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Based on observation, interview and record review, the hospital failed to comply with EMTALA regulations at CFR 489.24(b) and CFR 489.24 when:

1. Hospital A did not provide an appropriate medical screen examination (MSE, an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether or not an emergency medical condition [EMC] exists) within the capability and capacity of the hospital's emergency department for two of 20 patients, Pt 1 and Pt 5.
a. Pt 1 was brought in by ambulance with head trauma and other injuries as result of domestic violence and the hospital did not conduct appropriate triage and prioritization and medical screen exam and ensure the safety of Pt 1 upon arrival. Pt 1 was witnessed to leave the ED by hospital staff and no efforts were made to follow up with Pt 1. Pt 1 subsequently suffered an avoidable accident of motorcycle vs pedestrian and was hospitalized at a local hospital for traumatic wounds. (refer to A2406, finding 1)
b. Pt 5, a 36-year-old male, presented to the Emergency Department with suicidal ideation and eloped five minutes later. Pt 5 chief complaint was ' Danger to Self ', and was observed by an Emergency Department [ED] tech running out of the hospital. The QMP was not notified, and the hospital did not initiate follow-up actions such as a welfare check or notification to law enforcement in accordance with hospital policy. No medical screening exam was done or attempted. (refer to A2406, finding 2)

Because of the serious actual harm to Pt 1 and potential harm to Pt 5 resulting from not performing an appropriate MSE, determining whether an EMC existed and not providing stabilizing measures, an Immediate Jeopardy (IJ) situation was called under CFR 489.24(a), A2406, at 12:50 p.m. on 10/29/24 with the Chief Medical Officer, Chief Nursing Executive, and the Director of Accreditation and Regulatory. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 11/01/24. The IJ Plan of Removal included but was not limited to the following: 1. Staff contact local PD when a patient elopes and is a danger to self or others, is altered/confused, or a victim of abuse/assault. 2.Staff prioritize room assignments for victims of abuse/assault. 3. RNs appropriately assign ESI level. 4. Abuse screening and CSSRS (suicide risk) screen for all patients 5. 24/7 security was stationed at the ED EMS entrance mitigating risk of patients who are a danger to themselves or others (i.e. altered, confused) from eloping, On 11/1/24 the components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 11/1/24 at 4:10 p.m. with the Director of of Accreditation and Regulatory and the Associate Chief Nursing Executive.

2. The hospital failed to provide stabilizing measures for identified emergency medical conditions (EMC) within the capability and capacity of the hospital for 4 of 20 patients (Pt 2, Pt 3, Pt 6, and Pt 19).
a. Pt 2 arrived with her son to the hospital emergency department (ED) following a police report of physical assault of domestic violence. Pt 2 had traumatic injuries including neck abrasion, three left temporal hematomas and was reported to have been choked. The qualified medical professional (QMP) conducted an appropriate medical screen and stabilized the physical injuries of the EMC. The hospital failed to provide stabilizing measures for the psycho-social components of the traumatic injuries. Social work consult was not provided. Home environment was not evaluated for safety. The hospital failed to determine if Pt 2 benefited to be placed in a shelter meant to keep domestic violence victims safe. (refer to A2407, finding 1).

b. Patient 3 came to ED on 10/10/24 at 12:06 p.m. at 34 weeks and 5 days pregnant with complaints of abdominal pain, chest pain, palpitations (skipped, extra, or irregular heartbeats), and vomiting for a week. Hospital staff were aware Pt 3 had Type 1 diabetes mellitus (a chronic condition in which the body makes little or no insulin, which leads to high blood glucose [sugar] levels) and took daily insulin (a hormone that allows your body to use glucose for energy), and hospital staff were aware Pt 3 had a history of diabetic ketoacidosis (DKA--a serious, potentially life-threatening complication of diabetes that develops when a lack of insulin leads to uncontrolled hyperglycemia, inability to use glucose for energy, causing the liver to breakdown fat for fuel producing ketones [acids] which build up to dangerous levels in the blood). On arrival to the ED Pt 3 ' s heart rate was 138-155 beats per minute (bpm- normal 60-100 bpm). Pt 3 was examined by a Qualified Medical Person (QMP) and determined not to be in labor, a non-stress test was reactive, Pt 3 ' s glucose level was 200 mg/dl, and Pt 3 was moved back to the ED at 1:13 p.m. In ED, blood tests at 3 p.m. indicated low sodium, chloride, magnesium and calcium, carbon dioxide, and glucose 127 mg/dL, and beta-hydroxybutyric acid (BHB- a ketone) 3.69 mmol/L (HIGH- greater than 3 is associated with DKA) and a urinalysis indicated many ketones and glucose. Pt 3 was given intravenous (IV) fluid boluses, and IV calcium and magnesium, and medications for nausea and vomiting. During her almost 12 hour ED stay, blood glucose was recorded just once at 3 p.m., no output (urine or vomit) or oral intake (fluids or food) were recorded, no insulin was given, lab tests were not repeated, and fetal well-being was not assessed prior to discharge on 10/11/24 at 12:45 a.m. Tachycardia (heart rate greater than 100 bpm) continued throughout ED stay and the discharge heart rate was 132 bpm. These failures resulted in Pt 3 being discharged without the emergency medical condition being stabilized and led to harm to Pt 3 and her unborn baby. Pt 3 returned to the ED on 10/11/24 at 7 p.m. with worsening abdominal pain and tachycardia, blood sugar 303 mg/dl and lab tests indicated DKA. Fetal distress resulted in an emergency cesarean section on 10/11/24 at 10:52 p.m., and the baby required resuscitation with chest compressions and intubation. The baby was transferred to a children ' s hospital (Hospital C) and Pt 3 was admitted to the intensive care unit of Hospital A. (refer to A2407, finding 2).

c. Pt 6 arrived in the ED on 8/13/24 at 11:24 p.m. as walk in patient with chest pain, shortness of breath, high heart rate and low blood pressure and severe pain described as 10/10. Pt 6 was incorrectly assigned an ESI level 3, and left in the lobby to wait. The MSE was initiated at 11:57 p.m. and a Chest X-ray and EKG were done, and Pt 6 remained in the lobby to wait. The QMP failed to provide stabilizing measures for the emergency medical condition of CP, SOB and severe pain and Pt 6 left before the MSE was completed after two hours of waiting. These failures resulted in Pt 6 returning to the ED approximately ten hours later on 8/14/24 at 11:30 a.m., with chest pain, abdominal pain, dizziness, HR of 95, BP of 73/57, and a pain level of 10/10 requiring over eight hours of treatment in ED that included imaging and intravenous fluids. (refer to A2407, finding 3)

d. Patient (Pt) 19 was first brought in by ambulance on 10/7/24 at 2:59 p.m. with chief complaint of three days of worsening leg pain and swelling. Hospital staff were aware Pt 19 was homeless. Following triage and initiation of the medical screen exam by ED physician (MD 2), Pt 19 left sometime between 4 p.m. and 5 p.m. without further services being provided. No labs or medications were administered. On 10/7/24 at 8 p.m. Pt 19 returned to the ED with the same chief complaint of three days of worsening leg pain and swelling. ED physician (MD 3) diagnosed deep vein thrombosis (DVT-a blood clot [thrombus] in one or more of the deep veins in the body), following an ultrasound. Pt 19 was discharged with prescription for medication to treat the DVT and instructions to return to her Primary Care Physician (PCP) for follow up. No social work consult was obtained in accordance with hospital policy and procedure. Pt 19 did not have a PCP. Hospital staff did not determine if Pt 19 could obtain the medication from the pharmacy and did not determine if Pt 19 could follow the instructions. These failures resulted in Pt 19 being unable to obtain the prescription for medication to treat the DVT and led to Pt 19 ' s return to ED by ambulance for shortness of breath within fourteen hours of discharge. Pt 19 required additional work up and a two day hospital stay. (refer to A2407, finding 4)

Because of the serious potential harm to Pt 2, serious actual harm to Pt 3 and Pt 3 ' s baby, and serious potential harm to Pt 6, due to not providing stabilizing measures to address the emergency medical conditions, an immediate jeopardy situations (IJ) was called under CFR 489.24(d)(3), A2407, on 10/29/24 at 12:50 p.m. with the Chief Nursing Executive, the Chief Medical Officer, and the Director of Accreditation and Regulatory. The IJ template was provided to the hospital and instructed to submit in writing an acceptable Plan of Removal for the IJ. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 11/01/24. The IJ Plan of Removal included but was not limited to the following: 1. Nurses assign ESI level appropriately. 2. Nurses screen all patients for abuse and suicide risk 3. Nurses acknowledge clinical alarms and escalate to the provider. 4. Nurses escalate any patient safety concerns not addressed by the provider, prior to discharge. 5. Social worker referrals are made for victims of assault/abuse. 6. Local law enforcement is notified if a patient elopes who may be a danger to self or others, is confused, or altered. 7. OB and ED physicians review plan of care together for any OB pt in ED longer than four hours. 8. Patients with complaints of assault or abuse are prioritized for placement an ED room. The team verified by observations, interviews, and record review the actions of the IJ Removal Plan were implemented and the IJ was removed on 11/1/24 at 4:10 p.m. with the Associate Chief Nursing Executive and the Director of Accreditation and Regulatory.

