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Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA when:

1. The hospital failed to ensure an emergency medical condition (EMC) and stabilizing measures were provided prior to discharge for three of 24 Patients (Patient 1, Patient 7, and Patient 8) (Refer A2407)

2. The hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) for one of 24 sampled patients (Patient 10). (Refer to A2406)

Because of the potential serious harm to Patient 1 and Patient 7, and all pediatric patients in Hospital A who had an Emergency Medical Condition (EMC) and not provided an appropriate Medical Screening Exam (MSE) and stabilizing measures, an Immediate Jeopardy (IJ) situation was called for CFR 489.24 (b)(d)(1)(i) A2407 on 4/26/24 at 4:30 p.m., with the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Interim Chief Nursing Officer (ICNO), Director of Quality (DQ), Patient Safety Officer (PSO), and Associate Administrator (AA) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 4/29/24 at 9:46 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Primary care physician (PCP) referrals and chief complaints must be clarified with the PCP and/ or patient designated responsible person(s), 2) The QMP always conducts an appropriate MSE that includes a complete set of vital signs for pediatric patients and determine stabilizing measures when an EMC is identified, 3) Parent(s) of pediatric patients are provided a clear explanation of services available to treat and stabilize an EMC 4) All patients in psychiatric crises are properly placed and receive an appropriate psychiatric evaluation to ensure the safety of the patient, staff, visitors, and community 5) Proper follow up is provided for all patients who leave the ED with an identified EMC or in psychiatric crises which includes proper notification to the QMP, patient designated responsible person(s), and/ or local police department. On 4/9/24, the components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/29/2024 at 1:20 p.m. with the CEO, Group Chief Nursing Officer (GCNO), AA, ICNO, DQ, and PSO. Following the IJ removal, the facility remained in substantial non-compliance.

The cumulative effect of these systemic failures resulted in the inability of the hospital to provide care in a safe and quality manner in the Emergency Department and was not in compliance with the statutory requirement of EMTALA.

Based on interview and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) for one of 24 sampled patients (Patient 10) when Patient 10 was brought in by ambulance (BIBA) on a 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness for up to 72-hours) psychiatric hold for a danger to self and her chief complaint of a psychiatric hold was never evaluated by a QMP before she was transferred from the hospital to another facility.

This failure resulted in Patient 10 not receiving an appropriate MSE by QMP, and placed Patient 10 in danger of self-harm. The hospital failed to determine whether an emergency psychiatric condition existed for Patient 10 and did not initiate measures to ensure Patient 10's safety prior to being transferred.

Findings:

During a review of Patient 10's "Welfare and Institutions Code section 5150 (WIC)" dated 2/7/24, the WIC indicated, Patient 10 was placed on a 5150 hold on 2/7/24 at 10:48 a.m. for danger to self.

During a review of Patient 10's "ED Note Physician- Final Report (FR)", the FR indicated, " ...Chief Complaint: BIBA 5150 hold ... History of Present Illness: 64-year-old female BIBA on 5150 hold after being seen at her counseling clinic. Per Emergency Medical Services (EMS) report, patient fell from her wheelchair at the appointment and proceeded to hit herself, becoming hysterical uncooperative and verbally abusive ... she does not give further history due to being uncooperative ... Physical Exam: ... General: Alert, no acute distress ...Psychiatric: Appropriate mood and affect ... Medical Decision Making: Patient at this point is deemed medically stable for psychiatric evaluation ... Impression/Plan: suicidal ideation, depression and agitation ... Consultation: behavioral health consultation ...".

During a concurrent interview and record review on 4/24/24 at 10 a.m., with the Interim ED Clinical Manager (EDCM), Patient 10's entire Electronic Medical Record (EMR) dated 2/7/24 was reviewed. The EMR indicated, Patient 10 came in on a 5150 hold from a community clinic. The EDCM stated Patient 10 was calmed down, per a Licensed Vocational Nurse (LVN) note, by verbal de-escalation once in the ED room. The EDCM stated Patient 10 was medically cleared (no physical issues causing the psychiatric behavior) by an ED physician and the patient was ready to be evaluated psychiatrically. The EDCM stated Patient 10 did not have insurance in Stanislaus County and could have been transferred to a local psychiatric hospital. The EDCM stated when this happened, the ED unit secretary contacted Community Emergency Services Response Team (CERT- an outside program through Stanislaus County that delivers behavioral health services). The EDCM stated the CERT program was sent all of Patient 10's medical records via fax and they "acted like" a social worker to find mental health placement for the patient. The EDCM stated the CERT program does come to the hospital and does mental health evaluations in the ED with the ability to place 5150's or remove them; however, in this case they only found placement for the patient and never did a psychiatric evaluation to potentially clear the 5150. The EDCM stated the CERT program found placement at a [name of the Psychiatric Health Facility](16 bed inpatient acute psych hospital) in [location of the facility] and a physician at the psychiatric facility accepted the patient via the CERT program. The EDCM stated, transfer documentation was signed (by patient and ED physician- deemed stable) and the ED nurse gave report to the nurse at that psychiatric facility. The EDCM stated the patient was transported via ambulance to that facility.

