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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for three of 20 patients, Patients (Pts) 21, 22, and 3, when:

1. Pt 21 presented to the Emergency Department (ED) with complaints of abdominal pain lasting one day, pain level 8, and nausea and vomiting, with decreased output from his colostomy. A CT scan was completed and before the results were available Pt 21 was discharged home. The results of the CT scan indicated Pt 21 had a small bowel obstruction (a blockage in the small intestine, an emergency medical condition) and the hospital did not contact Pt 21 to inform him, ask him to return to the hospital, or instruct him not to eat or drink. Pt 21 returned to the ED in severe pain nine hours after he was discharged and was transferred to a higher level of care for further treatment. (Refer to C-2407)

2. Pt 22 presented to the ED by ambulance with a chief complaint of 5150 hold (an involuntary psychiatric hold for up to 72 hours for the purpose of assessment, evaluation, and crisis intervention or placement for evaluation and treatment) for being a danger to self (DTS) and gravely disabled (GD- as a result of a mental disorder, severe substance use disorder or both, is unable to provide for his or her basic personal needs). Pt 22 was confused and unsteady on her feet. When a medical cause for Pt 22 symptoms was ruled out Pt 22 was to be transferred to a facility capable of providing a mental health evaluation, however the hospital did not transfer Pt 22 to another facility prior to the expiration of the 5150 hold. Pt 22 was discharged without receiving stabilizing measures in the form of mental health evaluation and treatment to address the emergency medical condition. (Refer to C-2407)

3 Pt 3 presented to the ED at 35 weeks pregnant complaining of lower abdominal pain and a headache, pain level 8. Pt 3 also had discomfort with urination. A urinalysis was ordered, and the results indicated a culture was needed to rule out a urinary tract infection. The physician and nurses did not obtain Pt 3's pregnancy history, did not monitor pt 3's unborn baby or assess the baby's heart rate. The physician discharged Pt 3 less than an hour after she arrived without addressing Pt 3's abdominal pain, headache, or discomfort with urination and without assessing the well-being of Pt 3's unborn baby. (refer to C-2406)

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 or not an emergency medical condition [EMC] exists) within the capability of the hospital's Emergency Department (ED) for one of 20 patients (Patient 3) when:

Patient (Pt) 3 came to the ED on 10/26/24 at 12:05 p.m. at 35 weeks pregnant with a chief complaint of lower abdominal pain and a headache for one day, pain level 8 (on a scale of 0 [no pain] to 10 [worst possible pain], 8 is severe pain). Pt 3 also had discomfort with urination. Vital signs were within normal limits except for Pt 3 ' s heart rate which was 104 beats per minute (bpm- normal is 60-100). The QMP saw Pt 3 and ordered tests for COVID, influenza and a urinalysis at 12:30 p.m. The urinalysis indicated a need for culture which was sent, and the COVID and influenza tests were negative. At 12:58 p.m. the QMP indicated Pt 3 would be discharged with a diagnosis of headache and abdominal pain of unknown cause, and Pt 3 left the hospital at 2:20 p.m. with a discharge pain level of 8. The QMP and the nursing staff did not obtain any information from Pt 3 about her obstetric history, how many pregnancies and births, history of preterm labor, her prenatal care, or the presence of complications in this pregnancy; and the QMP incorrectly indicated Pt 3 was in her second trimester of pregnancy. The QMP and the nursing staff did not assess the fetal heart rate or inquire about whether there was active fetal movement present. The QMP did not address the discomfort with urination or discuss fluid intake and did not address Pt 3 ' s headache.

These failures resulted in Pt 3 and her unborn baby being discharged without having an appropriate MSE and had the potential to result in harm if an emergency medical condition existed.

Findings:

During a concurrent interview and record review on 12/18/24 at 12:15 p.m. with the ED manager (EDM), Pt 3 ' s medical record dated 10/26/24 was reviewed. The record indicated Pt 3 came to the ED on 10/26/24 at 12:05 p.m. at 35 weeks pregnant with a chief complaint of lower abdominal pain and a headache for one day. The triage note indicated at 12:16 p.m. Pt 3 had pain in her left and right lower quadrants of her abdomen and a headache on the top and temple areas. Pt 3 ' s, pain level was 8. The note indicated Pt 3 ' s last menstrual period was 2/27/24 and the gestational age was 35 weeks by dates. Vital signs were within normal limits except for Pt 3 ' s heart rate was 104 bpm. Pt 3 also indicated she had discomfort with urination. The EDM stated Pt 3 ' s triage was completed, and Pt 3 was moved to an ED room at 12:30 p.m. Review of the orders indicated orders were placed at 12:32 p.m. for COVID and influenza tests and a urinalysis. The EDM stated it is not clear in the ED Note what time the ED physician (MD 3) initiated the MSE.

