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Based on a review of medical records, hospital policies and procedures, Emergency Medical Services reports, and staff interviews, it was determined that multiple individuals, who came to the hospital's emergency department (ED) with presenting signs and symptoms of seizures (A burst of uncontrolled electrical activity in the brain, the burst of electoral activity causes stiffness, twitching, and changes in behavior), Headaches, Head injuries, Altered Mental Status (AMS-a change in mental function that stems from illnesses, disorders and injury affecting the brain) , and Cerebrospinal Fluid (CSF-is a clear colorless body fluid found within the tissue that surrounds the brain and spinal cord) leak, were not provided an appropriate medical screening examination. The facility failed to monitor patients in accordance with their own policies and failed to meet the needs of the patients while waiting in the emergency department. The hospital failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #10, Patient #14, Patient #15, Patient #16, Patient #17, Patient 18, Patient #19, and Patient #20) of 20 sampled ED medical records reviewed.


Refer to findings in Tag A- 2406.

Based on a review of medical records, hospital policies and procedures, Emergency Medical Services reports, autopsy report, and staff interviews, it was determined that multiple individuals, who came to the hospital's emergency department (ED) with presenting signs and symptoms of seizures (A burst of uncontrolled electrical activity in the brain, the burst of electoral activity causes stiffness, twitching, and changes in behavior), Headaches, Head injuries, Altered Mental Status (AMS-a change in mental function that stems from illnesses, disorders and injury affecting the brain) , and Cerebrospinal Fluid (CSF-is a clear colorless body fluid found within the tissue that surrounds the brain and spinal cord) leak, were not provided an appropriate medical screening examination. The facility failed to monitor patients in accordance with their own policies and failed to meet the needs of the patients while waiting in the emergency department. The hospital failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for 14 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #10, Patient #14, Patient #15, Patient #16, Patient #17, Patient 18, Patient #19, and Patient #20) of 20 sampled ED medical records reviewed.

The findings include:

1. The facility's policy titled "Emergency Screening, Stabilization, and Transfer, 7.11.16, effective 04/2023, Policy StatID1346593 was reviewed. The Policy revealed in part, "DEFINITIONS: A. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual (or, with respect to pregnant woman, the health of the woman of her unborn child) in serious jeopardy , (ii) serious impairment to bodily functions, or (iii) serious dysfunction f any bodily or part ... IV. PROCEDURES: A. EMERGENCY MEDICAL SCREENING EXAMINATION: 1. Any individual presenting for emergency care at BH hospital shall be provided with an emergency medical screening examination to determine whether that individual is experiencing an emergency medical condition. 2. Medical screening examinations shall be conducted by an ED (emergency department) physician, an Advanced Practice Registered Nurse, a physician's assistant, or a Qualified L&D Nurse. 3. Depending on the individuals presenting signs and symptoms, medical screening examination may involve a wide spectrum of actions, ranging from a simple process, (e.g., a brief history and physical examination) to a complex process that also includes performing ancillary studies and procedures (e.g., lumbar punctures, clinical laboratory tests, CT scans, and/or other diagnostic tests and procedures)."

2. The facility's policy titled, ED Triage Policy 7.01.04, effective 08/2023, Next review 08/2024, Policy StatID13972368, was reviewed. The policy revealed in part, "Procedure: Process ...K. Reassessments waiting patients: i. Nursing reassessments should be completed based upon the chief complaints, patient condition, acuity and at appropriate intervals. ii. Nursing reassessments should be completed with any change in condition while patient is waiting to be seen by a physician."

3. The facility's policy titled "Seizure Precautions, 7.03.03, effective 03/2023, Next review 03/2024, Policy StatID13389680, was reviewed. The policy revealed in part, "IV Procedures A. Seizure Precautions should be instituted for the following patients: 1. Physician orders for seizure precautions ....4. Patient admitted with head trauma, brain tumor, alcohol withdrawal, admitting diagnosis of subdural hematoma ...B. Precautions: 1. Educate patient/family regarding seizure precautions ...3. Cardiopulmonary monitor and pulse oximetry, as ordered. 4 Perform neuro checks, as ordered. 8. Maintain IV access per physician order ...9. document seizure precautions instituted in medical record."

