Arkansas Valley Regional Medical Center

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 52761 Based on interviews and document reviews, the facility failed to ensure a patient’s discharge needs were met in one of two patients reviewed who reported severe pain. (Patient #2) Findings include: Facility policy: The Patient Rights and Responsibilities policy read, patients shall receive appropriate pain management plans upon discharge. Upon discharge, the physician shall inform the patient of any instructions or information regarding their continuing healthcare needs. 1. The facility failed to ensure a patient who reported severe pain was discharged with an appropriate pain management plan according to facility policy. a. Review of Patient #2’s medical record revealed Patient #2 presented to the facility on 1/8/26 after a motor vehicle accident from which they sustained a 15 centimeter (cm) scalp laceration (jagged, irregular tear or cut in the skin). Patient #2 was treated in the emergency department (ED) from 2:36 p.m. until 9:09 p.m. Throughout this period, Patient #2 reported their pain to be 10/10 (severe) three times and received acetaminophen, hydromorphone, and ketorolac (intravenous (IV) pain medications). Additionally, a physician’s note from 6:54 p.m. revealed Patient #2 complained of a severe headache, which they described as feeling like their head was split. A surgeon’s note from 7:23 p.m. revealed Patient #2’s laceration required an operation to be irrigated (cleaned) and closed. The note also revealed Patient #2 was admitted to the facility under observation status (short-term care for monitoring or treatment while the physician determines whether or not inpatient admission is necessary) for pain control. Between 1/8/26 at 9:39 p.m., and 1/9/26 at 4:21 p.m., Patient #2 received hydrocodone (opioid medication used to treat moderate to severe pain) five times and acetaminophen IV once for pain scores of 8/10 - 10/10 (severe). At 4:21 p.m., Patient #2 had rated their pain as 8/10 and was administered two hydrocodone tablets. Patient #2 was discharged from the facility on 1/8/26 at 4:28 p.m., seven minutes later. Review of Patient #2’s discharge summary revealed instructions to continue taking their home medication of ibuprofen (medication used to treat mild to moderate pain), however failed to reveal prescriptions for medications to treat severe pain or a pain management plan. This was in contrast to the Patient Rights and Responsibilities policy, which revealed patients should have been provided with an appropriate pain management plan upon discharge. b. On 3/18/26 at 2:33 p.m., an interview was conducted with Physician #1. Physician #1 stated patients who complained of acute pain (pain that lasts for a short duration) throughout their hospitalization were prescribed pain medication upon discharge. Physician #1 explained the ordering provider determined the appropriate dose and type of pain medication based on what was effective for managing the patient’s pain during their hospitalization. This was in contrast to review of Patient #2’s medical record, which failed to reveal pain medication prescribed to Patient #2 upon discharge, despite Patient #2’s need for hydrocodone to control their pain during hospitalization. Additionally, Physician #1 stated they would have expected Patient #2’s discharge summary to include pain medication due to their reported pain scores of 8/10 - 10/10 (severe) and frequent need for pain medication. Physician #1 explained it was important to ensure patients were comfortable during and after their hospitalization. Furthermore, Physician #1 explained it was important to prescribe pain medication upon discharge because untreated severe pain could cause patients to become stressed or depressed. Additionally, Physician #1 explained patients might obtain unregulated pain medication illegally if not prescribed safely by a physician.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47962 Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2406: Applicability of Provisions of this Section (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction. Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted seven of 22 patients’ medical records reviewed. Tag 2407: Necessary Stabilizing Treatment for Emergency Medical Conditions (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either-- (i) Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. Based on interviews and document review, the facility failed to ensure patients presenting to the emergency department (ED) with an emergency medical condition (EMC) received stabilizing treatment according to facility policy. This failure impacted one of seven patients who were assessed in the ED and discharged home.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47962 Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted seven of 22 patients reviewed. (Patients #2, #4, #7, #8, #13, #15, and #21) Findings include: Facility policies: According to the Medical Screening Examination (MSE) policy, all individuals presenting to the Emergency Department (ED) and requesting medical treatment are entitled to a medical screening examination. The MSE will be performed regardless of race, color, national origin, or financial status. An MSE is the screening of sick, wounded, or injured persons in the emergency department to determine whether the person has an emergency medical condition. The MSE will include but not be limited to the chief complaint, vital signs, mental status showing evidence of abnormalities, general appearance showing the patient looks sick, skin looks poorly perfused, signs of dehydration, and ability to walk. Potential emergent patient examples may include vital signs including a temperature over 99° Fahrenheit (F), heart rate under 60 or over 100, blood pressure under 90 or over 150 systolic (the phase of the heartbeat when the heart muscle contracts and pumps blood), acute pain over five on a zero to ten scale, acute chest pain, acute abdominal pain, any abnormal mental/psychiatric status presenting with suicidal or homicidal ideation, gestures, or agitation, or patients under the age of five or over 65. According to the Admission Policies and Patient Care in the ED policy, all patients admitted to the ED will be seen by a provider and have a face sheet (summary of patient’s information) generated. All such patients will be triaged (given a preliminary assessment) into the system by the ED provider. Any patient who presents to the ED for care will be provided an MSE. According to the Policies of the Emergency Department policy, the reason is to stabilize and care for acutely ill and injured patients, to provide care on a continuous basis once entered into the system, to provide quality care of the patient and family within the scope of capability, to be aware of the patients’ clinical and personal needs and meeting them with rapid response, to provide adequately trained personnel and a safe environment at all times. The ED was open at all times to ill or injured patients so that the patients’ condition could be assessed. The hospital and medical staff are responsible for ensuring that emergency care meets the general