Emory Decatur Hospital

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 42060 Based on review of medical records, staff interviews, policy titled “Discharge of Patients,” and discharge protocol, it was determined that the nursing staff failed to be readily available to remove the peripheral Intravenous (IV) line (a thin, flexible tube used to administer fluids, medications, and blood products directly into a patient’s bloodstream) when one patient (P) (P#1) of six sampled patients was discharged from the Emergency Department with a peripheral IV in place. Findings included: Review of medical record revealed P#1 was brought into the emergency department (ED) by ambulance on 7/15/2025 at 7:37 p.m. with a chief complaint of Shortness of Breath on and off for one week. Upon triage, P#1 was assigned an ESI (emergency severity index) of 3. Provider orders were placed at 7:48 p.m. for Albuterol 2.5mg nebulizer (a respiratory treatment to allow the patient to breathe easier), and blood drawn for lab. These labs were for Troponin I and BNP (a marker for heart attack), Atrovent nebulizer solution and Solumedrol (a steroid medication) Intravenously (IV), Chest Xray (imaging to see if there was fluid in the lungs), and EKG (heart study tracing). At 11:39 p.m. the provider entered a discharge order for P #1. At 11:47 p.m. P#1 was reassessed and was stable. At 12:12 a.m. Registered Nurse (RN) GG administered a medication to P#1. At 12:46 a.m. ED personnel requested ambulance transport for P#1. At 6:03 a.m. RN GG documented vital signs for P#1. At 6:36 a.m. RN GG described P#1’s condition at departure as stable. P#1 was transported by stretcher to the ambulance. Continue review of nursing flowsheets included an IV removal date and time as 7/16/25 at 6:37 a.m. and the “Removal Reason” stated: Removed by patient. An interview with the ED Nurse Educator (RN AA) took place on 8/4/25 at 2:50 p.m. in the conference room. RN AA said she was aware that the family of P#1 called the ED in relation to the patient that went home without belongings. RN AA said she understood that the Nurse Manager back then referred the call to Charge Nurse BB to handle as the family was very angry. RN AA said Charge Nurse BB showed her P#1’s clothes packed in a bag and the clothes appeared wet and soiled. RN AA said she believed based on the appearance of the patient’s clothes that staff did not change her but rather allowed P#1 to go home in the hospital gown. RN AA said that was not uncommon for patients to get discharged from the ED in hospital gowns instead of their own clothes and usually these patients were elderly patients, and nursing home patients. RN AA explained in case patients left without their belongings, the facility would call and arrange with the patient’s family to have the items delivered, or some families would come to the ED to get the items. RN AA said the items were kept in a safe or locker with security until returned. An interview with the ED Charge Nurse BB took place on 8/4/25 at 3:10 p.m. in the conference room. Charge RN BB said he never met the patient (P#1) but spoke with the patient’s daughter on the phone that morning. He said the family called the ED and the Nurse Manager (no longer worked at the facility) transferred the call to him. RN BB said the family was very upset that P#1 came back from the facility not in her own clothes. RN BB said he was trying to explain to the daughter that possibly the patient was sleepy since she was being transferred early but she did not want to hear it. Charge Nurse BB said P#1’s daughter called a second time approximately two hours later and this time she reported that she just found ‘needle’ stuck in her mother’s arm and it was a hospital IV. Charge Nurse BB said that never happened in a patient being transported by ambulance. Charge Nurse BB said he immediately reported the incident to the then Nurse Manager. RN BB said he was aware that the Nurse Manager dispatched two nurses from the ED to P#1’s home to deliver the clothes and to remove the IV. RN BB said he was working in the ED since 2018, and that was the first time he knew of such an incident. Patients are usually called and asked to return to the ED to pick up any left belongings. An interview with RN CC took place on 8/4/25 at 3:45 p.m. in the conference room. RN CC recalled that she came in to work on the morning P#1 was discharged. RN CC said the Charge Nurse at the time asked her to go to a patient’s home to remove an IV that was left in the patients arm and to take the patient her clothes because the patient was discharged in hospital gown. RN CC said because it was a private home, the Nurse Manager sent a male nurse with her. RN CC said when they got to the doorstep, P#1’s daughter showed them the IV and said P#1 just removed it. RN CC said they still went inside the house to inspect the IV site, cleaned it and covered it with gauze. RN CC said there was no blood, no leaking of any kind. RN CC recalled that the daughter was very upset. RN CC collected the IV catheter and disposed of it in the ED sharps container. An interview with RN DD took place on 8/4/25 at 3:55 p.m. in the conference room. RN DD explained the discharge process and stated that first and foremost, the staff must know the patient had a safe place to go at the moment of discharge. He further indicated that once the provider and case worker cleared the patient, the nurse should make sure all devices were removed, in particular IV devices, indwelling catheter unless these devices were ordered permanently (i.e. Port for dialysis). RN DD said that was standard practice to also make sure patients had their belongings at discharge. RN DD said he did not take care of P#1; he had never met her before. RN DD recalled that the Nurse Manager (who no longer worked for the organization) approached him the morning that P#1 was discharged and asked him to go with RN CC to the patient’s home to remove the IV. The Nurse Manager told him that the patient had been discharged home earlier in the morning with her IV intact. RN DD recalled that when he and RN CC arrived to the home, the patient had already removed the IV. RN DD and RN CC assessed the patient to make sure the IV site was clean; they wiped it with alcohol and covered it with gauze. RN DD said he remained skeptical because the site did not look fresh at all, he said he could even see the needle mark in the patient’s arm. RN DD said the patient’s daughter was more upset because the ambulance did not return the patient’s clothes and P#1 was discharged in the hospital gown. An interview with ED Nurse Director/RN FF took place on 8/5/25 at 10:45 a.m. in the conference room. Director FF said he was aware of the incident with P#1. He said it was reported to him the same day. Director FF said he asked the nurse for an explanation as to how the patient was allowed to go home with the IV. Director FF said the nurse (RN GG) said he was busy with two other very critical patients that night. He said they called for transport sometime before midnight and the ambulance did not come until 6:30 a.m. or so. He was not in the room when EMS removed the patient from the room. Director FF said the facility had a policy and protocol that includes safe body inspection when patients were being discharged. Director FF said they were able to dispatch two nurses to the patient’s home to remove the IV without delay. Director FF said he also became aware that the patient was discharged in hospital