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Based on interview and record review, the hospital failed to ensure the hospital's P&P related to the reporting an EMTALA was implemented for one of 21 sampled patients (Patient 1). This failure had the potential for not identifying the inappropriate care provided to the patient.

Findings:

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated 8/2020, showed the hospital's Medical Staff Members and employees have the reporting obligations. The hospital's Medical Staff Members and employees who know of an apparent violation of the EMTALA transfer laws on the part of the hospital in its capacity as either a receiving or transferring hospital will immediately report such violation to the hospital administration. Where the hospital believes that the apparent violation may be reported to a federal or state survey agency, either by another facility, a patient, hospital staff or by the hospital itself, the operational communications and the hospital's marketing director will be notified.

On 11/7/22 at 1013 hours, Quality Manager 1 was interviewed about the hospital's P&P related to the reporting of EMTALA. Quality Manager 1 stated Patient 1 came to the ED on 9/4/22, and was transferred to Hospital B on 9/5/22. Quality Manager 1 stated the hospital was aware of the issues related to the ambulance services as the incident was reported by the House Supervisor's email. Quality Manager 1 further stated on 9/15/22, the hospital administrative staff reviewed the incident and confirmed the delay in transferring Patient 1 to Hospital B. Quality Manager 1 stated the hospital's action was to re-educated the staff about the hospital's P&P. Quality Manager 1 stated on 9/23/22, a follow-up meeting was held with the corporate medical director for the same incident. When asked about the reporting of incident as per the hospital's P&P, Quality Manager 1 stated Quality Manager 1 did not have any further information.

Based on observation, interview, and record review, the hospital failed to ensure the signages for EMTALA rights with respect to the examination and treatment for emergency medical conditions (EMC) and women in labor were posted conspicuously in the ED and L&D areas where the signages would likely be noticed by the individuals visiting the ED and L&D areas as evidenced by:

* Failure to ensure EMTALA signage was posted by the ambulance entrance to the ED.

* Failure to ensure EMTALA signage was posted in the ED treatment area.

* Failure to ensure EMTALA signage was posted in the L&D rooms of the L&D unit.

These failures had the potential result in the individuals to not be aware of their rights to the examination and treatment in the event of an emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated August 2020 showed the hospital will post in places likely to be noticed by all individuals entering the Emergency/Labor and Delivery Department, as well as those individuals waiting for examination and treatment, signs in clear and simple terms in multiple languages appropriate to the community which state the following:

* The hospital participates in the MediCal Program.

* The rights of the individuals, under the law with respect to examination and treatment for emergency medical conditions and of pregnant women having contractions without regard to ability to `pay.

1. On 11/2/22 at 1005 hours, during the initial tour of the ED with the Director of Med Surge & Women's Center, one posted EMTALA signage showing the patients' rights with EMC was observed on the wall of the lobby by the registration area.

However, there was no EMTALA signage posted by the ambulance entrance and treatment areas of the ED where the patients, family members, and visitors would be able to read and understand those signages.

On 11/7/22 at 1040 hours, during an interview with the Manager of ED/ICU/CCU who acknowledged the above findings.


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2. On 11/2/22 at 0956 hours, the initial tour of the L&D was conducted with the DON.

The DON stated the MSE for OB patients was usually conducted in L&D Room 2; however, any room including L&D Room 1 through L&D Room 6 could be utilized to provide the MSE for the patients.

When asked about the EMTALA signage in the L&D area, specifically in the rooms where the MSE would be provided to the patients, the DON stated there was no EMTALA signage in the L&D unit, including L&D Room 1 through L&D Room 6.

Based on interview and record review, the hospital failed to implement the hospital's P&P on obtaining and maintaining the on-call list of stroke neurologist to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. This failure could result in the delay in the stabilizing treatments and substandard health outcomes to the patients.

Findings:

Review of the hospital's P&P titled Stroke Team, ED Activation of dated September 2019 showed activation of Stroke Team will alert appropriate team members for staffing and patient placement. For the ED patients with signs and symptoms of less than 24 hours from time of onset, the ED physician receives radiologist interpretation of the CT scan result and notifies appropriate physician as follows:

* Telestroke neurologist on-call for no hemorrhage.

* Stroke neurological interventionalist on-call in addition to the telestroke neurologist on-call, for the suspected large vessel occlusion.

* Neurosurgeon call - call in addition to the telestroke neurologist, for the presence of hemorrhage.

Review of the hospital's P&P titled Transfer of Patient to Specialty Center Care dated September 2020 showed if a patient requires transfer to the HLOC than what the hospital can provide, the patient will be transferred following EMTALA guidelines. For Critical Stroke- Neurology, contact Stroke Neurologist on-call at Hospital B (The on-call list is in the Case Management Book and faxed over to Hospital A's ED every month).

On 11/3/22 at 1000 hours, an interview was conducted with ED Charge RN 1. When asked, ED Charge RN 1 stated there was no Hospital B's on-call list in their ED.

On 11/3/22 at 1058 hours, a tour of the ED was conducted with the Manager of ED/ICU/CCU.

The Manager of ED/ICU/CCU was asked to provide the on-call list for the Stroke Neurologist (from Hospital B) for November 2022 that should be faxed to Hospital A every month. The Manager of ED/ICU/CCU was observed looking in the multiple binders. The Manager of ED/ICU/CCU stated it was not found.

The Manager of ED/ICU/CCU stated if the on-call list for the Stroke Neurologist (from Hospital B) could not be found, the staff would "call the Transfer Center and they would contact the on-call physician (or the Stroke Neurologist from Hospital B)."

The Manager of ED/ICU/CCU was asked if the ED maintained an updated list of hospitals designated as Stroke Receiving hospitals in the event the TC could not coordinate the transfer of a patient requiring stroke neurologist services. The Manager of ED/ICU/CCU stated the ED staff could refer to the OC EMS's P&P for Emergency Receiving Centers.

The OC EMS's P&P was reviewed with the Manager of ED/ICU/CCU. The OC EMS's P&P dated 4/1/13, showed a list of General Acute Care Hospitals (GACH); however, there was no contact information for each hospital. The Manager of ED/ICU/CCU stated the RNs could go online to look up for the hospital's contact information as needed. When asked if the hospital's network was down, the Manager of ED/ICU/CCU stated each RN had a cell phone and it could be utilized to look up the hospital's contact information.

On 11/3/22 at 1100, RN 2 was asked to provide the on-call list for the Stroke Neurologist (from Hospital B) for November 2022. RN 2 was observed looking in the multiple binders. RN 2 confirmed it was not found.

On 11/3/22 at 1110 hours, RN 3 was asked if the ED had a reference list for GACHs with stroke neurologist services, RN 3 stated, "not that I'm aware of." When asked about the hospitals with neurologist services in addition to Hospital B in the event a patient required stroke neurologist services, RN 3 stated the patient would "go to sister facility first (referring to Hospital B)."

On 11/7/22 at 1400 hours, during the interview with the Manager of ED/ICU/CCU, the Manager of ED/ICU/CCU stated they did not maintain the on-call list; and the TC was responsible to facilitate in arranging the on-call specialist.

Based on interview and record review, the hospital failed to ensure the L&D Central Log was maintained when the disposition was not documented in the L&D Central Log for seven patients. This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the L&D Department for treatment for an emergency medical condition.

Findings:

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated August 2020 showed in part:

* "Central Log" means a log of each individual who comes to the ED/Labor and Delivery Department seeking assistance and whether he/she refuses treatment, was refused treatment; or he/she was transferred, admitted and treated, stabilized and transferred, referred to treatment in an alternative setting, or discharged.

* The Record Keeping section showed the hospital, whether transferring or receiving patients, must maintain the Central Log or the central log on each individual who comes to the Emergency Room/Labor and Delivery Department seeking assistance.

On 11/7/22 at 0952 hours, an interview and concurrent review of the L&D Central Log from June througth November 2022 was conducted with the DON and RN 1.

Review of the L&D Central Log showed the disposition for seven patients was not documented.

The DON confirmed the findings. The DON stated the L&D maintained a central log for OB patients who presented to the L&D Department and that had received an MSE by the L&D RN.

Based on interview and record review, the hospital failed to ensure an MSE was provided in a timely manner to determine whether or not an EMC existed for seven of 21 sampled patients (Patients 2, 3, 5, 6, 9, 10, and 11) as evidenced by:

1. For Patient 2, the ED nursing staff did not triage the patient within five to 10 minutes of arrival to the ED as per the hospital's P&P. In addition, the ED physician did not complete the MSE documentation for Patient 2 in a timely manner.

2. For Patient 3, the ED nursing staff did not triage the patient within five to 10 minutes and did not assign a triage category accurately as per the hospital's P&P. In addition, there was no documented evidence to show the ED staff addressed Patient 3's pain and the ED physician or healthcare provider conducted an MSE for the patient before the patient was LWBS.

3. For Patient 5, the ED staff did not triage the patient within five to 10 minutes after arrival to the ED as per the hospital's P&P.

4. For Patient 6, the ED staff did not complete the triage assessment but assigned the triage category to the patient as Category 4 which was not accurately as per the hospital's P&P.

5. For Patient 9, the ED staff did not complete the triage assessment and MSE for the patient when the patient came to the ED with abdominal pain.

6. For Patient 10, the ED staff did not complete the triage assessment for the patient before transferring the patient to the L&D Unit.

7. For Patient 11, the ED staff did not complete the triage assessment for the patient before transferring the patient to the L&D unit.