On 4/24/24 at 10:10 a.m., the LVN note when LVN calmed Patient 10 verbally was requested but not provided.

On 4/24/24 at 10:35 a.m., CERT transfer policy and/or contract was requested and but not provided. During an interview on 4/25/24 at 9:30 a.m., with Emergency Medicine Physician (EMP) 1, the EMP 1 stated he was the EMP who examined Patient 10 and cleared her medically. EMP 1 stated Patient 10 came in on a 5150 but was calmed by a staff member. EMP 1 stated he ordered [Brand name]Intramuscular (IM) injection, but it was never administered because Patient 10 was calm and had appropriate mood and affect on physical exam. The EMP 1 stated he was not qualified to evaluate the patient's 5150 status. The EMP 1 stated he could not place a 5150 or remove a 5150 hold. The EMP 1 stated he believed he "corroborated (to make certain or confirm) the 5150" by his physical exam having a psychiatric component and providing a psychiatric diagnosis. EMP 1 stated a specific exam for the patient's mental status in relation to the 5150 would have been "redundant". The EMP 1 stated the hospital does not employ or have a contract with any Psychiatrist, Psychologist or Mental Health Clinician that would be able to do a full psychiatric evaluation. The EMP 1 stated he never spoke to the receiving mental health hospital physician and said that is the "common practice".

During an interview on 4/26/24 at 11:10 p.m. with the Chief Executive Officer (CEO), the CEO stated to his understanding the CERT team was to complete a "purely psychiatric" evaluation after the patient was medically stable. The CEO stated medically stable meant there was no medical reason, such as an infection or electrolyte (minerals in your blood and other body fluids that carry an electric charge that affect how your body functions) abnormality that had caused the patient to be psychiatrically unstable. The CEO stated CERT was supposed to complete their evaluation before the patient was placed into another facility. The CEO stated the hospital responsibility was to reach out to CERT and defer to their expertise (high level of skill or knowledge).

During a review of the facility's policy and procedure (P&P) titled, "Management and Transfer of Acutely Psychotic, Aggressive, or Potentially Violent Patients in the ED", dated 2/14/23, indicated, " I. POLICY: patients who are potentially dangerous to themselves and/or others will receive careful consideration of both physical and psychological needs. EMC staff will make every attempt to maintain patient rights while providing for the safety of all patients and staff ... PURPOSE: To provide medical evaluation while preventing injury and ensuring safety to all patients and staff ... IV. INTERFACILITY TRANSFER TO A MENTAL HEALTH FACILITY: ... 2. Review the patient's Facesheet to determine whether the patient should be referred for services with the CERT ... a. CERT Transfer Process: 1. Phone the access line at (telephone number) to initiate mobile mental health evaluation. 2. Once placement is arranged by CERT, arrange transport with EMS ...".

Based on interview and record review, the hospital failed to ensure an appropriate Medical Screening Exam (MSE) and stabilizing measures were provided for three of 24 Patients (Patient 1, Patient 7, and Patient 8) when:

1. Patient (Pt) 1, a pediatric patient, was sent by her primary care physician (PCP) to Hospital A's emergency department (ED) on 2/21/24 at 12:30 p.m. with a chief complaint of physician reported hemoglobin (Hgb- protein in blood that carries oxygen to vital organs) level 5.5 and pallor (skin paleness). No diagnostic or laboratory studies were conducted for Pt 1 to determine the need for stabilizing measures for the abnormally low hemoglobin in a pediatric-age patient. Pt 1's blood pressure (BP) was not evaluated to determine whether additional stabilizing measures were needed. before Pt 1 was discharged to home on 2/21/24 at 1:14 p.m. from the ED. After Pt 1's discharge from Hospital A, Pt 1 was transported by family 79 miles in a private vehicle to Hospital B seeking emergent care. Pt 1 arrived at Hospital B, on 2/21/24 at 4:36 p.m., tachycardic (abnormally fast heartbeat) and pale. Labs drawn at Hospital B indicated Pt 1's Hgb level was 5.4. Pt 1 was given a blood transfusion (blood is put into the bloodstream) on 2/21/24, in Hospital B's ED and Pt 1's clinical status was stabilized.

This failure resulted in Pt 1 being discharged home from Hospital A with abnormally low Hgb levels and the EMC was not stabilized prior to discharge; and had the potential to cause injury, harm and/or stroke in Patient 1, a pediatric patient.