4. The medical record for patient (Pt.) #1 revealed the patient arrived at the Emergency Department (ED) at 2:24 PM on 2/20/2023, via privately owned vehicle accompanied by his father. The patient's reason for the ED visit revealed in part, "Chief complaint ...seizures (a sudden uncontrolled burst of electrical activity in the brain) family believes that he had 2 (two) focal seizures in the group home ...change in what he normally does. Pt. is autistic (a broad spectrum of conditions characterized by challenges with social skills, repetitive behaviors, speech and non-verbal communications).

The patient was triaged (sorting of patients in the ED according to the urgency of their need for care) by a Registered Nurse (RN) at 2:45 P.M. The triage acuity level was 2 (need to be seen rapidly, quickly, needs multiple resources). The patient consent for treatment was signed by the patient's father. The vital signs at 2:45 P.M. was listed as: Blood Pressure: 109/75; Heart Rate: 124 (normal heart rate is 60-100); Respirations: 21; and Oxygen saturation: 94%on room air. There were no other vital signs done by the staff during the patient's stay in ED lobby. Documentation in the medical record section titled "ED Notes" revealed in part, "Prior to patient being moved from the ED by the father, this patient was assigned to ED 8 room at 6:17 p.m. ED ACP (Associate Care Provider) ... was alerted to move this patient to the assigned room, and the patient was moved to the Electronic Health tracker board to the assigned room of ED 8 and a subsequent RN and physician was assigned. At 6:35 PM ACP ... notified the ANM (Assistant Nurse Manager) that the patient was being removed from the ED because of the long wait in the lobby. At 6:37 PM the patient disposition was set to Left without being seen (LWBS) after triage." Documentation revealed that on 2/20/2023 the patient physically left the ED at 6:05 PM. Despite the patient being assessed as an ESI level 2 Emergent, presenting complaint of seizures, and an abnormal heart rate of 124. The hospital failed to implement its ED Triage policies that required reassessments of waiting patients and nursing reassessments should be completed based upon the chief complaints, patient condition, acuity and at appropriate intervals while patient is waiting to be seen by a physician." Patient #1 did not receive a reassessment of seizure activity or heart rate while the patient waited in the hospital's ED lobby for 3 hours and 58 minutes. Patient #1 was not seen by an ED provider for a medical screening examination on 2/20/2023 to determine whether an emergency medical condition existed when he was brought to the ED seeking medical care and treatment. The medical record also did not contain documentation that the individual or person acting on the individual's behalf provided informed refusal of examination, treatment, or both, after being advised of the risks and benefits.

On 09/22/23 at 10:00 a.m., a return phone call was received by the complainants, the parents of Patient #1. Their son (P #l) was "autistic and non-verbal." The complainants, the parents of Patient #1, were taking care of him at home up until sometime in 2019. In 2019 their son became very aggressive and became physical with them. They decided to take him to a hospital and the hospital Baker Acted him. The hospital placed him on some meds and his emotions leveled out. They decided to file a complaint about that facility at that time. They decided that he should go to a group home at the time of his discharge. In 2020 their son had another incident at another facility (they did not go into detail) and that is when they stated that they have a database of all their complaints/lawsuits to various facilities over the years. The parents then discussed what had happened at Baptist South. The mother stated that she was out at lunch while her son was at a follow up appointment regarding his injuries that occurred at the group home. The son was also being seen for an eye appointment for a treatment to his eyes. The treatment he was receiving for his eyes had a potential side effect of seizures. She stated on a side note that they have filed a complaint with that facility and contacted a lawyer due to the seizures. They believe this eye treatment was the root cause of his new onset seizures. The son also received therapy to assist in his typing communication. He was able to type some communication. When the mother went to pick the son up from his follow up appointment, he had what appeared to be a focal seizure in the car. She drove him home but did not bring him into the house. She placed blankets and pillows in the back of their Expedition SUV and left him there until the father got home (unknown amount of time.) When the father got home, they decided to take him to an Emergency Department (ED). They stated that they live closer to Hospital B but went to Baptist South out of a recommendation from a friend. They stated they live about 25 minutes away from Baptist South. They stated that they looked up the ED wait times for various hospitals in the area and Baptist South had the longest wait time of 123 minutes. When they arrived at the ED of Baptist South, the father got a wheelchair and placed their son in the wheelchair. The mother went and parked their SUV. They stated that their son was triaged when they arrived by an Asian nurse. That was the only time he was assessed. While waiting in the ED, the son became hungry, and they got him some fries and water. He was able to eat and drink all of it with no difficulty. Dad later took him to the bathroom, and he stated that there were no issues in the bathroom. At 4:43 PM they called the administration and complained about the wait time. The Administration stated they would investigate it. The administration called them back and stated that it should not be much longer that the ED was working on a room. At 5:45 PM their son started to become agitated. She stated that a bed was assigned at 6:00 PM, but a new cardiac arrest patient arrived. They decided to leave the ED. At 6:09 PM, after leaving, the father called administration and left a message. After leaving Baptist South they stated that they decided to go have dinner and then discuss if they should take their son to another hospital related to his seizures. On their way to dinner, their son collapsed in the back of their SUV. They pulled over and called 911. The EMS stated Baptist Hospital was closer/faster. The son continued to be coded in the ED of Baptist South and ultimately, he passed away at 7:25 PM. The parents consented to his eyes, skin, and organs being donated.