8. The hospital failed to ensure the hospital's P&Ps related to triaging of the patients in the ED were consistently developed for the time frames for triaging the patients upon arrive to the ED and the patient's acuity levels.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients in the ED.

Findings:

Review of the hospital's P&P titled Triage dated January 2022 showed the following:

* All individuals who come to the hospital and require examination or treatment will be triaged by the ED RN within 5-10 minutes of arrival to the ED to determine priority of medical screen/care based on physical, psychological, and social needs.

* The four categories of triage include the following:

- Category 1 - Emergency

- Category 2 - Urgent

- Category 3 - Non-urgent

- Category 4 - Maternity. Pregnant women with gestational age of 20 weeks and beyond and whose complaint appears to be related to their pregnancy, will be transported to the Labor and Delivery Department for medical screening, examination, and treatment. Pregnant women with gestational age of less than or equal to 20 weeks and of greater than or equal to twenty (20) weeks whose complaint is clearly unrelated to their pregnancy, will be assigned an acuity level and evaluated and treated in the ED.

* The triage RN will evaluate and categorize each patient into either Emergent, Urgent, Non-urgent, or Maternity categories and will implement emergency intervention as needed.

* Immediately following the rapid assessment, the RN will record at a minimum the following on the ER nursing record:

- Time of Triage

- Chief Complaint

- Limited Subjective/Objective Data

- Pain Assessment

- Classification or Category

* Documentation on first page of Emergency Room Flow Sheet includes the LMP is applicable, objective including nursing observation, vital signs, and classification.

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated 8/2020, showed all women who are pregnant with a gestational age of twenty (20) weeks and beyond, who present to the ED with a complaint which is clearly unrelated to their pregnancy, will receive a medical screening examination the ED Physician, and where appropriate, will be sent to the Labor and Delivery area for monitoring.

Review of the hospital's P&P titled Triage of OB Patient dated 9/2020, showed all maternity patients who present to the ED for care, will be triaged by the RN. For the patient who is over 20 weeks gestation, the ED triage nurse is to complete the triage section of OB Triage form; and based on this assessment, it will be determined if the patient will be transported immediately to the L&D unit or stay in the ED for exam and treatment. For patient who is with less than 20 weeks gestation, the ED triage nurse will do initial screening and patient will be seen as ED patient.

1. On 11/2/22 at 1528 hours, an interview and concurrent review of Patient 2's medical record was conducted with Quality Manager 1.

Patient 2's medical record showed Patient 2 presented to the ED on 11/1/22 at 2243 hours and left AMA on 11/2/22 at 0435 hours.

Review of the Triage Report showed Patient 2 was triaged on 11/1/22 at 2309 hours, or 26 minutes after arrival to the ED which was not consistent with the hospital's P&P.

Further review of Patient 2's medical record showed the medications were ordered for nausea and vomiting on 11/1/22 at 2346 hours, and laboratory testing was done on 11/2/22 at 0100 hours. However, there was no MSE documentation found in the record.

Quality Manager 1 acknowledge the findings. Quality Manager 1 confirmed there was no MSE documentation in the record (approximately 17 hours and 45 minutes after Patient 2 presented to the ED). When asked how soon the physician should have documented the MSE, Quality Manager 1 stated she could not recall the time frame; Quality Manger 1 stated approximately 14 days but was not sure. Quality Manager 1 stated it would be best to interview the Director of Medical Staff to confirm how soon the ED physician should document the MSE.

On 11/2/22 at 1558 hours, the Director of Medical Staff was interviewed and was asked how soon the ED physician should document the MSE. The Director of Medical Staff stated the MSE should be documented in "real-time."

2. On 11/3/22 at 1345 hours, an interview and concurrent review of Patient 3's medical record was conducted with the Manager of ED/ICU/CCU. Patient 3 presented to the ED on 10/4/22 at 0530 hours with a headache and the pain level of nine out of 10 (on the pain scale from zero to 10, zero indicates the patient has no pain; and 10 indicates the patient has severe pain).

a. Review of the triage report showed Patient 3 was triaged on 10/4/22 at 0604 hours, or 34 minutes after arrival to the ED which was not consistent with the hospital's P&P.

b. Patient 3's acuity level was documented as Category 4 which was not consistent with the hospital's P&P titled Triage as the hospital's P&P showed Triage Category 4 was designated for the maternity patients.

c. Review of the Ambulatory Assessment/History Report showed Patient 3's pain level was 9 out of 10 on 10/4/22 at 0604 hours. There was no documented evidence showing the ED staff had addressed the patient's pain. There was no documented evidence showing the ED nursing staff had communicated with the physician about the patient's pain level. In addition, there was no MSE documentation in the record.

Review of the Central Log showed Patient 3 was LWBS on 10/4/22 at 0711 hours, or approximately 1 hours and 40 minutes after arrival to the ED.

The Manager of ED/ICU/CCU acknowledged the findings.

3. On 11/7/22 at 1628 hours, an interview and concurrent review of Patient 5's medical record and concurrent interview was conducted with the Manager of ED/ICU/CCU.

Patient 5's medical record showed Patient 5 presented to the ED on 10/31/22 at 1236 hours, with midsternal chest pain.

Review of the Triage Report dated 10/31/22, showed Patient 5 was triaged on 10/31/22 at 1258 hours, or 22 minutes after arrival to the ED.

Review of the Emergency Department Record dated 10/31/22 at 1257 hours, showed the ED provider contacted or screened Patient 5 on 10/31/22 at 1255 hours, or 19 minutes after arrival to the ED.

Patient 5 was not triaged within five to 10 minutes after arrival to the ED as per the hospital's P&P.

The Manager of ED/ICU/CCU acknowledged the findings.

4. On 11/2/22 at 1606 hours, an interview and concurrent review of Patient 6's medical record was conducted with Quality Manager 1.

Patient 6's medical record showed the patient presented to the ED on 11/1/22 at 2010 hours.

Review of the Triage Report showed the following:

* Patient 6 was triaged on 11/1/22 at 2020 hours. The patient's chief complaint was "MVC-Car: pain in limbs." The sections of "Pregnant?" and "LMP" were left blank.

* Patient 6 was in the bathroom on 11/1/22 from 2020 hours through 2040 hours. At 2040 hours, Patient 6 exited "lobby following coming out of lobby bathroom."

There was no documentation of the patient's pain level or vital signs. There was no documentation of limited subjective data including appearance or behavior. There was no documentation to show further action was taken when the patient was seen leaving the ED lobby.

Further review of the Triage Report showed the patient's acuity level was "4" which was not consistent with the hospital's P&P titled Triage as the hospital's P&P showed Triage category 4 would be designated for the maternity patient.

Quality Manager 1 acknowledged the findings.

5. On 11/4/22 at 1328 hours, an interview and concurrent review of Patient 9's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 9's medical record showed the patient presented to the ED on 6/25/22 at 2120 hours, for abdominal pain.

Review of the Triage Report showed Patient 9 arrived to the ED on 6/25/21 at 2120 hours, and was triaged on 6/25/22 at 2137 hours. The patient's chief complaint was abdominal pain. The patient was brought into the ED with the altered level of consciousness. At 2130 hours, the patient's blood sugar level was 36 mg/dL (a critical low level of blood sugar) and the patient was immediately given D50 (Dextrose 50, a medication used to treat low blood sugar). The patient's BP was 184/84 mmHg. The sections of "Pregnant?" and "LMP" were left blank. There was no documentation showing the nursing staff checked the patient's temperature. There was no documentation showing the nursing staff assessed the patient's pain level. Further review of the Triage Report showed Patient 9's acuity level was "2."

There was no MSE documentation by the ED physician. There was no documented evidence to show the physician's order was obtained to administer the D50 to the patient.

Further review of Patient 9's medical record showed Patient 9 was transferred to the Labor and Delivery Unit on 6/25/22 at 2141 hours.

Review of the L&D documentation dated 6/25/22 at 2145 hours, showed Patient 9 was 28 weeks pregnant and the patient's BP was 114/59 mmHg.

The Manager of ED/ICU/CCU acknowledged the findings. The Manager of ED/ICU/CCU stated there was no MSE documentation by the ED physician and there was no documentation of the patient's LMP, GA, or that the patient was pregnant. The Manager of ED/ICU/CCU stated it was not clear on the triage documentation why the patient had been transferred to the L&D Unit on 6/25/22 at 2141 hours.

6. On 11/4/22 at 1357 hours, an interview and concurrent review of Patient 10's medical record was conducted with the Manager of ED/ICU/CCU and Quality Manager 1.

Patient 10's medical record showed the patient presented to the ED on 7/9/22 at 0313 hours.

Review of the ED Summary Report dated 7/9/22, showed the patient's chief complaint was "pregnancy issues < (less than) 20 wk (weeks)." There was no documentation showing the triage category or ESI level.

The Manager of ED/ICU/CCU confirmed there no was documented evidence showing the ED staff completed the triage assessment for the patient. There was no documentation showing the patient's LMP, GA, and pain level. There was no documentation in the ED Summary Report showing the patient was transferred to the L&D unit.

Review of the L&D documentation dated 7/9/22 at 0436 hours, showed Patient 10 had the Estimated Gestational Age of 37 weeks and 5 days. Patient 10's reason for visiting was abdominal pain that started at midnight.

The Manager of ED/ICU/CCU acknowledged the findings.

7. On 11/4/22 at 1420 hours, an interview and concurrent review of Patient 11's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 11's medical record showed Patient 11 presented to the ED on 8/23/22 at 0156 hours, with abdominal pain.

