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Based on interview and record review, the hospital failed to provide stabilizing measures for two of 20 patients (Patient 1 and Patient 2) with identified emergency medical conditions (EMC- a medical condition that presents severe and sudden symptoms, and if they do not receive immediate medical treatment, their injuries could result in impairment, serious health complications, or loss of bodily functions) when:

1. Pt 1 expressed suicidal statements while being discharged and escorted out to the facility after discharge on 1/30/24. Patient (Pt) 1 was brought in by Emergency Medical Services (EMS) ambulance on 1/29/24 because he wanted to kill himself and "jump in front of a train". A medical screening exam (MSE-a screening to determine whether a patient has an emergency medical condition) exam was provided by a QMP (Qualified Medical Provider), medical clearance was done, and mental health evaluation cleared Pt 1 for discharge on 1/30/24. During the discharge process, Pt 1 expressed he wanted "to kill himself" to the Registered Nurse (RN) 1, and RN 1 did not seek consultation with the Social Worker in accordance with hospital expectations and had Pt 1 escorted out of the hospital. (Refer to A2407, Finding 1)

2. Pt 2 was transported to the emergency department (ED) on 3/13/24 at 5:35 a.m. by ambulance with a chief complaint of hematemesis (vomiting of blood). Pt 2 was triaged (the process to quickly examine patients in the emergency department to decide which patients are the most critically ill and must be treated first) with an ESI (a 5-level emergency department process that sorts patients into 5 groups from 1 (most urgent) to 5 (least urgent) based on the severity of a patient's illness and resources needed) of 3 and assigned to a hallway bed. Pt 2's medical screening exam (MSE-when a request is made for examination or treatment for an emergency medical condition) was initiated on 3/13/24 at 5:58 a.m. by Medical Doctor (MD) 4 and orders were placed for medications (a drug used to diagnose, cure, treat, or prevent disease) and labs (testing a sample of blood, urine, or other substance from the body to help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time). While in the ED on 3/13/24 at 11:30 a.m., Pt 2 developed a fever (a higher temperature than normal) increased heart rate (more than 100 beats per minute), and low blood pressure (BP-below 90/60 [Normal BP 90/60 to 120/80]). MD 4 ordered additional medications, labs, and monitoring for Pt 2's change in condition and stabilizing measures were not carried out in accordance with physician orders. (Refer to A2407, Finding 2)

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

Based on interview and record review, the hospital failed to provide stabilizing measures for two of 20 patients (Patient 1 and Patient 2) with identified emergency medical conditions (EMC- a medical condition that presents severe and sudden symptoms, and if they do not receive immediate medical treatment, their injuries could result in impairment, serious health complications, or loss of bodily functions) when:

1. Pt 1 expressed suicidal statements while being discharged and escorted out to the facility after discharge on 1/30/24. Patient (Pt) 1 was brought in by Emergency Medical Services (EMS) ambulance on 1/29/24 because he wanted to kill himself and "jump in front of a train". A medical screening exam (MSE-a screening to determine whether a patient has an emergency medical condition) exam was provided by a QMP (Qualified Medical Provider), medical clearance was done, and mental health evaluation cleared Pt 1 for discharge on 1/30/24. During the discharge process, Pt 1 expressed he wanted "to kill himself" to the Registered Nurse (RN) 1, and RN 1 did not seek consultation with the Social Worker in accordance with hospital expectations and had Pt 1 escorted out of the hospital.

These failures resulted in Pt 1 attempting to hang himself with a sheet from a tree on the facility's property immediately after being escorted out of the facility's Emergency Department (ED) on 1/30/24. Pt 1 was not brought into the ED for stabilization and instead provided transportation to another hospital (Hospital B).