standards of care. Emergency patient care shall be guided by written policies and shall be supported by appropriate procedure manuals and reference materials. There shall be written policies concerning the extent of treatment carried out in the ED. A control register shall be kept by the ED. The register shall contain at least the name, date, and time of arrival and departure, with a control number of each patient served. Reports of laboratory test results shall be made available promptly to the practitioner providing emergency care. There shall be a mechanism for notifying and recalling patients who require additional or repeat laboratory studies. According to the Standards of Nursing Practice-ED policy, Emergency Nursing Practice is the nursing care of individuals of all ages with perceived physical and/or emotional alterations which are undiagnosed and may require prompt intervention. The scope of nursing practice in an emergency setting encompasses nursing activities which are directed toward health problems of various levels of complexity. A rapidly changing physiological and/or psychological status, which may be life-threatening, requires assessment and supportive care. According to the Cardiac Monitor-Reasons for Placement in the ED policy, patients to consider for cardiac monitoring are all older (30 years or above), diabetics (high blood sugar), especially if complaining of abdominal pain or chest pain, previous heart and/or lung disease, any abnormal blood pressure, pulse, respiratory rate, pulse oximetry (measurement of oxygen) less than 88% or adult with fever over 103°F, shortness of breath (SOB), weakness, dizziness, syncope (fainting), altered consciousness or elderly patient with a history of a fall, abnormal lab, edema (swelling), abdominal pain, bleeding or anemia (lack of ability to carry oxygen to the tissues), chest pain, seizure (sudden, uncontrolled burst of electrical activity in the brain), substance use including alcohol intoxication, hypothermia (under 94°F), or multiple traumas. References: According to the Cardiac Routine Order Set, nursing interventions: place the patient in a monitor bed and obtain vital signs every 15 minutes four times, and then if stable, may change to every 30 minutes to one hour depending on the patient’s acuity. According to the Security Officer Job Description, the security officer protects the life and property of all persons on the facility premises and patrols buildings and grounds. Responds to security needs of facility personnel, visitors, and patients. Their duties and responsibilities include providing a visible deterrent to crime and prohibited activities by patrolling the buildings and grounds, responding quickly and effectively to emergent and non-emergent situations, ensuring that only authorized persons are admitted onto the premises, responding to emergency calls for assistance to control disorderly conduct or combative patients, patrolling buildings, grounds, and parking areas, demonstrates knowledge of the principles of growth and development over the lifespan, and excelling in verbal communication in diffusing volatile situations. 1. The facility failed to ensure patients presenting to the hospital with a potential EMC were medically screened according to facility policy. A. Medical Records and Security Surveillance Reports i. A review of medical records and a Security Surveillance Report revealed Patient #21 presented to the facility with a potential emergency medical condition, waited more than 10 hours in the facility lobby, was removed from the facility by security staff although the patient presented in an altered state, and was provided an MSE only after being found outside once removed from the facility, still in an altered state. a. A review of Patient #21’s medical record revealed Patient #21 was a 65-year-old who presented to the ED on 12/1/23 at 12:40 a.m. for altered mental status. The physician’s note revealed Patient #21 was dropped off in the lobby on 11/30/23 around 2:20 p.m. by the state patrol and the patient was first observed sitting in the lobby at 8:00 p.m. The note further revealed that ED staff had security “confront” Patient #21 after the other patients had been discharged from the ED. b. A review of a Security Surveillance Report revealed Patient #21 was seen in the facility lobby by an ED nurse on 11/30/23 at 8:00 p.m. and on 12/1/23 at 12:00 a.m. According to the security report, on 12/1/23 at 12:00 a.m., security was called and Patient #21 was asked to leave the facility. Patient #21 left and sat outside where security again “confronted” them before it was determined Patient #21 needed to be seen in the ED as they appeared mentally altered. The report revealed Patient #21 was brought to the ED where they were admitted and then later admitted to the inpatient unit for further treatment. The follow-up to the report revealed CNO #7 was informed of the incident and security staff were counseled to be more attentive to unusual situations. The follow-up education provided to security staff was requested and an interview on 3/6/24 at 9:27 a.m. with quality and risk director (Director) #9 revealed this education was provided to the security officers verbally and no written documentation of the counseling could be provided. In contrast to the Security Surveillance Report which revealed security asked Patient #21 to leave the facility on 12/1/23 at 12:00 a.m. and then found Patient #21 outside a short time later where Patient #21 was “confronted again” and determined to have alterations in their mental status, the physician’s note stated security brought Patient #21 to the ED after “confronting” them in the lobby. The physician’s note revealed the patient was provided care in the ED at 12:40 a.m. and was then admitted to the intensive care unit (ICU) at 8:06 a.m. for treatment of altered mental status. Also in contrast to the Security Surveillance Report, the nursing general assessment note written upon admission to the ED revealed Patient #21 told security they were late for an appointment when security originally encountered Patient #21, and then Patient #21 walked out the door. The nursing note read Patient #21 was later discovered outside cold and not making sense and was then brought into the ED by security. The nursing assessment revealed Patient #21’s temperature was 96.3°F with a pulse rate (PR) of 103. The medical record review and security report was in contrast to the MSE, the Admission Policies and Patient Care in the ED, and the Policies of the Emergency Department policies which read, all individuals who presented to the ED were entitled to an MSE to determine the presence of an emergency medical condition. The reason was to stabilize and care for acutely ill and injured patients and the ED was open to ill or injured patients so that the patients’ conditions could be assessed. This security report was also in contrast to the Security Officer Job Description which read, the security officer protected the life of all persons on the facility premises. ii. A review of medical records revealed Patient #2 was not provided with an appropriate MSE based on their presenting symptoms and past medical history. A review