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Based on interview, record review, policy review, and review of video surveillance, on 10/07/20 the hospital failed to provide a sufficient Medical Screening Exam (MSE) within its capability and capacity to determine if an Emergency Medical Condition (EMC) existed for one patient (#9) of 30 patients who presented to the hospital Emergency Department (ED) seeking care, out of a sample selected from April 2020 to October 2020. The hospital also failed to provide stabilizing treatment on 10/10/20, when Patient #9 presented to the ED with a head injury, facial injuries, and a laceration (a deep cut or tear in skin) to his ear. The patient was discharged and escorted in a wheelchair to the hospital's property line and left sitting on the sidewalk. The hospital's ED had an average of 3,843 emergency visits per month.

These failures had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment.

Please refer to A-2406 and A-2407 for details.

Based on interview, record review, policy review, and review of video surveillance, on 10/07/20 the hospital failed to provide a sufficient Medical Screening Exam (MSE) within its capability and capacity to determine if an Emergency Medical Condition (EMC) existed for one patient (#9) of 30 patients who presented to the hospital's Emergency Department (ED) seeking care, out of a sample selected from April 2020 to October 2020. This had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment. The hospital's ED had an average of 3,843 emergency visits per month.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act," (EMTALA, an act/law that obligates the hospital to provide medical screening treatment and stabilization of individuals with an emergency medical condition) dated 09/09/20, showed that the hospital is committed to compliance with the requirements of EMTALA and will ensure any individual requesting emergency care receives a MSE conducted by qualified medical personnel to determine the presence of an EMC. In the event that an individual presents with an EMC they will be provided stabilizing treatment to the extent of the hospital's capability and capacity and if indicated, provide an appropriate transfer to another hospital with the capability and capacity to stabilize the individual.

Review of the hospital's policy titled, "Abduction and Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) of Patients," dated 08/05/13, showed that:
- Elopement is when a patient, who is incapable of adequately protecting him- or herself, leaves the facility undetected, often at risk for serious harm, including death.
- Assessment by a registered nurse (RN) to determine adult patients' risk of elopement\abduction may include but is not limited to history or current clinical indications for confusion, dementia, wandering behavior, and previous elopement.
-When staff observe a patient attempting to leave the premises, staff should redirect the patient and ask him/her to return to his/her room, notify security and search the hospital property.
- Staff response may include a Code Strong (a response to escalating patient behavior by a designated trained team) and/or the use of restraints.
- Security will assist the nursing staff in pursuit of the patient while on the health center property. If the patient is a risk to himself or others, security will notify the police.
- If the patient is found, the attending physician should be contacted for determination of whether the patient should be brought back to the ED for medical evaluation.

Review of the hospital's policy titled, "Suicide Prevention for Patients in the Emergency Department," revised 12/03/19, showed that:
- The Columbia Suicide Severity Rating Scale (CSSRS) helps identify whether someone is at risk for suicide and assess the severity and immediacy of that risk.
- A High Risk patient status requires an assessment by a licensed mental health professional (LMHP) and implementation of suicide precautions, to include continuous one-to-one (1:1, continuous visual contact with close physical proximity) monitoring if not located in the dedicated behavioral health ligature (anything which could be used for the purpose of hanging or strangulation) resistant locked area-patients have no ability to leave this area.
- Continuous 1:1 is continuous visual observation that requires a trained and competent staff member to be in reasonable proximity to the patient such that the staff member is immediately available to provide appropriate interventions to prevent harm.
- Nursing interventions for all patients on suicide precautions will include documenting the patient's status every 15 minutes and the patient would be provided with hospital-approved clothing.

