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Based on observation, interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for five of 20 patients, Patients (Pts) 1, 2, 5, 6, and 7, when:

1. Based on interview and record review, the hospital failed to comply with regulatory requirements for EMTALA when Patient (Pt) 1 was brought in by an ambulance to the Emergency Department (ED) on 6/19/24 when the hospital was on diversion for the lack of radiology services, with a chief complaint of shortness of breath (SOB-difficulty breathing) and the Charge Nurse (CN) walked out of the ED and informed the Fire Fighter Medic (FFM) the hospital was in diversion. The FFM was given the impression Hospital A would not accept Pt 1 and Pt 1 was diverted to Hospital B which was over 40 miles away. Pt 1 was not evaluated by the CN and was not provided a Medical Screening Exam (MSE) for the purpose of identifying an emergency medical condition (EMC-a medical condition that requires immediate medical attention to prevent serious harm or death). (Refer to C2406)

2. Patient 2 was brought in by ambulance on 11/28/23 at 3:58 p.m. with a chief complaint of 5150 Danger to Others (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily [something is done without choice] detained for a 72-hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled [an inability to provider for their basic needs due to a mental illness]) and while in the emergency department (ED), Patient 2 did not receive a mental health evaluation (a test that assesses a person's mental health and well-being) to address her emergency medical condition (EMC-an illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm), there was no indication there were attempts to transfer Patient 2 to another hospital for a mental health evaluation and Patient 2 was discharged after her 5150 expired. While in the ED there was no suicide risk screening assessment (identifies individuals that require further mental health/suicide safety assessment) or documentation Patient 2 was not a danger to others. (Refer to C2407)

3. Patient 5 presented to the ED on 6/19/24 at 3:06 p.m. with a chief complaint of lower back pain after a fall. Patient 5's pain was not addressed while in the ED, the ED did not have radiology services due to lack of staffing therefore Patient 5 was told to come back in a couple days for an x-ray and was discharged with a prescription for pain medication. Patient 5's vital signs (measurements of body's most basic functions, such as temperature, pulse, breathing rate and blood pressure) and pain were not reassessed at discharge. (Refer to C2407)

4. Patient 6 presented to the ED with his mother on 8/9/24 at 11:37 p.m. with a chief complaint of fever and ear pain. Patient 6 had a fever on arrival to the ED, there was no indication fever reducing medication was administered to Patient 6 prior to arrival to the ED and the ED physician did not order any fever reducing medications while Patient 6 was in the ED. Patient 6 was tested for covid 19 (a nasal swab that checks for the Covid 19 virus), influenza (test used to determine if someone has the flu), and respiratory syncytial virus (RSV-checks a fluid sample from your nose to see if the RSV virus is causing symptoms of a respiratory infection) which were all negative. Patient 6 was eventually discharged home with acetaminophen (fever reducing medication) and amoxicillin (medication used to treat a wide range of germs) and Patient 6's temperature to include vital signs were not reassessed at discharge. (Refer to C2407)

5. Patient 7 was brought in by ambulance on 6/19/24 at 11:18 p.m. with a chief complaint of right shoulder injury. Patient 7's pain was not addressed while in the ED, there was no indication pain medications were ordered or administered. Patient 7was eventually discharged and told to go to Hospital B for x-rays due to the lack of a radiology tech. (Refer to C2407)

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

Based on interview and record review, the hospital failed to comply with regulatory requirements for EMTALA when Patient (Pt) 1 was brought in by an ambulance to the Emergency Department (ED) on 6/19/24 when the hospital was on diversion for the lack of radiology services, with a chief complaint of shortness of breath (SOB-difficulty breathing) and the Charge Nurse (CN) walked out of the ED and informed the Fire Fighter Medic (FFM) the hospital was in diversion. The FFM was given the impression Hospital A would not accept Pt 1 and Pt 1 was diverted to Hospital B which was over 40 miles away. Pt 1 was not evaluated by the CN and was not provided a Medical Screening Exam (MSE) for the purpose of identifying an emergency medical condition (EMC-a medical condition that requires immediate medical attention to prevent serious harm or death).

This failure resulted in Pt 1 not being provided the benefit of a timely MSE and stabilization of a potential emergency medical condition to the capabilities of the hospital.

Findings:

During a review of Pt 1's "Patient Care Record (PCR) ," dated 6/19/24, the PCR indicated, " ...[Pt 1] ...Male ...66 [years] ...Signs & Symptoms ...Shortness of breath ...Cough ...Fatigue ...Fever ...On scene found 66 [year old] male patient laying semi Fowler's on a bed ...in mild distress [chief complaint] of body pain. [Patient] stated that he was having all over body pain rating it at 4/10. Further information from Wife stated that he has had a cough [times] 1 week and had a fever of 103 last night. Vitals assessed on scene vitals [within normal limits]. [Patient] Denied any [nausea, vomiting, diarrhea]. [History] of diabetes [a disease that occurs when the body's blood sugar levels are too high], a triple bypass [a type of heart surgery that reroutes blood around three blocked arteries]. [No known drug allergies]. [Patient] Moved to gurney with help of engine crew using a mega mover. [Patient] Transported priority 2 to Coalinga originally but at destination we were advised that Coalinga was on diversion ...rerouted to [name of Hospital B]. During transport [patient] Complained of some SOB along with cough [Patient] Had audible wheezing [a high-pitched whistling sound made while breathing], 2.5 [milligrams (mg)-unit of measure] of albuterol [medication used to relax and open-air passages to the lungs to make breathing easier] breathing treatment given with improvement to patient breathing. No other interventions during transport. Vitals remained [within normal limits]. At destination, handoff report given to RN and care transferred to [registered nurse] ..."