of Patient #2’s medical record revealed they presented to the ED on 11/23/23 at 5:16 a.m. with a chief complaint of pain with urination, low back pain, and a headache. Nursing notes revealed Patient #2 had a temperature of 99.7°F (normal temperature was 98.6°F), a pulse rate of 99 (normal was 60-100), and pain rated at 10/10. The record revealed Patient #2 had a previous history of kidney stones. Laboratory testing revealed the patient’s urine contained blood and was positive for an infectious process. Physician notes revealed the treating physician diagnosed Patient #2 with a urinary tract infection. The physician’s note did not reveal the physician had considered kidney stones in the patient’s differential diagnosis although Patient #2 had kidney stones in the past, nor had the physician provided a screening exam that would have ruled this diagnosis out. This review of Patient #2’s medical record was in contrast to the MSE, the Admission Policies and Patient Care in the ED, and the Policies of the Emergency Department policies which read, all individuals who presented to the ED and requested medical treatment were entitled to an MSE to determine the presence of an EMC. iii. A review of medical records revealed Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 were not assessed at regular intervals as part of their MSE while in the ED. a. A review of Patient #4’s medical record revealed Patient #4 was a 34-year-old who presented to the ED on 1/8/24 at 5:16 p.m. after a suicide attempt (attempting to kill oneself) by overdosing on medication. Nursing notes revealed on 1/9/24, there was a gap in obtaining vital signs from 2:18 a.m. to 7:52 p.m. (17 hours and 34 minutes). There was another gap in obtaining vital signs between 1/9/24 at 7:52 p.m. to 1/10/24 at 5:30 a.m. (nine hours and 38 minutes). Also, nursing notes failed to reveal evidence nursing staff obtained Patient #4’s vital signs at the time of discharge. Nursing notes also revealed from 1/8/24 to 1/10/24, there were only two nursing assessments completed for the patient. The discharge assessment revealed the patient was transferred to inpatient care on 1/10/24 at 8:35 a.m. for further mental health treatment. b. A review of Patient #7’s medical record revealed Patient #7 was a 76-year-old who presented to the ED on 2/6/24 at 3:14 a.m. with chest pain. The physician ordered vital signs to be performed per the cardiac routine at 3:37 a.m. Nursing notes revealed the blood pressure (BP) at 3:14 a.m. was 81/57 (normal was 120/80), BP at 3:20 a.m. was 81/57, BP at 3:32 a.m. was 84/51, BP at 3:40 a.m. was 70/48, and the BP at 3:50 a.m. was 101/76. There was then a 24-minute gap between the 3:50 a.m. BP reading and the next at 4:14 a.m., when the BP was 87/58. This review of vital signs was in contrast to the Cardiac Routine Order Set which read, vital signs were to be taken every 15 minutes four times, and then if stable, decreased in frequency. c. A review of Patient #8’s medical record revealed Patient #8 was a 23-year-old who presented to the ED on 9/6/23 at 5:50 a.m. for high blood sugar. Nursing notes revealed the patient had a history of diabetes (inability to maintain blood sugars) and diabetic ketoacidosis (DKA) (the body does not have enough insulin (a hormone that allows blood sugar to enter the cells)) and Patient #8 had self-administered 23 units of insulin before presenting to the ED. Nursing notes revealed the patient’s blood glucose (sugar) was over 500 by point of care testing (POCT) glucose (normal 70-106) at 5:57 a.m. and was 574 by lab glucose at 6:16 a.m. The record revealed six units of intravenous (IV) insulin were ordered and administered at 6:31 a.m. At 8:26 a.m., an hour and 55 minutes after the IV insulin was given, Patient #8’s blood sugar was 461, which was also a gap of two hours and 10 minutes between the two blood sugar measurements. The patient was given another 10 units of IV insulin at 8:43 a.m. The nursing notes revealed Patient #8’s BP was taken on 9/6/23 at 5:55 a.m., 7:30 a.m., and 8:55 a.m., which was an hour and 35 minutes between the first two readings, and an hour and 25 minutes between the second and third readings. The medical record did not reveal evidence of cardiac monitoring. This review of Patient #8’s medical record revealed gaps in patient assessment and lack of cardiac monitoring, which was in contrast to the Cardiac Monitor-Reasons for Placement in the ED policy which read, patients to consider for cardiac monitoring included patients with diabetes. The review was also in contrast to the Cardiac Routine Order Set which read, vital signs were to be taken every 15 minutes four times, and then if stable, decreased in frequency. d. A review of Patient #13’s medical record revealed Patient #13 was an 86-year-old who presented to the ED on 1/12/24 at 3:16 p.m. for confusion and weakness. Nursing notes revealed Patient #13’s BP was obtained every 15 minutes four times then, starting at 4:00 p.m. when their BP was 163/88, there was a gap of 30 minutes until 4:30 p.m. when BP was 167/116. Then after 6:00 p.m. with a BP of 182/105, there was an hour gap in BP assessment until 7:00 p.m., when the BP was 132/116. At 7:15 p.m. the BP was 178/101, then there was a 50-minute gap in BP until 8:05 p.m. when the BP was 139/116, then another 22-minute gap until 8:37 p.m., when the BP was 168/93. e. A review of Patient #15’s medical record revealed Patient #15 was a 65-year-old who presented to the ED on 1/24/24 at 5:45 p.m. for altered mental status. The physician’s note revealed Patient #15 was diagnosed with sepsis during their stay. The nursing assessments revealed staff obtained Patient #15’s vital signs on admission and their BP was 61/41 and pulse rate (PR) was 109. Patient 15’s BP was taken every 15 minutes from 5:45 p.m. to 8:45 p.m., except from 6:45 p.m. to 7:15 p.m. when there was a 30-minute gap. Then from 8:45 p.m. to 1/25/24 at 3:50 a.m., there were no documented blood pressures for Patient #15. Patient #15’s PR was taken on 1/24/24 at 5:45 p.m. and then next taken on 1/25/24 at 3:50 a.m. The only documented temperature for Patient #15 was taken on 1/25/24 at 3:50 a.m. The medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 which revealed missing assessments, including vital signs, were in contrast to the interview with CNO #7 on 2/28/24 at 1:04 p.m. in which CNO #7 stated nurses continuously assessed patients in the ED and these assessments included obtaining vital signs, rechecking blood sugars, and reassessing pain levels. The medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 with gaps in patient assessments were also in contrast to the MSE, the Admission Policies, and Patient Care in the ED, and the Policies of the Emergency Department policies which read, all individuals presenting to the ED were entitled to a medical screening examination which screened sick, wounded, or injured persons to determine the presence of an emergency medical condition. The ED provided quality care and rapidly met the patient’s clinical needs. Additionally, these medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 were also in contrast to the Standards of Nursing Practice-ED policy which read, emergency