2. Pt 2 was transported to the emergency department (ED) on 3/13/24 at 5:35 a.m. by ambulance with a chief complaint of hematemesis (vomiting of blood). Pt 2 was triaged (the process to quickly examine patients in the emergency department to decide which patients are the most critically ill and must be treated first ) with an ESI (a 5-level emergency department process that sorts patients into 5 groups from 1 (most urgent) to 5 (least urgent) based on the severity of a patient's illness and resources needed) of 3 and assigned to a hallway bed. Pt 2's medical screening exam (MSE-when a request is made for examination or treatment for an emergency medical condition) was initiated on 3/13/24 at 5:58 a.m. by Medical Doctor (MD) 4 and orders were placed for medications (a drug used to diagnose, cure, treat, or prevent disease) and labs (testing a sample of blood, urine, or other substance from the body to help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time). While in the ED on 3/13/24 at 11:30 a.m., Pt 2 developed a fever (a higher temperature than normal) increased heart rate (more than 100 beats per minute), and low blood pressure (BP-below 90/60 [Normal BP 90/60 to 120/80]). MD 4 ordered additional medications, labs, and monitoring for Pt 2's change in condition and stabilizing measures were not carried out in accordance with physician orders.

These failures resulted in a delay of administering stabilizing measures, even after Pt 2 was admitted as an inpatient at 1:11pm and MD 5 assumed care. Stabilizing measures were not administered and Pt 2's clinical status declined in the ED and was pronounced dead at 10:14 p.m. time on 3/13/24.

Findings:

1. During a review of Pt 1's "Emergency Medical Services (EMS, paramedics) Run Sheet (RS,-a documentation of ambulance transport)", dated 1/29/24, the "RS" indicated EMS was called to respond to a " ... psychiatric problem/abnormal behavioral ...". The "RS" indicated Pt 1 " ... stated he wants to kill himself ... and plans to jump in front of a train ...". The "RS" indicated EMS transported Pt 1 to the facility and transferred Pt 1's care to the facility's ED on 1/29/24 at 7:16 p.m..

During a review of Pt 1's "ED timeline (EDT)", dated 1/29/24 to 1/30/24, the "EDT" indicated Pt 1 arrived in the ED at 6:47 p.m. and was placed on a 1799 hold (a California Health and Safety Code allowing a healthcare provider to detain an individual involuntarily for up to 24 hours, until a qualified mental health professional can evaluate the individual) at 6:54 p.m. The "EDT" indicated, " ... 19:20 [7:10 p.m.] ... Assumed care of patient, asleep on bed, not in any acute distress, denies SI [Suicidal Ideation, ideas of killing oneself] or HI [Homicidal Ideation, ideas of killing someone else] ... [Registered Nurse {RN} 1] ... The "EDT' indicated Pt 1 was medically cleared by Medical Doctor (MD) 2 and MD 2 placed an order to " ... Notify Provider if patient becomes agitated or is escalating [becoming more intense or serious] ... Urine Toxicology (UR [urine] Drugs of Abuse scrn [screen, a sample of urine to find drugs present in the body] ... Social Work Consult ..." at 7:41 p.m.

During a concurrent interview and record review on 4/4/24 at 10:14 a.m. with RN 7, RN 7 reviewed Pt 1's "Electronic Medical Record (EMR)", dated 1/29/24 to 1/30/24. RN 7 stated there were no urine toxicology results for Pt 1.

During a review of Pt 1's "Facility Encounters (FE)", the "FE" indicated Pt 1 had visits to the facility's ED on 7/27/23 for SI and was on a 5150 hold [a California code allowing a qualified mental health professional to detain an individual on an involuntary hold for up to 72 hours if the individual poses a danger to themselves or others, or gravely disabled {unable to provide their own food, clothing or shelter}], later cleared by the psychiatric Specialist On Call (SOC); on 2/1/23 for a laceration to the hand and was considered for admit for SI, later cleared by SOC; on 5/4/19 for SI and deliberately cutting himself, later cleared by SOC; and on 4/4/19 for SI with intent and left arm cutting, later cleared by SOC.