gown and the family was very upset about that. Staff delivered her clothes to the family. A phone interview with RN GG took place on 8/6/25 at 11:15 a.m. RN GG stated he was the nurse assigned to P#1 when she presented in the ED. RN GG said he was a night shift nurse. RN GG said P#1 came for respiratory distress and was stable after a couple respiratory therapy interventions. RN GG explained that he was busy with two patients that were intubated when he had P#1. RN GG said after the doctor put the order to discharge P#1; they requested an ambulance to take the patient home. He said it could take some time before an ambulance arrived especially if the system was getting calls for more critical patients. He said because he was busy with two critical patients, another nurse was keeping eye on P#1 for him. He said P#1 went to sleep and he put the discharge papers in the room waiting for the ambulance to arrive before he disconnected the peripheral IV. RN GG said the ambulance arrived around 6:30 a.m. and they went to the patient’s room and initiated transport without notifying him. RN GG said P#1 was covered with a blanket and EMS did not uncover her; and as a result, she was discharged with the IV. RN GG said the EMS staff did not take the patient’s clothes with them. He said it was later when he went to the room, he realized they had already taken the patient home. He said he returned the patient’s bag where they kept her clothes to the Nurse Manager. RN GG said he did not remove the IV because he had not been notified that EMS had arrived to transport the patient. He explained that should not happen because they had protocol to do a final assessment and remove any peripheral IV unless the doctor ordered to keep the IV for medication administration at home. Review of policy titled “ Discharge of Patients,” effective date 05/17/2023 revealed the purpose was to ensure a smooth and safe discharge process for patients, minimize risks, prevent unplanned readmissions, and maintain compliance with regulatory guidelines. The policy stated that patients in an admitted or observation status were to be discharged on the order of a physician or authorized practitioner. Further review of the procedures indicated the following: 1. The attending physician or designee was responsible for discharging the patient, performing a medication reconciliation, and providing a summary of the patient’s medical condition and care plan. 2. All patients received written and verbal post-discharge care instructions, including prescriptions, supplies, and follow up appointment details, through the EeMR After Visit Summary (AVS). 3. Patients who were driving themselves to their destination after discharge should not have narcotic medications administered within 4 hours of discharge. 4. Responsibilities of the nursing staff at discharge included: a. Inventory and pack personal belongings and retrieve any valuables from public safety and/or personal medications stored in the pharmacy or on the unit. b. Review and complete the discharge navigator checklist and finalize all care plan statuses i. In the event the patient needed to be discharged with IV access, an MD order was required with the appropriate indication. c. Provide and explain discharge instructions, including discharge prescriptions and supplies/DME and any follow up appointment details. d. Return hospital issued medications, supplies, and equipment for credit. e. Complete all required documentation, both electronic and on paper as applicable and discharge the patient from EeMR once the patient was physically out of the unit. A manual discharge required the completion of the date, time, and discharge disposition. i. If transport was requested at discharge, the discharge disposition must be entered prior to requesting transport. f. Prepare any paper documents to be included in the patient’s medical record for pick-up by medical records personnel. 5. The necessary means of transportation (wheelchair, caddy, or stretcher) will be provided. 6. All patients were escorted to the hospital exit or to their personal vehicle and assisted into the vehicle which will take the patient to their destination. Discharge Criteria: 1. Patients discharged from the facilities had to meet the following criteria: a. Blood pressure stable for patient per baseline within 4 hours prior to discharge. b. Temperature less than 38 degrees centigrade within 4 hours prior to discharge. c. Heart rate stable or within baseline within 4 hours prior to discharge. d. No complaints of shortness of breath exceeding baseline. e. No significant wound drainage if applicable. f. Pain and nausea were controlled to patient’s level of satisfaction. g. SpO2 or respiratory rate at patient’s baseline. The policy revealed if the patient demonstrated variation from the above criteria, the physician must be notified prior to patient discharge and response noted in the patient’s medical record. If a patient was discharged by ambulance, the ambulance personnel was to come to the patient’s room to transport the patient. Review of facility document titled “Discharge Protocol,” revised date: 5/19/2025 indicated staff were to retrieve patient’s valuables from facility’s safe and review each item with the patient. Then obtain the patient’s signature indicating that the patient’s belongings were returned to the patient. The protocol indicated that the nurse was to go over the discharge paperwork with the patient and/or family member and allowed opportunities to ask questions. Then the nurse was to perform hand hygiene, put on the necessary PPE such as gloves, perform a physical assessment and obtain vital signs. The document stated that the nurse was to ensure the removal of all devices discontinued by the practitioner and such devices included IV catheters, indwelling urinary catheters and drains to avoid potential complications. The protocol further indicated that the nurse helped the patient dress as needed.”

“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: 42060 Based on a review of medical records, staff interviews, policies and procedures, it was determined that the facility failed to provide a medical screening examination (MSE) and stabilizing treatment for one (P#1) of 21 sampled patients. Specifically: P#1 presented to the facility’s property on 9/11/24 at 4:30 a.m. with complaints of “pain, body locked, and chest pain”. Public Safety Officer (CC) established face to face contact with P #1 and called for medical assistance around 4:30 a.m. Emergency Medical Tech (Tech FF) and Registered Nurse (RN GG) arrived on scene and offered P#1 medical assistance. P #1 refused medical assistance, became verbally violent and made physical threats to the Security Officers, Tech FF and RN GG. Tech FF and RN GG left the scene when P #1 became violent. County police was contacted by facility’s dispatch and arrived on scene at approximately 5:18 a.m. As P #1 refused to calm down and made threats to shoot Public Safety Officers. County police Officers put P #1 in handcuffs and transported P #1 to another facility ED for medical and psychiatric treatments Tech FF, RN GG and Public Safety Officers on scene failed to request that the County Police Officer take P #1 to the ED for medical and psychiatric evaluations after P #1’s behavior was under police control and P #1 was no longer a threat. Cross refer to A-2406 as it relates to the facility’s failure to provide an appropriate medical screening examination to P#1.”