Review of MD 3 ' s ED Note dated 10/26/24, indicated, " ...CHIEF COMPLAINT: Lower abdominal pain starting this morning. HISTORY OF PRESENT ILLNESS [HPI]: 25 year-old female reports some pressure in her lower abdomen with some discomfort with urination. No vaginal bleeding, but patient reports she is in her second trimester pregnancy without any vomiting or diarrhea. No fever or problems breathing without any shortness of breath or cough. PHYSICAL EXAMINATION: ...ABDOMEN: soft fundal height is consistent with dates and patient reports having some tenderness in the suprapubic area without tenderness in the right lower quadrant or the right upper quadrant ...DIAGNOSTICS: [blank] IMAGING: None. Lab Results This Visit: COVID Negative, INFLUENZA A and B Negative. URINALYSIS/CULTURE: Collected ... DIFFERENTIAL DIAGNOSIS/CLINICAL COURSE/ MEDICAL DECISION MAKING: Differential diagnosis- COVID test were unremarkable, and urinalysis was noted. CONDITION: Improved. ASSESSMENT: Diagnoses headache, abdominal pain in second trimester pregnancy of unknown etiology. PLAN: Discharge ... " The ED Note was signed by MD 3 at 12:58 p.m. The EDM stated the urinalysis was positive for leukocyte esterase (an enzyme present in white blood cells. The presence of white blood cells in urine may indicate a urinary tract infection [UTI]) and bacteria which indicated the need for a culture, and it was sent to the lab. The EDM was asked if there is documentation indicating the nurse or the physician obtained information regarding Pt 3 ' s obstetric history such as the gravida (total number of confirmed pregnancies a woman has had, including the current pregnancy) and para (number of births a woman has had after 20 weeks of gestation), history of preterm labor/delivery, complications with previous or current pregnancy like gestational diabetes or high blood pressure, whether she has regular prenatal care and when her last appointment was. The EDM stated there is no indication that any of that information was obtained. The EDM was asked if there was an assessment by the physician or the nursing staff of the fetal heart rate and whether there was active fetal movement present. The EDM stated there is no documentation related to the baby. The EDM stated they have a doppler in the ED and do not need an order to obtain the fetal heart rate, however it would depend on the experience of the ED nurse whether or not they would think to do that, or ask questions related to the pregnancy. The EDM stated they do not have protocol or standards of practice to guide their assessment of patients who are pregnant.

Review of the discharge documentation indicated at discharge Pt 3 ' s heart rate was still elevated at 101 bpm, and Pt 3 ' s pain level was 8, the same as it was when she was triaged. Pt 3 received no medications, no fluids either oral or intravenous, and had no imaging or blood tests. There was also no indication in the record that Pt 3 ' s headache or discomfort with urination were addressed. The EDM stated MD 3 ' s note does not have much information or detail. Review of the discharge instructions given to Pt 3 dated 10/26/24 at 2:13 p.m. indicated, "Diagnosis: Abdominal pain in second trimester pregnancy of unclear etiology. Problems addressed today: No Problems Available. Plan: Discharge Medication given this visit: [blank]. Discharge Medications: No Discharge Medications Available. Follow up with your health care provider in two days.

During a review of the professional reference, American College of Obstetricians and Gynecologists ' Committee on Obstetric Practice, Committee Opinion Number 667, July 2016 (Reaffirmed 2023), " Hospital-Based Triage of Obstetric Patient, " the reference indicated, " ...Pregnant patients could present for care to any institution providing urgent or emergent care ...The federal Emergency Medical Treatment and Labor Act (EMTALA) requires an initial medical screening examination to determine if a medical emergency exists; in the case of a pregnant woman, this includes evaluation of the woman and the fetus ...To be considered an appropriate location to care for and evaluate pregnant patients, the unit should have the ability to perform basic ultrasonography and fetal monitoring ... "

During a review of the professional reference American College of Obstetricians and Gynecologists ' Clinical Consensus Number 4, " Urinary Tract Infections in Pregnant Individuals, " dated 8/23, the reference indicated, " ...Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies. The presence of UTIs has been associated with adverse pregnancy outcomes, including increased rates of preterm delivery and low birth weight. Furthermore, serious maternal complications of pyelonephritis include sepsis, disseminated intravascular coagulation, and acute respiratory distress syndrome (ARDS) ...The ability to recognize, diagnose, and treat them is essential for those providing care to pregnant individuals. Urinalysis is a useful tool for triage of UTI symptoms. Pyuria, defined as more than 5 white blood cells/high-power field or presence of leukocyte esterase, has up to 97% sensitivity for UTI ... "