There was no triage documentation. There was no documentation showing the ESI level. There was no documentation showing the patient was pregnant. There was no documentation showing the patient's LMP, GA, or the pain level. There was no documentation in the ED Summary report showing the patient was transferred to the L&D unit.

Review of the L&D documentation dated 8/23/22 at 0215 hours, showed Patient 11's gestation was 40 weeks and 5 days.

The Manager of ED/ICU/CCU acknowledged the findings.

8. On 11/7/22 at 1401 hours, an interview and concurrent review of the hospital's P&Ps related to triaging, ESI levels, and inconsistency was conducted with the Manager of ED/ICU/CCU.

Review of the hospital's P&P titled Assessment of Emergency Department Patient (Adult and Pediatric) dated September 2020 showed a walk- in patients will be triaged by ER RN within 30 minutes of arrival to the ED and the patients arriving by ambulance will be triaged by ER RN upon arrival to determine triage level.

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated August 2020 showed triage means the priority given to an individual or individuals for diagnostic and therapeutic interventions in the ED.

* There are five triage levels used by the ED staff as follows:

- Level 1 or Resuscitation

- Level 2 or Emergent

- Level 3 or Urgent

- Level 4 or Semi Urgent

- Level 5 or Non-Urgent

The Manager of ED/ICU/CCU was questioned about the P&Ps related to triaging and ESI levels and the inconsistencies. The Manager of ED/ICU/CCU confirmed the P&Ps related to Triage and ESI levels were conflicting, including the time frames for triaging the patients upon arrival to the ED and the ESI levels. The Manager of ED/ICU/CCU confirmed the time frame for triaging patient upon arrival to the ED was not consistent for the hospital's P&Ps titled Triage and Assessment of Emergency Department Patient (Adult and Pediatric). The Manager of ED/ICU/CCU stated one hospital P&P indicated patients should be triaged within 5-10 minutes upon arrival to the ED and the other P&P indicated patients should be triaged within 30 minutes. The Manager of ED/ICU/CCU stated one P&P indicated there were four ESI levels and the other P&P indicated there were five ESI levels.

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for nine of 21 sampled patients (Patients 1, 8, 12, 13, 14, 15, 16, 20, and 21) as evidenced by:

1. The ED staff did not implement the hospital's P&Ps related to mental health evaluations, suicidal risk precautions, and code gray for Patient 8. The ED staff did not conducting a thorough contraband search for Patient 8; did not place the patient in a safe, closely observed area, and clear of items that could cause harm to patient or others; did not active a Code Gray when the patient's violent behavior escalated; and did not ensure additional interventions to stabilize the patient as per the hospital's P&Ps.

2. The ED staff did not implement the hospital's P&P related to high risk patient for Patients 13 and 22. The ED staff did not provide the 1:1 sitter/observer to Patients 13 and 22 when Patients 13 and 21 were on an involuntary psych hold or 5150 hold.

3. The ED staff did not assess the vital signs every two hours to Patients 12, 13, 16, 20, and 21 as per the hospital's P&P.

4. The ED staff did not ensure the pain management for Patients 12, 14, 15, and 20 as per the hospital's P&P.

5. The ED staff did not check the temperature for Patient 1 when checking the vital signs for the patient as per the hospital's P&P.

6. The ED staff did not complete the neurological assessment for Patient 1.

7. The ED staff did not ensure Patient 1's SBP was maintained between 100 and 140 mmHg for approximately one hour and 34 minutes, or on 9/5/22 from 0615 to 0749 hours as per the tele neurologist's recommendation.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Mental Health Evaluations in the Emergency Department dated September 2020 showed in part:

* The hospital will provide assessment, care and referral for patients who suffer from psychiatric disturbances and/or symptoms of substance abuse.

* The Procedure section showed the following:

- All patients needing placement in behavioral health setting will be placed in a safe, closely observed area, clear of items that can cause harm, effective care, treatment and services.

- For Suicidal Patients: Patients who have attempted suicide or demonstrated suicidal tendencies will be evaluated by P.E.T evaluator prior to discharge. The suicide precautions are initiated by removing belts, ties, and sharps from area; keeping patient under constant observation; and contacting the House Supervisor/staffing office if additional staff needed. If a patient attempts to leave hospital or elope, contact Security and if necessary, [Name of Police Department], and notify physician. If the patient becomes assaultive, call code Gray and/or restrain the patient if the patient is danger to self and others and notify physician.

Review of the hospital's P&P titled Suicide Risk Assessment, Reassessment and Precautions dated 3/2021, showed when a patient is identified at risk for suicide, the staff shall:

* Place patient on "Suicide Precaution" immediately and notify the Department Manager/designee and the attending physician.

* Thoroughly examine the environment prior to placing the patient at risk for suicide in any room and/or treatment area to ensure that patients do not have to access to items that could be harmful (sharp objects, plastic bags, cleaning solvents, etc.).

* Perform contraband search of his/her belonging in order to remove any items that could be harmful (sharp objects, alcohol, drugs, rope, plastic bags, etc.) out of patient's reach.

* Monitor patient continuously and keep close physical proximity to the patient at all times.

* Suicidal patients will be on 1:1 observation. The Sitter/Observer will remain within 6 feet of patient and maintain constant visual contact with the patient at all times.

* Notify the physician if the patient threatens elopement. If the patient elopes, immediately notify the physician, security, House Supervisor, and [local] Police Department, call the patient's home/family, and initiate a Code Green in case the patient is still within the hospital.

* Patients will not be discharged while on suicide precautions unless they are transferred to an appropriate receiving facility for further care.

* Employees shall follow unit specific policies and document the screening/assessment, reassessment, monitoring, patient/family education, safety contracts, care and treatment plan of the suicidal patients; and use the Close Observation Form to document every 15 minutes checks during suicide precautions.

Review of the hospital's P&P titled Code Gray dated 1/2020, showed the following:

* The hospital will provide a safe and secure environment for patients, visitors, and staff. When staff are concerned about their own safety and the safety of others due to abusive or assaultive behavior of a patient, visitor, or staff, they are to initiate a CODE GRAY.

* There is a Code Gray team assigned every shift. This team responds to Code Gray calls. The team is comprised of staff Golden Years, Emergency Department, and Security Staff. Facilities Staff and Administrative Supervisor may also respond.

* Staff will respond to the page for Code Gray to help unit staff manage or de-escalate the situation by a show of force, to gain cooperation of the abusive or assaultive person, or to subdue and restrain the individual if necessary.

* If necessary, [Name of Policy Department] will be called to assist with combative individual.

On 11/3/22 at 1540 hours, an interview and concurrent review of Patient 8's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 8's medical record showed the patient came to the ED on 11/1/22.

Review of the Triage Report dated 11/1/22, showed Patient 8 was brought in by ambulance on 11/1/22 at 0224 hours, from a sober living facility with the chief complaint of suicidal ideation. As per the EMS, the patient "Used a kitchen knife to harm-self 20 minutes PTA (prior to arrival)." The patient had a laceration to the left forearm. The patient was triaged at 0241 hours.

Review of the Emergency Department Record electronically signed by Physician 1 on 11/1/22 at 0644 hours, showed the following:

* The History Of Present Illness section showed Patient 8's chief complaint was suicidal gesture. The patient admitted that he was not himself, but denied he wanted to harm anybody else.

* The Symptom Description section showed Patient 8 had depression for one to two days. The intensity of symptoms was mild. There was no alleviating factor reported. The exacerbating factors included "Broke up with girlfriend."

* The Physical Exam Narrative section showed the patient's mood appeared depressed.

* The Results section showed the urine drug screen was positive for THC.

* The Progress section showed Patient 8's condition was stable at 0545 hours. The plan included the patient was medically cleared for psychiatric evaluation.

* The ED Course/Medical Decision-Making section showed the following:

- At 0252 hours, the patient was assessed by Physician 1.

- Medical clearance was initiated.

- Based on history of present illness, physical exam, and ED evaluation, the patient would be medically cleared for psychiatric evaluation.

* The Disposition section showed:

- The disposition time was 0554 hours

- The diagnosis were suicidal gesture, suicidal ideation, and superficial forearm lacerations.

- The patient's condition was stable.

- The discharge section showed "pending psychiatric evaluation."

Review of the Blank ED Progress Note electronically signed by the Medical Director of ED on 11/1/22 at 1829 hours, showed the patient care was transferred to the Medical Director of ED on 11/1/22 at 0700 hours. At 1100 hours, the P.E.T. team came to evaluate Patient 8 and placed the patient on a 5150 for being a danger to self. The patient was diagnosed with depression NOS.

Review of the Application for up to 72-Hour Assessment Evaluation, And Crisis Intervention or Placement for Evaluation and Treatment signed by RN 4 on 11/1/22 at 1000 hours, showed the following:

* The RN was called to [Name of Hospital] ER to evaluate Patient 8 who was from sober living after found by staff cutting his forearm with a kitchen knife.

* Upon interview, the patient was guarded, had poor eye contact, withdrew to self, and soft spoken. The patient admitted to cutting himself as a suicidal attempt but would not disclose further. The patient was unable to formulate a viable safety plan. Patient lacked positive coping skills, had poor impulse control, and remained unpredictable.

* The patient reported a long psychiatric history of multiple hospitalization, the last over a year ago. The patient stated he had attempted suicide by cutting a few times in the past. The patient reported he was currently taking Seroquel (an antipsychotic), an antidepressant, and something for anxiety. The patient was currently at a sober living [Name of Facility]. The patient stated he was followed by a therapist and a psychiatrist there.

* Based upon the above information, there was a probable cause to believe that said person was, as a result of mental health disorder as Danger to Self (DTS).

