Jackson Health System

“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: 45329 Based on record review, policy review, interview, and video footage, the facility failed to ensure that 1) All patients that present to the emergency department seeking medical care are logged into the hospital’s emergency room log and 2) Failed to ensure an appropriate medical screening examination was conducted that was 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 existed. This failure impeded the facility’s ability to provide emergency care for 1 (Patient #1) out of 20 patient records reviewed and had the potential to affect all patients who presented to the ED for medical care with a minor child. The findings included: (1) Based on record review, policy review, interview, and video footage, it was determined that the facility failed to maintain an accurate log of everyone who presented to the emergency department seeking medical care whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (Patient #1) of 20 patient records reviewed. Cross Refer to A2405. (2) Based on record review, policy review, interview, and video footage, the facility failed to ensure that an appropriate medical screening examination was conducted that was 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 existed. This failure impeded the facility’s ability to provide emergency care for 1 (Patient #1) out of 20 patient records reviewed and had the potential to affect all patients who presented to the ED for medical care with a minor child. Cross Refer to A2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45329 Based on record review, policy review, interview, and video footage, it was determined that the facility failed to maintain an accurate emergency department (ED) log of everyone who presented to the emergency department seeking medical care whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (Patient #1) of 20 patient records reviewed. The findings included: Review of hospital Policy No. 209, Emergency Treatment and Patient Transfer Policy, Last revised 01/03/2025 documented: I. Purpose. The purpose of this policy is to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA), its amendments, regulations, and reporting requirements. EMTALA requires that all patients who request medical treatment for an emergency medical condition, or have such a request made on their behalf, receive certain basic threshold services and stabilizing treatment as necessary. III. Procedure A. Requests for Emergency Treatment 1. All patients who request medical treatment for an emergency medical condition EMC in any manner, or who have such a request made on their behalf, must receive a medical screening examination (MSE) by a qualified medical provider (QMP). 2. All such patients shall be registered and logged into the Emergency Department log. 3. Key Point: A patient does not need to be in the Emergency Department to make such a request. 4. Patient’s financial status will have no bearing on or delay in any way the conducting of the MSE. Review of the video footage (soundless video) dated 04/06/2025 was reviewed on 05/20/2025 at 10AM. Patient #1 is seen walking into the ED foyer with a child around 8:30AM and going to the security desk which is not visible in the video. Patient #1 begins walking toward the 2nd entrance and turns around and walks out of the facility with the child. Patient #1 returned approximately 2 minutes later with the child and entered the ED, stopping at the front desk. At 8:37AM, there was a brief conversation, and less than a minute later, Patient #1 is seen walking out of the ED while Staff B (greeter/patient care technician [PCT]) watched Patient #1 leave. Patient #1 was not observed to be checked in or offered /advised to complete a registration form to be seen and evaluated. During an interview on 05/20/2025 at 10:47AM, Staff B, ED Greeter/PCT who was at the ED registration desk on 04/06/2025 stated, Patient #1 was asked if there was anyone to keep the child because if she is admitted she might want to call someone to pick up the child. Review of the hospital’s ED log for 04/06/2025 revealed, Patient #1 was not found on the log for the 04/06/2025 ED visit. During an interview conducted with Staff L, (ED greeter/PCT) on 05/21/2025 at 12:40PM revealed, patients are told we don’t let the child go into the adult ED with the parent. We will try to accommodate them by treating the parents on the side to make sure the child is safe. Staff L reported, they had received EMTALA training. During an interview on 05/21/2025 at 3:40PM, Staff A (Risk Manager) stated that an Incident Report was not completed because the complaint about Patient #1 came through the Guest Relations Department. The surveyor was provided with investigative notes/staff interviews dated 04/30/2025. Staff A documented investigative notes and staff interviews, ED staff education was implemented (1) regarding the process for adult patients that present with minor children; that there were no barriers for medical care and (2) The process for escalation to the Charge Nurse, the Assistant Nurse Manager (ANM), and the Administrator in charge (AIC). Date completed 04/30/2025.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 45329 Based on record review, policy review, interview, and video footage, the facility failed to ensure that an appropriate medical screening examination was conducted that was within the capability of the hospital’s emergency department(ED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed. This failure impeded the facility’s ability to provide emergency care for 1 (Patient #1) out of 20 patient records reviewed and had the potential to affect all patients who presented to the ED for medical care with a minor child. The findings included: Review of Policy No. 209, Emergency Treatment and Patient Transfer Policy, Last revised 01/03/2025 documented: I. Purpose. The purpose of this policy is to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA), its amendments, regulations, and reporting requirements. EMTALA requires that all patients who request medical treatment for an emergency medical condition, or have such a request made on their behalf, receive certain basic threshold services and stabilizing treatment as necessary. III. Procedure A. Requests for Emergency Treatment 1. All patients who request medical treatment for an emergency medical condition (EMC) in any manner, or who have such a request made on their behalf, must receive a medical screening examination (MSE) by a qualified medical provider (QMP). 2. All such patients shall be registered and logged into the Emergency Department log. 3. Key Point: A patient does not need to be in the Emergency Department to make such a request. 4. Patient’s financial status will have no bearing on or delay in any way the conducting of the MSE. 5. The MSE must be documented in the patient’s medical record. 6. Patients who are deemed to have an EMC must be stabilized to the best of the treating facility’s service capabilities. Review of the video footage (soundless video) dated 04/06/2025 was reviewed on 05/20/2025 at 10AM. Patient #1 is seen walking into the ED foyer with a child around 8:30AM and going to the security desk which is not visible in the video. Patient #1 begins walking toward the 2nd entrance and turns around and walks out of the facility with the child. Patient #1 returned approximately 2 minutes later with the child and entered the ED, stopping at the front desk. At 8:37AM, there was a brief conversation, and less than a minute later, Patient #1 is seen walking out of the ED while Staff B (greeter/patient care technician [PCT]) watched Patient #1 leave. Patient #1 was not observed to be checked in or offered /advised to complete a registration form to be seen and evaluated. During an interview on 05/20/2025 at 10:47AM, Staff B, ED Greeter/PCT who was at the ED registration desk on 04/06/2025 stated, Patient #1 was asked if there was anyone to keep the child because if she is admitted she might want to call someone to pick up the child. Staff B (ED greeter/PCT) reported Patient #1 was not told she could not be seen. Staff B reported, we try to accommodate all patients and Patient #1 was not told to leave and left on her own. During an interview with Staff H, (ED Social Worker) on 05/20/2025 at 3:30PM revealed, if a patient is being admitted to the hospital, the nurse asks the parent if there is anyone to pick up the child. If not, the nurse contacts the Social Worker. The social worker speaks with the parent, and they are told the case may be escalated to the Department of Children and Families (DCF). The parents always find someone to pick up the child. Staff H stated this process is not dependent on the patient being admitted. When asked if there was a policy for this process, Staff H (ED Social Worker) did not know if there was a policy and stated this process was “learned from the manager”. During an interview on 05/21/2025 at 10:45AM, Staff J, (Associate ED Medical Director) stated all patients need to be seen and evaluated. Staff J reported, a medical provider is stationed in the triage area Monday through Friday from 10:00AM to 10:00PM. If there are no rooms available, the medical staff will come out to the triage area to see patients. Staff J stated, the case regarding Patient #1 was recently discussed with the Chief Medical Officer (CMO) and they are currently working on a policy to address the issue so that it doesn’t happen again. Staff J stated, the decision is usually made where to take the patient in triage. The welfare of the child is also considered and depending on the age, the patient may be placed in the pediatric ED. The pediatric physicians are scheduled from 11:00AM to 11:00pm. When they are not here, all ED physicians are able to care for all pediatric patients. Staff J stated, there is no protocol for treating patients that come in with lethargy, difficulty breathing, swallowing, and sweating. Treatment is based on symptoms and presentation. When asked what the facility’s policy is as it relates to the care of children or a child who presents to the facility with a medical complaint and/or an identified