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Based on interview and record review, the facility failed to provide appropriate examination and assessment of presenting signs and symptoms and stabilizing treatment for an emergency medical condition (EMC – any severe illness, injury or symptom that poses an immediate threat to life, limb or long-term health, requiring urgent professional care to prevent serious harm, permanent damage, or death) one of 25 Sampled Patients (Patient 1) during a visit to the facility ' s emergency department (ED – a hospital facility providing immediate, 24/7 care for severe injuries and acute illnesses, including heart attacks, strokes, major trauma, and sudden severe pain, with specialized staff, equipment, and a triage system to prioritize life-threatening conditions for urgent life-saving interventions), prior to being discharged home.

These deficient practices resulted in Patient 1 being unsafely discharged from the facility ' s ED, seeking emergency services from another hospital facility by calling 911, while still on the facility property, and getting transported to another hospital for emergency services, despite reported change of condition from Patient 1 to facility staff, prior to leaving the facility, which resulted in patient ' s death, at the receiving hospital.

Findings:

A review of Patient 1 ' s face sheet (medical face sheet – a concise, single-paged summary of a patient ' s essential demographic, insurance, and key clinical information, acting as a quick reference guide for healthcare providers to streamline patient intake, care coordination, and urgent decision-making), dated 9/15/2024, indicated patient was admitted at 3:42 AM and discharged at 6:25 AM, with a diagnosis of fever, and was under the care of ED Physicians, including MD 1, MD 2, and MD 3.

During concurrent interview and record review on12/2/2025, at 3:08 PM, with Clinical Operations Manager of the ED (ED Mgr.), Patient 1 ' s ED visit from 9/14/2024 to 9/15/2024 was reviewed, ED Mgr. stated Patient 1 arrived at the facility ' s ED on 9/14/2024, at 3:27 PM, by way of a basic life support (BLS) ambulance.



Concurrently, during interview and record review of Patient 1 ' s ambulance run sheet (documents a prehospital medical call and serves as a medical record for ambulance services, including patient information, incident location and time, chief complaint, condition, treatments, and transport information), dated 9/14/2024, ED Mgr. stated the following:

Patient was found standing with a chief complaint of weakness and flu-like symptoms, including fever. Patient was diagnosed with colon cancer and

vital signs (VS – essential measurements of the body ' s most basic functions, including temperature, pulse, breathing, and blood pressure) at 3:10 PM, included pain of 8/10 (severe pain). Transfer VS at 3:35 PM, included pain of 7/10 (severe pain). Transferred to receiving hospital for further evaluation of fever and muscle aches, in stable condition, with report given to triage (the preliminary assessment of patients to determine the urgency of their need for treatment and the nature of treatment required) nurse (RN) 1, who placed patient from gurney to a wheelchair, for laboratory draw.



During record review of Patient 1 ' s ED Timeline, dated 9/14/2024 to 9/15/2024, ED Mgr. stated the following:

Patient arrived on 9/14/2024, at 3:27 PM.

At 3:28 PM, patient ' s chief complaint was body pain and fever.

At 3:31 PM, ED Physician (MD 1) completed a rapid medical examination of patient.

At 3:38 PM, triage nurse (RN)1 documented patient arrived at the ED by way of BLS ambulance, was assessed with no pain, and a triaged at a classification of 3 (an urgent condition that is not life-threatening but requires relatively fast medical attention) acuity.

At 4:09 PM, MD 1 ordered laboratory (lab) tests, from blood and urine samples of the patient.

At 4:20 PM, MD 1 completed the rapid medical examination of the patient.

At 4:40 PM, patient ' s lab results for complete blood count (CBC – a blood test that assesses overall health by measuring the quantity and quality of red blood cells for carrying oxygen, white blood cells for fighting infections, and platelets for blood clotting) indicated white blood cells (WBC) were high at 14.4 k/uL (normal range 4.3 - 10.0 k/uL) showing infection and hemoglobin (HGB) was low at 7.7 grams/deciliter showing anemia. .

At 5:17 PM and at 7:39 PM, in the ED waiting area, patient ' s VS were obtained by ED Technician (EDT) 1, with the patient ' s complaint of new onset of pain 9/10 pain (severe pain), which was not reported to the licensed nurse (RN 1) or ED physician (MD 1).

ED Mgr. stated that the EDT 1 should have reported the new onset of pain to the triage nurse (RN 1), who should have reported this new abnormal finding to the ED physician (MD 1). ED Mgr. Stated pain management is a part of stabilizing treatments for patients in the ED.

On 9/15/2024, at 1:17 AM, in the ED waiting area, patient ' s VS were obtained by EDT 2, with an elevated blood pressure of 175/82 and a patient complaint of pain 7/10 (severe pain).

ED Mgr. stated the EDT 2 should have repeated the high blood pressure and/or reported the elevated blood pressure of the patient and the pain score of 7/10 to the triage nurse (RN 1), who should have reported the abnormal findings to the ED physician (MD 1), per policy and procedures, when a patient has a change in condition.

At 1:56 AM, in the ED waiting area, patient ' s VS were obtained by EDT 2, with a drop in blood pressure to 89/56 and a patient complaint of 7/10 pain.

At 2:18 AM, patient was reassigned to another ED nurse (RN 2), in the waiting room.

At 2:19 AM, another ED physician (MD 2) ordered intravenous (IV – by way of the vein) fluids with normal saline 1 liter bolus and IV pain medication – Toradol 30 milligram (mg) by IV injection.

At 2:30 AM, patient refused IV fluids and IV pain medication because wanted to wait for a room in the ED, for privacy.

At 2:37 AM, another ED physician (MD 3) changed the order for pain medication from intravenous (IV) to intramuscular (IM – into the muscle).

At 2:40 AM, patient received an IM injection of pain medication, Toradol 30 mg.

ED Mgr. stated patient was not reassessed for pain, within one hour after receiving pain injection, to check for the effectiveness of the pain medication, per hospital policy and procedures.

At 3:42 AM, patient was placed in an ED room (main ED) and was assigned to the same ED nurse (RN 2).