5. The medical record for patient #2 was reviewed. The patient arrived at the hospital on 2/20/2023 at 1:12 p.m., via car. Patient #2's Chief Complaint was "Migraine (Pt. states that she had been having a headache for 11 days now and had been taking medications that didn't help). The patient's vital signs at 2:12 p.m., was listed as: Temperature: 98.0 F (Fahrenheit); heart rate 88; Respirations: 18; and Blood pressure: 165/114 (normal blood pressure 90/60 mmHg to 120/80 mmHg); and oxygen saturation was 97% on room air. The patient's pain score :(Pain score scale on a chart that measures different levels of pain from zero (no pain) to 10 (worst pain - Unspeakable pain), moderate pain 4-6 (interferes with activity of daily living) 7-9 (severe pain- Disabling-unable to perform activities of daily living) was 7. At 2:14 p.m. the patient's ESI level was listed as "Patient Acuity:3 (Urgent). At 2:16 p.m., the patient's acuity level was changed to Patient Acuity: 2 (Emergent). Further documentation revealed that at 5:17 p.m., "Patient dismissed." The section of the medical record titled "ED Disposition" the ED Registered Nurse documented the patient "LWBS (Left without being seen) after Triage." There was no documentation in the medical record to indicate that the ED physician or a QMP was notified of the patient's elevated blood pressure, complaint of severe headache, or the change in her ESI level from Urgent to Emergent. No medical screening examination was done at all by a QMP; and no medical interventions were implemented for Patient #2's medical complaints while in the ED on 2/20/23.

6. The medical record for Patient #3 revealed that Patient #3 arrived at the hospital's ED on 2/4/2023 at 10:11 p.m. via car. Patient #3's Reason for visit was listed as "Chief Complaints ...Panic Attack (having a panic attack which is causing a HA (headache) and nausea. Has a history of anxiety, depression. Has medical marijuana card did not smoke today, having tremors), Headache." Documentation revealed the patient was alert, and her vital signs were within normal limits. The Pain level was listed as acute pain, Pain Score level of 8. The patient's triage started at 10:20 p.m. At 10:21 p.m. the patient' s triage was listed as "Patient Acuity:2" (Emergent). The RN documented the patient did have a suicide screening evaluation, which was negative. Continued review revealed that at 11:01 p.m., "Patient dismissed." The section of the medical record titled "ED Disposition" the EDRN Documented "ED Disposition LWBS after Triage." There was no documentation in the medical record to indicate that the ED physician or the QMP was notified of the patient's pain level of 8, reported complaint of nausea and that she was experiencing a panic attack. There was no medical screening examination completed by a QMP nor documentation of further assessments.