During a concurrent interview and record review on 4/5/24 at 11:03 a.m. with the Psychiatric Specialist (PS), the PS reviewed Pt 1's "SOC Consult (SC)", dated 1/30/24, The PS stated she did the psychiatric assessment for Pt 1 on 1/30/24. The PS stated Pt 1 was depressed but did not want to die or kill anyone. The "SC" indicated pt 1 had been released from prison and was living with his girlfriend's family for the past week and a half. The PS stated Pt 1 began drinking and using cocaine and marijuana and was subsequently kicked out of the house. The "SC" indicated, " ... Patient stated he has no clothes, no ID, no cell phone, no job, no money. Came to ED for help. Stated he has suicide thoughts all the time but he denies any intent ... he is also COVID-19 + [positive] ... He stated he wants to feel better about himself but this is no where to start from. He has a meeting with his PO [parole officer] on Wednesday that he plans to keep but he has no where to stay or how to get there. He is depressed about relapsing on drugs ... He now has lost everything because of it ... Is anxious about the future, worries about failing drug testing and being thrown back to prison ...". The PS stated Pt 1 stated he would feel safe if he had a place to stay and was open to drug rehab treatment. The PS stated patients in the ED admitted in the evening needing outpatient referrals usually waits the following morning for the Social Worker to provide resources and arranged referrals for outpatient needs. The PS stated he was clear with Pt 1 that he would get help from the hospital regarding resources. The "SC" indicated, " ... Disposition Recommendation ... Discharge home with support ... Treatment and Medication Recommendations ... 1. Cleared for discharge to outpatient treatment 2. Social work consultation for outpatient resources, housing and aftercare 3. Refer to outpatient substance abuse treatment providers in the community ... Reconsult ATC [around the clock] psychiatry as needed ... Patient NO LONGER MEETS CRITERIA for involuntary commitment ... Case discussed with [RN 1] ...". The PS stated he discussed the recommendations with Registered Nurse (RN) 1. The PS stated if Pt 1 had further suicidal statements or acting out, he would expect the nursing staff to call the SOC for another SOC consult.

During a review of Pt 1's "Provider Note (PN), dated 1/29/24 at 7:32 p.m. The "PN" indicated, " ... ED Course ... Mon Jan 29, 2024 ... 1941 [7:41 p.m.] **Patient is medically cleared and awaiting social services/psychiatric evaluation** ... Patient progress: 0100 [1:00a.m.]: patient evaluated by SOC psychiatry, does not meet inpatient psych [psychiatric] criteria, recommends d/c [discontinue] 5150 and discharge ...".

During a concurrent interview and record review on 4/5/24 at 11:50 a.m. with MD 2, MD 2 reviewed Pt 1's "SC". MD 2 stated RN 1 only told her the 1799 hold was lifted and not about the other recommendations on the "SC". MD 2 stated the "SC" was uploaded later into the medical record and not visible at the time of discharge.

During a review of Pt 1's "EDT", the "EDT" indicated, " ... 1/30/24 ... 01:20 [1:20 a.m.] ... SOC done and recommend discharge, informed [MD 2] about psychiatrist recommendations, 1799 discontinued, discharge instructions given but do not want to go and said he do not have a home to got to, asked if he want to go somewhere of his choosing still no address given for taxi voucher, refused to take his discharge paper, asked social worker but do not know also what kind of help we can give him, patient want to stay in ER [Emergency Room] as said because he do not have any place to go, stated call [sic] a taxi cab and he will go to a train track to kill himself. I told him we cannot do that [sic], patient was escorted outside by security ... RN 1 ...". The "EDT" indicated Pt 1 was discharged at 2:37 a.m..