emergency medical condition (EMC), Staff J stated, pediatric patients are fast tracked and a message is sent. Security and the triage staff have walkie-talkies to get a room as quickly as possible. The pediatric nurse may come out to assess the child. All pediatric patients are transferred if inpatient hospital admission is needed. During an interview with Staff K, (ED Physician) on 05/21/2025 at 11:45AM revealed, Staff K (ED Physician) has worked at the facility for many years. Staff K stated, all patients are always seen and it was very surprising to hear that a patient was not seen and evaluated because they had a child with them. We see patients with their children all the time. It’s never been an issue that I’m aware of. The front desk should always notify the nurse manager if they are unsure of what to do in certain situations. During an interview conducted with Staff L, (ED greeter/PCT) on 05/21/2025 at 12:40PM revealed, patients are told we don’t let the child go into the adult ED with the parent. We will try to accommodate them by treating the parents on the side to make sure the child is safe. Staff L reported, they had received EMTALA training. During an interview on 05/21/2025 at 3:40PM, Staff A (Risk Manager) stated that an Incident Report was not completed because the complaint about Patient #1 came through the Guest Relations Department. The surveyor was provided with investigative notes/staff interviews dated 04/30/2025. Staff A documented investigative notes and staff interviews, ED staff education was implemented (1) regarding the process for adult patients that present with minor children; that there were no barriers for medical care and (2) The process for escalation to the Charge Nurse, the Assistant Nurse Manager (ANM), and the Administrator in charge (AIC). Date completed 04/30/2025. During an interview in the pediatric ED on 05/21/2025 at 12:55PM, Staff N (Pediatric ED RN) stated their capacity is 9 patients. Staff N reported, there are 7 private rooms and 2 hallway beds. Staff N, confirmed that the rooms are used on occasion for adult patients that have small children with them. During an interview with Staff O, (ED Assistant Head Nurse) on 05/21/2025 at 1:10PM revealed, there was a recent ED meeting regarding the care of a patient that comes in with a child. The meeting was attended by the Risk Manager and Nurse Educator, and the ED staff were encouraged to focus on the patient’s concerns first, then follow-up with caring for the child.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45329 Based on observation, interview, record review and policy review, the facility failed to protect and promote the rights of pediatric patients to ensure care was provided in a safe setting to ensure pediatric patients were protected from abuse and neglect (neglect is considered as a form of abuse) when 2 (Pediatric Patient #1 and #2) out of 10 sampled pediatric patients were dropped/fell to the floor by the nurse due to a lack of adequate monitoring and appropriate safety measures. Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified. The findings included: Based on observation, interview, record review and policy review, the facility failed to ensure all patients received care in a safe setting. The cumulative effect resulted in Immediate Jeopardy at A144. 2 out of 10 (Pediatric Patient #1 and Pediatric Patient #2) sampled pediatric patients were not appropriately supervised by nursing staff and provided with adequate monitoring and safety measures to prevent a drop/fall to the floor due to unsafe practices. Patient #1 experienced a drop/fall from the lap of a nurse during bottle feeding resulting in an additional 36 days of hospitalization. Patient #2 experienced a fall from an isolette when the door was not properly closed. Refer to A144.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45329 Based on interview, record review and policy review, the facility failed to provide nursing care and services in accordance with accepted standards of nursing practice and ensure that patients at high risk for falls had adequate supervision and safety measures in place for 2 (Newborn Pediatric Patients #1 and Pediatric Patient #2) out of 10 sampled patients that were dropped/fell to the floor while under the care of a nurse. Based on the findings, the Condition of Participation at Code of Federal Regulations (CFR) 42, Part 482.23 Nursing Services was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients were identified. The findings included: Based on interview, record review and policy review, the facility failed to ensure all patients were appropriately supervised according to a patient specific plan of care based on assessed needs. The cumulative effect resulted in Immediate Jeopardy at A395. Two (Newborn Pediatric Patients #1 and Pediatric Patient #2) out of 10 sampled pediatric patients were not appropriately supervised by nursing staff and provided with adequate safety measures to prevent a drop/fall to the floor due to unsafe practices. Patient #1 experienced a drop/fall from the lap of a nurse during bottle feeding possibly resulting in additional days of hospitalization. Patient #2 experienced a fall from an isolette/crib when the door was not properly closed. Refer to A395.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45329 Based on observation, interview, record review and policy review, the facility failed to ensure all patients received care in a safe setting. The cumulative effect resulted in Immediate Jeopardy at A144. 2 out of 10 (Pediatric Patient #1 and Pediatric Patient #2) sampled pediatric patients were not appropriately supervised by nursing staff and provided with adequate monitoring and safety measures to prevent a drop/fall to the floor due to unsafe practices. Patient #1 experienced a drop/fall from the lap of a nurse during bottle feeding resulting in additional days of hospitalization. Patient #2 experienced a fall from an isolette when the door was not properly closed. Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified. Refer to A115. The findings included: Review of facility Policy No. 400.005; Subject: Patient Rights and Responsibilities, Last Revised 09/20/2023 documented in part, I. Purpose: The facility supports the Patient’s Bill of Rights and Responsibilities which is recognized as applying to all adult and pediatric patients, their parents and/or guardians. A patient has the right to a prompt and reasonable response to questions and requests. Any patient, patient advocate, parent or guardian who feels the patient is not being treated properly has the right, without recrimination, to voice complaints/grievances regarding the care received and to have those complaints/grievances reviewed and resolved. This includes the right to file a verbal or written complaint/grievance with the State against the hospital or a healthcare professional. (xiv) Receive Care in a Safe Setting. Review of facility Policy No. 400.095; Subject: Fall and Fall Injury Prevention and Management Program, Last Revised 01/10/2022 documented in part, I. Purpose: The purpose of this policy is to promote a culture of safety, foster an environment of care to reduce the incidence of patient falls and minimize the risk of injury. This policy aims to accomplish these goals by establishing procedures to systematically assess fall risk and risk of injury due to fall factors by providing guidelines for fall interventions and by outlining procedures for education, communication, and documentation. Ill. Procedure: A. Responsibility (1) The following staff members are responsible for the implementation and oversight of an individualized patient’s fall prevention care as follows: (a) Registered Nurses (b) Interdisciplinary Team (c) Therapy Staff. B. Fall Risk Assessment (1b) Humpty Dumpty Scale for Pediatric Inpatients (>12 High Risk) Key points: Patients may also be identified as high fall risk even when Humpty Dumpty Scale Score is less than 12, based on unit-specific risk factors and/or the caregiver’s judgment. (2) For children less than 3 years old the scale is to be done on admission and transfer only, as they are always high risk for falls. A review of Pediatric Patient #1’s medical record revealed that Pediatric Patient #1 was born at the facility on 08/12/2024 prematurely at 34.3 weeks of gestation weighing 3.5 pounds and admitted to the Level IV Newborn Intensive Care Unit (NICU) for respiratory distress. Review of Neonatology Progress Note dated 8/17/2024 at 11:37AM documented Pediatric Patient #1 transferred from NICU B, status post respiratory distress, tolerating feeds well. Vitals & Measurements: Temperature: 98.06°F (Axillary) Heart Rate: 138(Monitored) Respiratory Rate: 44; Blood Pressure: 61/33; Oxygenation (SpO2): 98%; Weight: 1.970 kg (4.3 pounds). Physical Exam General: Well nourished, well hydrated. No distress. Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion Cardiovascular: Normal rate, Regular rhythm, No murmur. