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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for five of 21 patients, Patients (Pts) 1, 3, 4, 8 and 18 when:

1.The hospital failed to provide an appropriate medical screen exam (MSE) for four of 21 patients (Patient 1, Patient 4, Patient 8 and Patient 18) when:
Patient 1 a homeless patient was brought in by ambulance (BIBA) with a complaint of leg pain and was told by Registered Nurse (RN) 3 he could not be registered and seen in the ED; no MSE was done.
Patient 4, a homeless patient was discharged from Emergency Department on 8/14/24 without an appropriate medical screening exam and discharge was not done in accordance with hospital homeless discharge policy.
Patient 8 was a 38 weeks 5 days pregnant woman who presented to Obstetrics Emergency Department (OBED) with a chief compliant of chest pain, and shortness breath, she was seen in OBED, cleared by an OB provider (physician who cares for women and their babies during pregnancy and childbirth), and was taken to main ED for a cardiac work up and was placed in the lobby after triage. Patient 8 was not assessed in accordance with the facility policy and medical screening exam was not started for over eight hours.
Patient 18, who was 21-week pregnant women was triaged in OBED the Medical Screening Exam (MSE) and triage assessment did not include fetal heart rate (FHR) in accordance with hospital policy prior to sending the patient to the main emergency department and eventual transfer to Hospital B behavioral health facility on 6/22/24.
(Refer to A 2406)

2.The hospital failed to provide stabilizing treatment within their capabilities for one of 21 patients, (Patient 3), with emergency medical conditions when Pt 3 was brought in by ambulance (BIBA) on 8/14/24 to the hospital ED with altered mental status, history of insulin dependent diabetes, high blood glucose and high blood pressure. An appropriate MSE was conducted by the ED physician and Pt 3 was discharged with high blood glucose and high potassium and the admission altered mental status had not improved. (Refer to A2407)

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE, an assessment performed by a Qualified Medical Personnel [QMP] for the purpose of determining whether an Emergency Medical Condition [EMC] exists) for four of 21 sampled patients (Patient (Pt) 1, Pt 4, Pt 8 and Pt 18 when:

1. Patient (Pt) 1 came by ambulance to the Emergency Department (ED) on 6/4/24 at 7:55 p.m. with a chief complaint of leg pain and was told by Registered Nurse (RN) 3 he could not be registered and seen in the ED. No MSE was done.

This failure resulted in the hospital not determining whether an Emergency Medical Condition (EMC) existed which placed Pt 1 at risk of harm, injury and possibly death.

2. Pt 4 was found in hospital gown on streets and was brought to the hospital emergency department by Emergency Medical Services (EMS) on 8/14/24. Pt 4 was a homeless patient that had been discharged from the hospital's inpatient unit on 8/13/24. Pt 4 was subsequently discharged from Emergency Department on 8/14/24 without appropriate medical screening exam and discharge was not done in accordance with hospital homeless discharge policy.

This failure resulted in Pt 4 returning to ED three hours and nine minutes after his first ED discharge on 8/14/24. Pt 4 was found to be positive for COVID (SARS-COV-2 respiratory infection) and was admitted for congestive heart failure (CHF-long term condition when the heart cannot pump blood well enough for the body) exacerbation.


3. Pt 8 was 38 weeks 5 days pregnant woman who presented to Obstetrics Emergency Department (OBED) with a chief compliant of chest pain, and shortness breath, she was seen in OBED, cleared by an OB provider (physician who cares for women and their babies during pregnancy and childbirth), and was taken to main ED for a cardiac work up. Pt 8 was assigned Emergency Severity Index (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious) of 2 and was placed in the lobby after triage. Pt 8 was not assessed in accordance with the facility policy and medical screening exam was not started for over eight hours. Pt 8 eloped from the main waiting room with abnormal labs and was not called by the hospital staff or provider in accordance with the hospital policy.

This failure had the potential for adverse outcome including cardiac arrest for Pt 8 and placed her and her unborn child at risk of harm.


4. Pt 18, who was 21-weeks pregnant was triaged in Obstetric Emergency Department (OBED) on 6/21/24 and the Medical Screening Exam (MSE) and triage assessment did not include fetal heart rate (FHR) in accordance with hospital policy prior to sending the patient to the main emergency department and eventual transfer to Hospital B behavioral health facility on 6/22/24.

This failure had the potential for an inaccurate Maternal Fetal Triage Index (MFTI - The MFTI is a five-level obstetric acuity tool for nurses to use when they triage a woman presenting for care to a birth unit in order to prioritize the woman's urgency for provider evaluation) evaluation and placed the unborn child at risk of harm or injury.


Findings:

1. During a review of the "ED 48-hour Return Report (RR, log indicating patient return visits to the ED within a 48-hour period)", dated 6/2024, the "RR" indicated Pt 1 came to the ED on 6/4/24 at 2:29 a.m., 12:17 p.m., and 7:55 p.m.

During a review of Pt 1's "ED Patient Care Timeline (PCT)", dated 6/4/24 at 2:28 a.m., the "PCT" indicated Pt 1 came to the ED with the chief complaint of chronic left knee pain with medication prescribed by Pt 1's Primary Care Physician (PCP) was not helping. The "PCT" indicated Pt 1 was administered ketorolac (a non-steroidal anti-inflammatory for pain), acetaminophen (medication to treat pain and fever) and a lidocaine patch (a local numbing medication applied to the skin, which provides pain relief for 8 - 12 hours). The "PCT" indicated Pt 1 was discharged at 8:33 a.m.