7. The medical record for Patient #4 was reviewed. Review of the medical record revealed that Patient #4, a 42-year-old male, presented to the hospital's ED on 12/12/2022 at 11:45 a.m., via car. Review of the section of the medical record titled "Patient Care Timeline" revealed that at 11:46 a.m. the patient's arrival complaint was listed as "Head injury." Further review of the medical record revealed the patient was not triaged, no vital signs were taken, and no information was documented beyond this point. At 1:36 p.m., the Physician Assistant notes revealed the patient left without being seen. At 4:04 p.m., the EDRN documented the patient's disposition as "LWBS after triage." Patient #4 did not receive a medical screening examination by a QMP, and no medical interventions were implemented for his medical complaints of "head injury" when he presented to the ED on 12/12/2022.

8. The medical record for Patient #5 revealed that Patient #5 arrived to at the hospital's ED on 12/29/2022 at 1: 30 p.m. via car. The patient's Reason for visit was listed as "Chief complaints" of fall and Head injury. A review of the ED Notes included ED RN documented Tripped on uneven ground, hit head on a car bumper, no loc (Loss of consciousness). No open wound. C/o (complaint of) low back pain, neck, shoulder pain, also right knee injury." The patient's triage acuity level was listed as 2 (Emergent) and the triage was completed at 1:40 p.m. The patient's vital signs were reviewed and were within normal limits. The patient's pain score was listed as an 8. The patient's injury mechanism onset was on 12/29/2022. Documentation by the ED RN revealed the patient was dismissed at 3:29 p.m. There was no documentation in the medical record to indicate what happened to the patient who presented to the hospital's ED with a complaint of fall with head injury and complaining of level 8 pain in his low back, neck, shoulder and right knee pain. There was no medical screening examination conducted by the QMP; and no medical interventions were implemented to address the patient complaint of Head injury from a fall. Further review revealed that patient #5 LWBS after triage at 3:51 p.m.

9. The medical record for Patient #6 revealed that Patient #6 arrived via car to the hospital's ED on 3/7/2023 at 1:48 p.m. The reason for the ED visit was listed as "Chief complaints: Nausea, Bloated, altered Mental status (Pt. Husband sts (states) pt. has loss of appetite, nausea and confusion for about 3 days, Sts he had noticed bloating); Shaking (Pt. Sts her legs have been shaking due to neuropathic pain).The patient's vital signs were listed as: Temperature 98.2; Heart rate: 67; Respirations :16; Blood Pressure :135/85; Oxygen Therapy: 100% on Room Air. The patient's vital signs were within normal limits. A pain assessment was conducted, and the patient denied pain. The patient's triage acuity level was listed as 3 (Urgent). The RN documented the patient was "Alert" however failed to document if the patient was alert to her name, date, or her surroundings. Despite the patient's presenting signs and symptoms of altered mental status, confusion, reported loss of appetite, shaking, nausea and bloating, the patient did not receive a medical screening from a QMP. There were no medical interventions such as blood laboratory tests, or diagnostic work -up done based on Patient #6 triage complaints.

10. The medical record for patient #10 revealed that Patient #10 was an 81-year-old female who arrived via car to the hospital's ED on 12/13/2023 at 12:17 p.m. The reason for the ED visit was listed as "Chief Complaint concern for seizure." At 12:52 p.m., the triage RN nurse documented in part, "General complaint: Details: Associated Symptoms: I had a lens replacement in L (left) eye in April 2021 and it was never successful. I just had the R (Right) eye done 1.5 months ago and it was perfect. Yesterday i (I) was driving and I could feel this tightness on the R side of my face and my eyes were going crazy. Lasted about 1-1.5 min (minutes) and felt like i (I) was in a fog afterwards. Was able to keep hands on the wheel and pull over. I've had several of these episodes since ive (I've)had my eye done. My MD (medical Doctor) thought I had a seizure yesterday. I do have visual migraines. I still feel like I am in a fog." The patient's Vital Signs were listed as: Temperature 97.5; Heart Rate: 79; Respirations: 16; Blood Pressure: 141/85 (mild elevation of Blood Pressure); Pulse oximetry: 98% and denied pain. The patient's SSI acuity was 3 (Urgent). The patient was dismissed from the ED tracker board at 4:47 p.m. The was no evidence in the medical record to indicate the patient received a medical screening examination by a QMP. There was no documented evidence that necessary medical interventions were provided for the patient when she presented to the ED on 12/13/2023. Additionally, there were no orders obtained from the MD for seizure precautions related to patient #10's presenting s/s of "possible seizures"; no documentation the patient was educated on seizure precautions; and no documentation that seizure precautions were instituted, during her approximate 3.5 hours stay in the lobby, as stated in the facility's policy.