During an interview on 4/5/24 at 7:35 a.m. with Security Officer (SO) 1, SO 1 stated he was sent to the ED to escort Pt 1 out of the building. SO 1 stated Pt 1 was sitting outside the Special Care Unit (SCU, a unit to closely monitor psychiatric patients) and asked SO 1 why he was being discharged, because he was still suicidal. SO 1 stated Pt 1 verbalized if he was discharged, he will walk in front of a moving car. SO 1 stated he asked SO 2 assigned in the SCU if medical staff were aware of Pt 1's statements and SO 2 stated " ... yes ...". SO 1 stated RN 1 told him Pt 1 was discharge and to escort Pt 1 outside. SO 1 stated as he walked Pt 1 out and before they got to the green zone (area of the ED just outside the ED lobby), Pt 1 stated he was going to walk in front of a moving car. SO 1 stated he told Pt 1 he could not do anything about the discharge. SO 1 stated Pt 1 followed him and continued to make remarks about being suicidal, having nowhere to go and no one to call. SO 1 stated he suggested to Pt 1 to go to a shelter, but Pt 1 stated he was COVID positive, and a shelter would not take him. SO 1 stated he attempted to reassure Pt 1 and directed him to the bus stop, but Pt 1 asked where the nearest freeway was located and SO 1 did not tell Pt 1. SO 1 stated he directed Pt 1 back to the bus stop. SO 1 stated he was concerned about Pt 1's statements and turned around and saw Pt 1 turn back and crossed the hospital campus street into the ED parking lot. SO 1 stated Licensed Vocational Nurse (LVN) 1 was in the parking lot and came up to SO 1 and said she heard Pt 1's suicidal statements. SO 1 stated LVN 1 asked him to call the ED Supervisor and SO 1 radioed security dispatch. SO 1 stated Pt 1 had a sheet he was wearing like a cape, and used the sheet to tie around his neck, made eye contact, jumped on top of the electrical box cage, and tied the other end of the sheet to the tree. SO 1 stated he called dispatch again, as Pt 1 jumped off the electrical box cage and hung himself. SO 1 stated he grabbed Pt 1 and tried to hold him up while LVN 1 tried to reach the sheet to untie it. SO 1 stated someone arrived with shears and LVN 1 cut the sheet. SO 1 stated Pt 1 said "... I told you I needed help and had nowhere to go ..." and stated he did not want to go back into the facility but to go somewhere else. Law enforcement officers and EMS were in the parking lot. EMS took him to another facility (Hospital B).

During a concurrent interview on 4/5/25 at 9:15 a.m. with LVN 1 and Clinical Supervisor (CS) 1 , LVN 1 stated she was working in the ED lobby when she heard Pt 1 making suicidal statements as he was being escorted by SO 1 out of the facility through the ED lobby. LVN 1 stated she heard Pt 1 asking SO 1 why he was being discharged. LVN 1 stated she heard Pt 1 ask where he was supposed to go and stated he needed help. LVN 1 stated SO 1 told her he was instructed to walk Pt 1 out of the facility. LVN 1 stated she heard Pt 1 verbalize he wanted to walk in front of a moving car. LVN 1 stated she followed Pt 1 and SO 1 outside and Pt 1 was yelling he was going to jump off the parking garage. LVN 1 stated she went to get help inside and when she came back outside, SO 1 was yelling for help and running to the tree where Pt 1 hung himself. LVN 1 stated she climbed a fence next to the tree attempting to reach the sheet while SO 1 was holding Pt 1 up and tried to give slack to the sheet. LVN 1 stated someone gave her scissors and she cut the sheet to get Pt 1 down. CS 1 stated when Pt 1 was cleared by the PS and the 1799 and 5150 was lifted, and Pt 1 continued to make suicidal ideation statements to RN 1, the expectation was for RN 1 to notify the doctor to re-evaluate Pt 1.

During a concurrent interview and record review on 4/5/24 at 3:48 p.m. with the Human Resource Business Partner (HRB), "Employee Relations Summary of Investigation (ERS)", dated 2/17/24, was reviewed. The "ERS" indicated, " ...Human Resource Department received a complaint from an Emergency Department employee ... After further investigation and chart review by the department it was determined that [RN 1] did not appropriately follow the discharge procedure nor did he escalate additional concerns from the patient ....". The HRB stated this was his summary of the investigation regarding the discharge of Pt 1.

During an interview on 4/8/24 at 9:18 a.m. with the Emergency Department Manager (EDM), the EDM stated according to the Emergency Medical Treatment and Active Labor Act (EMTALA), the ED was required to provide stabilization. The EDM stated the suicidal ideation's statements made by Pt 1 while he was being discharged from the ED was the same as a patient being discharged with an unstable blood pressure and the expectation was to hold the discharge and have the patient re-evaluated by the physician.

