evaluation and management. I have a page in to Dr. (name) and currently awaiting his return call. The patient remains in critical condition. Final Assessment: 1. Acute upper gastrointestinal bleed, likely secondary to #2. 2. History of esophageal varices. 3. Acute severe blood loss anemia. 4. Shock. 5. Respiratory insufficiency. 6. Coagulopathy. ..." Record review revealed the patient was transferred to the hospital's inpatient Critical Care Unit at 0615.

Review of a Discharge Summary dictated on 05/30/2011 at 0648 by Physician #6 revealed "Date of Admission: 05/29/2011 Date of Death: 05/29/2011 Time of Death: 10:29 a.m. Cause of Death: Massive GI bleed secondary to esophageal varices caused by hepatic cirrhosis secondary to alcohol abuse. The patient was a 50-year-old white male with a history of alcohol abuse who had abstained for about the last year. He presented to the emergency room with a couple of episodes of vomiting bright red blood. His Hematocrit was stable. The bleeding resolved and he was discharged. He did represent later that day with massive bleeding and asanguination. He was intubated, stabilized with 6 units of blood, and was transferred to the ICU for further work up and treatment. GI was contacted and Dr. (name) did an emergent EGD (esophagogastroduodenoscopy) at that time sclerotic agent ethanolamine was injected. Variceal banding was done distally, but the bleeding was not able to be controlled. The patient received a total of 12 units of paced red cells, 4 units of fresh frozen plasma, IV vitamin K. The patient's condition continued to deteriorate with hypotension, continued bleeding. The deteriorating condition was discussed with the patient's parents who made him a comfort care measure. He (Patient #9) expired at 10:29 a.m. in the ICU..."

Telephone interview on 06/22/2011 at 1430 with RN #7 revealed she was the primary care nurse for Patient #9 when he presented to the DED on 05/28/201 at 1927. Interview revealed she also triaged the patient upon his arrival by EMS. Interview revealed she recalled the "EMS workers were frantic." Interview revealed EMS reported the patient vomiting a large amount of blood and tissue in the trash can at the patient's residence. Interview revealed the patient was alert when he arrived at the DED. Interview revealed she does not recall the patient having blood on his clothes or face. Interview revealed the patient looked pale and yellow in color. Interview revealed she went and notified Physician #4 and he came and evaluated the patient. Interview revealed the patient's vital signs were stable at triage. Interview revealed the patient's abdomen was distended. Interview revealed she asked Physician #4 if he wanted to order a CT of the abdomen but he told her that a CT was not indicated, but he would order abdominal x-rays. Interview revealed the patient did not have any active vomiting while in the DED. Interview revealed the patient had blood work and x-rays performed. Interview revealed she spoke with Physician #4 about admitting the patient to observation due to his history and EMS's report of copious amounts of blood and tissue seen at the patient's residence. Interview revealed Physician #4 stated there was no indication for the patient to be admitted his orthostatics were negative, he had no active vomiting, and the abdominal x-ray was negative. Interview revealed the patient was to be discharged. Interview revealed "my gut said something was not right." Interview revealed the patient's mother and father were present in the DED. Interview revealed she and Physician #4 were made aware of the patient's history of esophageal varices prior to discharge by the family members. Interview revealed she was not the nurse that discharged the patient from the DED.

Interview on 06/22/2011 at 1420 with RN #8 revealed she did not remember the patient. Interview revealed according to medical record documentation she was the nurse who discharged Patient #9 on 05/28/2011 at 2215. Interview revealed the patient was alert and oriented, pink, warm, dry, and respirations even and unlabored at the time of discharge. Interview revealed the patient's discharge vital signs were stable. Interview revealed the patient requested additional pain medications prior to discharge but Physician #4 did not order any additional pain medications. Interview revealed he wrote a prescription for Percocet instead. Interview revealed the patient had no active vomiting at the time of discharge. Interview revealed the patient was discharged at 2215.