At 3:46 AM, patient was assigned to another ED physician (MD 2).

At 4:00 AM, RN 2 obtained patient ' s VS with no pain reported.

At 5:48 AM, RN 2 obtained patient ' s last VS, before discharge, with no pain reported.

ED Mgr. stated patient ' s VS were not obtained, per policy/procedures, within 30 minutes, prior to being discharged from the ED, on 9/15/2024, at 6:25 AM.



Concurrently, during record review of Patient 1 ' s ED Physician Notes, dated 9/15/2024, at 3:54 AM, ED Mgr. stated the following:

History of present illness (HPI) indicated patient had a history, which included, abdominal pain which began three days ago and a diagnosis of stage 4 for colon cancer, since April.

HPI indicated patient stated she was supposed to have surgery, but did not have surgery.

HPI indicated patient complained of having fever and chills.

Physical examination revealed tenderness in right upper and right lower portions of the patient ' s abdomen.

Laboratory results reported abnormal findings in the complete blood count with high WBC and low Hgb level and chemistry panel with high glucose (blood sugar levels), which indicated infection, anemia and high blood sugar.

Interventions indicated patient had intravenous access and was given pain medication by IM injection.

Plan indicated patient did not have an acute emergency condition that warrant admission and patient agreed with the plan for discharge home with a prescription for pain medication and discharge instructions to return if condition worsens.

Observation indicated patient was observed at 3:46 AM with lab work obtained, diagnostic imaging obtained, IV fluids administered, pain medication given, with improvement.

Patient was discharged from ED services at 5:48 AM.



During interview and record review of Patient 1 ' s Nursing Notes, dated 9/15/2024, at 5:49 AM, ED Mgr. stated patient verbalized understanding of discharge and home instructions, including following up with primary physician or return to the ED if symptoms worsen.

Concurrently, during record review of Patient 1 ' s Nursing Notes, dated 9/15/204, at 6:18 AM, ED Mgr. stated the patient refused to be discharged and reported, "I can ' t walk," despite being observed walking (earlier without deficits).Security guard was called because patient used profanity towards staff. Security guard escorted patient out of the ED, after patient got off the gurney, collected her belongings without assistance by staff. Patient was observed without any issues with gait or balance, while walking.

During interview and record review of Patient 1 ' s Social Worker (SW) notes, dated 9/15/204, at 6:28 a.m., with ED Mgr, ED Mgr. stated the SW indicated patient was provided a reloadable, contactless fare card for public transit (TAP Card – a ticket to ride, hop on a bike, catch a bus, jump on a train).Patient stated she needed surgery and needed medication. Patient stated she had nowhere to go and stated, "I can ' t walk." SW indicated she reviewed discharge planning and instructions. Patient was escorted out of the facility with security guard.



On 12/3/2025, at 2:07 PM, during concurrent interview with ED physician (MD 2) and record review of Patient 1 ' s ED Timeline, dated 9/14/2024 to 9/15/2024, MD 2 stated Patient 1 was assigned to him after patient was roomed, on 9/15/2024, at 3:46 AM.

During interview and record review of Patient 1 ' s ED Physician Notes, dated 9/15/2024, MD 2 stated HPI was obtained from a chart review of other facilities, where patient visited in the past/present, which indicated patient had stage 4 colon cancer and was supposed to have surgery. He examined the patient and found that patient had tenderness in the right upper and right lower areas of the abdomen, had an elevated white count (indicating an infection), had anemia (low hemoglobin), and a potentially contaminated urine sample. Patient ' s problems included a urinary tract infection (bladder infection), colon cancer, appendicitis, gallbladder infection. Patient had a computed tomography scan (CT – a medical imaging procedure that uses a computer and x-rays to create detailed, cross-sectional images of the inside of the body, used to diagnose diseases, plan treatments, and monitor their effectiveness by providing a 3-D view of organs and tissues), two days ago for appendicitis, and did not order another CT for the patient for this visit. Patient had no current emergent condition and was stable for discharge. Patient had abdominal pain and was discharged from the facility on 9/15/2024, in good condition.



During interview and record review of Patient 1 ' s Nursing Note, dated 9/15/2024 with MD 2, indicated that ED Mgr. stated patient refused to be discharge and stated, "I can ' t walk." MD 2 stated he did not remember that patient refused to be discharged home. MD 2 stated he did not remember if he observed Patient 1 walking.

Concurrently, during record review of Patient 1 ' s Social Worker note, dated 9/15/2024, MD 2 stated he ordered a social worker consultation, whenever a patient is not happy with the outcome of the ED visit and does not want to leave the hospital, after being discharged. MD 2 stated he did not remember if Patient 1 had difficulty walking. MD 2 stated he did not discharge Patient 1 into an ambulance, for transfer. MD 2 stated Patient 1 was discharged home from the hospital.

A review of Patient 1 ' s Ambulance Run Sheet (documents a prehospital medical call and serves as a medical record for ambulance services, including patient information, incident location and time, chief complaint, condition, treatments, and transport information), dated 9/15/2024, indicated the following:

At 10:15 AM, call to 9-1-1 dispatch for emergency medical services (EMS) for a person (Patient 1) found in the bushes outside the hospital ' s emergency department.

At 10:24 AM, ambulance staff found a person (Patient 1) seated in the bushes outside the referring hospital ' s emergency department, who was conscious and coherent with chief complaint of right sided body pain.

Patient 1 stated was seen at the referring hospital overnight with the hospital staff refusing to treat her since she was discharged from the emergency department at 5:00 AM.

Patient 1 stated was still experienced right sided body pain and was scheduled for colon cancer surgery at the receiving hospital and requested transportation to the receiving hospital.

Ambulance service left referring hospital with Patient 1, at 10:32 AM.

At 11:21 AM, Patient 1 ' s care was transferred to receiving hospital.



During a review of Patient 1 ' s ED Physician Note (an official document from an emergency room visit that is an ongoing record of a patient ' s condition, treatment, and progress with clinical events, observations, and changes over time, used to ensure continuity of care and to facilitate communication) from GACH 2, dated 9/15/2024, ) indicated the Lactate of 3.2 indicated severe sepsis (infection) and preliminary reading of CT of the abdomen was perforation with phlegmon (a severe, spreading inflammation of soft tissues), with the abdomen broadened.