Review of Patient #9's ED visit on 10/07/20 showed the following:
- On 10/07/20 at 3:21 PM, Patient #9 arrived at the ED via Emergency Medical Services (EMS). The patient presented with suicidal ideation (SI, thoughts of causing one's own death) as well as visual and auditory hallucinations (seeing and hearing things that are not seen or heard by others, imaginary). He requested to be returned to the Behavioral Health Unit (BHU), where he recently had an inpatient admission and had discharged two days prior.
- Patient #9 was a 31-year-old male with a history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), antisocial personality disorder (a chronic inflexible, maladaptive pattern of perceiving, thinking, and behaving), Methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) use disorder, and a recent psychiatric (relating to mental illness) admission from 09/29/20 through 10/05/20, when he presented with suicidal ideation, and visual and auditory hallucinations. He denied a suicide plan.
- At 3:43 PM, a Columbia Suicide Severity Rating Scale was completed and the patient answered yes to each question that pertained to suicidal thoughts and a suicide checklist was completed that included initiation of suicide precautions, physician was notified, the patient was dressed in hospital-approved clothing (blue scrubs), direct observation, with documentation checks every 15 minutes, and security staff were notified of the new SI evaluation. Since the patient was not roomed in the dedicated behavioral health ligature resistant area a room safety check was completed for ligature risks.
- At 3:45 PM, the physician ordered high risk suicide orders, routine continuous monitoring, and the patient must have no ability to leave that area.
- At 3:45 PM, the nurse documented safety band applied, patient changing into blue scrubs, security notified of new evaluation.
- At 4:45 PM, Patient #9 was assessed by the physician with the psychiatric evaluation of depressed mood (extreme sadness that doesn't go away), flat affect (absence or near absence of emotional expression), non-communicative, uncooperative, and withdrawn. Thought content included SI.
- At 4:45 PM, the physician ordered a behavioral health examination (BHE) through telepsychiatry (telepsych, physician or healthcare provided psychiatric care through a camera and video monitor, while the health care provider is at a separate location).
- At 4:51 PM, the central intake assessor documented that, central intake received an order for telemed consult and added patient to the behavioral health list for an assessment, the assigned behavioral health intake therapist will contact the appropriate ED staffer to initiate the assessment.
- The physician plan was to wait for disposition after recommendations of the pending intake psychiatric evaluation.
- At 5:45 PM, Staff HHHH, primary RN documented, the patient ran out of ED through the EMS doors. Elopement called, staff and security speaking with patient, no affidavit (a written statement confirmed by oath, for use as evidence in court) on file, patient not making any SI statements since being in ED, patient refusing to go back into room, patient ran out of the doors and down the hill, MD (medical doctor) aware.
- At 6:25 PM, Staff HHHH, primary RN documented, the patient returned to ED by EMS doors. Patient banging, kicking trying to break through the doors. Security made aware. Security in patient presence. Patient tried to attack security. Patient in security office at this time. The local police department (PD) called. Security notified this RN that patient would be going to jail.
- On 10/07/20 at 6:39 PM, the patient left with the local PD.

Review of the hospital's 10/07/2020 physician on-call schedule showed that a psychiatrist was on-call and available to come to the ED.

Review of the hospital's 10/07/2020 psychiatric unit census showed that there were 17 beds available on the Adult Acute psychiatric unit, 11 beds available on the Adult Intermediate psychiatric unit, 8 beds available on the Adult North psychiatric unit, and 3 beds available on the Adult South psychiatric unit.

Review of the hospital's video surveillance (no audio) of Patient #9, on 10/07/20, showed that:
- At 5:43 PM, Patient #9 exited his ED room and walked toward the EMS doors. Staff HHHH, primary RN, appeared in the hallway and followed at a distance behind him with her arm raised.
- At 5:44 PM, the patient exited the EMS doors with Staff HHHH, primary RN, and three other employees who followed him to the outer foyer and then they all stopped as the patient walked out the second set of doors. The legs of Staff MMMM, Security Officer, were seen as he ran after the patient outdoors, but then he stopped and allowed the patient to continue to walk down the hill. Staff HHHH, primary RN, waved her hand towards the patient, turned around and walked back into the ED with the other three employees.
- At 6:24 PM, Patient #9 returned and walked alone into the sliding doors of the foyer of the EMS entrance.
- At 6:24 PM, Patient #9 kicked at the locked second set of sliding doors into the ED.
- At 6:25 PM, the patient sat down on a chair. Staff LLLL, Security Officer in Charge, walked in and appeared to talk to the patient.
- At 6:26 PM, the patient appeared to talk and held his right arm up. Staff KKKK, Staff MMMM, and Staff P, Security Officers, walked in. The patient stood up, holding both arms outward to his side and appeared to be speaking.
- At 6:26:32 PM, the patient and the security officers walked outdoors.
- At 6:26:52 PM, the patient moved toward Staff KKKK, all of the officers moved towards the patient and the patient was then out of sight.
- At 6:27:42 PM, four security officers walked with the patient with his arms handcuffed behind his back to the EMS doors.