During a review of Pt 1's "Hospital B Emergency Department Note (HBEDN)", dated 1/30/24 at 7:17 a.m., the "HBEDN" was reviewed. The "HBEDN" indicated, " ...Chief Complaint: Suicidal (Recently released from prison, seen at [Hospital A] for SI, + [positive] COVID-19 (Coronavirus disease- an infectious disease) so [Hospital A] could not place him subsequently discharged. After discharge pt [Pt 1] hang himself with a blanket from a tree. [Hospital A] staff were able to cut him down. Then was placed on hold by CPD [Police Department] and sent to [Hospital B] ... He is now complaining of some pain to his throat. CBC [complete blood count- is a blood test used to look at overall health and wide range of medical conditions], CMP [comprehensive metabolic panel - is a blood test that gives doctors information about the body's fluid balance], ethanol (is a test that measures amount of alcohol in the blood) ... salicylate (is a test that measures the amount of salicylates [type of drug found in over the counter prescriptions] in the blood) were unremarkable. CT angio [angiogram] neck [computed tomography is a test used to provide detailed picture of the blood vessels, head, and neck) ... At this time patient is medically cleared. However, because the patient admits to suicidal ideation patient will be placed on a 5150 hold ..."

During a review of Pt 1's "HBEDN", dated 1/30/24 at 1:34 p.m., the "HBEDN" was reviewed. The "HBEDN" indicated, " ...Plan of care: Patient will be transferred to [name of facility- Mental Health Service] with the diagnosis attempt by hanging and suicidal ideations under the care of [name of physician] ..."

During a review of Pt 1's "Emergency Department Timeline from Hospital B (EDTB)", dated 1/30/24, the "EDTB" was reviewed. The "EDTB" indicated, " ... 16:36:25 [4:36] Accepted at [name of facility- Mental health service]: [name of physician] Male Day Room Requested Arrival: ASAP [as soon as possible] ... 1848 [6 p.m.] Patient discharged..."

During a review of the facility's policy and procedure titled, "Standard of Practice for Emergency Department (SP)", dated 9/14/22, "SP" indicated, " ... The patient will have a systemic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will ... Collect, document, and communicate data to the interdisciplinary team ... Advise the physician of any alterations in the patient's psychological and/or physiological condition ...".

During a review of the facility's policy and procedure titled, "Involuntary Detention of Mentally Disordered Persons - 5150/1799 Process (ID)", dated 2/25/22, "ID" indicated, " ... Medical clearance/stability is presumed to be a prerequisite to the application of WIC [Welfare and Institutions Code] 5150 guidelines ...".

During the review of the facility's policy and Procedure titled, "Medical Staff Emergency Medical Treatment and Active Labor Act (EMTALA)", dated 10/10/19, "EMTALA" indicated, " ... Policy ... for every patient presenting to the Emergency Department ... Definitions ... Emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including ... psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention should reasonably be expected to result in ... Placing the individual ... in serious jeopardy ... For EMTALA purposes, a patient is stabilized when, within a reasonable degree of medical probability, no material deterioration of the condition is likely to result from, or occur, during the transfer or discharge of a patient from the facility ...".




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2. During a record review of Pt 2's "Patient Care Report (PCR)," dated 3/13/24, the PCR indicated at 4:45 a.m. the dispatch was notified of the need for ambulance services and at 4:56 a.m. the ambulance was at the patient's bedside. The PCR indicated, "[Patient] is a 68 [year old] [male] [chief complaint] coffee ground emesis [with] [abdominal] pain [times] 1 day. [Patient] +[brand name-(Apixaban- blood thinner)] [blood thinner that reduces blood clotting], +[history] of bleeding ulcers, +hypotension. [Patient] extensive [history] of [gastrointestinal] bleeds ...[atrial fibrillation (A Fib-an irregular heartbeat)], paraplegic [the inability to voluntarily move the lower parts of the body], dementia [the impaired ability to remember, think, or make decisions]. [Patient] compliant [with] meds. [Patient] [by mouth] intake reduced ..." The PCR indicated at 5:24 a.m. a call was made to [name of Hospital A] with the estimated time of arrival. The PCR indicated at 5:31 a.m. Pt 2 arrived in the ED and transfer of care from emergency medical services (EMS) to RN 6 was at 6:05 a.m.

