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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 20 patients, Patients (Pts) 3, 4, 5, 6, and 7, when:

1. Patient 5 came to the ED by ambulance on 6/20/24 at 6:57 a.m., after having a witnessed fall at a homeless shelter, hitting her head, with unknown loss of consciousness. Pt 5 had a medical history of atrial fibrillation on blood thinners diabetes, a seizure disorder, and a past history of alcohol abuse. Pt 5 complained of pain in her head, left arm and leg. An MSE was initiated at 7:06 a.m. and orders for STAT (immediately, without delay) lab tests and computed tomography (CT scan) of head, neck and face were placed, and Pt 5 remained on the ambulance gurney until 8 a.m. Pt 5 was triaged at 8:02 a.m., assigned an ESI Level of 3. Urine tests for drugs and alcohol were negative. Pt 5 became agitated and angry, and at 10:55 a.m. Pt 5 was discharged to the street without the MSE being completed or pain addressed, and without follow up care arranged. (Refer to A 2406, Finding 1)

2. Patient 6 came to the ED on 8/13/24 at 2:48 p.m. with a chief complaint of psychiatric problem. Pt 6 was talking about brainwashing, mind control, and cyberstalking, and was triaged, assigned an ESI level of 2 and sent to the lobby to wait. An MSE was initiated over an hour later at 3:56 p.m., and Pt 6 remained in the lobby. There was no care documented after the MSE was initiated. Over two hours later at 6:23 p.m., a nurse went to get Pt 6 and could not locate him. Pt 6 was left unobserved in the lobby despite being paranoid and having delusions and left the hospital in unknown condition without the MSE being completed. There was no evidence of follow up. (Refer to A 2406, Finding 2)

3. Patient 7 came to the emergency department [ED] on 7/24/24 at 9 p.m. with a chief complaint of high blood pressure, was triaged and assigned an ESI level of 3. Pt 7's blood pressure on arrival was 118/100 millimeters of mercury (mmHg). An MSE was initiated at 9:13 p.m., a discharge order was placed at 9:38 p.m., and Pt 7 was discharged from the hospital at 11:03 p.m., without having her chief complaint addressed or her vital signs rechecked prior to discharge. (Refer to A 2406, Finding 3)

4. Patient (Pt) 3 came to the Emergency Department (ED) on 3/10/24, with a chief complaint of "Alcohol Withdrawal, had tachycardia (high heart rate) and received Chlordiazepoxide (a medication used to treat anxiety, insomnia and symptoms of withdrawal from alcohol and Lorazepam (medication to treat anxiety and sleeping problems that are related to anxiety) when her blood alcohol level was 212.50 mg/dL., and was prescribed Chlordiazepoxide for home use. Pt 3 was discharged two hours later by herself still tachycardic and without being evaluated to ensure she was functionally stable prior to discharge. .(Refer to A 2407, Finding 1)

5. Pt 4, a homeless patient, was brought in by the ambulance to the ED on 8/9/24 for a chief complaint of increased blood glucose of 450 mg/dl (a blood sugar reading of 300 mg/dL or higher is considered dangerous and can lead to serious complications). Pt 4 was given a bolus (administration of a concentrated dose of a substance for immediate effect) of normal saline solution by the paramedics. In the ED, Pt 4 was placed in the lobby, labs were drawn, and no other interventions were done. Pt 4's abnormal lab results were not addressed and Pt 4's Blood Glucose was not checked prior to discharge. Pt 4's discharge was not completed in accordance with the facility's policy and procedure (P&P) titled, "AD 3.08 California Hospital Discharge Planning for Homeless Patient," and Pt 4 was not offered a ride to the shelter or weather appropriate clothing, and access to prescribed medication was not arranged. (Refer to A 2407, Finding 2)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) for three of 20 sampled patients, Patient (Pt) 5, Pt 6, and Pt 7 when:

1. Patient 5 came to the ED by ambulance on 6/20/24 at 6:57 a.m., after having a witnessed fall at a homeless shelter, hitting her head, with unknown loss of consciousness. Pt 5 had a medical history of atrial fibrillation on blood thinners diabetes, a seizure disorder, and a past history of alcohol abuse. Pt 5 complained of pain in her head, left arm and leg. An MSE was initiated at 7:06 a.m. and orders for STAT (immediately, without delay) lab tests and computed tomography (CT scan) of head, neck and face were placed, and Pt 5 remained on the ambulance gurney until 8 a.m. Pt 5 was triaged at 8:02 a.m., assigned an ESI Level of 3. Urine tests for drugs and alcohol were negative. Pt 5 became agitated and angry, and at 10:55 a.m. Pt 5 was discharged to the street without the MSE being completed or pain addressed, and without follow up care arranged.

2. Patient 6 came to the ED on 8/13/24 at 2:48 p.m. with a chief complaint of psychiatric problem. Pt 6 was talking about brainwashing, mind control, and cyberstalking, and was triaged, assigned an ESI level of 2 and sent to the lobby to wait. An MSE was initiated over an hour later at 3:56 p.m., and Pt 6 remained in the lobby. There was no care documented after the MSE was initiated. Over two hours later at 6:23 p.m., a nurse went to get Pt 6 and could not locate him. Pt 6 was left unobserved in the lobby despite being paranoid and having delusions, and left the hospital in unknown condition without the MSE being completed. There was no evidence of follow up.

3. Patient 7 came to the emergency department [ED] on 7/24/24 at 9 p.m. with a chief complaint of high blood pressure, was triaged and assigned an ESI level of 3. Pt 7's blood pressure on arrival was 118/100 millimeters of mercury (mmHg). An MSE was initiated at 9:13 p.m., a discharge order was placed at 9:38 p.m., and Pt 7 was discharged from the hospital at 11:03 p.m., without having her chief complaint addressed or her vital signs rechecked prior to discharge.

These failures resulted in a delay in identifying a potential emergency medical condition had the potential to result in negative outcomes for Pt 5, Pt 6, Pt 7.