Review of the local PD confidential document dated 10/07/20, showed that:
- At 6:28:32 PM, a call was received that a male was in custody with hospital security and he was combative in the security office;
- At 6:43:21 PM, a male was sitting outside in front of the hospital;
- At 6:43:24 PM, the final disposition was "No Report Needed (NRN-no official police report filed, no charges filed and no arrest made)."

During a telephone interview on 11/03/20 at 9:00 AM, Staff IIII, Doctor of Medicine (MD), stated that:
- When she completed the MSE, she ordered a BHE consult for Patient #9 due to his mental state and suicidal thoughts.
- She was not aware of any of the events that surrounded the patient's elopement.
- She was not aware that the patient was discharged in police custody.
- If the patient left in police custody, he should have had a fit for confinement (patient is medically and psychiatrically stable to go to jail) exam, but she was unaware that the patient left with the police.
- She had not written discharge orders or given discharge instructions for the patient.
- This was not common practice and was an incorrect discharge procedure.

During telephone interviews on 11/03/20 at 12:20 AM and 11/24/20 at 10:00 AM, Staff M, RN, ED Manager, stated that:
- He was at a nursing meeting when he was told by Staff HHHH, RN, that a patient had eloped, but had returned to the ED, the patient was with the security officers, and the police had been called.
- An elopement risk assessment was not completed on the patient.
- The patient was dressed in blue scrubs that typically alerts staff that the patient was a behavioral health patient, including security staff; however, some patients were given blue scrubs due to soiled or torn clothing.
- He told Staff HHHH, primary RN, to be sure the patient was seen by everyone he needed to see, including the doctor, before he was discharged.
- A patient should be seen after an elopement and before being discharged in police custody.
- If a nurse said that he was no longer a patient, he would hope that nurse had made the physician aware and that they had not just made that statement on their own. If a patient eloped and returned, the patient should be treated as though they never left.
- He was not sure who made the decision to discharge the patient into police custody.
- Usually the PD would require a physician to examine the patient for a fit for confinement discharge, so the discharge did not follow protocol.

During telephone interviews on 11/03/20 at 3:00 PM and 11/25/20 at 9:56 AM, Staff HHHH, RN, stated that:
- When the patient came into the ED he stated he had been in the BHU for 21 days and they let him out too soon.
- The patient said that when he left the BHU he went to jail and EMS picked him up outside of jail because he felt suicidal.
- She applied a safety band, had the patient changed into blue scrubs, and initiated 15 minute checks. The patient's room was near the nursing station.
- He was in his ED patient room watching television when all of a sudden he decided he wanted to leave and he left his room and ran out the doors.
- An elopement was announced and a short time later the patient returned; he banged on the EMS doors in an attempt to get back inside. Security officers went outdoors and brought him back inside to the security office.
- A security officer, does not remember which one, told her that they called the police and pressed charges against the patient.
- She told Staff IIII, MD, that the patient had eloped, then returned, and was leaving in police custody, but the physician made no comment and no new orders were given.
- By the time she made it up front to the security office, the police had the patient in handcuffs and they said they were taking him to jail. She asked if the patient was going to have his BHE or a fit for confinement exam, but the police officers said he was going to jail.
- The patient was not examined again after the elopement, he didn't receive the BHE that was ordered, and he left with the PD in handcuffs.

During telephone interviews on 11/04/20 at 3:10 PM and 11/24/20 at 3:20 PM, Staff MMMM, Security Officer, stated that:
- An elopement was paged and when he went to apprehend the patient in the ambulance bay, he was told by a group of nursing staff that stood nearby to let him go because there was no affidavit to hold him and he was free to go.
- An hour later, the patient tried to re-enter through the EMS doors and Staff LLLL and Staff KKKK, security officers told the patient that he needed to enter through the ED entrance and go through triage again, but he refused.
- The patient wanted to return to the same room that he left when he eloped, but he was told that room was not available and he had to enter through triage again.
- The patient swung at Staff KKKK and was handcuffed in order to protect the patient and all of the security officers.
- The patient was taken to the security office and held there while the local PD was called.
- Officers from the local PD arrived, swapped handcuffs, and took the patient away in their vehicle.