During a review of Pt 1's "Emergency Department Physician Notes (Note )," dated 6/19/24 from Hospital B, the Note indicated, "Chief Complaint ...[Brought in by ambulance] for cough and wheezing [times] 1 [week], started with a fever yesterday and generalized body pain today ...Orders ...DuoNeb, 6 [milliliter-unit of measure], Chest radiograph ...No acute disease of the chest ...I was able to speak with the patient's wife and understand her concerns. She states that he had a documented elevated temperature yesterday however, the patient has not been febrile here today. She says that he has had a cough which has resolved by today as the patient has not been coughing at the bedside. He did receive a breathing treatment upon arrival and has since been feeling well ...Otherwise, the patient has had normal oxygen saturations on room air. Patient is having oxygenation at 96% on room air ...Patient already has home health at home ...The patient is stable and does not have any complaints here ...I was not able to visualize or appreciate pneumonia on his chest x-ray ...However, he may have an atypical pneumonia and so I placed him on azithromycin for the next 5 days. His wife will have him follow-up with a primary care physician or with his home health care and return here if there is any persistent or worsening symptoms ...Condition ...Stable ...Disposition ...Discharge to home ..."

During an interview on 8/21/24 at 11:06 a.m. with the Unit Clerk (UC), the UC stated on 6/19/24 the hospital was on diversion. The UC stated she called the dispatch for emergency medical services (EMS) and informed the dispatcher the hospital was on diversion for inability to staff a radiology technician (a healthcare professional who uses imaging equipment to create images of the human body). The UC stated diversion was when the hospital did not have a service and when EMS was informed of the diversion, the EMS staff decided which hospital to take the patient based on their symptoms. The UC stated the Director of Nursing (DON) and Emergency Department Manager (EDM) notified her when the hospital was on diversion. The UC stated on 6/19/24, an ambulance drove up to the emergency department (ED), she notified the Charge Nurse (CN) and he went outside to talk to the FFM.

During an interview on 8/21/24 at 11:19 a.m. with the CN, the CN stated a patient was considered a patient of the ED when they walked in through the door or pulled up in their vehicles. The CN stated on 6/19/24 the hospital was on diversion at 9:50 a.m. due to not having a radiology technician. The CN stated a call came in from EMS and a registered nurse (RN) picked up the call and informed him they had a 35-year-old female with shortness of breath (difficulty breathing) and no other information was obtained during the call. The CN stated he had the UC redial the number that just called so he could inform the FFM the hospital was in diversion and had no radiology services so they should proceed to the nearest hospital. The CN stated he thought the ambulance was proceeding the nearest hospital but the next thing he knew the ambulance was backing up in the EMS bay. The CN stated the FFM asked if the ED was closed, and the CN informed the FFM the ED was not closed. The CN stated the FFM asked if patients were accepted on a case-by-case basis and the CN stated yes. The CN stated he began walking back inside the ED and the ambulance drove off. The CN stated Pt 1 was not triaged and when the ambulance pulled up to the ED, he did not see Pt 1.

During an interview on 8/21/24 at 1:41 p.m. with the CN, the CN stated during his conversation with the FFM, there was no mention that the ED could not accept Pt 1 and the FFM did not ask if the ED would accept Pt 1. The CN stated he was not sure if Pt 1 should have been triaged, Pt 1 was on their property, but she was still under the FFM's care. The CN stated the importance of triage was to categorize how critical the patients were and if there was one bed available and many patients, they could prioritize which patient was more critical by their triage. The CN stated if patients were not triaged timely, the patient could deteriorate.

During an interview on 8/21/24 at 4:55 p.m. with the Director of Nursing (DON), the DON stated he had always given instructions to the ED staff regarding EMTALA. The DON stated regardless of whether they were on diversion, when an ambulance did not get the message and they pulled up to the ED, the hospital staff were to see the patient. The DON stated the patient should be triaged even if they have to transfer the patient out 15 minutes after arriving. The DON stated he had never educated staff to turn away patients and had continued to remind staff of the need to accept patients when they arrived at the ED .

During a concurrent interview and record review on 8/22/24 at 1:47 p.m. with the Communications Supervisor (CSR), the document titled, "Facility Status Audit Report (Report)," dated 8/22/24 was reviewed. The CSR stated a diversion occurred when the hospital could not take any patients. The CSR stated a diversion could occur at any time depending on what was happening at the hospital. The CSR stated the Report indicated, Hospital A had 10 episodes of diversion from 6/19/24 to 8/22/24. The CSR stated when they were informed a hospital was on diversion, they entered the diversion into their computer aided design (the program used by dispatch). The CSR stated if the EMS units had the need to transport a patient to that hospital, a diversion caution note would remind the dispatcher. The CSR stated the dispatcher would advise the unit of the diversion so they could make the appropriate change to either continue to the hospital or divert to a different hospital. The CSR stated the patient would be sent to another hospital depending on the patient's symptoms and possible need for radiology services. The CSR stated the most appropriate hospital for the patient's condition was decided by the medic, however a patient could also make a request for which hospital they preferred.

During an interview on 8/23/24 at 11 a.m. with the FFM, the FFM stated on 6/19/24 Pt 1 presented with cough for one week and a fever of 103 degrees Fahrenheit. The FFM stated he informed Hospital A he was bringing a patient to their ED and was not aware Hospital A was on diversion until they were already backing up to the ED EMS entrance. The FFM stated when they got to the ED EMS entrance one of their charge nurses (CN) came outside and told them the hospital was on diversion for not having radiology services available. The FFM stated once he was informed of the diversion by the CN, he contacted Hospital B and alerted Hospital B to what was going on. The FFM stated the CN said based on Pt 1's signs and symptoms, they were not going to accept Pt 1. The FFM stated he did not make face to face contact with the ED physician, and he assumed the ED physician told the CN which patients they could accept. The FFM stated if the CN did not come out of the ED to inform them of the diversion, they would have unloaded the patient and taken the patient into the ED. The FFM stated the ED physician did not see Pt 1. The FFM stated Pt 1 was taken to Hospital B which was about 42 miles away and it took about 45 minutes to get there. The FFM stated Hospital A has been on diversion on and off and the main reason was due to the lack of radiology services.