2. Patient 7 was brought in by ambulance to the ED on 3/16/24 at 4:18 a.m. with a chief complaint of head pain and hearing voices. Pt 7's family reported Pt 7's recent behavioral changes along with a history of underlying mental health problems. Pt 7's triage (a process used to prioritize who needs emergency medical attention first) assessment identified a behavioral health concern (thoughts of hurting people) and was given an emergency severity index (ESI- tool used to prioritize care) score of "2", emergent. The hospital's behavioral health screening tool indicated further screening by a qualified medical professional (QMP) was warranted. Evaluation of Pt 7's emergent psychiatric condition was not completed. Pt 7 was inappropriately placed in the ED waiting room where he later eloped (unsupervised/ undetected departure) on 3/16/24 from the ED. Pt 7 was called for care on 3/16/24 at 6:10 a.m., 8:31a.m., and 8:50 a.m. with no response from Pt 7. There was no documented evidence in Pt 7's electronic medical record (EMR) that indicated Pt 7's emergency contact, family, or local police department were contacted.

This failure resulted in Pt 7's emergent psychiatric problem not being stabilized and had the potential to worsen, lead to injury, harm, or death for Pt 7 and others who have a psychiatric emergency.

3. Patient 8 came to the ED via car on 3/21/24 for chief complaints of hyperglycemia (high blood sugar) and dizziness, where he received labs; results were abnormal, and patient left without being aware of those results. Patient 8 was not provided stabilizing treatment for the EMC and no Nurse, Physician nor staff member attempted to contact Pt 8, or the emergency contact after leaving the ED.

This failure resulted in Pt 8's blood glucose not being stabilized and had the potential for Pt 8's condition to worsen, lead to injury, harm, or death.

Because of the potential serious harm to Patient 1 and Patient 7, and all pediatric patients in Hospital A who had an Emergency Medical Condition (EMC) and not provided an appropriate Medical Screening Exam (MSE) and stabilizing measures, an Immediate Jeopardy (IJ) situation was called for CFR 489.24 (b)(d)(1)(i) A2407 on 4/26/24 at 4:30 p.m., with the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Interim Chief Nursing Officer (ICNO), Director of Quality (DQ), Patient Safety Officer (PSO), and Associate Administrator (AA) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 4/29/24 at 9:46 a.m. The IJ Plan of Removal included but was not limited to the following: 1) Primary care physician (PCP) referrals and chief complaints must be clarified with the PCP and/ or patient designated responsible person(s), 2) The QMP always conducts an appropriate MSE that includes a complete set of vital signs for pediatric patients and determine stabilizing measures when an EMC is identified, 3) Parent(s) of pediatric patients are provided a clear explanation of services available to treat and stabilize an EMC 4) All patients in psychiatric crises are properly placed and receive an appropriate psychiatric evaluation to ensure the safety of the patient, staff, visitors, and community 5) Proper follow up is provided for all patients who leave the ED with an identified EMC or in psychiatric crises which includes proper notification to the QMP, patient designated responsible person(s), and/ or local police department. On 4/9/24, the components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/29/2024 at 1:20 p.m. with the CEO, Group Chief Nursing Officer (GCNO), AA, ICNO, DQ, and PSO. Following the IJ removal, the facility remained in substantial non-compliance.

Findings:

1. During an interview on 4/18/24 at 1:15 p.m., with Pt 1's parent (P1P), P1P stated Pt 1 had a history of severe iron deficiency anemia (iron level in blood drops too low to support normal red blood cell production). Pt 1 was not tolerating iron supplements and her Hgb levels were trending downward over the last "several months." P1P stated Pt 1 was evaluated by her PCP on 2/21/24 and was told Pt 1 had "very low Hgb." Pt 1 was sent by the PCP to Hospital A ED for "immediate treatment" on 2/21/24, after the PCP visit. P1P stated she provided Pt 1's history and Hgb results (5.5) to "the nurse" and explained that Pt 1's behavior was different; Pt 1 looked "discolored or pale" and was "very tired." P1P stated she provided to the ED Physician (MD 2) Pt 1's Hgb results and asked if Pt 1 required a blood transfusion. P1P stated MD 2 told her that Pt 1's condition was not urgent, and the anemia could be managed as an outpatient. P1P stated she was told that results obtained from PCP clinics were inaccurate and Hospital A ED did not provide "transfusions." P1P stated she explained to MD 2 that Pt 1's Hgb level was 5.5 and that Pt 1 was referred by her PCP to the ED for a "blood" transfusion. P1P stated MD 2 offered to draw labs but the hospital would not "transfuse" Pt 1. P1P stated she refused the labs and told MD 2 she would have Pt 1 evaluated at Hospital B. Pt 1 was discharged to home on 2/21/24, from Hospital A. P1P stated she called Pt 1's PCP after discharge and the PCP referred Pt 1 to Hospital B the same day. P1P stated on 2/21/24, she drove Pt 1 to Hospital B, "an approximate one to two hour" commute from Hospital A. P1P stated Hospital B found Pt 1 to be anemic (not enough red blood cells to carry oxygen to body tissues) and was given a blood transfusion in the ED. P1P stated she made two attempts to contact Hospital A's ED Director to inquire why Pt 1's condition was not treated on 2/21/24, but stated she never received a return call from Hospital A.