Telephone interview on 06/29/2011 at 1656 with Physician #4 revealed he was the DED physician who performed the MSE on Patient #9 during visit #1 (05/28/2011). Interview revealed the patient presented with a normal blood pressure and pulse and was not actively vomiting blood. Interview revealed "I was aware of EMS's descriptive report, but it was not what I saw in the ED on exam." Interview revealed the patient was having epigastric pain and he (Physician #4) was more concerned about the patient's pain than the bleeding, he was concerned the patient may have perforated his bowel so he ordered an abdominal series and lab work. Interview revealed the abdominal series was negative and the H&H was unremarkable. Interview revealed he was aware the patient had a history of cirrhosis, alcoholism, and ulcerative colitis, and ulcers. Interview revealed "you treat the presumptive disease" and my impression was the patient had gastritis versus ulcers. Interview revealed "the pain was more important as a symptom than bleeding." Interview revealed the patient had a benign exam. Interview revealed "Unfortunately patients with esophageal varices can bleed and die." Interview revealed if the patient had unstable vital signs and had been actively bleeding he would not have discharged him home. Interview revealed a NG (nasogastric tube) was not ordered to check for bleeding because of the increased risk of bleeding in patients with esophageal varices and cirrhosis upon insertion of the NG tube. Interview revealed at the time he was unaware the patient had a history of esophageal varices. Interview revealed he was aware the patient had an upper GI endoscopy performed in the past but did not know the results. Interview revealed at the time the patient was discharged "his emergency medical condition was stable and resolved."

Interview on 06/23/2011 at 0845 with Physician #5 revealed he was the DED physician who performed the MSE on Patient #9 during visit #2 (05/29/2011). Interview revealed the patient presented hemodynamically unstable and actively bleeding. Interview revealed due to the way the patient presented he reviewed the patient's previous DED record for visit #1 and then researched the patient's past medical history in the computer (electronic medical records). Interview revealed he "happened to run across a CT report" from late 2010 that confirmed the patient had esophageal varices. Interview revealed esophageal varicies are not found on physical examination. Interview revealed they are usually diagnosed by endoscopy. Interview revealed the patient was in critical condition, treated, and admitted to the intensive care unit. Interview revealed after review of the DED record for visit #1, the patient presented with stable vital signs and the patient was not showing active signs of bleeding. Interview revealed excessive coughing, vomiting, or valsalva maneuvers can increase a tear in an esophageal varicies that has previously clotted. Interview revealed with the signs and symptoms documented in visit #1, it sounded like gastritis or a peptic ulcer type disease. Interview revealed without knowing about the history of esophageal varices the treatment the patient received during visit #1 appeared appropriate. Interview revealed EMS personnel usually give a verbal report to the nursing staff upon arrival to the DED and the RN documents in the record and then notifies the physician, unless the physician is present when EMS arrives and gets a first hand report. Interview revealed he has never seen a printed EMS call report on a DED record. After review of the EMS call report for visit #1, interview revealed if the DED physician for visit #1 had known of the profuse bleeding noted by EMS at the patient's residence, he may have ordered observation for a few more hours, repeat H&H's and may not have discharged the patient home.

Interview on 06/23/2011 at 0923 with Physician #1, the DED medical director, revealed he was aware of the outcome of Patient #9. Interview revealed the DED records of patients who return within 48 hours after discharge are reviewed. Interview revealed according to documentation in the DED record for visit #1 (05/28/2011 at 1927) the patient appeared stable based upon the patient's blood pressure, pulse and hemoglobin. Interview revealed there was no evidence of significant bleeding while in the DED. Interview revealed the patient's bleeding was thought to be more likely benign in nature. Interview revealed the patient had a history of ulcers. Interview revealed he believed Physician #4 thought the patient's bleeding was from an ulcer and treated him accordingly. Interview revealed the patient was discharged from the DED. Interview revealed the patient had a history of alcohol abuse and cirrhosis. Interview revealed the patient was at increased risk for developing esophageal varices. Interview revealed there was no documentation in the DED record for visit #1 the patient had a history of esophageal varices. Interview revealed a history of esophageal varicies was documented in the DED record for visit #2 (05/29/2011 at 0333) by the triage nurse and Physician #5. Interview revealed the physicians are able to look up a patient's past medical hist

Based on policy review, emergency medical services call reports, closed medical record review, staff and physician interviews the hospital's Dedicated Emergency Department (DED) failed to provide stabilizing treatment within it's capability and capacity for 1 of 5 sampled DED patients that were transferred with an unstable emergency medical condition (#14); and failed to provide stabilizing treatment within it's capability and capacity for 1 of 1 sampled DED patients that eloped from the DED with a psychiatric emergency medical condition (#5).

