HospitalInspections.org

Based on record reviews, video review, and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

The hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed for 2 (#5, #19) of 20 (#1- #20) sampled patients. Patient #5 presented by ambulance with stomach pain and was not triaged, placed in the waiting room and ultimately placed on the ground in pain at a bus stop across the street from the hospital by security where she was later found lying face down and unresponsive. Patient #19 who had been determined to need a psychiatric evaluation during triage was escorted out of the hospital by security for combative behavior and aggression towards ED staff (see findings A-2406).

Based on observation and interview the hospital failed to provide EMTALA rights signage at all entrances. This deficient practice is evidenced by failing to post EMTALA rights signage at the ambulance bay entrance or in a conspicuous area in the emergency department for patients arriving through the ambulance bay entrance.

Findings:

Policy review on 06/28/2021 at 12:17 p.m. the policy titled "EMTALA- Patient Transfers and Emergency Medical Treatment and Active Labor Act" {page 15 of 15, paragraph G} reveals in part: The Emergency Department and other areas likely to be noticed by all patients entering the Emergency Department, as well as those patients waiting for examination and treatment in areas other than the Emergency Department (that is, entrance, admitting area, waiting room, treatment area) shall post conspicuously a sign specifying the rights of patients with respect to examination and treatment for Emergency Medical Conditions and women in Labor.

Observation of the ED on 06/28/2021 at 11:07 a.m. reveals there was no EMTALA signage posted for patients entering the ED from the ambulance bay entrance.

In an interview on 06/28/2021 at 11:12 a.m. with S1CMO confirmed there was no EMTALA signage at the ambulance bay entrance or in the emergency department.

44763


Based on record review, video review, and interviews, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed for 2 (#5, #19) of 20 (#1- #20) sampled patients.

Patient #5 presented by ambulance with stomach pain and was not triaged, placed in the waiting room, and ultimately placed on the ground in pain at a bus stop across the street from the hospital by security where she was later found lying face down and unresponsive.

Patient #19 who had been determined to need a psychiatric evaluation during triage was escorted out of the hospital by security for combative behavior and aggression towards ED staff.

Findings:

Patient #5

Review of Patient #5's medical record on 06/28/2021 at 1:50 p.m. with S2RN navigating chart revealed Patient #5 arrived on 06/20/2021 at 12:00 a.m. by ambulance. Chief Complaint: Abdominal Pain.

Patient #5 was triaged at 12:06 a.m. by S5RN. Once triage was done, Patient #5 was brought to waiting room. Triage calls (to call patients to the ED from the waiting room) were documented as having been done on 06/20/2021 at 2:31 a.m., 2:35 a.m., and 2:49 a.m.

On 06/20/2021 at 2:56 a.m., Patient #5 was discharged from the ED board with the disposition of leaving without being seen after triage.

On 06/20/2021 at 4:27 a.m. Patient #5 was re-admitted to the hospital. Chief Complaint: Cardiac Arrest.

On 06/20/2021 at 4:37 a.m. Patient #5 was discharged from the ED board with the disposition of Patient #5 expired.


In review of the hospital's video monitoring from 06/19/2021 through 06/20/2021 revealed the following:

11:43 p.m., Patient #5 arrived to ED via EMS. Patient #5 was seen being brought through ED on EMS stretcher, the video was not time stamped.

11:46 p.m., Patient #5 placed in ED waiting by EMS. At this point, Patient #5 was not observed being assessed by a licensed medical professional.

11:53 p.m., S10Tech brought wheelchair to Patient #5 and placed Patient #5 in a wheelchair.

12:00 a.m., Patient #5 sat in waiting room chair.

12:34 a.m., S10Tech was seen helping Patient #5 get into wheelchair, and then S10Tech brought Patient #5 down the hallway.

12:36 a.m., S10Tech was seen wheeling Patient #5 into a room, propping the door open with the wheelchair and walking back down the hallway to the arrival desk. S10Tech was not observed returning to the room to check on the status of Patient #5.

2:27 a.m., (1 hour and 51 minutes after being placed into the room) S12SGS and S17SG were seen walking down hallway to the same place that S10Tech left Patient #5.

2:33 a.m., Patient #5 was seen in the wheelchair being pushed by S10Tech and stopped against the wall in the ED waiting room.