During telephone interviews on 11/04/20 at 9:30 AM and 11/24/20 at 3:00 PM, Staff LLLL, Security Officer in Charge, stated that:
- At 6:35 PM, he arrived on hospital property to come on duty and he saw a male patient at the outer EMS doors dressed in blue hospital scrubs.
- The hospital scrubs didn't alert him to an elopement because a lot of patients wear hospital scrubs due to the inappropriate clothing they often arrive in that was dirty or torn.
- He told the patient that he was at the wrong entrance and attempted to show him the correct ED entrance.
- The patient told him that he would get in those doors and stated, "Watch me," and he kicked and banged on the doors.
- Staff KKKK, Staff MMMM and Staff P, security officers came and tried to get the patient to go to the correct entrance. These officers informed him the patient had eloped and was now trying to return.
- The patient continued to get agitated and verbally aggressive and he moved toward Staff KKKK, security officer in a threatening manner.
- They handcuffed the patient for their safety and took him to the security office where they called the local PD.
- He was with the patient until officers from the local PD arrived. During that time the patient continued to talk aggressively.
- He met the local PD officers in front of the hospital, brought them in, and they spoke to a nurse, but he did not recall what nurse. The police officers returned to the security office and said they were taking the patient.
- Our standard of practice was that when a patient was aggressive and violent on the outside of the hospital, they called the security office, who then notified the ED and called the local PD.

During a telephone interview on 11/04/20 at 3:30 PM, Staff P, Security Officer, stated that:
- He was the last to arrive on the scene when the patient was trying to enter the ED through the EMS doors. He was not aware the patient had eloped.
- Staff KKKK, SO, tried to get the patient to enter through the ED entrance, but he refused and continued to be verbally aggressive.
- The patient lunged at Staff KKKK and the patient was handcuffed.
- The patient was not considered an ED patient anymore because security had been told he eloped, he did not have an affidavit, and he was free to go.
- The local PD was called and when they arrived, they placed their handcuffs on the patient and took him away.

The hospital failed to complete a MSE when Patient #9 presented to the ED with complaints of SI, audio and visual hallucinations. The physician documented that the patient required High Risk Suicide Precautions which included hospital approved clothing (blue scrubs), safety band, security notified, continuous observation, and the patient must have no ability to leave that area. The patient eloped through the EMS doors, and returned to the ED 41 minutes later, in blue scrubs, still seeking care and treatment. The local PD was notified and Patient #9 was removed from the premises prior to completion of a MSE, which included a BHE that was ordered by the physician. The physician did not reevaluate the patient prior to discharge with the PD. This placed all patients that presented to the ED with SI and/or audio and visual hallucinations at risk.

Based on interview, record review, policy review, and review of video surveillance, the hospital failed to provide stabilizing treatment on 10/10/20, when Patient #9 presented to the Emergency Department (ED) accompanied by local police with a head injury, facial injuries, and head lacerations (a deep cut or tear in skin). The hospital failed to provide a known homeless patient with the recommended 24 hour close observation after he received Ketamine (moderate sedation, a medication used as an anesthetic and analgesic drug and also as a hallucinogen). The hospital staff allowed the patient to be discharged, accompanied by security, who escorted the patient in a wheelchair off hospital property, assisted him out of the wheelchair, and left him alone at the curb without the recommended close observation. This failure by the hospital had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment that required sedation/anesthesia at increased risk for their safety. The hospital's ED had an average of 3,843 emergency visits per month.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act," (EMTALA, an act/law that obligates the hospital to provide medical screening treatment and stabilization of individuals with an emergency medical condition (EMC) dated 09/09/20, showed that in the event that an individual presents with an EMC they will be provided stabilizing treatment to the extent of the hospital's capability and capacity and if indicated, provide an appropriate transfer to another hospital with the capability and capacity to stabilize the individual.