The findings include:

1. Review of current hospital policy CC-3 "SUBJECT: PATIENT TRANSFER TO ANOTHER ACUTE CARE FACILITY" reviewed 12/03/2008, revealed "...POLICY DETAIL 1. EMERGENCY TRANSFER ...C. Physicians and other qualified personnel....initiating patient transfer should comply with applicable state and federal regulations regarding patient transfer. A medical screening exam....utilizing any/all ancillary services routinely available to the emergency department, will be performed by a physician or other qualified personnel....to determine whether or not an emergency medical condition exists. * If an emergency medical condition is determined to exist that requires the services of an on-call specialist, the on-call specialist must respond within a reasonable time frame. * For the purposes of this policy, the Medical Executive Committee has determined that a 30-minute response time is reasonable for unstable patents with emergency medical conditions. ...D. The patient should be transferred to another facility only after and emergency medical screening examination and, when possible, stabilization. Stabilization includes evaluation and initiation of treatment to ensure, within reasonable medial probability, that transfer of a patient will not result in death or in loss or serious impairment of bodily function, parts or organs. ..."

Closed dedicated emergency department (DED) record review on 06/22/2011 for Patient #14, revealed a 67 year old female who presented via family vehicle to Hospital A's DED on Monday, 04/25/2011 at 0755. Review revealed the patient was triaged at 0806 by a registered nurse. Review of triage nurse documentation revealed a chief complaint of Chest/Heart and a stated complaint of Chest Pain, Left arm pain, and Shortness of Breath. Further review revealed "C/ (complains) Mid Chest Pain and Pain down left arm since 7 AM Today. Denies HX (history). Heart problems." Review of the triage nurse's assessment revealed "General Appearance: Alert with skin warm and dry." Review revealed a blood pressure (BP) of 149/92, pulse (P) of 67, respiration (R) rate of 20, oxygen saturation (SpO2) of 98% on room air, Temperature (T) of 96. Further review revealed a pain assessment was performed using a numerical pain scale of 0 (no pain) to 10 (worst pain) with a verbalized pain intensity of 5 by the patient. Review revealed the patient was assigned a triage level of Priority 2 (Emergent). Review of the "Chest Pain Assessment" documented by a RN revealed the patient's chest pain was described as dull, midchest, and constant. The patient had shortness of breath, denied nausea and vomiting. The patient's lung sounds were clear, skin was warm and dry. Review revealed the patient was placed on a cardiac monitor, blood pressure monitor, continuous pulse oximetry monitor. The patient was placed on O2 at 2 liters per minutes via nasal cannula.

Review of nursing documentation by a RN at 0810 revealed "EKG was done on (Patient #14) and shown to Dr. (Physician #1). No new orders received." Review revealed an ECG (electrocardiogram) was performed at 0811. Review of the ECG revealed "...ST elevation consider inferior injury or acute infarct *** ** ** ** * ACUTE MI ** ** ** ** Abnormal ECG..." Review of nursing documentation by a RN at 0815 revealed "Code STEMI activated." Review revealed the patient received Aspirin 81 milligrams (4) by mouth at 0815, Nitroglycerin one tablet sublingual at 0816 and 0820. Review revealed intravenous (IV) fluids of normal saline were initiated at 250 milliliters per hour. Review revealed repeat vital signs were obtained at 0815: BP 113/57, P 66 (sinus rhythm), R 16, SpO2 100% on oxygen (O2), Pain Intensity of 5 and at 0825: BP 95/57, P 55 (bradycardia), R 16, SpO2 100% on O2, Pain Intensity of 5. Review of nursing documentation by a RN at 0830 revealed "EMS here and transported patient to (Hospital B)..." Review of nursing documentation by a RN at 0832 revealed "Report to (name) at (Hospital B) cath lab, pt out the door." Review of discharge assessment documentation by a RN revealed at 0842 the patient's BP was 95/57 (decreased), P 55 (bradycardia), R 16, SpO2 100% on O2, and a Pain Intensity of 5 (unchanged) upon transfer to Hospital B.

Review of a Emergency Department Report dictated on 04/25/2011 at 0902 by Physician #1 revealed "Chief Complaint: The patient came to the emergency department with chest pain. I was shown the EKG and a couple of minutes later went to see the patient . The patient started having pain, it began at 0700 this morning. It is substernal, associated with some nausea and sweating. No shortness of breath. She has not had pain like this before. Denies any recent exertional pain. ...Exam: She is alert and talkative, does not appear ill or uncomfortable... Cardiac: Regular rate and rhythm, no murmur. Pulmonary: No wheezes, rhonchi or rales. ...Skin: Warm and Dry. ...Further review revealed "EKG shows ST elevation inferior leads consistent with inferior MI." Review revealed "Diagnosis: Inferior MI." Further review revealed "The Cath Lab was called here at our hospital. There was no answer. We then immediately activated STEMI (Code STEMI). EMS was already here, they had just brought another patient. They were available for transfer and the patient will be transferred to (Hospital B). EKG reviewed now shows ST depression in lead I, aVL, V1, and V2, ST elevation as much as 5-6 mm (millimeters) in lead 2, 3, and aVF. ...Original BP was 149, just before transfer it was 95, however she had been given some nitroglycerine. Somebody was called. I did not get a call back from the cardiologist as the patient was being transferred soon after I saw her. Diagnosis: Acute Inferior MI. PLAN: Transfer to (Hospital B) for emergent PCI (Percutaneous Coronary Intervention also known as PTCA)."