During a review of Pt 1's "ED Provider Notes" obtained from Hospital B, dated 2/21/24 at 4:36 p.m., indicated, " ... Patient information was obtained from parent... Patient has history of iron deficiency anemia diagnosed on outpatient labs about eight months ago 6/2023 hemoglobin 8.5, as low as 6.9 a few months ago but today 5.5 at PCP office... Per mother she [Pt 1] has been more pale, fatigued/tired, no vomiting, no fevers ... has not been seen by hematology [a branch of medicine that studies blood and blood disorders] in clinic yet, no referral made yet... BP ... 106/46... Pulse [HR- heart rate] ...94... Temp [T- temperature] ... 97° F [Fahrenheit]... Resp [RR- respirations] ... 24... SpO2 [oxygen saturation] ... 98%... Well appearing, and no acute distress... Awake, alert, interactive... Repeat labs here show isolated microcytic anemia [red blood cells smaller than usual, probably due to not enough iron] with low iron studies... iron deficiency anemia. Will discuss with hematology... is symptomatic with tachycardia, fatigue [tiredness], pallor [paleness]... HGB 5.4... Hospitalist and hematologist OK with transfusion in ED... clinical impressions: Severe anemia..."

During a review of Pt 1's "Care Timeline" obtained from Hospital B, dated 2/21/24, indicated, " ... 1636 [4:36 pm]... Arrived...1741 [5:41 pm] ... Comprehensive metabolic panel [a routine blood test that measures 14 different substances found in blood] (Abnormal [not normal])... LDH, lactate dehydrogenase [blood test to check for tissue damage] (Abnormal)... type and screen [a set of tests that looks for harmful interactions between your blood and donor blood]... CBC and differential [blood test that measures components of blood] (Abnormal) ... Iron Panel- Iron + Transfusion + TIBC [total iron binding capacity] + Ferritin [protein found in blood that stores iron] (Abnormal) ... 2336 [11:36 pm] ... Transfuse Red Blood Cells (in mL up to 200 mL's): 64mL ... 02/22 0141 [1:41 am] ... Transfuse Red Blood Cells (in mL up to 200 mL's): 64mL ..."

During a concurrent interview and record review on 4/23/24 at 12:30 p.m., with the Interim ED Clinical Manager (EDCM), Pt 1's electronic medical record (EMR) was reviewed. The "ED Note- Physician (EN-P)" dated 2/21/24, indicated Pt 1 was a pediatric patient with a history of iron deficiency anemia who was referred to the ED by an urgent care clinic; brought in by parents for evaluation of anemia with 5.5 Hgb level and requesting an iron infusion. The record indicated Pt 1's family noted that the patient was pale, otherwise acting normally. Pt 1 was triaged at 1:14 p.m. and Emergency Severity Index (ESI) of "3" was assigned. Pt 1's vital signs (BP, HR, RR, T, and SpO2) at triage, were HR 130, RR 24, T 36.4 C (degrees Celsius) (37.5 degrees F), and SpO2 98%. No BP for Pt 1 was documented. Lab orders were placed on 2/21/24 at 1:26 p.m., for CBC, basic metabolic panel (BMP- blood test that measures fluid balance and electrolytes), iron level, transferrin (protein in blood the plays a role in iron metabolism), ferritin, iron binding (TIBC), and type and cross (type and screen), then cancelled on 2/21/24 at 2:01 p.m.
Pt 1 was discharged to home on 2/21/24 at 1:58 p.m. with instructions to seek referral to pediatric hematologist (internal medicine doctors or pediatricians who have extra training in disorders related to blood) and iron infusion appointment. The EDCM stated based on the clinical presentation, Pt 1 "appeared stable" for discharge. The EDCM stated there was no way to prove Pt 1 had an actual 5.5 Hgb level because labs were cancelled and not drawn. The EDCM acknowledged Pt 1's BP was not evaluated. The EDCM stated it was not the ED's practice to obtain BPs on pediatric patients.