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds. Eye: Extraocular movements are intact. Normal conjunctiva. Head: Normal, fontanelles soft, sutures movable. Integumentary: Normal color, No rash, No edema. Neurologic: Alert, Normal motor function, No focal deficits. Ins/Outs: Enteral feeding: 119 ml/kg/day. Urine output: 3.4 ml/kg/hour. Stools: 5. Reason For Continuing Hospitalization: Pediatric Patient #1 with low birth weight (LBW) in isolette. Starting feeds. Review of Neonatology Progress Note dated 08/20/2024 at 10:48AM documented Reason For Continuing Hospitalization - Pediatric Patient #1 still small, weaning well from isolette , now gaining weight better, will increase feeds, probable discharge in AM (08/21/2024). On the morning of 08/21/2024 around 6AM while being bottle-fed by a nurse, Pediatric Patient #1 was dropped/fell to the floor from the nurse’s lap. The fall incident was not reported by the nurse and Patient #1 did not receive immediate medical attention. After the fall, Patient #1 was no longer able to be bottle fed and required a feeding tube for weight management. Review of Neonatology Progress Note dated 08/21/2024 at 11:20AM (approximately 4 hours post morning fall) documented Pediatric Patient #1 weaned to open isolette, but lost weight and nippling very slowly this AM. Temperature: 97.88 °F (Axillary) Heart Rate: 154 (Apical) Respiratory Rate: 64; Blood Pressure: 67/42; Oxygenation (SpO2): 99%; Weight: 1.750 kg (3.85 pounds). Feeding tube inserted. Review of Neonatology Progress Note dated 08/22/2024 at 10:35AM (1-day post fall) documented Pediatric Patient failed weaning and failed to take all feeds 8/21/2024, now continues to require gavage to complete feeds. Review of Neonatology Progress Note dated 08/23/2024 at 1:22PM (2-days post fall) documented Reason For Continuing Hospitalization: Pediatric Patient #1 requiring gavage feeds. Needs isolette to keep temperature stable. Will get screening complete blood count (CBC) as Pediatric Patient #1 now nippling poorly (was nippling well 2 days ago). Review of Neonatology Progress Note dated 08/27/2024 at 9:10AM (6-days post fall). Pediatric Patient #1 still requiring gavage feeds, plan discharge when nippling all. Review of Neonatology Progress Note dated 08/29/2024 at 10:21AM (8-days post fall). Discharge plans for the next 1 to 2 days if Pediatric Patient #1 consistently take all feeds well. Review of Neonatology Progress Note dated 09/01/2024 at 10:33AM (11-days post fall). Pediatric Patient #1 nippled almost all, in open crib, but lost a bit of weight. Reason For Continuing Hospitalization: Very low hemoglobin/hematocrit. Over a 3-week period, Pediatric Patient #1 remained hospitalized in the unit and slowly progressed with feeding and improved anemia and was discharged home on 09/16/2024 (26 days post fall). The fall incident was eventually reported on 09/23/2024 by another parent who was in the unit and witnessed Pediatric Patient #1’s fall. On 09/26/2024 (10 days post discharge), during a clinic visit dated 09/26/2024, the parents of Pediatric Patient #1 were notified that Pediatric Patient #1 was dropped by the nurse on 08/20/2024. Review of the Assessment/Plan revealed Pediatric Patient #1 was preterm with a history of trauma to head 1 month prior - exam at this time unremarkable, but Pediatric Patient #1 had no imaging done as incident was not known so Head Ultrasound ordered. The Head Ultrasound showed a right germinoloytic cyst versus grade 1 intravascular hemorrhage (IVH), so repeat was ordered in 2 weeks. Pediatric Patient will be followed in clinic. Discussion was held with parents who voiced concern over future consequences of the fall, they were particularly concerned as another child in the family had been dropped as a baby and though no injury was found at the time the child had developmental issues. A statement from the nurse dated 09/24/2024 at 1:05PM documented the fall occurred when Pediatric Patient #1 became wiggly while being bottle fed on her lap (thigh). Pediatric Patient #1 was wrapped in several blanks and the nurse was unable to maintain a firm grasp of Pediatric Patient #1. Pediatric Patient #1 slipped out of the nurse’s hand and fell to the floor. Pediatric Patient #1 was picked up and consoled by the nurse. Vital signs were monitored but the nurse failed to report the fall to a medical provider because the vital signs were normal. As a result, Pediatric Patient #1 was not assessed for hospital acquired fall related injuries until 09/26/2024. An interview was conducted on 03/19/2025 at 10AM with the mother of Pediatric Patient #1 after a clinic visit using professional interpreter services provided to patient by the facility. The mother stated that after the fall was disclosed on 09/26/2024 Pediatric Patient #1 is being followed in a program to identify if developmental milestones are being reached and receiving occupational therapy once a week for spasticity (muscles stiffen or tighten), left side affected more than the right side. During an interview conducted with Pediatric Patient #1’s mother in the clinic on 03/18/2025, it was revealed she is having difficulty obtaining an appointment for pediatric neurology related to the spasticity Pediatric Patient #1 is experiencing and audiology to address Pediatric Patient #1 not reacting to a bell ring The appointments have been requested multiple times since December 2024. As of this visit (03/19/2025), Pediatric Patient #1 has not seen either specialist. During an interview on 03/14/2025 at 2:45PM with the Senior Vice-President and Chief Executive Officer (CEO) of the Children’s and Women’s Center, it was revealed that a Root Cause Analysis (RCA) was not performed because “criteria was not met”. During an interview conducted with the facility Risk Manager (RM) on 03/19/2025 at 9AM it was acknowledged that the education efforts were focused on reporting the incident not how Pediatric Patient #1 was positioned during feeding. The RM also acknowledged post fall management was reviewed but did not explore how to avoid or prevent the incident. Pediatric Patient #2 A review of Pediatric Patient #2’s medical record revealed that Pediatric Patient #2 was born 08/02/2023 prematurely at 26 weeks gestation weighing 0.8kg (1.76 pounds). On 10/02/2023 a physician reported that a parent of another baby reported to her that she saw Pediatric Patient #2 fall from the isolette on 09/26/2023 between 9PM and 12 midnight. Following confirmation, a meeting was immediately requested with the parents of Pediatric Patient #2. On 10/03/2023 a meeting was held with the parents, nurse manager, director of pediatric services, risk manager, and physician. The parents were informed that their baby had an accidental fall from an isolette on 09/26/2023. A head ultrasound done prior to and after 09/26/2023 were unchanged and skeletal survey done 10/03/2023 did not show any fractures. The parents were surprised and asked how this occurred. The parents were informed that in the process of changing the baby’s bed linens, an isolette door was not properly closed. Apologies were extended for the occurrence and the late disclosure. The parents expressed concerns about a swollen arm, and it was explained that this was secondary to a peripherally inserted central catheter (PICC) line and this was removed. The parents also wanted to know the plans for the fluid in the brain and the physician explained via speaker phone (and interpreter) that she hopes to do a reservoir very soon, however a lot of cerebrospinal fluid (CSF) drained out during the previous surgery, and it would not have been safe to place a reservoir during that surgery. The parents were also informed that a brain MRI would be done as head ultrasounds are not good for imaging the posterior fossa. The parents voiced understanding and were told that we are available at any time to address any further concerns. Per bystander report, Pediatric Patient #2 fell from an incubator onto the floor while the bedside nurse was providing care on Tuesday evening, September 26, 2023. The nurse did not report the fall to the clinical team. Pediatric Patient #2 was returned to the incubator and routine care provided. The bystander reported this event to the physician on October 2, 2023, at 3PM. Interviews conducted with NICU Intermediate nursing staff on 03/19/2025 between 2PM and 3PM revealed that newborns and premature infants are at risk for falls if not secured properly during feeding or routine activities because of their small size and weight. Two pediatric falls occurred in the facility’s Newborn Intensive Care Unit between 09/26/2023 and 08/21/2024. Both fall events were not reported by the nursing staff to provide an opportunity for immediate medical attention. The falls were discovered when the parents of other infants witnessed the fall events and reported their observations. On 09/26/2024 and 09/28/2024 the facility conducted nursing staff education focused on reporting fall events via unit huddles. The staff were also instructed to review Lippincott Procedures - Fall prevention for neonates. Huddle attendance was signed by approximately 61 out of 165 nursing staff working in the 4 newborn ICU’s. The unit consists of 4 contiguous areas totaling 121 beds. The nursing staff may be assigned to any of the areas to provide nursing care.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45329 Based on interview, record review and policy review, the facility failed to provide nursing care and services in accordance with accepted standards of nursing practice to ensure that patients at high risk for falls had adequate supervision and safety measures in place. 2 (Pediatric Patient #1 and Pediatric Patient #2) out of 10 sampled patients were dropped/fell to the floor while under the direct care of a nurse (during feeding and during bed linen change). The findings included: Review of facility Policy No. 400.095; Subject: Fall and Fall Injury Prevention and Management Program, Last Revised 01/10/2022 documented in part, I. Purpose: The purpose of this policy is to promote a culture of safety, foster an environment of care to reduce the incidence of patient falls and minimize the risk of injury. This policy aims to accomplish these goals by establishing procedures to systematically assess fall risk and risk of injury due to fall factors by providing guidelines for fall interventions and by outlining procedures for education, communication, and documentation. Ill. Procedure: A. Responsibility (1) The following staff members are responsible for the implementation and oversight of an individualized patient’s fall prevention care as follows: (a) Registered Nurses (b) Interdisciplinary Team (c) Therapy Staff. B. Fall Risk Assessment (1b) Humpty Dumpty Scale for Pediatric Inpatients (>12 High Risk) Key points: Patients may also be identified as high fall risk even when Humpty Dumpty Scale Score is less than 12, based on unit-specific risk factors and/or the caregiver’s judgment. (2) For children less than 3 years old the scale is to be done on admission and transfer only, as they are always high risk for falls. Review of Policy No. 400.095, Subject: Interdisciplinary Plan of Care (IPOC), Last Reviewed 04/10/2023 documented in part, I. Purpose: To describe the process by which the clinical members of the interdisciplinary care team collaborate to customize and implement an interdisciplinary Plan of Care (IPOC) that focuses on the patient needs, problems, and outcomes. A review of Pediatric Patient #1’s medical record revealed that Pediatric Patient #1 was born at the facility on 08/12/2024 prematurely at 34.3 weeks of gestation weighing 3.5 pounds and admitted to the Level IV Newborn Intensive Care Unit (NICU) for respiratory distress. Review of Neonatology Progress Note dated 8/17/2024 at 11:37AM documented Pediatric Patient #1 transferred from NICU B, status post respiratory distress, tolerating feeds well. Vitals & Measurements: Temperature: 98.06°F (Axillary) Heart Rate: 138(Monitored) Respiratory Rate: 44; Blood Pressure: 61/33; Oxygenation (SpO2): 98%; Weight: 1.970 kg (4.3 pounds). Physical Exam General: Well nourished, well hydrated. No distress. Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion Cardiovascular: Normal rate, Regular rhythm, No murmur. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds. Eye: Extraocular movements are intact. Normal conjunctiva. Head: Normal, fontanelles soft, sutures movable. Integumentary: Normal color, No rash, No edema. Neurologic: Alert, Normal motor function, No focal deficits. Ins/Outs: Enteral feeding: 119 ml/kg/day. Urine output: 3.4 ml/kg/hour. Stools: 5. Reason For Continuing Hospitalization: Pediatric Patient #1 with low birth weight (LBW) in isolette. Starting feeds. Review of Neonatology Progress Note dated 08/20/2024 at 10:48AM documented Reason For Continuing Hospitalization - Pediatric Patient #1 still small, weaning well from isolette , now gaining weight better, will increase feeds, probable discharge in AM (08/21/2024). On the morning of 08/21/2024 around 6AM while being bottle-fed by a nurse, Pediatric Patient #1 was dropped/fell to the floor from the nurse’s lap. The fall incident was not reported by the nurse and Patient #1 did not receive immediate medical attention. After the fall, Patient #1 was no longer able to be bottle fed and required a feeding tube for weight management. Review of Neonatology Progress Note dated 08/21/2024 at 11:20AM (approximately 4 hours post morning fall) documented Pediatric Patient #1 weaned to open isolette, but lost weight and nippling very slowly this AM. Temperature: 97.88 °F (Axillary) Heart Rate: 154 (Apical) Respiratory Rate: 64; Blood Pressure: 67/42; Oxygenation (SpO2): 99%; Weight: 1.750 kg (3.85 pounds). Feeding tube inserted. Review of Neonatology Progress Note dated 08/22/2024 at 10:35AM (1-day post fall) documented Pediatric Patient failed weaning and failed to take all feeds 8/21/2024, now continues to require gavage to complete feeds. Review of Neonatology Progress Note dated 08/23/2024 at 1:22PM (2-days post fall) documented Reason For Continuing Hospitalization: Pediatric Patient #1 requiring gavage feeds. Needs isolette to keep temperature stable. Will get screening complete blood count (CBC) as Pediatric Patient #1 now nippling poorly (was nippling well 2 days ago). Review of Neonatology Progress Note dated 08/27/2024 at 9:10AM (6-days post fall). Pediatric Patient #1 still requiring gavage feeds, plan discharge when nippling all. Review of Neonatology Progress Note dated 08/29/2024 at 10:21AM (8-days post fall). Discharge plans for next 1 to 2 days if Pediatric Patient #1 consistently taking all feeds well. Review of Neonatology Progress Note dated 09/01/2024 at 10:33AM (11-days post fall). Pediatric Patient #1 nippled almost all, in open crib, but lost a bit of weight. Reason For Continuing Hospitalization: Very low hemoglobin/hematocrit. Over a 3 week period, Pediatric Patient #1 remained hospitalized in the unit and slowly progressed with feeding and improved anemia and was discharged home on 09/16/2024 (26 days post fall). The fall incident was eventually reported on 09/23/2024 by another parent who was in the unit and witnessed Pediatric Patient #1’s fall. On 09/26/2024 (10 days post discharge), during a clinic visit dated 09/26/2024, the parents of Pediatric Patient #1 were notified that Pediatric Patient #1 was dropped by the nurse on 08/20/2024. Review of the Assessment/Plan revealed Pediatric Patient #1 was preterm with a history of trauma to head 1 month prior - exam at this time unremarkable, but Pediatric Patient #1 had no imaging done as incident was not known so Head Ultrasound ordered. The Head Ultrasound showed a right germinoloytic cyst versus grade 1 intravascular hemorrhage (IVH) so repeat was ordered in 2 weeks. Pediatric Patient will be followed in clinic. Discussion was held with parents who voiced concern over future consequences of the fall, they were particularly concerned as another child in the family had been dropped as a baby and though no injury found at the time the child had developmental issues. A statement from the nurse dated 09/24/2024 at 1:05PM documented the fall occurred when Pediatric Patient #1 became wiggly while being bottle fed on her lap (thigh). Pediatric Patient #1 was wrapped in several blanks and the nurse was unable to maintain a firm grasp of Pediatric Patient #1. Pediatric Patient #1 slipped out of the nurses’ hand and fell to the floor. Pediatric Patient #1 was picked up and consoled by the nurse. Vital signs were monitored but the nurse failed to report the fall to a medical provider because the vital signs were normal. As a result, Pediatric Patient #1 was not assessed for hospital acquired fall related injuries until 09/26/2024. An interview was conducted on 03/19/2025 at 10AM with the mother of Pediatric Patient #1 after a clinic visit using professional interpreter services provided to patient by the facility. The mother stated that after the fall was disclosed on 09/26/2024 Pediatric Patient #1 is being followed in a program to identify if developmental milestones are being reached and receiving occupational therapy once a week for spasticity (muscles stiffen or tighten), left side affected more than the right side. During an interview conducted with Pediatric Patient #1’s mother in the clinic on 03/18/2025, it was revealed she is having difficulty obtaining an appointment for pediatric neurology related to the spasticity Pediatric Patient #1 is experiencing and audiology to address Pediatric Patient #1 not reacting to a bell ring The appointments have been requested multiple times since December 2024. As of this visit (03/19/2025), Pediatric Patient #1 has not seen either specialist. During an interview on 03/14/2025 at 2:45PM with the Senior Vice-President and Chief Executive Officer (CEO) of the Children’s and Women’s Center, it was revealed that a Root Cause Analysis (RCA) was not performed because “criteria was not met”. During an interview conducted with the facility Risk Manager (RM) on 03/19/2025 at 9AM it was acknowledged that the education efforts were focused on reporting the incident not how Pediatric Patient #1 was positioned during feeding. The RM also acknowledged post fall management was reviewed but did not explore how to avoid or prevent the incident. Pediatric Patient #2 A review of Pediatric Patient #2’s medical record revealed that Pediatric Patient #2 was born 08/02/2023 prematurely at 26 weeks gestation weighing 0.8kg (1.76 pounds). On 10/02/2023 a physician reported that a parent of another baby reported to her that she saw Pediatric Patient #2 fall from the isolette on 09/26/2023 between 9PM and 12 midnight. Following confirmation, a meeting was immediately requested with the parents of Pediatric Patient #2. On 10/03/2023 a meeting was held with the parents, nurse manager, director of pediatric services, risk manager, and the physician. The parents were informed that their baby had an accidental fall from an isolette on 09/26/2023. A head ultrasound done prior to and after 09/26/2023 were unchanged and skeletal survey done 10/03/2023 did not show any fractures. The parents were surprised and asked how this occurred. The parents were informed that in the process of changing the baby’s bed linens, an isolette door was not properly closed. Apologies were extended for the occurrence and the late disclosure. The parents expressed concerns about a swollen arm and it was explained that this was secondary to a peripherally inserted central catheter (PICC) line and this was removed. The parents also wanted to know the plans for the fluid in the brain and the physician explained via speaker phone (and interpreter) that she hopes to do a reservoir very soon, however a lot of cerebrospinal fluid (CSF) drained out during the previous surgery and it would not have been safe to place a reservoir during that surgery. The parents were also informed that a brain MRI would be done as head ultrasounds are not good for imaging the posterior fossa. The parents voiced understanding and were told that we are available at anytime to address any further concerns. Per bystander report, Pediatric Patient #2 fell from an incubator onto the floor while the bedside nurse was providing care on Tuesday evening, September 26, 2023. The nurse did not report the fall to the clinical team. Pediatric Patient #2 was returned to the incubator and routine care provided. The bystander reported this event to the physician on October 2, 2023 at 3PM. Interviews conducted with NICU Intermediate nursing staff on 03/19/2025 between 2PM and 3PM revealed that newborns and premature infants are at risk for falls if not secured properly during feeding or routine activities because of their small size and weight. Two pediatric falls occurred in the facility’s Newborn Intensive Care Unit between 09/26/2023 and 08/21/2024. Both fall events were not reported by nursing staff to provide an opportunity for immediate medical attention. The falls were discovered when the parents of other infants witnessed the fall events and reported their observations. On 09/26/2024 and 09/28/2024 the facility conducted nursing staff education focused on reporting fall events via unit huddles. The staff was also instructed to review Lippincott Procedures - Fall prevention for neonates. Huddle attendance was signed by approximately 61 out of 165 nursing staff working in the 4 newborn ICU’s. The unit consists of 4 contiguous areas totaling 121 beds. The nursing staff may be assigned to any of the areas to provide nursing care.”