During a review of the Patient Safety Advisory article titled, " Triage of the Obstetrics Patient in the Emergency Department: Is There Only One Patient?, " dated 9/08, the article indicated, " When a pregnant patient arrives at the emergency department, there are really two patients. Risk reduction strategies include having policy and procedures in place that ensure a systematic approach to the triage and initial assessment of the pregnant patient ...There are two patients that need care ... "

Based on observation, interview and record review, the hospital failed to provide stabilizing measures for identified emergency medical conditions (EMC) within the capability and capacity of the hospital for two of 20 patients, Patient (Pt) 21 and Pt 22 when:

1. Pt 21 came to the Emergency Department (ED) on 11/15/24 at 8:32 p.m. with complaints of abdominal pain lasting one day and nausea, with decreased output from his colostomy (an opening [stoma] that connects the large intestine to the surface of the abdomen creating a path for stool to leave the body). A Computed Tomography (CT- diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) scan of the abdomen pelvis was performed at 10:42 p.m. and sent to the radiologist for interpretation. At 1:37 a.m. before the radiologist had completed his review of the CT scan, Pt 21 was sent home with a diagnosis of abdominal pain with relative constipation and instructions to increase oral fluids, increase fruits and vegetables in diet, and follow-up with his (Pt 21 ' s) doctor in three days. The radiologist ' s report indicating Pt 21 had a small bowel obstruction (a blockage in the small intestine, an emergency medical condition) was available at 3:44 a.m., and the hospital did not contact Pt 21 to inform him, ask him to return to the hospital, or instruct him not to eat or drink.

These failures resulted in Pt 21 being discharged without the emergency medical condition being stabilized and led to Pt 21 experiencing increased pain and worsening symptoms of a small bowel obstruction. Pt 21 returned to the ED nine hours later with severe abdominal pain and imaging confirmed a worsening small bowel obstruction. Pt 21 was transferred to a higher level of care for further treatment on 11/16/24.

2. Patient (Pt) 22 came to the ED by ambulance on 10/8/24 at 6:20 p.m. after a police officer placed Pt 22 on a 5150 hold (an involuntary psychiatric hold for up to 72 hours for the purpose of assessment, evaluation, and crisis intervention or placement for evaluation and treatment) for being a danger to self (DTS) and gravely disabled (GD- as a result of a mental disorder, severe substance use disorder or both, is unable to provide for his or her basic personal needs). Pt 22 was confused, unsteady on her feet and smelled of alcohol. Pt 22 was evaluated, lab tests and imaging were negative, there was no evidence of drugs or alcohol in Pt 22 ' s system. Pt 22was medically cleared on 10/9/24 at 12:40 a.m. Pt 22 was not evaluated by a mental health professional in order to address the reason for the altered mental status leading to the 5150 and the hospital did not transfer Pt 22 to another facility for a mental health evaluation prior to the expiration of the 5150 hold.

These failures resulted in Pt 22 not receiving stabilizing measures in the form of mental health evaluation to address the emergency mental health condition and had the potential to result in harm.

Findings:

1. During a review of the ED readmission log (A report of ED patients who were discharged and returned to the ED within 48 hours), the log indicated Pt 21 had an ED visit on 11/15/24 from 8:37 p.m. until 11/16/24 at 1:46 a.m., and then returned to the ED less than nine hours later on 11/16/24 at 10:32 a.m. Review of the transfer log indicated Pt 21 was transferred to Hospital B on 11/16/24 at 6:51 p.m.

During a concurrent interview and record review on 12/17/24 at 2:15 p.m. with the emergency department manager (EDM), Pt 21 ' s medical record was reviewed. The triage notes dated 11/15/24, indicated Pt 21 was a 79 year-old Spanish-speaking male who came to the ED accompanied by his son on 11/15/24 at 8:37 p.m. with a chief complaint of cramping abdominal pain in the umbilical region (the belly button area) lasting one day, pain level 8 (on a scale of 0 [no pain] to 10 [worst possible pain]). The triage notes indicated Pt 21 had a permanent colostomy (an opening [stoma] that connects the large intestine to the surface of the abdomen creating a path for stool to leave the body) located in the left lower quadrant of his abdomen. The EDM stated triage was completed at 8:42 p.m. and then Pt 21 was taken to an ED room to wait for the medical screening exam (MSE). Review of the ED nurses notes dated 11/15/24 at 9:09 p.m. indicated Pt 21 ' s vital signs were stable, and Pt 21 had " ...Rebound tenderness (more pain when pressure on the tender area is released) and guarding (contraction of the abdominal wall muscles to avoid pain) ... "