“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: 42060 Based on review of policy and procedures, medical staff bylaws a security incident report, and staff interviews it was determined that the facility failed to provide an appropriate medical screening examination (MSE) for one patient (P) (P#1) of 21 sampled patients. Specifically, P #1 was found on the facility’s property and complained of ‘pain, body locked, and chest pain’. Although the facility’s staff witnessed county police obtain physical control of P #1, staff failed to request that county police bring P#1 into the ED for a medical and psychiatric evaluation. County police transported P#1 to another acute care facility for treatment. Findings included: Review of policy title “Medical Screening, Treatment and Related Issues”, effective date: 10/03/23 revealed the purpose of the policy sets forth procedures to ensure that all Hospitals with Dedicated Emergency Departments (DED) in the Emory Health Care (EHC) system meet all the requirements set forth in the Emergency Medical Treatment and Labor Act (“EMTALA”) for the examination and treatment of patients for whom a request for emergency care is made. The policy indicated that all facility workforce members, including employees, volunteers, house staff, and Medical Staff members are responsible for adhering to these guidelines in their interactions with patients, families and visitors or any individual who comes to the EHC facilities. Policy: The policy delineated that any individual who comes to the Emergency Department or Labor & Delivery Department requesting care should be offered an appropriate Medical Screening Examination to determine if the individual has an Emergency Medical Condition. If an Emergency Medical Condition exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the policy, “EMTALA - Transfers To/From Other Facilities”. Procedure: The policy stated that an appropriate Medical Screening Examination should be provided by a Qualified Medical Personnel (QMP) to any individual who comes to the Emergency Department (and/or on Hospital Property) and: (1) the individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition; or (2) it is apparent that the person needs an examination or treatment of a medical condition based on the individual’s appearance or behavior. If an Emergency Medical Condition is determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer if the Hospital lacks the capacity and capability to provide the stabilizing treatment. Stabilizing treatment should be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, ethnicity, insurance status, color, national origin, sexual orientation, disease or handicap). The policy further indicated that if an individual presents on Hospital Property that is located outside of the DED and appears to be suffering from an Emergency Medical Condition or requests an examination or treatment for a medical condition, the individual should be transported to the DED or another area in the Hospital that is capable of providing a Medical Screening Examination and delivering emergency services appropriate to the individual’s condition. Medical Screening Examination: 1. “Medical Screening Examination” or “MSE” means the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not the patient has an Emergency Medical Condition. An MSE is not an isolated event. It is an ongoing process that begins but does not end with Triage. 2. All individuals coming to the Emergency Department should be provided an MSE appropriate to the individual’s presenting signs and symptoms, as well as the capability and capacity of the Hospital. Depending on the individual’s presenting signs and symptoms, an appropriate MSE can involve a wide spectrum of actions. 3. The medical record should reflect continued monitoring according to the individual’s needs until it is determined whether or not the individual has an Emergency Medical Condition and, if they do, until they are stabilized and/or appropriately transferred. There should be evidence in the medical record of this ongoing monitoring of the individual prior to discharge or transfer. Under section “Definitions” of the policy “Emergency Medical Condition” is defined as: a. The presence of acute symptoms (including pain or the psychiatric symptoms discussed below) of such severity that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing an individual’s health in serious jeopardy. 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. c. With response to an individual with psychiatric symptoms, an Emergency Medical Condition is one in which: 1. Acute psychiatric or acute substance abuse symptoms are manifested; or 2. An individual is expressing suicidal or homicidal thoughts or gestures or other thoughts or gestures that indicate the potential to harm self or others and is determined to be a danger to self or others. “Hospital Property” means the entire main Hospital campus, including the Hospital’s main buildings and other areas and structures owned by the Hospital that are not attached to the Hospital’s main buildings but are located within 250 yards of the Hospital’s main buildings, including parking lots, sidewalks, driveways, and Hospital Departments. “Qualified Medical Personnel” or “QMP” means individuals qualified to perform a Medical Screening Examination as designated by the Hospital’s Bylaws (except, as provided below, at all Emory Hospitals, this must be a physician, physician’s assistant or advanced practice registered nurse). An MSE with respect to psychiatric conditions at Emory Decatur Hospital may be performed by an associate professional counselor (APC), licensed professional counselor (LPL), a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW). Review of the facility’s Medical Staff Bylaws, Rules and Regulations approved by the Board on 8/14/23, Section 5 “Emergency Services” revealed A “medical screening examination (MSE)” is required by federal law and regulation (42 USC § 1395dd, 42 CFR § 489.24) to be provided to any person who comes to the Hospital’s emergency room or Labor and Delivery Unit and requests examination or treatment. The Medical Screening Examination (MSE) may be provided in the emergency room by the following individuals: a Practitioner with appropriate Clinical Privileges. b.an Associate Professional Counselor (APC), a Licensed Professional Counselor (LPC) a Licensed Clinical Social Worker (LCSW) or a Licensed Master Social Worker (LMSW) with respect to psychiatric conditions; or a nurse practitioner or physician’s assistant or by the emergency room Physicians. The Bylaws delineated that no patient may be directed to another location, including but not limited to a Physician’s office or a different hospital, until: (i) that patient has been fully evaluated according to law and the requirements of these Rules and Regulations, and (ii) the patient has been evaluated by a specialty Physician as deemed appropriate and available per the ED on-call coverage list, as determined by the emergency room Physician or other Hospital Physician. A review of Incident Report, Case Number IR20240911-000824 Narrative Text revealed that on 9/11/24 at approximately 4:30 a.m. a public safety officer responded to the outside driver’s entrance of the Women’s Tower to a report of a male lying on the ground requesting medical assistance. The public safety officer found the individual blocking the interior drive of the Women’s Tower. When asked, the individual relayed that he was in pain, his body locked up and he collapsed. He responded that he needed medical assistance. At 5:03 a.m., an ED nurse and ED technician arrived with a wheelchair to assist the individual to the ED for evaluation. The individual refused assistance and became verbally aggressive making threats toward medical staff and public safety officer. The individual refused to get up from the driveway. At 5:09 a.m. local law enforcement