Findings:

1. During a review of Pt 5's Patient Care Record (PCR- Record of pre-hospital care provided by Emergency Medical Services [EMS] personnel) dated 6/20/24, the PCR indicated Pt 5 had tripped and fell to the ground at the shelter and hit the left side of her forehead sustaining an abrasion and opening up a scab from a previous injury (two days prior) which was bleeding, and Pt 5's left eye was swollen. Pt 5 agreed to be transported to the ED for further evaluation. The PCR indicated Pt 5 appeared intoxicated (drunk), was alert and oriented, and had a history of high blood pressure and diabetes and alcohol use. Pt 5 was placed in a C-collar (a neck brace used to support the neck and limit head movement) and was transported to the hospital arriving at 6:57 a.m. The PCR indicated vital signs on arrival were blood pressure 172/95, heart rate 77 beats per minute, respiratory rate 14 per minute, and oxygen saturation of 98% on room air. The PCR indicated the EMS staff stayed with Pt 5 until 8 a.m. when Pt 5 was put into an ED room.

During a concurrent interview and record review on 8/20/24 at 11:40 a.m. with the ED clinical manager (EDM 2), Pt 5's medical record was reviewed. Review of the face sheet (a document with information including patient's demographic information, insurance information, emergency contacts name and phone number) dated 6/20/24, indicated Pt 5 was brought to the ED by ambulance on 6/20/24 at 7 a.m. with a chief complaint of "Fall; Head Injury." The face sheet also indicated Pt 5 was homeless.

During a concurrent interview and record review on 8/20/24 at 11:45 a.m. with EDM 2, Pt 5's "ED Triage Form," dated 6/20/24 at 8:02 a.m., was reviewed. The triage form indicated Pt 5 was triaged at 8:02 a.m. and assigned an 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 is the most serious, in order to prioritize care) Level of 3. The triage note indicated Pt 5 complained of pain, level 4 (on a scale of 0-10, 0 is no pain, 10 is worse possible pain, 4 is moderate pain). EDM 2 stated before Pt 5 was triaged, the MSE was initiated, and orders were placed by the ED physician (MD 3) at 7:06 a.m. Review of the document "ED Note-Physician," dated 6/20/24, at 8:31 a.m., indicated Pt 5 was seen by MD 3 at 7:06 a.m. The note indicated, " ...Chief Complaint: BIBA [brought in by ambulance] from [Name of Shelter] after a witnessed GLF [ground level fall]. Pt significant history of ETOH [alcohol] abuse. Unknown LOC [loss of consciousness], dried blood noted to majority of left face, no active bleeding noted. Pt c/o (complains of) pain to left arm and leg ...History of Present Illness: ...Patient was reportedly previously hospitalized after being struck by a car. Earlier today, she fell while walking and struck the left side of her face ...reportedly opened up a previous scab on forehead. No reported blood thinners. Past history is significant of alcohol abuse ..." The ED Physician's Note indicated Pt 5 had a past medical history which included atrial fibrillation (an arrhythmia that occurs when the upper chambers of the heart [atria] beat irregularly and fast), hypertension (high blood pressure), and a seizure (a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings, and levels of consciousness) disorder. The ED Physician's note indicated Pt 5's current medication list included Eliquis (a "blood thinner" to prevent blood clots), Keppra (to prevent seizures), metoprolol and lisinopril (to treat hypertension), and two medications to treat diabetes. MD 3 ordered a CT scan of the head, spine, face and jaw, a chest x-ray, and a urine test for drugs and alcohol.

During a concurrent interview and record review on 8/20/24 at 11:55 a.m. with EDM 2, Pt. 5's Nursing Note, dated 6/20/24, indicated at 8:15 a.m. "Pt cussing and yelling demanding help to urinate. Pt refusing VS [vital signs]. Pt placed on PureWick [an external urinary catheter] at this time. This RN [RN 1] assisting with trauma patient; will attempt assess and get VS after Pt calm." At 9 a.m., " ...Pt yelling out for help ...Pt still refusing to let RN get baseline VS for triage. Refusing to go to CT scan/XR [x-ray] until she gets pain medication ...Charge nurse and [Name of MD 3] made aware ..." The Nursing Note indicated at 9:17 a.m. Pt 5 was complaining of pain to her left arm and leg, and was agitated, frustrated, and angry. RN 1 was unable to assess Pt 5 or obtain vital signs, and at 9:45 a.m., RN 1 obtained a urine specimen from the Purewick cannister and sent it to the lab. The Nursing Note indicated at 10:30 a.m. Pt 5 was yelling and refused to let RN 1 assess her. At 10:48 a.m. RN 2 indicated, "[Name of MD 3] notified patient refusing everything until she gets pain meds. [Name of MD 3] states pt. to be d/c [discharged]." The Nursing Note indicated at 10:50 a.m. Pt 5 removed own C-collar and walked out of room. Pt 5 declined to let RN 1 clean her (Pt 5's) face; refused to wait for discharge paperwork. The record indicated MD 3 placed a discharge order at 10:45 a.m.

During a review of the lab test results dated 6/20/24 at 10:28 a.m., the lab results indicated no drugs or alcohol were present in Pt 5's urine.

During a concurrent interview and record review on 8/20/24 at 12 p.m. with EDM 2, Pt 5's Nursing Note dated 6/20/24 at 11:03 a.m. was reviewed. The Nursing Note indicated at 11:03 a.m., RN 1 edited her pain assessment documentation from 8:02 a.m. At 8:02 a.m., RN 1 had indicated Pt 5 had "Actual or suspected pain," and "Pain Score: 4." At 11:03 a.m., RN 1 revised the 8:02 a.m. entry to indicate at 8:02 a.m. Pt 5 had "No actual or suspected pain," and the 8:02 a.m. "Pain Score: 4" was lined through at 11:03 a.m. as an "ERROR." RN 1 indicated at 11:03 a.m. (for the 8:02 a.m. pain assessment), "Pt complaining of pain but refusing to give any pain scale or answer questions regarding pain."

During a concurrent interview and record review on 8/20/24 at 12:05 p.m. with EDM 2, Pt 5's "ED Discharge Form," dated 6/20/24 at 11:01 a.m. indicated Pt. 5 was discharged to the "Street" at 10:55 a.m. The ED Discharge Form indicated at discharge Pt 5 had "No actual or suspected pain," and "Pt refusing to state pain scale on discharge." The record indicated Pt 5 did not have a primary care provider (PCP).