During an interview on 8/23/24 at 4:10 p.m. with Medical Doctor (MD) 1, MD 1 stated he did not recall the incident on 6/19/24 which involved Pt 1. MD 1 stated a patient was considered a patient of the ED when they entered the hospital's property. MD 1 stated the ED should have taken Pt 1 in if they did not.

During an interview on 8/26/24 at 1:48 p.m. with the Director of Nursing (DON), the DON stated he was made aware of the incident that occurred on 6/19/24 the following day when he reviewed his email. The DON stated with the information provided to him, he let the CN know that anytime an ambulance presents whether they were on diversion or not, that it was their patient. The DON stated the CN was somewhat confused about what happened, and the CN reiterated (repeated) that he did not turn the ambulance away. The DON stated he informed the CN that the CN should have informed the FFM to bring Pt 1 into the ED. The DON stated there had not been any formal education about the incident with Pt 1, but he had been talking to staff and discussed it daily when he went to the ED. The DON stated he was irritated about the incident from the beginning because anytime a patient came to the ED, the patient should be evaluated by the ED physician. The DON stated EMTALA protected patients and was the emergency medical treatment act and labor act, which ensured every person who came within 250 yards of the hospital were seen, no matter what their race, ethnic background, or ability to pay. The DON stated the patients should be treated to determine if there was an EMC and if the ED was able to stabilize the patient. The DON stated the patient should be cared for there at the hospital and if transfer was required, the patient was transferred to another facility.

During an interview on 8/26/24 at 3:39 p.m. with the EDM, the EMD stated she was aware of the incident on 6/19/24 after it occurred when the CN informed her about what happened. The EDM stated she asked the CN what occurred, and they discussed the situation and the EDM wanted to make sure they were able to account for Patient 1, so they created an EMS log to log all the EMS calls that came into their ED. The EDM stated this was the first time they were unable to log the situation where the patient did not come inside the ED. The EDM stated there was no education provided to ED staff regarding the incident with Patient 1. The EDM stated she had one to one conversation with the CN about what happened, went over diversion, EMTALA, and ED protocols and the CN understood. The EDM stated she was not sure how many times the ED had to go on diversion since 6/19/24.

During an interview on 8/26/24 at 3:55 p.m. with the Compliance/Infection Preventionist (CIP), the CIP stated the EDM notified him about the incident involving Pt 1 on 6/19/24 when the EDM was notified by the CN. The CIP stated once he was notified, the CIP asked around to see what happened, notified the Administrator (ADM), and decided to self-report (report the incident to the California Department of Public Health (CDPH). The CIP stated the self-report was emailed on 6/19/24. The CIP stated they discussed the situation with Pt 1 during huddles, on the spot education, and updated their leaders in the ED to ensure this incident did not happen again.

During an interview on 8/27/24 at 10:08 a.m. with MD 2, MD 2 stated he was aware of the incident that occurred on 6/19/24 which involved Pt 1. MD 2 stated he was told Pt 1 did not enter the ED and he was not sure if Pt 1 was triaged. MD 2 stated he was aware the ED was on diversion for the past couple of months due to radiology staffing. MD 2 stated hospitals were allowed to self-divert and the only reason the hospital self-diverted was due to the lack of radiology services. MD 2 stated a patient was considered a patient of the ED when the patient was registered. MD 2 stated when a patient was in the EMS entrance and up to 200 feet from the hospital, the patient should be seen in the ED.

During a concurrent interview and record review on 8/28/24 at 3:05 p.m. with the DON, the hospital's policy and procedure (P&P) titled, "Saturation-Emergency Department," dated 8/2/21 was reviewed. The P&P indicated, " ...The Administrator or Chief Nursing Officer has the responsibility of reporting any incidents of "diversion" to the California Department of Public Health within 24 hours by phone or fax ..." The DON stated the incidences of diversion was not reported to CDPH and it was not their policy to report incidences of diversion to CDPH unless the diversion was going to last longer than 24 hours.

During a concurrent interview and record review on 8/28/24 at 3:15 p.m. with the ADM, the hospital's P&P titled, "Saturation-Emergency Department," dated 8/2/21 was reviewed. The ADM stated anytime there were any issues whether its equipment failure or staffing in the ED, he was notified of the issues. The P&P indicated, " ...The Administrator or Chief Nursing Officer has the responsibility of reporting any incidents of "diversion" to the California Department of Public Health within 24 hours by phone or fax ..." The ADM stated the information was not accurate, all their P&P needed to be reviewed and revised for best practices. The ADM stated if the hospital did not have radiology services, the EMS needed to be aware so as to not delay patient care.

During a review of the hospital's P&P titled, "Saturation-Emergency Department," dated 8/2/21, the P&P indicated, " ...To establish criteria on when the Emergency Department may declare saturation ...ED diversion is only determined as a last resort when the ED cannot safely care for incoming patients ...Other internal incidents that may trigger the ED to go on "diversion" from EMS calls include inability to perform CT or diagnostic x-rays for a period greater than 4 hours, loss of laboratory function and inability to send lab to nearby facilities for resulting, anything that may result in the ED having the capability to sustain the appropriate level of care necessary. Prior to the Emergency Department going on "diversion" for any reason, the charge nurse and the ED physician shall immediately notify the Chief Nursing Officer or the Administrator (Admin on call if previous unavailable) of the facility occurrence ...The Administrator or Chief Nursing Officer has the responsibility of reporting any incidents of "diversion" to the California Department of Public Health within 24 hours by phone or fax ..."