nursing care addressed undiagnosed physical and emotional alterations which required prompt intervention. Nursing activities were directed towards health problems of various levels of complexity with the potential for rapidly changing physiological and/or psychological status. This rapid change could be life-threatening and required assessment and supportive care. iv. A review of Security Surveillance Reports revealed unhoused individuals were removed from the facility by non-clinical staff prior to determining if the individuals required medical screening examinations for potential emergent medical conditions. a. A review of a Security Surveillance Report revealed on 1/23/24 at 1:00 a.m., a person wanted to enter the facility to warm up. The report read the person was told by security staff they needed to leave if they did not need medical attention. The follow-up activity from the Security Surveillance Report suggested having ED staff call security for an escort when leaving the facility. b. A review of a Security Surveillance Report revealed on 12/24/23 at 6:25 a.m., a person was found sleeping in the chapel. The report read the person was told by security staff they could not sleep in the facility and they had to leave if there was no medical reason for them to be present. According to the report, the police arrived to remove this person from the facility. There was no follow-up activity identified. B. Document review i. Policies a. Upon request on 2/27/24 and 2/28/24, the facility was unable to provide a policy providing guidance on patient assessment and reassessment in the ED. On 2/28/24 at 1:04 p.m. and 4:26 p.m., the chief nursing officer (CNO) #7 stated there was not a policy on patient assessment and reassessment in the ED. C. Interviews i. On 2/29/24 at 7:53 a.m., an interview was conducted with security officer (Officer) #1. Officer #1 stated they worked in security and trained other security staff. They stated they did not have a clinical background. They stated they patrolled the facility property and grounds to ensure safety. Officer #1 stated they encountered people who were not patients, visitors, or staff, and who did not appear to have a purpose at the facility. Officer #1 stated they asked people they encountered, in the stairwell or chapel for example, if they had a purpose at the facility. They stated if those people became belligerent with security staff and did not state their purpose, Officer #1 knew those people did not have a reason to be at the facility and they were made to leave. Officer #1 stated they were not trained in recognizing patients with medical or psychological needs although they were trained to ask if people needed help and if they needed to be seen. Officer #1 stated they tried to ask these questions of every person but some people were not receptive to questions about their medical history. Officer #1 stated if officers felt there was a health concern, although they had no clinical training, they directed people to the ED. Officer #1 stated they received Emergency Medical Treatment and Labor Act (EMTALA) training but were not sure how this training applied to their position or responsibilities. Officer #1 stated there was tension between security staff and the ED staff, including nurses, resulting in a lack of communication which impacted security’s ability to keep everyone safe or protect patients. Officer #1 stated security should have had a conversation with Patient #21 assessing their awareness before they were asked to leave. They stated if security had gauged that Patient #21 was not aware of their surroundings, the security staff was to have notified the ED to initiate a medical assessment. Officer #1 stated with regards to other security incidents where security encountered people whom they asked to leave, many unhoused people came to the facility to sleep or warm up. They stated security could not do their job of keeping staff and security safe if these unhoused people remained at the facility. Officer #1 stated there was a risk to people not receiving an MSE for a health need. They stated if people did not receive the necessary medical care, they could leave the facility and die. ii. On 2/29/24 at 8:32 a.m., an interview was conducted with security supervisor (Supervisor) #5. Supervisor #5 stated they did not have a medical or clinical background although they knew when people needed psychiatric treatment in the ED due to their years of security experience. Supervisor #5 stated some unhoused people entered the facility to stay warm. They stated they expected their officers to ask these people if they had an appointment and be made to leave if there was no appointment. This was in contrast to the Policies of the Emergency Department policy which read, the ED was open at all times to ill or injured patients so that patients could be assessed and did not require appointments. Supervisor #5 stated security escorted people to the ED for medical care, for instance, if there was a slip and fall in the parking lot. They stated it was the patient and ED staff’s responsibility to ensure people received an MSE for medical or psychiatric needs. Supervisor #5 stated there was not a risk to turning patients away if those people were not able to voice their needs. iii. On 3/4/24 at 3:10 p.m., an interview was conducted with Officer #8. Officer #8 stated they trained the other security officers to ask the nature of someone’s purpose at the facility as people were not allowed to enter the facility without having a reason. Officer #8 stated they talked to and asked questions of people to assess if people were ill. They stated when patients were discharged but had not yet left the facility, security would ask these people to leave as they had been medically screened and there was no reason to stay. Officer #8 stated they did occasionally ask if these patients had new medical needs. Officer #8 stated they used their experience in security and history as an emergency medical technician (EMT) and were able to tell when someone was mentally altered. Officer #8 stated they had not received EMTALA training during their employment, which was in contrast to interviews with other security staff and a review of personnel files. They stated the risk of not being familiar with EMTALA was making incorrect assumptions about a person and their medical or psychiatric health. Officer #8 stated there was tension between security and the staff in the ED which interfered with security’s ability to carry out their duties. They stated they had communicated this tension to CNO #7. Officer #8 stated there was a risk to patient safety if ED nurses chose not to communicate or collaborate with security. Officer #8 stated ED staff were not always willing to leave the ED to assess people within the facility or on the grounds outside the ED. They stated if ED nurses were not willing to collaborate with security to assess people outside the ED, this posed a risk to the patient and security staff. iv. On 2/29/24 at 9:21 a.m. an interview was conducted with registered nurse (RN) #11. RN #11 stated the risk of patients being turned away without having received an MSE was a higher risk of cardiac (heart) and