“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: 45329 Based on the review of medical records, Policy and procedure review, Emergency Medical Services (EMS) ambulance report, Incident Report, Autopsy report, Police Report, review of the facility’s video footage, and interviews, it was determined that the facility failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital’s Emergency Department (ED), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed for 1 (Patient #1) out of 20 Sampled Patients. Refer to Findings in Tag A-2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 45329 Based on the review of medical records, Policy and procedure review, Emergency Medical Services (EMS) ambulance report, Incident Report, Autopsy report, Police Report, review of the facility’s video footage, and interviews, it was determined that the facility failed to ensure an appropriate medical screening examination that was within the capability of the hospital’s Emergency Department (ED), including ancillary services routinely available to the ED, was provided to determine whether or not an emergency medical condition existed for 1 (Patient #1) out of 20 Sampled Patients. The patient presented to the hospital’s emergency department on 4/17/2024, 4/18/24, 4/19/24, and 4/20/24 with presenting signs and symptoms on initial visit (4/17/2024) with elevated heart rate, and an abnormal heart rhythm QTc prolonged (a heart rhythm disorder that causes the fast heartbeats, irregular heartbeats) at 510ms (Normal QTc is >360 milliseconds, > 460 in women considered prolonged, potential fatal ventricular rhythm) on Electrocardiogram, complaining of weakness, fatigue, nausea vomiting and lightheadedness, and discharged. There was no documentation that a medical screening examination was performed. The patient returned to the ED 1.5 hours later after discharge on 4/17/24 complaining of not feeling well, the patient was escorted out of the hospital’s emergency department via hospital police and did not receive a medical screening examination. The patient returned to the hospital’s emergency department on 4/18/2024 (Day 2 visit) with an elevated heart rate of 132 beats per minute, elevated diagnostic laboratory tests of mild transaminitis (elevated liver enzymes), and an abnormal ECG with continued QTc prolonged, Tachycardia, and enlarged right atrium, the patient was discharged from the hospital ED. The patient returned to the hospital’s ED on 4/19/2024 (Day 3 visit) and on 4/19/24 (Day 4 visit) with complaints of weakness, continued tachycardia critically high blood pressures, and subsequently discharged on 4/19/24 and 4/20/24. Patient #1 was known by the hospital employees to occupy an outside patio bench within the 250 yards of the main hospital building for the past 4 days was found on 4/21/2024 around 2:20 P.M. lying on the ground in the hospital’s patio area unresponsive and in full cardiac arrest. The clinical staff was made aware, and the patient was taken into the hospital’s ED for evaluation and treatment. During the resuscitation efforts “Exam shows ... there is blisters in the med torso area from the mid abdomen to the mid-thigh an area of dark discoloration what appears to be something like a second-degree burn with blistering and sloughing of the skin. There is also sloughing of the skin on the left upper extremity.” Where the resuscitation efforts were unsuccessful, and Patient #1 expired at 2:38 P.M on 4/21/2024. The facility failed to ensure that on 4/17/24, 4/18/24, 4/19/24 and 4/20/24 appropriate medical screening examinations were provided for Patient #1 placed the health and safety of the patient in serious jeopardy. Findings include: Review of the facility’s policy entitled (2) Administration Policy No. 209, Subject: Emergency Treatment and Patient Transfer Policy, Last Revised 08/22/2023 included but wasn’t limited to: I. Purpose The purpose of this policy is to ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA), its amendments, regulations, and reporting requirements. EMTALA requires that all patients who request medical treatment for an emergency medical condition or have such a request made on their behalf, receive certain basic threshold services and stabilizing treatment as necessary. ..To ensure the facility meets EMTALA’s rules and requirements, including adherence to the 250-yard rule. This policy outlines the process for treating requests under EMTALA, as well as how to handle the transfer and acceptance of patients at Jackson Health System facilities ...III. Procedure: A. Requests for Emergency Treatment: All patients who request medical treatment for an EMC (Emergency Medical Condition) in any manner, or who have such a request made on their behalf, must receive an MSE by a QMP (Qualified Medical Professional-means a health practitioner acting within his or her scope if practice as defined in the medical staff bylaws or rules and regulations may perform a medical screening examination and in consultation with a physician) ... a. A patient may request such case anywhere on the hospital premises, within 250 yards of the main buildings, including any treatment areas, the parking lot, sidewalk or driveway ... 5. The medical screening examination must be documented in the patient’s medical record.” Review of the facility’s video footage captured Patient #1 at various times while in the ED foyer/ED Registration area on 04/17/2024, 04/18/2024, 04/19/2024, and 04/20/2024. Patient #1 was seen in the ED on 4 consecutive days prior to expiring. At no time did Patient #1 leave the facility’s property within the four days preceding her death. The Police Report dated 4/21/2024 at 6:17 P.M. was reviewed. The Police Report revealed in part, “Narratives ... On Sunday, April 24, 2024, ...dispatched to (Jackson Memorial Hospital) in reference to a death. Upon arrival contact was made with reporting person/nurse ...who advised (Pt#1) was pronounced deceased ...at approximately 2:38 P.M ...Contact was then made via phone with Security Guard ...who advised at approximately 2:10 P.M ...Upon his arrival to the picnic area he noticed (Pt.#1) on the ground laying on her right side and appeared unresponsive. He then called for medical assistance to where (Patient #1) was transported inside of the hospital.” The facility’s incident report dated 4/28/2024 for Patient #1 was reviewed. The section of the report titled “GENERAL INFORMATION ABOUT THE DIAGNOSIS/TREATMENT EVENT; Specific event type: Diagnosis issue ... Severity Level (Reported) X. Person’s Death Due to Admitting Diagnosis or Unrelated disease.” The report revealed in part, “GENERAL INFORMATION ABOUT THE DIAGNOSIS/TREATMENT EVENT: ...Brief Factual Description: On Wednesday April 17, 2024, unknown black female patient was observed in the Emergency Room and later discharged. However, the patient complained about having continued pain she couldn’t describe her pain to medical staff, The female patient checked herself in again to emergency room over a four (4-day period) and discharged. On Sunday April 21, 2024, at 2:10 the patient was found on the Emergency Room Patio location, it was discovered that the female patient had marks on her leg and stomach area that appeared to be burn marks.” (3) Review of Patient #1’s medical records revealed the following documentation: Emergency Department Visit #1 The EMS ambulance report dated 4/17/2024 at 1:36 P.M. was reviewed. The section of the report titled, “Narrative Treatment Summary” revealed in part, Pt. (patient) stated she has been experiencing flu like symptoms and requested transport to the hospital. Vitals WNL (within normal limits). The patient was oriented to person, place, time an event, The patient was transferred to Jackson North Medical Center, Emergency Department on 4/17/2024 at 1:44 P.M. Review of the medical record dated 4/17/2024 revealed that patient #1 registered into the Emergency Department at 2:10 P.M. Review of the “ED Note -Physician” revealed the patient was seen by ED Physician Staff P on 4/17/2024 at 2:26 P.M. The patient’s complaint was listed as “Weakness or Fatigue.” Documentation by the ED physician Staff P revealed, in part “History of Present Illness: Patient #1 who denies any chronic medical conditions presenting to the emergency department for evaluation of nausea vomiting. The patient says over the last 2 (two) days she has had multiple episodes of nonbloody, nonbilious emesis that has resulted in her feeling weak. She also feels lightheaded and some spinning whenever she stands ... Patient #1 reports to smoking marijuana, has not done this in a couple days. Plan to treat Patient #1 with a Liter of IV fluids and IV Zofran (medication for nausea). If her symptoms do not resolve will administer Haldol and today, she is suffering from cannabinoid hyperemesis syndrome (a condition that leads to repeated and severe bouts of vomiting). Electrocardiogram (EKG) ordered to monitor QTc (Stands for heart rate corrected QT interval-on EKG measures efficiency of the repolarization of the left ventricle). Electrocardiogram: 04/17/2024 at 3:26 PM, heart rate 101 (normal heart rate- 60-100), QTc prolonged (a heart rhythm disorder that causes the fast heartbeats, irregular heartbeats) at 510ms, otherwise intervals within normal limits. The abnormal laboratory tests resulted on 4/17/2024 T 5:34 P.M. and 6:10 P.M. were reviewed: Glucose: 110 High (Normal 60-100); Potassium:3.1 low (mineral keeps heartbeat regularly and blood pressure stable. Normal value 3.5 to 5.2); Total Protein 9.1 High (test performed to help diagnose nutritional problems, kidney, and liver disease- Normal value- 6.0 to 8.3); Total Bilirubin 1.8 High (test ordered if suspect liver or gallbladder problems. Normal level between 0.1 to 1.2); AST- 89 High (Aspartate Transferase- test measures potential damage to liver or muscles. Normal range 8 to 33); ALT-101 Hi (Alanine Transaminase- helps to assess liver health. Normal Range: 7 to 56). The patient was triaged as an ESI (emergency severity index- prioritize patients according to their illness and injury, severity or acuity) acuity 3 (urgent-abdominal pain, dehydration, and fractures). Further review revealed, “Reevaluation Time: 04/17/2024 at 4:28 PM. Patient #1 feels some