Record review revealed no diagnostic studies (lab or radiology) were ordered on the patient while in the DED on 04/25/2011 with the exception of an ECG prior to transfer to Hospital B.

Review of the "Patient Transfer to Another Acute Care Facility" form (physician's certification) dated 04/25/2011 at 0820 revealed "I. MEDICAL CONDITION: Diagnosis MI (hand written on a line) ...[x marked in box] Patient Unstable - An EMC Identified: The patient has been examined, an EMC has been identified and patient is not stable, but the transfer is medically indicated and in the best interest of the patient.: Further review revealed "...II REASON FOR TRANSFER: ...[x marked in a box] Medically Indicated: When medically indicated, check appropriate box below: ...[x marked in a box] Service Not Available: Explain Emergent PCI (hand written on line)." Further review revealed "III RISK AND BENEFITS FOR TRANSFER: ...Risks: Fatal Arrythmia (hand written on a line) Benefits: PCI (hand written on a line)... Review revealed "...RECEIVING FACILITY AND INDIVIDUAL: ...Full name & title of person accepting transfer for facility: (Physician #7 name hand written on a line). Further review revealed " Date: 04/25/2011 (hand written on a line) Time: 0820 (hand written on a line) Transferring Provider Signature: (Physician #1 hand written signature on a line)."

Closed record review from Hospital B on 04/23/2011 for Patient #14, revealed the patient was transferred to Hospital B from Hospital A and taken emergently to the cardiac catheterization lab on 04/25/2011, arriving at 0843. Review revealed the patient underwent a left heart catheterization and PTCA, Stent and Thrombectomy. Review revealed the procedures were performed by Physician #7. Review revealed post-procedure the patient was transferred to a telemetry unit to recover and was discharged on 04/28/2011 with a diagnosis of inferior wall myocardial infarction, status post percutaneous coronary intervention of the right coronary artery.

Review of a current "DIAGNOSTIC ANGIOGRAPHY SERVICES DEPARTMENT (Operations)" document (not dated) revealed "I. Scope of Service The Diagnostic Angiography Services Department offers the following services: ...PTCAs (Percutaneous transluminal coronary angioplasty)...A board-certified....Cardiologist is present for all procedures. ...III. Staffing Plan Department hours are Monday through Friday 7:30 a.m. to 4:00 p.m. Emergency or urgent procedures are done during the remaining hours through the use of a call team. ..."

Review of current hospital policy P-30 "Hours of Operation" reviewed 09/27/2010, revealed "SUBJECT: Hours of Operation ...II. POLICY DETAIL Percutaneous transluminal coronary angioplasty (PTCA) can only be offered 5 days a week, Monday through Friday during the hours of 7:30 AM until 4:00 PM according to the LLC agreement with (Hospital B)."

Review of a current DED form (not dated) titled, "STEMI (ST Elevation Myocardial Infarction)" revealed "If 8am to 4pm Monday through Friday call (Hospital A) Cath Lab first at 3###. They will let you know whether they can take the patient. If not: ER MD Call (Hospital B) at 1-866-###-####: Info needed: Patient Name, DOB, Cardiologist..."
Review of the DED Speciality On-Call schedules for Cardiology for Monday, April 25, 2011 revealed Physician #2 (interventional cardiologist) was scheduled on-call for "STEMI-Call" when Patient #14 presented to the DED of Hospital A at 0755.

Review of "time card" documentation for Hospital A, revealed nine (9) Diagnostic Angiography Services Department (Cath Lab) staff were on duty in the department on 04/25/2011, of which (8) eight were on duty prior to Patient #14 presenting to Hospital A's DED at 0755.

Review of Hospital A's "Cath Lab Procedure Log" (schedule) for 04/25/2011, revealed case #11-203 was the first case scheduled for 04/25/2011. Closed record review for case #11-203 revealed the patient was picked-up from her room at 0944 and transported to the Cath Lab, arriving at 1010 (3 hours and 15 minutes after Patient #14 presented to the DED).