During a concurrent interview and record review on 8/20/24 at 12:10 p.m. with EDM 2, Pt 5's medical record dated 6/22/24 was reviewed. The record indicated Pt 5 came to the ED by ambulance on 6/22/24 at 8:19 a.m. after having a seizure. Review of the ED Note-Physician dated 6/22/24 at 8:23 a.m., indicated MD 3 saw Pt 5 at 8:20 a.m. and noted, " ...Brought in by ambulance from a bus stop, had a 10 second seizure and sustained a right eyebrow laceration. Patient [Pt 5] was seen at [Name of Hospital] ED on 6/20/24 but signed out AMA [against medical advice] ..." EDM 2 verified Pt 5 was discharged on 6/20/24, she did not leave AMA. The record indicated on 6/22/24, Pt 5 was discharged in stable condition after imaging of her head and neck were negative and Pt 5 received intravenous medication for seizures.

During a review of the hospital's P&P titled, "Pain Management Policy," dated 4/7/22, the P&P indicated, " ...It is the policy of [Name of Hospital] to do the following: Conduct an appropriate assessment and/or reassessment of a patient's pain consistent with the scope of care, treatment, and service provided in the specific care setting in which the patient is being managed. The 0-10 Numeric Rating Scale shall be used to score pain as appropriate using the Mild, Moderate, and Severe pain indications ... [Name of Hospital] requires that methods used to assess a patient's pain are consistent with the patient's age, condition, ability to understand ...Wong-Baker faces scale: used for pediatric, non-English speaking patients, any patient with limited communication, the verbally impaired patient, or those who prefer to point or motion at his/her pain level on a diagram ..."

During a review of the hospital's P&P titled, "Triage Nurse Policy [ED 1.06]," dated 4/24/24, the P&P indicated, " ...In cases of apparent patient dissatisfaction intervene, if appropriate, and facilitate immediate communication with Department Director, House Supervisor, shift Manager, or Security Officer as needed ..."

During a review of the professional reference titled," Emergency Severity Index Handbook, Version 5," dated 2023, the reference indicated, " ...Patients presenting to the ED who have a past or current history of behavioral health issues or substance use are particularly susceptible to the effects of bias and stigma. Patients who are described as "difficult" are perceived similarly..."

During a review of the research article titled, "A Qualitative Study of Emergency Physicians' and Nurses' Experiences Caring for Patients With Psychiatric Conditions and/or Substance Use Disorders," Annals of Emergency Medicine, Volume 81, no. 6: June 2023, the article indicated, " Our findings reveal a cyclical model of difficult care dynamics for emergency nurses and physicians caring for patients with psychiatric conditions and/or substance use disorders [SUDs]: often interconnected logistical, diagnostic, and emotional challenges in caring for these patients can create and reinforce negative attitudes and biases toward them, adversely influencing patient care ..."

2. During a concurrent interview and record review on 8/19/24 at 4:15 p.m. with the ED clinical manager (EDM 2), Patient (Pt) 6's medical record was reviewed. Review of the Face Sheet dated 8/13/24 indicated Pt 6 came to the ED at 2:48 p.m. with a chief complaint of Psych Eval [Psychiatric Evaluation]. The face sheet also indicated Pt 6 was homeless. The ED Triage Form dated 8/13/24 at 2:55 p.m., indicated Pt 6 was triaged at 2:52 p.m. Pt 6's chief complaint was, "Needs Psych Eval. Denies SI/HI [suicidal ideation- thoughts of self-harm or ending one's life /homicidal ideation-thoughts of killing another person]. Talking about brainwashing and mind control, and cyberstalking." The triage nurse obtained Pt 6's heart rate and oxygen saturation, assigned an ESI Level 2, and Pt 6 was sent to the lobby to wait. Review of the ED Nursing Note dated 8/13/24, indicated at 3:38 p.m. " ...Pt [6] called for vital signs. Pt [6] states 'Please don't read my mind it's not nice.' Attempted to de-escalate the situation. Pt begins to laugh out loud and then sits down. Vital signs obtained. Pt states he is not suicidal or homicidal ..." Pt 6 remained waiting in the lobby. Review of the ED MSE Note dated 8/13/24 indicated the MSE was initiated at 3:56 p.m. The note indicated, " ...Pt is requesting an x-ray or MRI because he has heard about brainwashing and mind control and wants to make sure he does not have devices implanted in his mind. States he can hear his voice in his head. PMHx [Past Medical History]: schizophrenia [a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality], ADHD [Attention Deficit Hyperactive Disorder- a mental health disorder that includes problems, such as difficulty paying attention, hyperactivity, and impulsive behavior.]. States he does not take his schizophrenia medication because it makes him severely ill. Admits to using cannabis. Medical Screening Exam Initiated: I have reviewed the patient's chief complaint, vital signs, level of distress, current medications, as well as completed a focused, limited exam, further evaluation will be necessary in the emergency department to determine if an emergency medical condition exists ..."

During a concurrent interview and record review on 8/19/24 at 4:20 p.m. with EDM 2, the record of Pt 6's orders dated 8/13/24 indicated at 5:30 p.m. orders were placed by the ED physician for a urine drug and alcohol screen, blood alcohol level, a complete blood count (CBC), a Comprehensive Metabolic Panel (CMP), and a CT scan of the head or brain. Review of the medical record did not indicate any care was provided or contact made with Pt 6 after the physician initiated the MSE at 3:56 p.m. Review of the record indicated none of Pt 6's orders were carried out. The ED Nursing Note dated 8/13/24 at 10 p.m., indicated at 6:23 p.m. the nurse called Pt 6 for care but was unable to find him in the lobby. The note indicated the nurse called Pt 6 again at 7:24 p.m., and at 8:50 p.m., but was not able to find Pt 6. Pt 6 did not have a phone to contact. Review of the ED Note-Physician dated 8/13/24 at 5:41 p.m. indicated, " ...Differential Diagnosis: Acute psychosis, medication reaction, mood disorder secondary to substance use, metabolic encephalopathy, medication noncompliance, depression, suicidality ..." and the ED physician indicated, "Patient eloped from the emergency department while awaiting workup and evaluation." Discharge diagnoses were Delusional Ideas, and Paranoia.