Review of the hospital's policy titled, "Adult Patient Moderate Sedation," dated 03/19/20, showed:
- Moderate sedation/analgesia was a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulations, and spontaneous ventilation is adequate.
- Prior to the procedure using moderate sedation an informed consent should be completed.
- A pre-sedation assessment to include the patient's medical history, airway, pain status, level of consciousness, assignment of an American Society of Anesthesiologists (ASA) classification (metric to determine if someone is healthy enough to tolerate anesthesia), and indication for procedure should be completed and documented.
- The patient's vital signs, level of consciousness is evaluated immediately after the procedure and the Aldrete score (method of determining post anesthesia recovery) will be utilized to assess the patient's recovery from sedation.
- The patient and responsible party should be advised that, despite the appearance of recovery, it is recognized that patients may have a prolonged period of amnesia and/or impaired judgment.
- In all instances, discharge planning shall include safe and appropriate transportation from the hospital.

Review of Discharge Instructions/After Visit Summary, dated 10/10/20, showed:
- The patient received a sedation/anesthesia medication that may cause dizziness and sleepiness;
- It may take some time before the patient felt like he was back to normal;
- Anesthesia can cause dehydration;
- Anesthesia remained in the body for 24 hours; and
- The patient should not be left alone.

Review of Patient #9's medical record dated 10/10/20, showed the following:
- On 10/10/20 at 5:18 PM, he arrived to the ED via Emergency Medical Service (EMS) and local Police Department (PD) escort, with complaints of a large laceration through his right ear and scalp, and several facial contusions (injured tissue that caused bruising) after reportedly being struck with a metal object.
- He was agitated (excessive motor activity associated with a feeling of inner tension) and confused, and would not answer questions appropriately, he cursed at the physician, and he repeatedly screamed out during examination.
- His medical history was documented as Attention-Deficit/Hyperactivity Disorder (ADHD, a neurobehavioral disorder), Bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), conduct disorder, and nondependent drug abuse.
- The physician was unable to perform a review of systems (ROS) due to the patient's mental status change.
- A neurological examination showed that the patient was alert, somnolent (sleepy, drowsy), uncooperative, and he cursed at the physician and nurses.
- At 5:18 PM, the patient was sedated with a Geodon (an antipsychotic medication used to treat schizophrenia and the manic symptoms of bipolar disorder) 20 milligram (mg, a measure of dosage strength) injection and at 8:20 PM, he received a Ketamine, 300 mg injection, and the suture procedure was documented as completed at 11:50 PM.
- The physician documented in the Progress Notes that the patient was awake and alert enough that he should have been able to control his behavior; however, he continued to act irrationally with violent outbursts. The patient was sedated for agitation (excessive motor activity associated with a feeling of inner tension) and violent outbursts and he tolerated the procedure far better with the chemical sedatives.
- At 9:33 PM, the physician documented that the patient was to be discharged into police custody once he was awake and alert.
- At 11:14 PM, nursing documentation showed that the patient felt better and could be discharged with follow-up care instructions. Instructions included, pain treatment, post-anesthesia information, and to return to the ED around 10/17/20 for suture removal. The post-anesthesia instructions stated to have someone stay with the patient for the first 24-hours after anesthesia. Discharge instructions showed that the patient could feel tired, sleepy, or dizzy after anesthesia and that anesthesia remained in the body for at least 24-hours.
- At 11:57 PM, the physician documented that the local PD would be contacted to extricate the patient from hospital property and may place him under arrest at that time for his earlier offense.
- The physician documented in the ED Clinical Impressions that there were injuries of the head, an ear lobe laceration, polysubstance (multiple drugs) abuse, a personality disorder (a chronic inflexible, maladaptive pattern of perceiving, thinking, and behaving, and that the patient was considered safe for discharge.

Review of the hospital's video surveillance of Patient #9 leaving the ED in a wheelchair on 10/10/20, showed that (no audio):
- At 11:15 PM, the camera in parking lot E-008, Lot 13 showed three staff members, two security officers and an ED Technician pushing the patient out of the hospital in a wheelchair. The ED Technician returned inside.
- Two security officers continued down the hill of the parking lot, but they were no longer visualized once they exited the parking lot area.
- At 11:15 PM, the camera in parking lot E-007, Lot 13 A showed two security officers pushing the patient in a wheelchair through the parking lot and down the hill.
- At 11:16 PM, they were no longer in sight.
- At 11:18 PM, two security officers returned back up the hill to the parking lot.
- At 11:19 PM, a security vehicle stopped and picked up one of the security officers and gave him a ride to the ED doors; the second security officer continued to walk back pushing the empty wheelchair.