was called. At approximately 5:16 a.m., the individual began making physical gestures toward the public safety officers and threatened to shoot the public safety officers. At approximately 5:18 a.m. local law enformcement arrived. The individual continued to make threats and at approximately 5:36 a.m., the individual was restrained and placed in the police vehicle. An interview with Operation Manager Public Safety (Manager) AA took place in a private office on 9/24/24 at 10:00 a.m. Public Safety Manager AA stated she was over public safety for the county; she also stated that the Lieutenants reported to her; she stated she did not have any direct contact with patients. Manager AA explained that the Safety Officers made rounds and some of them were posted in specific locations around the hospital campus. Manager AA said the officers did not have contact with patients except in cases where patients were aggressive, became a threat to the public, staff, and themselves. Manager AA said there was always an Officer stationed in the ED that monitored patients and the public activities in the ED main lobby and hallways via visual observation. Manager AA said officers did not make decision to send people away regardless of behavior they displayed, it was the decisions of nurses and doctors to request that patients be escorted out of the ED. Manager AA said that all Officers had a clear understanding of the EMTALA law which stated that everyone presented to the facility and asked for medical assistance should receive medical care until they were stable. An interview with Public Safety Lieutenant (Lieutenant) BB took place in the conference room on 9/24/24 at 4:03 p.m. Lieutenant BB stated she had worked at the facility for 10 years. Lieutenant BB recalled the event of 9/11/24 regarding P #1. Lieutenant BB said dispatch received a call on the radio describing a black male laying on the ground near the entrance of the Women’s Tower (a building located about on the other side of the ED). Lieutenant BB said she heard the call on the radio made by one of the Officers on campus that night. Lieutenant BB said the officer said male on the ground stated he had chest pain, and the male said he could not move, his legs hurt. Lieutenant BB said she was in the ED next to the triage nurse, and she related the call about the male individual to the nurse (RN GG). Lieutenant BB said RN GG and ED Tech FF took a wheelchair and went to the scene where the male individual was said to be located. Lieutenant BB said about two minutes later the same officer radioed again that the male individual was very aggressive, combative, and refused to get out of the roadway; stated the individual said he was fine, and he did not need medical assistance. Lieutenant BB said about two to three minutes after the radio call, the Nurse and the Tech returned to the ED. Lieutenant BB said the nurse stated that she went to the tower and the individual refused to come in the ED. Lieutenant BB said she decided to go to the scene and on her way there, the Officer radioed again that the individual threatened to shoot him and that he had a gun. Lieutenant BB said when she heard that, she asked dispatch to call the County police. Lieutenant BB said when she got to the scene, she saw a male individual standing and pacing, making physical and verbal gesture with hands inside a coat he carried. Lieutenant BB said the individual claimed that he had a gun. Lieutenant BB said the police arrived very quickly on scene (in about five minutes). Lieutenant BB said the male individual threatened the female police officer when she arrived; Lieutenant BB said the police officer put the individual in handcuffs after he said he was going to shoot them all. Lieutenant BB said once the police arrived and took control of the scene , she left to the ED because there was other behavior health issue they were dealing with in the ED. Lieutenant BB said she was aware that when a person came to the ED and asked for medical assistance, they should not turn the person away; but they must treat the person. An interview with Public Safety Officer (Officer) CC took place in the conference room on 9/24/24 at 4:26 p.m. Officer CC said he was in post at the Women’s Tower when one of the employees reported to him that she saw a male individual laying on the driveway near the entrance of the building. Officer CC said he went to the individual and asked him if he was okay. Officer CC said the individual said he was hurting and his legs “did not work” and he was in pain. Officer CC said he asked the individual if he needed medical assistance and replied yes. Officer CC said he called on the radio and it did not take long for RN GG and Tech FF to arrive with a wheelchair. Officer CC said the nurse and the male Tech offered the individual to go in the ED and to get in the wheelchair. Officer CC said the individual started cussing the nurse and calling her nasty names, in particular he was calling the nurse f ...ing bitch the whole time. The individual said he did not need help and that he did not want the nurse to touch him. Officer CC said the individual became really upset and reached to his coat and claimed that he had a gun in his pocket. Officer CC said at that point the nurse said they had to get back in the ED and left. Public Safety Officer CC said after the individual made threats to kill them, they called the police who arrived shortly after. By the time the police arrived the individual was up and walking, continuing to make threats even towards the police officer. Public Safety Officer CC said the police handcuffed him and took off. Public Safety Officer CC explained that he understood the law of EMTALA and stated they must provide medical care to all persons coming in the ED and requesting medical assistance; and that was the reason he went to him and asked if he needed medical assistance. An interview with Public Safety Officer (Officer) DD took place in the conference room on 9/24/24 at 4:40 p.m. Officer DD said he was a Public Safety Officer for two years. Officer DD said he was on patrol when he heard the call coming on the radio about a black male individual laying in the driveway of the Women’s tower. He said he remembered that Officer CC made the call and indicated that the male individual said he was in pain and needed medical assistance. Officer DD said he went to the scene and saw a black male laying on the driveway and said he just walked a few miles after someone was chasing him and he was in pain. Officer DD said within 2-3 minutes, the nurse and a Tech arrived with a wheelchair. Officer DD said the nurse asked the individual some questions and that was when he became hostile, loud and told the nurse not to touch him. Officer DD said the individual used foul language and lots of F word sentences. Officer DD said the individual said they could call the police and refused to get in the wheelchair. Officer DD said the individual also refused to get off the driveway. Officer DD said he believed the police was not far because the police cruiser arrived in about five minutes. Officer DD said it was a female police officer and she was trying to calm him down, but the individual continued to make threats to them and to the police officer as well. Officer DD said the goal was to get him to the ED, but he did not want to get in the chair. Officer DD said the police officer put the individual in handcuff, put him in the car and drove off. Public Safety Officer DD said he received EMTALA training and was able to explain the idea of the law was to give care to everyone who came to the ED and asked for medical help. An interview with Public Safety Officer (Officer) EE took place in the conference room on 9/24/24 at 5:00 p.m. Officer EE said he remembered the event of early morning of 9/11/24. He heard Officer CC on the radio stating there was a black male laying in the driveway at the Women’s tower