During a review of Patient 1 ' s CT of the Abdomen and Pelvis with Contrast (substance agents given to patients to make specific tissues, organs, or blood vessels stand out more clearly in medical imaging to allow physicians ability to diagnose conditions) report from GACH 2, dated 9/15/2024 at 4:17 p.m., the report indicated, "Large heterogeneously enhancing mass in the right lower quadrant which appears to arise from cecum/ascending colon suspicious for colonic malignancy."

During a review of Patient 1 ' s "Surgical Consultation" from GACH 2, dated 9/15/2024 at 6:36 p.m., the "Consultation" indicated, "[Patient 1] was in so much pain that she cannot walk ... Cecal cancer has most likely perforated ... Patient was amenable to ex lap [exploratory laparotomy a major surgery where a surgeon makes an incision into the abdomen to visually examine the abdominal organs, diagnose internal issues (like bleeding, tumors, blockages, injuries, or infections), take biopsies (samples for testing), or treat conditions when the cause isn't clear] and possible of ileostomy [a surgical opening (stoma) in the abdomen connecting the end of the small intestine (ileum) to the outside, allowing stool and gas to exit the body when the large intestine can't] if it is the only option ... as she was in such severe pain and wanted to proceed with surgery."

During a review of Patient 1 ' s "Surgical Progress Note" from GACH 2, dated 9/16/2024 at 3:38 p.m., the "Note" indicated that Patient 1 had a bowel perforation (there was a hole or tear in the wall of the bowel, allowing digestive contents and bacteria to leak into the abdominal cavity and cause severe infection, and requiring immediate emergency to prevent further life-threatening complications) and was status post (indicates the patient ' s condition after they have a procedure or surgery) open right colectomy (a surgical procedure to remove the right side of the colon) on 9/16/2024.

During a review of Patient 1 ' s Surgical Intensive Care Unit History and Physical (H&P – essential medical documentation where a healthcare provider gathers the patient ' s story through questions and performs physical examination to assess the patient ' s current health, forming the foundation for diagnosis and treatment plans, detailing symptoms, past illnesses, lifestyle, and objective findings from vital signs)" from GACH 2, dated 9/23/2024 at 12:37 p.m., the H&P indicated the following for Patient 1:

1. became tachypneic (abnormally fast, shallow breathing) and hypoxic (a state where the cells in the body are deprived of oxygen);

2. a rapid response was called and she was upgraded to SICU services.

3. upon arrival to the SICU, Patient 1 began refused any escalating interventions and decided to pursue comfort care (only managing symptoms and improve quality of life at the end of life).

During a review of Patient 1 ' s "Death Summary" from GACH 2, dated 9/25/2024, the "Summary" indicated Patient 1 expired at GACH 2 on 9/24/2024 at 6:20 p.m.







A review of facility ' s EMTALA Guidelines policy, dated 11/6/2025, indicated the following:

All patients presenting to the facility requesting medical care will receive a Medical Screening Examination (MSE) regardless of the patient ' s insurance or ability to pay.

The MSE shall be performed by a physician or qualified medical person and shall include all necessary testing and on-call services within the capability of the hospital to reach a patient diagnosis and stabilization or arrangements for appropriate transfer of the individual to another medical facility will be made.

The hospital shall provide an on-call list of physicians who are available to consult or provide treatment necessary to stabilize an individual with an Emergency Medical Condition (EMC).

If it is determined that the individual has an EMC, the patient will be provided with further medical examination and treatment, as required, to stabilize the EMC, within the capability of the hospital or arrangements for appropriate transfer of the individual to another medical facility will be made.

The hospital proper included the entire main medical center, hospital campus, parking lot, sidewalk, and driveway, and physical areas immediately adjacent to the main buildings on the hospital campus, other areas, and structures located within 250 yards of the main buildings that provide patient care for patients.



A review of facility ' s Triage policy, dated 9/15/2022, indicated the following:

Patients presenting to the ED receive a medical screening by a provider.

Patients presenting to the ED are triaged by a physician and/or a registered nurse (RN), in a timely manner.

An acuity level is assigned to the patient, with a destination for main ED, pediatric ED, or Fast Track is determined.

Patients arriving via ambulance (advanced life support or basic life support) are assigned a room, in a timely manner.

Acuity assignment: 1 for immediate life-threatening emergencies including resuscitation, 2 for emergent conditions including threat to life/limb/function, 3 for urgent conditions including significant pain/discomfort, 4 for semi-urgent conditions with potential for deterioration, and 5 for non-urgent conditions including chronic problems.

Patient placement is determined by the acuity assigned and the availability of beds in the ED.



A review of facility ' s Assessment of Patient policy, dated 2/1/2024, indicated the following:

The purpose of this policy is to determine the appropriate level of care, with each discipline performing patient assessment and reassessments within their scope of practice and expertise.

Information gathered through assessments by the healthcare team is used to identify and prioritize the patient ' s plan of care, in collaboration with the patient, the physician acting as the leader of the team, and the RN acting as the coordinator of care.

Focus assessments on the patient ' s chief complaint and other identified problems must include documentation of vital signs, pain scores, chief complaint, symptoms, physical/sensory/communication limitations.

Reassess patients a minimum of every two hours in the emergency department (ED) with focus on chief complaints, identified problems and patient ' s responses to treatments.

Upon discharge, document a final assessment and a complete set of vital signs, including pulse, breathing, temperature, blood pressure, pain scale, and oxygen saturation, within 30 minutes of leaving the ED.

If a patient ' s condition has changed prior to discharge, document changes in the medical records and notify a physician.

Assess and document pain status using a 0 to 10 number scale for patients treated for pain management.

Assess patient ' s functional status that may affect care.



A review of facility ' s Pain Assessment and Management policy, dated 12/2/2024, indicated the following:

The physician and registered nurse are responsible for the assessment and reassessment of pain and the effectiveness of interventions.