Review of the local county Police Department's confidential document, dated 10/11/20, at 4:30 PM, showed the following:
- The patient was a 31-year-old homeless man that was taken to the hospital with multiple lacerations to the facial area, various lacerations to his forearms, shards of glass adhered to his back and arms, and a severe laceration to the ear after an altercation. The patient did not have a shirt on.
- EMS manned by paramedics transported the patient to the hospital.
- A police officer arrived at the ED where the patient remained uncooperative and combative.
- Medical staff advised, because the patient was sedated, he would not be conscious for several hours and would remain at the hospital for observation.
- The police officer left the hospital and the case was listed as active.

During a telephone interview on 10/21/20 at 10:00 AM, Staff WW, Doctor of Medicine (MD), stated that:
- The patient came in with an ear laceration that required quite a few sutures. He thought the patient needed medical clearance for fit for confinement (patient is medically and psychiatrically stable to go to jail) since the police brought him in so they could arrest him once he was treated.
- Police brought the patient in an agitated state and Geodon was given. The patient continued to scream while he attempted to suture his laceration, so Ketamine was given to sedate him.
- A behavioral health exam (BHE) was not indicated because there were no indicators of suicidal ideation (SI, thoughts of causing one's own death) or homicidal ideation (HI, thoughts of causing another person's death) he was a sociopath (a person with a personality disorder manifesting itself in extreme antisocial attitudes and behavior and a lack of conscience) that needed to go to jail.
- His documentation that stated "irrational and violent outbursts" did not mean physically violent, but verbally violent. If he would have been physically violent, he would have been evaluated for a restraint (limit a patient's movement).
- When patients were uncooperative and brought in as a criminal patient, he felt it would be appropriate to contact the police and let them return to arrest the patient.
- He felt that it was a safe discharge because the patient was fit for confinement and he had no grounds to hold him in the ED and no grounds for admission.
- He felt that the time that the patient was allowed to sleep was appropriate for the dosage of Ketamine that was given.
- He wanted to know why the local county PD felt it was ok to change their mind about the patient's arrest, remove his cuffs, and leave the patient in the ED when he should have been taken to jail.

During a telephone interview on 11/02/20 at 4:45 PM, Staff GGGG, ED RN, stated that:
- The patient had been in a psychiatric safe room until after he was sedated and had his ear sutured, then he was moved to the overflow area in the hallway to sleep off the sedation.
- The police had been with him, but when they were told that the patient would need to sleep off the sedation for a few hours they decided to leave and released the patient to hospital custody.
- The physician's orders were to, "Discharge when sober from the anesthesia," and after three hours, he woke the patient up and completed a cognition (mental) assessment, which included his date of birth, the date, his location, and why he was there. The patient asked him if the police were still there and then he rolled over to go back to sleep.
- The patient was told he had to get up because he was discharged, but he refused to roll back over and get up.
- Security was called and assisted the patient into the wheelchair and they left. That was the last interaction he had with the patient.

Review of the local PD confidential document, dated 10/10/20 at 11:24 PM, showed the following:
- White male crawling down the roadway, jeans and no shirt.
- Responsible person states hospital security wheeled down near the helicopter pad dumped him onto the roadway and walked back to the ED.
- Patient was taken to the western city limits.

During a telephone interview on 10/22/20 at 7:50 PM, Police Officer SS, with the local PD, stated that:
- The PD was dispatched to the site near the hospital where the patient was lying on the ground.
- He went to talk to security at the hospital and was told that the patient was discharged from the hospital and he refused to leave so he was escorted off the property.
- He called EMS and they knew the patient from previous encounters. The patient told them he wanted to return to the hospital. EMS assessed him and told him that he was ok and no further medical assistance was needed; he had no reason to return to the ED.
- EMS left and the police officer took the patient in his car to the area where the patient was known to always hang out.
- He stated that the patient was homeless and the police officers knew him and felt comfortable to return him to the area he was familiar with.
- There was no official police report on file because the patient was not arrested.

