Grady Memorial Hospital

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 49224 Based on facility policies and procedures, medical record review, and staff interviews, it was determined that the facility failed to provide dignity and respect to the demised (death) fetus of one patient (P) (P3) by leaving fetus on top of a cooling cot unwrapped after birth until the following day. Findings included: Review of the policy titled “Patient Rights and Responsibilities,” review dated 04/2004, revealed all patients deserve care, treatment, and services provided in a way that respects and fosters their personal dignity, autonomy, positive self-regard, civil rights, cultural, psychosocial, spiritual values, beliefs, and preferences. The purpose of the policy was to ensure care, treatment, and services are provided in a way that respects and fosters the patient’s rights. Patients have a right to have his or her decisions addressed regarding care, treatment, and services received at the end of life, to receive care in an environment that preserves dignity and contributes to a positive self-image. Patients had a right to participate and make informed decisions about his or her care, treatment or services. Review of the policy titled “Care of Fetal and Neonatal Death Procedure,” review date 04/2026, revealed the purpose was to define a process for facility personnel in the management of a fetal demise or neonatal/infant death that conveys respect and supports the grieving process. Induced termination of pregnancy was defined as the purposeful interruption of pregnancy with the intention other than to produce a live-born infant or to remove a dead fetus which does not result in a live birth. The parent and/or family member will be provided with opportunity to see and hold the baby, mementos, grief support referral and resources. Patient and family will also be educated on process of induction, delivery, and post-delivery. Post delivery death procedure included respect patient and family privacy as much as possible, handle the baby gently as you would a living baby, and inquire about and provide for any special cultural practices/observances, ask parents if they would like to bathe and dress their baby and complete these tasks for them if they do not, encourage parents to see, touch, and hold infant, allow adequate time for parents to hold and touch baby and offer them the opportunity to be alone with the baby, utilize cold packs to cool the body and extend the time families can have with their baby, normalize photography by suggesting it to the family as a very normal and valued keepsake. Review of medical record revealed that P3 was admitted to the facility on 04/01/2026 at 1:18 PM for chronic hypertension and twenty-one week gestation evaluation with decreased fetal movement. P1 was diagnosed with intrauterine fetal demise (death of a fetus in the womb) and managed with induction of labor (medical initiation of uterine contractions before labor begins naturally) and post-partum (immediately after childbirth and generally lasts six to eight weeks) blood pressure control. A post-partum progress note revealed P3 had displeasure of staff treatment after delivery of her baby. The note stated P3 said her baby was not dressed up and not measured afterwards. P3 was discharged from the facility to home in stable condition on 04/05/2026 at 6:00 PM. An interview was conducted with Registered Nurse (RN) CC on 05/26/2026 at 4:39 PM in the conference room. RN CC stated there was not a medical record flowsheet that was dedicated to documentation of care of the baby after delivery, but documentation would be placed into nursing notes. She said the patient’s provider discussed medical and plan of care topics with the patient. She said the nurses provided emotional support to the patient. RN CC stated following fetal demise, a death packet was completed. An interview was conducted with Registered Nurse (RN) DD on 05/27/2026 at 11:43 AM in the conference room. RN DD stated she remembered P1 and was aware that P1 experienced a fetal death and that she took care of P1 and baby the next morning after delivery. She said P1’s baby was placed on top of a cooling cot, and that she saw the baby undressed. She said she supported P1 and allowed her to vent. She said patients had options following a fetal demise regarding labor, pain management and whether they decided to hold or not hold their baby, or have the baby wrapped. She said that the patient’s nurse should ask the patient about their needs and wants. She said that if P1 didn’t hold her baby until the next day, there was no reason for that to occur. RN DD stated she wasn’t sure if there was a protocol to follow regarding demise of a baby. A follow-up interview was conducted with Registered Nurse (RN) CC on 05/27/2026 at 2:00 PM in the conference