During a concurrent interview and record review on 4/24/24 at 10:10 a.m., with Emergency Physician (MD 2), Pt 1's medical record was reviewed. MD 2 stated on 2/21/24 at 1:21 p.m., she evaluated Pt 1 in Hospital A ED. MD 2 stated the "EN-P" indicated Pt 1 was a pediatric patient that presented to the ED on 2/21/24, with a Hgb 5.5 and family was requesting an iron infusion. MD 2 stated she could not recall if Pt 1's family provided a prescription or if the family verbally reported the Hgb value. MD 2 stated she informed Pt 1's family that iron infusions were not given in the ED. MD 2 stated she "offered" to have labs drawn but Pt 1's family refused. MD 2 stated Pt 1 was awake, alert, and showed no signs of distress. Pt 1's family reported Pt 1 was pale, but "my documented assessment did not indicate such." MD 2 stated pediatric patients could not always express what bothered them and she relied heavily on family to reporting. However, based on her assessment documented in the "EN-P" , Pt 1 was interactive, appropriate, and "looked stable" despite Pt 1's family reporting patient was pale and fatigued. MD 2 stated Pt 1 had a history of chronic (persistent) anemia which could be managed outpatient. MD 2 stated Pt 1's vital signs were stable, and Pt 1 did not display symptoms of blood loss or distress. MD 2 stated Pt 1 was stable to be discharged home. MD 2 stated she did not need to evaluate Pt 1's BP. MD 2 stated hospital practice was not to take blood pressures on pediatric patients. MD 2 stated Pt 1's EMC did not warrant a consult with the pediatric hospitalist on call. MD 2 stated she could not recall if Pt 1's family requested a blood or iron transfusion, but based on her documentation it appeared Pt 1's family requested an iron transfusion. MD 2 stated she did not attempt to clarify this with Pt 1's referring physician because Pt 1 "came from urgent care and when you call over there, you usually can't get ahold of the person that sent them to the ED."

During a concurrent interview and record review on 4/24/24 at 10:25 a.m., with the Director of Emergency Services (DES) and PSO, Pt 1's EMR was reviewed. The DES stated the EMR indicated Pt 1 came from urgent care for an iron transfusion. Pt 1 was assigned an ESI of 3 which was "appropriate- not urgent." The DES stated Pt 1's vital signs were stable, and Pt 1 presented with no active signs of bleeding or any other clinical symptoms other than the family stating Pt 1's Hgb was 5.5. The DES stated Pt 1's Hgb level "may have changed" and since lab work was refused, MD 2 could not validate the family reported Hgb level. The DES stated, "Can't just go off of what is verbally reported." The DES stated the ED did not perform iron transfusions and Pt 1 was appropriate for outpatient services. The DES stated Pt 1 was alert and interactive and vital signs were "normal" for her age. The DES stated a BP reading was not needed to determine if Pt 1 was stable for discharge. The DES stated hospital practice was not to take BPs on pediatric patients unless there was a clinical indication, according to Emergency Nurses Association (ENA- a professional organization that provides education and publishes professional guidelines for emergency nurses) professional standards for patients less than 10 years old. The DES stated Pt 1 " appeared" healthy and was sent home with education on anemia and instructions to follow up with her PCP.

During a concurrent interview and record review on 4/25/24 at 2:35 p.m., with Hospital A's Pediatric Hospitalist (MD 3), MD 3 reviewed Pt 1's medical record and a second record used as a comparison of care provided to pediatric patients of similar ages and chief complaint. MD 3 stated Pt 1 presented to the ED with a physician reported Hgb level of 5.5 which was half of what a normal Hgb level was for a child her age. MD 3 stated she considered 10 to 10.5 a "normal" Hgb for Pt 1. MD 3 stated Pt 1 had a history of chronic anemia and pallor would be an expected symptom. However, if Pt 1 experienced other symptoms in addition to pallor such as fatigue, low blood pressure, and tachycardia, then Pt 1 should have been looked at more closely because "most likely" Pt 1 required some type of intervention or blood transfusion. MD 3 stated a pediatric patient cannot always report or describe their symptoms. MD 3 stated Pt 1's parent declined lab work but "I would have pushed for it." MD 3 stated she was surprised to hear that Pt 1's BP was not taken on 2/21/24, when Pt 1 presented to the ED with the low Hgb level. MD 3 stated, "Not sure what the practice of this ED is, but report of Hgb 5.5, BP should have been taken." MD 3 stated the American Academy of Pediatrics (AAP- largest professional association of pediatricians in the United States) recommended to start taking BP readings on children at 2 years of age. MD 3 reviewed the PCP's "After Visit Summary (AVS)" note, dated 2/21/24 at 11:30 a.m., that was presented to the ED by Pt 1's parent. MD 3 stated the "AVS" note indicated Pt 1 was not tolerating oral iron, Hgb had been dropping, and Pt 1's HR was148 during the PCP visit. MD 3 stated based on this note, hematology should have been contacted, regardless of whether labs were collected or the ED's inability to provide an iron infusion. MD 3 stated for pediatric patients of Pt 1's age, ED physicians should consult hematology or pediatrics for Hgb levels less than 6. MD 3 stated pediatric patients of Pt 1's age with severe anemia and Hgb "that low" are at risk for stroke (a loss of blood flow to part of the brain, which damages brain tissue). MD 3 stated it would have been prudent to consult with a hematologist prior to discharging Pt 1. MD 3 then reviewed Pt 2's medical record (comparison record). MD 3 stated Pt 2 was the same age as Pt 1 and presented to the ED with similar symptoms (low Hgb, pallor, and fatigue). MD 3 stated the medical care provided to the Pt 2 was "more appropriate."