Review of the [Name of Mental Health Facility] Crisis Response Team Evaluation dated 11/1/22, showed the assessment was completed at 1030 hours. Further review showed the following:

* The Areas of Impairment section showed the boxes of Suicidal Behavior, Suicidal Thought, and Dysphoric Mood were checked.

* The Mental Status section showed the patient's appearance was appropriate. The patient was soft spoken. The patient was depressed. The patient had poor insight and poor judgment. The patient was oriented to person, place, purpose, and time. The box of "thought blocking" was checked.

* The Legal Status Following Evaluation section showed the boxes of "Meet 5150 Criteria as:" and "Danger to Self: were checked. The patient's legal status was "5150" and the patient had no conservatorship.

* The Interventions/Recommendations section showed to refer to Inpatient Receiving Facility as To Be Determined

A subsequent review of the Blank Progress Notes electronically signed by the Medical Director of ED on 11/1/22 at 1839 hours, showed the following:

* At 1530 hours, Patient 8 came to the nursing station and stated he was no longer suicidal. The patient requested his telephone and the rest of his belonging. The patient was told he could not receive his belonging because he was on a 5150 hold. The patient had a vaping device in his possession and began to vape in the hallway in the ED. The patient stated again that he was not suicidal and desired to leave. He states that the PET team representative evaluated him when he was sleeping and that it was not an appropriate evaluation.

* At 1706 hours, the police arrived at the ED and stated that they could not force the patient to stay in the safety watch room.

* At 1730 hours, the news that the patient should stay was a 5150 as he was determined to be a danger to self. Patient stated that he was not a danger to himself, was not suicidal. The patient stated that this was not a present and he did not desire to hurt himself or anyone else. He then proceeded to throw the EKG machine on the ground, the vital signs machine on the ground, dumped his food, and dumped several trash cans.

* The physician's impression was that "the patient is alert and orientated x3, conversant, and does not desire to stay in hospital. He stated that he cut himself on his left forearm because he wanted to relieve stress, but he stated he was no suicidal. It is my impression that the patient has had a previous episode of this type, he does not desire to stay in the hospital. It is my impression that the patient did not desire to stay in the hospital, and escalated the behavior to leave the hospital, the patient decide to disrupt the patient flow, and attempted to damage equipment because he was not obtaining is desired result. I do not believe that his behavior was calculated and measured."

* "[Name of Mental Health Hospital] PET team was called to reevaluate the patient, they stated that they could not reverse a 5150 hold."

* The patient was given his belonging, the patient elected to elope.

* The Disposition section showed the disposition as "Transfer."

Review of the Progress Notes Report from 11/1/22 at 0224 hours to 11/5/22 at 0212 hours, showed the following:

* On 11/1/22 at 0550 hours, "Patient's belonging placed in locked room with patient labels placed on bag."

* On 11/1/22 at 0700 hours, the patient had a sitter at the bedside for 1:1 monitoring.

* On 11/1/22 at 1158 hours, the patient was on suicide precautions.

* On 11/1/22 1407 hours, Hospital H called to update the ED that Hospital H did not have beds available.

* On 11/1/22 at 1530 hours, "Patient seen walking standing in front of nurses station. Refused to return to his room." The patient stated "I want my stuff. I need to leave." The patient refused to listen to explanation by multiple staff members, including the Medical Director of ED, nurses, and Manager of ED/ICU/CCU regarding the 5150 status or "72 hour psych hold." The patient continued to walk around the nurse's station repeating the same statement for 50 minutes. The Medical Director of ED was aware. At 1620 hours, the patient walked out the ED door. The Police Department was notified to come to the ED by the Manager of ED/ICU/CCU.

* On 11/1/22 at 1637 hours, "Patient seen using vape in hospital hallway. Instructed to stop and hand over vape device. Patient is non compliant. (the name of the Medical Director of ED) aware. Awaiting further orders. MD declines to give order for Geodone (an antipsychotic) at this time. Awaiting Police Department."

* On 11/1/22 at 1740 hours, "Patient see violently destroying property. Pt (patient) throwing fire extinguisher, isolation cart, IV pump, EKG machine to the floor. Pt difficult to re-direct. Patient stepped out of ER doors at 1750 and left hospital premises with steady gait. Police Department notified."

* On 11/1/22 at 1800 hours, "Officers here. Informed them that the patient eloped."

On 11/3/22 at 1540 hours, during an interview and concurrent review of Patient 8's medical record with Manager of ED/ICU/CCU. The Manager of ED/ICU/CCU stated Patient 8 had been evaluated by the P.E.T clinician and was placed on a 5150 hold. The Manager of ED/ICU/CCU stated she was present in the ED and witnessed the patient "Getting more aggressive...very agitated." He positioned himself in front of the nursing station and became disruptive and violent, including throwing medical equipment around the ED. The Manager of ED/ICU/CCU stated the patient was "non cooperative." In addition, the patient was intimidating as he was "tall." The Manager of ED/ICU/CCU confirmed the RNs, Charge Nurse, and Manager of ED/ICU/CCU had recommended to the Medical Director of ED "other intervention" including medicating the patient; however, the Medical Director of ED did not order medications or other interventions to subdue the patient. The Manager of ED/ICU/CCU confirmed the patient was given back his belonging and the patient left the ED. When asked if the patient had indeed "eloped" or if the patient was allowed to leave the ED, the Manager of ED/ICU/CCU did not respond. The Manager of ED/ICU/CCU confirmed Patient 8's medical record did not show documentation the patient had any subsequent visits to the ED after the patient "eloped" on 11/1/22.

On 11/7/22 at 1523 hours, an interview and concurrent review of Patient 8's medical record was conducted with Quality Manager 1. The following findings were shared and acknowledged by Quality Manager 1.

* The ED staff did not implement suicide precautions, including conducting a thorough contraband search for Patient 8. The patient was in his possession a vaping device and the patient's belonging were returned to the patient.

* The ED staff did not place Patient 8 in a safe, closely observed area, and clear of items that could cause harm. The patient was allowed to walk around the ED, destroying hospital property, which placed the ED staff and ED patients at risk for harm and the potential for an adverse event.

* The ED staff did not active a Code Gray when Patient 8's violent behavior escalated.

* The ED staff did not ensure additional interventions were implemented, to stabilize the patient. The Nursing Progress notes showed additional interventions had been suggested to the Medical Director of ED. The hospital's P&P showed that if the patient became assaultive, a Code Gray should be called and/or restrain the patient if danger to self and others.


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2. Review of the hospital's P&P titled High Risk Patients, Observation of dated March 2021 showed in part:

* The Policy section showed to ensure safety of those patients requiring a higher level of observation, the guidelines as described in this policy will be followed. A team approach to determine the appropriate level of care needed to ensure patient safety will include discussion with team members and the Department Director or Administrative Supervisor after hours.

* The Procedure section showed the following:

- If identified the patient at suicide risk, notify the physician and obtain order for suicide precaution.

- The "Close Observation Flowsheet" form will be used to document the patient's location, activity, and/or response.

- The Charge RN will arrange, assign, and inform the observer of coverage for breaks/meals; and will provide immediate assistance when observer asks for assistance.

* The Point of Emphasis section showed for suicidal risk patients and patients who are on an involuntary psych hold, the 1:1 sitter/observer will maintain constant visual contact and be within six feet of the patient at all times.

a. Review of Patient 13's medical record was initiated on 11/2/22. Patient 13's medical record showed the patient was presented to the ED on 9/11/21 at 2005 hours with the chief complaint of emotional distress; and transferred to Hospital H on 9/13/21 at 0030 hours.

Review the [hospital name] Crisis Response Team Evaluation showed the Crisis Response Team Evaluation for Patient 13 was completed on 9/12/21 at 1430 hours. The patient had suicidal thought. The patient was placed on a 5150 hold for danger to self and danger to others.

Review of Patient 13's medical record showed on 9/12/21 at 2400 hours, Patient 13 was assigned a sitter for 1:1 observation and the 1:1 observation was discontinued on 9/12/21 at 1915 hours. There was no documented evidence showing Patient 13 was provided with 1:1 observation for 5 hours and 15 minutes, or from 9/12/21 at 1915 hours to 9/13/21 at 0030 hours. There was no documented evidence to show the physician's order was obtained for the 1:1 observation for Patient 13.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

b. Review of Patient 21's medical record was initiated on 11/3/22. Patient 21's medical record showed the patient was presented to the ED on 9/29/22 at 1346 hours, with the chief complaint of emotional distress for one 1 day and suicidal ideation. The patient was transferred to Hospital H on 9/30/22 at 1345 hours.

Review of the Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment showed the form was completed on 9/30/22 at 0327 hours. The form also showed Patient 21 was placed on a 5150 hold.

There was no documented evidence to show Patient 21 was assigned a sitter or was observed as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

3. Review of the hospital's P&P titled Assessment of Emergency Department Patient (Adult and Pediatric) dated September 2020 showed the patients will be reassessed every two hours while in the treatment areas plus any change in condition or upon transfer to another facility, discharge, or admission. Reassessments will be done depending on patients' condition. Critical patients will be reassessed at least every two hours. Reassessment will include, but not limited to the vital signs and pain, response to treatment and/or medication, condition prior to discharge or transfer, and their progress regarding the plan of care.

a. Patient 12's medical record was reviewed on 11/2/22. Patient 12's medical record showed the patient came to the ED on 9/11/21 at 1811 hours, with a complaint of chest pain and was transferred to Hospital B's Cath Lab on 9/12/21 at 1036 hours.