room. She said there was no standardized protocol for post-delivery after a fetal demise. She said two nurses were required to conduct fetal heart tones, and then a doctor followed up with an ultrasound if no heart tones were detected. She said labor and delivery nursing staff completed a perinatal fellowship training that included perinatal loss upon hire only. She said there was consideration to include the perinatal fellowship into staff’s annual competencies. An interview was conducted with Registered Nurse (RN) JJ on 05/27/2026 at 4:10 PM via telephone. RN JJ stated she remembered P1 and that she was aware P1 had experienced a fetal death. She said she took care of P1 the next day after delivery on the night shift. She said when she walked into P1’s room, P1’s baby was in the room next to her in a bassinet. She said P1’s baby was not covered and that P1 didn’t ask to have her baby covered or wrapped. She said staff followed the wishes of the baby’s mother regarding how the baby was to be cared for. RN JJ stated P1 had no complaints to her about the care of her baby.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 46188 Based on review of medical records, staff interviews, and facility policies and procedures, it was determined that the facility failed to ensure that patients are informed of their rights through consents when two (P#1 and P#3) of four (P#1, P#2, P#3, and P#4) medical records failed to include a signed consent to treatment. Findings Included: A review of P#1’s medical record failed to reveal a consent for treatment. A review of P#3’s medical record failed to reveal a consent for treatment. A review of the facility’s policy titled, “Patient Rights and Responsibilities”, last reviewed 04/2024, revealed that the purpose of the policy was to: Continued review revealed, Procedure, A, Patient Rights, the facility recognizes that each patient has the right to: 2. Participate and make informed decisions about his or her care, treatment, or services. 3. Give or withhold informed consent. During a telephone interview on 7/30/25 at 11:45 a.m., MD FF said that if a patient comes into the ED staff should make an attempt to obtain the patient’s consent for treatment. MD FF said that if the situation is emergent, then the physician may bypass this due to the critical nature of the situation however, nursing staff or registration will obtain consent for treatment afterwards with the patient or family members as appropriate. During a telephone interview on 7/30/25 at 10:02 a.m., Charge Nurse (CN) HH said that she has been a nurse for almost 16 years and worked as a CN for 6 years. CN HH said that registration and sometimes nursing staff will obtain consent for treatment with a patient. CN HH said that depending on the situation it may be difficult to, so staff are informed to contact family members if possible and appropriate. CN HH said that staff will not halt any lifesaving interventions to obtain consent, but rather they may obtain it afterwards.”

“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: 46188 Based on review of medical records, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to provide care in a safe setting when one (P#1) of four (P#1, P#2, P#3, and P#4) sampled patients was being treated in the facility’s emergency department (ED) for confusion and potential stroke and left the facility without the staff’s knowledge. Specifically, P#1 was screened in the ED on 7/22/25, received a sedative and a computed tomography (CT). The treating provider in the ED had determined that P#1 required an inpatient admission. P#1 left the facility without staff’s knowledge and was taken to another hospital’s ED by law enforcement one day later. Findings Included: A review of Patient (P) #1’s medical record revealed that P#1 presented to the facility’s emergency department (ED) On 7/22/25 at 1:58 p.m. via emergency medical services (EMS) due to dysarthria (a motor speech disorder that makes it difficult to articulate words due to weakness or impaired control of the muscles used for speaking) and signs of a stroke (when blood flow to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen potentially causing disabilities or death). A review of “ED Notes” dated 7/22/25 at 2:12 p.m. revealed that a stroke alert was activated. A review of an “ED Provider Notes” dated 7/22/25 at 2:24 p.m. by MD FF revealed that P#1 was stable, had a stroke scale score of five (zero to four indicates a minor stroke, five to 15 indicated a moderate stroke, 16 to 20 indicates a moderately severe stroke, and 21-42 indicates a severe stroke), and would require additional work up and inpatient admission to expand for stroke work up. Continued review revealed that P#1 required 2.5 milligrams (mg) of Versed, medication used for a sedative effect or anxiolytics, prior to the