2:34 a.m., S10Tech, S12SGS, and Patient #5 were in the ED elevator on the second floor.

2:35 a.m., Patient #5 was placed outside in front of the hospital by S10Tech and S12SGS. Not at any times during the observation of the video, during the above mentioned times, which included the 3 times documented by S5RN as having called for her, was S5RN seen open the doors to the ED waiting room to triage call Patient #5. S10Tech was seen walking back into the door of the hospital and then S12SGS also left the patient.

2:37 a.m., S10Tech was seen arriving back into the ED via elevator.

2:44 a.m., Patient #5 was seen on the ground in front of the hospital, there was no hospital staff outside with Patient #5.

2:56 a.m., Patient #5 was seen sitting in the wheelchair outside in front of the hospital.

2:57 a.m., Patient #5 was seen on the ground again in front of the hospital, there were no hospital staff outside with Patient #5.

3:07 a.m., Patient #5 was seen crawling on the grass, Patient #5 stood up and tried opening the door to the main entrance of the hospital which was locked.

3:08 a.m., S12SGS was seen opening that same door from the inside.

3:09 a.m., Patient #5 was seen on the ground by the door where S12SGS was holding the door open from the inside and he was looking at Patient #5.

3:10 a.m., S13SG was seen driving up in the circle drive in front of the hospital.

3:11 a.m., S12SGS and S13SG helped Patient #5 back into the wheelchair.

3:12 a.m., Patient #5 was again seen on the ground, S12SGS was seen walking up to Patient #5 and left Patient #5 on the ground and S13SG was seen driving away from the area.

3:18 a.m., S12SGS walked out of the hospital and S13SG drove up in front of the hospital.

3:20 a.m., S12SGS and S13SG helped Patient #5 back into the wheelchair. Then S12SGS was seen wheeling Patient #5 across the street from the hospital to a bus stop.

3:22 a.m., S12SGS was seen leaving Patient #5 on the ground at the bus stop and walked back to the hospital with the wheelchair. S13SG was seen driving away from the area. At this point in the video footage, Patient #5 was lying on the ground at the bus stop alone in the early morning hours.

3:46 a.m., S13SG was seen driving by the bus stop where Patient #5 was lying on the ground.

3:58 a.m., S13SG was seen driving by the bus stop again and S12SGS was seen walking out of the hospital door, walked across the street to the bus stop of where Patient #5 was lying on the ground.

4:06 a.m., S12SGS was seen walking slowly back across the street to the hospital.

4:09 a.m., S12SGS entered the ED and spoke with S18RN.

4:13 a.m., S9MD came into view of the ED video footage.

4:15 a.m., the ED staff exited the ED.

4:16 a.m., ED staff was seen entering the elevator in the ED waiting room on the second floor of the hospital.

4:17 a.m., ED staff were seen arriving at the bus stop across the street where Patient #5 was located.

4:18 a.m. ED staff were seen wheeling Patient #5 on the stretcher toward the hospital performing CPR on Patient #5. At 4:19 a.m. ED staff were seen getting out of elevator in the ED waiting room on second floor, wheeling Patient #5 on the stretcher towards the ED and continued to perform CPR.


On 06/28/2021 at 2:03 p.m. review of New Orleans East Hospital Emergency Department Triage Pathways reveals in part:
Pathway details:

To be started if provider unable to see patient within 10 minutes or if SORT provider is not available.

These orders are designed to improve patient care and quality.

Provider will verbally initiate pathways after the case is presented by the nurse.

Nurses are to enter approved protocol orders for patient in EPIC under manage order sets and choose the ordering mechanism of per protocol, no cosign required.

Initiate for any vital signs outside of normal limits or Registered Nurses judgement.

Protocol for abdominal pain:

Abdominal Pain: start saline lock IV, drawing labs, and obtaining urine for UPT and UA. Administer oxygen as needed to maintain SPO2 > 89%.


In review of policy titled Code RRT: Rapid Response Team reveals in part, Criteria Guidelines for Initiating the RRT
Any or all the criteria meets the guidelines for initiating the RRT Team. The key to using the guidelines properly is the identification of:

Staff member worried, concerned about patient

Acute change in level of consciousness

Agitation or delirium

Uncontrolled pain


In review of Security Daily Log Report revealed on 06/20/2021 at 2:45 a.m., ED requested for security to escort Patient #5 off campus that was loitering in ED bathroom. Patient #5 was placed in a wheelchair. S10Tech pushed the wheelchair while S12SGS and another security guard escorted.