The physician is responsible for the ordering of pharmacologic agents, administering and monitoring pharmacologic agents.

The licensed nurse is responsible for administering and monitoring the effectiveness of the pharmacologic agents.

Unlicensed health care givers are responsible for monitoring and reporting changes in patient ' s pain experiences.

The patient ' s right to pain management across the continuum of care is respected and supported.

Pain is assessed using numeric scale from: 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 or greater = severe pain.

On initial report of pain, assess the patient to collect additional information to identify/describe the pain including location, nature of, and tolerance/acceptable intensity of pain.

Reassess for the presence of pain and the effectiveness of interventions: before/after each pharmacologic intervention, within 60 minutes following administration of pharmacologic agents.

Report to the physician unexplained/unanticipated pain.

Documentation of pain assessment, intervention, and response to treatment shall be found in the patient ' s medical records.

Based on interview and record review, the facility failed to provide appropriate examination and assessment of presenting signs and symptoms and stabilizing treatment for an emergency medical condition (EMC – any severe illness, injury or symptom that poses an immediate threat to life, limb or long-term health, requiring urgent professional care to prevent serious harm, permanent damage, or death) one of 25 Sampled Patients (Patient 1) during a visit to the facility ' s emergency department (ED – a hospital facility providing immediate, 24/7 care for severe injuries and acute illnesses, including heart attacks, strokes, major trauma, and sudden severe pain, with specialized staff, equipment, and a triage system to prioritize life-threatening conditions for urgent life-saving interventions), prior to being discharged home.

These deficient practices resulted in Patient 1 being unsafely discharged from the facility ' s ED, seeking emergency services from another hospital facility by calling 911, while still on the facility property, and getting transported to another hospital for emergency services, despite reported change of condition from Patient 1 to facility staff, prior to leaving the facility, which resulted in patient ' s death, at the receiving hospital.

Findings:

A review of Patient 1 ' s face sheet (medical face sheet – a concise, single-paged summary of a patient ' s essential demographic, insurance, and key clinical information, acting as a quick reference guide for healthcare providers to streamline patient intake, care coordination, and urgent decision-making), dated 9/15/2024, indicated patient was admitted at 3:42 AM and discharged at 6:25 AM, with a diagnosis of fever, and was under the care of ED Physicians, including MD 1, MD 2, and MD 3.

During concurrent interview and record review on12/2/2025, at 3:08 PM, with Clinical Operations Manager of the ED (ED Mgr.), Patient 1 ' s ED visit from 9/14/2024 to 9/15/2024 was reviewed, ED Mgr. stated Patient 1 arrived at the facility ' s ED on 9/14/2024, at 3:27 PM, by way of a basic life support (BLS) ambulance.



Concurrently, during interview and record review of Patient 1 ' s ambulance run sheet (documents a prehospital medical call and serves as a medical record for ambulance services, including patient information, incident location and time, chief complaint, condition, treatments, and transport information), dated 9/14/2024, ED Mgr. stated the following:

Patient was found standing with a chief complaint of weakness and flu-like symptoms, including fever. Patient was diagnosed with colon cancer and

vital signs (VS – essential measurements of the body ' s most basic functions, including temperature, pulse, breathing, and blood pressure) at 3:10 PM, included pain of 8/10 (severe pain). Transfer VS at 3:35 PM, included pain of 7/10 (severe pain). Transferred to receiving hospital for further evaluation of fever and muscle aches, in stable condition, with report given to triage (the preliminary assessment of patients to determine the urgency of their need for treatment and the nature of treatment required) nurse (RN) 1, who placed patient from gurney to a wheelchair, for laboratory draw.



During record review of Patient 1 ' s ED Timeline, dated 9/14/2024 to 9/15/2024, ED Mgr. stated the following:

Patient arrived on 9/14/2024, at 3:27 PM.

At 3:28 PM, patient ' s chief complaint was body pain and fever.

At 3:31 PM, ED Physician (MD 1) completed a rapid medical examination of patient.

At 3:38 PM, triage nurse (RN)1 documented patient arrived at the ED by way of BLS ambulance, was assessed with no pain, and a triaged at a classification of 3 (an urgent condition that is not life-threatening but requires relatively fast medical attention) acuity.

At 4:09 PM, MD 1 ordered laboratory (lab) tests, from blood and urine samples of the patient.

At 4:20 PM, MD 1 completed the rapid medical examination of the patient.

At 4:40 PM, patient ' s lab results for complete blood count (CBC – a blood test that assesses overall health by measuring the quantity and quality of red blood cells for carrying oxygen, white blood cells for fighting infections, and platelets for blood clotting) indicated white blood cells (WBC) were high at 14.4 k/uL (normal range 4.3 - 10.0 k/uL) showing infection and hemoglobin (HGB) was low at 7.7 grams/deciliter showing anemia. .

At 5:17 PM and at 7:39 PM, in the ED waiting area, patient ' s VS were obtained by ED Technician (EDT) 1, with the patient ' s complaint of new onset of pain 9/10 pain (severe pain), which was not reported to the licensed nurse (RN 1) or ED physician (MD 1).

ED Mgr. stated that the EDT 1 should have reported the new onset of pain to the triage nurse (RN 1), who should have reported this new abnormal finding to the ED physician (MD 1). ED Mgr. Stated pain management is a part of stabilizing treatments for patients in the ED.

On 9/15/2024, at 1:17 AM, in the ED waiting area, patient ' s VS were obtained by EDT 2, with an elevated blood pressure of 175/82 and a patient complaint of pain 7/10 (severe pain).

ED Mgr. stated the EDT 2 should have repeated the high blood pressure and/or reported the elevated blood pressure of the patient and the pain score of 7/10 to the triage nurse (RN 1), who should have reported the abnormal findings to the ED physician (MD 1), per policy and procedures, when a patient has a change in condition.

At 1:56 AM, in the ED waiting area, patient ' s VS were obtained by EDT 2, with a drop in blood pressure to 89/56 and a patient complaint of 7/10 pain.

At 2:18 AM, patient was reassigned to another ED nurse (RN 2), in the waiting room.