During review of Pt 2's "EN-P" dated 2/7/24 at 7:43 p.m., the "EN-P" indicated, " ... CHIEF COMPLAINT: Mother states seen by PMP [primary medical physician] for blood work was called and told to be seen due to low HGB ... pt is pale hurts to walk and fatigues easily ... sent for possible anemia ..."

During review of Pt 2's "EN-P" dated 2/7/24 at 7:43 p.m., the "EN-P" indicated Pt 2's vital signs taken on 2/7/24 at 8:46 p.m. were T 36.7degC (98.1 degrees F), HR 137, RR 26, BP 106/55, and spO2 100%. Pt 2's BP was obtained during triage, physical re-evaluations, and upon discharge.

During review of Pt 2's "EN-P" dated 2/7/24 at 7:43 p.m., the "EN-P" indicated laboratory and diagnostic testing were collected on 2/7/23 at 9:27 p.m., as part of Pt 2's medical screening exam. A CBC with differential (CBC with number of each type of white blood cell), Chem Panel (CMP- includes the same eight tests as a BMP, plus six more tests), Ammonia level (measures the amount of ammonia (NH3) in blood), TSH (test to diagnose a thyroid [gland that releases hormones] disorder), folate study (measure the concentration of folate [Vitamin B9] and vitamin B12) procalcitonin (measures a hormone specific for bacterial infections), B12 level (measures vitamin in blood), venous blood gases (measures oxygen and carbon dioxide in blood), coagulation studies (measures the ability of blood to clot), PT/ INR (measures how long blood takes to clot), fibrinogen (protein that helps blood to clot), D-dimer (checks for blood clotting problems), type and screen, hepatitis panel (checks for liver infections), ethanol level (a metabolite [a substance made or used when the body breaks down food, drugs, or own tissue] in blood) used when the body, chest x-ray (imaging test to look at structures of the chest), and ultrasound (imaging test that uses sound waves) of the abdomen were obtained as part of Pt 2's ongoing examination and evaluations. Pt 2 was transferred via ambulance on 2/8/24 at 1:15 a.m., to Hospital B in stable condition.

During an interview on 4/26/24 at 9:49 a.m., with ED Licensed Vocational Nurse (LVN) 2, LVN 2 stated his role in the ED was to assist registered nurses with patient management by medicating patients within his scope as an LVN, checking vital signs, and discharging patients. LVN 2 stated a complete set of vital signs included BP, HR, RR, T, and SpO2. LVN 2 stated vital signs were routinely checked in the ED and at discharge to ensure patients were stable during the ED visit and prior to going home. LVN 2 stated it was important to monitor BP because it provided information of how well a patient was perfusing (supply organs and tissues with blood). LVN 2 stated it was not necessary to check the BP of children less than 5 years of age if their "general appearance" was good. LVN 2 stated not checking the BP of children under 5 years was the routine practice in the ED.

During a concurrent interview and record review on 4/26/24 at 10:20 a.m., with ED Registered Nurse (RN) 2, stated a complete set of vital signs included BP, HR, RR, SpO2, and T. RN 2 stated a BP should be checked on all patients, regardless of their age. RN 2 stated it was important to check BP to ensure effective output (volume of blood pumped). RN 2 reviewed Pt 1's medical record and stated on 2/21/24, he triaged Pt 1. RN 2 stated Pt 1 came to the ED to be evaluated for low Hgb. RN 2 acknowledged no BP was documented for Pt 1. RN 2 stated Pt 1's low Hgb warranted a BP to be taken, however Pt 1's behavior was age appropriate, and Pt 1 was "moving, awake, tracking, and not lethargic [fatigue, drowsiness, sleepiness]." RN 2 stated Pt 1 appeared stable .

During an interview on 4/26/24 at 11:10 a.m., with the Chief Executive Officer (CEO) and physician advisor (MD 4), the CEO stated a medical screening exam (MSE) was the ED provider's initial assessment conducted to determine whether or not an EMC existed. The MSE continued until the ED provider determined the patient was stable for discharge. The CEO stated patient stability depended on whether or not the EMC was stabilized, or the patient was transferred to a higher level of care. The CEO stated Pt 1 was not stabilized when discharged on 2/21/24 from the ED. The CEO stated an appropriate MSE and patient stabilization could not have occurred without a complete set of vital signs (BP, HR, T, RR, SpO2). The CEO stated for a pediatric patient with a history of anemia and reported Hgb of 5.5, at minimum he expected a complete set of vital signs and orders for Hgb and hematocrit [volume of red blood cells] blood draw to ensure with certainty that Pt 1 was safe to be discharged home. The CEO stated the expectation was that a complete set of vital signs, including BP, were checked on every patient that came to the ED seeking emergent care and at discharge .