3. Hospital A failed to meet its Recipient Hospital Responsibilities for 6 of 7 requested patient transfers (Patients A, B, C, D, E, and F).

a. Hospital D contacted Hospital A on 7/3/24 requesting to transfer Patient A who had a diagnosis of ascites (the abnormal build-up of fluid in the abdomen), and needed a higher level of care. Hospital A declined to accept Pt A due to physician refusal and otherwise had the capacity and capability to accept the transfer.
b. Hospital B contacted Hospital A on 7/20/24 requesting to transfer Pt B who had a diagnosis of sepsis and needed a higher level of care. Hospital A declined to accept Pt B due to physician refusal and otherwise had the capacity and capability to accept the transfer.
c. Hospital B contacted Hospital A on 7/20/24 requesting to transfer Pt C who had a diagnosis of kidney stone and needed a higher level of care. Hospital A declined to accept Pt C due to physician refusal and otherwise had the capacity and capability to accept the transfer.
d. Hospital E contacted Hospital A on 7/30/24 requesting to transfer Pt D who had a diagnosis of kidney stone and needed a higher level of care. Hospital A declined to accept Pt D due to physician refusal and otherwise had the capacity and capability to accept the transfer.
e. Hospital E contacted Hospital A on 8/14/24 requesting to transfer Pt E who needed urologist and a higher level of care. Hospital A declined to accept Pt E due to physician refusal and otherwise had the capacity and capability to accept the transfer.
f. Hospital B contacted Hospital A on 8/16/24 requesting to transfer Pt F who had a gastrointestinal bleed (GIB) and needed a higher level of care. Hospital A declined to accept Pt F due to physician refusal and otherwise had the capacity and capability to accept the transfer. (refer to A2411)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the statutory requirements for EMTALA and provide for patient care in a safe setting.

Based on interview and record review, Hospital A failed to provide an appropriate medical screening examination (MSE, an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether or not an emergency medical condition [EMC] exists) within the capability of the hospital's Emergency Department (ED) for two of 20 sampled patients (Patient [Pt] 1 and Pt 5) when:



1. Pt 1 came to the ED on 9/7/24 at 11:09 p.m. by ambulance accompanied by a police officer after being punched in the face multiple times and choked by her husband, sustaining cuts and bruises to her face and head. Pt 1 ' s triage vital signs were abnormal, and an assessment indicated her verbal response to questions was confused. The triage nurse indicated Pt 1 had no signs of abuse, denied being assaulted or having pain. Pt 1 was triaged as Emergency Severity Index level 3 (ESI- a 5-level acuity scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed in order to prioritize care; ESI 1 is the most serious) and was assigned a bed in the ED hallway. Pt 1 was observed leaving the ED out the ambulance entrance at 11:38 p.m., twenty-nine minutes after arrival to the ED, before the MSE was initiated. The hospital did not notify the police department or call Pt 1 ' s family despite it being almost midnight and the hospital being aware Pt 1 was a victim of domestic violence, was injured, and confused, and an emergency medical condition had not been ruled out.


These failures resulted in Pt 1 suffering an avoidable accident by running into the street and being struck by a motorcycle sustaining life-threatening injuries within fourteen minutes of leaving the ED. Pt 1 spent three weeks at Hospital B.

2. Patient (Pt) 5, a 36-year-old male, presented to the Emergency Department with suicidal ideation and eloped five minutes later. Pt 5 chief complaint was ' Danger to Self, ' and was observed by an Emergency Department [ED] tech running out of the hospital. The QMP was not notified, and the hospital did not initiate follow-up actions such as a welfare check or notification to law enforcement in accordance with hospital policy. No medical screening exam was done or attempted.

These failures resulted in Pt 5 not receiving an appropriate MSE and the benefit of stabilizing measures for a probable emergency condition and could have led to Pt 5 causing self-harm or injury.

Because of the serious actual harm to Pt 1 and potential harm to Pt 5 resulting from not performing an appropriate MSE, determining whether an EMC existed and not providing stabilizing measures, an Immediate Jeopardy (IJ) situation was called under CFR 489.24(a), A2406, at 12:50 p.m. on 10/29/24 with the Chief Medical Officer, Chief Nursing Executive, and the Director of Accreditation and Regulatory. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 11/01/24. The IJ Plan of Removal included but was not limited to the following: 1. Staff contact local PD when a patient elopes and is a danger to self or others, is altered/confused, or a victim of abuse/assault. 2.Staff prioritize room assignments for victims of abuse/assault. 3. RNs appropriately assign ESI level. 4. Abuse screening and CSSRS (suicide risk) screen for all patients 5. 24/7 security was stationed at the ED EMS entrance mitigating risk of patients who are a danger to themselves or others (i.e. altered, confused) from eloping, On 11/1/24 the components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 11/1/24 at 4:30 p.m. with the Director of of Accreditation and Regulatory and the Associate Chief Nursing Executive.


Findings:

1. During a review of Pt 1 ' s medical record, the Patient Care Record (PCR- Record of prehospital care provided by Emergency Medical Services [EMS] personnel) dated 9/7/24, indicated on 9/7/24 at 10:41 p.m. the paramedics responded to the location of a reported assault. The PCR indicated, " ...Arrived on scene to find Pt [Pt 1] laying on the floor post assault surrounded by PD [police department] and bystanders. Pt presented with multiple hematomas [abnormal collections of blood outside of a blood vessel] to her left forehead, and a laceration to her left temple. Pt was GCS 14 [Glasgow Coma Scale- a tool used to assess a patient ' s level of consciousness. Scores range from 3 (worst) to 15 (alert and oriented)]. The PCR indicated Pt 1 ' s score for verbal response was determined as " confused. " The PCR indicated, " ...Unable to determine if she suffered LOC [loss of consciousness] ...Reported by [name of city] PD that patient was punched in the face multiple times and was choked by the assailant. Pt reports [her] only pain was from the obvious injuries to her head. Pain level 10 [on a scale of 0 (no pain) to 10 (worst pain)] ... "

During a review of the triage record dated 9/7/24 at 11:16 p.m., the record indicated Pt 1 arrived to the ED at 11:09 p.m. and was triaged by RN 1 at 11:16 p.m. Triage vital signs: temperature 98.5 degrees Fahrenheit (F), pulse 123 beats per minute (bpm- normal range 60-100 bpm), respirations 18/minute, blood pressure (BP) 164/109 millimeters of mercury (mmHg- normal is less than 120/80 mmHg), oxygen saturation 98 %. The triage record indicated on 9/7/24 at 11:16 p.m. RN 1 documented Pt 1 ' s reason for visit, " Assaulted by husband, loc? No vomiting. Presented with head injury, multiple laceration of the face and scalp. Patient denied assault and denied pain, paramedic stated that PD was on scene. PD came in with the patient to ED, " and assigned an ESI of 3 (urgent). GCS was 14, verbal response " confused. " RN 1 completed the abuse screen (adult/elderly/domestic), indicating " No signs of abuse. " RN 1 indicated Pt 1 ' s pain as acute and constant, however Pt 1 ' s pain level was assessed as 0 (no pain). Pt 1 was assigned to a gurney in the ED hallway. The triage record indicated at 11:28 p.m., RN 1 changed the ESI level from 3 to ESI 2. The record indicated at 11:38 p.m., " Pt walked to the back door and ran off. MD made aware Pt eloped. " There was no evidence in the record the hospital notified the police department or Pt 1 ' s family that Pt 1 eloped prior to being seen by the physician. On 9/9/24 at 7:28 a.m., RN 1 amended the medical record, changing the ESI 2 to ESI 3, changing " no signs of abuse " to " according to accompanying PD, the patient had been assaulted by husband, patient said nobody assaulted her when I asked. "



During a review of Pt 1 ' s PCR dated 9/7/24-9/8/24, the PCR indicated on 9/7/24 at 11:51 p.m. 911 was called after Pt 1 was hit by a motorcycle while walking in the middle of the street. When the ambulance arrived on scene Pt 1 was laying in the middle of the street unconscious, with a GCS of 3 and hypotensive, blood pressure 63/31 mmHg. The PCR indicated, " ...According to PD [police] patient had recently left hospital without prior notification or formal release and was reported to be altered [a change in mental status] ... " Pt 1 was transported to Hospital B for trauma care. Review of the Pt 1 ' s medical record from Hospital B indicated Pt 1 required intubation on arrival to the ED due to respiratory compromise. Imaging revealed Pt 1 ' s injuries included a subarachnoid hemorrhage (bleeding in the area between the brain and one of the three protective layers surrounding it), a subdural hematoma (an abnormal collection of blood under the dura mater, one of the protective layers surrounding the brain), acute right second, third, fourth, 11th and 12th rib fractures, transverse process fractures (a break in the wing-like sides at the back of the vertebrae [bones]) of the lumbar spine (lower back), and multiple areas of scalp hematoma. The record indicated Pt 1 was discharged from Hospital B on 9/28/24, three weeks after the accident.