computed tomography (CT) (medical imaging technique that uses x-rays to create detailed cross-sectional images of the body). Continued review revealed P#1 had a disposition of eloped. A review of an “Emory Neurology Stork Consult”, dated 7/22/25 at 3:29 p.m. by MD LL revealed that upon examination, P#1 had expressive aphasia, delay in following commands, and decreased right upper extremity sided sensory deficits. Continued review revealed that MD LL recommended further workup for toxic, metabolic, or infectious contributing etiology (the cause or reason for something). A review of an “ED Note”, dated 7/22/25 at 4:57 p.m., by RN AA revealed that RN AA was unable to located P#1 at that time and looked throughout the ED unit. RN AA notified MD FF. A review of an “ED Note”, dated 7/22/25 at 5:27 p.m., by RN AA revealed that RN AA was still unable to locate P#1 at the time. RN AA notified security to activate a Code Green. (facility’s internal code for missing patient). A review of an “ED Note” dated 7/22/25 at 6:20 p.m., by RN AA revealed that RN AA was still unable to locate P#1, a brief description of P#1 was given to security and per security contact will be made to the Atlanta Police Department (APD). RN AA notified Charge Nurse (CN) HH. A review of the facility’s policy titled, “Patient Rights and Responsibilities”, last reviewed 04/2024, revealed Procedure, A, Patient Rights, the facility recognizes that each patient has the right to: 3. Receive care in a safe environment free of neglect, exploitation, verbal, mental, physical, or sexual abuse. A review of the facility’s policy titled, “Assessment / Reassessment in the Emergency Department”, last reviewed 3/10/25, revealed that the purpose of the policy was to establish guidelines, timelines, and expectations for the assessment and reassessment of patients in the emergency department (ED). A. Reassessment 1. All ED patients must be reassessed regularly based on their acuity level. 2. Reassessment is a focused review of systems pertinent to the patient’s presenting complaints and condition. Continued review revealed, IV, Definitions, Reassessment, a focused evaluation performed after the initial assessment to monitor changes in a patient’s condition, response to treatment, and to ensure continued appropriate care. During a telephone interview on 7/30/25 at 9:29 a.m., Registered Nurse (RN) BB recalled that P#1 came to the ED via ambulance. RN BB recalled that a stroke alert was eventually activated for P#1 however P#1 was uncooperative and refusing care. RN BB recalled that the Medical Doctor (MD) LL was present at the bedside performing a stroke assessment and MD FF was redirecting P#1 and providing education on the reason why P#1 should agree with treatment. RN BB recalled that P#1 eventually agreed. RN BB recalled that P#1 was agitated and anxious prior to getting a computed tomography (CT) scan and required a small dosage of Versed (a medication used for its anxiolytic and sedative effects). RN BB recalled that P#1 got the CT scan done and then when returning to the ED, Charge Nurse (CN) HH told RN BB to place P#1 in a hallway bed. RN BB gave a handoff to RN AA. RN BB recalled that P#1 was still in bed while the handoff occurred. RN BB recalled that after she spent an hour or so in the CPR bay with the new patient, she later returned to the nurses’ station where she learned that staff reported P#1 as missing. RN BB said that no physician mentioned that P#1 should be an elopement risk. During a telephone interview on 7/30/25 at 10:02 a.m., Charge Nurse (CN) HH recalled P#1 in that he presented as a stroke callback. CN HH recalled that after P#1 received his computed tomography (CT) scans, he was placed in a hallway bed because a more critical patient was coming into the ED. CN HH recalled that Registered Nurse (RN) AA received handoff from RN BB, but RN AA was also very busy with another intensive care unit (ICU) patient who required going to CT twice. CN HH said that it was never reported that P#1 was a high-risk patient or requiring a safety sitter. CN HH recalled that she later came back to the nurses’ station and saw Security Officer (SO) GG filing out a report that P#1 was missing. CN HH recalled that she looked in P#1 chart and never saw any orders that P#1 was a high-risk or had diminished capacity which would have alerted nursing staff to implement other protocols for P#1. During an interview on 7/30/25 at 10:22 a.m. in the conference room, Security Officer (SO) GG said that he has been employed with the facility for almost eight years in public safety. SO GG recalled 7/22/25 he received a called about a missing patient, P#1, in zone three of the emergency department (ED). SO GG recalled speaking with Registered Nurse (RN) AA who provided a description of P#1 and the last known whereabouts. SO GG