During a review of the hospital's P&P titled, "Compliance with Emergency Medical Treatment," dated 2/10/24, the P&P indicated, " ...It is the policy of the Hospital to comply with the EMTALA obligations. These policies are mandated by Section 1867 of the Social Security Act, as amended, and regulations adopted by the Centers for Medicare Services (CMS), and applicable state laws governing the provision of emergency services and care ...Failure to comply with EMTALA may result in termination by CMS of the hospital's participation in the Medicare and Medicaid programs, as well as civil monetary penalties impose by the OIG for both the Hospital and Physicians of up to $50,000 and possible exclusion from Medicare/Medicaid. Failure to comply with the state laws on emergency services is subject to a licensing enforcement action. A violation of EMTALA is also subject to civil lawsuits for damages ...Comes to the Emergency Department means an individual who ...Is in a ground or air ambulance owned and operated by the Hospital for the purposes of examination or treatment for a medical condition at the hospital's dedicated emergency department, unless the ambulance is operated (i) under community EMS protocols that direct the ambulance to transport the individual to another facility ...or ...at the direction of a physician is not employed or affiliated with the Hospital ...Is in a non-Hospital owned ground or air ambulance that is on Hospital property for presentation for examination or treatment for a medical condition at the Hospital's dedicated emergency department ...Hospital Property means the entire main Hospital campus, including ...Areas and structures that are located within 250 yards of the main building, and any other areas determined on an individual case basis by the CMS regional office, to be part of the main Hospital's campus. Hospital property includes the parking lots, sidewalks, and driveways on the main Hospital campus ..."

During a professional review of an article from the National Library of Medicine titled, "EMS Emergency Department Diversion," dated 2/24/24, the Article indicated, "Emergency medical services (EMS) are an essential healthcare component in the United States. EMS provides skilled acute car and timely access to definitive care for critically ill or injured patients. Situations like epidemics may overwhelm a medical facility's capabilities, affecting patient care quality or availability. EMS diversion occurs when emergency departments (EDs) temporarily close to incoming ambulance traffic. When an ED assumes a diversion status, EMS must bypass that hospital and proceed to the closest facility with availability. Diversion may affect all ambulance traffic or limit admissions to certain patient types, such as trauma services, OB care, or advanced cardiac care ...EMS diversion was initially intended to combat the growing issue of ED crowding. Facilities previously experienced rising ED wait times due to increasing patient volume. The perceived solution to this problem was to disperse incoming volume to less crowded facilities. However, EMS diversion has been shown recently to not only perpetuate the ED crowding issue but also to incite new problems. Understanding the difficulties, initiatives, and proposed plans to tackle EMS diversion and its effects on healthcare is crucial for safeguarding patient safety, optimizing resource allocation, enhancing system efficiency, protecting public health, informing policy and planning decisions, managing costs, and maintaining care standards within healthcare systems ...Ambulance diversion is undesirable yet unavoidable in the face of severe ED crowding and facility limitations. EMS and ED directors and hospital system administrators should collaborate to decrease ED crowding and EMS diversion hours. EMS plays a critical role in enabling patients to access the healthcare system. Patients may receive improved care by reducing diversion and subsequent offload delays. Ambulances can return to service quicker, enhancing efficiency and patient outcomes ..."

Based on interview and record review, the hospital failed to ensure stabilizing measures were provided for four of 20 patients (Patient 2, Patient 5, Patient 6, and Patient 7) when:

1. Patient 2 was brought in by ambulance on 11/28/23 at 3:58 p.m. with a chief complaint of 5150 Danger to Others (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily [something is done without choice] detained for a 72-hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled [an inability to provider for their basic needs due to a mental illness]) and while in the emergency department (ED), Patient 2 did not receive a mental health evaluation (a test that assesses a person's mental health and well-being) to address her emergency medical condition (EMC-an illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm), there was no indication there were attempts to transfer Patient 2 to another hospital for a mental health evaluation and Patient 2 was discharged after her 5150 expired. While in the ED there was no suicide risk screening assessment (identifies individuals that require further mental health/suicide safety assessment) or documentation Patient 2 was not a danger to others.

This failure resulted in Patient 2's emergent psychiatric problem not to be stabilized and had the potential to worsen, lead to injury, harm, or death for Patient 2 and others who have a psychiatric emergency.

2. Patient 5 presented to the ED on 6/19/24 at 3:06 p.m. with a chief complaint of lower back pain after a fall. Patient 5's pain was not addressed while in the ED, the ED did not have radiology services due to lack of staffing therefore Patient 5 was told to come back in a couple days for an x-ray and was discharged with a prescription for pain medication. Patient 5's vital signs (measurements of body's most basic functions, such as temperature, pulse, breathing rate and blood pressure) and pain were not reassessed at discharge.

This failure resulted in Patient 5 being discharged home without her EMC being appropriately addressed and had the potential for her back pain to worsen, and cause possible long-term damages and continued pain.

3. Patient 6 presented to the ED with his mother on 8/9/24 at 11:37 p.m. with a chief complaint of fever and ear pain. Patient 6 had a fever on arrival to the ED, there was no indication fever reducing medication was administered to Patient 6 prior to arrival to the ED and the ED physician did not order any fever reducing medications while Patient 6 was in the ED. Patient 6 was tested for covid 19 (a nasal swab that checks for the Covid 19 virus), influenza (test used to determine if someone has the flu), and respiratory syncytial virus (RSV-checks a fluid sample from your nose to see if the RSV virus is causing symptoms of a respiratory infection) which were all negative. Patient 6 was eventually discharged home with acetaminophen (fever reducing medication) and amoxicillin (medication used to treat a wide range of germs) and Patient 6's temperature to include vital signs were not reassessed at discharge.

This failure had the potential for Patient 6 to continue to have unrelieved fever and worsening symptoms due to the lack of addressing Patient 6's fever while in the ED.

4. Patient 7 was brought in by ambulance on 6/19/24 at 11:18 p.m. with a chief complaint of right shoulder injury. Patient 7's pain was not addressed while in the ED, there was no indication pain medications were ordered or administered. Patient 7 was eventually discharged and told to go to Hospital B for x-rays due to the lack of a radiology tech.