respiratory (breathing) complications and potentially, death. v. On 3/5/24 at 9:53 a.m., an interview was conducted with RN #14. RN #14 stated they had observed Patient #21 in the front area of the hospital at 8:00 p.m. on 11/30/23 and they had exchanged greetings. They stated security talked to the patient on 12/1/23 at 12:00 a.m. and at this time, Patient #21 stated they had an appointment. RN #14 stated security asked the patient to leave as all clinics were closed at that time. They stated shortly afterward, security found Patient #21 outside cold and exhibiting signs of altered consciousness and brought them into the ED. RN #14 stated Patient #21’s care had fallen through the cracks. They stated they did not understand how this patient was left unattended for over 10 hours with no food or water and without any staff being aware that Patient #21 needed help. RN #14 stated Patient #21 could have died if they had a severe medical emergency. This interview was in contrast to the security report for Patient #21 which read the patient had been seen by an ED RN on 11/30/23 at 8:00 p.m. and again on 12/1/23 at 12:00 a.m. before the patient was asked to leave the facility. This interview was also in contrast to the medical record which read security brought Patient #21 to the ED after security “confronted” them in the lobby without mentioning the patient had been asked to leave the facility. vi. On 3/4/24 at 2:27 p.m. an interview was conducted with RN #12. RN #12 stated they worked closely with security to ensure patient safety. They stated in their experience, they felt security could have received more training on patient care and de-escalation of aggressive patients. RN #12 stated all patients who entered the ED received an MSE. They stated an MSE was important as the ED physicians needed to perform an assessment to provide a diagnosis and treatment. They stated the risk if a patient was not provided with an MSE or an MSE appropriate to the presenting concerns, was further complications of their presenting health concern or death. This was in contrast to Patient #2’s medical record which did not reveal an MSE that had included kidney stones in the differential diagnosis, Patient #21’s medical record which did not reveal an MSE provided to a patient presenting to the facility with altered mental status until 10 hours after arriving, and Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15’s medical records which revealed missing assessments during their stay in the ED. vii. On 2/28/24 at 1:42 p.m. an interview was conducted with RN #6. RN #6 stated the frequency of patient assessments in the ED was decided by the nursing staff based on the patients’ complaints, administered medications, and previous vital signs. They stated more acutely ill patients were assessed more frequently which was in contrast to the medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 which revealed a lack of assessments during their time in the ED. RN #6 stated RNs used their skills and experience to determine the appropriate frequency of patient assessment and had the support of the ED physicians who were also closely involved in providing patient care. RN #6 stated patients with psychiatric health concerns were assessed at regular intervals to determine changes in condition although there was also not a set schedule on when the assessments would occur. RN #6 stated nurses in the ED performed POCT to assess blood glucose levels. They stated RNs typically assessed blood glucose every 15-30 minutes in patients with blood sugar imbalances and once the patients were stabilized, they decreased the frequency of assessment. RN #6 stated if patients were given insulin, blood glucose was checked 15 minutes afterward to ensure their blood sugar did not drop below a healthy level. This statement was in contrast to the medical record for Patient #8 which revealed IV insulin was administered at 6:31 a.m. and blood glucose was checked one hour and 55 minutes afterward. At that time, Patient #8’s blood sugar was 461 (normal 70-106). RN #6 stated blood sugar imbalances could have resulted in a compromised airway (inability to breathe), putting a strain on the heart, and decompensation (inability of the heart to maintain circulation). RN #6 stated for patients presenting with urinary complaints, one of the diagnostic tools used by the physicians was imaging, which could have ruled out kidney failure. They stated physicians would sometimes order Toradol (a prescription pain medication) for pain relief in patients with a history of kidney stones. This interview was in contrast to Patient #2’s medical record which revealed they were diagnosed with a urinary tract infection (UTI), their pain was acutely elevated at 10/10, and although kidney stones were documented in Patient #2’s past medical history, this was not considered in the differential diagnosis. RN #6 stated regular patient assessment was important, as being at a rural facility, the patient could have waited for transport or a bed to open in a facility that offered a higher level of care. They stated if patients were not reassessed, patients could decompensate; for example, in patients with chest pain, the heart could change from having a normal rhythm to ST Elevation Myocardial Infarction (STEMI) (a heart attack with a completely blocked coronary artery), a patient with abdominal pains could experience a rupture in the intestines, or a patient with altered mental status could lose the ability to breathe and their heart could stop. This interview was in contrast to the medical records for Patient #4, Patient #7, Patient #8, Patient #13, and Patient #15 which revealed a lack of assessments during their time in the ED. This was additionally in contrast to the medical record for Patient #21 who presented with altered mental status and was not assessed by the facility as they were not recognized as needing medical attention. viii. On 2/28/24 at 1:16 p.m., an interview was conducted with the ED medical director (Medical Director) #2. Medical Director #2 stated patients were assessed by the nurses on a regular basis and the frequency of vitals was determined by the nurses based on the patients’ clinical conditions. Medical Director #2 stated the importance of assessment in the ED depended on patients’ presenting concerns and all patients did not require the same type and frequency of assessment. They stated the RN assessments did assess and reassess pain as it was important to know if a patient was feeling better or worse. Medical Director #2 stated patients with a history of diabetes and on insulin needed their blood sugar to be rechecked one hour after insulin was administered so that the patients did not develop altered mental status. They stated a patient with Patient #2’s presenting concerns was to have been medically screened for kidney stones with imaging. Medical Director #2 stated they were unsure why this imaging was not conducted for Patient #2. ix. On 2/28/24 at 3:00 p.m. and at 4:39 p.m., interviews were conducted with Physician #3. Physician #3 stated the type and frequency of patient assessments were based on the patients’ conditions. They stated their practice was to allow nurses to