Review of the the ED physician ' s note indicated MD 1 saw Pt 21 on 11/15/24 at 9:29 p.m.. The note indicated, " ...History of Present Illness [HPI]: ...History of colon cancer, underwent a permanent diverting colostomy for upper sigmoid adenocarcinoma several years ago, presents with decreased colostomy output for the last several hours and crampy abdominal pain. Patient [Pt 21] is burping, has crampy belly pain, he usually has 3-4 colostomy bowel movements daily and today has had only a couple ...no vomiting ...slight nausea ...no fever ...Physical Exam: ... ABDOMEN: Bowel sounds present throughout abdomen, slightly distended, non-tender, no guarding, no rebound ...soft formed stool within the [colostomy] bag ...ED Course: Computed tomography [CT- diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body] scan of the abdomen pelvis will be performed. Intravenous [IV- into a vein] fluids will be administered. IV Toradol [pain medication] will be provided ... " Review of the ED nurses notes dated 11/15/24 at 9:35 p.m. indicated, Pt 21 complained of cramping abdominal pain in the epigastric region (the upper middle part of the abdomen), level 8/10, was moaning, grimacing and restless and had nausea and emesis (vomit). The note indicated Pt 21 ' s abdomen was taut (tight) with normal bowel sounds, and Pt 21 ' s last bowel movement (BM) was " abnormal, constipation, no BM. "

Review of the nurses notes dated 11/15/24 at 9:50 p.m. indicated an IV was started, labs were drawn, and IV pain medication was given for pain level 8/10. A normal saline fluid bolus was initiated at approximately 10:15 p.m. At 10:30 p.m. Pt 21 complained of nausea and had yellowish colored emesis, and orders were obtained for Zofran 4 milligrams (mg) IV which was administered. The EDM stated the CT scan was completed at 10:42 p.m., and the record indicated at 11 p.m. Pt 21 was resting in bed, pain level 0/10. Pain reassessed at 11:30 p.m. and was 5/10.

Review of the ED physician ' s note indicated, "Medical Decision Making: Laboratory evaluations are reassuring this evening. Complete Blood Count [CBC] normal, chemistries are normal with a creatinine of 1.13. COVID and Influenza A and B are negative. CT scan of the abdomen pelvis demonstrates no evidence of bowel obstruction. There is copious stool throughout the colon, no air-fluid levels are observed however. Assessment: Abdominal pain with obstipation [a severe form of constipation that results in a person being unable to have a bowel movement]. Plan: Push fluids, increase fruits and vegetables in diet, see your doctor for recheck on Monday [11/18/24]. Disposition: The patient appears comfortable and without distress upon final reevaluation following completion of the clinical evaluation shortly before dismissal ... " The note was signed by MD 1 on 11/16/24 at 12:51 a.m. The EDM stated the ED physician completes the discharge instruction note and the RN reviews the instructions with the patient/family and has the patient sign that they have received the instructions. Review of the Pt 21 ' s ED discharge instructions indicated, " Diagnosis Today: Abdominal pain with relative constipation. Diet: Resume normal diet. Additional Instructions: Push fluids, increase fruits and vegetables in diet. See your doctor for follow up on Monday [11/18/24]. Activity: Return to School/Work in 3 days. Follow up with: Your Primary Care Provider in 3 days for recheck. " The record indicated Pt 21 was discharged from the hospital on 11/16/24 at 1:37 a.m. Pain level 2/10.

Review of the " Radiology Report " dated 11/16/24 at 3:44 a.m., indicated Pt 21 had a CT Abdomen and Pelvis without contrast on 11/15/24 and the images were received by the teleradiologist for review on 11/15/24 at 11:30 p.m. The report of the findings was available on 11/16/24 at 3:44 a.m. The report indicated, " Findings: ...Multiple loops of mid small bowel show moderate diffuse distention with a probable caliber change in the anterior mid lower abdomen ...IMPRESSION: Mid small bowel obstruction ... "

Review of Pt 21 ' s medical record dated 11/16/24 at 10:32 a.m., indicated Pt 21 returned to the ED at 10:30 a.m. with complaints of severe abdominal pain with a pain level 10/10, nausea and vomiting. Pt 21 reported no stool or gas from colostomy since the morning of 11/15/24. Pt 21 had an abdominal x-ray at 11:40 a.m., was given IV fluids and had a CT of the abdomen with contrast at 1:50 p.m. Review of the " Radiology Report " dated 11/16/24 at 2:07 p.m., indicated, " ...Findings- GI Tract/abdominal wall: Again seen is postsurgical changes of abdominal perineal resection with lower left quadrant ostomy. There are postsurgical changes in the anterior abdominal wall. There is atrophy of the abdominal wall muscles with eventration of the abdominal contents. Increased air and fluid filled distention of small bowel in the anterior abdomen up to 4.8 centimeters [cm] in maximum distention with transition point in the left lower quadrant and collapsed bowel distally compatible with ongoing small bowel obstruction. IMPRESSION: Interval worsening of small bowel obstruction with transition point in the left lower quadrant ... " Pt 21 was given IV antibiotics and medication for pain and nausea and was later transferred to a higher level of care (Hospital B) on 11/16/24 at 6:51 p.m.