Review of the local EMS document titled, "Prehospital Care Report," dated 10/10/20 at 11:44 PM, showed the following:
- EMS responded to the helipad area of the hospital for a patient they had transported earlier that day to the hospital for head injuries.
- Patient was dumped there by hospital security.
- Hospital ED contacted by phone and inquired if the patient had left against medical advice (AMA) or was discharged.
- The ED charge RN states he was discharged and that the local county PD was on their way to pick him up because he was under arrest.
- EMS conveyed that information to the local PD who was on the scene.
- Disposition was canceled on scene with no patient contact.
- The patient left with the local PD and the EMS team left and returned to service.

During an interview on 10/19/20 at 4:10 PM, Staff P, Security Officer, stated that:
- ED staff had called dispatch and he was sent to the ED with a message that a patient was discharged but didn't want to leave.
- This was a frequent problem in the ED so when security heard the dispatch, they knew it would be to assist a patient to leave.
- It was a patient that the police had brought in earlier that day whose face and upper body were bloody due to a laceration on his ear and facial injuries.
- The police stayed for several hours because he was in police custody and it was their intent to arrest him, but they left and he was no longer in police custody.
- It was security's practice to escort patients off the property when they refused to leave, and if they became combative to call the police.
- The patient's upper body was bloody and he did not have a shirt on, but he refused the shirt that was offered to him.
- The Charge Nurse (Staff UU), the patient's nurse (Staff GGGG), the security officer (Staff PP), and an ED Technician (Staff TT), assisted with getting a wheelchair and removing the patient off the hospital property. The ED Technician (Staff TT) walked with the two security officers down the hill to the property line.
- When they made it to the property line, the patient continued to curse and said he wasn't going to leave.
- The patient got up from the wheelchair and sat down on the sidewalk.
- Hospital staff returned to the ED and left the patient sitting on the sidewalk.

During an interview on 11/20/20 at 8:45 AM, Staff PP, Security Officer, stated that:
- Dispatch was notified that security was needed to help remove a discharged patient that refused to leave.
- Staff GGGG, ED RN, told him that the doctor had seen the patient, he was medically cleared for discharge, and they wanted him escorted off the property.
- The patient didn't have a shirt on and he had dried blood on him, the patient sat down on the sidewalk, continued to curse, and threw the shirt down on the ground that the hospital had offered him.
- The security mobile unit that drove around the hospital perimeter was notified that the patient was discharged to a safe place off hospital property and should not return.
- Usually, if the patient was cooperative and they didn't have a ride, hospital staff tried to accommodate them with a bus pass or a cab voucher and Security staff would drive them to the bus stop, but this patient was bloody, he refused a shirt, and he refused to cooperate.
- Security dealt with patients almost every night that didn't want to leave the hospital and each patient was different. Some received bus passes, some received cab vouchers, and some had to have police intervention.
- Security does not know the discharge plans of the patients, they are just told when patients refuse to leave.

During a telephone interview on 10/22/20 at 5:00 PM, Staff TT, ED Care Technician, stated that:
- The patient was treated by the physician and was discharged, but he refused to leave.
- He tried to get the patient to call someone, but he refused. He stated that the patient said he just wanted to stay and sleep.
- Staff P, Security Officer, helped him try to get the patient up from the stretcher, but the patient continued to return to the stretcher to lay down and sleep.
- The patient got verbally aggressive with staff and the patient was told, "He didn't have to call for a ride if he didn't want to, but he was not going to stay at the hospital."
- The patient was pushed in a wheelchair down the hill to the property line, he refused to get up from the wheelchair, and he was assisted by security as they stood the patient up from the chair. He continued to be verbally aggressive and cursed, but he sat down on the sidewalk.
- Staff returned to the ED and he had no further encounters with the patient.