Interview on 06/23/2011 at 0955, with Physician #1 revealed he was the DED physician on duty at Hospital A on 04/25/2011 when Patient #14 presented at 0755. Interview revealed the patient presented with a ST elevated Myocardial Infarction (STEMI). Interview revealed patient's that have a STEMI should have a cardiac catheterization and PCI procedure done with-in 90 minutes of arrival to the DED. Interview revealed that is generally the standard time frame. Interview revealed on 04/25/2011, the DED staff called the cath lab number and there was no answer. Interview revealed a Code STEMI was activated. Interview revealed EMS was present in the DED and were available to transfer the patient to Hospital B. Interview revealed he completed and signed the transfer forms. Interview confirmed the documentation by Physician #1 in the record "Somebody was called. I did not get a call back from the cardiologist as the patient was being transferred soon after I saw her." Interview revealed "I did not talk to anyone, the cardiologist did not call me back." Interview revealed Hospital A did have a interventional cardiologist on-call (Physician #7) for STEMIs on 09/25/2011. Interview revealed he did not contact Physician #7. Interview revealed the patient was transferred to Hospital B and who ever the interventional cardiologist was at Hospital B would take care of the patient. Interview revealed Hospital A has one cath lab. Interview revealed when the cath lab is unavailable the patients are transferred to Hospital B. Interview revealed the two hospitals have an agreement. Interview revealed Physician #1 did not know why the cath lab did not answer the telephone on 04/25/2011 when called. Interview revealed he did not go to the cath lab to check for it's availability. Interview revealed he is unaware if any DED staff went to the cath lab to verify it's availability.

Telephone interview on 06/23/2011 at 1035, with Physician #2 revealed he was the interventional cardiologist on-call for Hospital A's DED for STEMI call when Patient #14 presented on 04/25/2011 at 0755. Interview revealed he does not recall getting a call or being paged on the morning of 04/25/2011 for a STEMI in the DED. Interview revealed if he would have received a call "he would have done the procedure."

Interview on 06/22/2011 at 1100 with the Cath Lab Nurse Manager for Hospital A revealed the hospital had only one room to preform procedures in and there is no on-site surgical (open heart) procedures done at the Hospital. Interview revealed there was no receptionist for the Cath Lab. The Cath Lab staff would answer any phone calls or the phone would roll over to the receptionist at the X-Ray Dept.

Follow-Up interview on 06/23/2011 at 0900 with the Cath Lab Nurse Manager for Hospital A revealed there was no patient scheduled for a procedure prior to case 11-203 on 09/25/2011 and that they could have performed the PCI/PTCA procedure on Patient #14. Interview revealed the Cath Lab was in the same building as the DED and to walk from one department to the other would take no more than 3 minutes. Interview revealed the hospital has no formal, written policy for Code STEMI. The only document that refers to STEMI is the form (not dated) titled, "STEMI (ST Elevation Myocardial Infarction)" that hangs on the department wall.

Consequently, the findings revealed at the time Patient #14 presented to the DED of Hospital A on 04/25/2011 at 0755 and at the time of transfer to Hospital B at 0832, the cardiac cath lab and STEMI on-call cardiologist for Hospital A were available to perform the emergency PCI (PTCA) to stabilize Patient #14 prior to transfer.



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2. Review of current hospital policy PC-25, "SUBJECT: SUICIDE PRECAUTIONS/RISK LEVEL SYSTEM" dated 03/07/2011, revealed "PURPOSE To reduce the risk of harm to self or others for the patient with suspected or known suicidal ideation. ...IMPLEMENTATION This policy applies to....patients who are treated in the emergency department for an emotional or behavioral disorder.... In an effort to provide optimum protection, any patient deemed to be at risk for suicidal behaviors will be placed on suicide precautions. ...A. Suicide Precautions: 1. ...The psychiatric resource nurse....will be consulted to assist with the patient assessment. ...2. Any patient who verbalizes ideation-involving thoughts of self-harm or suicide will be placed on suicide precautions. ...5. In ED, ...discontinuation can only occur through a team decision of the ED PCC (Patient Care Coordinator) or Primary Nurse, and Psych Resource Nurse and then presented & approved by Suicide Prevention Team or Psychiatry PCC. ...the Psych Resource Nurse will utilize Psychiatry's suicide re-assessment scale to determine level of risk. ...the Psych Resource Nurse will also utilize Psychiatry's suicide re-assessment scale to determine risk level.... Suicidal Precautions/Risk Levels: ...C. 1:1 Suicidal Precautions: A 1:1 order may be implemented for constant observation of the patient if the patient is actively suicidal and/or attempting to inflict self-harm while hospitalized. A 1:1 order may also be necessary if the risk of injury, death, or elopement is too great to leave the patient alone for any period of time. ..."\