During a concurrent interview and record review on 4/3/24 at 2:16 p.m. with the Emergency Department Manager (EDM), Pt 2's "Electronic Medical Record (EMR)," dated 3/13/24 was reviewed. The EMR indicated, Pt 2 was triaged at 5:46 a.m. with an ESI of 3. The EDM stated the EMR indicated Pt 2's MSE was initiated by MD 4 and physician orders were placed. The EMR indicated at 11:30 a.m. Pt 2 developed a fever and additional physician orders for acetaminophen STAT (meaning immediately) once at 11:54 a.m. and at 11:57 a.m., sodium chloride 0.9% [a salt formula] bolus [a medication given over a short period of time]1,000 mL [milliliters- unit of measurement] routine once, erythromycin (an antibiotic medication used to treat infections) 500 mg [milligrams-unit of measurement] tablet STAT once, lactic acid sepsis (used to diagnose lactic acidosis [is a severe medical illness in which blood pressure is low and too little oxygen is reaching the body's tissues] and find out how severe it is), blood culture (a test that checks samples of blood for the presence of disease-causing germs); heart rate (the number of times the heart beats per minute), respiratory rate (the number of breaths a person takes per minute), manual BP [blood pressure], temperature and oxygen saturation (measures the amount of oxygen in the blood) routine every two hours and heart rate, respiratory rate, and oxygen saturation-Units where continuous monitoring available routine continuous.

During a concurrent interview and record review on 4/3/24 at 2:30 p.m. with the EDM, Pt 2's EMR, dated 3/13/24 was reviewed. The EMR indicated Pt 2 was accepted for inpatient admission by MD 5 at 12:44 p.m. and Pt 2 remained in the ED, in his assigned hallway bed , indicating Pt 2 was not moved to another area where Pt 2 could have been closely and continuously monitored. The EMR indicated there was no indication Pt 2 was placed on a cardiac monitor (a way of watching the electrical activity of your heart to ensure it is working normally). The EDM stated the EMR indicated Pt 2's physician order for acetaminophen at 11:54 a.m., with a start time of 12:10 p.m. was administered at 1:16 p.m. (a time lapse of one hour and 6 minutes after the order was placed) and a reassessment of Pt 2's temperature was not done. The EDM stated within an hour of acetaminophen administration, Pt 2's temperature should have been rechecked and was not. The EMR indicated the next vital signs were documented at 6:33 p.m. (a time lapse of five hours and 17 minutes from the time of acetaminophen administration), also indicating Pt 2 was not monitored according to MD 4's physician's orders which indicated Pt 2's vital signs should have been assessed every two hours with continuous oxygen saturation monitoring.

During a concurrent interview and record review on 4/3/24 at 2:35 p.m. with the EDM, Pt 2's EMR, dated 3/13/24 was reviewed. The EDM stated the EMR indicated Pt 2 had a physician's order placed at 11:57 a.m. for sodium chloride bolus to correct hypotensive shock [a life-threatening condition when the systolic blood pressure is less than 90 mm Hg or MAP less than 65 mmHg] was administered at 1:19 p.m. (a time lapse of one hour and 16 minutes after the order was placed).

During a concurrent interview and record review on 4/3/23 at 2:40 p.m. with the EDM, Pt 2's EMR, dated 3/13/24 was reviewed. The EDM stated the EMR indicated, the lactic acid and blood cultures ordered at 11:57 a.m. were drawn at 1:29 p.m. (a time lapse of one hour and 26 minutes after the order was placed). Pt 2's lactic acid resulted 4.2 at 1:56 p.m., which was a critical value (a test result which is significantly outside the normal range and may represent life-threatening values [normal range: 0.5-2.2]).

During a concurrent interview and record review on 4/3/24 at 2:45 p.m. with the EDM Pt 2's EMR dated 3/13/24 was reviewed. The EDM stated Pt 2' physician order laboratory included Complete Blood Count (CBC) and Chemistry (CHEM) 10 (test used to look for patients overall health and find a wide range of medical conditions such as infection) were not drawn in a timely manner and was delayed because Pt 2 was a hard stick (a patient whose veins are difficult to locate) and the phlebotomist was not able to obtain the CBC and Chemistry 10 and did not notify the assigned RN to Pt 2. The EDM stated the RN should have used the chain of command and notified the clinical supervisor and physician if the labs were unable to be drawn to find another way to obtain Pt 2's labs.