During an interview on 10/24/24 at 11:30 a.m. with the Director of ED (DED), the DED stated he had reviewed Pt 1 ' s record and had interviewed staff. The DED stated he did not know what happened to Pt 1 until a couple of days after the ED visit on 9/7/24. The DED stated he identified some things the staff could have done differently such as determining the correct ESI level. The DED stated Pt 1 should have been triaged as an ESI level 2, instead of 3. An ESI 2 may have resulted in prioritization of the MSE for Pt 1. The DED stated Pt 1 was assigned to hallway bed 3 which is near the ambulance entrance which was unsupervised and not monitored. . The DED stated an ED tech saw Pt 1 leave and informed the Lead Nurse (LN) 1. The DED stated he does not know what prompted Pt 1 to leave but since Pt 1 was assessed as GCS 14 and was a victim of an assault, the lead nurse should have alerted the police right away so they could try to find Pt 1. The DED stated the nurse should not ask the physician whether or not to call the police if there is a concern the patient is altered or at-risk, the notification of the police should occur as well as informing the physician. The DED stated when he spoke to LN 1, LN 1 had acknowledged that he should have notified the police department and said it was " a lapse in judgment. " The DED stated since this incident occurred, there is a security guard scheduled at the ambulance entrance around the clock.


During an interview on 10/28/24 at 3:15 p.m. with the ED Lead Nurse (LN) 1, LN 1 stated he was working the night shift in ED on 9/7/24. LN 1 stated patients who come in by ambulance to the ED are triaged by the lead nurse to determine whether they should go to a bed or out to the lobby to wait. LN 1 stated if the lead nurse is with another patient, then another RN can triage the patient. LN 1 stated he asked RN 1 to assist with triage on 9/7/24 when Pt 1 arrived in ED. LN 1 stated he was aware of Pt 1 ' s chief complaint and noticed there was a police officer with Pt 1 when she arrived, but LN 1 stated he does not know how long the officer stayed before leaving the ED. LN 1 stated Pt 1 was assigned to a hallway bed. LN 1 stated he was told by one of the nurses that Pt 1 left the ED, going out the ambulance entrance which was near Pt 1 ' s hallway bed. LN 1 stated he asked the nurse who witnessed Pt 1 leaving if Pt 1 looked impaired, and the nurse said no. LN 1 stated he also asked an ED tech if Pt 1 looked impaired, and the ED tech said no. LN 1 stated Pt 1 did not appear impaired to him (LN 1). LN 1 acknowledged he did not interview or assess Pt 1 and the nurse who saw Pt 1 leave did not interview or assess Pt 1. LN 1 stated he looked at the chart and it stated she (Pt 1) was alert, but LN 1 stated he did not look at the GCS 14. LN 1 stated he informed the physician on duty that Pt 1 had eloped. LN 1 stated the physician had not seen Pt 1 yet. LN 1 stated Pt 1 ' s family showed up to the ED after Pt 1 had eloped, and LN 1 stated he told them Pt 1 had left and suggested they look for her. LN 1 stated he did not call the police department or make a social services referral to follow up. LN 1 stated, " My confusion was whether she was altered or not, whether she was of right mind, I should have called the police. "

During an interview on 10/28/24 at 3:30 p.m. with RN 1, RN 1 stated he was working the night of 9/7/24. RN 1 stated he was not working as the triage nurse that night but was asked to help LN 1. RN 1 stated he triaged Pt 1 and that was the extent of his involvement with Pt 1 ' s care, and had no idea what happened to Pt 1 after she left the hospital until the manager told him days later. RN 1 was asked about the screening of Pt 1 for suicide risk, and RN 1 stated Pt 1 did not need to be screened because she was there for a medical issue. RN 1 was asked about the changes he made to Pt 1 ' s medical record on 9/9/24, two days after Pt 1 ' s ED visit. Regarding the ESI change from ESI 2 to 3, RN 1 stated the ESI was 3, and was not changed to 2. RN 1 stated the ED manager asked him about the ESI and when he looked at it he corrected it to ESI 3. RN 1 stated he never changed it to 2 and doesn ' t know why the medical record indicated he had changed it on 9/7/24 to 2. As far as the change to the abuse screening, RN 1 stated " it was a miss-click, " referring to charting in the electronic health record (EHR).

During an interview on 10/28/24 at 9:45 a.m. with the social worker (SW) 1, SW 1 stated on 9/9/24 she was made aware of Pt 1 ' s elopement and suspected domestic violence by the ED manager. SW 1 stated she reviewed the record which indicated Pt 1 had a seven year-old child and because of this a referral to Child Protective Services (CPS) was required, and due to the allegation of domestic violence, a referral to Adult Protective Services was required which is what she did on 9/9/24. SW 1 stated the nursing staff can make the referrals also.


During an interview on 11/1/24 at 2:20 p.m. with the medical director of the ED (EDMD), the EDMD stated he was working in the ED the night of 9/7/24. He did not see Pt 1, but the lead nurse (LN 1) informed him that Pt 1 had eloped and asked him if he had seen Pt 1 yet. The EDMD stated he recalled LN 1 saying Pt 1 may have been intoxicated. The EDMD stated LN 1 asked him if he should call the police, and EDMD stated he asked LN 1 what the policy says. The EDMD stated he did not think the physicians are aware of the details of the policy regarding notifying the police for patients who elope and are altered. The EDMD stated he was aware a physician ' s order was not required for the staff to notify the police. The EDMD stated triaging patients appropriately is important since the physician sees the ESI level on the ED board and that information along with any other pertinent information about the patient determined which patient is seen next.

During an interview on 11/4/24 at 10:55 a.m. with the Manager of ED (EDM) 1, EDM 1 stated she was told about Pt 1 on 9/9/24. EDM stated had reviewed the record and asked RN 1 about the initial ESI 3 in triage on 9/7/24 at 11:16 p.m. that was changed to ESI 2 on 9/7/24 at 11:28 p.m. EDM 1 stated she was aware that RN 1 changed the ESI back to ESI 3 on 9/9/24, but did not ask him to change that documentation. EDM 1 stated she would never ask a nurse to change an ESI level. EDM 1 stated she was aware RN 1 documented " no signs of abuse " despite the report from the paramedics describing Pt 1 ' s injuries and the presence of a police officer with Pt 1 on arrival to ED. EDM 1 stated RN 1 was not very thorough in his assessment of Pt 1. EDM 1 stated nurses must " use critical thinking and should not be on autopilot. "

During a review of the hospital ' s policy and procedure (P&P) titled " Standards Of Care, Emergency Department, " dated 6/27/24, the P&P indicated, " ...All patients will be screened for Assault/Abuse Screenings, Screening for Suicidal/Homicidal ideations, Fall Risk, Advanced Directive, and Homelessness ... "

During a review of the reference titled, " Comprehensive Accreditation Manual for Hospitals, CAMH Update, " dated 7/1/24, the reference indicated, " ...The Joint Commission considers the following list of events, though not comprehensive, to be sentinel events if they occur under any Joint Commission-accredited health care organization: ... Any elopement (that is, unauthorized departure) of a patient from a staffed around the-clock care setting (including the ED), leading to death, permanent harm, or severe harm to the patient ... "

During a review of an article in American College of Emergency Physicians (ACEP) Now: Vol 39 No 03, March 2020, titled, " Don ' t Overlook Traumatic Brain Injury in Intimate Partner Violence, " dated 3/17/20, the article indicated, " ...While IPV is often associated with traumatic brain injury (TBI), TBI often goes unrecognized and undiagnosed among its victims. Even mild TBI may cause chronic disability without appropriate rehabilitation. Emergency physicians are in a unique position to prevent long-term sequelae by diagnosing TBI and providing appropriate referrals .... Victims of IPV may suffer repeat episodes of TBI within a similar timeframe, as they are at high risk of multiple violent encounters. Also, while strangulation causing anoxic brain injury is uncommon among other patients at risk of TBI, it is disturbingly common among victims of IPV. These patients may experience headaches, dizziness, memory issues, sleep problems, poor judgment, and emotional lability. Often these symptoms are incorrectly chalked up to substance abuse, mental illness, or the psychological trauma of IPV ... Victims of IPV are often discharged from the emergency department without adequate information about lasting symptoms and without appropriate follow-up ... "