improvement. Stated she is currently experiencing homelessness. Spoke to population health or social worker for disposition help. She declined to give urine sample though on questioning has no Urinary Tract Infection (UTI) symptoms, so it was canceled. Repeat Reevaluation Time: 04/17/2024 at 6:15 PM Patient #1 has tolerated the turkey sandwich, apple sauce and juices given. No witnessed vomiting so no Haldol was ordered especially since her QTc is prolonged. She is otherwise non-toxic appearing. No admission criteria based on her exam, vitals and labs. Stated she called 911 from her hotel. Spoke with the bedside nurse to see if we can help her with transportation back to her hotel. .. Notes: The bedside nurse stated Patient #1 was still mildly tachycardic [114] (Fast heart rate), likely still mildly dehydrated (a condition where the body does not have enough fluids to function properly) however she is trying multiple things of juice and water. She has no chest pain, no dyspnea, no vomiting, no diarrhea, no other acute process that will warrant admission at this time based solely on her mild tachycardia. Patient #1 was stable for discharge.” The section of the medical record titled “Physical Examination” revealed no documentation that a medical screening examination was performed by ED physician Staff P. Additionally, there was no repeat of an ECG prior to discharge, given the patient’s initial ECG showing prolonged QTc abnormally high at 510. Documentation in the Physical Examination section were vital signs and body measurements.” The section titled, “Impression and Diagnosis” revealed the patient’s discharge diagnoses were homelessness, hypokalemia and mildly dehydrated. Patient #1 was discharged on 4/17/2024 at 6:21 P.M. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a physical examination was documented for Patient #1 on 4/17/2024, to determine whether or not an EMC existed. Further review of the medical record the section titled “Assessments and Treatments” revealed that on 4/17/2024 at 8:00 P.M., “Nursing Note 1- Patient was advised that they were discharged and patient denied to go and kept stating that they felt bad. Security was called and escorted patient out of the ER (emergency room). Patient #1 returned to the hospital’s ED 1.5 hours later after being discharged from the hospital’s ED, requesting to be evaluated because she was feeling bad. Instead, the patient was escorted out of the hospital’s ED by security. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that a medical screening examination was provided for Patient #1 when she presented to the hospital’s ED again on 4/17/24 at 8:00 P.M. requesting a medical evaluation. Emergency Department Visit #2 Review of the medical record revealed that Patient #1 registered into the ED on 4/18/2024 at 6:30 A.M. At 6:35 the patient’s abnormal heart rate was listed as 132 (high) beats per minute. The section of the medical record titled “Emergency/Trauma Documentation, revealed documentation by the ED physician Staff Q revealed, on 04/18/2024 at 7:18 AM, “History of present illness: The patient presents with nausea and vomiting. The onset was 5 days ago. The course / duration of symptoms is constant ... Additional history ... Patient with significant past medical history of schizophrenia, bipolar disorder presented to the hospital for evaluation of nausea vomiting and severe weakness. Patient was seen and evaluated yesterday in the hospital for similar complaints ...She admitted being using marijuana ...Patient was given fluids and Zofran, and she was able to tolerate foot (food). Patient was discharged home ...Review of Systems: Constitutional symptoms: Weakness, fatigue ...Gastrointestinal symptoms: Nausea, vomiting ... Physical Examination: General: Alert, mild distress; Skin: Dry and pink. Review of the Radiology results reveled that an Ultrasound was completed on 4/18/24 on 12:41 P.M. The reason for the exam was for right upper quadrant pain. The findings of the Ultrasound were “Findings::Limited evaluation right arm. Liver not well seen. No definitive gallstones appreciated. Common bile duct not seen ... IMPRESSION: Limited exam. Liver and gallbladder poorly visualized. No obvious pathology.” The resulted abnormal Labs for 4/18/2024 at 11:19 A.M., and 11:43 A.M. were reviewed: Glucose -110; Sodium: 136 9 Low; Sodium-136 Low; Potassium- 3.3 low; Chloride-93 Low (electrolyte help maintain body fluid and acid base balance); Osmolality Calculated -273 Low (test measures electrolyte helps maintain body fluids and acid base balance); Total Protein- 8.4 Hi; AST-79; AST- 89 Hi; ALT 79 Hi- Reexamination/ Reevaluation Time: 04/18/2024 at 1:04 PM. Labs with mild transaminitis (elevated liver enzymes), hypokalemia (low potassium) noted that was replaced. Right upper quadrant ultrasound was done to rule out cholecystitis, difficult study, no evidence of acute pathology. Patient #1 able to tolerate oral intake. Patient #1 was evaluated yesterday for similar complaints and was discharged. Patient #1 will be discharged home to follow up with primary care physician (PCP). Impression and Plan: Diagnosis: Cannabinoid hyperemesis syndrome, history of psychiatric disorder, nausea and vomiting. Condition: Stable. Prescriptions: ondansetron 4 mg oral tablet every 8 hours, for 3 day(s), as needed for nausea/vomiting. The section titled, “Certification of Emergency Condition”, on 4/18/2024 at 1:07 P.M. the Advanced Practice Registered Nurse documented, yes Patient #1 met criteria for an emergency condition. Further review revealed the patient was triaged as an ESI -3 (URGENT). The section of the medical record titled, “Cardiology Procedures dated, 4/18/24 at 8:34 A.M. the results of the status of the 12 lead EKG (Electrocardiogram- test that records the electrical activity of the heart, including abnormal heart rhythms) was reviewed. The review revealed the finding of the 12-lead electrocardiogram, sinus tachycardia, right atrial enlargement (a condition in which the right atrium of the heart is enlarged), Prolonged QT interval. The EKG was interpreted as an abnormal ECG on 4/18/2024 at 9:58 P.M. There was no documentation in the medical to indicate the ED physician was notified of the abnormal ECG. Patient #1 had an identified emergency medical condition and required further evaluation and treatment of the abnormal ECG on 4/18/2024. Emergency Department Visit #3 Review of the medical record revealed that Patient #1 registered into the ED on 4/19/2024 at 7:43 A.M. The section of the medical record titled, “Emergency/Trauma Documentation” revealed the patient was seen by a Physician Assistant Staff R, on 4/19/2024 at 8:30 A.M. Review of the “History of Present Illness” revealed in part, “ ...female presents to the ED secondary to weakness. Patient has been seen here the past 2 days and discharged ...back for a 3rd (third) day straight. Patient states she has a history of bipolar schizophrenia and has not been taking her medications. Patient is a poor historian, barely speaking or answering questions. Patient denies cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, headache. Review of the Physical Examination revealed in part, “General: No acute distress ...Cardiovascular: Regular rate and rhythm, No Murmur, Normal peripheral perfusion ...Gastrointestinal: Soft, nontender, Obesity ...Psychiatric: Not very cooperative, Not aggressive.” Review of the patient’s Vital Signs: Peripheral Pulse Rate: 102 to 126 beats per minute; Blood Pressure at 7:55 AM and at48 A.M.: 151/123. Blood Pressure at 8:48 AM: 150/79. Further review revealed the patient was triaged as an ESI acuity -3 (URGENT). Labs positive for Cannabinoid. Radiology results updated Chest X-ray, 1 View 4/19/2024 11:07 AM. Reason For Exam: Elevated Blood Pressure, Nausea and Vomiting. Impression: No radiographic evidence of acute cardiopulmonary disease. Reexamination/ Reevaluation Time: 04/19/2024 at 2:20 PM Course: Improving. Pain status. Impression and Plan: Diagnosis: Depression, Chronic bipolar disorder Calls-Consults - 04/19/2024 at 1:04 PM, recommends to follow-up with outpatient psychiatry. Condition: Improved. Stable. Disposition: Medically cleared, Discharged: 04/19/2024 at 2:32 PM.to home. There was no documentation in the medical record to indicate that an EKG was ordered given Patient #1’s presenting signs and symptoms weakness, Tachycardia 126, and elevated blood pressures 150/79 to 152/126 as this resulted in an inappropriate medical screening examination. The patient was again discharged to home. Emergency Department Visit #4 Review of the medical record revealed that Patient #1 registered into the ED on 4/20/2024 at 7:02 A.M. The patient’s Vital Signs were taken at 7:15 A.M. and listed as: Temperature Oral: 98.0; Peripheral Pulse Rate: 124 beats per minute; Respiratory Rate: 18 breaths per minute; Blood Pressure: 144/110. The section of the medical record titled “Emergency/Trauma Documentation revealed the patient was seen by ED Physician Staff O at 7:59 A.M. Staff C documented “History of Present Illness: Patient #1 is a 32-year-old with past medical history of schizophrenia, bipolar, anxiety presents to the ED for generalized weakness. This is her third visit for this month. Patient #1 was evaluated by psych yesterday and did not meet inpatient criteria. Her case management came to see her. According to her case manager, Patient #1 received money monthly. She is currently homeless. Shelter resources provided yesterday.” Further review revealed, the patient’s “Active Problem” list included: Agitation, Bipolar 1 disorder, current or most recent episode manic, sever, Cannabis dependence, abuse GAD (generalized anxiety disorder). There was no mention of the patient’s persistent elevated heart rate since 4/17/2024, elevated blood pressure on this visit and 4/19/24 visit, and the abnormal ECG. Continued review revealed “Impression and Plan: Diagnosis: Homeless / Condition: Stable. Disposition: Discharged 8:36 AM Saturday morning.” There was no documentation in the medical record that diagnostic laboratory tests were ordered, or that an ECG was ordered to evaluate the patient’s abnormal elevated heart rate and critically high blood pressure on 4/20/2024. As this resulted in an inappropriate