During a concurrent interview and record review on 4/3/24 at 3 p.m. with the EDM, Pt 2's EMR, dated 3/13/24 was reviewed. The EMR indicated Pt 2's physician order for erythromycin placed at 11:57 a.m. by MD 4 was not administer and was discontinued at 1:13 p.m. by MD 5. The EMR indicated MD 5 ordered another antibiotic at 6:37 p.m., which was piperacillin-tazobactam (medication used to treat bacterial infections [the invasion and growth of germs in the body]) intravenous piggyback (IVPB-a small bag of IV medication that must be administered separately from the other IV fluids). The EMR indicated piperacillin-tazobactam was not administered. The EMR indicated there were no nurses' notes indicating the reason Pt 2 was not administered the erythromycin and the piperacillin-tazobactam. The EDM stated the physician ordered antibiotic medications should have been administered to Pt 2 which could have helped improve Pt's 2 medical condition.

During a concurrent interview and record review on 4/3/24 at 3:10 p.m. with the EDM, Pt 2's EMR, dated 3/13/24 was reviewed. The EMR indicated at 10:01 p.m. a physician note under Significant Event (any unintended or unexpected event, which could or did lead to harm of a patient) indicated, "I was notified by RN that the family noticed that the patient became unresponsive. Repeat lactic acid is up to 10.6. I assessed the patient at bedside. ED attending (name of MD 7) was also present in the room and talked to the daughter about the code status. Patient's daughter states that patient's code status is [do not resuscitate (to revive a person who has lost consciousness)/do not intubate (to put a tube in a person's mouth or nose then down into the windpipe to assist with breathing) DNR/DNI] but she wants the patient to continue receiving medical treatment. Daughter also states that patient had a severe reaction to penicillin [medication used to treat infections] in the past. A dose of [piperacillin-tazobactam] was ordered by the day hospitalist but has not been given. Will change [piperacillin-tazobactam] to cefepime [medication used to treat bacterial infections] and [metronidazole-medication used to treat bacterial infections] and add vancomycin [medication used to treat bacterial infections] for broad spectrum coverage [effective against a wide range of germs]. Patient was also hypoxic [having too little oxygen-normal range is 95% to 100%] (SpO2 70s on [non-rebreather mask (NRB-a device used to assist in the delivery of oxygen]). Asked [respiratory therapist] to place patient on NRB and [high-flow nasal cannula (HFNC-an oxygen supply system capable of delivering up to 100% humidified [to warm and moisten the oxygen being inhaled by the patient] and heated oxygen at a flow rate of up to 60 liters per minute)]. Will also order another bolus of [sodium chloride 0.9%] 1 [liter (L-a unit measure of volume)] and repeat the lactate..."

During a record review on 4/3/23 at 3:20 p.m. with the EDM, Pt 2's EMR, dated 3/13/24 was reviewed. The EDM stated the EMR indicated, at 10:16 p.m. MD 6 documented a physician note under Significant Event, "I was notified by RN that patient became pulseless. I examined patient at bedside. Patient's daughter was also present in the room. There were no breath or heart sounds on exam. Pulses absent. Pupil dilated and non-reactive to light. Patient was pronounced at 10:14 PM."

During a review of Pt 2's "Discharge Summary Note (Note)," dated 3/14/24, the Note indicated, " ...Findings and Hospital events leading to death: Patient was loaded with IV pantoprazole and started on pantoprazole drip. Serial hemogram [every] 6 [hour] was ordered. Patient was given additional normal saline [times] 1L. Chest xray was ordered and resulted left lower lobe consolidation. Lactic acid returned 4.2. Patient then developed fever; all findings concerning for aspiration pneumonia with sepsis. Patient had received 20 [milliliters (mL-one thousand mLs equal one liter)/kilogram (kg-a unit of measurement)] fluid bolus per sepsis guidelines and continued with normal saline infusion. Initial repeat vitals showed improvement. [urinalysis] was pending. Blood cultures were drawn. Patient was ordered piperacillin/tazobactam to cover both aspiration pneumonia and possible [extended spectrum beta-lactamase (ESBL-germs cannot be killed by many of the antibiotics used to treat infections)] [urinary tract infection (UTI)] related to chronic foley; noted allergy to amoxicillin with diarrhea but considered benefits of outweighing risks. Repeat hemogram and lactic acid were pending. Patient was waiting for [esophagogastroduodenoscopy (EGD-a medical procedure which allows doctors to inspect and observe the inside of the body without performing major surgery)] ...This morning, upon knowledge of patient's expiration, I called patient's family and spoke with patient's daughter and answered all her questions ...Presumed cause of death: Acute respiratory failure with hypoxemia (hours) Aspiration pneumonia (hours) Severe sepsis (hours) Upper GI bleed (days) ...Coroner Notification: no ...Coroners Case: no ...Autopsy Ordered: no ..."