A review of the professional reference from the Journal of Emergency Nursing titled "Pediatric Readiness in the Emergency Department," dated 2018, indicated, " ...This policy statement delineates the recommended resources necessary to prepare emergency departments (EDs) to care for pediatric patients ... These recommendations are intended to apply to all EDs that provide care for children ... the [American Academy of Pediatrics- largest professional association of pediatricians in the United States] AAP released the revised policy statement ... Policies, procedures, and protocols for the emergency care of children are age specific and include neonates, infants, children, adolescents, and children with special health care needs ... These include, but are not limited to, the following ... Documentation of a full set of pediatric vital signs, including core temperature, respiratory rate, pulse oximetry, heart rate, blood pressure (including manual confirmation), pain, and mental status when indicated ... All EDs must be continually prepared to receive, accurately assess, and, at a minimum, stabilize and safely transfer acutely ill or injured children ..."

A review of the professional reference at https://publications.aap.org/pediatriccare/articleabstract/doi/10.1542/aap.ppcqr.396051/1543/Anemia-and-Pallor?redirectedFrom=fulltext titled "AAP Point of Care Quick Reference ... Anemia and Pallor," dated 3/12/24, indicated, " ... Anemia and pallor are clinical manifestations of an underlying disease process... Children younger than five years, women of reproductive age, and those in the older population are the groups who are most vulnerable for anemia... For diagnosis, initial workup will include complete blood cell count with differential, reticulocyte site count ... ferritin... other tests are performed as second tier tests to go further identify the etiology of anemia... early diagnosis and treatment of iron deficiency anemia is important to prevent permanent neurocognitive issues..."

During a review of the "Pediatric Assessment, Recognition, and Stabilization (PEARS) Pediatric Reference Chart," from the American Heart Association [Organization dedicated to fighting heart disease and stroke] and AAP, undated, indicated, " ...Vital Signs in Children ... Normal Heart Rates (beats/min [minute])... Toddler... 98-140... Normal respiratory Rates (breathes/ min)... Toddler... 22-37... Normal Blood Pressure... Toddler (1-2 y [years])... Systolic Pressure [pressure in arteries when heart is contracting]... 86-106... Diastolic Pressure [pressure in arteries when heart is at rest] ... Toddler... 42-63... Primary Assessment... A rapid hands- on ABCDE approach to evaluate respiratory, cardiac [heart], and neurological [brain] function: this step includes assessment of vital signs..."

2. During a concurrent interview and record review on 4/25/24 at 10:40 a.m., with the EDCM, Pt 7's EMR was reviewed. The EMR indicated Pt 7 was brought to the ED on 3/16/24 at 4:18 a.m., via ambulance with chief complaint head pain, hearing voices, chest pain (CP), and shortness of breath. Pt 7 was triaged at 4:33 a.m. and ESI of "2"- critical was assigned. Pt 7's vital signs at triage were BP 138/87, HR 129, RR 20, T 36.6 C (37.9 F), and SpO2 95%. The ED Physician Assistant (PA 2) indicated in the "EN-P" note that Pt 7's medical history included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function) who reported mild chest pain , difficulty breathing, and headache for two weeks. The Columbia- Suicide Severity Rating Scale (suicide risk assessment tool) completed on 3/16/24 at 4:33 a.m. indicated Pt 7 had a "behavioral complaint" and a full suicide screening (SI) assessment by a qualified medical professional (QMP) was indicated. The full SI assessment was not done, and Pt 7 was placed to wait in the ED lobby to wait for further testing. The EDCM stated labs, chest x-ray, and EKG were completed, however Pt 7 eloped from the ED before being evaluated by the ED physician. The EDCM stated the last documented contact with Pt 7 was on 3/16/24 at 5:55 a.m. Pt 7 was called for care on 3/16/24 at 6:10 a.m., 8:31a.m., and 8:50 a.m. with no response. The EDCM stated there was no documented evidence in Pt 7's EMR to indicate Pt 7's emergency contact, family, or local police department were contacted. The EDCM stated patients brought in by ambulance (BIBA) in psychiatric crises were placed in the main ED area so they could be supervised. The EDCM stated Pt 7 was inappropriately placed in the ED which contributed to his elopement. The EDCM stated the record did not indicate why Pt 7 was placed in the lobby to wait, however it was a safety concern.

During review of Pt 7's ambulance run sheet (medical record for ambulance services) document "Ambulance Report," dated 3/16/24, the document indicated, " ... arrived on scene to find a 46 y/o mail who was with his family in his front yard. Upon contact with the pt family reported him returning from walking in the middle of the night and report feeling as if her was being followed by people. His family reported recent behavior changes along with a Hx. [history] of underlying mental health problems. Pt reported a complaint of Asthma, CP/ abdominal pain, dehydration and being tired ... His family reported that they'd like to get him seen for behavioral changes ... Chief Complaint ... psych episode ... History of Present Illness ... Hx. Schizophrenia ..."