During a review of an article in ACEP Now: Vol 37 No 08, August 2018, titled, " How to Help Victims of Intimate-Partner Violence, " dated 8/14/18, the article indicated, " ...Emergency department staff have a unique opportunity to identify victims of intimate partner violence [IPV] and to provide safety planning and community referrals. Multiple organizations, including the American College of Emergency Physicians (ACEP) and The Joint Commission, recommend universal screening for IPV. For IPV screening to be done routinely, it must be built into the workflow of the emergency department. If the screen is positive, the patient requires a safety plan prior to discharge ... "

During a review of the Brain Sciences journal article titled, " Update on Domestic Violence and Traumatic Brain Injury: A Narrative Review, " dated 1/17/22, retrieved from , the article indicated, " ...Victims of domestic violence are unlikely to report their abuse. These patients are afraid to come forward for several reasons including fear of retaliation from their partner and losing custody of their children. There is a general mistrust of healthcare professionals in this population, due to fear of being judged, or even being blamed themselves for allowing someone to be violent towards them ...Traumatic brain injuries (TBI) are categorized by the Glasgow Coma Scale, with scores of 13-15 being mild, 9-12 being moderate, and less than 8 being severe TBI. Despite 80% of all reported TBIs being mild, the incidence of mild TBIs [mTBI] is very underreported, likely because mTBI can present as a transient feeling of being dazed, disoriented, or confused. Without proper treatment, there is a risk for repetitive injuries which can have a cumulative result, leading to detrimental outcomes such as chronic traumatic encephalopathy, depression, suicidality, and Alzheimer ' s-like syndromes ... "


2. During a concurrent interview and record review on 10/24/24 at 2:53 p.m. with the Emergency Room Director (DED), Manager Regulatory Team (MRT), and Regulatory Specialist (RS) 2, Pt 5 ' s Electronic Medical Record (EMR)" was reviewed for the Emergency Department (ED) visit on date 8/1/24. The " EMR " indicated, that Pt 5 arrived at the ED on 8/1/24 at 9:46 p.m. Five minutes later, at 9:51 p.m., the patient was documented as eloped on depart summary from the emergency department. The EMR indicated ... " Visit Reason: Danger to self ...Arrival Mode Walk-in " . The EMR indicated patient left without being seen before MSE was initiated. The DED stated Pt 5 was registered with chief complaint of ' Danger to Self, ' and was observed by an ED staff running out of the hospital. The DED stated Pt 5 ' s EMR does not reflect safety sitter was initiated. The DED stated he was unable to find any documentation that the QMP was notified about Pt 5 ' s chief complaint and elopement after registering the chief complaint of danger to self. The hospital did not initiate follow-up actions such as a welfare check or notification to law enforcement in accordance with hospital policy according to DED. The DED stated Pt 5 " clearly notified registration " upon arrival of his intent to hurt himself and was registered as a " Danger to self " . The DED stated he expected that emergency department staff members were upholding the hospital ' s policies and procedures, and in this case failed to escalate to the charge nurse, or provider or notify law enforcement for a welfare check. The DED stated the only documentation he was able to find for the entire visit was a note written by a patient access team member (person that registers patient in main lobby upon arrival to ED) on 8/1/24 at 9:51 p.m. stating " Pt ran out " . The DED stated Pt 5 was seen in ED twelve hours before the visit of 8/1/24 at 9:46 p.m. for the chief complaint of suicidal thoughts. The DED stated Pt 5 had a history of schizophrenia (a serious mental health condition that affects how people think, feel, and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) as well as methamphetamine use (powerful, highly addictive stimulant drug that affects the central nervous system) and was discharged after being cleared by mental health team for outpatient follow up for mental health or return to ED if unable to follow up as outpatient within 72 hours. The DED stated regardless of the previous visit, Pt 5 returned in 12 hours seeking help for suicidal ideation and should have received a medical screening exam and evaluation of mental health. The DED stated Pt 5 had the potential to hurt himself with suicidal ideation and stated it was not acceptable that staff failed to escalate and follow up. The DED stated he was glad to see that Pt 5 did return to ED for the third time on 8/1/24 at 11:16 p.m. (one hour and twenty-five minutes after elopement) seeking help for suicidal ideation. Pt 5 was evaluated upon return by the mental health team and was offered resources. The DED stated that MSE was started, the mental health team cleared the patient, and physician assessment was done, however, Pt 5 eloped again before additional workup could be completed. The DED stated the provider called the patient to return to ED and the patient refused to return to the ED. The DED stated on the 3rd visit hospital policy was followed as Pt 5 was evaluated by the mental health team and deemed safe before elopement. Pt 5 also received information on resources from the mental health team prior to elopement and the provider called the patient after elopement. The DED stated his staff should have followed the same process when Pt 5 eloped before MSE on the second visit on 8/1/24 at 9:51 p.m. with active suicidal ideation.

During an interview on 11/1/24 at 2:21 p.m. with the ED Medical Director (EDMD), the EDMD stated he had been the ED medical director for a year and three months. The EDMD stated it was his expectation that staff was following the hospital policies. The EDMD stated for patients who are dangerous to themselves and elope from ED, he expected that staff members follow the elopement process outlined in the facility policy. The EDMD stated staff usually will escalate these types of elopement situations to him and he would escalate to law enforcement authorities if it had not been escalated as needed. The EDMD stated he has called law enforcement in the past for patients who were danger to themselves when it was appropriate for the patient ' s condition. The EDMD stated he was not familiar with Pt 5, but the expectation would be the same that staff follow the facility ' s process and policies.

During an interview on 11/4/24 at 9:24 a.m. with the Manager Social Services (MSS), the MSS stated she had been working at the hospital for nine years and had been promoted to manager in September of this year. The MSS stated patients who are a danger to themselves and others, an ED social worker may get notified. The MSS stated they are limited in what social work team can do. The MSS stated the social work team makes sure they work with [local county name] crises team and provide resources as needed for the outpatient follow-up and continuity of care. The MSS stated if the patient elopes while they are a danger to self and others, and the social worker is notified, their process is to notify law enforcement and request a welfare check. The MSS stated usually nursing staff or Provider take care of that and the social worker does not get notified of an elopement in the ED.

During a review of the facility ' s policy and procedure (P&P) titled, " EMTALA - Patient LWBS, Elopement, AMA, LABS " , with an effective date 6/6/19, the P&P indicated " ...POLICY SUMMARY/INTENT: To ensure all departments of the Hospital that provide Emergency Services and Care take appropriate steps to follow up on patients who leave the Hospital prior to receiving the Medical Screening Examination (MSE) and/or completing the necessary Stabilizing treatment ... Left Without Being Seen (LWBS) - Before MSE: The patient leaves before receiving the initial Medical Screening Examination ... All patients leaving the Emergency Department (and/or add all Dedicated Emergency Departments) before completion of the Medical Screening Examination will be offered the Medical Screening Examination and encouraged to remain in the Department to receive Emergency Services and Care ...Patient Does Not Notify Staff Before Leaving ...Patient in the Waiting Room. If a patient is not in the Dedicated Emergency Department waiting room ...when called for service, Hospital staff will call the patient two (2) additional times to escort the patient to the treatment area ...Each time a patient is called, the time of the call will be noted on the patient record indicating " patient name called, no response. " The note will be documented by the staff signature or initial with the corresponding time. Other efforts to locate the patient who is not in the waiting area should be noted in the patient ' s chart ...Patient in a Treatment Room. If the patient leaves after being placed in a treatment room, a search for the patient will be conducted within the immediate area of the Department ...Efforts to locate the patient will be recorded on the patient record. The note will be documented by the staff signature or initial with the corresponding time ...If the patient is or may be a danger to self or others, local law enforcement will be notified if a psychiatric evaluation and hold may be necessary ... "

Based on observation, interview and record review, the hospital failed to provide stabilizing measures for identified emergency medical conditions (EMC) within the capability and capacity of the hospital for 4 of 20 patients (Pt 2, Pt 3, Pt 6, and Pt 19) when:

1. Pt 2 arrived with her son to the hospital emergency department (ED) following a police report of physical assault of domestic violence. Pt 2 had traumatic injuries including neck abrasion, three left temporal hematomas and was reported to have been choked. The qualified medical professional (QMP) conducted an appropriate medical screen and stabilized the physical injuries of the EMC. The hospital failed to provide stabilizing measures for the psycho-social components of the traumatic injuries. Social work consult was not provided. Home environment was not evaluated for safety. The hospital failed to determine if Pt 2 benefited to be placed in a shelter meant to keep domestic violence victims safe.