During a review of Pt 1's "ED Provider Notes (PN)", dated 6/4/24, indicated Pt 1 was discharged without any prescriptions and was instructed to follow up with a family medicine physician and schedule an appointment with orthopedics (physicians specializing in the musculoskeletal system).

During a review of Pt 1's "Emergency Medical Services Run Sheet (RS, a record of ambulance services)", dated 6/4/24 at 11:43 a.m., the "RS" indicated, " ... Pt states he has been drinking. Pt called us out for leg pain and being intoxicated. Leg pain been going on for 20 years ... Pt allowed crew to assess ... per pt request he was transported to [hospital name] ...".

During a review of Pt 1's "PCT", dated 6/4/24 at 12:17 p.m., the "PCT" indicated Pt 1 arrived I the ED at 12:17 p.m. with a chief complaint of alcohol intoxication and left leg pain for more than 20 years with a current pain score of 6/10 (scale of 0-10, 10 being the worst pain). The "PCT" indicated Pt 1 was assessed for violence using the Broset Violence Checklist (checklist to assess for short-term prediction of violence and an absence of behavior gives a sum score of zero) and Pt 1's sum score = 0 at 12:23 p.m. The "PCT" indicated Pt 1 was placed in a room at 12:30 p.m. the "PCT" indicated, " ... 12:31 [p.m.] ... Patient BIBA [brought in by ambulance] for alcohol intoxication and left knee pain x 1 year. Patient was previously here this morning at 0200 [2:00 a.m.]. Has been given multiple resources multiple times. Patient unruly, verbally abusive to md [medical doctor], able to ambulate while holding onto things due to knee pain. No increased wob [work of breathing]. Noted to have wet pants due to incontinence. No vomiting or distress noted at this time ... RN 5 ... 06/04/24 12:34 [p.m.] ...". The "PCT" indicated, " ... 12:40 [p.m.] ... ED disposition set to Discharge ... [MD {Medical Doctor} 1] ... 12:47 [p.m.] ... Patient is not cooperating with interview or propose workup, and as such will be discharged ... [Scribe 1, an individual who documents for the physician] ... 12:48 [p.m.] ... Patient refused to sign discharge paperwork. Advised that he has been given resources multiple times and chooses to keep getting drunk. Security at bedside. Tech [ED Technician] at bedside with wheelchair to wheel patient out. he has cell phone to be able to call for a ride ... RN 5 ... 13:00 [1:00 p.m.] ... Patient discharged ... RN 5 ...".

During an interview on 9/5/24 at 1:05 p.m. with RN 5, RN 5 stated Pt 1 was in the ED on 6/4/24 for his second visit of the day and he was intoxicated per EMS, " ... you could see it in his eyes ...", and belligerent and cursing at the doctor. RN 5 stated the doctor only requested a Road test (a test for intoxication by having the person walk a straight line) and she believed the physician attempted to complete an MSE. RN 5 stated Security escorted him out after approximately 30 minutes.

During a review of Pt 1's "PN", dated 6/4/24 at 12:17 p.m., the "PN" indicated, " ... Chief Complaint: leg Pain and Alcohol Intoxication (+ [positive for] ETOH [scientific reference to alcohol] with last ETOH at approx. [approximately] 1130 [11:30 a.m.] which a pint of liquor [sic]. Pt also with left leg pain for 20+ years per pt) ... History limited to due pt [sic] being aggressive and showing anger ...Review of Systems [ROS] Reason unable to perform ROS: aggression and anger ... Physical Exam ... Constitutional [a symptom indicating general effect of a disease]: ... Patient is very upset, verbally aggressive, refusing to follow any directions ... Musculoskeletal ... patient is very angry, and will not allow me to examine his knee ... Neurological ...He is alert and oriented to person, place, and time ... Stable ambulation with left limp at baseline ... Psychiatric ... Mood normal. Affect is angry ... Behavior is agitated and aggressive ... Thought content normal ... Judgement is impulsive ...Speaking in non-slurred speech ... Medical Decision Making ... patient is very well-known to me with multiple previous visits, was here at 2 AM this morning and eloped ... On instigating conversation with him, he he [sic] became increasingly upset ... ED Course ... 1247 [12:47 p.m.] ... Patient not cooperating with interview or proposed workup, and as such will be discharged ...".

During a review of Pt 1's "RS", dated 6/4/24 at 7:20 p.m., the "RS" indicated, " ... Pt complains of chronic L [left] knee ... pain scaled 10/10, that is constant ... Pt requests to be taken to [hospital name] ... Upon arrival to [hospital name], the pt sat in a wheelchair and was taken to the lobby. [Hospital name] nurse refused to sign the pt into their care because the pt has been to their ED 3x [3 times] today ...". The "RS" indicated, " ... Refused ..." on the signature line for Transfer Receiver of patient care.

During a concurrent interview and record review on 9/5/24 at 9:10 a.m. with the Emergency Department Director (EDD), Pt 1's "ED Patient Care Timeline (PCT)", dated 6/4/24 at 8:10 p.m., was reviewed. The EDD stated she was made aware of Pt 1 being turned away on 6/5/24 from an anonymous report. The EDD stated she and Risk Management began to investigate the incident. The EDD stated the hospital surveillance video was viewed and showed Pt 1 was never registered and RN 3 talked to Pt 1 outside. The EDD stated the video showed Pt 1 left the hospital. The "PCT" indicated, " ... 6/4/24 ... 19:55 [7:55 p.m.] ... Patient arrived in ED ... [Regional Patient Access Manager (RPAM)] ... 20:10 [8:10 p.m.] ... Patient dismissed ... RN 7 ...". The EDD stated she had the RPAM document the arrival of Pt 1 retrospectively (after the fact) because the RPAM knew how to document retrospectively. When asked if Pt 1's "PCT" was accurate, the EDD stated she believed it was accurate and captured Pt 1's arrival to the ED even though Pt 1 was not allowed to register in the ED. The EDD stated RN 3 dismissed Pt 1 and was under the impression patients returning within 24 hours with the same complaint and no new issues did not need another MSE. The EDD stated during the investigation, other staff were under the same impression. The EDD stated 100% of patients seeking care at the ED need to be registered at every encounter.