determine the frequency of these assessments. Physician #3 stated the MSE was important to diagnose patients in the ED. They stated a comprehensive MSE, including the history and physical and labs, provided necessary information for understanding patients’ concerns. Physician #3 stated in the case of patients presenting with a psychiatric concern, they could have a medical concern driving their mental health, such as a thyroid imbalance, electrolyte imbalance, or head trauma. Physician #3 stated understanding a patient’s history was important for understanding their current health concern and there was a risk to the patient if a comprehensive MSE was not performed. Physician #3 stated in the example of Patient #2 with their medical history of kidney stones and their presenting symptoms, they would have ordered imaging as part of the MSE to rule out kidney failure. They stated there was no reason not to order a computed tomography scan (CT) (used to obtain detailed internal images of the body) for these types of cases and the imaging would have helped determine the next steps. x. On 2/28/24 at 1:04 p.m. and 4:26 p.m. and 3/4/24 at 4:40 p.m., interviews were conducted with CNO #7. CNO #7 stated there was not an ED policy for assessing vitals. They stated RNs performed patient assessments upon admission which included vital signs and the RNs continuously reassessed patients for changes in condition. CNO #7 stated if medications were provided in the ED, including insulin or pain medications, the patient would be reassessed. They stated the lack of assessments in the patients’ medical records presented an opportunity for the facility to improve. Additionally, CNO #7 stated Patient #21, who presented with an altered mental status, was not provided with an MSE after arriving at the facility and waiting over 10 hours in the facility’s lobby as the patient did not ask to be seen.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47962 Based on interviews and document review, the facility failed to ensure patients presenting to the emergency department (ED) with an emergency medical condition (EMC) received stabilizing treatment according to facility policy. This failure impacted one of seven patients reviewed who were assessed in the ED and discharged home. (Patient #2) Findings include: Facility policies: According to the Admission Policies and Patient Care in the ED policy, all patients admitted to the ED will be seen by a provider and have a face sheet (summary of patient’s information) generated. All such patients will be triaged (given a preliminary assessment) into the system by the ED provider. Any patient who presents to the ED for care will be provided any necessary stabilization or treatment. According to the Policies of the Emergency Department policy, the reason is to stabilize and care for acutely ill and injured patients, to provide care on a continuous basis once entered into the system, and to provide quality care of the patient and family within the scope of capability, to be aware of patients’ clinical and personal needs and meeting them with rapid response, to provide adequately trained personnel and a safe environment at all times. The ED was open to ill or injured patients so that the patients’ conditions could be assessed and treatment rendered. The hospital and medical staff are responsible for ensuring that emergency care meets the general standards of care. Emergency patient care shall be guided by written policies and shall be supported by appropriate procedure manuals and reference materials. There shall be written policies concerning the extent of treatment carried out in the ED. A control register shall be kept by the ED. The register shall contain at least the name, date, and time of arrival and departure, with a control number of each patient served. Reports of laboratory test results shall be made available promptly to the practitioner providing emergency care. There shall be a mechanism for notifying and recalling patients who require additional or repeat laboratory studies. According to the Standards of Nursing Practice-ED policy, Emergency Nursing Practice is the nursing care of individuals of all ages with perceived physical and/or emotional alterations which are undiagnosed and may require prompt intervention. The scope of nursing practice in an emergency setting encompasses nursing activities which are directed toward health problems of various levels of complexity. A rapidly changing physiological and/or psychological status, which may be life-threatening, requires assessment and supportive care. Reference: According to the Cardiac Routine Order Set, nursing interventions: place the patient in a monitor bed and obtain vital signs every 15 minutes four times, and then if stable, may change to every 30 minutes to one hour depending on the patient’s acuity. 1. The facility failed to ensure patients presenting to the ED with an EMC received necessary and stabilizing treatment according to facility policy. A. Medical Records i. A review of medical records revealed Patient #2 was not provided with the appropriate and necessary stabilizing treatment for their EMC. A review of Patient #2’s medical record revealed they presented to the ED on 11/23/23 at 5:16 a.m. with a chief complaint of pain with urination, low back pain, and a headache. Nursing notes revealed Patient #2 had a temperature of 99.7°F (normal temperature was 98.6°), a pulse rate of 99 (normal was 60-100), and pain rated at 10/10. The record revealed Patient #2 had a previous history of kidney stones. Laboratory testing revealed the patient’s urine contained blood and was positive for an infectious process. Physician notes revealed the treating physician diagnosed Patient #2 with a urinary tract infection. The physician’s note revealed the patient was given ciprofloxacin (an antibiotic) in the hospital and was given a prescription for this same medication to pick up at a pharmacy. At discharge, the patient was instructed to alternate acetaminophen (over-the-counter (OTC) pain medication) and ibuprofen (an OTC pain medication) for pain control. The urine culture, which resulted after the patient had left the hospital, revealed the bacteria present in Patient #2’s urine was resistant to ciprofloxacin. The medical record failed to reveal that ED staff had prescribed a more effective antibiotic for Patient #2 to eliminate their bacterial infection or attempted to contact Patient #2 to inform them of the new laboratory results. This review of Patient #2’s medical record was in contrast to the Policies of the Emergency Department policy which read, acutely ill and injured patients were stabilized and treated with rapid and quality care. The facility and medical staff were responsible for ensuring emergency care met the general standards of care. Reports of laboratory test results were made available promptly and there was a mechanism for notifying and recalling patients. This review of Patient #2’s medical record was also in contrast to the Admission Policies and Patient Care in the ED policy which read, all individuals who presented to the ED and requested medical treatment were provided any necessary stabilization or treatment