These failures had the potential for Pt 2 to return to an unsafe environment and experience further assault.

2. Patient 3 came to ED on 10/10/24 at 12:06 p.m. at 34 weeks and 5 days pregnant with complaints of abdominal pain, chest pain, palpitations (skipped, extra, or irregular heartbeats), and vomiting for a week. Hospital staff were aware Pt 3 had Type 1 diabetes mellitus (a chronic condition in which the body makes little or no insulin, which leads to high blood glucose [sugar] levels) and took daily insulin (a hormone that allows your body to use glucose for energy), and hospital staff were aware Pt 3 had a history of diabetic ketoacidosis (DKA--a serious, potentially life-threatening complication of diabetes that develops when a lack of insulin leads to uncontrolled hyperglycemia, inability to use glucose for energy, causing the liver to breakdown fat for fuel producing ketones [acids] which build up to dangerous levels in the blood). On arrival to the ED Pt 3 ' s heart rate was 138-155 beats per minute (bpm- normal 60-100 bpm). Pt 3 was examined by a Qualified Medical Person (QMP) and determined not to be in labor, a non-stress test was reactive, Pt 3 ' s glucose level was 200 mg/dl, and Pt 3 was moved back to the ED at 1:13 p.m. In ED, blood tests at 3 p.m. indicated low sodium, chloride, magnesium and calcium, carbon dioxide, and glucose 127 mg/dL, and beta-hydroxybutyric acid (BHB- a ketone) 3.69 mmol/L (HIGH- greater than 3 is associated with DKA) and a urinalysis indicated many ketones and glucose. Pt 3 was given intravenous (IV) fluid boluses, and IV calcium and magnesium, and medications for nausea and vomiting. During her almost 12 hour ED stay, blood glucose was recorded just once at 3 p.m., no output (urine or vomit) or oral intake (fluids or food) were recorded, no insulin was given, lab tests were not repeated, and fetal well-being was not assessed prior to discharge on 10/11/24 at 12:45 a.m. Tachycardia (heart rate greater than 100 bpm) continued throughout ED stay and the discharge heart rate was 132 bpm.

These failures resulted in Pt 3 being discharged without the emergency medical condition being stabilized and led to harm to Pt 3 and her unborn baby. Pt 3 returned to the ED on 10/11/24 at 7 p.m. with worsening abdominal pain and tachycardia, blood sugar 303 mg/dl and lab tests indicated DKA. Fetal distress resulted in an emergency cesarean section on 10/11/24 at 10:52 p.m., and the baby required resuscitation with chest compressions and intubation. The baby was transferred to a children ' s hospital (Hospital C) and Pt 3 was admitted to the intensive care unit of Hospital A.

3. Pt 6 arrived in the ED on 8/13/24 at 11:24 p.m. as walk in patient with chest pain, shortness of breath, high heart rate and low blood pressure and severe pain described as 10/10. Pt 6 was incorrectly assigned an ESI level 3, and left in the lobby to wait. The MSE was initiated at 11:57 p.m. and a Chest X-ray and EKG were done, and Pt 6 remained in the lobby to wait. The QMP failed to provide stabilizing measures for the emergency medical condition of CP, SOB and severe pain and Pt 2 left before the MSE was completed after two hours of waiting.

These failures resulted in Pt 6 returning to the ED approximately ten hours later on 8/14/24 at 11:30 a.m., with chest pain, abdominal pain, dizziness, HR of 95, BP of 73/57, and a pain level of 10/10 requiring over eight hours of treatment in ED that included imaging and intravenous fluids.

4. Patient (Pt) 19 was first brought in by ambulance on 10/7/24 at 2:59 p.m. with chief complaint of three days of worsening leg pain and swelling. Hospital staff were aware Pt 19 was homeless. Following triage and initiation of the medical screen exam by ED physician (MD 2), Pt 19 left sometime between 4 p.m. and 5 p.m. without further services being provided. No labs or medications were administered. On 10/7/24 at 8 p.m. Pt 19 returned to the ED with the same chief complaint of three days of worsening leg pain and swelling. ED physician (MD 3) diagnosed deep vein thrombosis (DVT-a blood clot [thrombus] in one or more of the deep veins in the body), following an ultrasound. Pt 19 was discharged with prescription for medication to treat the DVT and instructions to return to her Primary Care Physician (PCP) for follow up. No social work consult was obtained in accordance with hospital policy and procedure. Pt 19 did not have a PCP. Hospital staff did not determine if Pt 19 could obtain the medication from the pharmacy and did not determine if Pt 19 could follow the instructions.

These failures resulted in Pt 19 being unable to obtain the prescription for medication to treat the DVT and led to Pt 19 ' s return to ED by ambulance for shortness of breath within fourteen hours of discharge. Pt 19 required additional work up and a two day hospital stay.

Because of the serious potential harm to Pt 2, serious actual harm to Pt 3 and Pt 3 ' s baby, and serious potential harm to Pt 6, due to not providing stabilizing measures to address the emergency medical conditions, an immediate jeopardy situations (IJ) was called under CFR 489.24(d)(3), A2407, on 10/29/24 at 12:50 p.m. with the Chief Nursing Executive, the Chief Medical Officer, and the Director of Accreditation and Regulatory. The IJ template was provided to the hospital and instructed to submit in writing an acceptable Plan of Removal for the IJ. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 11/01/24. The IJ Plan of Removal included but was not limited to the following: 1. Nurses assign ESI level appropriately. 2. Nurses screen all patients for abuse and suicide risk 3. Nurses acknowledge clinical alarms and escalate to the provider. 4. Nurses escalate any patient safety concerns not addressed by the provider, prior to discharge. 5. Social worker referrals are made for victims of assault/abuse. 6. Local law enforcement is notified if a patient elopes who may be a danger to self or others, is confused, or altered. 7. OB and ED physicians review plan of care together for any OB pt in ED longer than four hours. 8. Patients with complaints of assault or abuse are prioritized for placement an ED room. The team verified by observations, interviews, and record review the actions of the IJ Removal Plan were implemented and the IJ was removed on 11/1/24 at 4:10 p.m. with the Associate Chief Nursing Executive and the Director of Accreditation and Regulatory.

Findings:
1. During a concurrent interview and record review on 10/28/24 at 10:00 a.m. with the Emergency Department Director (DED), patient (Pt)2 ' s electronic medical record (EMR) was reviewed for the Emergency Department (ED) visit on 9/1/24. The EMR indicated Pt 2 arrived at ED on 9/1/24 at 2:30 a.m. with scalp hematoma, neck abrasion, and left-hand injury due to physical assault. The document titled " ED Triage and Initial Assessment " was reviewed and Indicated Pt 2 ' s preferred language was Spanish, and Pt 5 ' s son was used as interpreter. The initial vitals on 9/1/24 at 2:51 a.m. indicated HR 101 beats per minute (bpm-normal 60-100), Respiratory rate 17 breaths per minute (normal 12-20), Blood pressure 144/80 millimeters of mercury (mmHg - Unit of measurement-normal less than 120/80), Pain intensity level of 8 (on a scale of 0 [no pain] to 10 [worst possible pain], 8 and above is severe pain). The " ED Triage and Initial Assessment " indicated, " ...ED SOCIAL HISTORY ...CSSRS Suicide screening ED: Not Screened: Clinical Judgement and Non-BH ...Abuse Screen, adult/elderly/domestic: No signs of abuse ... " The DED stated Pt 2 needed language assistance services, and he was unable to find any documentation in the medical record that indicated the patient was provided language assistance services or was made aware of the available resources per hospital policy. The DED stated the Triage documentation indicated Pt 2 ' s son was used as an interpreter, and the waiver form to use family member instead of language assistance service was not completed in accordance with the hospital policy. The DED stated he was unable to comment on why Pt 2 ' s son was used for translation, and he was unsure if Pt 2 ' s son was old enough to translate. The DED stated the Triage documentation was inaccurate as it indicates no signs of abuse, while Pt 2 presented with a chief complaint of scalp hematoma, neck abrasion, and left-hand injury due to physical assault. The DED stated the nurse who completed the " ED Triage and assessment " was not a qualified certified interpreter, and without the use of language assistance service, the assessment was not completed appropriately accordance with the facility policy. The DED also stated the patient was assigned incorrect emergency severity index (ESI) level 4 (ESI- a 5-level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed in order to prioritize care, ESI 1 being the most serious) and should have been assigned higher ESI (ESI level 2) based on presentation and abuse as stated in chief compliant in Triage. The DED stated assigning incorrect ESI in Triage could have the potential to cause delays in medical care.