During a concurrent interview and record review on 9/5/24 at 10:55 with Risk Manager (RM) and the Director of West Region Risk Management & Safety (DRM), Pt 1's "Root Cause Analysis and Investigation Communication (RCA)", dated 6/5/24, was reviewed. The "RCA" indicated a possible EMTALA violation summary was sent to senior leadership prior to the investigation and the concern was a patient was not offered a MSE twice on 6/4/24. The "RCA" indicated Risk Management recommended a legal representative review and the legal representative determined the facility did not have to self-report the EMTALA violation. The RM stated senior leadership made the decision not to self-report the violation to the Centers for Medicare and Medicaid Services (CMS). The "RCA" indicated interviews were conducted with staff, Pt 1's chart was reviewed, and video surveillance was viewed. The RM stated it was determined there was a " ... cultural normalized deviance ..." from policy. The "RCA" indicated the Former Director of Quality (FDQ) recommended a " ... book of action [record of actions taken] ...", as the California Department of Public Health (CDPH) would probably find the violation on an EMTALA Revisit Survey for the 3/2024 EMTALA Survey, while asking for six months review the "ED 48-Hour Return Reports".

During a concurrent interview on 9/6/24 at 8:06 a.m. with RN 3, RN 3 stated she was in the role of Patient Coordinator (PC) and she was aware of Pt 1's previous visits on 6/4/24 when she received report in the afternoon. RN 3 stated she was notified by a Patient Access Registrar (PAR) when Pt 1 arrived on the third visit. RN 3 stated the PARs did not usually notify her of patient's arrivals, but the PARs were informed not to register Pt 1 again by the day shift PC (RN 2). RN 3 stated she told Pt 1 he could not be registered and seen in the ED on 6/4/24. RN 3 stated when she was oriented to her job, she was told if a patient returned with the same complaint and no new issues, she was not to register the patient. RN 3 stated she has worked in EDs for 18 years and her understanding of Federal Emergency Medical Treatment and Labor Act (EMTALA) regulations was a MSE was good for 24 hours. RN 3 stated she now has a very different understanding of EMTALA.

During a review of the facility's policy and procedure titled "Emergency Care Services (ECS)", dated 2/2024, the "ECS" indicated, " ... Outcome: To Provide care in a safe and consistent manner for patient's receiving care in the emergency department ... Policy: Triage: ... Patient access will perform a quick registration process on all patients entering the Emergency Department ... Emergency Severity Index (ESI) Score will be given after initial assessment by a trained triage RN ... All patients who seek care will be offered a medical screening exam (MSE) by ED provider ...".

During a review of the facility's policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance (EMTALA)", dated 6/2024, the "EMTALA" indicated, " ... Procedure ... Examination and Treatment ... The Hospital will provide an MSE, within the capacity of the Hospital, for purposes of determining whether an EMC exists, to the following individuals ... any individual presenting at a DED [Dedicated Emergency Department] seeking examination and treatment of a medical condition ... any individual presenting on Hospital Property other than a DED seeking examination and treatment of a potential EMC ...".


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2. During a review of Pt 4's "Ambulance report", with date of service 8/14/24 at 7:48 a.m., the "Ambulance report" indicated, " ...Incident Address: Surface Street ...The patient has no specific complaint. He has cough, some [shortness of breath (SOB)] with exertion and some occasional swelling/edema to his lower extremities, however, nothing new or acute. He was seen at the [Emergency Department (ED)] yesterday and evaluated [without] any diagnosis. He is not very compliant with his medications for his [blood pressure] and heart failure. He is still in his hospital gown and socks from his visit yesterday ..."

During a concurrent interview and record review on 9/5/24 at 10:45 a.m. with the Emergency Department Director (EDD) and Quality Analyst (QA) 1, Pt 4's medical record was reviewed for his ED visit on 8/14/24. The document titled "Patient Care Timeline" dated 8/14/24 was reviewed and indicated Pt 4, 69-year-old Male, was brought into ED by ambulance on 8/14/24 at 8:22 a.m. The ED chief complaint was "weakness- generalized ...here yesterday, states we didn't tell him what's wrong. States he's living in transitional living. Everything done yesterday"'. On 8/14/24 at 8:25 a.m. Pt 4 was assigned ESI level 3. Initial vitals on 8/14/24 at 8:25 a.m. indicated Heart Rate 83 beats per minute (bpm) (normal 60-100), Temperature 36.6, Blood Pressure (BP) 151/109 millimeters of mercury (mmHg - Unit of measurement)(normal 120/80), Oxygen saturation 92% (spo2- a measurement of the amount of oxygen in the blood) (normal 95- 100%). On 8/14/241 at 10:03 a.m. physician was assigned, and medical screening exam (MSE) was started. X-ray (a quick, painless test that captures images of the structures inside the body) for shoulder and ibuprofen was ordered on 8/14/24 at 10:06 a.m. Pain assessment on 8/14/24 at 10:10 a.m. indicated right shoulder pain level of 6 (1-10 pain scale is a numeric scale that measures pain from 0-no pain to 10-the worst pain possible). On 8/14/24 at 10:07 a.m. Pt 4 received ibuprofen 600 mg. On 8/14/24 X-ray of the shoulder was completed at 10:39 a.m., and at 10:43 a.m. Pt 4's disposition was set to discharge. On 8/14/24 at 11:21 a.m. documentation by licensed practical nurse (LPN) indicated Pt 4's Spo2 was 88% and ED physician was notified. The Spo2 on 8/14/24 at 11:23 a.m. were 96%. The EDD stated documentation by LPN on 11:33 a.m. indicated, " Patient received discharge instructions from provider and has no further questions at this time, [Vitals Signs Stable] ...[Alert and oriented x4 (A&Ox4 - is a medical term that means someone is fully alert and oriented to their person, place, time, and situation)], GCS 15. Ambulatory with steady gait out ED Exit. Per patient he lives in a home with 5 others and there will be someone home to open door to him. Patient did not want bus token stated he doesn't have to pay when he takes bus [Pt 4 was provided fluids to drink per EDD] ". Pt 4 was discharged on 8/14/24 at 11:35 a.m.