Patient 12's medical record showed Patient 12 was assessed for the vital signs on 9/11/21 at 1826 hours and on 9/12/21 at 0055 hours. Patient 12 was not reassessed for their vital signs every two hours as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU. The Manager of ED/ICU/CCU stated the nursing staff should have assessed the patient's vital signs every two hours as per the hospital's P&P.

b. Review of Patient 13's medical record was initiated on 11/2/22. Patient 13's medical record showed the patient was presented to the ED on 9/11/21 at 2005 hours with the chief complaint of emotional distress; and transferred to Hospital H on 9/13/21 at 0030 hours.

Review of the nursing documentation showed the vital signs was completed for Patient 13 on 9/11/21 at 2012 hours; and on 9/12/21 at 0643, 0945, 1200, 1600, and 2000 hours.

However, there was no documented evidence to show the nursing staff assessed Patient 13's vital signs every two hours as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

c. Review of Patient 16's medical record was initiated on 11/3/22. Patient 16's medical record showed the patient was presented to the ED on 9/6/22 at 1654 hours, with the chief complaint of Tylenol (a medication used for pain and fever) overdose; and was transferred to Hospital J on 9/7/22 at 0014 hours.

Further review of Patient 16's medical record showed the vital signs was assessed for Patient 16 on 9/6/22 at 1658 and 2224 hours; and on 9/7/22 at 0013 hours. There was no documented evidence to show Patient 16 was reassessed for vital signs every two hours as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

d. Review of Patient 20's medical record was initiated on 11/3/22. Patient 20's medical record showed the patient was presented to the ED on 9/2/22 at 2317 hours and transferred to Hospital B on 9/4/22 at 1034 hours.

Review of the vital signs documentation showed the vital signs were completed for Patient 20 on 9/3/22 at 0035 hours; and 9/3/22 at 0621, 1200, 1600, and 1900 hours.

There was no documented evidence to show Patient 20's vital signs was completed every two hours as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

e. Review of Patient 21's medical record was initiated on 11/3/22. Patient 21's medical record showed the patient was presented to the ED on 9/29/22 at 1346 hours, with the chief complaint of emotional distress for one 1 day and suicidal ideation. The patient was transferred to Hospital H on 9/30/22 at 1345 hours.

Review of the vital signs documentation showed Patient 21 was assessed for vital signs on 9/29/22 at 1400, 1708, and 1757 hours; and 9/30/22 at 0730 hour. There was no documented evidence to show Patient 21 was assessed for vital signs every two hours as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

4. Review of the hospital's P&P titled Pain Management dated 8/2020, showed the following:

* Pain will be assessed in all patients. Patient/residents are screened on admission for the presence of pain. The patients and family can expect the patient in pain to be assessed and treated promptly, effectively and for as long as pain persists. The team member will continually evaluate the patient's response to his/her pain management plan and communicate to patients and families that pain management is an important part of care.

* The pain assessment tools used at [name of the hospital] include the numeric 0-10 pain intensity scale. The numeric intensity scale is as follows:

- The pain scale from one to three indicates the patient has mild pain.

- The pain scale from four to six indicates the patient has moderate pain.

- The pain scale from seven to 10 indicates the patient has severe pain.

* Pain will be reassessed at a minimum when a complete set of vital signs are taken and after interventions.

* If pain is poorly controlled (i.e. patient's goal not met consistently), notify the physician. If problem persists, follow the chain of command.

a. Patient 12's medical record was reviewed on 11/2/22. Patient 12's medical record showed the patient came to the ED on 9/11/21 at 1811 hours, with a complaint of chest pain and was transferred to Hospital B's Cath Lab on 9/12/21 at 1036 hours.

Review of the Emergency Department Record dated 9/11/21 at 1820 hours, showed the ED physician evaluated Patient 12 on 9/11/21 at 1825 hours. The patient had the left-sided chest pain. The patient rated his pain as 5 out of 10 on a pain scale of 0 to 10.

Review of the physician's order dated 9/11/21 at 1830 hours, showed to administer nitroglycerin (a medication used to treat chest pain) once now.

Further review of Patient 12's medical record showed the nitroglycerine was administered to the patient on 9/11/21 at 1830 hours, for the chest pain with the pain level as of 5 out of 10. Patient 12's reassessment for chest pain was completed on 9/11/21 at 1944 hours, or one hour and 14 minutes after the nitroglycerine was administered to the patient.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU. The Manager of ED/ICU/CCU stated the nursing staff should have assessed Patient 12 five minutes after administered the nitroglycerin to the patient.

b. Review of Patient 14's medical record was initiated on 11/2/22. Patient 14's medical record showed the patient was presented to the ED on 9/26/21 at 1450 hours, with the chief complaint of abdominal pain and vomiting once; and was transferred to Hospital C on 9/27/21 at 0220 hours.

Review of the Vital Sign Report showed Patient 14's pain level was 10 out of 10 on 9/26/21 at 1455, and eight out of 10 on 9/26/21 on 1627 hours.

Further review of Patient 14's medical record showed Patient 14 was medicated for pain on 9/26/21 at 1627 hours.

Review of the Vital Sign Report showed Patient 14's vital signs were checked on 9/26/21 at 1719, 1821, 1915, and 1935 hours. The patient was assessed for pain on 9/26/21 at 1935 hours, or approximately three hours after the patient received pain medications.

There was no documented evidence to show the nursing staff conducted pain assessment for Patient 14 when checking the vital signs for the patient on 9/26/21 at 1719, 1821, 1915 hours.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

c. Review of Patient 15's medical record was initiated on 11/2/22. Patient 15's medical record showed the patient was presented to the ED on 9/30/21 at 0916 hours, with the chief complaint of right great toe infection for two weeks; and was transferred to Hospital E on 9/30/21 at 2049 hours.

Review of the Emergency Department Record dated 9/30/22 at 1017 hours, showed Patient 15's pain level was eight out of 10.

Review of the Vital Sign Report showed the vital signs were checked for Patient 15 on 9/30/21 at 0930, 1300, 1600, and 1816 hours.

However, there was no documented evidence to show the ED staff provided pain intervention to Patient 15. There was no documented evidence to show the nursing staff assessed Patient 15 for pain when checking the patient's vital signs on 9/30/21 at 1300, 1600, and 1816 hours as per the hospital's P&P.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.

d. Review of Patient 20's medical record was initiated on 11/3/22. Patient 20's medical record showed the patient was presented to the ED on 9/2/22 at 2317 hours and transferred to Hospital B on 9/4/22 at 1034 hours.

Review of the ED triage form dated 9/3/22 at 0036 hours, showed Patient 20's chief complaint was the right cheek, right neck, and shoulder pain.

Review of the Progress Notes Report showed the following:

- On 9/3/22 at 0255 hours, Patient 20 stated the patient had pain in the right cheek. The pain was increased with movement and was radiated to her head. However, there was no documented evidence of the patient's pain level.

- On 9/3/22 at 0441 hours, the patient stated when she ambulated to the restroom, the pain was increased with change of position and movement. However, there was no documented evidence of the patient's pain level.

- On 9/3/22 at 0639 hours, the patient received morphine (a pain medication) 2 mg PRN as per the physician's order. The patient's pain level was six out of 10 when resting. The patient was increased with movement and change of position. However, there was no documented evidence of the patient's pain level was assessed when the patient's pain was increased with the movement and change of position. In addition, there was no documented evidence to show the patient was reassessed for pain and the effectiveness of the pain medication after the morphine was administered to the patient as per the hospital's P&P.

- On 9/4/22 at 0000 hours, the patient stated the pain was the same; however, the pain was increased with the movement. However, there was no documented evidence showing Patient 20's pain level was assessed.

On 11/7/22 at 1525 hours, the above findings were confirmed by the Manager of ED/ICU/CCU.


22553


5. Review of the hospital's P&P titled Vital Signs dated 9/2022, showed vital signs include temperature, pulse, respiration, and blood pressure.

On 11/8/22 at 1118 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 1's medical record showed the patient came to the ED on 9/4/22 and was transferred to Hospital A on 9/5/22 at approximately 0949 hours.

Review of the Vital Sign Report from 9/4/22 at 2225 hours through 9/8/22 at 0108 hours, showed Patient 1's vital signs were monitored every 15 minutes. However, there was no documented evidence the nursing staff checked the patient's temperature when checking the patient's vital signs from 9/4/22 2225 hours to 9/5/22 0749 hours, except on 9/5/22 at 0030 hours.

On 11/8/22 at 1118 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Manager of ED/ICU/CCU. The Manager of ED/ICU/CCU confirmed the findings.

On 11/3/22 at 1200 hours, an interview was conducted with ED MD 1. When asked, ED MD 1 stated he was not aware that the patient's temperature was not monitored.

6. On 11/8/22 at 1118 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Manager of ED/ICU/CCU. On 11/8/22 at 1118 hours, an interview with the Manager of ED/ICU/CCU was conducted. When asked, the Manager of ED/ICU/CCU stated the neurological assessment included a NIH Stroke Scale, Glasgow Coma Scale, and pupillary light reflexes. The Manager of ED/ICU/CCU provided the blank NIH Stroke Scale for review. When ask about the use the NIHSS, the Manager of ED/ICU/CCU stated there was no guideline, protocol or P&P for the use of NIHSS.

Patient 1's medical record showed the patient came to the ED on 9/4/22 and was transferred to Hospital A on 9/5/22 at approximately 0949 hours.