and he needed medical assistance. Officer EE said he believed the Lieutenant (LT BB) answered the call and related the message to the triage nurse. Officer EE said the triage nurse (RN GG) came to the location with a wheelchair. Officer EE said he was listening to the call on the radio, and he heard that the individual did not want medical assistance. Officer EE said the next call that came on the radio from Officer CC indicated the male individual was aggressive and threatened to shoot officer CC. Public Safety Officer EE said he arrived at the scene at the same time the police pulled up; he said it was a female Officer who showed up. Officer EE who carried a weapon, said when he got there, the individual told him that he was going to shoot him right in between the eyes. Officer EE described the individual’s demeaner as very angry. Officer EE said the police officer asked the individual to show his ID and he refused. Officer EE said he believed the individual might have elbowed the police Officer as she was approaching him and at that point, she put him in handcuff and forced him into the police vehicle. Officer EE said he was not sure where the police Officer was taking the gentleman. Public Safety Officer said he was not sure that anyone asked the police Officer to take the individual to the ED. Officer EE said he was aware that anyone presented in the ED for medical assistance should have a medical exam even if they were not able to pay. He said he received training on EMTALA law. A phone interview with Emergency Medical Technician (Tech FF) FF took place on 9/25/24 at 9:30 a.m. Tech FF said he was in triage that night; Tech FF said he remembered there was an individual laying in the driveway of the Women’s tower during the overnight hours. He said public safety sent a radio call to the ED and he along with the triage nurse went on scene to see what was happening. Tech FF said he saw the individual laying on the concrete in the middle of the road. Tech FF said they both were trying to convince the guy to get in the wheelchair, but he refused. Tech FF said he remembered the individual said he was running away from a car that was chasing him and he covered a long distance running and he was out of breath. Tech FF said when the nurse asked him if he needed medical treatment, he said yes but became very aggressive. Tech FF said he believed they were trying to lift him off the ground but refused to be touched. Tech FF said the individual said they needed to bring a bed for him right where he was instead of a wheelchair. Tech FF said then he and the nurse decided to leave and return to the ED. Tech FF said he had been working in the ED for a year and he was well aware that anyone who came to the ED for medical treatment should receive treatment regardless of insurance status. A phone interview with Registered Nurse (RN GG) took place on 9/25/24 at 10:15 a.m. RN GG said she remembered the event. RN GG said security called about a male individual laying on the ground entrance at the Women’s tower. RN GG said she went to the scene with a Tech that was in triage with her. RN GG said as soon as she asked the individual what was going on, he started cussing staff. RN GG said the individual stated that a car was chasing him, and his chest now was hurting. RN GG said the individual wanted to fight with security. RN GG said the individual was agitated and violent that they ended up calling the police as the individual was making gun threats. RN GG said they went there with a wheelchair to bring the guy in the ED, but he just refused care. RN GG said from his appearance the guy was in the right state of mind, he was not in any kind of distress from what she could observe. And there was no indication to place him in restraint to force him in the ED. RN GG said as things were getting hot, she decided to go back in the ED because the conversation was not getting anywhere. RN FF said the individual was verbally aggressive and it was unsafe to remain on scene. An interview with the ED Nurse Director (Director) HH took place in the conference room on 9/25/24 at 11:55 a.m. Director HH said he was not familiar with the incident because the individual did not make it to the ED. Director HH said they got calls all the times about behavior health patients coming to the ED with violent behavior. Director HH said when EMS brought a violent person in the ED, first thing they called security. Security would control the scene to make sure everyone was safe. Director HH said they maintained four seclusion rooms in the ED for that purpose and they had sitter and security officers to watch over violent behavior health patients. Director HH said they had a rapid response team that dealt with these types of calls. Director HH said in any case, they had protocol in place dealing with violent behavior health patient in the ED. Director HH explained that security was always the first line of defense, then seclusion until the patient was assessed by the doctor and declared safe. Director HH said in any case all behavior health patients got to see a Behavior Health Counselor at least. Director HH said aggressive patient was something they dealt with daily in the ED and they always had security stationed in the ED to intervene if necessary. An interview with ED Medical Director (Doctor) II took place in the conference room on 9/25/24 at 12:10 p.m. Doctor II explained that Behavior Health Patients coming to the ED had the opportunity to see the EMTALA signage first as they had it posted at the main entrance and in the ambulance bay. Director II said the triage nurse did a quick triage, and the behavior health patients went to the back area reserved for Behavior Health patients. Director II said they had security involved sometimes immediately if the patients was aggressive. Director II said security directed the patients to change in scrubs and the patient was placed in a safe room in line of sight. Director II said all behavior health patients had to have a medical screening exam before Behavior Health could see the patient. Director II said the ED doctor put a consult for behavior health after he completed the MSE. Director II said then the Behavior Health professional made recommendations for inpatient or discharge to outpatient. Doctor II said when it came to the incident related to the Gentleman, it remained unclear to him why the gentleman was taken to Grady because they could treat him here. Doctor II said they received calls about violent patients all the time and they had protocol and security in the ED for these cases. Director II said even if the gentleman was under police custody, they still required to provide care to him. Director II stated that violent behavior did not disqualify a person to get the care he deserved. Director II said this individual fell under the critical care category. Director II said they had policy on Physical and Chemical Restraints; he clarified that restraint was always the last option, but it was an option when there was no other choice. Director II said misbehavior on the part of a patient should not constitute a barrier to care delivery. Director II said he was not aware of the details, but he still did not understand why the police took the gentleman to Grady; something they were well equipped to deal with in their ED.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45841 Based on record review, staff interview, and facility policy review, the facility failed to meet the condition of participation for patient rights. The facility failed to protect and promote patient’s rights of being free from improper use of restraints, restraint orders, and monitoring of restraints for two patients (P) (P#4, P#5) of two patients reviewed for restraints. Findings included: Cross refer to A-0154 as it relates to the facility’s failure to protect the patient’s right of being free from improper use of restraints. Cross refer to A-0168 as it relates to the facility’s failure to ensure restraints were only in accordance with an order. Cross refer to A-0169 as it relates to the facility’s failure to ensure that restraint orders were not on an as needed basis. Cross refer to A-0175 as it relates to the facility’s failure to ensure patients restrained or secluded due to violent behavior were monitored.