During a concurrent interview and record review on 9/5/24 at 10:50 a.m. with the EDD and QA 1, Pt 4's medical record was reviewed for his first ED visit on 8/14/24. The document titled "[name of facility] Emergency Department Note" dated 8/14/24 was reviewed. The document indicated, " ...Past Medical History ... Acute on chronic systolic Congestive Heart Failure [serious condition that occurs when the heart is unable to pump blood efficiently] ... Anemia [problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue] ...Benign Hypertension [high blood pressure] ...Chronic Kidney Disease, stage III (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), History of COPD [a common lung disease causing restricted airflow and breathing problems], Type 2 Diabetes Mellitus with chronic kidney disease without long term use of insulin[used as a medication to treat diabetes] ...Patient presents with mild shoulder pain and was found to have mild noninfectious arthritis. He is resting comfortably and safe for discharge and was advised outpatient follow-up with primary care. Emergent return precautions given ...". The EDD stated Pt 4 only received X-ray of the shoulder and ibuprofen during the ED visit. The EDD stated no labs, chest X-ray or other interventions were done during the ED visit. The EDD stated she looked at the previous encounter and Pt 4 was admitted in the hospital from 8/7/13 to 8/13/24 for CHF exacerbation and was discharged on 8/13/24, a day before the ED visit. The EDD stated the record reflected patient was discharged to an address and unable to comment why the patient was discharged in hospital gown and socks. The EDD validated the patient was flagged as homeless to the ED visit on 8/14/24 and was found on streets by EMS. The EDD stated Pt 4 was a return patient to ED with significant past medical history of cardiomyopathy (caused heart to loose its ability to pump effectively) with poor ejection fraction (a measurement of the percentage of blood leaving the heart each time it squeezes) of 20% and it was unclear that patient had resources as an outpatient for follow up. The EDD stated she would have expected lab work for CHF exacerbation if the provider had concerns about CHF. The EDD stated she was unable to comment why the Pt 4 was discharged again on the first ED visit on 8/14/24 without homeless checklist being completed, and without social worker evaluation. The EDD stated Pt 4 was found on street and brought back in hospital gown and she would have expected Pt 4 to be evaluated for appropriate outpatient follow up and resources prior to discharge on the first ED visit on 8/14/24.

During a review of Pt 4's "Ambulance report", with date of service 8/14/24 at 2:28 a.m., the "Ambulance report" indicated, " ...[complaint of] weakness and feeling hungry. Pt release from [hospital name] walking across lawn to [ City bus service name ] bus requesting 911. [upon arrival] pt sitting on bus requesting ice water and food. Pt currently homeless. No [Chest Pain]- [shortness of breath]. Neuro intact. Ambulatory to scene. No obvious trauma. Pt taken back to [facility] for reevaluation ..."