11. The medical record for patient #14 revealed the patient arrived via car ambulance on 12/8/2022 at 3:04 p.m. Review of the ED Triage Notes, the Triage Nurse "Hit on Tuesday, seen at downtown ed (emergency department) an has a negative ct (Computerized Tomography- diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body). Still having ha (headache), states 'someone told me they felt a fluid sac on the back of my head. Getting on a plane tomorrow and wanted to make sure I was ok.' Still having ha (headache), took 400 mg ibuprofen (medication used to treat fever, swelling pain and redness) this am with relief." Patient #14 Chief Complaint was listed as "Head Injury" the injury's onset was 2 days ago. The patient's triage acuity level was 3 (Urgent). The patient's signs vital were: Temperature: 97.9; Heart rate: 72; Respirations: 19; Blood Pressure: 136/101 (normal blood pressure 90/60 mmHg to 120/80 mmHg;) Oxygen saturation: 98% on room air. The patient's assessment on a pain score of 0-10 was 6 (moderate pain). According to the documentation the patient was "Alert". Documentation by the triage ED nurse revealed the patient's "ED Disposition: LWBS after Triage." According to medical record review the patient did not have a MSE performed by a QMP, and no medical interventions were performed.

12. The medical record for patient #15 revealed the patient arrived at the hospital's ED on 12/13/2022 at 5:55 a.m. via car. The reason for the ED visit was "Chief Complaint: Dizziness (Pt. was home when he felt dizzy, checked his blood pressure which was elevated. Denies any CP (chest pain), SOB (Shortness of Breath), HA (headache), n/v (nausea/vomiting), he took a medication Vascepa (medication used to reduce the risk of heart attacks and strokes) and think it might have to do with this. Hx (history) of htn (hypertension) takes Losartan (medication that treats high blood pressure)." The patient's triage acuity level was 3 -Urgent. The patient's vital signs were: 98.7; Heart rate -102 (elevated); Respirations: 18; Blood pressure: 161/102 (Elevated); Oxygen Saturation; 98% on room air. The patient denied pain and he was alert. Further review revealed that at 6:18 a.m., a stat 12 lead ECG (electrocardiogram- a quick test to check the heartbeat) was ordered by a physician. At 6:25 a.m. the ECG the final results were Abnormal ECG and Sinus Tachycardia (fast heart rate). The abnormal ECG was confirmed as being read by a physician. The patient's ED disposition was "LWBS after Triage" on 12/13/2022 at 10: p.m. Further review of the Medical record review revealed that no medical screening examination was done by a QMP. There was no documentation in the medical record to indicate the patient's elevated blood pressure was re-assessed or that that the ED physician was made aware of the patient's elevated blood pressure or heart rate. There was no evidence in the medical record to indicate that a MSE was performed by a QMP.