medical screening examination. The facility failed to ensure that their policy and procedure was followed o ensure that an appropriate medical screening was provided as evidenced failing to ensure that an appropriate medical screening examination was provided within the capability of the hospital’s emergency department to include ancillary services routinely available to the emergency department to address the patient’s presentation to the ED of persistent tachycardia for 4 days ,and progressed to critically high blood pressure determine whether or not an emergency medical condition existed for patient #1on 4/17/2024, 4/18/2024, 4/19/24 and 4/20/2024. Emergency Department Visit #5 A review of the medical record revealed that on 4/21/2024 Patient #1 was registered into the ED on 4/21/2024 at 2:23 P.M. EDMD Staff N documented in part on the “Emergency/Trauma Documentation” form “Cardiac-Respiratory Arrest *ED. Further review of the ED note dated 04/21/2024 at 2:53 P.M. revealed in part, “Emergency Trauma documentation” History of Present illness Patient #1 presents in cardio-respiratory arrest. The onset was unknown. Witnessed arrest no. Initial cardiac rhythm Asystole (no heartbeat). Preceding symptoms unknown. Patient #1 32-year-old female was found unresponsive outside in the sitting area, security apparently saw her laying on her right side she was unresponsive and medical staff was called. Upon their evaluation the Patient #1 was pulseless and was immediately brought to the resuscitation Bay doing Cardiopulmonary Resuscitation (CPR). Once in the resuscitation Bay, CPR continued, an Intraosseous (IO-medical procedure involves inserting a hollow needle into the bone to deliver fluids and medications) was attempted on the left shoulder however secondary to body habitus it was not a acceptable placement, a right tibia IO was placed. Epinephrine calcium bicarb were given, multiple rounds of CPR, bedside evaluation with bedside ultrasound shows cardiac standstill with poor windows. Exam shows central cyanosis on the mucosal membrane, pupils are fixed dilated, the body is warm, there is blisters in the mid- torso area from the mid-abdomen to the mid-thigh with an area of dark discoloration of what appears to be something like a second-degree burn with blistering and sloughing of the skin. There is also sloughing of the skin on the left upper extremity. Patient #1 was also intubated during CPR. After multiple rounds Patient #1 remained asystole with no cardiac activity on ultrasound resuscitative efforts were discontinued”. Physician N documented “Disposition: Time 4/21/2024 at 2:38 P.M. Expired.” Patient #1’s autopsy report dated 4/23/2024 at 9:15 A.M. The section of the report titled “evidence of injury’ revealed in part, “Areas of the skin sloughing with underlying erythema and surrounding drying are on the left cheek, abdomen, anterior aspects of the thighs, and posterior aspect of the left arm.” Patient #1’s “CAUSE OF DEATH: Cannabinoid Hyperemesis Syndrome. CONTRIBUTORY CAUSE: Hot Weather.” The facility failed to ensure that an appropriate medical screening was provided as evidenced by failing to ensure that an appropriate medical screening examination was provided within the capability of the hospital’s emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for patient #1 on 4/17/2024, 4/18/2024, 4/19/24 and 4/20/2024. Security/Staff Interviews - Documented in chronological order of interviews. Interview with Staff D (Security Specialist #1) and Staff E (Security Specialist #2) on 09/16/2024 at 12:20 PM. Staff D (Security Specialist #1) stated that because it was very hot on 04/21/2024, he and a co-worker Staff F (Security Specialist #3) were taking Patient #1 Gatorade and snacks. Patient #1 was found lying down on an outdoor ED patio bench on her side. She was very still. Staff D (Security Specialist #2) stated, I touched her to see if she was asleep. She did not respond. I radioed dispatch that a patient was down. Staff D stated another security specialist was standing between the registration desk and the front door. Staff F (ED Patient Care Technician) was standing nearby and overheard what was going on, she went and got other medical staff to come and assist. Staff D stated he did not write a report, and the information was passed on to the oncoming 2nd shift. Staff I (Security Specialist #4) who is in charge sometimes may have written the report. Staff D stated shift hours are from 6:00 AM - 2:30 PM and they get relieved around 2:15 PM. Staff E (Security Specialist #2) interviewed during the same time stated that they were dealing with Patient #1 over several days. On one of the days, a social worker was called to speak with Patient #1 and they were told there was nothing they could do (something about her funding). Staff E stated that it was tricky because Patient #1 was discharged and brought back in for several days. We had almost a week of that. Staff E stated the outdoor patio is checked during building checks anywhere from every 30 to 45 minutes and the focus is the outside and interior. Staff E stated they round for maybe 20 -30 minutes, then they do the outside of the ED. If there is an issue, they let the staff know inside. Staff E stated they are only allowed to move from the registration desk to where visitor passes are made. Interview with Staff G (Emergency Medical Technician) conducted on 09/16/2024 at 1:05 PM. Staff G stated she is unable to recall the date or time of the incident; When the overhead page was made, she grabbed some gloves and walked outside. Patient #1 was lying on her side. A sternal rub was done, checked and there was no pulse. Security was asked to go inside to get help because she didn’t have her radio with her. Security helped get the patient on the ground and cardiopulmonary resuscitation (CPR) was started. Interview with Staff H (ED Registered Nurse) on 09/16/2024 at 1:15 PM revealed she observed Patient #1 sitting on the patio bench when coming into work on the morning of 04/21/2024 and Patient #1 was not in distress. Staff H stated during the code she was involved with triaging and assisting in the Resuscitation room. Interview with Staff I (Security Specialist #4) conducted on 09/16/2024 at 2:37 PM. Staff I stated when coming in on Sunday (04/21/2024), they gave me a number to call the family because Patient #1 had been here for days. While getting report in front of the ED, Staff D (Security Specialist #1) was walking by with water. A little while later, heard Staff D (Security Specialist #1) say, she’s down, throwing up. Staff I stated after that he ran to the ED and got Staff G (Emergency Medical Technician) to come and called for security back up to come. Staff G (Emergency Medical Technician) started compressions and went to get more help. Patient #1 was put on stretcher and taken inside. Interview with Staff J (Security Manager) conducted on 09/16/2024 at 2:53 PM. Staff J stated he was a Lieutenant at the time of the incident; the previous manager retired. He is predominately responsible for doing the schedule for all 3 shifts. Staff J stated every time one of the security guards spoke to Patient #1, she stated she was not feeling well, and that was why she was not escorted off the premises. The facility’s practice is to have the patient check back into the ED to see the physician again. If the person is not feeling well, we’re supposed to have them check back in. Interview with Staff K (ED Director) conducted 09/16/2024 at 3:08 PM. Staff K stated Patient #1 is known to us. Unfortunately, this is not an unusual occurrence. We frequently have homeless patients coming in asking for juice or complaining of abdominal pain. Chest pain protocol is done, the physician is notified and labs, chest x-ray is done. Staff K stated many patients coming in with cannabis hyperemesis syndrome. Reviewed labs on 04/17/2024. Potassium level 3.1, if the patient is not symptomatic there is no reason to treat a low potassium. Patient #1 was discharged at 8:24 PM and was taken out to the foyer. My understanding was that she walked around the campus and came back. Patient #1 was registered at 6:35 AM the next morning. EKG. Labs, ultrasound of the abdomen. Dx: cannabinoid hyperemesis syndrome. Reviewing the medical record, Patient #1 received 40 milliequivalents of potassium on 04/17/2024 and 04/18/2024, however additional review revealed no documentation that the staff administered additional milliequivalents of potassium to Patient #1 on 4/20/2024 and 4/21/2024. Interview with Staff J (Security Manager) revealed Staff F (Security Specialist #3) was in charge on 04/20/2024 and 04/21/2024. Staff J stated that security specialists are assigned to zones within the campus. Staff J stated the Rover Patrol zones include the ED patio area, and the expectation is for each shift to make observations twice a day. Interview with Staff F (Security Specialist #3) on 09/17/2024 at 1:34 PM revealed Staff F was in charge on Saturday 4/20/2024 and Sunday 4/21/2024. Staff F stated she first made contact with Patient #1 on Thursday (04/18/2024). A code grey was called in the fast-track area. Upon arrival me and Staff E (Security Specialist #2) told Patient #1 to move from the area. We took her to the foyer in the ED, and told Staff E (Security Specialist #2) to call the case manager. Patient #1 started crying. I did not see her on Friday. Upon return to work on Saturday, I noticed the same [ ____ ] female still sitting inside. Miami-Dade police was contacted. The Police arrived on the premises and attempted a conversation with Patient #1. The only thing she said was the word “pain”. Patient #1 was assisted to the police car and was leaning on the hood. The police stated if Patient #1 continued to complain of pain, there is nothing they could do. Patient #1 was taken back into the ED via wheelchair by the police officer to be seen. I went to the security office to complete the shift summary report. The Chief Operating Officer (COO) stepped into the office, and I informed him about Patient #1 and he took a picture of my summary report and stated he would send it to Staff K (ED Director). Upon return to work at 5:45 AM on Sunday 04/21/2024, I noticed same the [ ____ ] female was no