Review of the Emergency Department Record electronically signed by ED MD 1 on 9/5/22 at 0640 hours, showed Patient 1 was seen on 9/4/22 at 2231 hours. Patient 1 was alert and oriented. The patient's speech was normal. The patient had mild to moderate facial droop. The patient was unable to move right side of face. The patient had PERRL.

Review of the physician's order dated 9/4/22 at 2343 hours, showed to conduct the n

Based on interview and record review, the hospital failed to ensure the ED staff appropriately transferred four of 21 sampled patients (Patients 1, 5, 16, and 21) from the ED to other hospitals as evidenced by:

1. For Patient 1, the ED staff did not implement the hospital's P&Ps related to transferring the patient to the HLOC.

a. The ED physician did not contact and secure the receiving physician of Hospital B who would attend the medical needs of the patient and would accept the responsible for the patient's medical treatment and hospital care as per the hospital's P&P and the Transfer Agreement between Hospital A and Hospital B.

b. The ED staff did not call 911 to transfer the patient to the HLOC or Hospital B after obtaining the destination from Hospital B and after being aware the ETA of Ambulance Company 4 was more than 30 minutes as per the hospital's P&P.

c. The ED staff did not send the Ambulatory Assessment, Progress Notes, and Vital Sign reports when transferring the patient to Hospital B as per the hospital's P&P and did not ensure the Transfer Summary and Certification was signed when the patient was about to be transferred to the HLOC.

2. The hospital failed to maintain an updated list of ambulance services and ensure yearly evaluation of contracted services including the ambulance services as per the hospital's P&P.

3. For Patients 5, 16, and 21, the ED staff did not complete the Transfer Summary and Certification when transferring these patients to other hospitals as per the hospital's P&P.

4. The EMTALA training was not provided to the ED physicians to ensure compliance with federal law(s) specifically for emergency transfers.

These failures had the potential to result in poor clinical outcomes and serious adverse event for patients receiving ED services in the hospital.

Findings:

1. Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated August 2020 showed the following:

* The ED Physician is responsible for evaluating, ordering, and arranging for all transfers or referrals of patients from the ED to other facilities for immediate care.

* After an initial medical screening examination, if the ED physician/Labor and Delivery RN determines that the individual requires the services of an on-call physician to complete the evaluation and/or stabilize the individual the ED Physician/RN will contact the on-call physician. The on-call physician must respond to a request by the ED physician/Labor and Delivery RN for consultation or to come into the hospital to examine and/or treat an individual within a reasonable time. When the on-call physician fails or refuses to adequately response to such request, the ED Physician/Labor and Delivery RN must decide what is medically in the best interest of the individual. Where there is not another physician available or willing to respond to the ED physician/Labor and Delivery RN request, the ED physician/Labor and Delivery RN may transfer the individual to another facility and the hospital shall report the names of the on-call physicians on the Transfer Summary Form sent to the receiving facility at the time of transfer.

* "Within a Reasonable Time" means not more than 30 minutes, unless the ED Physician determines that additional time is appropriate.

* It is the responsibility of the ED Physician/Labor and Delivery RN to ensure that all transfers for immediate care of an individual to another care facility will be carried out in accordance with the following:

- Medical treatment,

- Informed consent,

- Informed request,

- Contact receiving facility and confirmed that the receiving facility has available spaces and qualified personnel to treat the individual and the receiving physician has been contacted and agrees to accept and treat the individual.

- Copy of the medical records, consents, and certifications and send them to the receiving facility.

- The ER physician/Labor and Delivery RN shall ensure that a completed Transfer Summary Form, accompanies the individual.

* For transferring an unstable patient for the care outside of the hospital, if the ED physician certifies in writing on the Transfer Summary Form that based on reasonable risks and benefits to the patient and based on the information available at the time of the patient's transfer.

* The Copies of the Medical records/Consents/Certifications section showed the hospital will send to the receiving facility copies of all pertinent medical records related to the EMC available at the time of transfer, including:

- Transfer Summary and Consents

- History

- Treatment provided

- Preliminary diagnosis

- Results of diagnostic studies or telephone reports of the studies

- Observations and sign and symptoms.

Patient 1's medical record review was initiated on 11/2/22. Patient 1's medical record showed the patient came to the ED of Hospital A on 9/4/22 at 2227 hours.

Review of the Emergency Department Record electronically signed by ED MD 1 on 9/5/22 at 0640 hours, showed the ED provider contacted and screened Patient 1 on 9/4/22 at 2231 hours. Further review showed the following:

* The History of Present Illness section showed Patient 1 came to the ED with the complaints of the right-sided facial droop, slurred speech, and weakness. As per the patient's family member, the patient started feeling dizzy and noticed with the slurred speech on 9/4/22 around 1700 hours; and the patient had difficulty eating and picking up objects and had right-side facial droop around 1900 hours.

* The Assessment section showed Patient 1 was alert and oriented, had mild to moderate facial droop, was unable to move the right side of face. There was motor deficit on the right side of face. The patient's speech was normal.

* The ED Course/Medical Decision Making section showed the following:

- On 9/4/22 at 2231 hours, the Code Stroke was called for Patient 1 and the protocols were in place. The patient was immediately brought to the radiology for CT scan. While waiting to get the CTs to be done, the patient vomited all over. The patient was disoriented and unresponsive to painful stimuli.

- On 9/4/22 at 2234 hours, ED MD 1 consulted with Physician 2 who was at Hospital I who stated Patient 1 had intraventricular hemorrhage with possible subarachnoid hemorrhage.

Review of the Tele Neurology Consultation Report signed by Physician 2 for the date of service as of 9/4/22 at 2253 hours, showed the recommendations included to transfer Patient 1 to Hospital B for the HLOC, consult neurology and neurosurgery, conduct CTA head, and keep the SBP between 100 and 140 mmHg.

Review of the Progress Notes Report dated 9/4/22 at 2348 hours, showed Patient 1 was alert and oriented when the patient was transferred to the CT scan. The patient shifted himself from the gurney to the CT scan table. Shortly after that, Patient 1 stated he felt headache. The patient then became unresponsive. The physician was called. When the physician arrived, the patient started to projectile vomit. The patient was turned to his side as he threw up. After the patient threw up, the patient became alert and stated he was no longer throwing up. The patient then started to throw up again and became unresponsive. The patient was intubated. At 2359 hours, the patient's pupils were pinpoint with no response to light.

Further review of the Emergency Department Record electronically signed by ED MD 1 on 9/5/22 at 0640 hours, showed the following:

* The Result section showed the CT head result showing Patient 1 had an extensive intraventricular hemorrhage involving bilateral ventricles and third ventricle, questionable small subdural hematoma, and ruptured aneurysm that could not be excluded. The CT head result was communicated with the ED physician on 9/4/22 at 2315 hours.

* The ED Course/Medical Decision Making section showed the following:

- On 9/4/22 at 2316 hours, Patient 1 was intubated and would be admitted to Hospital B.

- On 9/5/22 at 0015 hours, ED MD 1 spoke with the neurosurgeon of Hospital B. The neurosurgeon advised to get the CTA head and neck for the patient at Hospital A's ED. The neurosurgeon recommended that if there was vascular abnormality or issue with the arteries, then they needed to contact an interventionalist; if the result was negative, the neurosurgeon advised to admit the patient and consult the neurosurgery.

Review of the TC record for Patient 1 showed the following:

* On 9/4/22 at 2346 hours, the TC received a call from Hospital A requesting to transfer Patient 1 from ED to ED. The patient needed the HLOC as the ED or neuro ICU. The referring physician was ED MD 1.

* On 9/5/22 at 0045 hours, the neurosurgeon of Hospital B was willing to consult. The patient needed the interventionalist if the CTA result would be abnormal.

* On 9/5/22 at 0051 hours, the TC staff reached out the on-call ED interventionalist and left a voice message to call the TC staff back.

Review of the Patient 1's CTA results signed by the physician on 9/5/22 at 0153 hours, showed Patient 1 had an aneurysm, measuring 7 mm in transverse and 1 cm in diameter at the junction of the left internal carotid artery and left MCA. The aneurysmal sac appeared to be irregular in which ruptured aneurysm should be considered.

Review of the ED Course/Medical Decision Making section of the Emergency Department Record electronically signed by ED MD 1 on 9/5/22 at 0640 hours, showed the following:

* On 9/5/22 at 0335 hours, the CTA head and neck were done. Patient 1 appeared to have a ruptured aneurysm as a source of this bleeding. The ED of Hospital A had contacted Hospital B the entire way, and they were currently looking for their neurological interventionalist. Once the neurological interventionalist was on board, they would talk to their transferring admitting physician, ICU physician of Hospital B, and have the interventionalist for consultation.

* On 9/5/22 at 0630 hours, Patient 1 had been "status quo to this time." The patient had no response to anything. The ED of Hospital A was going to transfer Patient 1 to the ICU of Hospital B. Hospital B was ready for Patient A. The physician of Hospital B accepted the patient.

a. Review of the Transfer Agreement between Hospital A and Hospital B showed this transfer agreement was effective as of 9/1/2019. Further review of the Transfer Agreement showed in the event any patient of either facility is deemed by that facility (Transferring Facility) as requiring the services of the other facility (Receiving Facility) and the transfer is deemed medically appropriate, a member of the nursing staff of the Transferring Facility or the patient's attending physician will contact the Admitting Office or Emergency Department of the Receiving Facility to arrange for appropriate treatment as contemplated herein. The responsibilities of the Transferring Facility include that prior to patient transfer, the transferring physician shall contact and secure a receiving physician at the Receiving Facility who shall attend to the medical needs of the patient and who will accept responsibility for the patient's medical treatment and hospital care.