At 2:19 AM, another ED physician (MD 2) ordered intravenous (IV – by way of the vein) fluids with normal saline 1 liter bolus and IV pain medication – Toradol 30 milligram (mg) by IV injection.

At 2:30 AM, patient refused IV fluids and IV pain medication because wanted to wait for a room in the ED, for privacy.

At 2:37 AM, another ED physician (MD 3) changed the order for pain medication from intravenous (IV) to intramuscular (IM – into the muscle).

At 2:40 AM, patient received an IM injection of pain medication, Toradol 30 mg.

ED Mgr. stated patient was not reassessed for pain, within one hour after receiving pain injection, to check for the effectiveness of the pain medication, per hospital policy and procedures.

At 3:42 AM, patient was placed in an ED room (main ED) and was assigned to the same ED nurse (RN 2).

At 3:46 AM, patient was assigned to another ED physician (MD 2).

At 4:00 AM, RN 2 obtained patient ' s VS with no pain reported.

At 5:48 AM, RN 2 obtained patient ' s last VS, before discharge, with no pain reported.

ED Mgr. stated patient ' s VS were not obtained, per policy/procedures, within 30 minutes, prior to being discharged from the ED, on 9/15/2024, at 6:25 AM.



Concurrently, during record review of Patient 1 ' s ED Physician Notes, dated 9/15/2024, at 3:54 AM, ED Mgr. stated the following:

History of present illness (HPI) indicated patient had a history, which included, abdominal pain which began three days ago and a diagnosis of stage 4 for colon cancer, since April.

HPI indicated patient stated she was supposed to have surgery, but did not have surgery.

HPI indicated patient complained of having fever and chills.

Physical examination revealed tenderness in right upper and right lower portions of the patient ' s abdomen.

Laboratory results reported abnormal findings in the complete blood count with high WBC and low Hgb level and chemistry panel with high glucose (blood sugar levels), which indicated infection, anemia and high blood sugar.

Interventions indicated patient had intravenous access and was given pain medication by IM injection.

Plan indicated patient did not have an acute emergency condition that warrant admission and patient agreed with the plan for discharge home with a prescription for pain medication and discharge instructions to return if condition worsens.

Observation indicated patient was observed at 3:46 AM with lab work obtained, diagnostic imaging obtained, IV fluids administered, pain medication given, with improvement.

Patient was discharged from ED services at 5:48 AM.



During interview and record review of Patient 1 ' s Nursing Notes, dated 9/15/2024, at 5:49 AM, ED Mgr. stated patient verbalized understanding of discharge and home instructions, including following up with primary physician or return to the ED if symptoms worsen.

Concurrently, during record review of Patient 1 ' s Nursing Notes, dated 9/15/204, at 6:18 AM, ED Mgr. stated the patient refused to be discharged and reported, "I can ' t walk," despite being observed walking (earlier without deficits).Security guard was called because patient used profanity towards staff. Security guard escorted patient out of the ED, after patient got off the gurney, collected her belongings without assistance by staff. Patient was observed without any issues with gait or balance, while walking.

During interview and record review of Patient 1 ' s Social Worker (SW) notes, dated 9/15/204, at 6:28 a.m., with ED Mgr, ED Mgr. stated the SW indicated patient was provided a reloadable, contactless fare card for public transit (TAP Card – a ticket to ride, hop on a bike, catch a bus, jump on a train).Patient stated she needed surgery and needed medication. Patient stated she had nowhere to go and stated, "I can ' t walk." SW indicated she reviewed discharge planning and instructions. Patient was escorted out of the facility with security guard.



On 12/3/2025, at 2:07 PM, during concurrent interview with ED physician (MD 2) and record review of Patient 1 ' s ED Timeline, dated 9/14/2024 to 9/15/2024, MD 2 stated Patient 1 was assigned to him after patient was roomed, on 9/15/2024, at 3:46 AM.

During interview and record review of Patient 1 ' s ED Physician Notes, dated 9/15/2024, MD 2 stated HPI was obtained from a chart review of other facilities, where patient visited in the past/present, which indicated patient had stage 4 colon cancer and was supposed to have surgery. He examined the patient and found that patient had tenderness in the right upper and right lower areas of the abdomen, had an elevated white count (indicating an infection), had anemia (low hemoglobin), and a potentially contaminated urine sample. Patient ' s problems included a urinary tract infection (bladder infection), colon cancer, appendicitis, gallbladder infection. Patient had a computed tomography scan (CT – a medical imaging procedure that uses a computer and x-rays to create detailed, cross-sectional images of the inside of the body, used to diagnose diseases, plan treatments, and monitor their effectiveness by providing a 3-D view of organs and tissues), two days ago for appendicitis, and did not order another CT for the patient for this visit. Patient had no current emergent condition and was stable for discharge. Patient had abdominal pain and was discharged from the facility on 9/15/2024, in good condition.



During interview and record review of Patient 1 ' s Nursing Note, dated 9/15/2024 with MD 2, indicated that ED Mgr. stated patient refused to be discharge and stated, "I can ' t walk." MD 2 stated he did not remember that patient refused to be discharged home. MD 2 stated he did not remember if he observed Patient 1 walking.

Concurrently, during record review of Patient 1 ' s Social Worker note, dated 9/15/2024, MD 2 stated he ordered a social worker consultation, whenever a patient is not happy with the outcome of the ED visit and does not want to leave the hospital, after being discharged. MD 2 stated he did not remember if Patient 1 had difficulty walking. MD 2 stated he did not discharge Patient 1 into an ambulance, for transfer. MD 2 stated Patient 1 was discharged home from the hospital.

A review of Patient 1 ' s Ambulance Run Sheet (documents a prehospital medical call and serves as a medical record for ambulance services, including patient information, incident location and time, chief complaint, condition, treatments, and transport information), dated 9/15/2024, indicated the following:

At 10:15 AM, call to 9-1-1 dispatch for emergency medical services (EMS) for a person (Patient 1) found in the bushes outside the hospital ' s emergency department.