longer on the foyer bench but was sitting ED patio area. Again, I contacted the social worker. Staff L (Social worker #2) was on duty for the ED and stated that if the person is not in the ED, she could not offer any assistance. I brought to her attention that Patient #1 was discharged and has been here for a couple of days. I also informed her that I spoke with the COO regarding Patient #1, and he stated he would send the information to Staff K (ED Director). Interview with the COO conducted on 09/17/2024 at 2:30 PM. The COO stated Patient #1 had multiple visits and was discharged multiple times. Received phone call on weekend from security. The ED was called, and I spoke to Staff K (ED Director), he was asked to check on Patient #1. Staff K (ED Director) called back from the ED to say Patient #1 was okay and was being discharged. The next day I received a call that Patient #1 was dead. The Risk Manager probably followed up with the clinical team. In August, approximately 3 weeks ago, we placed an armed police officer in the ED. The officer rides around the campus for visibility. The incident sort of escalated the decision because we were contemplating the idea because of the violence staff encounters. The officer attends ED huddles, and there are improved feelings of security for the staff. We want the staff to know that we listened to them and responded to their concerns. Interview with the Risk Manager conducted on 09/17/2024 at 3:10 PM. Provided with the Risk Manager’s investigation notes for review. The Risk Manager stated the records, and the video were reviewed and did not feel it was necessary to interview security staff or investigate any further. Interview with Staff K (ED Director) conducted on 09/17/2024 at 3:18 PM. Staff K stated he does not recall receiving a call from the COO on the morning of 04/20/2024 asking him to check on Patient #1. Interview with Staff L (Social Worker #2) conducted on 09/18/2024 at 1:50 PM revealed she does not recall speaking with anyone requesting assistance for a patient outside of the ED. Staff L stated, if I am called to assist someone, I will go to assist them. The Director of Case Manager confirmed that Staff L worked Saturday and Sunday 8 AM - 4:30 PM, the weekend of 04/20/2024 and 04/21/2024. Interview with Staff J (Security Manager) conducted on 09/18/2024 at 2:18 PM revealed a call was received sometime on Saturday (04/20/2024) from Staff F (Security Specialist #3) regarding Patient #1. Stated, Staff F (Security Specialist #3) was told to call the Administrator In Charge (AIC), Social Worker and if no response, call the police. Interview with Staff I (Security Specialist #4) conducted on 09/18/2024 at 2:50 PM revealed on 04/20/2024 he was asked by Staff N (Security Specialist #6) in the ED to escort Patient #1 outside to the patio because the ED staff wanted her outside. Staff I stated that she checked on Patient #1 several times when driving by the area. Interview with Staff M (Security Specialist #5) conducted on 09/19/2024 at 11:00 AM revealed her Saturday morning post was in the ED triage area. The night shift (4/19/2024) security specialist briefed me about what was going on with Patient #1. The police officer works with us on the weekend, now they are here 24 hours. Patient #1 constantly stated pain. When she (Patient #1) looked at you, her eyes were glossy. The police officer assisted her on the outside to the car, and he called his superior. When he brought her back in, he told me and the front desk that his commander stated he could not take her anywhere. They brought her back into the triage area and brought her back out within 15 minutes. I told them not to take her back outside and placed her in the triage chairs directly in front of the front desk. She was monitored all day. Staff F (Security Specialist #3) and I was working on getting a social worker. Staff F (Security Specialist #3) also called the COO that day, and the Administrator in Charge (AIC). The AIC gave the number to call the social worker. A social worker or no one else showed up by the end of my shift. I think it’s a [ ___ ] thing. An example is a [ ___ ] or [ ___ ] family is allowed to go in the back with their family member. But the [ ___ ] families are always redirected and told to wait. The nursing staff makes exceptions for others even allowing babies to come in. The nurses and medical staff are quick to say call security. Patient #1 did a lot of crying. When I asked what was wrong, she (Patient #1) would look up holding her lower abdomen and say pain. She could barely stand up, we cried for days. We tried to call her family, but no one answered the phone. She never asked to use the restroom or for anything to eat or drink. She did not have an odor. I don’t understand what happened. She did not smell like urine. Interview with Staff N (Security Specialist #6) conducted on 09/19/2024 at 12:22 PM revealed she worked a double on Saturday, 04/20/2024 and came in around 2 PM. Staff N stated that Patient #1 was sitting in the triage area and was offered her 2 juices and water, and she was able to drink them. Staff N stated the area was too full and the seats were needed for patients coming in and everyone not waiting to be seen was asked to leave. Staff N stated Patient #1 was sitting there, she didn’t talk much but said she wanted to go outside and sit by the blue benches; Staff I (Security Specialist #4) walked her out. Interview with Staff O (ED Attending Physician) on 09/19/2024 at 1:15 PM revealed the physician saw Patient #1 twice, once with the physician assistant on 04/19/2024 and again on 04/20/2024. Both times Patient #1 was seen in the Fast Track area. Staff O stated Patient #1 was depressed the first time. The second time Patient #1 stated she felt unwell and weak, and seemed very depressed. Patient #1 was seen by Psychiatry. No criteria for admission. Staff O stated Patient #1 had money. Everything was fine. Referred to Social Worker. Patient #1 told there was nothing else to offer. The social worker stated this is how she is. There was no reason to admit. To me, she was just depressed. Patient #1 did not complain of any pain.”

“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: 45329 Based on the facility’s policy and procedure and the review of records, the facility failed to ensure that 1 out of 20 Sampled Patients (SP)’s medical records contained a description of the examination, treatment, or both if applicable, that was refused by SP#l. Additionally, the facility failed to take all reasonable steps to secure SP#1’s written informed refusal on 12/06/2023. Refer to findings in A-2407”

“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: 45329 Based on the facility’s policy and procedure and the review of records, the facility failed to ensure that 1 out of 20 Sampled Patients (SP)’s medical records contained a description of the examination, treatment, or both if applicable, that was refused by SP#l. Additionally, the facility failed to take all reasonable steps to secure SP#1’s written informed refusal on 12/06/2023. Findings include: Review of the facility’s Policy No. 136 Section: 100-200 Administration entitled Patient Leaving Hospital Against Medical Advice last revised on 10/31/2023 included but wasn’t limited to: I. Purpose: To describe the responsibility of _____System towards the act of - Leaving Against Medical Advice “AMA” upon a patient’s release. II. Procedure: A. Any patient leaving a _____facility who has not been discharged by a physician must have a properly executed Patient Leaving Hospital Against Medial Advice/ Refusal of Treatment/Procedure (AMA form) (Form C602c/C602s). 1. It is the physician’s responsibility to see that the AMA form is properly executed. 2. This specifically requires that the patient, or the individual who may legally consent for the patient, must be made fully aware of the possible medical risks associated with leaving against medical advice. Review of Emergency Department (ED) records for Patient #1 on 12/06/2023 documented Patient #1 seen, evaluated and treated appropriately for a left lateral flank stab wound 3 - 4 days old with IV(Intravenous) fluids, IV antibiotics and tetanus vaccine. Patient #1 was advised to stay for overnight observation however requested discharge because of a current house arrest program and needed to return home. Patient #1 was discharged as requested against medical advice on his own free will at 2:12 PM on 12/06/2023. Patient #1 was provided with discharge instructions, patient education, and a prescription for medication. Review of SP#1’s medical record revealed a section entitled “Final report” completed on 12/06/2023 at 13:56 by ED Physician/ Staff G. Basic information: History of present illness The patient presents with Stab wound. Additional history: Patient reports ambulatory to the emergency department with a stab wound to the left flank of the abdomen sustained 4 days ago. Patient presents with normal vital signs. Stab wound site with underlying hematoma. No active bleeding. No other associated injuries. Last tetanus unknown. 12/06/2023 13:54:56 EST trauma saw and evaluated patient who recommended admission to observation overnight however patient requested discharge as he is currently at a house arrest program and needs to return. He will return to ED if any concerning signs or symptoms arise. Impression and Plan: Diagnosis Stab wound of lateral abdomen Abdominal wall hematoma Left against medical advice Plan: Condition: Unchanged Disposition: 12/06/2023 13:40:00, left against medical advice Patient was given the following educational materials: Medicine for Pain, Laceration, Old: Not sutured Follow up with: Follow up with primary care provider Within 1-2 days. Return to ER as needed: Primary care no physician within 1-2 days. Counseled: Patient, regarding diagnosis, regarding diagnosis results, regarding treatment plan, regarding prescription, patient indicated understanding of instructions. Further record review revealed no documentation that the facility executed the Patient Leaving Hospital Against Medial Advice/ Refusal of Treatment/Procedure form or took all reasonable steps to secure SP#1’s written informed refusal when the patient was discharged on 12/06/2023.”