During a concurrent interview and record review on 9/5/24 at 11:05 a.m. with the EDD and QA 1, Pt 4's medical record was reviewed for his second visit on 8/14/24. The documented titled "Patient Care Timeline " dated for 8/14/24 for his second ED visit indicated Pt 4 was brought back to ED on 8/14/24 at 2:44 p.m. three hours and nine minutes after his previous ED discharge. Pt 4 was assigned ESI of 4 on 8/14/24 at 2:49 p.m. and Pt 4's chief complaint indicated "Weakness- Generalized (seen and treated here today, recent discharge at 11:14 [a.m.]. Told [company name] bus driver he was weak and tired; bus driver called EMS for transport to ED. Here for shoulder pain. Wants ice water and food)". Initial vitals on 8/14/24 at 2:50 p.m. indicated HR 82 bpm (normal 60-100), BP 150/85 mmHg (120/80), Spo2 97% (95-100%). The "Patient Care Timeline" indicated medical screening exam (MSE) was started at 6:08 p.m., order was placed for blood glucose testing at 6:11 p.m., MSE was completed 6:12 p.m. The order for blood glucose testing was discontinued at 6:12 p.m. and Pt 4's disposition was set to Discharge. Pt received discharged instructions on 8/14/24 at 7:01 p.m. On 8/14/24 at 7:37 p.m. Pt 4's vitals indicated HR 93 bpm (normal 60-100), BP 169/95 (normal 120/80), Spo2 90% (normal 95 -100%). On 8/14/24 at 7:42 p.m. nursing note indicate, "Pt [oxygen saturation] 90-92% on room air. [Physician name] notified. On 8/14/24 at 7:43 p.m. orders were placed for labs that includes B-Type Natriuretic Peptide (BNP - is a blood test that measures levels of a protein called BNP that is made by heart and blood vessels. BNP levels are higher than normal in heart failure), Comprehensive Metabolic Panel (CMP - a routine blood test that measures 14 substances in the blood to provide information about your overall health), troponin (a blood test that detects a protein found in heart muscle cells. This test can help diagnose heart injury and acute coronary syndrome earlier than other tests), CBC and differential (blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells) and other tests that includes 12- lead-EKG (a medical test that measures the heart's electrical activity and records it on graphed paper), XR Chest (projection radiograph of the chest used to diagnose conditions affecting the chest) 2 views. On 8/14/24 at 8:05 p.m. Pt 4 Spo2 was 98% on 2 lpm oxygen. Pt 4 received albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as asthma and COPD) 2.5 mg & ipratropium (medication that treats lung diseases and conditions, help relax airways and make it easier to breath) 0.5 mg via nebulization at 8:18 p.m. on 8/14/24. Pt 4 also received dexamethasone (medication help immune system control inflammation) 10 mg intravenous (administer into Vein) at 8:26 p.m. On 8/14/24 at 8:48 p.m. CMP results indicated Blood Urea Nitrogen (BUN- test that can help diagnose or monitor kidney disease or disorders) 53 mg/dL (normal range 8-21), Creatinine (creatinine lab test measures the amount of creatinine in the blood to evaluate how well kidneys are working) 1.21 mg/dL, total bilirubin (test use to assess how well liver is functioning) 2.4 mg/dL (normal 0.1-1.3), BNP 4, 221 pcg/ml (normal 0-100). On 8/14/24 at 9:10 p.m. results of troponin high sensitivity indicated 75 ng/L ( normal 0-20) . On 8/14/24 at 9:17 p.m. Respiratory Virus Panel results indicated Pt 4 was positive for SARS-COV-2 (COVID) (normal-not detected). On 8/14/23 at 11:48 p.m. Pt 4's ED disposition was set to Admit to inpatient. Pt 4 was admitted to inpatient on 8/15/24 at 12:12 a.m. The EDD stated in reviewing the record, Pt 4 was being discharged again without any lab work or testing after a MSE was completed. ED nurse found low Spo2 and escalated to physician and upon further work up patient found positive for COVID.

During a concurrent interview and record review on 9/5/24 at 11:15 a.m. with the EDD and QA 1, Pt 4's medical record was reviewed for his second visit on date 8/14/24. The documented titled "[hospital name] Emergency Department note" was reviewed. The document indicated, " ...Medical Decision Making ...This is a 69 [year old] male who presented to the Emergency Department due to Weakness-Generalized (Seen and treated here today, recent discharge at 11:14[a.m.]. Told the bus driver he was weak and tired; bus driver called EMS for transfer to ED. Here for shoulder pain. Wants ice water and food) Patient seen here earlier today for shoulder pain and was discharged. His return complaint was that he was hungry, on his physical exam he was ambulatory, well-appearing ...During the time of discharge [he] was found to be hypoxic. The warranted further work up, and patient was found to be in CHF exacerbation with COVID-19. He was ultimately admitted to medicine services ...". The EDD stated Pt 4 returned after three hours and nine minutes later after discharged from ED visit. The EDD stated labs are ordered based on clinical presentation of the patient and physician assessment. The EDD stated, Pt 4 was a known patient with CHF, 20% ejection fraction, returning to ED within one day of inpatient discharge, found in hospital gown on streets, Pt 4 should have been evaluated more thoroughly for his complaint of generalized weakness. The EDD stated this patient was identified as homeless and the homeless discharge checklist was not completed as per hospital policy prior to Pt 4's first discharge on 8/14/24.

During a concurrent interview and record review on 9/9/24 at 3:35 p.m. with the Emergency Department Medical Director (EDMD) and Emergency Department Manager (EDM), Pt 4's medical record was reviewed for the both ED visits on 8/14/24. The EDMD stated [physician name] was the ED provider for the patient. The EDMD stated the physician was not concerned about Pt 4's CHF. The EDMD stated the medical record did not reflect that Pt 4 was tachypneic (abnormally rapid and shallow breathing) or hypoxic (low levels of oxygen in your body) on his first visit. The EDMD stated it would be dependent on provider's assessment whether patient needed further evaluation. The EDMD stated behavioral health is a big challenge and the ED is like revolving door for some of these homeless patients. The EDMD validated with EDM that Pt 4 had seven visits to ED since 1/1/24 and was admitted four out the seven times. The EDMD stated that Pt 4 was very fragile patient and " a small bag of chips can put patient in CHF exacerbation, high sodium level". The EDMD stated Pt 4 did return in three hours and nine minutes, tested positive for COVID and was found to be in CHF exacerbation. The EDMD stated labs work and additional testing would have helped to identify that on the first visit, however, the provider assessment medical decision making did not reflect that it was needed. The EDMD stated the facility has been working on discharge instruction process and it could be better to avoid gaps.

During a concurrent interview and record review on 9/9/24 at 3:45 p.m. with the EDM, the EDM stated she had reviewed the medical record for Pt 4. The EDM stated she would have expected the nursing staff to have advocated for the patient and asked the provider about further testing and lab work on the first visit to ED on 8/14/24 since this patient was a known patient and had a previous encounter 24 hours ago. The EDM stated a homeless discharge checklist is a requirement and she was not able to find it in the medical record. The EDM stated the patient returned in hospital gown, was found on street and should have been evaluated for a need for resources according to policy prior to ED discharge.