for an EMC. B. Interviews i. On 2/28/24 at 12:09 p.m., an interview was conducted with registered nurse (RN) #10. RN #10 stated physicians and nurses in the ED worked closely together and this contact allowed for patients to receive the necessary care. ii. On 2/28/24 at 1:42 p.m. an interview was conducted with RN #6. RN #6 stated for patients presenting with urinary complaints and a history of kidney stones, physicians would sometimes order Toradol (a prescription pain medication) for pain relief. This interview was in contrast to Patient #2’s medical record which revealed although they were diagnosed with a urinary tract infection (UTI), their pain was acutely elevated at 10/10, and although kidney stones were documented in Patient #2’s past medical history, pain medications were not provided at the facility. iii. On 2/28/24 at 3:00 p.m. and at 4:39 p.m., an interview was conducted with Physician #3. Physician #3 stated in the example of Patient #2 with their history of kidney stones and presenting symptoms, the treatment for kidney stones would have included Toradol (pain medication), intravenous (IV) fluids, and Flomax (a medication to help with urination) and potentially, a referral to a urologist. Physician #3 stated Patient #2’s urine culture was ordered to ensure the bacteria in the urine was sensitive to the prescribed antibiotic. They stated if the bacteria was resistant to the antibiotic, as Patient #2’s culture had determined, the patient was called and a more effective antibiotic was prescribed. Physician #3 stated ensuring all appropriate medical care was provided for an EMC was important as there was no guarantee patients would seek follow-up care. iv. On 2/28/24 at 1:16 p.m., an interview was conducted with the ED medical director (Medical Director) #2. Medical Director #2 stated if the assessment revealed kidney stones, staff were to have provided pain medication to patients with Patient #2’s presenting concerns and history of kidney stones. They stated if kidney stones were revealed on imaging, physicians may have also referred Patient #2 to a urologist. Medical Director #2 stated for Patient #2 and any patient for whom a culture had been obtained, the physician and nurse were to call the patients with the results of their lab tests and call in new prescriptions if needed. Medical Director #2 stated they were unsure why the lab results were not provided to Patient #2.”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.614, PATIENT RIGHTS, was out of compliance. C-2523 The patient has the right to receive care in a safe setting. Based on observations, interviews, and document review, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure suicidal patients were monitored according to policy and that ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) were identified and removed from patient care rooms, including call light cords, clothing, shoelaces, and personal belongings. This failure was identified in four of the twelve patients reviewed who presented with psychiatric complaints.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50313 Based on observations, interviews, and document review, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure suicidal patients were monitored according to policy and that ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) were identified and removed from patient care rooms, including call light cords, clothing, shoelaces, and personal belongings. This failure was identified in four of the twelve patients reviewed who presented with psychiatric complaints. (Patients #4, #25, #22, and #27) Findings include: Facility policies: According to the Suicide Precautions policy, suicide precautions shall be initiated on all patients with the potential for self-directed harmful behavior. The Ask Suicide-Screening Questions (ASQ) risk screen level will guide the precautions needed to keep the patient safe. In the case of an acute positive screen, staff shall initiate suicide precautions immediately to protect the patient as this patient is at the highest risk of suicide and self-harm. An acute positive screen requires staff to place the patient in a private room near the nurse’s station, 1:1 monitoring, to place the patient in a paper gown without strings. The registered nurse (RN) will remove all patient personal belongings from the room and complete the suicide risk precaution checklist at the time a patient is placed under suicide precautions and with every bedside hand-off and shift report. Patients on suicide precautions shall not be allowed to go into the bathroom alone and close the door. Staff must remain with the patient and maintain line of sight supervision. A safe environment shall be maintained to protect the patient from injury. According to the Patient Rights and Responsibilities policy, the staff should ensure all patients have their rights supported. Patients have a right to access to care including accommodations or treatment that are available and medically indicated. According to the Policies of the Emergency Department policy, the reason is to stabilize and care for the acutely ill and injured patient, to provide care on a continuous basis, to provide quality care of the patient and family, to be aware of the patients’ clinical and personal needs, meeting them with rapid response, to provide adequately trained personnel, current equipment, and a safe environment at all times, and to respond to the needs of the patient. 1. The facility failed to remove ligature risks from patient care rooms and failed to monitor suicidal patients according to policy. A. Observations i. Observations conducted on 2/27/24 at 9:02 a.m. revealed the facility had an isolation room, room #9, which did not contain a call light, corded monitoring equipment, or any items affixed to the wall. However, standard patient rooms in the emergency department did contain call lights connected to the wall by a cord. Patient rooms also contained monitoring equipment with attached cords, as well as examination equipment affixed to the wall (otoscope). The two patient bathrooms in the emergency department contained a pull cord affixed to the wall for patients to use if they needed assistance. B. Document Review i. Medical record review revealed on 1/8/24 at 5:16 p.m., Patient #4 presented to the emergency department (ED) after overdosing on two grams of naproxen (a nonsteroidal anti-inflammatory medication used to treat pain). At 5:16 p.m., RN #15 administered an ASQ screening and classified Patient #4 as an acute positive screen for suicide. RN #15 initiated suicide precautions at 5:16 p.m., indicating the call light, and monitoring cords, would be removed from Patient #4’s room, Patient #4 would have continuous 1:1 monitoring, and Patient #4 would not be permitted to use the restroom alone. On 1/8/24 at 5:16 p.m., RN #15 documented the call light was within reach of Patient #4, and Patient #4 was placed on the cardiac monitor (a device with multiple cords attached to the patient used to monitor heart rhythm). From 1/8/24 at 5:16 p.m. to 1/9/24 at 4:16 p.m., ED Nursing Notes revealed the call light was within Patient #4’s reach 14 times. Additionally, ED Nursing Notes revealed