In an interview on 06/28/2021 at 3:34 p.m., S9MD stated he saw Patient #5 passing by inside the ED via ambulance stretcher. S9MD states he did not perform a medical screening examination on Patient #5. He said, later a security guard came into the ED and stated there was a patient at the bus stop lying on their stomach, not moving. S9MD stated, he told ED staff to grab an ambu bag, Narcan, and a stretcher. S9MD stated, when he arrived to the bus stop, Patient #5 was lying prone and noted Patient #5 to be pulseless, unresponsive, and pupils fixed and dilated. He stated, Patient #5 was then given Narcan, transferred to stretcher, and CPR was initiated, and Patient #5 was vented via ambu bag. He stated, once Patient #5 was in trauma bay of ED, Patient #5 was intubated and an IO was established via tibia. He stated, Patient #5 was given multiple rounds of Epinephrine and Narcan with no success. S9MD stated, a bedside echo was performed that showed no cardiac movement.


In an interview on 06/29/2021 at 8:45 a.m. S13SG stated, the ambulance brought Patient #5 to the ED. He stated, Patient #5 stayed in the bathroom for two hours and then S10Tech wanted patient #5 removed from the hospital property. S13SG said, at 3:00 a.m. he rode around the hospital property in the security truck. He said, Patient #5 was in the circle drive in front of the hospital, Patient #5 then slid out of wheelchair to the ground. He said, Patient #5 was on the ground so he and S12SGS assisted Patient #5 back into the wheelchair and Patient #5's purse fell and some needles fell out of Patient #5's purse so S13SG put her belongings back in her purse. S13SG asked S12SGS if the patient was okay because she does not look good. Then S12SGS wheeled Patient #5 across the street to the bus stop where he left her lying on the ground. He said Patient #5 started taking her clothes off at the bus stop and S13SG called S12SGS to let him know and S12SGS said he would go check on Patient #5. S13SG stated, Patient #5's eyes were rolled back and her tongue was hanging out of her mouth. Then S13SG said, he saw the nurses and doctors go to the bus stop. S13SG said, he has been employed at the hospital as a security guard for about 4 months. S13SG stated, the security guards need more training to de-escalate situations. S13SG stated, the security guards are not adequately trained. S13SG stated he took a crisis prevention class but not CPR. In review of S13SG's hospital training record revealed S13SG never received hospital orientation training/annual training.


In an interview on 06/29/2021 at 9:06 a.m. S4RN stated, they had a new traveler nurse working that night and the traveler nurse had an unstable patient and S4RN was helping that nurse with her patients. She said, the ambulance came in and the ED was full and had no available rooms. S4RN asked EMS if Patient #5 was stable enough to be put into the waiting room and EMS said yes. She said, EMS brought patient to waiting room. She said, S5RN triaged the patient and she went to help the traveler nurse. S10Tech told S4RN that Patient #5 had been in the bathroom and Patient #5 got off the floor and got into wheelchair. S4RN stated that she was notified Patient #5 was at the bus stop and needed help by S12SGS. S4RN stated, she did not know Patient #5 was at the bus stop until S12SGS came to ED and said, Patient #5 was at the bus stop not moving. S4RN gave the Narcan nasally, ED staff placed Patient #5 on stretcher, started CPR and Patient #5 was brought into ED. S4RN states S5RN is responsible for initiating the protocols. S4RN stated, when a patient is found on the floor/ground, they usually call a rapid response. S4RN stated, patients should not be allowed to lay on the bathroom floor.


In an interview on 06/29/2021 at 9:20 a.m., with S10Tech, she stated, her role was working the desk and to admit patients into the system that night. She said, EMS came from the back, Patient #5 was on the stretcher and EMS told S10Tech they were told by S4RN to bring Patient #5 to waiting room. She said, the nurse in the back triaged Patient #5 before EMS brought Patient #5 to the waiting room. S10Tech stated, Patient #5 was laying in the chairs in the waiting room and then started hollering she needed to use the bathroom so S10Tech walked over to Patient #5 and explained to Patient #5 that she had to get into the wheelchair so S10Tech could bring her to the bathroom. S10Tech brought Patient #5 to bathroom and told Patient #5 she needed to admit other patients and to yell at her when she was done in the bathroom. S10Tech said she propped the bathroom door open with the wheelchair. S10Tech said when she went to check on Patient #5, she was on the bathroom floor sleeping. S10Tech stated, she told S4RN Patient #5 was on the bathroom floor and S4RN stated to leave Patient #5 there and check on her periodically.