During a concurrent interview and record review on 10/28/24 at 10:10 a.m. with the DED, Pt 2 ' s " ED Physician note " dated 9/1/24 was reviewed. The " ED Physician note " indicated, " ...History of present illness ...38 Year-old female ...emergency department for evaluation after an assault ...Physical Exam: Spanish speaking ... [Head Eyes Nose Throat] ...She has 3 left temporal hematomas ...SKIN Abrasion/contusion to zone 3 of neck ... Psychiatric ... Tearful ... Communication altered due to language ...Medical Decision Making: Patient reports that she was at her mother's house and her boyfriend was drunk ...all of a sudden assaulted her. She says that he pulled her hair and was choking her at 2 different occasions during this altercation. She further says that she is having pain to her left wrist as he yanked her from there during assault... [Police Department] was involved in the incident and report has been filed ...Patient reporting pain to her left temporal region as well as pain to her left wrist ...On presentation, [Pt 2 ' s] Glasgow Coma Scale 15 [GCS- a system to " score " or measure how conscious a person is. Scores range from 3-15, 15 is alert and oriented] and appropriately protecting her airway on room air ...Results of x-ray do not demonstrate any bony fracture nor dislocation or foreign body. Patient felt better after treatment emergency department. Results of workup were shared with the patient. [pain medication prescription] sent to pharmacy of choice. Pain management discussed with patient. Instructed to follow-up with PCP within 72 hours of discharge. Patient expresses understanding and is amenable to outpatient follow-up. At this time, patient be discharged home ... " The DED stated patient received Acetaminophen (medication to treat minor aches and pains, and reduces fever) and Methocarbamol (muscle relaxant) on 9/1/24 at 3:34 a.m. and was discharged on 9/1/24 at 5:26 a.m. The DED stated although the discharge instructions were provided in Spanish, there was no documentation indicating that a certified interpreter or language assistance services were used by the provider. The DED reported no documentation within the entire medical record on for the 9/1/24 ED visit indicating that a social worker had been consulted before discharge. According to the DED, both the ED physician ' s notes and medical record indicated police involvement before Patient 2 ' s arrival. However, the medical record lacks evidence that Pt 2 received a social worker consultation, psychosocial assessment, safe discharge planning, or follow-up resources for abuse victims before discharge. The DED emphasized that, as a known victim of abuse, Pt 2 should have undergone an assessment for a safe discharge location and received referrals for appropriate follow-up support. Additionally, the DED found no physician documentation verifying that language assistance services were used, nor was it confirmed if the ED physician was a certified interpreter, as per hospital policy. The DED stated physician ' s note, which documented " communication altered due to language, " highlighted the importance of using a certified interpreter to ensure a thorough discharge assessment and to identify any barriers to a safe discharge with necessary outpatient resources for abuse victims. The DED also stated that Pt 2 had an inaccurate abuse screen completed during triage, lacked a social worker referral and evaluation, and did not receive documented resource evaluation before discharge, resulting in an unsafe discharge. The DED expressed an expectation for ED staff to complete abuse assessments accurately and involve a social worker to evaluate patients presenting to the ED as potential abuse victims.

During a concurrent interview and record review on 10/28/24 at 10:15 a.m. with the DED, Pt 2 ' s EMR was reviewed. Review of the document titled " ED Depart " dated 9/1/24, indicated Pt 2 was discharged on 9/1/24 at 0527 by Licensed Vocational Nurse (LVN) 2. The " ED Depart " indicated, " ...Preferred language: Spanish ... Interpreter/Translator name, if used: Staff ... Location Information: Nurse Unit- ED Hallway. New Medications ...methocarbamol ... " The DED stated while discharge instructions were provided in Spanish, there was no documentation indicating that a certified Spanish interpreter was used by the nurse discharging the patient, nor did the instructions contain abuse-related information or resources for the patient. The DED confirmed that LVN 2, who provided the discharge instructions, was not a certified interpreter and should have used language assistance services in accordance with hospital policy to ensure the patient ' s comprehension of the discharge instructions. The DED expressed that, without a certified interpreter, it is unclear whether Pt 2 fully understood the discharge process and follow-up care. The DED stated that he would have expected the patient to be provided with resources for abuse victims and to undergo a safety assessment facilitated by language assistance services before discharge. Additionally, the DED noted the absence of documentation regarding the age of Patient 2 ' s son and stated an assessment should have been done to ensure the safety of any minors in the household who may be at risk. The DED stated it was inappropriate for Pt 2 to be left in the ED hallway and that abuse victims should be placed in a more private, secure area within the ED.

During an interview on 11/1/24 at 2:30 p.m. with the EDMD, the EDMD stated he was the medical director for the ED. The EDMD stated for patients presenting to the ED with domestic abuse, the ED provider and staff were expected to inquire if the patient had filled out a police report. The EDMD stated it was important to ensure that they have a safe place to go after discharge. The EDMD stated additionally, if the patient was elderly or pediatric, they were obligated to report to Adult Protective Services (APS) or Child Protective Services (CPS). The EDMD stated that the ED provider completes the full assessment and documents it in the medical record, assessed for signs of abuse, asked patients where they are hurting, and used a certified interpreter or language assistance service for patients with a language barrier. The EDMD stated that, at times, these cases are very emotional, and the patient only wants the family to translate, and in those cases, they have a process in place. The EDMD stated if a patient presents with a significant other, they make every attempt to separate them and interview the patient. The EDMD stated before discharge, patient functionality gets assessed, and they make sure the patient has a safe place to go and resources. The EDMD stated he would expect all of this to be documented. The EDMD stated that a social worker consult is ordered as needed, however, they do have limited resources at night. The EDMD stated he had not reviewed Pt 2 ' s chart, but the expectation would be the same for any patient presenting with domestic abuse.

During an interview on 11/4/24 at 9:24 a.m. with the Manager of Social Services (MSS), the MSS stated her team gets calls and referrals from ED for all types of patients, such as homeless, child abuse, and difficult discharges. The MSS stated currently, the social worker is assigned to ED during weekdays until 11:00 p.m. and on weekends on site until 4:30 p.m. The MSS states for victims of domestic violence; their role is to speak with the patient, do screening, which consists of assessing for domestic violence, if children are involved, ensure a CPS report is filed, and, most importantly, offer domestic violence resources. The MSS stated even if the patient denied, their team provides the resources in case the victim later needs it. If the victim does not want to go home, their team provides the shelter resources. The MSS stated social workers are certified in Spanish. If the social worker does not speak Spanish, they are required to use translation services and document that in the medical record. The MSS stated regarding Pt 2, she ideally the doctor would have made a referral to social work, and her team would have come in to do an assessment. The MSS stated part of their assessment is to ensure no children are in the home and at risk where domestic abuse occurred. If the children are present, they would like to make sure the children are safe along with the patient. The MSS stated social workers always provide resources in case patients need to use them in the future, even if the patient refuses them for the visit. The MSS stated that victims of domestic violence are not ready to leave and need to prepare therefore, these resources are critical. The MSS stated her team has packets ready that prepare the victims of domestic violence to leave and make them aware of the available resources. The MSS stated they also do not have any social worker available for ED at night after 11 p.m., and if the social worker consult is ordered and the patient is discharged before the morning shift, the social worker team would not get any notification and order would fall off where her team is not able to track. The MSS stated if Pt 2 arrived after 11:00 p.m. and was discharged before the day shift, her team would not be aware, and currently, they do not have a way to track this or our patient follow-up. The MSS stated ED nurses have been made aware of these packets, have access to them after hours, and expected to provide these to patients after hours.