Review of the Disposition section of the Emergency Department Record electronically signed by ED MD 1 on 9/5/22 at 0640 hours, showed Patient 1 was in a serious condition. The patient would be transferred to the ICU of Hospital B. The disposition time was at 0630 hours. The patient had a ruptured cerebral aneurysm with intraventricular bleed.

Review of the Blank ED Progress Note electronically signed by ED MD 2 on 9/5/22 at 1119 hours, showed at 0700 hours, ED MD 2 was informed by ED MD 1 that Patient 1 was accepted for transporting to Hospital B. The transportation was already arranged and the estimated time of transferring the patient to Hospital B was at 0800 hours. Further review of the Blank ED Progress Note showed ED MD 2 was informed at three separated times that the transport company delayed in transferring the patient to Hospital B until 0900, 1000, and 1030 hours. The patient's pupils were fixed and dilated at 0915 hours. 911 was called to transfer the patient due to the delay of the transport. The patient left the ED at approximately at 0950 hours. The section of Disposition showed the sections of "Time," "Condition:" and "Care transferred to Dr:" were left blank.

Review of the Transfer Summary and Certification signed by the physician on 9/4/22 at 0300 hours and by Patient 1's family member on 9/5/22 at 0300 hours, showed the sections of "the receiving facility [Hospital B] had available space and qualified personnel for treatment as acknowledged by: [name of a staff]" and "The receiving physician had agreed to accept transfer and to provide appropriate medical treatment as acknowledged by: [name of the receiving physician] [name of neurosurgeon]" were checked.

However, there was no documented evidence showing ED MD 1 and ED MD 2 followed up if the interventionalist would be available. There was no documented evidence showing ED MD 1 and ED MD 2 contacted or talked to the ICU physician of Hospital B regarding to the transfer of Patient 1 to the HLOC at Hospital B as per the hospital's P&P and the Transfer Agreement between Hospital A and Hospital B.

Review of the H&P examination from Hospital B dictated by Physician 4 who was Hospital B's physician on 9/5/22 at 1751 hours, showed Patient 1 was transferred to Hospital B after being found to have an intracranial lesion outside hospital (or Hospital A). The physician saw the patient first time today after the patient had already been transferred. The physician was suspicious that the patient was brain death. The physician accepted the patient immediately when the physician was asked to be called for transfer early this morning (or 9/5/22). The physician was the only one who accepted the patient as there was difficulty transferring from Hospital A.

On 11/3/22 at 0904 hours, during an interview with the Manager of ED/ICU/CCU, the Manager of ED/ICU/CCU was asked whose was responsible for an ED patient who would be transferred to the HLOC. The Manager of ED/ICU/CCU stated it would be the ED MDs.

On 11/3/22 at 1000 hours, an interview was conducted with ED Charge RN 1. ED Charge RN 1 Patient 1 came in the ED with slurred speech. ED Charge RN 1 stated the patient went to CT scan, became unresponsive, required intubation, and stayed on the ventilator ever since. ED Charge RN 1 stated the patient had a tele neurologist consult and needed to be transferred to the HLOC. ED Charge RN 1 stated the Hospital A's ED physician did not talk to the Hospital B's ED physician. ED Charge RN 1 stated there was one call that ED MD 1 talked to Hospital B's on-call neurosurgeon and Hospital B's on-call neurosurgeon recommended they would need the neurological interventionalist if the CTA results were abnormal. ED Charge RN 1 confirmed there was no other call from the ED physician or ED MD 1 to Hospital B's providers. ED Charge RN 1 stated Hospital A's ED physician did not talk to the Hospital B's ED physician.

ED Charge RN 1 stated ED Charge RN 1 started to call the TC to transfer Patient 1 to the HLOC. ED Charge RN 1 stated when CTA results were available, she made the verbal report to the TC. ED Charge RN 1 stated Hospital A's ED staff then waited for the TC to arrange for the assigned bed and accepting physician to transfer Patient 1 to the HLOC or to Hospital B. ED Charge RN 1 stated the TC informed ED Charge RN 1 that the TC was not able to reach their on-call neurological interventionalist. ED Charge RN 1 further stated about 0300 hours, the TC informed ED Charge RN 1 that Hospital B could accept the patient; and provided to ED Charge RN 1 Patient 1's assigned ICU bed number at Hospital B, the names of the accepting physician and neurological specialist of Hospital B. ED Charge RN 1 stated ED Charge RN 1 documented that information on the Transfer Summary and Certification form and had ED MD 1 to sign the Transfer Summary and Certification form. ED Charge RN 1 was asked about Patient 1's Transfer Summary and Certification showing Hospital B as the receiving hospital, name of the receiving physician, name of the neurosurgeon, and name of the staff. ED Charge RN 1 stated the ED staff prepared and filled out all information for ED MD 1 to sign at 0300 hours; the 0300 hours was the time that they got the patient's family consent and the confirmation from the TC about the patient's assigned ICU bed at Hospital B, admitting physician and neurosurgeon who were accepting the patient at Hospital B. ED Charge RN 1 further stated the information was obtained from the TC staff; ED Charge RN 1 did not call to verify information; ED Charge RN 1 did not recall if ED MD 1 contacted the accepting physician of Hospital B.

On 11/3/22 at 1200 hours, an interview was conducted with ED MD 1. ED MD 1 was asked for arranging and finding the neuro specialist for Patient 1. ED MD 1 stated Patient 1's ED treatment plans were followed as per the tele neurologist's recommendations which included to transfer the patient to the HLOC and consult with the neuro-specialist. ED MD 1 stated the TC arranged for ED MD 1 to talk to Hospital B's on-call neurological specialist (or neurosurgeon). ED MD 1 stated the neurosurgeon instructed Hospital A to do the head and neck CTAs for Patient 1. ED MD 1 further stated the treatment plan would be based on the findings from the CTA results; if the CTA findings were abnormal, the patient needed the neurological interventionalist; if the CTA finding were not abnormal, Hospital B would accept Patient 1 with neurosurgeon consult. ED MD 1 stated ED MD 1 was informed the CTA result was abnormal. ED MD 1 stated ED MD 1 assumed the TC would work with the ED nurses to find the on-call neurological interventionalist; coordinate the transfer; and find the hospital bed, accepting physician, and neurological interventionalist. ED MD 1 stated he was informed Patient 1 had an assigned hospital bed and had been accepted by the ICU physician of Hospital B. ED MD 1 stated ED MD 1 ordered to discharge Patient 1 on 9/5/22 at 0630 hours that was closed to the end of his shift and ED MD 1 transferred the patient care to ED MD 2. ED MD 1 stated ED MD 1 did not contact the accepting physician or the neurological interventionalist. ED MD 1 stated he documented the patient care in the medical record.

On 11/3/22 at 1333 hours, an interview and concurrent review of Patient 1's medical record was conducted with ED MD 2. ED MD 2 stated ED MD 2 did not call or contact any physician of Hospital B. ED MD 2 stated Patient 1's transfer was arranged by the night shift. ED MD 2 stated it was the ED physician's responsibility to call the specialty of the receiving hospital, but he did not call Hospital B's specialist for Patient 1. ED MD 2 confirmed ED MD 2 did not complete the Disposition section of the Blank ED Progress Note.

b. Review of the hospital's P&P titled Stroke Team, ED Activation dated September 2019 showed the following:

* The Purpose section showed the activation of Stroke Team alerts appropriate team members for staffing and patient placement.

* The Procedure section showed for all ED patients with stroke symptoms and signs less than 24 hours from time of onset, activation of the Stroke Team will run as follows:

- ED Physician and Telestroke Neurologist/Stroke Neuro Interventionalist/Neurosurgeon will decide appropriate treatment for the patient with suspected stroke.

- Stroke documentation is completed in the EMR.

- The goal times from the arrival to discharge for HLOC is 90 minutes.

Review of the hospital's Suspected Stroke Algorithm (undated) showed the following:

* The signs of suspected stroke include sudden weakness or numbness, sudden change in vision, sudden difficulty speaking or understanding, sudden dizziness or loss of balance, and sudden headache.

* If the patient has hemorrhage, call the on-call neurosurgeon at Hospital B, and transfer the patient for the HLOC.

* If transfer to HLOC needed, obtain destination from Hospital B (ED vs. BED); call [name of the ambulance company] Dispatch and " identify transport as "Hospital Stroke Transfer " ...obtain ETA (if > (more than) 30 minutes Call 9-1-1 for transfer) " ; prepare face sheet and insurance cards for EMS; and RN transferring patient to obtain written transport orders.

Review of the hospital's P&P titled Transfer of Patient to Specialty Center Care dated September 2019 showed the following:

* The Policy Statement section showed if a patient requires transfer to a HLOC than what the hospital can provide, the patient will be transferred following EMTALA guidelines. This includes acceptance from the receiving facility, acceptance by receiving physician, sending copies of medical records, completing transfer summary and all appropriate transfer forms.

* The Critical Stroke-Neurology section of the Procedure section showed the following:

- Contact Stroke Neurologist on-call at Hospital B. Once accepted by MD, call the ED to inform them of the transfer and call 911 for transfer.

- If Hospital B is unable to accommodate the patient, contact closest open Stroke -Neurosurgical center. Determine which one is open via the ReddiNet.

Review of the Progress Notes Report showed the following:

* On 9/5/22 at 0347 hours, the ED nursing staff received a call from [name of a staff] showed stated the neurosurgeon was on board and the staff was waiting for a call from the neurological interventionalist. At 0418 hours, the ED nursing staff received a call from [name of the staff] from the TC and was informed that Patient 1 would be admitting to Hospital B's CCU 2 under the attending physician (Physician 4) and the neurosurgeon.