She said Patient #5 stayed about an hour or two on the bathroom floor. S10Tech asked S4RN and S18RN to help her with putting Patient #5 back into the wheelchair from the bathroom floor. S10Tech stated, this was a very busy night and she was trying to work the desk and help Patient #5 to the bathroom. S10Tech stated, it is not normal for patients to sleep on the bathroom floor. S10Tech stated Patient #5 stated she wanted some air and to smoke and S10Tech told Patient #5 she could not smoke but she would bring her outside for some air. S10Tech said, she took Patient #5 down the elevator and left her outside next to the pole to get some air.

S10Tech stated, S12SGS stayed with Patient #5 outside and he told S10Tech Patient #5 was fine. S10Tech stated, it was 30-45 minutes from the time she left Patient #5 with S12SGS in the circle drive to the time S12SGS notified her Patient #5 was unresponsive at the bus stop. S10Tech stated, she does not know how Patient #5 got across the street to the bus stop. S10Tech stated, Patient #5 was not responding and foaming at the mouth, lying on the ground face down, and Patient #5's belongings including some needles were on the ground so S10Tech gathered Patient #5's things and put them back into her purse. S10Tech stated that she told S4RN that Patient #5 was in the bathroom. S10Tech stated, her desk is next to the door where the nurses come out of the ED to call patients but she never heard S5RN do a triage call for Patient #5 to go to the back.


In an interview on 06/29/2021 at 9:45 a.m., S5RN stated S4RN said Patient #5 was stable and put into the waiting room. S5RN stated, she did not triage Patient #5 because S4RN said that Patient #5 was stable enough to wait in lobby. S5RN stated, she was triaging another patient at the time Patient #5 was brought into waiting room by EMS. S5RN stated, she was told by someone S4RN said that Patient #5 was here with abdominal pain with no complications. S5RN stated, she took report from EMS but never triaged Patient #5. S5RN stated, S4RN made the judgement to put Patient #5 into the lobby. S5RN stated, Patient #5 was screaming in pain in waiting room. S5RN stated, she never knew Patient #5 was on the bathroom floor.

S5RN said, she thought Patient #5 left the hospital because S5RN didn't see Patient #5 when she tried calling Patient #5 to the back. S5RN stated, she called for Patient #5 2-3 times. S5RN stated, she did not know where S10Tech was when she was calling for Patient #5. S5RN stated, she took Patient #5 off the ED board because Patient #5 didn't come when S5RN called Patient #5 to the back.

S5RN heard someone say pull some Narcan for Patient #5 across the street, when S5RN asked who, someone said Patient #5 that was here earlier. S5RN stated, S4RN had the Narcan and they both went across the street to the bus stop. S5RN stated, Patient #5 looked like she was down for a while; Patient #5 was cold and unresponsive with no pulse. S5RN stated, S4RN gave the Narcan nasally, Patient #5 was placed on the stretcher, and CPR was immediately started. S5RN stated, she never knew Patient #5 was on the floor in the bathroom, outside, or across the street until everything was over. S5RN stated, she received vitals, review of allergies, review of medications, chief complaint information from EMS. S5RN stated, she never talked to Patient #5 and moved on triaging other patients. S5RN stated she did not ask Patient #5 the triage questions and triage vitals were given to her by EMS. S5RN verified that she did not take Patient #5's vital signs. S5RN confirmed that she did not correctly triage Patient #5 and that she documented the information that she received from EMS as the triage documentation.


In an interview on 06/29/2021 at 10:27 a.m., S12SGS stated he has been in the position of supervisor for only four weeks. S12SGS stated, security was called to ED lobby to help S10Tech put Patient #5 back into wheelchair. S12SGS stated, he arrived to ED lobby and Patient #5 was already back in wheelchair.