recalled paging out a be on the lookout (BOLO) over facility radio for other SO to scan their areas of the hospital. SO GG recalled going to check the surrounding ED vicinity, both inside and outside. SO GG recalled contacting the Atlanta Police Department (APD). SO GG recalled that APD arrived around 8:00 p.m. and they spoke with P#1’s family member. SO GG recalled that his supervisor did review camera footage, and they were able to trace where P#1 left out of the facility too but were still unable to locate him. During a telephone interview on 7/30/25 at 11:05 a.m., Registered Nurse (RN) AA said that he was been an RN for five years and employed at the facility in the emergency department (ED) for four years. RN AA recalled that on 7/22/25 he came back from the computed tomography (CT) room with an intensive care unit (ICU) patient he was caring for. RN AA recalled that RN BB gave him a handoff on P#1 and they both visualized P#1 in the hallway bed resting. RN AA recalled that after he provided care for another patient, he later saw P#1 speaking with two providers in the hallway but then his ICU patient required more attention. RN AA recalled that he then had to take his ICU patient back to CT and when he later got back, he noticed that P#1 was not in the hallway bed. RN AA said that he originally thought that maybe the patient went to the restroom. RN AA recalled that Medical Doctor (MD) FF later came up to RN AA and asked if RN AA knew about the location of P#1. RN AA recalled that MD FF told RN AA to call in a Code Green to security. RN AA recalled that there were never any orders in P#1’s chart that suggested P#1 was an elopement risk or a high-risk patient that required closer monitoring. RN AA recalled that Security Officer (SO) GG interviewed RN AA and MD FF later spoke with P#1’s family members. During a telephone interview on 7/30/25 at 11:17 a.m., Doctor of Osteopathy (DO) EE said that she has been an attending physician in the emergency department (ED) since 2014 and employed at the facility since 2017. DO EE recalled P#1 and that a stroke alert was called in. DO EE recalled that a physician assistant in triage initiated the stroke alert and reported that P#1 was alert, had some slight altered mental status changes per family, and a history of a stroke. DO EE recalled that P#1 was given some medication to assist with agitation and anxiety prior to the CT scan. DO EE said that to place a patient on a high-risk or elopement precaution would be determined by factors of if a patient represented a danger to themselves or others or were unable to be verbally redirected. DO EE recalled that P#1 never displayed any signs of attempting to leave, danger, and he was redirectable. DO EE said that many patients come into the ED with altered mental status, but they do not all require to be placed on elopement precautions because every patient is different, and staff are trained to go by their assessments of the patient. During a telephone interview on 7/30/25 at 11:45 a.m., Medical Doctor (MD) FF recalled P#1 and said that P#1 presented to the facility’s emergency department (ED) via emergency medical services (EMS) due to a possible stroke which was activated by the triage team as a Code Stroke. MD FF recalled that P#1 initially refused care but was redirectable. MD FF recalled that P#1 did require medication, Versed, for the imaging because P#1 was agitated and anxious. MD FF recalled that after P#1 received the imaging P#1 went back to the ED while MD FF assisted with another emergency. MD FF recalled that when he went to reassess P#1, P#1 was nowhere to be found in the hallway bed. MD FF alerted nursing staff and instructed them to initiate a Code Green which prompted security to get involved and later Atlanta Police Department (APD). MD FF said that he never saw P#1 again after imaging. During a telephone interview on 7/30/25 at 1:44 p.m., Medical Doctor (MD) LL said that she is a neurologist resident during the time that P#1 presented to the facility’s emergency department (ED). MD LL recalled performing a stroke assessment on P#1 and that he had some aphasia and that he could not get his age or the month right. MD LL recalled that P#1 made sentences that did not fully make sense but were in the right context. MD LL recalled going downstairs to see P#1 in the ED with another provider and saw P#1 in the hallway bed. MD LL recalled explaining to P#1 that they wanted to admit P#1 for further workup and that they would tell the ED team. MD LL recalled that some time afterwards she saw a note by the ED team that P#1 walked out of the ED.