13. The medical record for patient #17 revealed the patient arrived at the hospital on 3/27/2023 at 4:02 p.m. via car. At 4:03 p.m. The Triage RN documented the patient's presenting signs and symptoms at triage "Arrival Complaint: POSS (possible) SPINAL FLUID LEAK". At 6:10 p.m. the patient's chief complaint was updated to state, "Cerebrospinal Fluid Leak (Pt/ c/o clear fluid leaking from the right nostril when leaning over). Documentation by the Triage RN revealed the patient was "Alert." The patient's vital signs were" Temperature: 98.0; Heart Rate: 111 (abnormal/elevated); Respirations: 18; Blood Pressure: 172/99 (elevated); oxygen saturation: 100% on room air. The patient denied complaint of pain. Patient #17 ESI triage level was 2 (Emergent). Further review of the record revealed that on 3/27/2023 at 7:34 p.m. the patient's "ED Disposition" was "LWBS after Triage". There was no documentation in medical record to indicate that the QMP was notified of the patient's abnormal blood pressure, and elevated heart rate, or of the patient's statement of, "cerebrospinal fluid leak', " ...clear leaking from right nostril when leaning over." There was also no documentation of an assessment of a clear leakage from the patient's nostril. The facility failed to ensure that their policy was followed as evidenced by failing to ensure that this patient's abnormal blood pressure and heart rate was reassessed as stated in the facility's policy. The patient was not seen by a QMP for MSE, and no medical interventions were done relating to the patient's presenting signs and symptoms.

14. The medical record for patient #18 revealed the patient arrived at the hospital on 12/13/2022 at 4:21 p.m. via car, "Chief Complaint: Seizures." At 4:26 p.m., documentation by the Triage RN revealed in part, "General Complaint: Details: Associated Symptoms: my wife (patient's husband) had deep brain stimulation in April 2019, in November same year they had to reverse it. They had to reverse it. There was a cyst in brain tissue which caused left sided paralysis. Occasionally she will have a slight seizure where she falls into a deep sleep and won't wake up at all. She hears but cannot move the body. Had one of those episodes last night that lasted until this AM. Today feeling ok but afraid it will happen again." There was no documentation of an assessment of the patient's level of consciousness/mental status. The patient's vital signs were: Temperature: 97.9; Heart rate: 74; respirations: 20; Blood pressure: 128/101 (diastolic blood pressure abnormal); Oxygen saturation:100%; denied pain. Review of the medication list for this patient revealed that she was on Keppra (a medication used to treat certain types of seizures) 250 mg two (2) times a day. At 4:32 p.m. the patient was triaged as an ESI acuity 2 (Emergent). The patient's "ED Disposition" on 12/13/2022 at 7:30 p.m., was "LWBS after Triage." The was no evidence in the medical record to indicate the patient received a medical screening examination by a QMP. There were no orders obtained from the MD for seizure precautions related to patient #18's presenting complaint of "seizures." There was no documentation the patient's family member was educated on seizure precautions; and no documentation that seizure precautions were instituted during her approximate 3.0 hours stay in the ED lobby, as stated in the facility's policy.

15. The medical record for patient #19 revealed the patient arrived at the hospital's ED on 5/7/2023 at 4:25 p.m. via car. The patient's "Reason for Visit: Chief Complaint: Seizures (Seizures at home) laceration (Bilateral wrist lac(laceration), R (right) knee lac) Chest Pain (X 3 days). The ED RN Triage nurse documented the patient's level of consciousness as "Alert." The patient's vital signs were: Temperature: 97.7; Heart Rate: 101 (elevated); Respirations: 18; Blood pressure: 127/90, and oxygen saturation 97% on room air. The patient's ESI acuity level was 2 (Emergent). Further review of the record revealed that on 5/7/2023 at 5:15 p.m. the patient's "ED Disposition" was "LWBS after Triage". There was no documentation that a pain assessment was provided at triage, despite the patient complaining of chest pain. The patient's ESI acuity level was 2 (Emergent). Further review of the medical record revealed on 5/7/2023 at 4:51 p.m. physician orders were placed for a stat 12 lead ECG. Review of the medical record revealed the ECG was not done. The patient's "ED Disposition" was "LWBS after Triage." No medical screening examination was conducted by a QMP, no medical interventions related to the patient's complaint of seizures, and lacerations to bilateral wrists or right knee were addressed. Additionally, no suicide risk assessment was completed during the triage related to bilateral lacerations to the patient's wrist.