At 10:24 AM, ambulance staff found a person (Patient 1) seated in the bushes outside the referring hospital ' s emergency department, who was conscious and coherent with chief complaint of right sided body pain.

Patient 1 stated was seen at the referring hospital overnight with the hospital staff refusing to treat her since she was discharged from the emergency department at 5:00 AM.

Patient 1 stated was still experienced right sided body pain and was scheduled for colon cancer surgery at the receiving hospital and requested transportation to the receiving hospital.

Ambulance service left referring hospital with Patient 1, at 10:32 AM.

At 11:21 AM, Patient 1 ' s care was transferred to receiving hospital.



During a review of Patient 1 ' s ED Physician Note (an official document from an emergency room visit that is an ongoing record of a patient ' s condition, treatment, and progress with clinical events, observations, and changes over time, used to ensure continuity of care and to facilitate communication) from GACH 2, dated 9/15/2024, ) indicated the Lactate of 3.2 indicated severe sepsis (infection) and preliminary reading of CT of the abdomen was perforation with phlegmon (a severe, spreading inflammation of soft tissues), with the abdomen broadened.

During a review of Patient 1 ' s CT of the Abdomen and Pelvis with Contrast (substance agents given to patients to make specific tissues, organs, or blood vessels stand out more clearly in medical imaging to allow physicians ability to diagnose conditions) report from GACH 2, dated 9/15/2024 at 4:17 p.m., the report indicated, "Large heterogeneously enhancing mass in the right lower quadrant which appears to arise from cecum/ascending colon suspicious for colonic malignancy."

During a review of Patient 1 ' s "Surgical Consultation" from GACH 2, dated 9/15/2024 at 6:36 p.m., the "Consultation" indicated, "[Patient 1] was in so much pain that she cannot walk ... Cecal cancer has most likely perforated ... Patient was amenable to ex lap [exploratory laparotomy a major surgery where a surgeon makes an incision into the abdomen to visually examine the abdominal organs, diagnose internal issues (like bleeding, tumors, blockages, injuries, or infections), take biopsies (samples for testing), or treat conditions when the cause isn't clear] and possible of ileostomy [a surgical opening (stoma) in the abdomen connecting the end of the small intestine (ileum) to the outside, allowing stool and gas to exit the body when the large intestine can't] if it is the only option ... as she was in such severe pain and wanted to proceed with surgery."

During a review of Patient 1 ' s "Surgical Progress Note" from GACH 2, dated 9/16/2024 at 3:38 p.m., the "Note" indicated that Patient 1 had a bowel perforation (there was a hole or tear in the wall of the bowel, allowing digestive contents and bacteria to leak into the abdominal cavity and cause severe infection, and requiring immediate emergency to prevent further life-threatening complications) and was status post (indicates the patient ' s condition after they have a procedure or surgery) open right colectomy (a surgical procedure to remove the right side of the colon) on 9/16/2024.

During a review of Patient 1 ' s Surgical Intensive Care Unit History and Physical (H&P – essential medical documentation where a healthcare provider gathers the patient ' s story through questions and performs physical examination to assess the patient ' s current health, forming the foundation for diagnosis and treatment plans, detailing symptoms, past illnesses, lifestyle, and objective findings from vital signs)" from GACH 2, dated 9/23/2024 at 12:37 p.m., the H&P indicated the following for Patient 1:

1. became tachypneic (abnormally fast, shallow breathing) and hypoxic (a state where the cells in the body are deprived of oxygen);

2. a rapid response was called and she was upgraded to SICU services.

3. upon arrival to the SICU, Patient 1 began refused any escalating interventions and decided to pursue comfort care (only managing symptoms and improve quality of life at the end of life).

During a review of Patient 1 ' s "Death Summary" from GACH 2, dated 9/25/2024, the "Summary" indicated Patient 1 expired at GACH 2 on 9/24/2024 at 6:20 p.m.







A review of facility ' s EMTALA Guidelines policy, dated 11/6/2025, indicated the following:

All patients presenting to the facility requesting medical care will receive a Medical Screening Examination (MSE) regardless of the patient ' s insurance or ability to pay.

The MSE shall be performed by a physician or qualified medical person and shall include all necessary testing and on-call services within the capability of the hospital to reach a patient diagnosis and stabilization or arrangements for appropriate transfer of the individual to another medical facility will be made.

The hospital shall provide an on-call list of physicians who are available to consult or provide treatment necessary to stabilize an individual with an Emergency Medical Condition (EMC).

If it is determined that the individual has an EMC, the patient will be provided with further medical examination and treatment, as required, to stabilize the EMC, within the capability of the hospital or arrangements for appropriate transfer of the individual to another medical facility will be made.

The hospital proper included the entire main medical center, hospital campus, parking lot, sidewalk, and driveway, and physical areas immediately adjacent to the main buildings on the hospital campus, other areas, and structures located within 250 yards of the main buildings that provide patient care for patients.



A review of facility ' s Triage policy, dated 9/15/2022, indicated the following:

Patients presenting to the ED receive a medical screening by a provider.

Patients presenting to the ED are triaged by a physician and/or a registered nurse (RN), in a timely manner.

An acuity level is assigned to the patient, with a destination for main ED, pediatric ED, or Fast Track is determined.

Patients arriving via ambulance (advanced life support or basic life support) are assigned a room, in a timely manner.

Acuity assignment: 1 for immediate life-threatening emergencies including resuscitation, 2 for emergent conditions including threat to life/limb/function, 3 for urgent conditions including significant pain/discomfort, 4 for semi-urgent conditions with potential for deterioration, and 5 for non-urgent conditions including chronic problems.

Patient placement is determined by the acuity assigned and the availability of beds in the ED.



A review of facility ' s Assessment of Patient policy, dated 2/1/2024, indicated the following:

The purpose of this policy is to determine the appropriate level of care, with each discipline performing patient assessment and reassessments within their scope of practice and expertise.

Information gathered through assessments by the healthcare team is used to identify and prioritize the patient ' s plan of care, in collaboration with the patient, the physician acting as the leader of the team, and the RN acting as the coordinator of care.