Closed DED record review on 06/22/2011 for Patient #5 revealed a 40 year old male who presented via ambulance to the DED of Hospital A on 03/04/2011 at 0715. Review revealed the patient was triaged by a registered nurse (RN #5) at 0735. Review of triage nurse documentation revealed the patient's "chief complaint" was Psychiatric and the patient's "stated complaint" was suicidal ideation. Further review revealed "Brought by EMS for ETOH (alcohol) use and suicidal ideations states jumped in front of train this am (morning) but train only clipped him no injuries noted states today is a good day to die HX (history) of suicidal gestures by cutting and overdose denies any recent episodes of overdose or cutting." Review of the triage nurse's assessment revealed a general appearance "Alert but not oriented to day or date ambulatory fine motor skills intact rambling speech patterns." Review revealed a blood pressure of 158/98, pulse of 89, respiration rate of 18, oxygen saturation of 99% on room air. Further review revealed a pain assessment was performed using a numerical pain scale of 0 (no pain) to 10 (worst pain) with a verbalized pain intensity of 6 by the patient. Review revealed a past medical history of Manic Depressive Disorder, Alcoholism, Panic Attacks, Visual Hallucinations and Bipolar Disorder. Review revealed the patient was assigned a triage level of Priority 2 (Emergent) and was placed on suicide precaution "Level One (does not require 1:1 Suicidal Precautions, requires observation/monitoring every 15 minutes)." Record review revealed the patient was actively suicidal upon triage to the DED.

Review of nursing documentation by RN #5 at 0732 revealed "Pt (patient) is deshelved (disheveled), clothing dirty and stained and smell of alcoholic beverage he is alert and oriented X 2 (normal is AOX4) and ambulatory with steady gait....Inappropriately touching staff members..." Review of a Psychiatric Assessment documentation by RN #5 at 0740 revealed "Patient complaint:" with a "Y (yes)" marked next to the following questions: Anxiety? Depression? Insomnia? Panic Attack? Heart Racing? Shortness of Breath? Agitation/behavioral problems? Further review revealed "Y (yes)" marked next to Suicidal Ideation? Plan/Attempt? Further review revealed "How: Stand in front of train." Review revealed a "Y" marked next to History of overdose/suicide attempt? Alcohol Intoxication? Last drink: "Two hours ago."

Review of "Psychiatric Check in Screen" documentation by RN #5 at 0743 revealed the patient was placed in paper scrubs and the patient's belongings were inventoried to include gray pants, gray T-shirt and black shoes. Review revealed the belongings were removed from the patient's room and placed in a locker.

Review of documentation by the Psychiatric Resource Nurse (RN #6) at 0818 revealed "Psych(iatric) Resource Note: Pt tearful, strong smell of alcohol. Does not remember anything about why he is here. Will re-evaluation when sober. Dr. (Physician #3) updated."

Record review revealed documentation "MD to Eval(uate)" at 0743 and "MD Signup" documented at 0843. Review of a emergency department report dictated at 1200 revealed a medical screening examination (MSE) was initiated by Physician #3. Review revealed a chief complaint of "I need help." Further review revealed a "History of Present Illness: The patient claims he stepped in front of a train and it clipped him this morning....He claims he is going to kill himself with alcohol. he has been meaning to step in front of a train for a long time. ...Past Medical History: The patient was admitted here for acute alcohol intoxication with encephalopathy and delirium tremens on 01-25-11. He has a long history of alcohol abuse. ...Physical Examination: ...The right lower leg has two very small contusion. No significant tenderness. ...Psychiatric: His speech is slurred but he is alert. He is smiling but is intoxicated. Lab work is pending. ...Alcohol level is 315. it was drawn at 09:18 this morning. ..."

Review of a physician's order sheet revealed Physician #3 ordered laboratory studies on Patient #3 to include a complete blood count, complete metabolic panel, lipase, urine drug screen, and a blood alcohol level. Review of a "Medical Record Report - Laboratory Results" form dated 03/04/2011 at 0918 revealed an ethyl alcohol level of 315 (high), reference range (0-80) milligrams/deciliter.

Further review of MSE documentation by Physician #3 revealed "...At 11:00 a.m. I was notified that the patient would like to leave. At 11:05 a.m. he was not in his room. At 11:30 a.m. we were still unable to locate the patient. We will (have) hospital security look for him as well. He has apparently taken his clothes and left without notice. His initial alcohol level was high. He was mentating normally with me when I saw him. Diagnosis: 1. Alcohol Abuse 2. Left the Emergency Room without notice."