This failure resulted in delayed pain control and care for Patient 7 when he was discharged and had to be driven to Hospital B which was 42 miles away for treatment to resolve his EMC.

Findings:

1. During a review of Patient 2's "Electronic Health Record (EHR-an electronic version of a patient's medical history)," dated 11/27/23, the EHR indicated, "68-year-old female brought in by ambulance on law enforcement 5150 hold after she was found setting fires in a creek bed. EMS reports that the patient was agitated [very worried or upset] and aggressive [likely to attack other people or behave violently] during transport, attempting to assault [hit] them; patient was given [midazolam-an injection that helps you relax or sleep] 4 mg (milligram-unit of measurement) which resulted in diminished [decreased] aggression. She was initially noted to have [Glasgow coma scale-GCS-a tool used to measure a patient's level of consciousness] of 13, but has increased to 15 as the [midazolam] wore off. Multiple attempts to obtain a history from the patient have proven successful as she is verbally aggressive, challenging, demanding, and uncooperative ...Past Medical History: methamphetamine abuse [a highly addictive drug], homelessness ...Thin, disheveled [in a state of disorder] female, poor hygiene, intermittently agitated ...ordered an [electrocardiogram-EKG-a simple, painless test that records electrical activity of the heart to assess its function] ...Interpretation ...Abnormal ... Imaging ...[anteroposterior-AP-a type of chest x-ray that examines the lungs, heart, and other structures of the chest] view of the chest ...Impression: No focal airspace consolidation [normal finding] ...Clinical Course/Medical Decision Making: Anemia [a condition that develops when your blood produces a lower than normal amount of healthy red blood cells] ...Hypokalemia [a condition where the level of potassium (electrolyte) in your blood is lower than normal] ...Hypoalbuminemia [a condition in which the body has low levels of albumin(a protein that helps keep fluid in blood vessels)] ...Hypocalcemia [a condition in which the body has too little calcium in the blood] ...Condition: unchanged ...Continue with 72 hour hold ..."

During a review of Patient 2's "EHR," dated 11/29/23, the EHR indicated, " ...Test ...Potassium ...3.4 ...Ordered medication ...11/27/23 ...sodium chloride [a source of electrolytes and water for hydration] 0.9% 1000 ml [millimeter-unit of measurement] bag ...potassium chloride premix [intravenous (IV) solution used to treat hypokalemia] 10MEQ/100ML ...potassium chloride tab [oral tablet used to treat hypokalemia] 20MEQ ...11/28/23 ...diphenhydramine injection [used as a sedative for mental health patients] 50mg/ml ...haloperidol [medication used to manage symptoms including hallucinations [false perceptions of sensory experiences] and delusions [a false belief that is fixed and persists] 5mg/1ml ...lorazepam [medication used to relieve anxiety] injection solution 2mg/1ml ...sodium chloride 0.9% 1000ml bag ...potassium chloride tab 20 [milliequivalent (MEQ-a unit of measurement)] ...potassium chloride premix 10 MEQ/100ml ...potassium chloride tab 20 MEQ ...hydroxyzine pamoate oral [used to treat anxiety (a feeling of fear or dread)] capsule 25 mg ...nitrofuran mono [commonly used to treat bladder infections] cap 100mg ...Clinical Course ...Patient remain stable. Occasional episodes of agitation managed with hydroxyzine. Largely cooperative ...Assessment ...5150 ...Hypokalemia ...methamphetamine positive toxicology screen ...urinary tract infection [UTI-an infection of the urinary tract] ...Plan: Start [nitrofurantoin100mg, 1 tab by mouth twice a day ...5150 expires tomorrow ...In past patient has been discharged to the care of her daughter who lives in town ..."

During a review of Patient 2's "EHR," dated 11/30/23, the EHR indicated, " ...GCS 15 ...Some anxiety persists-she is indeed quite anxious about "getting out"-her 5150 is over 3 PM today. We have contacted a "friend" by telephone who states he might be able to pick her up-we are to contact him again ...[Patient 2] has no physical complaints; tolerates her diet well; has no auditory nor visual hallucinations ...Psychiatric: GCS 15. The patient is oriented [times] 4. Mood and affect are appropriate ...ED Course ...Examined and Evaluated in ER. Did well under current regimen. Discussed all aspects with patient. Appears will be stable for discharge off of 5150 at 3PM today. Was a bit somnolent during the day after earlier sedation; however did well. Patient appears to be a safe discharge 5:20PM ...Reeval: Improved clinical status on repeated examinations and evaluations ...Diagnostic Impression: (1). 5150 Hold-Release (2). Anemia (3). Hypothyroid (4). Hypokalemia-Treated (5). UTI-Treated (6). Amphetamine [stimulant drug] Intoxication [a temporary condition that affects the central nervous system (CNS-the brain and spinal cord which work together to process and respond to sensory information, and control nearly all of the body's functions)]-Resolved ...Disposition/Plan: (1). Discharge Home (2). Follow up with [primary medical doctor] /Rural Clinic in 1-2 days (3). Return to ER if symptoms persist or worsen in any way. (4). Review Discharge Instructions given to you prior to discharge ...Condition: Stable ...Disposition: Home ..."

During a review of Patient 2's "Nursing Note (NN)," dated 12/1/23, the NN indicated, " ...[Patient] given clothes, jeans, jacket, and socks, has been discharged since yesterday when her 5150 expired at 1457. At this time [patient] got up from bed, put on her clothes that were given to her, and stated she wanted to leave. [Patient] walked out the front of the hospital and said that she would be leaving at this time ..."