During an interview on 8/21/24 at 1 p.m. with the Chief Nursing Officer (CNO- and also the acting ED Director), the CNO stated in May this year the ED implemented the practice of reassessing the patient's vital signs every two hours for all patients who are waiting in the ED lobby regardless of what their ESI Level was on arrival. This reassessment can alert the staff to changes and can also establish contact with the patient in order to possibly prevent a patient from leaving unnoticed.

During a review of the hospital's P&P titled, "Triage Nurse Policy [ED 1.06]," dated 4/24/24, the P&P indicated, " ...Upon arrival an initial assessment is performed to determine the need for immediate treatment, or close observation based upon presenting clinical assessment by the primary triage nurse ...All patient conditions will be classified and prioritized as follows- ESI Level 1: The patient is unstable and requires immediate life-saving interventions. ESI Level 2: The patient is assessed as high risk. The patient's condition may deteriorate if left unattended, and therefore should not wait. Upon determination of an ESI Level 2 condition, the triage nurse will expedite placement of the patient in a treatment area securing additional resources as necessary ..."

During a review of the professional reference titled," Emergency Severity Index Handbook, Version 5," dated 2023, the reference indicated, " ...ESI level-2 patients remain a high priority, and placement and treatment should be initiated rapidly. ESI level-2 patients have the potential to be very ill and at high risk for decompensation..."

3. During a concurrent interview and record review on 8/19/24 at 3:45 p.m. with the ED clinical manager (EDM 2), Patient (Pt) 7's medical record was reviewed. Review of the Patient Summary Report, dated 7/24/24 at 9 p.m., indicated Pt 7 came to the ED at 9 p.m. with a chief complaint of high blood pressure. Pt 7 stated she was at [Name of facility] for alcohol detox and her blood pressure had been elevated all day. Pt 7's was prescribed Librium for withdrawal symptoms during the previous ED visit on 7/23/24 when Pt 7 was medically cleared for alcohol rehab. Pt 7's vital signs at triage at 9:03 p.m. were, temperature 36.9 degrees centigrade, heart rate 94 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation 100% on room air, and blood pressure 118/100 millimeters of mercury (mmHg- hospital reference range for the bottom number [the diastolic blood pressure, measures the pressure in the arteries between heartbeats] is 60=90 mmHg). Pt 7 was assigned an ESI Level 3. Review of the ED Note-Physician dated 7/24/24 at 9:39 p.m. indicated that Pt 7 was seen by the ED physician (MD 5) at 9:13 p.m. The note indicated Pt 7's chief complaint that her blood pressure had been elevated all day. MD 5's note indicated Pt 7's complaint was of alcohol withdrawals and was requesting something to help her sleep. The ED Note indicated, " ...Medical Decision-Making: History obtained from the patient. Prior medical records reviewed. High complexity medical decision making required given the nature of the patient's chief complaint, history, physical exam, and breadth and severity of the differential diagnosis considered. I personally reviewed and interpreted vital signs, EKG, labs, imaging. Pt's social determinants of health also considered. I then compiled the information to determine if the patient would benefit from admission/transfer, or if the patient is stable for discharge ..." EDM 2 verified that no EKG, imaging, or lab tests were ordered or done, and vital signs were taken once during Pt 7's ED visit.

During a concurrent interview and record review on 8/19/24 at 3:55 p.m. with EDM 2, Pt 7's ED Note-Physician dated 7/24/24 indicated, " ...Differential diagnosis includes but not limited to alcohol dependence, alcohol withdrawal, polysubstance use. Patient [7] has no other complaints besides wanting medical clearance for alcohol rehab ...Patient medically cleared ...Patient discharged in stable condition ..."

The record indicated MD 5 placed a discharge order at 9:38 p.m., and prescribed melatonin (a supplement that can help a person fall asleep) for sleep. There was no mention in MD 5's note addressing Pt 7's stated chief complaint about her elevated blood pressure and Pt 7's abnormal blood pressure reading in triage was not rechecked prior to Pt 7's discharge at 11:03 p.m. EDM 2 stated abnormal vital signs should be rechecked prior to discharge.

During a review of the hospital's policy and procedure (P&P) titled, "Standard of Care Policy [ED 1.04]," dated 10/26/22, the P&P indicated, " ...Vital signs will be taken on all patients admitted to the ED ...The patient's nurse is responsible for continually assessing the patient's condition and obtaining vital signs as the situation warrants. Abnormal vital signs will be checked prior to discharge, and persistent abnormalities will be brought to the physician's attention ...Continued evaluation and care of the patient includes: a. Documentation of any changes in patient condition and physician notification ...b. Documentation of treatments, patient tolerance of the treatment, and outcomes ...c. Informing the patient and support persons of reasons for tests, treatment, and delays ..."

During a review of the hospital's P&P titled, "Medical Screening Examination [ED 1.03]," dated 9/28/22, the P&P indicated, " ...State and Federal regulations require the provision of a medical screening examination to all patients presenting to the Emergency Department for care. The medical screening exam may include the provision of ancillary diagnostic services routinely available in the hospital if necessary to determine whether the individual has an emergency medical condition ...The determination of the patient's presenting condition [i.e., emergent, or non-emergent] will be made for each patient. MSE- Each patient may be triaged to determine priority for medical screening. The MSE will be based on the patient's condition and prior history and may include at least the following: a. Patient's chief complaint, age, sex, duration of onset of chief complaint, date and time, level of distress, and any other pertinent medical history. b. Vital signs, general observation, and focused examination. c. Initiation and documentation of any necessary testing, treatments and/or procedures. The scope of the examination is tailored to the patient's presenting symptoms and the medical history of the patient. The MSE is an ongoing monitoring process, which continues until a medical emergency condition is found not to exist or until appropriate steps to stabilize the presenting emergency medical condition begin..."