that Patient #4 ambulated to the restroom three times during their ED admission, without 1:1 monitoring. There was no evidence that Patient #4 received 1:1 monitoring during their stay. This was in contrast to the Suicide Precautions policy which required patients to have 1:1 monitoring when suicide precautions were implemented. ii. Medical record review revealed on 2/8/24 at 1:12 p.m., Patient #22 presented to the ED after overdosing on Zoloft (a medication used to treat mood disorders and depression). RN #17 administered an ASQ screening at 3:24 p.m. and classified Patient #22 as an acute positive screen for suicide. RN #17 initiated suicide precautions at 3:24 p.m. At 4:23 p.m. ED nursing notes revealed Patient #22’ s mother told staff at 4:23 p.m. that they had been 1:1 with Patient #22 since 10:00 a.m. At 4:23 p.m., approximately three hours after the patient presented to the ED, the ED nursing notes revealed the patient’s shoes were sent to security due to there being laces in the shoes. At 5:45 p.m., the ED nursing notes revealed the patient’s personal clothing was collected and Patient #22 was placed in a paper gown. There was no evidence Patient #22 received 1:1 monitoring by a trained staff member during their stay. This was in contrast to the Suicide Precautions policy which required patients who screened acute positive to have 1:1 monitoring, to have personal belongings removed, and to be placed in a paper gown. iii. Medical record review revealed on 2/22/24 at 1:53 p.m., Patient # 27 presented to the ED for a mental health evaluation after making suicidal and homicidal statements. RN #11 administered an ASQ screening at 2:09 p.m. and classified Patient #27 as an acute positive screen for suicide. ED nursing notes revealed Patient #27’s grandmother was at Patient #27’s bedside on 2/22/24 at 2:23 p.m., 2:35 p.m., 5:08 p.m., 7:09 p.m., 10:12 p.m., and on 2/23/24 at 12:51 a.m., 2:09 a.m., 3:52 a.m., 4:40 a.m., 7:18 a.m., 10:17 a.m., and 4:33 p.m. From 2/22/24 at 1:53 p.m. until 2/23/24 at 6:04 p.m., there was no evidence that Patient #27 received 1:1 monitoring from a trained staff member during their stay. iv. Medical record review on 2/26/24 at 11:30 a.m., Patient #25 presented to the ED for a mental health evaluation. RN #16 administered an ASQ screening at 11:30 a.m. and Patient #25 was classified as an acute positive screen for suicide. At 11:30 a.m., RN #16 documented the call light was within Patient #25’s reach. C. Interviews i. An interview was conducted with RN #4 on 2/27/24 at 9:02 a.m. RN #4 stated patients placed in the isolation room (room #9) would be changed into paper scrubs, and their clothing would be cataloged. RN #4 stated room #9 was the only isolation room. RN #4 stated if multiple patients required 1:1 monitoring, a patient would be placed in a standard exam room. RN #4 stated staff would pull all things out of the standard exam room that a patient could use to hurt themselves. RN #4 stated someone would sit in the doorway of the standard room to conduct 1:1 monitoring. An additional interview was conducted on 2/28/24 at 3:31 p.m. with RN #4. RN#4 stated suicide precautions occurred when a patient was placed in emergency room #9. RN #4 stated the patient would be placed in a gown or paper scrubs, and the patient’s items would be cataloged and sent to security. RN #4 stated a patient on suicide precautions would have a sitter. RN #4 stated the facility had used family members as a sitter for patients on suicide precautions. RN #4 stated patients would be placed on suicide precautions if they made statements of self-harm. RN #4 stated it was important to place patients on suicide precautions to prevent completion of a suicide attempt. RN #4 stated the risk of not monitoring a suicidal patient included having access to call light cords or bathroom cords. RN #4 stated all cords would be removed if a suicidal patient was placed in a back room, and a sitter would remain in the doorway of the room. RN #4 stated the risk of not monitoring or not removing a cord would be strangulation. ii. An interview was conducted on 2/28/24 at 4:26 p.m. with chief nursing officer (CNO) #7. CNO #7 stated the facility did not have a specific training process for mental health sitters in the emergency department. CNO #7 stated patients on suicidal precaution should not have had call lights within their rooms because this was a ligature risk. An additional interview was conducted on 3/4/24 at 1:06 p.m. with CNO #7. CNO #7 stated it was not appropriate to use family members as sitters conducting 1:1 monitoring of patients placed on suicide precautions. CNO #7 further stated each room in the emergency department had different levels of risk to patients placed on suicide precautions. iii. An interview was conducted on 2/28/24 at 1:15 p.m. with emergency physician (Physician) #2. Physician #2 stated triage nurses determined if a patient was suicidal. Physician #2 stated suicidal patients who were not placed in emergency room #9 were required to have a sitter. Physician #2 stated parents of adolescent patients counted as sitters, and they were unsure if a family member could be a sitter for an adult patient. Physician #2 stated cords were removable from all ED rooms. Physician #2 stated there was a risk of harm if a cord was left in a suicidal patient’s room. Physician #2 stated suicidal patients were escorted to the restroom in the ED, and it was important to monitor suicidal patients in the restroom to prevent harming themselves. iv. An interview was conducted on 2/28/24 at 3:00 p.m. with Physician #3. Physician #3 stated suicidal patients were placed with a sitter and the patients would be put in a gown. Physician #3 stated the room should have been cleared of personal effects including clothing or items that could have been hidden. Physician #3 stated call lights would be left in the patient’s room unless the patient was in room #9, which did not have a call light. Physician #3 stated staff who monitored suicidal patients must have basic knowledge of working with psychiatric patients. Physician #3 stated it was important for sitters to be trained on how to react and de-escalate situations for patient and staff safety. Physician #3 stated 1:1 monitoring would be important because there were many distractions in the emergency department. Physician #3 also stated it would not be permissible for a family member to monitor suicidal patients for safety due to concerns for domestic violence. Physician #3 stated that patients could have used a call light or cords as ligatures to hang themselves. Physician #3 stated it would be important to have a 1:1 monitor for suicidal patients, and there would be an increased risk for harm if no monitoring were conducted. v. An interview was conducted on 3/4/24 at 2:10 p.m. with quality and risk director (Director) #9. Director #9 stated even if family members were present with a suicidal patient, the facility still needed to have a staff member present to conduct 1:1 monitoring. Director #9 stated staff who provided 1:1 monitoring needed training, and it would not be appropriate for a family member to be a sitter even if the same training were provided to the family member.”