During a telephone interview on 4/4/24 at 3:14 p.m. with MD 4, present during the interview were VPQ and MD 3, MD 4 stated he remembered Pt 2. MD 4 stated typical orders for a patient who presented with hematemesis included CBC, Chem 10, hemoglobin, platelets to determine the patient's hemodynamic stability (indicates a patient has a stable pumping heart and a good circulation of blood). MD 4 stated Pt 2 presented with hematemesis and a history of atrial fibrillation (A Fib) and an EKG (electrocardiogram- test used to record the hearts electrical activity) should be ordered for patients with this history. MD 4 stated the patient should be monitored based on their presentation and vital signs. MD 4 stated all the labs in the ED was ordered STAT labs (labs should be drawn within an hour or less). MD 4 stated his expectations for labs to be drawn was within a couple hours of the physician order and drawn within the first few hours of the patient's arrival to the ED. MD 4 stated the importance of timely lab draws was once they were ordered; the physician determined the patient's management based on the lab results. MD 4 stated the frequency of the hemogram reassessments would depend on the first results. MD 3 stated he reviewed Pt 2's ED visit thoroughly and there were no physician orders for imaging or EKG for Pt 2 while he was an ED patient. MD 4 stated he worked 10-hour shifts and at the end of his shift he would give report to the oncoming physician and if the patient had active orders pending, the oncoming physician followed up on the pending active orders or if the patient was admitted, he turned over the patient's care to the hospitalist. MD 4 stated for Pt 2 he reported to the hospitalist over the phone. MD 4 stated when the hospitalist put in the admit orders for Pt 2, the hospitalist took over care of the patient.

During a review of Pt 2's "ED Provider Note (Note)," dated 3/13/24, the Note indicated at 8:36 a.m., "Considered CT abdomen, however no abdominal pain on exam and patient had a CT abdomen on 3/4/24 that was unremarkable."

During a concurrent interview and record review on 4/5/24 at 8:22 a.m., with RN 6, present during the interview were RN 7, Clinical Nurse Educator (CNE), and EDM, Pt 2's "EMR", dated 3/13/24 was reviewed. RN 6 stated she was assigned Pt 2 about an hour prior to shift change and was aware Pt 2 presented with hematemesis. RN 6 stated Pt 2 had orders for ondansetron (medication used to prevent nausea and vomiting) and pantoprazole ( medication used to treat heartburn) by way of intravenous (IV) but Pt 2 did not have an IV access. RN 6 stated she tried to do an IV cannulation (is a technique in which a cannula [a small plastic tube inserted into vein] is placed inside a vein to provide a venous access) a few times but was unsuccessful and asked another RN to assist her with Pt 2's IV insertion, which was successful. RN 6 stated she was then able to administer both medications. RN 6 stated Pt 2 responded to her when she asked him questions and she remembered he was a hard stick for the IV insertion and was quadriplegic (partial or complete paralysis of both the arms and legs) . RN 6 stated Pt 2 was alone and did not have any family at bedside. RN 6 stated Pt 2 was assigned to YY-02, which was a hallway bed in the yellow zone (not urgent area of the ED). EDM stated YY-02 was located in a hallway and they were no longer using the hall space for patient assignments as of 3/14/24. RN 6 stated the charge nurse or clinical supervisor assigned the patients their ED space/room assignment. The EMR indicated at 6:03 a.m. RN 6 assigned herself as Pt 2's RN and a Fall Risk Intervention indicated, "Place patient in highly visible area." RN 6 stated the area Pt 2 was assigned was not hig