Based on interview and record review, the hospital failed to ensure an emergency medical condition was stabilized prior to discharge for two of 20 sampled patients, Patient 3 and Patient 4 when:

1. Patient (Pt) 3 came to the Emergency Department (ED) on 3/10/24, with a chief complaint of "Alcohol Withdrawal, had tachycardia (high heart rate) and received Chlordiazepoxide (a medication used to treat anxiety, insomnia and symptoms of withdrawal from alcohol and Lorazepam (medication to treat anxiety and sleeping problems that are related to anxiety) when her blood alcohol level was 212.50 mg/dL., and was prescribed Chlordiazepoxide for home use. Pt 3 was discharged two hours later by herself still tachycardic and without being evaluated to ensure she was functionally stable prior to discharge.

This failure resulted in worsening of Pt 3's condition and Pt 3 returned to the ED on 3/12/24 by ambulance after Pt 3 was found walking around not acting normal, had been drinking alcohol, mixing [name of mouthwash] shots, and taking Chlordiazepoxide. Pt 3 was placed on a 1799 hold (a 24-hour involuntary medical hold that can be placed on a patient in California by certain licensed staff and healthcare providers) and transferred to an inpatient psychiatric treatment center.

2. Patient (Pt) 4, a homeless patient, was brought in by the ambulance to the ED on 8/9/24 for a chief complaint of increased blood glucose of 450 mg/dl (a blood sugar reading of 300 mg/dL or higher is considered dangerous and can lead to serious complications). Pt 4 was given a bolus (administration of a concentrated dose of a substance for immediate effect) of normal saline solution by the paramedics. In the ED, Pt 4 was placed in the lobby, labs were drawn, and no other interventions were done. Pt 4's abnormal lab results were not addressed and Pt 4's Blood Glucose was not checked prior to discharge. Pt 4's discharge was not completed in accordance with the facility's policy and procedure (P&P) titled, "AD 3.08 California Hospital Discharge Planning for Homeless Patient," and Pt 4 was not offered a ride to the shelter or weather appropriate clothing, and access to prescribed medication was not arranged.

These failures resulted in Pt 4 experiencing worsening hyperglycemia and being brought back to the ED by ambulance after being found outside a convenience store with a blood sugar of 347 mg/dL, 11 hours after being discharged from the ED.

Findings:

1.During a review of the hospital's report of returns to Emergency Department (ED) within 48 hours (of a previous ED visit) for March 2024, the report indicated Pt 3 was a 29-year-old female who came to the ED at 3:49 p.m. on 3/10/24 with a chief complaint of "Alcohol withdrawal; STATES NEEDS TO DETOX" and was discharged on 3/10/24 at 8:59 p.m. The report indicated that Pt 3 was brought back to ED via ambulance on 3/12/24 at 8:48 p.m. with a chief complaint of "[Brought in by ambulance] from home for [ethanol alcohol] use.; [Emergency Medical Services - EMS] mentions pt reported physical abuse from live in [boyfriend] and [name of city] police were present."

During a concurrent interview and record review on 08/16/24 at 10:30 a.m. with the Emergency Room Manager (EDM) 1 and Quality Registered Nurse (RNQ) 1, Pt 3's medical records for ED visits for dated 3/10/24 and 3/12/24 were reviewed. The "ED Note - Physician" dated 3/10/24, indicated, " ... 29 [year old female] presents herself to the ED for alcohol withdrawals. Patient reports that she normally drinks 3 bottles of wine a night. However, her most recent intake was a tall can of beer about 2 days ago since she is trying to detox from it. Since then, she states she has been feeling shaky and feels as if she had a seizure the night prior. No other symptoms reported. She reports that she did try [Chlordiazepoxide (medication used to treat anxiety, insomnia, and symptoms of withdrawal from alcohol)] for her symptoms but states that it brought no relief. No other medical history ...Home medications ...acamprosate (This medication is used along with counseling and support to help people who are alcohol dependent not drink alcohol. Acamprosate works by restoring the natural balance of chemicals in the brain), sertraline (antidepressant) and trazodone (antidepressant) ...ED Course: Patient presents for the above reasons. Based on the patient's ED work - up today, I believe discharge is the appropriate course of action. Patient was educated on their results and instructed to follow-up with the listed physician/clinic below in their discharge paperwork, and given return precautions if their symptoms continue or worsen ...Follow up... Follow with primary care physician ...within 3-5 days ... PCP NO KNOWN ..."
The "Patient Summary Report" indicated Pt 3 arrived in the ED on 3/10/24 at 3:49 p.m. The patient was triaged at 3:52 p.m. and was assigned an emergency severity index (ESI) level 3 (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). Patient received Lorazepam (medication to treat anxiety and sleeping problems that are related to anxiety) and Chlordiazepoxide at 6:05 p.m. The review of "ED triage form" indicated initial vital signs on 3/10/24 at 3:52 p.m. Heart Rate (HR) 150 beats per minute (bpm-normal values 60-100 bpm), Blood Pressure (BP) 141/99 millimeters of mercury (mm/Hg - Unit of pressure that is used to measure blood pressure; normal 120/80 mmHg). The review of "lab results" indicated complete blood count with differential (CBC- blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells), ethanol level and Comprehensive Metabolic Panel (CMP - a routine blood test that measures 14 substances in the blood to provide information about the body's chemical balance and metabolism) were completed on 3/10/24 at 6:49 p.m. The lab results showed Ethanol level (measure the amount of alcohol in a person's blood) 212.50 and Ethanol Percentage 0.21 at 6:49 p.m. The flow sheet titled "Vitals" indicated on 3/10/24 at 8:11 p.m. HR was 132, BP 135/89, oxygen saturation 96%. Review of the document titled "ED Discharge form-Text" dated 3/10/24 indicated " ...Discharged from ED, Mode of discharge: Ambulatory; Mode of transportation: Private vehicle ...ED Discharged: Home ...ED Condition: Stable ... ED accompanied by: Self ...Discharge comments: See provider documentation for full assessment details, plan of care and discharge plan ...". The "ED Note- Physician" dated 3/10/24 indicated Pt 3 was prescribed chlordiazepoxide to take at home and the record indicated patient was discharged at 8:59 p.m. on 3/10/24. The review of "Nursing note" dated 3/10/24 at 3:59 p.m. indicated " ...Pt's roommate came up to this [Registered Nurse] and stated pt told him she needs to be on a hold but "they [would not] put her on a hold because she [would not] get out of the car and walk in the building, then she got arrested but they didn't press charges so now she is going to tell you she is coming in asking for alcohol pills but she needs to be on a hold." Pt denies [suicidal ideation/homicidal ideation] to this [Registered Nurse] at this time. EDM 1 stated she was not able to find any documentation that physician was notified about the concerned shared by roommate with nurse regarding need for hold. EDM 1 stated discharge instructions indicate patient was discharged to self, left by herself in a private vehicle at 8:59 p.m. The EDM 1 stated the discharge instructions lists the patient's condition as stable and no other documentation existed regarding patient's mental capacity or ability to take care of herself. EDM 1 validated Pt 3 received Lorazepam and Chlordiazepoxide at 6:05 p.m., and Pt 3's blood ethanol level was 212.50 at 6:49 p.m., three hours after arrival to ED. EDM 1 validated the discharge instructions to "follow up with NO Physician" in 3-4 days. EDM 1 stated ideally, they would discharge the patient with family or someone responsible to take care of the patient if they are not able to provide for themselves. EDM 1 stated the discharge instructions do not provide clear follow up instructions and needs to be worked on. EDM 1 stated the ED nurse does the assessment before discharge and would not have discharged the patient if they had any concerns. EDM 1 stated she cannot validate if the patient was functionally stable and ok to drive without having any documentation, however, they normally do not document the assessment before discharge and stated most likely the documentation is incorrect or missing regarding self-discharge in a private vehicle. EDM 1 stated HR greater than 130 prior to discharge was not concerning.