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 45841 Based on review of facility policies, record review, and staff interview it was determined that the facility failed to protect patients’ right of being free from improper use of physical restraints, which affected one patient (P) (P#5) of two patients reviewed for restraints. Findings included: A facility policy titled, “Restraint,” dated 04/12/2023, indicated, “[Facility Name] hospitals do not use restraint or seclusion as a means of coercion, discipline, convenience or retaliation.” A facility policy titled, “Patient’s Rights and Responsibilities,” dated 09/08/2021, revealed, “All patients at [Facility Name] are entitled to the rights listed below:” to include “Be free from restraint/seclusion used as a means of coercion, discipline, convenience or retaliation by staff.” The hospital record for P#5 revealed that P#5 arrived at the emergency department (ED) on 07/27/2024 at 2:53 p.m. for aggressive behavior. The record revealed an order dated 07/28/2024 at 10:19 p.m. for “Restraints Violent or self-destructive adult (age 18 and older).” Further review revealed the order was for two-point soft wrist restraints continuous for four hours due to the patient being a danger to themself. A “Non-Violent Restraints” flowsheet dated 07/28/2024 at 10:06 PM, revealed staff documented the clinical indication was for “Fall prevention.” During an interview on 09/25/2024 at 10:34 AM, Nurse Education Coordinator (NEC) #10 stated that restraints should never be used for fall prevention. She stated that restraints could be indicated for patient safety but should not be used for falls.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45841 Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure restraints were used only in accordance with an order, which affected one patient (P) (P#4) of two patients reviewed for restraints. Findings included: Review of facility policy titled “Restraint,” dated 04/12/2023, indicated, “1. Therapeutically Unsafe or Disruptive Behavior (Medical Restraints)” included “a. A physician’s order is required to initiate restraint use.” The policy also indicated, “3) The order must be dated and timed, contain reason or clinical justification for restraint, type of intervention/device, and time limit of use.” The hospital record for P#4 revealed the facility admitted the patient on 07/06/2024 for generalized weakness. The record revealed an order dated 07/06/2024 at 10:29 p.m., for “Restraints non-violent or non-self-destructive.” The record revealed the order was for 24 hours for right upper extremity and left upper extremity wrist restraints due to “Interference with medical treatment.” A “Restraint Type” flowsheet dated 07/06//2024 at 10:54 PM, revealed staff documented a left mitt, right wrist restraint, and left wrist restraint were started. During an interview on 09/25/2024 at 10:44 a.m., Nurse Education Coordinator (NEC) #10 stated that the order for P#4 on 07/06/2024 at 10:29 p.m. was only for bilateral upper wrists, but the nurse documented that the patient was placed in a left mitt as well.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 45841 Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure that orders for the use of a restraints were not written on an ‘as needed’ basis, which affected one patient (P) (#4) of two patients reviewed for restraints. Findings included: Review of facility policy titled “Restraint,” dated 04/12/2023, indicated, “PRN [pro re nata, as needed] orders cannot be used to authorize the use of restraint.” The hospital record for P#4 revealed the facility admitted the patient on 07/06/2024 for generalized weakness. The record revealed an order for “Restraints non-violent or non-self-destructive” that was electronically signed by the medical doctor on 07/07/2024 at 7:32 p.m.. Further review revealed the order was for 24 hours for right upper extremity and left upper extremity limb restraints due to interference with medical treatment. Review of the medical record did not reveal that the patient was placed in restraints during this time. During an interview on 09/25/2024 at 10:55 a.m., Nurse Education Coordinator (NEC) #10 stated that the order for P#4 on 07/07/2024 at 7:32 p.m., for bilateral upper wrist restraints was never documented as started and was not discontinued until the system discharged the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45841 Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure patients who were restrained or secluded due to violent behavior were monitored, which affected one patient (P) (P#5) of two patients reviewed for restraints. Findings included: Review of facility policy titled “Restraints,” dated 04/12/2023, indicated, “Patients restrained/secluded due to violent or self-destructive behavior will be assessed every 15 minutes.” The policy also indicated, “Continuous Monitoring and Care of the Restrained Patient” included “1. The condition of the patient and the restrained used must be continually assessed, monitored, re-evaluated, and documented. Frequency of re-assessment is dependent upon the condition of the patient.” The policy revealed, “b. If violent or self-destructive behavioral restraints are necessary, those individuals are monitored and assessed a minimum of every 15 minutes, with vital signs obtained every 2 hours (if safe to do so), upon discontinuation of intervention or as needed. c. If the patient is in seclusion, those individuals are monitored and assessed every 15 minutes, with vital signs obtained upon discontinuation of intervention. The hospital record for P#5 revealed that the patient arrived at the emergency department on 07/27/2024 at 2:53 p.m. for aggressive behavior. The record revealed an order dated 07/28/2024 at 11:35 a.m. for “Restraints Violent or self-destructive adult (age 18 and older).” Further review revealed the order was for seclusion due to the patient being a danger to others and to themself. The record revealed that the order was for four hours and was renewed on 07/28/2024 at 3:23 p.m. The “Violent Restraints or Self-Destructive Restraints” flowsheets for P#5 did not reveal when the seclusion was started. The Violent Restraints or Self-Destructive Restraints flowsheets indicated that the seclusion was continued on 07/28/2024 at 1:35 p.m. but revealed no documentation of 15-minute assessments of the patient. During an interview on 09/25/2024 at 11:21 a.m., Unit Director (UD) #14 stated that the record showed P#5 was transferred into a seclusion room on 07/28/2024 at 11:34 a.m., but that the nurse did not document that in the restraint flowsheets.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45841 Based on review of facility policies, medical records, and staff interview it was determined that the facility failed to ensure that licensed nurses adhered to hospital policies, which affected 4 four patients (P) (P#1. P#3, P#6, and P#7) of six patients reviewed for following hospital policies. Findings include: 1. A facility policy titled, “Patient’s Rights and Responsibilities,” dated 09/08/2021, indicated, “All patients at [Facility Name] are entitled to the rights listed below,” which included “Have a family member involved in decisions about care, treatment and services.” A facility policy titled, “Certificate Authorizing Transport to Emergency Receiving Facility,” dated 10/01/2022, indicated, “F. Responsibilities of the Care Team Prior to Transfer” included “4. The staff will attempt to notify the patient’s family/significant other prior to transfer or as soon as possible.” The hospital record for P#1 revealed the P#1 arrived at the emergency department on 05/31/2024 for a mental evaluation and was admitted that day. An “H&P [History and Physical]” dated 05/31/2024, revealed that P#1 presented with new onset psychosis with auditory hallucinations telling the patient to kill their family member. The record revealed that it was determined that the patient required psychiatric hospitalization for crisis stabilization, medication management, and discharge planning. A “Discharge Summary” dated on 06/02/2024, revealed P#1 had been disorganized and delusional and was transferred to a “1013 receiving facility.” Further review of the medical record revealed no documentation that the patient’s family was notified of their transfer. 