During a concurrent interview and record review on 12/17/2024 at 2:25 p.m., the EDM stated she was aware of this patient because they review the records of patients who have a return visit and then get transferred. The EDM stated MD 1 discharged Pt 21 before the teleradiologist had finished his report of the CT scan findings. The EDM stated the report was not completed until 3:44 a.m. by the radiologist and Pt 21 left the hospital at 1:37 a.m. There was no indication in the record that results of that CT scan were still pending at the time Pt 21 was discharged, and no indication that Pt 21 wanted to leave or requested to be discharged. The EDM was asked about MD 1 ' s note signed on 11/16/24 at 12:51 a.m. which indicated the CT scan " demonstrates no evidence of bowel obstruction. " The EDM stated that MD 1 reviewed the imaging, " but he is not a radiologist. " The EDM stated she does not know of a policy for follow up with a patient a radiology report indicated abnormal findings and the patient had already been discharged. The EDM stated the report comes by fax to the ED and she does not know if the report was received and/or reviewed by anyone during the night.

During an interview on 12/18/24 at 11:30 a.m. with the radiology department manager (RDM), the RDM stated the imaging performed at the hospital is interpreted by the teleradiologists twenty-four hours a day. The radiology techs are at the hospital during the day and are on call at night. The radiology tech will complete the imaging and it will be received by the teleradiologist who will interpret the imaging and prepare the report which gets automatically faxed to the ED unit clerk and also to a fax machine in the radiology department. There are not staff in the radiology department who are waiting for the fax to come. The RDM stated the turnaround time from the time of the order to the time the test is performed depends on the radiology tech ' s workload at the time meaning the number of imaging tests being ordered. The turnaround time from the time the image is performed by the radiology tech to the time the report is available would likely depend on the workload of the teleradiologists. During the night, it may take longer than during the day. The RDM stated in this case the turnaround time from when the images were received by the teleradiologist and the report from the teleradiologist being available was approximately four hours and fifteen minutes which would not be considered to be too long. The RDM stated once the radiology tech has completed the imaging it is automatically in the Picture Archiving and Communication System (PACS- a medical imaging technology used to store and digitally transmit electronic images) and the teleradiologist accesses the images remotely from wherever they are. The RDM stated the physicians on site at the hospital can access the imaging as well but do not review the imaging for the purpose of formal interpretation of the scan, that is only done by the radiologists. The RDM stated the radiology department does not have a policy for follow up with patients if a report indicated abnormal findings, they would not be aware of the results. The report that is sent to their fax machine in radiology is not for the purpose of someone receiving it and reviewing the results. When the report is completed with the interpretation by the radiologist it is sent by the system to the ED where the patient is.

Review of the journal article in Radiology: Volume 275: Number 2-May 2015 titled, " Review of Small-Bowel Obstruction: The Diagnosis and When to Worry, " the article indicated, " Small-bowel obstruction (SBO) is a substantial cause of morbidity and mortality, accounting for up to 16% of hospital admissions for acute abdominal pain in the United States. Most patients with SBO are treated successfully with nasogastric tube decompression. However, the mortality of SBO ranges from 2% to 8% and may increase to as high as 25% if bowel ischemia is present and there is a delay in surgical management ...Clinical presentation, physical examination findings, and laboratory tests are neither sufficiently sensitive nor specific to determine which patients with SBO have coexistent strangulation or ischemia. This uncertainty has led to the widespread use of imaging to not only diagnose SBO but to detect complications that require prompt surgery ...CT has been proven to be the single best imaging tool for evaluating patients suspected of having SBO, with sensitivity and specificity of 95%; it is also highly accurate in detecting the complications of SBO. The job of the radiologist is to diagnose the suspected SBO, determine its site and cause, and determine the presence or absence of complications such as ischemia or perforation ... "