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 40979 Based on medical record review, internal investigation report, staff interviews, and policies and procedures it was determined that the facility failed to ensure that the patient’s next of kin or guardian was notified of unexpected events when it was determined that one patient (P) (P#1) of three patients reviewed sustained an injury to his head during transport. Family of P#1 was not notified of the injury. Findings include: A review of the facility’s policy titled “Patient Rights and Responsibilities,” last revised 05/2019 revealed II. Purpose. The purpose of this policy is to a. ensure care, treatment, and services are provided in a way that respects and fosters the patient’s rights as outlined in this policy. III. Procedure. 9. Receive care in a safe environment free of neglect, exploitation, verbal, mental, physical or sexual abuse. GHS reports cases of neglect and abuse to law enforcement and other protective services at any of the offices listed below. A review of the facility’s policy titled “Patient Safety Observation,” last revised 2/2022 revealed it is the policy to provide monitoring, observation and supervision to all patients who meet the appropriate risk criteria. Implementation of this policy is a nursing decision based upon clinical data, potential for patient safety concerns, and unique patient care needs. The type of monitoring that will be provided to the patients is dependent upon the condition of the patient as assessed by the Registered Nurse (RN) or physician providing care. A review of the facility’s policy titled “Informing Patients and/or Families of Unanticipated/Unexpected Outcome of Care,” last revised 1/2019 revealed Policy Statement. It is the goal to have open, honest communication with patients and that all patients feel involved in their care and treatment. This communication may take the form of informed consent, communication of an unanticipated event, and talks with physician and staff. Patients or the appropriate guardian or representative will be provided relevant information about all outcomes of care. The Health System requires that patients and when appropriate, his/her legal guardian, healthcare representative or family are informed about the outcomes of care, including unanticipated/unexpected outcomes. It is the responsibility of the providing Licensed Independent Practitioner, or his/her designee to clearly explain the outcome of any treatment or procedures to the patient, and when appropriate his/her legal guardian, healthcare representative and/or family, in layman terms, wherever those outcomes differ significantly from the anticipated outcome. This policy will also be adhered to by all (facility) staff for all outcomes which includes: unanticipated/unexpected events. A review of P#1 medical record revealed that P#1 was admitted to the facility on 10/5/2024 with a diagnosis of fall with dislocation of shoulder. Review of nursing note dated 10/12/2024 at 1:01 a.m. revealed upon transferring pt from on bed to another, draw sheet was used to assist pt to the top of the bed, however, pt’s head was struck on the backboard of the bed. A skin tear with small amount of blood was noted to the top of the pt’s head. Pt did not complain of any pain or discomfort and neuro assessment was still intact. Upon my departure, pt was resting in bed with no complaints and side rails activated. Care transferred. Review of nursing note dated 10/12/24 at 1:02 a.m. revealed patient on arrival to the unit, transferring patient from ICU bed to the unit bed, patient head hit to the head of the bed and started bleeding, 4x4 guess [sic] dressing was placed on it with pressure to stop the bleed, team trauma 1 called and notified, said they would be there to assess patient, A&Ox3, admission assessment and it’s takes two performed by two nurses, on the skin assessment patient had generalized bruises, skin tear to the sacrum, vitals taken, all safety measures in place, will continue with plan of care. Review of physician note dated 10/12/24 at 4:08 a.m. revealed assessed the pt at bedside after nurse informed me that during transfer, the patient’s head hit the bed and started bleeding. He has 2 skin tears on the superior aspect of his scalp approx. 1 and 2 cm. Both wounds are hemostatic. Please change dressings as needed. Review of physician progress note dated 10/12/24 at 7:09 a.m. revealed patient hit head during a transfer overnight, CT Head negative, patient resting in bed, tolerating a diet. Discussed discharge plans with the patients daughter who is requesting the patient to discharge home health. Will plan for physical therapy to evaluate the patient working towards going home. Review of Nurse Practitioner progress note dated 10/15/24 at 5:25 p.m. revealed patient resting in bed; alert and oriented x3; denies pain just reports he is “uncomfortable”; new skin tear to left elbow from yesterday. Dressing changed, photo of wound in chart. Scalp dressing changed. Photo of wound in chart. Son and daughter-in-law at