Focus assessments on the patient ' s chief complaint and other identified problems must include documentation of vital signs, pain scores, chief complaint, symptoms, physical/sensory/communication limitations.

Reassess patients a minimum of every two hours in the emergency department (ED) with focus on chief complaints, identified problems and patient ' s responses to treatments.

Upon discharge, document a final assessment and a complete set of vital signs, including pulse, breathing, temperature, blood pressure, pain scale, and oxygen saturation, within 30 minutes of leaving the ED.

If a patient ' s condition has changed prior to discharge, document changes in the medical records and notify a physician.

Assess and document pain status using a 0 to 10 number scale for patients treated for pain management.

Assess patient ' s functional status that may affect care.



A review of facility ' s Pain Assessment and Management policy, dated 12/2/2024, indicated the following:

The physician and registered nurse are responsible for the assessment and reassessment of pain and the effectiveness of interventions.

The physician is responsible for the ordering of pharmacologic agents, administering and monitoring pharmacologic agents.

The licensed nurse is responsible for administering and monitoring the effectiveness of the pharmacologic agents.

Unlicensed health care givers are responsible for monitoring and reporting changes in patient ' s pain experiences.

The patient ' s right to pain management across the continuum of care is respected and supported.

Pain is assessed using numeric scale from: 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 or greater = severe pain.

On initial report of pain, assess the patient to collect additional information to identify/describe the pain including location, nature of, and tolerance/acceptable intensity of pain.

Reassess for the presence of pain and the effectiveness of interventions: before/after each pharmacologic intervention, within 60 minutes following administration of pharmacologic agents.

Report to the physician unexplained/unanticipated pain.

Documentation of pain assessment, intervention, and response to treatment shall be found in the patient ' s medical records.

Based on interview and record review, the facility failed to complete an appropriate Patient Transfer to another facility for two of 25 Sample Patients (Patient 21 and Patient 24 ).

This deficient practice resulted in Patient 21 and Patient 24 not receiving appropriate transfer, which had the potential for patient harm.



Findings:

A. During a record review, on 12/3/2025 at10:00 am with Emergency Department Manager (EDMgr), Patient 21 ' s Emergency Department Patient care timeline dated 6/18/2024 was reviewed. The Emergency Department Patient care timeline indicated Patient 21 arrived at the Emergency Department (ED) 11:51am with complaint of abdominal pain. Patient 21Triage (preliminary assessment of patients) Time was 12:09 pm and was triage at a level 3 (urgent medical condition that isn ' t immediately life-threatening). Patient 21 temperature 99.4; pulse 179, respiratory rate 42 and Pulse oximetry (measurement of oxygen in the blood) 98% on room air. Patient 21 was placed in a room at 3:21pm and Medical Screening Exame (MSE) (initial evaluation to quickly determine if an urgent medical condition exist) complete at 4:00pm. Patient 21 ' s labs included Complete Blood Count (CBC), White Blood Count (WBC)13.6 ,C-reactive protein (CRP-protein made in the liver indicate infection) 22; and RVP (respiratory viral panel) positive for Rhinovirus and enterovirus and Computed Tomography (CT-test use x-rays and a computer) of abdomen. Initial result of CT of Abdomen at10:50pm included "Right sided colon thickening consistent with right sided colitis (inflammation of large intestine) either infectious or inflammatory and appendix (small worm-like organ) visualized".

A Review of Patient 21 Emergency Department (ED) provider note dated 6/18/2024 at 6:24 pm, indicated Patient 21 is unvaccinated with abdominal pain and fever since yesterday and sent by their Primary Medical Doctor (PMD) to rule out intussusception (one part of the intestine slides inside a part next to it). The ED Provider note also indicate, Patient presents with abdominal pain, fever, no vomiting and Ultrasound negative for intussusception. The abdomen was soft, nondistended and guarding and very tender to palpation and crying whenever even lightly touched. Total time observation: 5.5hours. Initial result of Computed Tomography (CT-test use x-rays and a computer) of Abdomen at 10:50pm included "Right sided colon thickening consistent with right sided colitis either infectious or inflammatory and appendix visualized". CT results discussed with Parents Recommended admission for observation to ensure that the patient is feeling better. Parents prefer to go home at this time. Return precautions discussed with parents."

During an interview on 12/3/2025 at 11:15am with Emergency Department Manager (EDMgr), EDMgr stated there was no AMA (against medical advice) signed when Patient 21 was discharge on 6/18/2024.

A Review of Patient 21 Emergency Department (ED) Provider note dated 6/19/2024 at 12:46 pm, indicated "called Parent of Patient 21 "CT of abdomen done 6/18/24 final reported by radiologist 6/19/24 "CT did not visualize appendix" Parents indicated Patient 21 had continued abdominal pain and not drinking and would return to ED for recheck and Intravenous (IV-within a vein) fluids".







During a record review, on 12/3/2025 at10:00 am with Emergency Department Manager (EDMgr), Patient 21 ' s Emergency Department Patient care timeline dated 6/19/24 was reviewed. The Emergency Department Patient care timeline indicated Patient21 arrived at the Emergency Department (ED) on 6/19/24 at Patient21 time of Triage (Acuity Level-severity of patient ' s illness) at 2:19pm Patient 21 at Acuity level3 (urgent condition that could potentially progress to a serious problem requiring emergency intervention may be associated with significant discomfort or affecting ability to function at work or perform daily acts). Patient 21 ' s vital signs(basic bodily functions used to assess a person ' s health) were; temperature: 99.8Fahrenheit(F)-a unit of measurement )(normal 97F to 99F); Pulse 137 (normal 98 to 140); Respiration rate (RR): 50breaths per minute (normal RR 22-37) Blood Pressure not taken90/55 to (normal BP86/46 to 112/72) Pulse oximetry (measurement of oxygen in the blood) 99% on room air (RA), and Pain assessment:. Patient 21 was placed in a room at 2:48 pm. Patient 21 MSE Completed and orders by MD at 3:12 pm. Laboratory tests including Comprehensive Blood count (CBC) (blood test to measure white cell Red cell; platelets hemoglobin and)CMP (blood test to measure the body chemical balance); C reactive Protein ( CRP) test to indicate inflammation or infection) and included IV fluid hydration ( Sterile fluid hydration directly in to the vein for including dehydration).