During a concurrent interview and record review on 08/19/24 at 2:30 p.m. with the Emergency Room Medical Director (EDMD), EDM 1 and RNQ 1, Pt 3's medical records dated 3/10/24 and 3/12/24 were reviewed. EDMD stated he has reviewed patient record for both ED visits. EDMD stated he was not sure why the discharge information lists "NO physician". EDMD stated they do not update this information and this information gets pulled automatically. The EDMD stated he was not too concerned with "HR of 132 in otherwise healthy individual." The EDMD stated before discharge they look at the patient to ensure that patient is functionally stable. The EDMD stated RN will assess and communicate with assigned provider as needed. The EDMD stated providers do not document functional stability of the patient but always assess before the discharge disposition. The EDMD stated the blood alcohol level of 212.50 could be where the patient normally lives. The EDMD stated that patient most likely did not drive herself upon discharge and stated the documentation was missing.

During a review of Pt 3's "EMS Patient Care Record (PCR)" dated 3/12/24, the PCR indicated, " ... Pt is a 29-year-old female not acting right. Boyfriend called 911. On arrival found Pt in a trailer walking around not acting normal. Per boyfriend he called for possible overdose. Pt has been drinking alcohol today and taking shots of Listerine during the day. Pt states she is being mental abused by her boyfriend and he slapped her around about 3 weeks ago. Ceres PD was called, and they came out and did a report. Pt is not on 5150 hold, pt does not want to harm herself. Pt has no complaints during transport ..."

During a concurrent interview and record review on 08/19/24 at 2:35 p.m. with EDM 1 and RNQ 1, Pt 3's medical record dated 3/12/24 was reviewed. The document titled "Patient Summary Report" dated 3/12/24 indicated, Pt 3's returned to ED by ambulance with diagnoses which included: Alcohol use, Poly pharmacy and Altered Mental Status on 3/12/24 at 8:48 p.m., and was triaged at 9:00 p.m. Review of "ED Note-Physician" dated 3/12/24 indicated, " ...HISTORY OF PRESENT ILLNESS: 29-year-old female history of alcohol abuse recently evaluated on 3/10 for alcohol withdrawal presents to the ED for intoxication, brought in by initially called for domestic violence, reportedly had been slapped by the boyfriend, patient however denies this, denies any pain, patient had [Chlordiazepoxide] medication bottle next to her bedside, appears intoxicated able to provide city where she lives slurring speech ...no external sings of trauma concerning for ICH or fracture ...I was worried for the patient safety, so I have placed them under 1799 hold with plans for further evaluation ...Patient was seen taking unknown number of the [Chlordiazepoxide] medications despite medications ordered to be taken away from patient. Patient was monitored for period of time in the emergency department ..." Review of "Nursing Note" dated 3/12/24 at 11:39 p.m., indicated, " ...Pt found with empty [Chlordiazepoxide] bottle states "It's not a big deal I just took a couple...". The record indicated after this, Pt 3 was placed on a 1799 hold on 3/12/24 at 11:57 p.m. and transferred to an inpatient psychiatric treatment center on 3/13/24 at 4:57 a.m. The EDM 1 stated she does not know how the patient was able to take [Chlordiazepoxide] in ED. EDM 1 stated medication should have been taken away from the patient.

During a review of the facility's P&P titled, "MOD COMP-RCC 5.16 EMTALA POLICY," dated 4/24/24, indicated, "..To ensure individuals presenting to [hospital name]emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment of appropriate transfer in accordance with Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ...[hospital name] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care ..."

During a professional reference review retrieved from (https://www.ncbi.nlm.nih.gov/books/NBK547659/) titled, "Chlordiazepoxide", dated 1/30/20, the reference indicated, " ...Contraindications ... The use of benzodiazepines, including chlordiazepoxide, exposes individuals to the risk of misuse, abuse, and potential addiction, resulting in overdose or death. Benzodiazepine abuse and misuse often involve concurrent alcohol and illicit substances, contributing to a higher incidence of severe adverse outcomes. Before prescribing chlordiazepoxide and throughout treatment, evaluate each patient's susceptibility to abuse, misuse, and addiction ... Patients should be informed about life-threatening adverse effects if combined with opiates, alcohol, and other CNS-depressant medications ..."

2. During a review of the hospital's report of patients who returned to the ED within 48 hours of a previous ED visit for August 2024, the report indicated Pt 4 was a 32-year-old male who came to the ED at 4:41 p.m. on 8/9/24 with a chief complaint of "Increased blood sugar" and was discharged on 8/9/24 at 7:49 p.m., three hours and nine minutes later. The report indicated that Pt 4 returned to the ED on 8/10/24 at 6:44 a.m. with a chief complaint of "Increased Blood Sugar; DIABETIC".