bedside and updated. A review of the facility’s incident log dated July 2024 through October 2024 revealed an incident #272246 was reported on 10/12/2024 regarding P#1 and Skin/Tissue harm. Continued review revealed that staff assisted the transfer of P#1 into the bed upon arrival to unit 5A. “The pt then needed further assistance to the head of the bed. A 5A Nurse and Tech were at the top of the bed, one on each side, and the 7KIS tech and I were assisting at the end of the bed with the pt’s feet. The pt was assisted to the top of the bed via draw sheet, however, he was pulled up too far and hit his head on the backboard of the bed. A skin tear with small amount of blood was noted to the top of the pt’s head. Pt did not complain of any pain or discomfort and neuro assessment was still intact. The primary RN was notified, pressure was held to top of head with gauze and Provider was notified and to come see pt at bedside. Upon my departure pt was resting in bed with no complaints and side rails activated.” An interview was conducted with Nurse Practitioner (NP) GG on 10/23/2024 at 10:30 a.m. in the Risk Management conference room. NP GG stated that she did recall caring for P#1 on Unit 5A for two days during his admission. She continued to explain that the skin tear injury to P#1’s scalp occurred the day before she began caring for him however, when she saw P#1 for the first time she notice the skin tear on his scalp and changed the dressing. NP GG stated that the nursing staff will not generally call family regarding skin tears because with some vulnerable patients it happens all too often. NP GG continued to explain that when she saw P#1 for the second time he did have a new skin tear on his left elbow area that was not present on the previous day. She continued to explain that there was no documentation in his medical record as to how the skin tear on his left elbow happened. NP GG continued to explain that she did have one conversation with P#1’s daughter about discharge planning and answered her questions and concerns, however, did not advise her of the injury to his scalp or left elbow. She continued to explain that she had a separate conversation with P#1’s son who was at bedside during the second visit and he was upset about the skin tear on P#1’s elbow because it was unexplained as to how it happened. A telephone interview was conducted with Registered Nurse (RN) HH on 10/23/24 at 11:30 a.m. RN HH stated that he did recall P#1 during his admission on Unit 5A. He continued to explain that he did recall when P#1 received the skin tear on his scalp. RN HH stated that when P#1 was with transport transferring from one unit to Unit 5A he and the Tech were transferring P#1 from the transport bed to the bed in his room and during the transfer process we accidentally hit his head at the top of the headboard which caused the skin tear. RN HH continued to explain that he immediately contacted the unit manager and the Nurse Practitioner. He stated that he was advised to treat the wound and place a 4x4 gauze on his head and change gauze as needed. RN HH stated that he does not know how P#1 received the skin tear on his elbow. RN HH confirmed that he did not make contact with P#1’s responsible party regarding the incident. He continued to say that P#1 has not sat for extended amounts of time in feces or urine. He continued to say that P#1 received bed baths during his admission to Unit 5A. A telephone interview was conducted with RN II on 10/24/24 at 9:30 a.m. RN II stated that she did recall P#1 during his admission to the facility. She continued to explain that she cared for P#1 for approximately two days when to transferred from another unit to Unit 5A. RN II stated that she was present when P#1 was transferring from the previous unit’s hospital bed to a bed on Unit 5A and during the transfer she was assisting another nurse and two other technicians when the transfer was a little rough, although unintentional, P#1’s head hit the headboard of the bed to which he was transferring. She continued to explain that as a result of the hit to his head he sustained a skin tear to his scalp that began to bleed. RN II stated that she immediately advised the head nurse, RN HH, who walked in after P#1 sustained the hit to his head, about what had happened and then she immediately cleaned the wound and applied the 4x4 gauze to the injury. RN II stated that RN HH stated that he would report the injury to the NP. RN II stated that she advised RN HH that she would enter the incident report in the system. She stated that she could not confirm any information regarding the skin tear on P#1’s elbow without reviewing his chart because he came to the facility with several injuries due to his fall. RN II confirmed that she did not contact P#1’s family regarding the incident to his scalp.”