During a concurrent interview and record review on 8/22/24 at 3:15 p.m. with the EDM, Patient 2's "EHR," dated 11/27/23 was reviewed. The EDM stated the EHR indicated Patient 2's Suicide Risk assessment and documentation of whether Patient 2 was a danger to others was not documented. The EDM stated the suicide risk assessment should be assessed at triage for all patients and when Patient 2 was cognitively available to complete the assessment the nurse should have assessed Patient 2's suicide risk. The EDM stated Patient 2 was never medically cleared by the time her hold was up, they were not able to get Patient 2 a mental health evaluation. The EDM stated unless there was a medical reason to transfer Patient 2 or once Patient 2 was medically cleared, the ED physician should have transferred Patient 2 to a hospital for a higher level of care or to another hospital for a mental health evaluation. The EDM stated the hospital did not have mental health evaluators and patients who required a mental health evaluation should be transferred to another hospital that had those services. The EDM stated the importance of a mental health evaluation was to make sure the patient received the necessary care and resources.

During a concurrent telephone interview and record review on 8/27/24 at 11:15 a.m. with MD 2, Patient 2's "EHR," dated 11/27/23 was reviewed. MD 2 stated 5150 patients are usually brought in custody or in the presence of law enforcement. MD 2 stated the patient could be a danger to self or others or gravely disabled. MD 2 stated the patient was kept under constant observation with a sitter MD 2 stated when patients are under constant observation their personal belongings are taken and put in a secure area and the patient was asked to change into a pair of green paper jump suit. MD 2 stated he would order labs,urinalysis and if the patient's mental status was questionable, he could order imaging. MD 2 stated he would collect information such as the patient's past medical history and assess the patient. MD 2 stated once all the labs, imaging or urinalysis results are back he was able to determine if the patient was medically cleared and the transfer requests were initiated. MD 2 stated transfer requests for mental health evaluations had been unsuccessful and the hospital did not have a dedicated tele psychiatry (a type of telemedicine that uses technology to provider psychiatric care remotely) to assess patients who required a mental health evaluation. MD 2 stated after the 5150 expired, if the patient was medically stable, and they were not suicidal (marked by an impulse to end one's life) or homicidal (having tendencies towards the killing of another person)they are usually discharged to family or friends. MD 2 stated occasionally they had to get the police department to extend a patient's 5150 especially when they found a hospital who accepted the patient. MD 2 stated due to transportation delays the patient's 5150 expired so they would have to extend the 5150 in order for the hospital to accept the patient. MD 2 stated the EHR indicated, " ...[Patient] given clothes, jeans, jacket, and socks, has been discharged since yesterday when her 5150 expired at 1457. At this time [patient] got up from bed, put on her clothes that were given to her, and stated she wanted to leave. [Patient] walked out the front of the hospital and said that she would be leaving at this time ..." MD 2 stated there was no indication Patient 2 left with a family member or friend and there was no documented indication whether Patient 2 was a danger to others during her ED stay or prior to discharge. MD 2 stated ideally a patient on a 5150 should have a mental health evaluation. MD 2 stated the importance of a mental health evaluation was to ensure the patient's care was addressed.

During an interview on 8/27/24 at 1:35 p.m. with the Registered Nurse (RN), the RN stated when a patient arrived in the ED, the patient was registered and then the patient was called back to triage. The RN stated the patient was called to triage within 10-15 minutes, their vital signs were taken, the patient was triaged and assigned an emergency severity index (ESI-a tool used in the emergency department triage) level of 1-5. The RN stated level 1 was death, CPR in progress; level 2 acute respiratory distress, life or limb; level 3 required two or more interventions; 4 and 5 required lesser resources. The RN stated a patient on a 5150 should have an ESI of 2. RN stated an ESI of 2 is determined by assessing if patient had an active plan to hurt themselves. Interventions put into place were a one to one sitter, the patient was asked to change into paper scrubs and personal clothing was secured in a locked area due to the fact that the patient could use their clothing to hurt themselves. The RN stated the abuse and suicide risk screening was completed at triage. The RN stated the ED did not have a licensed mental health evaluator so during the 72 hour period, the ED staff were actively trying to transfer the patient to a mental health facility in the area to get assessed. The RN stated sometimes there could be up to three patients in the ED on 5150's and the ED staff may have a hard time to find accepting facilities, if they were unable to find a facility within 72 hours, the police department could reassess the patient and reissue the 72 hour hold. The RN stated the importance of a mental health evaluation was to ensure the patient's care needs were met.

During an interview on 8/27/24 at 3:10 p.m. with the Director of Nursing (DON), the DON stated his expectations of 5150 patients was, these patients should be assessed by an ED physician, if the patient had an emergency or medical condition, their needs should be addressed and once medically cleared, start the transfer process. The DON stated the transfer process should be documented on the Transfer Call Log. The DON stated if the patient was suicidal, the patient required a one-to-one sitter who would monitor and document the patient's behavior every 15 minutes. The DON stated the importance of a mental health evaluation was very important so the patients could receive the help they needed . The DON stated unfortunately due to the hospital location and the availability of beds for patients who required mental health evaluations, sometimes the facility was unable to transfer these patients and once their hold expired, they were free to leave as they could not hold these patients. The DON stated the nurses were responsible to document each patient's suicide risk screening and this screening should be completed on all patients during triage. The DON stated the suicide risk screening for 5150 patients should be completed initially at triage and then on an ongoing basis.

During a concurrent interview and record review on 8/27/24 at 3:15 p.m. with the DON, the hospital's policy and procedure (P&P) titled, "Patient Awaiting Psychiatric Evaluation," dated 2/2/24 was reviewed. The P&P indicated " ...For those who are brought for suicidal ideation, A Suicidal Screening must be completed by the RN/LVN each shift and any time the patient expresses suicidal ideation or makes self-harming gestures ...Observation of signs and symptoms of mental, emotional, behavioral or suspected substance abuse ...Documentation of potential danger to self, staff, or others ..." The DON stated his expectations were nurses should follow all hospital P&P.