During a review of the journal article in American Family Physician Volume 98, Number 6, titled, " Intestinal Obstruction: Evaluation and Management, " dated 9/15/18, the article indicated, " ...The hallmarks of intestinal obstruction include colicky abdominal pain, nausea, vomiting, abdominal distension, and cessation of flatus and bowel movements ...As soon as acute intestinal obstruction is suspected, intravenous isotonic fluid should be started, and oral intake should be restricted. Nasogastric intubation should be performed for decompression in most patients ... "

During a review of the article titled, " Small Bowel Obstruction, " dated 12/2/24, retrieved from , the article indicated, " ...Emergency Department Care- Initial emergency department (ED) treatment of small-bowel obstruction (SBO) consists of aggressive fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically, early surgical consultation, and administration of antibiotics ... "

During a review of the journal article from Clinics in Colon and Rectal Surgery Vol. 34 No. 4/2021, titled, " Imaging Modalities for Evaluation of Intestinal Obstruction, " the article indicated, " ...Diagnostic imaging is an essential aspect of the modern management of both LBO and SBO. While history and physical exam remain the backbone of evaluation, clinical assessment alone lacks accuracy for bowel obstruction diagnosis and guidance of management ...Computed tomography is usually the most appropriate and accurate diagnostic imaging modality for most suspected bowel obstructions. Regardless of the imaging modality used, interpretation of imaging should involve a systematic, methodological approach to ensure diagnostic accuracy ... "

2. During an interview on 12/13/24 at 1:30 p.m., with ED physician (MD 1), MD 1 stated the hospital does not have a process in place to provide a mental health evaluation or treatment to patients who are brought to the hospital under a 5150 hold. MD 1 stated the hospital also does not have a process to get a 5150 hold lifted prior to 72 hours when the hold expires. MD 1 stated police officers place the patient on the hold, but they do not come back to reevaluate whether the hold should remain, and the police officers do not lift the holds. MD 1 stated the physicians working in the ED are not authorized by the county to either place or lift a 5150 hold. MD 1 stated after a police officer puts the patient on a hold, the patient is brought to the ED and then ED physician sees the patient only for the purpose of medically clearing the patient for transfer to a facility that provides evaluation and treatment for mental health disorders, the physician does not perform a mental health evaluation. MD 1 stated after the patient is medically cleared, the hospital starts the process for initiating the transfer. MD 1 stated the problem they run into is when they are unable to arrange the transfer within the 72 hours and the hold expires. MD 1 stated the hospital does not contract with a telepsychiatry provider.

During a concurrent interview and record review on 12/17/24 at 2 p.m. with the EDM, Pt 22 ' s medical record was reviewed. The record indicated Pt 22 was brought to the ED by ambulance on 10/8/24 at 6:20 p.m. with a chief complaint of 5150 hold placed by law enforcement due to Pt 22 being a DTS, and GD. Review of the Patient Care Record (PCR- a record completed by EMS personnel documenting the prehospital care of a patient) indicated Pt 22 was observed by law enforcement officers to be standing in a gas station/convenience store staring at the ceiling and then walked outside and attempted to walk into traffic. The PCR indicated at 6:05 p.m., Pt 2 had altered mental status with a Glasgow Coma Scale score of 14 (GCS- a tool used to assess a patient ' s level of consciousness; scores range from 3 [worst] to 15 [alert and oriented]- Pt 22 ' s score of 14 was due to confused verbal responses), was unsteady on her feet and smelled of alcohol. The PCR indicated, Pt 22 ' s current medications were Zyprexa (a medication given to treat schizophrenia and bipolar disorder) and Depakote (a medications used to treat bipolar disorder).

Review of the triage notes dated 10/8/24 at 6:30 p.m. indicated Pt 22 ' s " speech is significantly slurred; she is cooperative however noted to be lethargic. Denies suicidal ideation [SI]/ homicidal ideation [HI] ...Unsteady on feet unable to get standing scale weight ... " The triage note indicated Pt 22 did not have a primary care provider (PCP). At 6:30 p.m., Pt 22 ' s GCS was 12. Triage was completed and Pt 22 was assigned an Emergency Severity Index level 3 (ESI- a 5-level acuity scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, in order to prioritize care). Pt 22 was taken to an ED room and a staff member was assigned to provide one to one observation.