S12SGS stated, S10Tech called security to escort Patient #5 out (remove patient from the premises). S12SGS stated Patient #5 was in the bathroom for two hours and had not been seen by the ED doctor. S12SGS stated he, S10Tech, and another security officer were present when Patient #5 got up from the floor in the bathroom and sat in the wheelchair. Then S12SGS and S10Tech brought Patient #5 outside to the front of the hospital.

S12SGS stated, Patient #5 got up out of wheelchair and fell outside. S12SGS stated Patient #5 fell 1-2 times out the wheelchair. S12SGS stated, Patient #5 was downstairs for like an hour in the circle drive in front of hospital. S12SGS stated, he told S13SG to monitor Patient #5 while making his rounds and S12SGS went back to security office. S12SGS stated, Patient #5 was left alone in front of the hospital. S12SGS stated, S13SG said Patient #5 didn't look good.

S12SGS stated, he and S13SG brought Patient #5 across the street to the bus stop. S12SGS stated, S13SG then reported to him Patient #5 was pulling down her pants so he went outside to check on her. S12SGS stated, when he got there to check on Patient #5, Patient #5 was lying face down and was not moving so he shined his flashlight on her face and she had no eye movement and it appeared she had aspirated. S12SGS walked back to the ED and informed S10Tech Patient #5 was unresponsive across the street. When asked why didn't he radio/call the ED to report Patient #5's condition instead of walking across the street and up the elevator to the second floor, S12SGS stated, he didn't want to blast that information all throughout the ED. S12SGS stated, when they get a call to escort a patient out of hospital, they do not report it to anyone but they do include it in a report. S12SGS stated that security guards are not trained. In review of S12SGS's hospital training record revealed S12SGS received hospital orientation training/annual training when hired in 2019 but not since then.


In an interview on 06/29/2021 at 3:21 p.m., S1CMO verified EMS should stay with the patient until there is an ED bed available. S1CMO verified a Rapid Response should have been called when the patient was on the floor in the bathroom. S1CMO verified no one checked on Patient #5 for two hours while Patient #5 was in the bathroom. S1CMO stated, it should have been Patient #5's decision to leave the hospital, not S10Tech's decision to have Patient #5 escorted out of the hospital. S1CMO verified a Rapid Response should have been called when Patient #5 slipped out of the wheelchair outside of the front entrance of the hospital multiple times. S1CMO verified Patient #5 should have not been wheeled across the street to the bus stop. S1CMO confirmed S12SGS should have radioed for help when he found Patient #5 lying on the ground at the bus stop instead of walking back to the hospital for help. S1CMO confirmed anyone can call a rapid response.


In an interview on 06/29/2021 at 3:54 p.m., S3RN verified Patient #5 should have not been brought to the ED waiting room by EMS. S3RN said, a Rapid Response should have been called when Patient #5 was found on the floor in the bathroom. S3RN stated, S10Tech should have notified S4RN Patient #5 was on the bathroom floor. S3RN also verified ED staff should have not left Patient #5 outside alone. S3RN verified a Rapid Response should have been called every time Patient #5 was on the floor/ground. S3RN said, S12SGS should have radioed for the ED staff from the bus stop instead of walking back to the hospital. S3RN confirmed ED staff should have immediately gone to Patient #5 instead of calling EMS and discussing if Patient #5 was on hospital grounds. S3RN said, a patient coming to hospital by ambulance should always be triaged by a nurse and not just get report from EMS. S3RN said, Patient #5 should have stayed on EMS stretcher with EMS staff until there was an ED bed available. S3RN verified a patient that needs some fresh air needs to be brought to the ramp where the ambulance bay is located with ED staff present.


In an interview on 06/28/2021 at 2:04 p.m., S2RN confirmed S5RN did not follow protocol of New Orleans East Hospital Emergency Department Triage Pathways. In a review of the ED available room log, S2RN stated, S4RN was assigned rooms: trauma 2, room 3 and room 4. S2RN stated ED room 3 and ED room 4 were not occupied by patients. S2RN stated, "it is inhumane to leave a patient on the bathroom floor." S2RN stated, a rapid response should have been called when Patient #5 was found on bathroom floor. S2RN stated, Patient #5 should never have been left alone outside of the hospital in the middle of the night, especially across the street at the bus stop.