2. The hospital record for P#3 revealed the patient arrived at the emergency department on 06/08/2024 for “mental health.” An “Initial Psychiatric Assessment,” dated 06/09/2024, revealed that P#3 was admitted due to being unable to care for their self because of mental illness. The record revealed the patient had worsening agitation, confusion, and paranoia since beginning on antidepressant medication. The record revealed that during the provider’s interview with the patient, the patient was noted to have delusional thought content, believed they were being shot in the back of the head, disorientation, and paranoia against their family. “Form 1013-Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health),” dated 06/09/2024, for P#3 revealed P#3 required involuntary treatment in that they appeared to be mentally ill and appeared to be unable to care for their own physical health and safety as to create an imminently life-endangering crisis. The record revealed that at the time of evaluation, the patient appeared to be mentally ill based on the observation of “psychosis.” The record revealed that the patient presented an imminently life endangering crisis to their self because they were unable to care for their own health and safety due to “disorganized thought content/process,” paranoia, and delusions. “Progress Notes,” dated 06/10/2024, revealed P#3 was cleared for transfer to a receiving facility and would be transported at around 3:00 p.m. A “Discharge Summary,” dated 06/10/2024, revealed that P#3 remained delusional at the time of discharge, and that a transfer to a “1013 receiving facility” was appropriate. Further review of the medical record revealed no documentation that the patient’s family was notified of their transfer. During an interview on 09/24/2024 at 1:33 p.m., Social Worker (SW) #4 stated that there were various levels of involvement for social work staff with a patient that was under an involuntary commitment via a 1013 form. He stated that usually, the process began in the emergency department, and the patient was moved to the behavioral health or medicine department while the 1013 acceptance was pending at an emergency receiving facility. He stated that the social work staff’s primary role in the 1013 process was arranging transportation and sending records. He stated that the expectation was that nursing staff or social work staff notified family of a transfer. He stated that he was unsure whether there was a policy that outlined whose responsibility it was to notify the family. During an interview on 09/24/2024 at 2:08 p.m., Registered Nurse (RN #3) stated notification to the family about transfer varied in responsibility. He stated that it could be done by nursing staff or social work staff, but he believed it was primarily the responsibility of social work staff. He stated that family or next of kin would be notified if the patient wanted them to. He stated that if the patient was not able to make decisions for themself, their next of kin would be notified. During an interview on 09/25/2024 at 11:00 a.m., RN #13 stated the nurse’s discharge note was where nursing staff would document family notification of transfer. During an interview on 09/25/2024 at 12:10 p.m., RN #13 stated that they could not find any notification that family was notified of Patient #1’s or Patient #3’s transfer to an emergency receiving facility. She stated that social work staff or care coordination staff would normally document the notification in a note. 3. A facility document titled, “IV [intravenous] catheter removal,” revised 08/19/2024, indicated, “Removal of a short peripheral IV catheter should occur as soon as the catheter is no longer indicated for the patient’s plan of care or when the catheter hasn’t been used for at least 24 hours.” A facility document titled, “Discharge,” revised 05/20/2024, indicated, “Implementation” included “Ensure proper removal of all devices discontinued by the ordering practitioner, such as IV catheters, indwelling urinary catheters, and drains, before discharge to avoid potential complications.” An e-mail dated 09/26/2024 at 12:26 p.m., revealed the Accreditation Manager (AM) stated that there was no specific facility policy for ensuring accurate documentation. The email revealed they “pretty much go by the honor system.” The hospital record for P#6 revealed the facility admitted the patient on 09/14/2024 for rectal bleeding. The record revealed the facility discharged P#6 on 09/20/2024 at 9:27 p.m. An “IV Assessment” flowsheet revealed P#6 had a posterior, right wrist peripheral IV line that was documented as removed on 09/20/2024 at 11:33 p.m., and a posterior, right hand peripheral IV line documented as removed on 09/20/2024 at 11:33 p.m. During an interview on 09/25/2024 at 11:49 a.m.,, Nurse Education Coordinator (NEC) #10 stated that the best practice would be to document lines were removed prior to patient discharge. She stated that there was no other documentation that showed P#6 peripheral IV lines were removed prior to discharge. 4. The hospital record for P#7 revealed the facility admitted the patient on 08/29/2024 for hypoxia. An “Events” flowsheet revealed that P#7 was discharged on 09/01/2024 at 2:30 p.m. An “IV Assessment” flowsheet revealed staff documented that P#7 right antecubital peripheral IV line was removed on 09/01/2024 at 4:34 p.m. The record revealed “Clinical Notes,” dated 09/01/2024 at 6:22 p.m., entered by Registered Nurse (RN) #6, revealed that the nurse documented the patient’s IV line and remote telemetry had been discontinued intact. During an interview on 09/26/2024 at 12:10 PM, RN #6 stated IV lines should be removed when a patient was discharged. She stated they do not take them out until right before a patient left in case there was an emergency with the patient while they waited to be picked up. She stated that she documented when the IV line was taken out. She stated that it was a shared responsibility between the patient care technicians (PCTs) and nursing staff. Per RN #6, if the PCT removed it, they usually notified the nurse that it was taken out. She stated that she was unsure of what the protocol was for if a patient discharged with an IV line. She stated that she remembered that P#7 family member called and reported that the patient had gone home with an IV line in place. She stated that she did not remember who discharged the patient, she had been floated to the unit that day, and did not remember if she did the discharge fully on her own. She stated that she did not remember whether the patient did or did not have an IV line when they left. She stated that she normally removed a patient’s IV line when she was going over discharge instructions with the patient but could not remember if they were the one who went over the instructions with P#7 that day. She stated that she entered a note that the IV line was removed. RN #6 stated that she always wrote a note and addressed what the patient had removed based on what the patient had in place. She stated that she was “pretty sure” she had taken out the IV line, or she would not have documented it.”