Review of the ED Physician ' s Note dated 10/8/24, untimed, indicated the MSE was initiated by MD 2. The EDM stated the physician would need to indicate on the note what time an entry was made, the electronic record does not do that. The electronic record does automatically record what time the note is completed and signed. The note indicated, " HISTORY OF PRESENT ILLNESS [HPI] 43 y/o female was found disoriented staring up at the sky and police involved placed a 5150. Patient has not been able to give any specific statements reports of harm fall or injury. No prehospital reports of pinpoint pupils /intentional harm or pill ingestion was reported without anybody able to coordinate patient 's care prior to arrival here by ambulance ...SOCIAL HISTORY: Denies using alcohol or tobacco ...REVIEW OF SYSTEMS [ROS] ...Psychiatric: Pt denies mental health issues although patient has poor thought process ...ROS limited from the patient is 5150 with patient not able to give much history about how she ended up arriving here. PHYSICAL EXAMINATION: ...Psychiatric: Good eye contact but patient has blank stare with patient not making any spontaneous speech or answering to confirm a congruent thought process. Flat affect ... " The note indicated the results of the lab tests including a complete blood count (CBC), Complete Metabolic Panel (CMP) were within normal limits, and the tests for drugs and alcohol were negative. The note indicated, " ...DIFFERENTIAL DIAGNOSIS/ CLINICAL COURSE/ MEDICAL DECISION MAKING: Differential [BLANK]. CONDITION: Improved. ASSESSMENT: Diagnosis: 5150 placement PLAN: Patient was medically clear to continue psychiatric care and evaluation of the 5150 after patient was medically cleared/ care signed out to the next emergency room physician [MD 3] ... " The EDM stated medical clearance was on 10/9/24 at 12:40 a.m. The EDM stated the physicians work 24 hour shifts from 8 a.m. to 8 a.m. so the handoff to the next physician was at 8 a.m. on 10/9/24.

Review of MD 3 ' s ED Note dated 10/9/24 at 10:25 a.m. indicated, " Pt care was assumed from MD 2 at 8 a.m. on 10/9/2024 (Change of Shift). Patient on 5150 apparently noted by PD to be confused and disoriented and staring at the sky and placed patient on 5150. Patient is poor historian drug screen negative ... " The rest of MD 3 ' s ED note consisted of a table with the results of all of the lab tests previously reported, and the vital signs ending at 10/9/24 at 9:45 a.m.

Review of the orders report dated 10/8/24 through 10/11/24 indicated on 10/9/24 at 8:50 p.m. Zyprexa 10 milligrams and Depakote 500 mg were ordered and given on 10/9/24, 10/10/24, and 10/11/24. The order report also indicated a CT scan of the brain was ordered on 10/10/24 at 9:21 a.m. and the results were negative.

Review of MD 2 ' s ED Note dated 10/10/24, indicated, " Care continued on 10/10/24 ...Patient continues to demonstrate hemodynamic stability and she has a flat affect with patient cooperative with care with patient medically clear for psychiatric evaluation. Patient was not found to have any evidence of a substance abuse disorder with the patient having medical clearance given without any organ disfunction to determine ... ROS: Psychiatric: Poorly defined mental health issues. DIFFERENTIAL DIAGNOSIS/ CLINICAL COURSE/ MEDICAL DECISION MAKING: Differential [BLANK] ...There is no medical cause of the patient ' s change in mental status that caused the need for the 5150. Patient continued to have a very flat affect with poor insight ...remaining essentially nonverbal ... Patient is medically clear to receive further psychiatric assessment which is beyond the capabilities of our facility. We do not have an online service or any remote telemedicine ability to perform psychiatric evaluation which she is being on the spectrum of her care at our emergency department ... Patient has had a 5150 placed on her and patient is medically clear. The patient needs to have further psychiatric evaluation of this beyond the capabilities of our facility. Transfer center is reaching out to a facility that has psychiatric services where the patient can go for complete evaluation of the patient ' s medical condition. ASSESSMENT: Diagnosis: 5150 placement. Patient continues to be medically cleared today and will need to have further psychiatric assessment. Transfer center is involved in this higher level of care transfer ... " The EDM stated they did not have a transfer center. As soon as the patient was medically cleared the ED staff (unit clerk or charge nurse) were the ones who will initiate the transfer process to a facility that provides evaluation and treatment for mental health disorders. The EDM stated for all patient transfers, a log is maintained to document the date and time and name of all of the facilities contacted, their response, and when patient information was faxed to the facility. The log with the record of the efforts made by the hospital to transfer Pt 22 was requested. The hospital was unable to locate a log and could only provide evidence that one facility was faxed Pt 22 ' s information on 10/9/24 at 5:36 a.m. The EDM was unable to find any documentation of a discussion by the staff with the physician regarding progress with the transfer request and there is no way to know if any other facilities were contacted and/or why they were not, or if the request was escalated due to difficulty with the transfer. The EDM stated the log of the transfer requests should have been maintained and it was not. The EDM provided a piece of paper with handwriting from an unknown person indicating the name of a physician and an appointment date 10/17/24 at 9:30 a.m. The person who wrote the note was not identified. There was no patient name or other patient identifier on the piece of paper, and no indication who or what the appointment was for. The EDM stated the hospital does not employ any social workers or mental health workers to assist with the transfer process, perform mental health evaluations, provide crisis intervention, or reevaluate a patient on a hold to assess whether it is still needed.