During a review of the facility's policy and procedure (P&P) titled, "EMERGENCY DEPARTMENT ARRIVAL (TRIAGE), DOCUMENTATION, AND DISCHARGE" with a reviewed date of February 2024, the P&P indicated, " ...Discharge ...All patient discharged from the Emergency Department will receive appropriate discharge instructions including information regarding any necessary follow up care and instructions on medication, devices and diagnosis ...The nurse will involve other resources deemed necessary to facilitate a safe discharge ..."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA) Compliance", with a reviewed date of June 2024, the "P&P" indicated, " ... Policy Statement ...Any individuals who comes to [Hospital Name] (the "Hospital") seeking an examination and treatment of potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition, necessary stabilizing treatment for any emergency medical condition, and if necessary, an appropriate transfer to another medical facility, without regard to the individual's ability to pay or method of payment ...Treatment of Individual with an [emergency medical condition]exists, the Hospital shall: provide further examination and treatment, within the capability of the Hospital, until the individual's condition is stabilized; or provide for an appropriate transfer of an un-stabilized individual to another medical facility as set forth in this policy ..."

During a review of the facility's policy and procedure (P&P) titled, "Clinical Protocol- Homeless Patients", with a review date of March 2022, the "P&P" indicated, " ...Purpose: To assist homeless patients in managing health conditions (to include behavioral health) while supporting discharge planning arrangements for ongoing care and supportive needs ...The needs of homeless patients for emotional support and discharge needs will be assessed by the clinical Social Work Staff. Individual discharge plans will be developed with consideration of each patient right to self- determination and the availability within the community to link patients with appropriate resources ...Procedure: Inpatient and Emergency Department: ...Review of medical record specific to:.. Patient face sheet- age, address ...Most current nursing observation and notes ...Most current notes by physician ...Determine support systems, access to follow-up material care, medication, and basic needs, including safe housing, food, weather-appropriate clothing, transportation ...Assess coping skills and orientation ...Make appropriate referrals ...The clinical social worker assumes primary responsibility for working with the patient regarding discharge plants, exploring and arranging for community housing options, access to needed medication/medical follow-up ...The Clinical Social worker shall coordinate with the treating staff to ensure, in compliance with SB 1152, the homeless Patient Discharge Checklist (Appendix A) is completed and signed off upon all involved disciplines; upon completion, placing the checklist in to patient's physical (dark blue) chart to be scanned into the EMR.


3. During a concurrent interview and record review on 9/5/24 at 2:20 p.m. with Obstetric Emergency Department (OBED) Charge Nurse (CN) 1 and Registered Nurse Manager Consultant (RNMC), Pt 8's medical record was reviewed for the OBED & Emergency Department (ED) visit dated 7/7/24. The document titled "Patient Care Timeline (PCT)" indicated, "...[9:28 p.m.] Patient arrived in L&D [9:39 p.m.] Patient transferred ...bed ...Chief complaints ...Chest Pain [Supraventricular tachycardia -SVT- a condition that causes the heart to beat abnormally fast, usually originating in the upper part of the heart], ...[9:40 p.m.] Primary Assessment ...[oxygen saturation - the amount of oxygen carried by red blood cells (normal 95-100%)] 98% ...Vital Sings ...Temp 36.8..Heart Rate 89 [normal 60-100] ...Respirations 16 [normal 12-20] ...BP..128/84 [normal 120/80] ...[9:50] ...Heart Rate 100 [normal 60-100 ...[10:08 p.m.] Labor ...Membrane Status: Intact ...[10:13 p.m.] [Elector Cardiogram- (EKG- a test to record the electrical signals in the heart was performed)] ...[10:14 p.m.] Labor ...Acceleration ( Accelerations are a sign that the fetus has an adequate supply of oxygen)15x15 ...Decelerations (Deceleration occurs when the FHR temporarily slows during labor): Absent ...Mode: External [Ultra Sound - imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside your body] ... Variability (refers to the variation in a fetus's heart rate (FHR) and is an indicator of the autonomic nervous system's response - normal range 5-25 beats per minute (bpm)) ... Bas

Based on interview and record review, the hospital failed to provide stabilizing treatment within their capabilities for one of 21 patients, (Patient 3), with emergency medical conditions when Pt 3 was brought in by ambulance (BIBA) on 8/14/24 to the hospital ED with altered mental status, history of insulin dependent diabetes, high blood glucose and high blood pressure. A medical screening exam was conducted by a ED physician, and Pt 3 was discharged with high blood glucose and high potassium and the admission altered mental status had not improved.

These failures of not stabilizing Pt 3 resulted in Pt 3 returning to the ED by ambulance within eight hours of discharge with altered mental status, high blood glucose and diabetic ketoacidosis and the need for a higher level of care, in an inpatient unit.

Findings:

During a review of Pt 3's "Ambulance record" dated 8/14/24, the "Ambulance record" indicated, " ...Arrived on scene to find the patient sitting in the kitchen with her family. The patient's [chief complaint] is [Altered Mental Status (AMS)], last seen normal is [7:30 p.m.] yesterday. The patient's son states that the patient has [history] of type 1 diabetes (a chronic condition in which body makes little or no insulin (insulin is a hormone the body uses to allow sugar [glucose] to enter cells to produce energy) and her [blood glucose level] was high when they checked [patient on arrival]. The patient takes insulin; however, it is not known if she took it today. The Patient's last meal was a cup of noodles last night and today she has not eaten anything. The patient has been taking several naps today and complains of weakness and confusion. The patient was transported to the hospital last week for a similar complaint. Upon making contact with the patient, she is a Glasgow Coma Scale (GCS - is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive))14 [patient baseline GCS 15]. [Blood Glucose Level (BGL)] reads high, and she is also hypertensive, all other vitals [with in normal limits]. The patient is unable to state this year, day, or month ..."