Review of documentation by RN #5 at 1006 revealed "...Has voiced desire to leave." Review of documentation by RN #5 at 1040 revealed Dr. (Physician #3) informed that patient wants to leave demanding belongings, belongings removed from locker and placed at desk." Review of documentation by RN #5 at 1112 revealed Dr. (Physician #3) aware of pt possible left AMA (against medical advice). Further review revealed "Pt not in room or lobby at this time. Review of documentation by RN #5 at 1113 revealed "Paged overhead, not in lobby or room at this time." Review of documentation by RN #5 at 1122 revealed "Campus Police notified to look for pt."

Review of a "Emergency Department: Suicide Precautions Observation Record" dated 03/04/2011 revealed the patient was placed in DED treatment room #9. Further review revealed documentation of every 15 minute monitoring by nursing staff from 0745 until 1115. Review revealed at 0745 and 0800 the patient's behavior was documented as Restless/Fidgety. From 0815 until 1000 the patient's behavior was documented as calm/appropriate. Further review revealed from 1015 to 1100 the patient's behavior was documented as Restless/Fidgety. At 1115 the patient's behavior was documented as "Other - Not in room/lobby." Record review revealed 60 minutes prior to the patient eloping from the DED (unwitnessed), the nursing staff documented the patient's behavior as being restless and fidgety, and that the patient verbalized a desire to leave, then demanded to leave at 1006 and 1040 respectively.

Telephone interview on 06/22/2011 at 1150 with Physician #3 was the DED attending physician who initiated the MSE on Patient #5 on 03/04/2011. Interview revealed patient's with suicidal ideation are assessed for their risk of suicide and evaluated for any underlying medical conditions. Interview revealed "somebody who is suicidal , we do not let walk out." Interview revealed the DED physician does not always consult a psychiatrist for patients with psychiatric complaints. Interview revealed the hospital has psychiatric resource nurses who come to the DED and evaluate the patient's psychiatric complaints and risk of suicide. Interview revealed the DED physician will evaluate the patient and make a disposition. Interview revealed he does not know if a psychiatric resource nurse evaluated the patient's risk of suicide prior to his elopement on 03/04/2011. Interview revealed a blood alcohol level of 315 is considered high. Interview revealed the patient would be intoxicated. Interview revealed the patient's blood alcohol level would have been high when he eloped. Interview revealed he does not know if the patient was suicidal when he eloped. Interview confirmed the ongoing MSE was not completed when Patient #5 eloped from the DED. Interview confirmed the patient's EMC was not resolved nor had been stabilized when the he eloped.

Interview on 06/22/2011 at 1300 with RN #6, revealed she was the Psychiatric Resource Nurse on duty when Patient #5 presented to the DED on 03/04/2011. Interview revealed the Psychiatric Resource Nurses are available 24 hours per day. Interview revealed she remembers the patient because "he walked out." Interview revealed she was called by the DED staff to come and evaluate the patient for his psychiatric complaint and suicidal ideation. Interview revealed the patient was "so drunk" he could not form sentences and was slurring his speech. Interview revealed she was unable to perform an accurate assessment of the patient's psychiatric complaint and suicide risk. Interview revealed she was unable to determine if the patient was suicidal. Interview revealed the patient was to be kept on suicide precautions until he sobered up and she could return and complete an accurate suicidal risk and psychiatric assessment. Interview revealed before she was able to return to the DED, she checked the computer and noticed the patient had been "taken out" of the computer. Interview revealed she contacted the DED staff and was informed the patient had "walked out." Interview revealed when the patient voiced to the DED staff that he wanted to leave, she should have been notified by the DED staff so she could return and evaluate the patient's risk for suicide. Interview revealed if the patient had continued to want to leave and her assessment found the patient to be at risk for suicide she would have recommended to the DED physician the patient be admitted to the inpatient psychiatric unit for further treatment and stabilization under involuntary commitment. Interview revealed "the patient should not have been allowed to leave." Further interview revealed the DED staff's documentation of the patient's behavior as being restless and fidgety with repeat request to leave within the hour before he eloped should have been a "red flag" the patient was at increased risk for elopement. Interview revealed additional interventions such as 1:1 suicidal precautions should have been initiated or the hospital police placed outside the patient's room door. Interview revealed she did not know if the patient was suicidal when he walked out. Interview confirmed a psychiatric nor suicidal risk assessment was performed prior to the patient's elopement by the Psychiatric Resource Nurse. Interview confirmed the ongoing MSE was not completed and the patient's EMC was not resolved nor had been stabilized when he eloped.