During an interview on 8/27/24 at 4:26 p.m. with the CIP, the CIP stated there were no documented attempts to transfer Patient 2 to another hospital.

During an interview on 8/28/24 at 3:05 p.m. with the DON, the DON stated the importance of nurses following P&P was to ensure everything was done correctly and should always be the same.

During a review of the hospital's P&P titled, "Compliance with Emergency Medical Treatment," dated 2/10/24, the P&P indicated, " ...To stabilize means with respect to an emergency medical condition, to ...either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital or, in care of a woman in labor, that the woman has delivered the child and the placenta ...Stable for Discharge means a determination by the treating physician, within reasonable clinical confidence, that an individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provide the individual is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable for discharge when he/she is no longer to be a threat to himself/herself or to other ..."

2. During a record review of Patient 5's "EHR," dated 6/19/24, the EHR indicated Patient 5 came to the ED with a chief complaint of 9/10 (pain scale usually 0-10 with 10 being the worst pain) lower back pain after a fall. The EHR indicated, " ...32 year old female presents emergency room complaining of pain in the middle of her lumbar area. Patient fell on Saturday landing directly on the mid lumbar area. She has most of the tenderness is over the mid posterior spinous processes of the lumbar area with a little bit of tenderness in the paraspinous muscles adjacent to that. The patient is up and while ambulatory ...Examination shows tenderness over the posterior spinous processes of the mid lumbar area with some mild discomfort over the paraspinal muscles. Patient is fully ambulatory and does not seem to be having a lot of pain although she says the pain is 9 on a scale of 10 and she is able to walk without showing any evidence of discomfort. Unfortunately the [radiology] department is closed today because the [radiology] tech developed an acute illness. This morning and had to go home and there was not sufficient notice to get somebody else to pull the shift today. We will have an x-ray tech in the morning. Patient may return at that time and will be lumbar spine ...Plan: Return tomorrow for x-rays lumbar spine ...Norco 5/3/2025 1 every 4 hours #12 ..." The EHR indicated Patient 5 was not administered any pain medications while in the ED. The EHR indicated Patient 5 was discharged at 4:25 p.m. with a diagnosis of tenderness over lumbar spine, back pain and Patient 5's vital signs and pain were not reassessed at discharge.

During an interview on 8/21/24 at 2:25 p.m. with the EDM, the EDM stated, "The importance of vital signs if the patient's chief complaint was pain, was their pain should be assessed to ensure the patient didn't have any physiological issues before the patient was discharged." The EDM stated pain was considered a vital sign as well and should be assessed with the vital signs. The EDM stated if Patient 5's vital signs were not assessed prior to discharge, depending on what the patient presented with, the patient could have a form of distress and if they did not appear in distress, something could be missed.

During a concurrent interview and record review on 8/23/24 at 4:10 p.m. with MD 1, Patient 5's "EHR," dated 6/19/24 was reviewed. The EHR indicated Patient 5 came to the ED for lower back pain after a fall with a 9/10 pain. MD 1 stated it was the ED physician's judgement call, whether to transfer Patient 5 or if could wait to take x-rays. MD 1 stated the common practice is to discuss discharge with the patient and having the patient coming back for an x-ray. MD 1 state the option is also given to the patient to be transferred. The EHR indicated there was no indication MD 1 discussed a possible transfer for an x-ray with Patient 5. The EHR indicated while in the ED Patient 5 was not administered any pain medications or interventions to assist with Patient 5's 9/10 pain. MD 1 stated the importance of pain interventions was to relieve the patient's pain as much as they could, and he did not have any issues with ordering pain medications if it was in the patient's best interest. MD 2 stated if the patient's pain was not addressed, he was not sure what could happen to the patient.

During a telephone interview on 8/26/24 at 4:46 p.m. with Patient 5, Patient 5 stated she was told her back pain was not that bad. Patient 5 stated the doctor gave her a prescription for pain medication and told her to go back to the ED in two to three days for an x-ray due to not having anyone available to take x-rays. Patient 5 stated the doctor did not offer to transfer her to another hospital for x-rays. Patient 5 stated she felt the ED did not address her back pain when she was in the ED. Patient 5 stated she did not return to the ED for x-rays due to having to go back to work and take care of her kids.

During a concurrent interview and record review on 8/27/24 at 10:30 a.m. with MD 2, Patient 5's "EHR," dated 6/19/24 was reviewed. MD 2 stated he addressed his patient's pain based on the patient's self-report which was subjective and then he used the Baker-Wong pain assessment (pain assessment tool to help a person effectively communicate the severity of their physical pain) to determine what level of pain the patient really had. MD 2 stated the EHR indicated, " ...Examination revealed a well-developed well-nourished female no acute distress ...Examination back shows tenderness over the posterior spinous processes of the mid lumbar area with some mild discomfort ..." MD 2 stated there was no documented Baker-Wong score by the ED physician. MD 2 stated the EHR indicated, "Clinical Observation of Pain: relaxed; calm expression ...Pain Level: 9 ..." MD 2 stated the EHR indicated, according to the nurse's notes and ED physician assessment, the patient's pain level based on Baker Wong was less than 5. MD 2 stated if Patient 5's pain level was truly 9/10, the patient's pain should have been addressed but the nurse's notes and ED physician's assessment indicated that was not the case. MD 2 stated when the ED did not have radiology services and a patient came in for abdominal or central or peripheral neurological issues, he would transfer these patients to another hospital. MD 2 stated if the examination of the patient's abdomen and chest did not have any problems or the patient had a normal neurological examination or non-critical orthopedic problem then those patients would be discharged and told to come back to the ED. MD 2 stated the EHR indicated Patient 5's pain was not addressed while in the ED but when Patient 5 was discharged MD 1 gave her a prescription for pain medication to address her pain.