During a record review Pt 3's medical record was reviewed for the Emergency Department (ED) visit for 8/14/24 and 8/15/24. The document titled "[Hospital Name] Emergency Department Note" dated 8/14/24 was reviewed and indicated, " ...[Pt 3 was] a 75-year-old female [with past medical history of] hypertension (high blood pressure) and type 1 diabetes (a chronic condition in which the hormone insulin is not produced in sufficient quantity to regulate blood glucose) was BIBA with altered mental status. Per [Emergency Medical Services], patient was last seen normal at [7:30 p.m.]. States family reports pt was lethargic and confused. Blood sugar in route was 600. [Blood pressure] systolic in 200s. Pt's GCS 15 at baseline. Per patient, she did not take insulin today. History is limited secondary to AMS ...physical exam...confused ...ED course: Patient evaluated for hyperglycemia (high blood sugar) and non-compliance. She received 3 [liters] of normal saline and insulin. She was re-evaluated much improved blood sugar under 400 upon discharge. She was counseled at length regarding taking her medications ...Hospitalization [inpatient or Observation] was considered and discussed with the patient. After discussion it was decided (and the patient agreed) that: the patient was stable for discharge with close follow up ...ED Disposition: Discharge ..."

During a concurrent interview and record review on 9/5/24 at 10:10 a.m. with the Emergency Department Director (EDD) and Quality Analyst (QA) 1, Pt 3's medical record was reviewed for the ED visit for 8/14/24 and 8/15/24. The document titled "Patient Care Timeline (PCT)" for the visit dated 8/14/24 was reviewed and indicated Pt 3 arrived to ED on 8/14/24 at 8:10 p.m. with a chief complaint of AMS. GCS on arrival to ED at 8:10 p.m. was 14. Initial Vitals on 8/14/24 at 8:10 p.m. indicated Heart Rate (HR) 71 beats per minute (BPM) (normal 60 -100 bpm), Blood Pressure (BP) 204/69 millimeters of mercury (mmHg- Unit of measurement)(normal 120/80), oxygen saturation 97 % (normal 95% to 100%) on 2 liters per minute (lpm-Unit of measurement) oxygen. Pt 3 was assigned emergency severity index (ESI) level 2 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious). Lab results at 8:49 p.m. indicated glucose level of 641 Milligrams per deciliter (mg/dL - Unit of measurement) (normal 70-105), Potassium (measurement of electrolyte in blood) 5.3 millimoles per liter (mmol/L- Unit of measurement)(normal 3.5- 4.9), Sodium (measure the level of electrolyte) 132 mmol/L, TCO2 Venous POCT(measurement of carbon dioxide) 22 mmol/L (normal 23-29). Lab results on 8/14/24 at 9:02 p.m. indicate blood glucose level of 655 mg/dL. Pt 3 lab results at 9:02 p.m. indicated pH Venous (measurement that tells how acidic or basic something is) 7.28 (normal 7.31 - 7.41), potassium 5.4 mmol/L (normal 3.5 to 4.9) and sodium level 134 mmol/L (138-146). Lab results on 8/14/24 at 9:27 p.m. indicated hemoglobin (Hb -protein in red blood cells that carries oxygen from your lungs to the rest of your body) 11.6 grams per deciliter (g/dl - Unit of measurement)(normal Hb 12-16). Lab results on 8/14/24 at 9:32 p.m. indicated blood glucose of 575. Pt 3's vitals were rechecked on 8/14/24 at 10:09 p.m. and record indicated BP of 174/50. Pt 3's disposition set to discharge on 8/14/24 at 11:58 p.m. Pt 3's blood glucose level on 8/15/24 at 12:21 a.m. indicated 459 mg/dL. Pt.3's blood glucose level on 8/15/24 at 1:38 a.m. indicated 298 mg/dL. The "Patient Care Timeline" indicated, " ...Departure condition: Stable ...Temp: 36.8 ...Heart Rate 73 ...BP 160/68 ...Patient observation: pt is discharged. GCS 14 ...picked up by son ...". Pt 3 was discharged at 1:52 a.m. The EDD stated Pt 3 was discharged in five hours and forty-nine minutes. The EDD stated she was unable to find any documentation regarding high potassium level or low sodium level. The EDD stated Pt 3 received 3-liter normal saline bolus, 30 units of insulin and 20 mg of hydralazine (medication to treat high blood pressure) and was discharged. The EDD stated Pt 3's GCS was 14 documented at the time of discharge. The EDD stated she was not too concerned with vitals, BP 160/68 at the time of discharge. The EDD stated she was not able to comment if the BG of 298 mg/dL at the time of discharge was acceptable and would have to defer to the provider and his assessment. The EDD stated the ED provider note indicated hospitalization was discussed and patient agreed. The ED physician note also stated pt was counseled about medications. The EDD validated the last documented GCS before discharge was 14 and stated a patient with GCS 14, pt would be confused and it would be hard for patient to understand and participate in decision making.