During a telephone interview on 10/20/20 at 5:30 PM, Staff UU, ED Charge Nurse, stated that:
- The patient was in a psychiatric room when he was admitted to the ED because he yelled and screamed at staff. When the doctor tried to suture his ear, he continued to scream so he was sedated with Ketamine.
- Once his ear was stitched, he was considered medically cleared and he was moved to a cot in the hallway to eat and sleep off the sedation.
- Once he was discharged, the nursing staff continued to arouse him and get him up from the stretcher. The patient screamed and crawled back on the stretcher to sleep. He refused to get up and stay up.
- When they tried to put him in the wheelchair, he fell to the ground and acted like he couldn't stand.
- The physician was at the desk and watched the whole thing.
- It was pretty common that patients didn't want to leave after discharge, but she had never seen one pushed off the property in a wheelchair.

During interviews on 10/19/20 at 3:15 PM and 11/24/20 at 10:00 AM, Staff M, RN, ED Manager, stated that:
- The patient was brought in for injuries he sustained during an altercation at a gas station.
- The police accompanied him and planned to arrest him, but decided not to wait.
- If a patient was cooperative and needed a ride somewhere after discharge, the ED staff tried to help and called the Medicaid transportation van, or gave a bus pass or a cab voucher.
- If a patient was difficult or belligerent and displayed agitated behaviors, they were escorted out by security.
- The discharge process in the ED was decided by the ED staff and the physician.
- If there was a concern between the nurse and the physician, Risk Management (RM) would be called to help assist and/or resolve concerns with the discharge plan, if needed; however, RM was not notified because the patient was medically cleared by the physician and there was no need to get them involved.
- If he were asked if a patient with fresh sutures, a head injury, and post anesthesia was safe for discharge, his answer would be no, but it had to be on a case-by-case basis.
- Ketamine discharge instructions stated it could remain in a patient's system for 24 hours and the patient should not be left alone during that time in case of side effects, but patients that received Ketamine were usually never held in the ED for 24 hours because that would almost require an admission.
- The RN assessed the patient and determined he was alert and oriented, the effects of the Ketamine had worn off, and he was safe for discharge.
- It was common that patients were made to leave when they hoped to be admitted.
- If there was a problem, security would be called and it was usually resolved quickly and the patient would leave.
- It was rare that a patient had to be wheeled down the hill off of hospital property.

During an interview on 10/19/20 at 3:50 PM, Staff O, Security Manager, stated that:
- On 10/10/20 at approximately 11:15 PM, he was notified that that the patient didn't want to leave the hospital after he was discharged.
- Two security officers arrived at the ED after nursing staff called for them because the patient refused to leave.
- The patient still refused to leave so the two security officers, (Staff P and Staff PP), assisted the patient to a wheelchair and pushed him to the hospital property line.
- The patient didn't have a shirt on and there was blood on his upper body from his injury and the sutures he received in the ED.
- The distance from the ED door to the public sidewalk was 590 feet, the patient walked 17 feet before he sat down, and he moved 56 feet before he laid on the yellow curb.
- It was not uncommon for homeless or behavioral health patients to refuse to leave the hospital. They often sat down on the curb and eventually walked to the corner or down the street.
- The two security officers, (Staff P and Staff PP), left the patient sitting there and pushed the empty wheel chair back up the hill to the ED entrance.
- Approximately 20 minutes later, security received a call from the local PD who inquired about a male that was lying on the ground.
- ED nursing staff talked to the police officer and explained the patient's situation. He was placed in the police officer's car and they drove off.

During an interview on 10/21/20 at 4:45 PM, Staff RRR, MD, ED Medical Director, stated that all ED staff received EMTALA education annually and his expectation was that stabilizing treatment would be completed on all patients.

The hospital failed to provide stabilizing treatment when Patient #9 presented to the ED on 10/10/20 and received Ketamine for repair of two lacerations on his head. The discharge instructions directed the patient to have someone stay with him for the first 24-hours post sedation administration because the patient could experience feeling tired, sleepy or dizzy after the administration of the anesthetic. The discharge instructions included that the patient would require close observation and should not be left alone. The hospital failed to provide the patient with the recommended 24 hour close observation recommendations, when the patient was allowed to be discharged without proper observation due to his homeless status and was removed from hospital premises in a wheelchair and assisted from the wheelchair by hospital security, where the patient sat on the ground and was found asleep at the curb by a pedestrian.