During a review of Pt 4, "[Emergency Medical Services (EMS)] Patient Care Record (PCR)" dated 8/9/24, the PCR indicated, " .... Address: Homeless ...dispatched code 3 ...male siting up talking to fire [department]... [Glasgow Coma Scale (GCS) is a system to "score" or measure how conscious you are. The score ranges from 3-15. Patients with scores of 3 to 8 are usually considered to be in a coma and 15 is the best you can get] GCS of 15. Pt stated he smoked meth and now his sugar is high [Blood glucose level (BGL)] 414 and pt stated his mouth is dry.... [arrival on site-Hospital name], charge [nurse] advised to take pt to triage. Report given to triage nurse ...Medication administration ...Normal Saline (mixture of sodium chloride and water) ...Intravenous (IV - Into or within a vein) ...500 milliliters (ml-unit of measurement) ..."

During a concurrent interview and record review on 08/20/24 at 10:30 a.m. with the EDM 1 and RNQ 1, Pt 4's record dated 8/9/24 was reviewed. The document titled "Patient Summary Report," dated 8/9/24 indicated, Pt 4 arrived in the ED on 8/9/24 at 4:41 p.m., was triaged at 4:57 p.m. and emergency severity index (ESI) level 3 (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) was assigned. The order was placed for Complete Blood Count with auto differential (CBC- blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells), Hemoglobin A1C (blood test that measures the average blood sugar level over the past three months), Basic Metabolic Panel (BMP- blood test that measures eight substances in the blood to evaluate various body functions and processes), and Beta Hydroxybutyrate (test used to detect ketones in blood or urine and monitor ketosis, metabolic state that occurs when your body burns fat for energy instead of glucose.) on 8/9/24 at 6:02 p.m. The patient was discharged on 8/9/24 at 7:49 p.m. Pt 4's vital signs at 4:57 p.m. were normal. The review of "ED Note-Physician" dated 8/9/24 indicated, Pt 4 arrived with chief complaint "High blood sugar, 450. EMS administered 500 ml, [normal saline -(NS)], [blood glucose] after 350. Used meth today per patient. EMS IV pulled before coming out to ED lobby". The document indicated " ...Pt states that he has no current [Diabetes mellitus (DM - condition when body does not produce enough insulin, or the body's cells do not respond to insulin)] medications, but used to be on Metformin and insulin. Unable to obtain further information and medical [history] due to pt's medical status ...Physical exam...General: Patient is thin-appearing, cachectic, looking around, and not following instructions ...lab summary statements ...normal white blood cells (WBCs- are part of the body's immune system. They help the body fight infection and other diseases) count 9.0, hemoglobin (Hb- is the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) is low at 8.6 with low [Mean corpuscula volume (MCV- measures the average size of your red blood cell, help identify anemia and other conditions) of 61.1 Platelets (are a blood component whose function is to react to bleeding from blood vessel injury by clumping, thereby initiating a blood clot) adequate at 338. Patient's electrolytes show a low sodium (blood test measures the amount of sodium in your blood) of 129 but I believe this is due to elevated blood sugar of 314. Creatine (a lab test to assess kidney functions) is normal at 0.8 although [Blood Urea Nitrogen (BUN -test measures how much urea nitrogen is in your blood. It helps to determine if kidneys are working as they should is slightly up at 37 which may go along with some mild dehydration. Hemoglobin A1c is 9.1 showing poor control ...He is not willing to give much information and appears to be under the influence of methamphetamine. Physical exam shows him to be cachectic and somewhat pale appearing. His vitals sings were unremarkable ...He is microcytic anemic. His blood sugar is elevated at 314 consistent with his poor control. His BUN is elevated at 37 and EMS did give him a bolus ...I will be discharging him with prescription of metformin. He needs to work with his doctor at his clinic to control his anemia but more importantly he needs to be in a treatment program for his methamphetamine use and I have given him referrals ..." The review of "lab results for Beta Hydroxybutyrate" dated 8/9/24 at 6:02 p.m. also indicated 1.06 millimoles per liter (mmol/L) (normal 0.02 -0.27). EDM 1 stated she was unable to find any interventions done in ER besides lab draws. EDM 1 also validated no documentation regarding plan or rationale for high Beta Hydroxybutyrate level on provider note. EDM 1 also validated no blood glucose check was done during the entire ED stay and only documented glucose level in patient record is 314 from BMP that was done on 3/9/24 at 6:02 p.m. EDM 1 stated patient was treated by paramedics with fluid bolus and blood glucose check was completed by EMS, no other medications were administered in ED. The EDM 1 stated BG level of 314 is high and she could not provide an explanation as to why no other interventions were completed in ED to address blood glucose, to recheck the blood glucose level or to address the high Beta Hydroxybutyrate level in ED prior to discharge on 8/9/24 at 7:49 p.m.

During a concurrent interview and record review on 08/20/24 at 10:40 a.m. with the Emergency Room Manager (EDM) 1 and Quality Registered Nurse (RNQ) 1, Pt 4's record dated 8/9/24 was reviewed. The document titled "ED Discharge Form-Text" indicated, Pt 4 was discharged on 8/9/24, a Friday at 7:49 p.m., ED Disposition: discharge, ED discharged: home (although homeless). The EDM 1 stated although a shelter list was provided, the document does not reflect if the patient was offered or given taxi voucher or ride as needed to a shelter along with weather appropriate clothing. The EDM 1 stated the missing elements are required prior to discharge in accordance with hospital policy and state law concerning homeless patient discharge. The EDM 1 validated 8/9/24 was Friday, and stated she did not know what resources would be open/available to a patient upon discharge to pick up his medication or if the shelter accepts patients at nighttime.

During a review of Pt 4's "[Emergency Medical Services (EMS)] Patient Care Record (PCR) " dated 8/10/24, the PCR indicated, " ...32-year-old male outside of seven eleven shop with fire department crew by his side. Patient stated that he has been having diabetic issues, has been going in and out of [hospital name] for past few days. Patient reported he has not been able to take his medications. Patient also complaint of some left ankle pain, no obvious sign of trauma noted. Patient denies falls, stated he has been doing lot of walking. Patient admitted to weed and meth usage. Patient able to ambulate to gurney ..."