Interview on 06/22/2011 at 1600 with RN #5 revealed the patient's name did not "ring a bell." Interview revealed after record review, she was the primary care nurse on 03/04/2011 for Patient #5 when he presented to the DED. Interview revealed the patient was brought to the DED by ambulance. Interview revealed she performed the triage and nursing assessments for Patient #5. Interview revealed the patient was brought in by EMS because of alcohol abuse and suicidal ideation. Interview revealed the patient was triaged as, at risk for harming self and others and was placed on Level: One suicide precautions. Interview revealed the patient was placed into a safe room, placed into blue paper scrubs, and monitored every 15 minutes. Interview revealed the patient was not placed on 1:1 suicidal precautions. Interview revealed his belongings were placed into a secured locker, not in the room. Interview revealed the Psychiatric Resource Nurse (RN #6) was consulted to come evaluate the patient. Interview revealed RN #6 was unable to evaluate the patient for psychiatric complaint and suicidal ideation until he sobered up. Interview revealed the patient was becoming restless, fidgety and requesting to leave prior to his elopement. Interview revealed no additional precautions were implemented by nursing staff when the patient voiced a desire to leave. Interview revealed she informed Physician #3 of the patient's desire to leave. Interview revealed she removed the patient's belongings from the locker and placed them at the nurse's desk. Interview revealed when she returned to the room, the patient had left. Interview revealed she does not know who gave nor how the patient obtained his clothing. Interview revealed the patient was paged overhead and was not found in the lobby. Interview revealed the hospital police were notified of the patient leaving. Interview revealed RN #6 had not returned to evaluate the patient's psychiatric and suicidal risk prior to his elopement. Interview revealed she does not know if the patient was suicidal when he eloped. Interview revealed the patient "should not have been allowed to leave." Interview confirmed she had not explained to the patient, the hospital's legal obligations, the risks and benefits of refusing further examination or stabilizing treatment and/or re-assessed the patient to determine if the patient was competent to refuse further examination and stabilizing treatment. Interview confirmed the DED staff did not exercise every effort to obtain the patient's signature on a Refusal to Stay form. Interview confirmed the ongoing MSE was not completed and the patient's EMC was not resolved nor had been stabilized when he eloped.

Interview on 06/23/2011 at 1100 with DED Nursing Management Staff revealed the DED does have a policy in place for patients with suicidal ideation. Interview revealed the policy is implemented based on nursing assessment and judgment. Interview revealed placing a patient on 1:1 suicidal precautions is an intervention available to ensure patient safety and no harm. Interview revealed a physician's order is not needed to place a patient on 1:1. Interview revealed 1:1 suicidal precautions is used for patient's who are actively suicidal. Interview revealed Patient #5 would have been considered actively suicidal because he was having suicidal ideation, voiced a active plan, and attempted to carry out his plan prior to arrival to the DED. Interview revealed Patient #5 should have been placed on 1:1 suicidal precautions, not just Level I precautions.

Interview on 06/23/2011 at 0923 with the Physician #1, the DED medical director revealed the medical record contained no documentation Patient #5 had a psychiatric evaluation or risk assessment for suicide conducted by the Psychiatric Resource Nurse, a Psychiatrist, or the DED physician. Interview revealed "we do not know if he was suicidal when he left." Interview revealed "we should have done more to keep the guy in the ED." Interview confirmed the patient's MSE was ongoing at the time he eloped. Interview confirmed no available documentation the patient's EMC had resolved or had been stabilized prior to his elopement.

Consequently, record review revealed no available documentation RN #5 or Physician #3 contacted the Psychiatric Resource Nurse (RN #6) to return to the DED and complete a Psychiatric suicide assessment in order to determine the patient's level of suicide risk, at the time the patient notified RN #5 of his desire to leave. Record review revealed no available documentation RN #5 nor Physician #3 took all reasonable steps to obtain informed written consent from the patient for refusing further examination, treatment or transfer after they were made aware of the patient's desire to leave. Further review failed to reveal any available documentation RN #5 or Physician #3 explained to the patient, the hospital's legal obligations, the risks and benefits of refusing further examination or stabilizing treatment and/or re-assessed the patient to determine if the patient was competent to refuse further examination and stabilizing treatment. Furthermore, review revealed no documentation the DED staff exercised every effort to obtain the patient's signature on a Refusal to Stay form. Record review revealed no available documentation the patient's MSE was completed (lacking psychiatric/suicide risk assessment) nor was his emergency medical condition resolved or stabilized prior to the patient's elopement.

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