During a review of the hospital ' s policy and procedure (P&P) titled, " Language Assistance Program - Interpretation and Hearing Impaired, " dated 6/20/24, the P&P indicated, " ...[Hospital A] will take reasonable steps to ensure that persons requiring language assistance services (such as oral language assistance or written translation) and who have Limited English Proficiency (LEP) will have meaningful access and an equal opportunity to participate and understand services, activities, programs and other benefits involving medical conditions and treatment. Assistance will be offered for the communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment forms, financial and insurance benefit forms, etc. Patients/clients and their families will be informed of the availability of such assistance free of charge. Language assistance will be provided using competent bilingual staff, providers, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services ... OBTAINING A QUALIFIED INTERPRETER ...A qualified staff interpreter must pass the competency exam as outlined in the instructions on CVN Interpreter Services Connect ...Note: Sites may choose not to use staff for translating or interpreting, unless during an emergency involving an imminent threat to the safety or welfare of an individual or the public...Maintaining an accurate and current list showing the name, language, phone number and hours of availability of competent bilingual staff - located on CVN Interpreter Services Connect ] ...Contacting the appropriate competent bilingual staff member to interpret, in the event that an interpreter is needed, if an employee who speaks the needed language is available and is qualified to interpret ...Site staff who have a limited familiarity (not deemed competent or qualified) with sign language or language/interpreter skills should interpret only in emergency situations for a brief time until a qualified interpreter can be present ...Obtaining an outside interpreter if a competent bilingual staff or qualified staff interpreter is not available or does not speak the needed language ...[[Company name] Language Solutions, (866) 745 - 5010, is available 24 hours per day, 7 days per week. [Company name] Interpreting (559) 636 - 3294, is available for live ASL interpreting between the hours of 8am to 5pm Monday - Friday] ... Some LEP persons may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the LEP person will not be used as interpreters unless specifically requested by that individual and after the LEP person has understood that an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented with the waiver of rights form, in the patient's medical/health record. The waiver of rights must include a statement giving the LEP person the right to request an interpreter at any time ... Children and other clients/patients/residents will not be used to interpret, in order to ensure confidentiality of information and accurate communication ... "

During a review of the facility ' s P&P titled, " ABUSE, REPORTING OF " , with a review date of 8/6/2023, the P&P indicated " ...POLICY INTENT ... To provide directions to staff in the mandatory reporting of child abuse, elder / dependent adult abuse, and the victims of domestic violence ... Domestic Violence: Abuse committed against an adult or fully emancipated minor who is ...Spouse or former spouse ...Cohabitant or former cohabitant ...Person with whom the suspect has had a child ... Physical Abuse: Physical injury that results in substantial harm to the person, or the genuine threat of substantial harm from physical injury to the person, including an injury that is at variance with the history or explanation given and excluding an accident or reasonable discipline by a parent, guardian or conservator that does not expose the person to a substantial risk of harm ... POLICY COMPLIANCE - KEY ELEMENTS ...Staff of the hospital and its associated facilities and clinics will adhere to the mandatory reporting requirements for victims of elder / dependent / child abuse and / or neglect and domestic violence ...If allegations of abuse or neglect are raised, reporting must take place ...If the staff, either medical practitioner or other staff, suspects or sees possible abuse / neglect, reporting is mandatory ...Appropriate forms will be completed and notifications of appropriate law enforcement agencies will be made ...incident reporting system file should be completed and a copy of the reporting form forwarded to Risk Management ... Domestic Violence ...Upon suspicion of domestic violence, initiate a verbal report via telephone call to the law enforcement agency of jurisdiction ...Complete the "Domestic Violence Report" (Form No. 8756F1210) and distribute per instructions at the bottom of the page ...Encourage the victim to call the Domestic Violence Hotline and if in immediate danger, ask for assistance to enter the shelter ...Document assessment findings, treatments, pertinent statement of victim and others in the medical record ... "

During a review of the facility ' s P&P titled, " STANDARDS OF CARE EMERGENCY DEPARTMENT " , with a review date of 6/27/24, the P&P indicated " ...Assessments/Reassessments ...All patients will be triaged by a registered nurse (RN) ... All patients will be screened for Assault/Abuse Screenings, Screening for Suicidal/Homicidal ideations, Fall Risk, Advanced Directive, and Homelessness ... Discharge ...The ED physician will determine if the patient meets discharge criteria, needs to be transferred to another facility or higher level of care, or requires hospital admission. For patients who are discharged, all patients will receive after care instructions in the form of discharge instructions upon completion of their treatment. Medication instructions and educational handouts are provided as appropriate. Patients identified as homeless will be offered resources ... "

During a professional reference review retrieved from (https://pmc.ncbi.nlm.nih.gov/articles/PMC4393790/ ), dated Dec 2014, titled " Managing Intimate Partner Violence in the Emergency Department " , the reference indicated, " ... Intimate partner violence (IPV) is a pattern of assaultive or coercive behaviors, perpetrated by someone who was or is in an intimaterelationship with the person ....The ED provider should seek to encourage and empower patients to speak to health care providers and to overcome any reluctance to seek help for their abuse, both during the current visit and in the future. Patients may be divulging abuse for the first time, and may experience it as emotional, embarrassing, and frightening .... Assessing the immediate safety concerns of the patient for themselves and for any children in the household will determine the next critical steps ...Patients should be asked if they feel safe to leave the ED; a brief formal danger assessment tool may be used as a follow up to a positive screen to calculate risk of severe future IPV and may perform better than self-assessment of risk ...If the patient does not feel safe to go home, they will need to be linked to domestic violence agencies to seek alternative housing ...Given the shortage of domestic violence shelter beds, patients may need to consider alternative housing through friends or family for the short term; some hospitals will admit a patient in danger of violent victimization who do not feel safe to go home and have no other options ... Child protective services must be consulted if there is concern for the safety of children in the household ... Patients experiencing abuse should be offered the opportunity to receive assistance contacting law enforcement to make a report and initiate the process of obtaining a restrain orders. If they do not wish to initiate this process while in the ED, they should be given information on how to do so, and made aware that domestic violence agencies' services include navigating law enforcement and legal aid ... Child abuse and elder abuse, in contrast, must be reported; if these are revealed to coexist with partner violence, providers cannot assure confidentiality. In the vast majority of cases, patients will be returning home, rather than to a shelter. Anticipating and understanding this, remaining supportive and encouraging, and avoiding responses of frustration, disbelief, or disapproval will ensure the patient does not feel judged or looked down upon, and may increase the possibility that they will seek help from health care providers in the future. It can take many attempts at leaving before someone leaves an abusive relationship permanently ... Ideally, patients should be instructed in a variety of steps they can take to keep themselves and their children safe and to allow them to leave the home quickly in case violence should escalate ... the patient should be encouraged to learn more about safety behaviors with domestic violence agencies as an outpatient ... Patients experiencing IPV should receive, at the minimum, referrals to local or national domestic violence hotlines... "

2. During a concurrent interview and record review on 10/28/24 at 10:55 a.m. with the Director of Obstetrics (OBD) and the Manager of Obstetrics (OBM), Pt 3 ' s medical record was reviewed. Review of the record indicated Pt 3 came to the ED on 10/10/24 at 12:06 p.m. with complaints of abdominal pain, chest pain and palpitations, was triaged and assigned an ESI level 2. Pt 3 ' s heart rate was 138-155 bpm. The ED triage nurse ' s note dated 10/10/24 indicated Pt 3 was 34 weeks, 5 days pregnant and had a history of Type 1 diabetes and DKA and was initially going to be put into an ED room but because she was pregnant and had abdominal pain she was sent to labor and delivery (L&D) after an EKG was done. On 10/10/24 at 1 p.m. Pt 3 ' s heart rate was 127 bpm, and a non-stress test was performed and was reactive with a baseline fetal heart rate of 155 bpm. Pt 3 ' s vaginal exam indicated her cervix was closed, and there were no regular contractions noted. The L&D record indicated at 12:56 p.m. the obstetrician was notified of, " edc [estimated date of confinement, due date], gestational age, fetal heart rate, complaint of chest pain, walked over by ED, feeling generally bad, Type 1 DM, having trouble controlling bs [blood sugar], current BS 200. " The record did not indicate how that blood sugar was obtained since it did not show up on the lab report. The OBD called the L&D nurse (RN 6) who stated Pt 3 was wearing a continuous glucose monitor (CGM) and RN 6 read the glucose level off of the CGM. At 1:13 p.m., Pt 3 was transported back to the ED.
Review of the " ED Physician Notes, " dated 10/10/24 at 2:16 p.m., indicated the MSE was initiated by the nurse practitioner (NP 1) at 1:28 p.m. The note indicated, " ...27 year-old female who is 34 weeks and 5 days pregnant with a history of Type 1 diabetes ...Patient reports she has been experiencing palpitations with simple movements like sitting up in the bed. The palpitations are associated with shortness of breath. States she can only walk a few steps before started feeling short of breath and feeling like her heart is racing. Patient also reports that she has been experiencing vomiting and heartburn and has not been eating or drinking as much for the past week ... " Blood and urine tests, and a chest x-ray were ordered, and two IV fluid bolus of 1000 milliliters normal saline each, medication for vomiting, and IV magnesium were given. Review of the lab results dated 10/10/24 at 2:58 p.m., indicated sodium 124 mmol/L (range; 136-144), chloride 93 mmol/L (101-111), CO2 19 mmol/L (22-32), Anion Gap 12mmol/L (5-15), random glucose 127 mg/dl (70-110), Osmolality 249 (275-295), calcium 8.6 mg/dL (8.9-10.3), Magnesium 1.1 mg/dL (1.8-2.4), Beta-Hydroxybutyric Acid (BHB) 3.69 mmol/L. Urinalysis indicated Glucose-150 mg/dL (Negative is the normal value), protein-30 mg/dL (negative is normal) and Ketones-Many (negative is normal).