Review of the nurses notes dated 10/11/24 at 12:15 p.m. indicated, " ...Mother called who is her caregiver and is aware her 72 hour hold is up at 6:01 p.m. as long as [Pt 22] is not a threat to herself or others ... " The record indicated Pt 22 was screened for suicide risk and no risk was identified, however the 5150 hold was not placed for suicidal ideation or homicidal ideation. The EDM stated Pt 22 did not receive a mental health evaluation.

Review of the " ED Discharge Instructions, " indicated the note was completed by MD 1 on 10/11/24 at 5:42 p.m. The note indicated, " Reason for Visit: Chief Complaint- 5150. Diagnosis Today: 5150 Hold Expired. Diet: Resume normal diet. Additional Instructions: See your mental health provider 5-7 days. Resume current medications. Return for any further problems. For any new problems please reach out to your crisis hotline or return to the emergency department. " The EDM stated this is the only note from MD 1, there is not a discharge assessment and there is not a discharge order. The EDM stated if a patient is on a hold and does not get transferred within 72 hours, the hold expires. There was no documentation in the record regarding Pt 22 ' s mental health history, no documentation of a discussion with anyone regarding Pt 22 ' s disposition. and Pt 22 did not have a primary care physician.

During a review of the hospital ' s Policy and Procedure (P&P) titled, " Scope of Services, " dated 12/19/23, The P&P indicated, " ...Scope and Complexity of Patient Care Needs: All patients that present to [Hospital A] premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department Physician that includes providing all necessary testing and on-call services within the capability of [Hospital A] to reach a diagnosis. Support services including, but not limited to, clinical laboratory studies and x-rays will be provided to the patient in a timely manner. All necessary definitive treatment will be given to the patient within the hospital ' s capabilities. Emergency Department patients are then evaluated for response to treatment and are admitted, transferred for further treatment not provided by [Hospital A], or discharged with follow-up instructions as appropriate ... "

Review of the document " County of Fresno Department of Behavioral Health 2023-2024 Annual 5150 Re-Certification Training, " the document indicated, " ...The danger to self or others does not have to be an " active " danger, the person doesn ' t need to be actively suicidal or making threats, threatening or physically injuring another party. Danger can come in many forms, including " passive " danger such as endangering one ' s child or own health and safety through behaviors caused by untreated symptoms of mental illness. Such " passive " danger could include, not taking needed medication for a serious medical condition or exposing oneself to violent elements on the streets. The governing rule becomes whether this " passive " danger is the result of a mental disorder ... " The document indicated when placing a person on a 5150 hold, the following Detainment Advisement (part of the Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment form) must be given orally to the person, " I am a peace officer/mental health professional with [name of agency]. You are not under arrest, but I am taking you for examination by mental health professionals at [name of facility] You will be told your rights by the mental health staff. "

During a review of the emDocs article titled, " Medical Clearance of Psychiatric Patients: Pearls & Pitfalls, " dated 5/28/15, retrieved from , the article indicated, " ...Medical Clearance is a term commonly used for the initial medical evaluation or focused medical assessment performed in the ED prior to transfer to a psychiatric facility. The term " medical clearance " can be problematic because there is no singular accepted standard definition or process among EPs or psychiatrists. Medical clearance is not a term to represent the absence of medical issues, but rather the absence of medical instability or a medical condition causing or contributing to the psychiatric presentation. Determining medical causation for psychiatric disease is the most essential reason for the medical evaluation in the ED prior to psychiatric placement. There are numerous conditions that can cause psychiatric symptomatology including medication side effects, drug and alcohol abuse and withdrawal, infections, central nervous system disease, metabolic/endocrine conditions, and cardiopulmonary disease. If an underlying medical condition is found to be causing or exacerbating the psychiatric complaint, treatment in the ED or in a medical hospital is indicated ... "

During a review of the Western Journal of Emergency Medicine Volume 18, no. 4, article titled, " American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults, " dated 6/2017, the article indicated, " The goal of medical assessment of psychiatric patients in an ED is to identify potential causative factors for a patient ' s presenting complaint (i.e., medical mimics) as well as medical problems that will need ongoing care but do not contribute directly to the presenting psychiatric complaint ... Medically clear A term meaning that, in the opinion of the examining provider, the patient does not have any medical condition which merits further treatment or concern ... "