During a concurrent interview and record review on 9/5/24 at 10:20 a.m. with the EDD Pt 3's "After Visit Summary (AVS)" for the ED visit dated 8/14/24 was reviewed. The EDD stated the AVS did not have the discharge instructions. The EDD stated the record does not reflect that Pt 3 received instructions regarding hyperglycemia, medication and follow up treatments upon discharge. The EDD stated she would have expected to see education regarding discharge diagnosis, information regarding when and where to follow up and new medications if patient received any. The EDD stated without the documentation, Pt 3's discharge was a "poor discharge and medical decision making was not clear" The EDD stated record reflects that patient had abnormal labs, was a GCS 14 and did not receive any discharge instructions at the time of the discharge. The EDD stated this visit of Pt 3's would be reviewed by the facility for unsafe discharge as the patient returned with hyperglycemia. The EDD stated it was her expectation that patient critical labs get addressed and patient receive appropriate discharge instructions and education prior to discharge. The EDD stated, "it probably would have been best to keep the patient for additional time if her GCS was 14 to ensure she was back to baseline ".

During a review of Pt 3's "Ambulance record" dated 8/15/24, the "Ambulance record" indicated, " ... 75 [year old] female sitting in a chair at home in mild distress. GCS 14. Pt baseline GCS 15. Per Pt son pt was seen and treated at [hospital name] yesterday with the same complaint. Pt [history]with hyperglycemia ...Pt son stated that the pt was still disoriented with BG in the 300's when she was discharged from the ED around [2:00 a.m.]this morning. Pt's son stated he left the Pt sleep. When the Pt woke Pt's son stated pt was more disoriented. Pt's son checked Pt's BG and it read 429. Pt's BG was 427 for EMS ....Pt noted as hypertensive ...Pt transported to [hospital name] ..."

During a record review Pt 3's medical record was reviewed for the ED visit for 8/14/24 and 8/15/24. The document titled "Patient Care Timeline (PCT" and "[Hospital Name] Emergency Department Note" dated 8/15/24 was reviewed. The documented "Patient Care Timeline" indicated, Pt 3 was brought back to the ED on 8/15/24 at 9:23 a.m.(seven hours and thirty minutes after discharge) by ambulance with the chief complaint of AMS, GCS of 14 and upon arrival ESI of 2 was assigned. Vitals on 8/15/24 at 9:26 a.m. indicated HR 77 bpm (normal 60-100), Temp 36.7, BP 193/72 mmHg (normal 120/80). Labs indicated blood glucose level was 402 mg/dL on 8/15/24 at 10:36 a.m. Lab results on 8/15/24 at 11:11 a.m. indicated beta hydroxybutyrate (test to detect ketones to diagnose and monitor diabetic ketoacidosis ) at 3.20 mmol/l (normal 0.02-0. 27). amylase level on 8/15/24 at 11:11 a.m. indicated amylase (an enzyme that helps digest carbohydrates) 20 unit/liter(unit/L- Unit of measurement) (normal 29-103). On 8/15/24 at 11:21a.m. Pt 3 disposition was set to admit to inpatient and patient was admitted at 11:56 a.m. The "[Hospital Name] Emergency Department Note" dated 8/15/24 indicated, " ...Patient presents with increased generalized weakness. She has noted to be persistently hyperglycemic with signs of early diabetic ketoacidosis and mild confusion and dehydration. She was started on routine therapy will be admitted to the hospital for further management.... Pt requires admission at this time. Unable to counsel patient secondary to AMS ...". The PCT indicated patient was admitted to Inpatient unit for blood glucose management.

During a concurrent interview and record review on 9/9/24 at 3:20 p.m. with the Emergency Department Medical Director (EDMD) and Emergency Department Manager (EDM), Pt 3's medical record was reviewed for the ED visit for date 8/14/24 and 8/15/24. The EDMD stated he was the medical director for the ED and was also the ED provider for the patient on the visit dated 8/14/24. The EDMD stated patient 3 was treated appropriately on 8/14/24, and all vitals were stable at discharge. The EDMD stated Patient 3 was dehydrated and was given a bolus. The EDMD stated he identified that discharge instructions could be better and reeducation to all ED providers had been started. The EDMD stated he does not recall the patient or the case specifically but believes that patient was not confused based on his note as he documented "It was considered to admit the patient, but he felt with shared decision making she can go home". The EDMD stated he wrote patient agreed, back to base line and it would have been based on his assessment. The EDMD stated it was not a pre template note therefore he believes everything was done appropriately. The EDMD stated he reviewed Pt 3's medical record for revisit and does not feel Pt 3 was in true DKA when the patient returned to ED.

During a review of the facility's policy and procedure (P&P) titled, "EMERGENCY DEPARTMENT ARRIVAL (TRIAGE), DOCUMENTATION, AND DISCHARGE" with a reviewed date of February 2024, the P&P indicated, " ...Discharge ...All patient discharged from the Emergency Department will receive appropriate discharge instructions including information regarding any necessary follow up care and instructions on medication, devices and diagnosis ...The nurse will involve other resources deemed necessary to facilitate a safe discharge ..."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Treatment and Labor Act (EMTALA) Compliance", with a reviewed date of June 2024, the P&P indicated, " ... Policy Statement ...Any individuals who comes to [Hospital Name] (the "Hospital") seeking an examination and treatment of potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition, necessary stabilizing treatment for any emergency medical condition, and if necessary, an appropriate transfer to another medical facility, without regard to the individual's ability to pay or method of payment ...Treatment of Individual with an [emergency medical condition]exists, the Hospital shall: provide further examination and treatment, within the capability of the Hospital, until the individual's condition is stabilized; or provide for an appropriate transfer of an un-stabilized individual to another medical facility as set forth in this policy ..."