During review of Pt 7's "MICN [mobile intensive care nurse] Hospital Report Form" dated 3/16/24 at 4:08 a.m., indicated, " ... Complaint ... Psychiatric episode; CP, abdopain [abdominal pain], asthma [respiratory condition that affects lung airways] ..."

During review of Pt 7'The "ED-N" indicated Pt 7 "had been hearing voices in his head since young and the voices tell him to hurt other people. Pt on psychiatric medications (Brand name) ... I have reviewed the patient's chief complaint... As well as completed a focused, limited exam and determined that he/ she is stable at this time. Labs and medications were ordered, but the patient will require further evaluation by the ED physician. The patient was moved to the waiting room per ED hospital staff protocol and will be given an ED bed upon availability. The patient is aware to notify staff if any symptoms change while waiting, as a patient's status can deteriorate before they are able to receive an ED bed. The ED physician on staff will assume full care of this patient at this point... Electronically Signed [PA 2] 3/16/24 05:46 ... "

During review of Pt 7's "History and Screening" document dated 3/16/24 at 4:33 a.m., indicated, " ... BIBA [Brought in by Ambulance] HEAD PAIN AND HEARING VOICES ..."

During a concurrent interview and record review on 4/24/24 at 10:25 a.m., with the Director of Emergency Services (DES) and PSO, the DES described the process for the flow of patients through the ED. The DES stated patients BIBA were triaged in the back between the main ED hallway and rapid patient management (RPM) area where a triage nurse entered the patients' chief complaints and pertinent information. The triage nurse then assigned an ESI score 1-5 depending on patient acuity and patients were placed in different areas of the ED based on their needs and priority (ESI). The DES stated patients assigned ESI scores 1 or 2 were assessed as "critical or very ill" and per ED protocol, placed in the main ED rooms in the back. The DES stated all patients in psychiatric crises were assigned ESI 2 and placed in the main ED for supervision and safety.

During concurrent interview and record review on 4/28/24 at 3:54 p.m., with PA 2, PA 2 reviewed Pt 7's medical record. PA 2 stated she recalled evaluating Pt 7 on 3/16/24, in the ED. PA 2 stated during the MSE, Pt 7 indicated he was short of breath with mild CP for which she ordered labs, an EKG, and chest x-ray. PA 2 stated Pt 7 did not exhibit suicidal/ homicidal behaviors during his examination. PA 2 stated he had a history of "hearing voices to hurt others" but was on appropriate medications that treated psychiatric illness. PA 2 stated it was not communicated to her that Pt 7 exhibited psychiatric symptoms prior his arrival to the ED. PA 2 reviewed the ambulance run sheet for Pt 7's visit to the ED on 3/16/24. PA 2 stated "this is very concerning." PA 2 stated it was apparent Pt 7 had a psychiatric medical emergency that she did not identify during her MSE. PA 2 stated "many times EMS does not report" and often times there were huge disparities between how patients presented to the ED and what was reported. PA 2 stated she would have changed her assessment if she had the information listed in the run sheet beforehand. PA 2 stated she was aware of Pt 7's responses in Columbia Suicide Severity Rating Scale (CSS-R , screening tool used to identify and assess individuals at risk for suicide) but did not follow up with Pt 7 after he was triaged. PA 2 stated she assumed Pt 7 "got care" because he fell off her provider screen. PA 2 stated Pt 7 was appropriately assigned an ESI 2 but could not recall why Pt 7 was placed in the ED main lobby. PA 2 stated she was not made aware that Pt 2 eloped on 3/16/24 from the hospital prior to being seen by the ED physician and stabilized for his psychiatric emergency. PA 2 stated Pt 7's condition could have worsened and was at risk for harm to self or others.

3. During a review of Patient 8's "Discharge Summary (DS)" dated 3/21/24, the DS indicated Patient 8's, " ...Visit Reason: Hyperglycemia (there's too much sugar (glucose) in your blood. It's also called high blood sugar or high blood glucose) - symptomatic; Dizziness, feeling tired, heart patient ... Arrival time: 8:58 a.m. Emergency Department (ED) Discharge Time: 11:36 a.m. ... Chief Complaint: c/o hyperglycemia throughout the night, cannot get it down and complaint of dizziness ... Major Tests and Procedures: ... Urine Screen ... Blood- Stat Collect (immediately) ... Emergency Department (ED) EKG- Stat ...".

During a review of Patient 8's "ED Discharge Form (EDF)", dated 3/21/24, the EDF indicated, " ... (Hospital Name) Disposition: ED Disposition: Eloped ... 3/21/24 11:34 a.m. ...".

During a review of Patient 8's "Flowsheet Laboratory (FL)", dated 3/21/24, the FL indicated, " ...Routine Chemistry: Sodium level 134 (L- low) ... Glucose Level 360 (H- high) ... Blood Urea Nitrogen (BUN- lab result in relation to kidney function) 31 (H) Creatinine level 1.73 (H- lab result in relatio