* The form showed the ED nursing staff called eight ambulance companies at 0422, 0428, 0430, 0432, and 0437 hours. Ambulance Company 4 was one of those eight ambulance companies.

Further review of the Progress Notes Report showed the following:

* On 9/5/22 at 0422 hours, Ambulance Company 4 was called and provided the ETA as of 0800 hours (or three hours or 38 minutes later).

* On 9/522 at 0804 hours, Ambulance Company 4 was called to inquire of the ETA and advised that Ambulance Company 4 was still waiting for the nurse. They were looking at the ETA as of 0900 hours.

* On 9/5/22 at 0856 and 0857 hours, Ambulance Company 4 was called to inquire about the ETA and was advised that the ETA would be at 1000 hours. The ED staff called other ambulance companies and there was no available. This information was communicated with the House Supervisor.

* On 9/5/22 at 0910 hours, Patient 1 was still waiting to be transferred to Hospital B.

* On 9/5/22 at 0938 hours, the ED MD was updated the situation.

* On 9/5/22 at 0945 hours (or approximately five hours and 27 minutes after obtaining the destination from Hospital B), it was suggested to the charge nurse and ED MD to transfer Patient 1 via calling 911. The CNO approved to transfer the patient via 911. 911 was called and the patient was prepared to be transferred.

The ED staff did not transfer Patient 1 to Hospital B by calling 911 when the ED staff was aware the ETA from Ambulance Company 4 was more than 30 minutes as per the hospital's P&P.

On 11/2/22 at 1116 hours, an interview and concurrent review of Patient 1's medical record was conducted with the House Supervisor regarding the delay in transferring Patient 1 to the HLOC. The House Supervisor stated the House Supervisor got a call from an ED staff regarding the frustration from the care to Patient 1 in the ED. The House Supervisor further stated the frustrations were related to the TC services and ambulance transportation. The House Supervisor reviewed Patient 1's medical record and confirmed the nursing staff had called eight different ambulance services on 9/5/22 at 0422 hours; and Ambulance Company 4 provided the ETA as of 0800 hours. The House Supervisor stated the ETA was changed to 0900 hours and again changed to 1000 hours. The House Supervisor further stated Patient 1 was finally transferred to Hospital B via 911. The House Supervisor stated the frustration related to the TC was when ED Charge RN 1 called the TC, it took a long time to find the on-call specialists. The House Supervisor stated the TC did not sense of the urgency of the HLOC needs.

On 11/2/22 at 1230 hours, an interview was conducted with the DON about the delay in transferring Patient 1 for the HLOC. The DON stated ED charge nurse should follow their chain of commands to get help. The ED RN could reach out to the House Supervisor, and then reach out to the Department Director. The DON further stated if needed, the ED RN could report to the CNO or CEO. The DON confirmed the nursing documents did not show the ED staff or ED Charge RN 1 had approached or reached out the Chain of Command for the delay in transferring Patient 1 to the HLOC.

On 11/2/22 at 1610 hours, an interview was conducted with the Medical Director of ED. The Medical Director of ED Stated Patient 1 was delayed in transferring to Hospital B because Patient 1 was a high acuity needed patient. The Medical Director of ED stated there was a long time to wait for the call back from the TC.

On 11/3/22 at 0904 hours, an interview was conducted with the Manager of ED/ICU/CCU about the delay in transferring Patient 1 for the HLOC. The Manager of ED/ICU/CCU stated she was aware that the list of the ambulance companies was not current, consistent, or clear. The Manager of ED/ICU/CCU stated the ED staff had to call the ambulance company(ies) by going through the list; and tried to call the ambulance company(ies) as their luck.

On 11/3/22 at 1045 hours, an interview was conducted with ED Charge RN 1 about the transferring Patient 1 to the HLOC. ED Charge RN 1 stated she tried to call multiple ambulance companies; she called all ambulance companies listed on the list and found one ambulance company that could transfer Patient 1 at 0800 hours, or in approximately four hours later. ED Charge RN 1 stated she endorsed this ETA of the ambulance company to the coming shift. ED Charge RN 1 further stated ED MD 1 was aware of this ETA of the ambulance company. ED Charge RN 1 stated on 9/5/22, she informed the problem of the delay in transferring Patient 1 to ED MD 1 and the House Supervisor as the chain of commands.

On 11/3/22 at 1200 hours, an interview was conducted with ED MD 1. When asked about the roles of the ED physician ED MD 1 stated the ED physician was providing medical treatment to the patients. When asked about the delay in transferring Patient 1 to Hospital B, ED MD 1 stated the transfer was on hold because the TC was looking for the neurological interventionalist. ED MD 1 stated he was aware that ED Charge RN called multiple ambulance companies and only one responded with the ETA as of 0800 hours. ED MD 1 stated it was common and it happened all the time when they needed. ED MD 1 state they did not have any control, they (the ambulance) told the ED staff when they could transfer the patient.

On 11/3/22 at 1333 hours, an interview and concurrent review of Patient 1's medical record was conducted with ED MD 2. ED MD 2 stated ED MD 2 was aware that the transport was delay when he took over the care for Patient 1. ED MD 2 stated ED MD 2 was aware that Patient 1 would be picked up by the ambulance company at 0800 hours. ED MD 2 stated ED MD 2 was aware the patient was a critical patient with intracranial bleeding. ED MD 2 stated the patient would need the neurological specialists immediately. ED MD 2 stated the patient with large and ruptured aneurysm could benefit with a surgical intervention such as craniotomy or a EVD shunt; unfortunately, this hospital was not equipped for those cares. ED MD 2 stated this patient's transfer to the HLOC was urgent and critical. ED MD 2 stated the patient should be transferred out ASAP. ED MD 2 stated ED MD 2 knew the patient's pupil was dilated and fixed on 9/5/22 at 0915 hours. ED MD 2 stated there was the delay in transportation; he tried to work with ED Charge RN 2; 911 was called; and Patient 1 was transferred to the HLOC on 9/5/22 at approximately 1000 hours. ED MD 2 stated ED MD 2 witnessed that the charge nurse kept calling the ambulance companies. ED MD 2 stated for patient's safety, the hospital should get the patient to be transferred out; but it did not happen for many times.

On 11/4/22 at 0900 hours, an interview was conducted with ED Charge RN 2 about the transferring Patient 1 to the HLOC. ED Charge RN 2 stated they could call 911 without the permission needed when transferring a patient who had brain bleed, to the HLOC. ED Charge RN 2 stated ED Charge RN 2 was not sure ED MD 2 helped with calling 911 when transferring Patient 1 on 9/5/22. ED Charge RN 2 stated an ambulance company was scheduled to come at 0800 hours which was known as being late. ED Charge RN 2 stated the TC had been utilized in transferring patients between hospitals. The TC would determine the accepting hospital and accepting physician, but ED Charge RN 2 was not sure what the responsibility of the TC should be.

On 11/4/22 at 1033 hours, an interview was conducted with the CEO. The CEO was asked about ambulance services relating to Patient 1's transferring event. The CEO stated the delay of ambulance in transporting patients was a common issue everywhere. The CEO stated he was new to this hospital and did not know the details of the delay in transferring Patient 1. The CEO stated the CEO expected all of hospital staff would use their chain of commands to elevate the needs.

On 11/4/22 at 1306 hours, an interview and concurrent review of Patient 1's medical record was conducted with the DON. The DON reviewed Patient 1's medical record and stated the ED staff should call 911 for the emergency transfer. The DON further stated for any patient who needed the HLOC for diagnosis, testing, or treatment, they should transfer the patient ASAP.

c. Review of the Transfer Summary and Certification signed by the physician on 9/4/22 at 0300 hours and by Patient 1's family member on 9/5/22 at 0300 hours, showed Patient 1 was transferred to Hospital B at 1000 hours. The section of "appropriate medical records of the examination and treatment of the patient provided at the time of patient transfer" showing the sections of "Nursing Record" was checked.

On 11/2/22 at 1610 hours, an interview was conducted with the Medical Director of ED. The Medical Director of ED stated the Transfer Summary and Certification should be signed when the patient was about to be transferred.

On 11/2/22 at 1400 hours, an interview was conducted with ED RN 1. When asked, ED RN 1 stated he prepared all records related to Patient 1 and gave them to 911 transporters; those records included the Ambulatory Assessment, Progress Notes report, and Vital Sign report.

On 11/3/22 at 0904 hours, the Manager of ED/ICU/CCU requested Hospital B for Patent 1's medical records that were sent to Hospital B by ED RN 1. However, there were no copies of the Ambulatory Assessment, Progress Notes report, and Vital Sign report were sent to Hospital B. The Manager of ED/ICU/CCU confirmed the findings.


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2. Review of the hospital's P&P titled Contracted Services dated August 2020 showed the following:

* A contractual agreement is a form of written agreement with another organization, group, agency, or individual to provide care, treatment, and/or services on behalf of the organization.

* There shall be a written contractual agreement with each contract entity providing care, treatment, and service. The expectations of the contract entity, as well as the nature and scope of care, treatment, and services to be provided shall form a part of the contractual agreement.

* Contracted entities providing patient care shall be evaluated in relation to the expectations placed upon them by the organization. In general, the evaluations should be conducted on an annual basis; however longer or shorter time frames may be allowed based on the history and performance level of the contract entity.

* The results of the evaluation should be submitted to the appropriate clinical leaders and medical staff for review and input.

* Evaluation Process includes the following:

- On an annual basis, the Department Director will com