On 06/28/2021 at 3:45 p.m., S2RN verified the staff had not been formally reeducated on EMTALA, triage, or rapid response after the events on 6/20/21. On 06/29/2021 at 9:15 a.m., S2RN stated all security guards should have hospital orientation training when they are hired and annually thereafter. On 06/29/2021 at 10:50 a.m., S2RN verified the only people that can authorize a patient to be escorted off the property is the house supervisor or charge nurse. S2RN also verified New Orleans Police Department should be the only ones that should be escorting patients out of the hospital. She also confirmed S5RN falsified Patient #5's triage documentation. S2RN stated she reviewed the EMS run report and the vital signs that EMS documented and the vital signs S5RN documented did not match. S2RN stated she does not know where S5RN got the vital signs that she documented on Patient #5's triage documentation.


Patient #19

Review of the hospital policy titled, "Psychiatric Patient Care", Policy Number: ED-162, revealed in part:

I. Purpose

A. To establish a system for identifying and addressing behavioral health needs of patients at risk for violent and self-destructive behavior and/or under a PEC/CEC.

B. To provide staff guidelines to minimize the suicidal or psychiatric patient's potential for self-harm and/or elopement and to ensure his/her safety until the patient can assume responsibility for his/her own safety or too be transferred to the appropriate care facility.

III. Procedure:

A. Emergency Department:

1. Screening patients at risk for suicide and the need for behavioral health services is completed by a Physician and/or Registered Nurse.

4. Staff who monitor patients deemed "at risk" for violent or self-destructive behavior will be trained in the following areas:

a. Non-physical intervention skills or de-escalation training,

b. Techniques to identify patient behaviors, events, and environmental factors that may trigger circumstances requiring the use of restraints ....

f. Early intervention in the escalation cycle with verbal and non-verbal de-escalation techniques.

6. Security is notified of all patients presenting to the ED who are at risk for suicide and/or have behavioral health needs.

B. Physician Assessment:

The physician is responsible for completing a focused medical assessment by which other illnesses and/or injuries in need of acute care are detected and treated.

5. The physician shall determine whether the patient requires treatment in a hospital or other supervised setting and what follow-up will be required if the patient is not placed in a supervised setting ....

8. The level of risk may be modified based upon physician's re-evaluation and assessment of patient's mood, behaviors, and plan.

D. Primary Nurse Assessment:

1. The primary nurse will complete an assessment per unit assessment guidelines and/or acuity level if present in the ED.

4. In the ED, the level of immediate risk may be altered based upon the physician's re-evaluation and assessment of the patient.

F. Safety:

5. In the event a patient becomes verbally or physically abusive and disruptive to the staff, a Code White will be initiated via the overhead paging system.


Review of Patient #19's ED EMR, assisted by S14RN, revealed that the patient had presented to the ED on 06/14/2021 at 6:58 p.m. with complaints of a sore throat and pain in his groin and toe. Further review of the patient's ED record revealed, the patient had a past medical history of Schizophrenia and psychosis with past ED visits documented as follows:

04/02/2021: Diagnosis: Psychosis;

08/13/2019: Diagnosis: Schizophrenia, chronic with acute exacerbation;

06/26/2019: Diagnosis: Schizophrenia; and

11/19/2018: Diagnosis: Schizophrenia.


Review of the ED Care Timeline portion of the ED record for Patient #19's visit on 06/14/2021 revealed the following:

6:58 p.m.: Patient arrived in ED and Emergency Encounter created;

6:59 p.m.: Arrival Complaint: sore throat; toe pain; groin pain;

8:21 p.m.: General complaint onset today; pain related to recent injury: no;

8:21:56 p.m.: Chief Complaint Updated: Psychiatric Evaluation - Patient states he has bugs all over his body because the place he is living is unclean. Patient also states someone is trying to kill him and has put many spells on him. Patient denies SI/HI.;

8:22 p.m.: Pain and Sepsis assessment completed.;

8:23 p.m.: Triage plan: Patient Acuity: 2 (Emergent) - Triage completed.;

8:27:39 p.m.: Patient roomed in ED.;

8:27:49 p.m.: ED Notes Addendum: Patient combative with staff in triage room in which security removed patient from the ED. Patient was unable to be re-directed or de-escalate the situation. Patient was refusing to answer appropriate questions. Patient screaming and cussing at triage and charge nurse.;

8:28:29 p.m.: ED disposition set to LWBS after triage.; and

8:30 p.m.: Patient discharged.