Review of the medical decision-making part of NP 1 ' s note indicated, " ...Upon reevaluation, patient ' s heart rate at rest is between 105-120s and with activity such as sitting up or walking heart rate goes up to the 140s. Given patient continues to experience tachycardia with shortness of breath with simple movements after receiving 2 L of fluid, I discussed with the patient the possibility of PE [pulmonary embolism-a blood clot in the lungs] ...CT ordered ...I have transitioned care to [name of ED Physician] [MD 1] , we have discussed the clinical presentation, work up, and ED course course thus far ... " NP 1 indicated s

Based on interview and record review, Hospital A failed to meet its Recipient Hospital Responsibilities for 6 of 7 requested patient transfers (Patients A, B, C, D, E, and F) when:

1. Hospital D contacted Hospital A on 7/3/24 requesting to transfer Patient A who had a diagnosis of ascites (the abnormal build-up of fluid in the abdomen), and needed a higher level of care. Hospital A declined to accept Pt A due to physician refusal and otherwise had the capacity and capability to accept the transfer.
2. Hospital B contacted Hospital A on 7/20/24 requesting to transfer Pt B who had a diagnosis of sepsis and needed a higher level of care. Hospital A declined to accept Pt B due to physician refusal and otherwise had the capacity and capability to accept the transfer.
3. Hospital B contacted Hospital A on 7/20/24 requesting to transfer Pt C who had a diagnosis of kidney stone and needed a higher level of care. Hospital A declined to accept Pt C due to physician refusal and otherwise had the capacity and capability to accept the transfer.
4. Hospital E contacted Hospital A on 7/30/24 requesting to transfer Pt D who had a diagnosis of kidney stone and needed a higher level of care. Hospital A declined to accept Pt D due to physician refusal and otherwise had the capacity and capability to accept the transfer.
5. Hospital E contacted Hospital A on 8/14/24 requesting to transfer Pt E who needed urologist and a higher level of care. Hospital A declined to accept Pt E due to physician refusal and otherwise had the capacity and capability to accept the transfer.
6. Hospital B contacted Hospital A on 8/16/24 requesting to transfer Pt F who had a gastrointestinal bleed (GIB) and needed a higher level of care. Hospital A declined to accept Pt F due to physician refusal and otherwise had the capacity and capability to accept the transfer.

These failures had the potential to result in a delay in care and could have led to injury or harm to Pts A, B, C, D, E, and F.

Findings:

During a review of the inbound transfer request log dated 6/18/24 through 10/22/24, the log indicated:

1. On 7/3/24 at 1:34 a.m., Hospital D (a rural hospital without specialists) contacted Hospital A to request to transfer Pt A, a 52 year-old with a diagnosis of ascites who needed a gastroenterologist ' s care. The log indicated the case transfer reason was a higher level of care (HLOC) and the patient type was " emergency. " The transfer was declined due to physician refusal. The log did not have any information regarding why the physician refused, or whether the decision to refuse was escalated to anyone.

2. On 7/20/24 at 5:54 p.m., Hospital B contacted Hospital A to request to transfer Pt B, a 70 year-old with a diagnosis of sepsis (a life-threatening complication of an infection) who needed a urology specialist. The log indicated the case transfer reason was a higher level of care (HLOC) and the patient type was " emergency. " The transfer was declined due to physician refusal. The log did not have any information regarding why the physician refused, or whether the decision to refuse was escalated to anyone.

3. On 7/20/24 at 3:19 p.m., Hospital B contacted Hospital A to request to transfer Pt C, a 42 year-old with a kidney stone, who needed a urology specialist. The log indicated the case transfer reason was a higher level of care (HLOC) and the patient type was " emergency. " The transfer was declined due to physician refusal. The log did not have any information regarding why the physician refused, or whether the decision to refuse was escalated to anyone.

4. On 7/30/24 at 11:42 a.m., Hospital E contacted Hospital A to request to transfer Pt D, a 55 year-old with a diagnosis of " Other " who needed a urology specialist. The log indicated the case transfer reason was a higher level of care (HLOC) and the patient type was " emergency. " The transfer was declined due to " Outpatient Follow-up. " The log did not have any information regarding the reason the transfer was declined, or whether the decision to refuse was escalated to anyone.

5. On 8/14/24 at 10:45 p.m., Hospital E contacted Hospital A to request to transfer Pt E, a 53 year-old with a diagnosis of " Other " who needed a urology specialist. The log indicated the case transfer reason was a higher level of care (HLOC) and the patient type was " emergency. " The transfer was declined due to " capacity-specialist. " The log did not have any information explaining the reason the transfer was declined, or whether the decision to refuse was escalated to anyone.

6. On 8/17/24 at 10:33 a.m., Hospital B contacted Hospital A to request to transfer Pt F, a 79 year-old with a diagnosis of GIB who needed a GI specialist. The log indicated the case transfer reason was a higher level of care (HLOC) and the patient type was " emergency. " The transfer was declined due to " capacity-specialist. " The log did not have any information explaining the reason the transfer was declined, or whether the decision to refuse was escalated to anyone.


During an interview on 11/4/24 at 2:20 p.m. with the transfer center manager (TCM), information regarding the six transfer requests was reviewed. The TCM stated the transfer center had been handling transfer requests for Hospital A since April. The TCM stated she does not have much information regarding the individual transfers other than what is on the log already. For Pt A, the TCM stated the reason for the physician refusal was the gastroenterologist indicated he was " at capacity for the day. " The TCM stated there is no indication Hospital A was at capacity, and there is no additional information regarding this transfer request, and she does not know if this refusal was escalated to anyone at Hospital A, or what was meant by at capacity for the day at 1:30 a.m., or if there was any effort to accommodate the transfer at a later time.

The TCM stated for Patient B, the physician refused the patient and indicated the labs were within normal limits, there was no obstruction, and the current facility can treat a complicated urinary tract infection. The TCM stated there is no information regarding the patient ' s diagnosis other than sepsis, or what labs were within normal limits. The TCM stated she does not have any information about whether this refusal was escalated to be reviewed by anyone else at Hospital A.

The TCM stated for Pt C, the physician refused the patient and indicated interventional radiology (IR) should place a nephrostomy tube and the patient can follow up as an outpatient. The TCM stated she does not know whether this refusal was escalated at Hospital A or whether the sending hospital (Hospital B) had the capability or staff available for IR.

The TCM stated for Pt D, there is no further information on the patient ' s diagnosis in addition to " other. " The physician refused the transfer and indicated the patient did not have a fever and labs were normal. The physician indicated interventional radiology should put a nephrostomy tube and the patient can follow up as an outpatient. The TCM did not know whether this refusal was escalated at Hospital A, or whether the sending hospital (Hospital E) had the service of IR, or the availability of an interventional radiologist.

The TCM stated for Pt E, there is no further information regarding Pt E ' s diagnosis of " other. " The reason the transfer was declined was physician refusal and the urologist indicated he was " at capacity for the day. " The TCM stated there is no indication Hospital A was at capacity, there is no additional information regarding this transfer request, and she does not know if this refusal was escalated to anyone at Hospital A, or what is meant by capacity for the day at 10:45 p.m., or if there was any effort to accommodate the transfer at a later time.

The TCM stated for Pt F, the reason the transfer was declined was physician refusal and the gastroenterologist indicated he was " at capacity for the day. " The TCM stated there is no indication Hospital A was at capacity, there is no additional information regarding this transfer request, and she does not know if this refusal was escalated to anyone at Hospital A, or what is meant by capacity for the day at 10:33 a.m., or if there was any effort to accommodate the transfer at a later time.

The TCM stated the physicians don ' t submit the information in writing, it is in their head. The decisions might have been escalated to someone, but she does not have a good record of that. If the physician declines then they will look at another hospital. The TCM stated this is a new process and they are figuring out how to document.

During a review of the hospital ' s policy and procedure (P&P) titled, " EMTALA-Acceptance of Emergency Transfers, " dated 8/23, the P&P indicated, " ...If the transfer center determines that the request is an appropriate transfer, the transfer center will assess the capability and capacity of the hospital ...If the hospital has the capacity to accept the patient, the transfer center will contact the appropriate on-call specialist or emergency department physician to determine acceptance of the patient ...Reporting of Denial of Transfer Request. If the receiving physician declines a transfer, he/she will immediately report the denial of the transfer to the house nursing supervisor on duty. If a physician and/or house nursing supervisor refuses a transfer, he/she will submit a written report to the Transfer Center within 24 hours. The written report will include the name of the patient condition and need for care, the reason given for the transfer and the reason that the physician or house nursing supervisor declined the transfer ... "