During a concurrent interview and record review on 08/20/24 at 10:45 a.m. with the Emergency Room manager (EDM) 1 and Quality Registered Nurse (RNQ) 1, Pt 4's record dated 8/10/24 was reviewed. The document titled, "Patient Summary Report" indicated patient returned to the ED on 8/10/24 at 6:44 a.m. Pt was triaged at 6:49 a.m. and ESI of 3 was assigned. The order was placed for chest X-ray (use to create picture of inside the body), Electrocardiogram (EKG - a test to record the electrical signals in the heart), X-ray ankle, Urinalysis (test that examines urine for physical properties, cells, organisms, and other substances), Troponin1(blood test to detect heart damage and diagnose heart conditions), CBC, and CMP were ordered. Pt 4 was also given Insulin Regular and Sodium Chloride IV and blood glucose levels. Review of document titled "ED Note- Physician" dated 8/10/24 indicated, " ...Chief Complaint: [brought in by ambulance (BIBA)] for elevated blood sugar. Has [left] ankle pain, feels like a burning sensation. [fingerstick blood sugar (FSBS)] 345 ...Radiology/Diagnostic Results ...XR Ankle ..findings ...Impression: Negative Ankle/Foot ...Degenerative arthritic changes ...No fracture ...XR Chest ...Impression: Negative ...EKG ...Sinus, No PVCs, No obvious ST changes, No [bundle branch block (BBB - condition that occurs when the electrical signal that causes the heart to beat is blocked or delayed in one or both of the heart's bundle branches )] " The "lab results" dated 8/10/24 indicated glucose level at 6:59 a.m. 347, at 8:22 a.m. 382, at 10:36 a.m. 317, at 11:21a.m. 181. The "Medication Administration Record (MAR)" dated 8/10/24 indicated, Pt 4 received 5 units of insulin (medication used in the treatment and management of high blood sugar) at 10:41 a.m. and sodium chloride (used for replenishing fluid and for restoring and maintaining the concentrations of sodium and chloride) 0.9% 1000 ml at 10:29 a.m. Review of document titled "ED Discharged Form" dated 8/10/24 indicated, " ED Disposition: Discharge Mode of discharge: Ambulatory ... Mode of transportation: Other: bus pass ...ED Discharged: Shelter ...ED condition: Stable ...ED Accompanied by: Self ...Discharge Comments: Clothes weather appropriate, gave sandwich and bus pass. The EDM 1 stated patient was discharged appropriately on 8/10/24 at 11:35 a.m.

During a concurrent interview and record review on 08/20/24 at 11:00 a.m. with the Emergency Room manger (EDM) 1 and Quality Registered Nurse (RNQ), the P&P titled, " AD 3.08 California Hospital Discharge Planning for Homeless Patient," dated 6/22/22 was reviewed. The EDM 1 stated regarding Pt 4, she was not able to locate any documentation regarding referral or consult by a social worker. The EDM1 stated it was not the facility process to get a social worker consult for homeless discharges. The EDM 1 stated she was not able to find documentation of a full cognitive assessment as outlined in the policy.


During a review of the facility's policy and procedure (P&P) titled, "MOD COMP-RCC 5.16 EMTALA POLICY," dated 4/24/24, the P&P indicated, "..To ensure individuals presenting to [hospital name] emergency department receive an appropriate Medical Screening Examination (MSE) and stabilizing treatment of appropriate transfer in accordance with Emergency Medical Treatment and Labor Act of 1986 (EMTALA) ...[hospital name] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care ..."

During a review of the facility's P&P titled, " AD 3.08 California Hospital Discharge Planning for Homeless Patient," dated 6/22/22, the P&P indicated, " ...Purpose of this policy is to ensure transition management and discharge planning for the homeless patient is conducted with dignity, respect and compassion, in accordance with regulatory requirements and accreditation standards to improve continuity of care and follow a process for discharge planning that will address health care needs of the homeless patient population in the State of California (State) ...This policy applies to Homeless Individual presenting to Hospitals in California and includes in patients, observation admissions and certain types of outpatients, including, outpatients in a bed and Emergency Department patients ...The discharge planning process will be individualized and will begin as soon as possible, in the Emergency Department once the homeless patient is medically stable, or upon direct admission as an Inpatient or Outpatient. If there are complex discharge needs, Hospital Case Management assistance must be requested. The Discharge Planning Checklist for homeless patient will be initiated at this to develop an initial discharge plan for homeless patients presenting to the Hospital with the goal of balancing available community resources with patient choice and continuity of care. Prior to discharge, an appropriate discharge plan for the post-hospital medical care will be completed and documented in the medical record ...the hospital will offer weather-appropriate clothing and/or shoes to the patient as provided in this policy ...Social services/designated trained staff will assess homeless patient's ability to maintain mental cognition and stability post-hospitalization. The following are factors to be considered: history of frequent admissions, incarceration, interactions with law enforcement, associations with family or friends, frequents housing transitions, inconsistent locations for sleeping or food, ability to maintain/access public benefits and ability to maintain a treatment regimen ... Cognitive Assessment. When developing discharge plans, treating physicians, nurses, discharge planners and/or social workers will evaluate and document the patient's mental status during their clinical examination or assessments over the course of the patient's hospital stay to determine whether the patient is cognitively intact. The cognitive assessment will consider the homeless patient's individual circumstances (i.e. the patient's living arrangements and available support system post post-hospitalization) and details of the discharge plan what is to be implemented for the patients. The cognitive assessment will include the patient's orientation to person, place, circumstances and time, ability to provider self-care, his or her ability carry out usual activities or to protect his or her rights, the ability to obtain follow-up medical/mental health care, food and shelter, and ability to negotiate the environment being discharge to. The assessment will be documented in the patient's medical record ...Services offered to Homeless Patients Before Discharge ...Clothing...if the patient does not arrive with weather appropriate clothing, the hospital will offer weather appropriate clothing and encourage the patient to change in to weather-appropriate clothing before leaving the hospital ..."