16. The Medical Record for patient #20 revealed the patient presented at the hospital's ED on 1/27/2023 at 1:10 P.M. via car. The "Reason for Visit: Chief Complaint: Seizures. I keep having what I thought were seizures. I was just here last night, but I blanked out and don't know what happened. Sister has a video of patient sitting on the bed walking around the house in nothing but a bra and pt appears to have a blank stare on her face." At 1:10 p.m., the triage RN documents the patient arrival complaint is "Blacken out." The patient's level of consciousness was "Alert." The patient's vital signs were: Temperature: 97.9; Heart Rate: 67; Respirations:16; Blood Pressure: 137/103 (diastolic number is elevated); Oxygen saturation 99% on room air. There was no documentation that a pain assessment was performed at Triage. The patient triage acuity was 3 (Urgent). Continued review revealed a suicide screening was done and it was negative for suicidal thoughts. The "ED Disposition: LWBS after Triage." There was no documentation in the medical Record to indicate the patient received a MSE by a QMP. Additionally, there was no documented evidence that medical interventions were provided to address the patient's presenting compliant of "Blacking out", elevated diastolic blood pressure, possible reported seizures, and an abnormal behavior at home. Further review revealed there were no orders obtained from the MD for seizure precautions related to patient #20's presenting complaint of "possible seizures"; no documentation the patient was educated on seizure precautions; and no documentation that seizure precautions were instituted during her hours stay in ED lobby as stated in the facility's policy.

17. On 9/7/2023 at 12:45 p.m., an interview was conducted with PCT (Patient Care Technician) Tech #1. He stated that he had worked at the facility for little over a year. He was working at the time Patient #1 was in the ED waiting room. He saw that P#1 had a room assigned. He went out to the waiting and called the patient's name, and when a patient leaves without being seen (LWBS), he places it on the ED board so that the team is aware. His role in the back of the ED included any ancillary tasks such as calling patients back to their assigned room, VS (vital signs), splints, assisting the staff as needed. Up front in the ED he completes EKG for any chest pain patient. He also takes VS every two hours on each patient while they are in the waiting room. Vital sign parameters included HR (heart rate) over or under 60, oxygen sat (saturation) less than 94%, RR (respiratory rate) over 18, BP (Blood Pressure) above 140 systolic, 100 diastolic. He stated that there is a mobile scanner that he uses. He scans the patient wristband and then takes the VS. The VS are auto loaded into the EHR (Electronic Health Record). He also keeps it manual in case the system does not cross over, and he would then manually input them into the EHR. He did not have any staffing concerns.

18. On 09/07/23 at 1:00 PM an interview was conducted with Triage Nurse she stated that she had worked at the facility since 2019. She was familiar with P# 1. She stated that when the patient came into the ED the mom immediately told her that the patient was autistic. It was difficult to get VS on him. She had to persuade him to get the VS. The mom stated that he had two focal seizures per patient's group home. The mom stated that the patient did not have a history of seizures. The patient did not display any other behaviors. He was not combative or screaming. Her concern was that he was autistic but did not see any medical issue that would prioritize his care over the other patients waiting. When the PCT called them back to the room, they were gone. The parents did not speak to her prior to leaving. Acuity level 2 was placed for P# l due to new onset seizure and her nursing judgment.

19. On 09/07/23 at 1:45 PM an interview was conducted with Patient Access Services (PAS) #1. She stated that she had worked at the facility for two years. She was working at the time P# l arrived but was unable to recall him or the situation. She stated that her role in the ED is to check patients in as they arrive. She gets their chief complaint and places it into the system. She then scans the palm of the patient's hand and places a patient ID band on their wrist. If the patient is actively in distress, she lets the triage nurse know immediately. She can see the ED waiting area from her desk. Any patients that demonstrate a sign of distress she immediately notifies the clinical team. She stated that some patients do leave without being seen. She stated that if a patient notifies her that they are leaving she checks to see if the patient has a room or not. She does not want them to leave if a room has just come open for them. She also stated that if someone appears to be in distress, she attempts to get a clinical person to speak to them before the patient leave Often the patient does not state they are leaving, and she does not know until the patient gets called to their room. She did not have staffing concerns.

The facility failed to ensure that their own policies and procedures were implemented to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the ED to determine whether or not an emergency medical condition existed for patient #'s: 1, 2, 3, 4, 5, 6, 10, 14, 15, 16, 17, 18, 19, and 20.