During a review of the hospital's P&P titled, "Pain Assessment-Emergency Department," dated 3/1/24, the P&P indicated, " ...It is the policy of this organization to respect and support the patient's right to optimal pain assessment and management. Pain is assessed in all patients in our organization. The organization will also address the appropriateness and effectiveness of pain management ...Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness. Patients need to be involved in all aspects of their care including pain management ...It is the responsibility of nursing staff to assess and periodically reassess the patient for pain and relief from pain and may include the intensity and quality ...and response to treatment ...At time of admission to the facility, the patient will be questioned regarding pain during the initial nursing assessment ...The patient will undergo reassessment of pain at least once per shift and after the administration of narcotic medication for pain control ...Any patient care provider, from any department, that has implemented a narcotic pain control medication will reassess the patient within one (1) hour to determine amount of pain control or relief achieved ...As part of the reassessment, the nurse shall assess and document the pain in terms of its duration numerical value and any use of analgesics. Also include other pain interventions, vital signs, the effectiveness of all interventions including non pharmacological if utilized and any side effects or adverse reactions. This ongoing reassessment should be done minimally once per shift while active and during the night time hours when pain often becomes more intense and the patient's ability to sleep does not always mean that there is an absence of pain ..."

During a review of the hospital's P&P titled, "Compliance with Emergency Medical Treatment," dated 2/10/24, the P&P indicated, " ...To stabilize means with respect to an emergency medical condition, to ...either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital or, in care of a woman in labor, that the woman has delivered the child and the placenta ...Stable for Discharge means a determination by the treating physician, within reasonable clinical confidence, that an individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provide the individual is given a plan for appropriate follow-up care with the discharge instructions. For the purpose of discharging an individual with psychiatric condition(s), the individual is considered to be stable for discharge when he/she is no longer to be a threat to himself/herself or to other ..."

3. During a concurrent interview and record review on 8/23/24 at 4:30 p.m. with the EDM, Patient 6's "EHR," dated 8/9/24 was reviewed. The EHR indicated Patient 6 came into the ED for a chief complaint of fever and ear pain and a fever of 102.8 degrees Fahrenheit (Unit of measurement). The EDM stated the EHR indicated the ED physician ordered a covid 19, influenza, and RSV test which were all negative. The EDM stated the EHR indicated Patient 6 was not administered a fever reducing medication while in the ED and there was no indication from the ED physician's note that Patient 6 was administered a fever reducing medication prior to the ED visit. The EDM stated the EHR indicated Patient 6 was discharged at 12:56 a.m. with a diagnosis of febrile (fever) illness and bilateral otitis media (middle ear inflammation). The EHR indicated Patient 6's vital signs and pain were not assessed at discharge. The EDM stated Patient 6's vital signs and pain should have been reassessed at discharge at least 30 minutes prior to discharge. The EDM stated the importance of reassessing a patient's temperature was to ensure their fever was stabilized. The EDM stated if the patient's temperature was not checked prior to discharge the patient's condition could worsen or continue to have a fever.

During an interview on 8/26/24 at 4:28 p.m. with the Family Member (FM), the FM stated Patient 6 had a fever and ear pain. The FM stated the doctor ordered a few tests and the results came back negative. The FM stated Patient 6 was discharged with acetaminophen (pain or fever mediation) and amoxicillin (antibiotic). The FM stated she did not remember if Patient 6's temperature was reassessed prior to discharge.

During a concurrent telephone interview and record review on 8/27/24 at 11 a.m. with MD 2, Patient 6's "EHR," dated 8/9/24 was reviewed. MD 2 stated the EHR indicated Patient 6 did have a fever and ideally he would have liked to see the fever come down prior to discharge. MD 2 stated the EHR indicated Patient 6 was not administered any fever reducing medications while in the ED. MD 2 stated Patient 6 was still febrile at discharge so his fever was not resolved prior to discharge. MD 2 stated if Patient 6 received instructions for acetaminophen and amoxicillin at discharge. MD 2 stated the importance of reassessing a patient's vital signs and pain at discharge was to ensure the patient was stable for discharge. MD 2 stated patients should have had their vital signs and pain reassessed at least 30 minutes prior to discharge.

During an interview on 8/27/24 at 3 p.m. with the DON, the DON stated his expectations of nurses was assessing and reassessing their patients'. The DON stated vital signs and should be completed at triage, at least once an hour after triage, at the time of discharge and if there were any pain interventions. The DON stated the importance of vital signs was to monitor the patient's progress. The DON stated if a patient's vital signs were not assessed or reassessed they could have a bad outcome.

During a review of a professional resource titled, "Vital Signs Assessment," dated January 2024 was reviewed, the Article indicated, " ...Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name "vital" as their measurement and assessment is the critical first step for any clinical evaluation. The first set of clinical examination is an evaluation of the vital sings of the patient. Triage of patients in an urgent/prompt care or an emergency department is based on their vital signs as it tells the physician the degree of derangement that is happening from the baseline. Healthcare providers must understand the various physiologic and pathologic processes affecting these sets of measurements and their proper interpretation. If we use a triage method where we select patients without determining their vital signs, it may not give us a reflection of the urgency of the patient's presentation ...The degree of vital signs abnormalities may also predict the long-term patient health outcomes, return emergency department visits, and frequency of readmission of hospitals, and utilization of healthcare resources ...Traditionally, the vital signs consist of temperature, pulse rate, blood pressure, and respiratory rate. Pulse oximetry sometimes helps to clarify the patient's physiological functions, which would sometimes be unclear by checking just the traditional vital signs ..."

During a review of the hospital's P&P titled, "Compliance with Emergency Medical Treatment," dated 2/10/24, the P&P indicated, " ...To stabilize means with respect to an emergency medical condition, to ...either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital or, in care of a woman in labor, that the woman has delivered the child and the placenta ...Stable for Discharge means a determination by the treating physician, within reasonable clinical confidence, that an individual has reached the