In an interview on 06/29/2021, during Patient #19's ED EMR review, S14RN reported that Patient #19 was in the waiting area from 6:58 p.m. - 8:21 p.m. for 83 minutes before triage was started. S14RN further confirmed, based on EMR review, there were no other provider notes (RN or MD) and verified the patient had not been assessed by the ED RN or the ED MD or any other provider. She also confirmed that there was no documentation in the record that the physician had been notified about Patient #19. S14RN said, a Security Code White should have been called to handle Patient #19's combative behavior instead of the patient being removed by security without being assessed for his paranoia and possible hallucinations.

A review of the video from 06/14/2021, when Patient #19 presented to the ED for assessment and treatment, was performed by the hospital's legal staff. The video review revealed 2 security guards went into the ED on 06/14/2021 at 8:22 p.m. A few seconds later Patient #19 walked out of the ED and the security guards were following him. Patient #19 got into the elevator with the guards and he exited the hospital.


In an interview on 06/29/2021 at 3:15 p.m. with S2RN, she reported that when S16PM realized Patient #19 was in a manic state, paranoid, and hallucinating, S15RN Charge should have been involved at that point. She said, if a patient presented to the ED and it is determined during triage that the person is paranoid and/or manic, then the Triage level should be Level 2. She confirmed the patient's presenting problem should be switched to psychiatric evaluation. She reported, the charge nurse should have been alerted when the patient escalated when being questioned regarding suicidal/homicidal ideations and the patient should have been assessed by a provider at that time. She said, S15RN Charge should have called a Security Code White, which summons all CPI certified males to address combative patients when Patient #19 became combative with S16PM during triage. She reported that if Patient #19 couldn't be de-escalated then the patient could have been restrained. She said, even if a patient isn't PEC'd yet, a Security Code White can be initiated. S2RN reported, security had walked up to the room where Patient #19 was because they had heard yelling and screaming. She said, S15RN Charge made a harmful error against policy when she didn't call a Security Code White to handle the patient's behavior instead of having the patient leave without being assessed.


In an interview on 06/29/2021 at 2:55 p.m. with S1CMO, she was informed of the details regarding Patient #19 when he presented to the ED for treatment on 06/14/2021. After review of the patient's ED record indicating the patient had voiced complaints of being covered with bugs, believing others were trying to kill him and "putting spells on him" during triage, she agreed Patient #19 should have had a psychiatric assessment by the physician.


In an interview on 06/29/2021 at 2:57 p.m., with S16PM, he indicated he functions in the ED as triage staff and he confirmed the ED Charge Nurse is next in his chain of command. S16PM reported, he remembered Patient #19. He said in the triage office he was asking him questions, he was moving from system to system, and the patient was in a manic state. S16PM reported, he was trying to gather what Patient #19's mental status was. S16PM indicated, he had asked Patient #19 what his name was and what month it was. S16PM reported, Patient #19 was having auditory hallucinations and paranoia. S16PM said Patient #19 became angry when he was questioning him, like he was Bipolar or Schizophrenic. He stated, he was asking the patient if he wanted to harm himself or anybody else, and the patient said I am not crazy and told him he felt he had no place to go and thought people were stealing his money and he was unsafe. He reported, S15RN Charge had heard Patient #19 yelling and came into the room. S16PM said S15RN Charge let Patient #19 leave the ED. S16PM reported Security came up and he indicated he did not remember what happened after that. S16PM reported he did not remember a Security Code White being called. S16PM stated he was scared Patient #19 would overreact if a bunch of people arrived. S16PM said if a patient denies SI/HI they are not technically able to hold them against their will.


In an interview on 06/30/21 at 8:27 a.m. with S15RN Charge, she said Patient #19 was extremely combative in triage. She said she heard yelling so she went in the room and S16PM was cornered by Patient #19. S15RN Charge reported the patient was in S16PM's face. S15RN Charge said they had tried to get him to calm down and he was upset over the questions S16PM was asking him. S15RN Charge said Security walked behind Patient #19 and they escorted him out. S15RN Charge said typically they would call a Security Code White for a Psychiatric patient who was combative. S15RN Charge confirmed the doctor had never seen Patient #19 because he left without being seen. S15RN Charge said, in retrospect, that Patient #19 should have been evaluated by the doctor.