“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: 42060 Based on review of medical records, facility policies and procedures, and staff interviews it was determined that the facility failed to provide a nursing assessment to one Patient (P) (P #2) of five sampled patients when P #2 received Benadryl (medication used for allergy and itching) and Morphine (a controlled medicine used for severe pain) (IV) intravenously (through a small catheter into a vein) at 7:48 p.m. on 5/22/23 and was discharged at 8:15 p.m. A nursing reassessment was not performed on P#2 prior to discharge. Review of P #2’s medical record revealed that she received the following medications on 5/22/23: 4:08 p.m., Peripheral IV line started by RN GG. 4:11 p.m. RN started IV fluids 4:11 p.m. RN GG administered Morphine 4mg IV. 4:11 p.m. RN GG administered Zofran (medication used for nausea and vomiting) 4mg IV. 5:28 p.m. P #2 received Protonix (medication that treated acid reflux in the stomach) 40mg. 4:32 p.m. P #2 received Mylanta (a medication used to treat too much acid in the stomach) Oral suspension. 5:28 p.m. RN GG did a pain assessment for P #2 and the pain was described as severe. 5:29 p.m. RN GG administered P #2 Morphine 4mg IV 5:47 p.m. P #2’s vital signs included: Blood Pressure: 114/66, Heart Rate:85, Oxygen Saturation: 98% at room air. 5:56 p.m. P #2 received Decadron 10 mg IV (a steroid used for congestion of the lungs and cough). 5:57 p.m. P #2 received Benadryl 12.5 mg IV 7:22 p.m. P #2 received Pepcid 20mg IV (medication to treat excess acid in the stomach) 7:48 p.m. P #2 received Benadryl 12.5mg IV and Morphine 4 mg IV. RN HH Administered both medications. 7:48 p.m. IV fluid stopped. 7:52 p.m. RN HH removed the IV line from P #2’s arm. 8:14 p.m. RN HH progress notes stated P #2’s departure condition was “Good” and P #2’s mobility at departure was ambulatory. The notes stated P #2 ambulated easily and independently to the registration area. There was no further relevant nursing documentation. 8:15 p.m. P #2 was discharged. A review of the facility policy titled “Medication Administration for Ambulatory Care”, effective 1/19/23 revealed the purpose of the policy was to ensure that medications were administered safely. The policy delineated under its procedures that only licensed medical providers and authorized clinical staff, acting within their legally defined scope of practice and Clinic policies may administer medications to patients. Further review of the “Procedures” section of the policy on page 5 number 16 revealed that it was the facility’s policy to observe patients receiving high alert medications (high-alert medications were defined as drugs that carried high risk of causing significant patient harm when they were used in error) or allergy injections for at least 30 minutes. A review of the facility policy titled “Pain Management”, effective 11/30/22 revealed it was the policy of the facility to ensure optimal patient comfort through a proactive pain control plan that was mutually established with the patient, family members, and members of the healthcare team. The policy stated all patients had the right to appropriate assessment and management of pain. This policy established standards for safe and effective pain management for patients receiving care within the facility. The rationale behind the policy stated that effective pain assessment and management could remove the adverse psychological and physiological effects of unrelieved pain. The policy delineated that Optimal management of the patient experiencing pain enhanced healing and promoted both physical and psychological wellness. The policy statement indicated that the standard of the facility was to provide every patient with effective pain management as a part of their plan of care. A review of Section E under “Policy Statement “revealed that patients were to receive interventions (pharmacological and/or non-pharmacological to reduce or eliminate pain associated with their diagnoses, procedure or treatment and were to be re-assessed for the effectiveness of the intervention(s) within one-hour of intervention. This reassessment was to be documented. A review of Section H under “Policy Statement” revealed that following pharmacological interventions, the patient’s level of sedation was to be assessed using the Pasero Opioid Sedation Scale (POSS) (POSS: a valid, reliable tool used to assess sedation after administration of opioid medications for pain) along with pain reassessment; this assessment was to be done within 1 hour of any intervention. The policy explained that The POSS was designed to identify unintended opioid-induced respiratory depression. A review of Section C “Pain Reassessment” of the policy revealed that patients receiving interventions in pain management had to be reassessed within one-hour of interventions. The policy stated for both pharmacological and non-pharmacological pain interventions, effectiveness of the intervention was evaluated through reassessment. The policy reiterated that following pharmacological intervention, patient level of sedation was to be assessed using the Passero Opioid Sedation Scale (POSS), as part of the pain reassessment. During a phone interview with Registered Nurse (RN) GG on 12/5/23 at 11:45 a.m., RN GG said the nurses monitored all patients after they received medications. RN GG said he did not remember P #2 therefore he could not tell why the patient was not assessed after she received medicines. RN GG explained that it was protocol for the nurses to assess patients after they gave them pain medicines. During an interview with Unit Director (Unit Director) of Emergency Services and Clinical Decision Unit (II) on 12/5/23 at 1:30 p.m. in his office, Unit Director II reviewed P #2’s medical record and concluded in a statement that P #2 should have stayed at least 30 minutes for the nurse to watch him. Unit Director II said the facility followed their established Medication Administration’s policies and procedures and also the Lippincott Procedure Manual. Unit Director II said they encouraged the nursing team to discharge patients in wheelchairs, but the concern was that the nurse should have kept P #1 after he received the Morphine and the Benadryl. Unit Director II said that was a very isolated case because the nurses were well aware of policies of patient assessment after giving certain medications that could cause patients to experience changes in mental state and in blood pressure. Director II explained that staff were instructed to discharge patients in a wheelchair, especially after they received narcotics. Unit Director II confirmed RN HH did not work at the facility anymore. During an interview with Charge Nurse KK on 12/5/23 at 2:15 p.m. in Director II’s office, Charge Nurse KK said she had been a Charge Nurse for about five years total. Charge Nurse KK admitted there should have been a pain assessment completed for P #2 before RN HH discharged him. Charge Nurse KK explained that nurses should document a brief discharge summary about the effectiveness of administered medication. Charge Nurse KK said went on to explain that vital signs were a part of the post medication administration assessment before discharge that should be completed within an hour of discharge. Charge Nurse KK said that the last vital signs recorded in P #2’s medical record was too old and RN HH should have taken P #1’s vitals again at the time of discharge. A request was made to interview RN HH. Facility administrator confirmed RN HH was no longer working at the facility and was not available to be interviewed.”