A review of ED Provider note dated 6/19/2024 at 3: 02 pm, Patient 21 had continued Abdominal pain, and decreased intake. Patient was seen in ED 6/18/24 for abdominal pain work up on 6/18/24 included: CRP elevated at 22; RVP(Respiratory Viral Panel) positive for Rhinovirus and enterovirus. CT of abdomen 6/18/24 and preliminary reported visualized appendix". Patient 21 Abdomen CT final report resulted 6/19/2024 indicated "unable to visualize appendix and R sided colitis" .Review of an ED Provider note Patient 21 Physical exam Abdomen: "Mild diffuse abdominal tenderness." Pediatric Surgery consultation ED on 6/19/24 at 5:26 pm recommendation included Patient 21 admission to Pediatrics for antibiotics and IV fluids, recommended sending stool studies for Cdiff; O/P ( Ova and Parasite) full infections work up and Consultation with GI.

A review of ED Provider note dated 6/19/2024 at 6:40 pm , Patient 21 had decreased Po (oral) intake and abdominal pain. Patient 21 vomited in ED and had Bowl movement with blood on outside, no diarrhea." and " Patient admitted in stable condition. Surgeons to follow inpatient"

A Review of Patient care time line at 10:37 pm, Transfer to Hospital C" Discharge readmit). EDmgr confirmed no Transfer and consent to transfer was in the Medical record reviewed..





Review of the document titled Admit Transfer Discharge for patient 21 discharge destination Hospital C discharge disposition hospital C discharge date 6/19/2024 at10:37 pm. There were no Transfer documents and were requested from EDM and Dir of Qual,

During an Interview on12/3/2025 at 11:15 am with The Director of Quality (Dir Qual), Dir Qual stated, there was no transfer document and consent to transfer Patient 21 on 6/19/2024 from ED to Hospital C. Dir Qual confirmed Hospital C is not same license as Hospital A.



B. During record review on 12/3/2025 at10:00 am with Emergency Department Manager (EDMgr), Emergency Department (ED) Patient care timeline dated 6/18/2024 was reviewed. Patient 24 Patient care timeline indicated, Patient 24 arrived at ED on 6/18/24 at 10:03 am. Patient 24 was Triaged at10:07am at a Acuity level2 (Emergent-conditions that are potential threats to life limb or function requiring rapid medical intervention or delegated (give a take or responsibility to another person) acts). Patient 24 ' s vital signs(basic bodily functions used to assess a person ' s health) were; temperature: 98.8Fahrenheit(F)-a unit of measurement )(normal 97F to 99F); Pulse 148 (normal 60 to 100); Respiration rate (RR): 42breaths per minute (normal RR 12 to 20); Blood Pressure120/84(normal BP 120/80) Pulse oximetry (measurement of oxygen in the blood) 91% on room air (RA), and Pain assessment 1 /10(mild pain level): Patient24 was placed in a room at 10:13 am and the MSE completed at 10:18 am..

A Review of ED provider notes dated 6/18/2024 at 10:25am, indicated Patient 24 had decreased breath sounds and expiratory wheezes (high pitch musical sound breath). Patient ED treatment included: Steroids, IV fluids, Nebulized treatment. Patient Diagnosis included Hypoxia, and Asthma exacerbation, Condition of Patient "Critical", Plan to admit Patient 24 to PICU at Hospital C.

A Review of Patient care time line dated 6/18/2024 at 3:20 pm , indicated that the patient was transported to PICU" at 3:25pm via Gurney". There was no transfer document available and was requested from Qual Dir.

During an interview on 2/3/2025 at11:15am with Dir Qual1, Dir Qual stated there was no transfer documentation and Consent signed by parents for Patient 24 admit date 6/18/24 from ED to Hospital C. Dir Qual confirmed Hospital C is not on same license as Hospital A.



During an interview on12/5/2025 at12:45pm with Medical Doctor (MD7), MD 7 stated the consent and transfer should be completed when Patient is transferred from ED to Hospital C or other Hospital.

A Review of EMTALA Guidelines last revised 11/6/202025 under section" Transfer out non stabilized "patient license independent practitioner this responsibility provide medical treatment within hospital capacity that minimizes the risk of the patient's health "and "complete " the inter facility patient transfer form"," determine and document and EHR certification that risks of transferring the patient care outweighed by the potential benefits in supporting information and determine the appropriate medical transfer vehicle appropriate equipment " staff responsibilities ":send inter facility transfer form copies of medical record and diagnostic results with the patient" and "obtain patient and or agent signature on the appropriate form"



A Review of a Facility document undated titled" Request for transfer Consent for transfer Certification for transfer" includes on page 2" the following requirements must be met prior to transfer " the nurse has obtained patient signature on Patient Transfer Acknowledgement "and also includes physician or qualified medical person certification for transfer"

A Review of a Facility Policy and Procedure titled, "Admission Transfer Discharge and Scope of Service Emergency Department" dated 5/3/2021, under section "Interfacility transfer out criteria from ED to another inpatient facility "Hospital A "will comply with the provisions of EMTALA and California Health and Safety Code Section 1317 and appropriate Medical Standards" and ".patients requiring pediatric or neonatal services are discharged from the ED" at Hospital A" and admitted" to Hospital C "and "interfacility transfer forms will be completed by the physician and nursing personnel as appropriate and be maintained with Medical Records. Children seen in the ED and admitted to" Hospital C" do not require transfer documents" and under Section "Transfer Document: A medical Record that documents": including: : "6. Physician or qualified medical persons certification for transfer;7Patient request for transfer or consent for transfer"; 11. Signature of responsible physicians and nurse".



A Review of policy titled" Consent Decision Makers Consent and Informed Consent" dated 10/3/2024 , indicated the patient or his representative has the right to make informed decisions regarding his or her care the patient or patients representative will be given adequate information in a manner they can understand" and " responsibility for informed consent is generally with the practitioner performing procedure."