“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: 46188 Based on reviews of medical records, policy and procedures, ambulance report, facility incident Report Form, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s Emergency Department (ED) including ancillary services routinely available to the ED, to determine whether or not an EMC (Emergency Medical Condition) existed for 1 (#1) of 20 sampled patients who presented to the ED via ambulance on 2/212024 at 2:36 P.M., with suicidal ideations (SI), and with plans to hang himself. The patient reported to hospital ED staff that he was having SI for three days and felt that he was getting closer to harming himself and had attempted to kill himself more than six months ago. The patient requested he be evaluated for inpatient hospitalization to keep him safe. The patient’s behavioral assessment was completed by a Licensed Professional Counselor (LPC) who determined Patient #1 was a “Moderate Imminent Risk for suicide” and documented the patient’s “judgement was poor.” The medical record did not contain evidence that the MSE included collateral information from the patient’s family member (sister), who was identified in the medical record as somebody he contacted frequently about his suicidal thoughts, unstable housing, and financial barriers. There was not documentation that patient #1’s suicidal thoughts, plans, and attempt prior were assessed or contextualized as part of his risk assessment during this visit. The MSE also identified that patient #1 had diabetes was out of insulin for three weeks but failed to evaluate whether this complaint was associated with an EMC. Patient #1 was discharged to self with a diagnosis of “suicidal ideation” after his MSE was concluded on 2/21/2024 at 3:21 PM (45 minutes after arrival). On 2/21/2024 at 6:02 P.M., Patient #1 was found after discharge in the ED waiting room restroom unresponsive from an apparent self-inflicted hanging. Resuscitation efforts were unsuccessful, and Patient #1 was declared deceased on 2/21/2024 at 6:11 P.M. Refer to finding in Tag 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: 25370 Based on reviews of medical records, policy and procedures, ambulance report, facility incident Report Form, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s Emergency Department (ED) including ancillary services routinely available to the ED, to determine whether or not An EMC (Emergency Medical Condition) existed for 1 (#1) of 20 sampled patients who presented to the ED via ambulance on 2/212024 at 2:36 P.M., with suicidal ideations (SI), and with plans to hang himself. The patient reported to hospital ED staff that he was having SI for three days and felt that he was getting closer to harming himself and had attempted to kill himself more than six months ago. The patient requested he be evaluated for inpatient hospitalization to keep him safe. The patient’s behavioral assessment was completed by a Licensed Professional Counselor (LPC) who determined Patient #1 was a “Moderate Imminent Risk for suicide” and documented the patient’s “judgement was poor.” The medical record did not contain evidence that the MSE included collateral information from the patient’s family member (sister), who was identified in the medical record as somebody he contacted frequently about his suicidal thoughts, unstable housing, and financial barriers. There was not documentation that patient #1’s suicidal thoughts, plans, and attempt prior were assessed or contextualized as part of his risk assessment during this visit. The MSE also identified that patient #1 had diabetes was out of insulin for three weeks but failed to evaluate whether this complaint was associated with an EMC. Patient #1 was discharged to self with a diagnosis of “suicidal ideation” after his MSE was concluded on 2/21/2024 at 3:21 PM (45 minutes after arrival). On 2/21/2024 at 6:02 P.M., Patient #1 was found after discharge in the ED waiting room restroom unresponsive from an apparent self-inflicted hanging. Resuscitation efforts were unsuccessful, and Patient #1 was declared deceased on 2/21/2024 at 6:11 P.M. Findings included: A hospital document titled, “Facility Incident Report” dated 2/22/2024 was reviewed. The section of the incident report titled “Details of Incident’ revealed in part, “Pt. [Patient] #1 presented at Grady Health System via EMS [Emergency Medical Services] at 5:17 P.M. on 2/21/2024. His chief complaint was suicidal ideation with a plan ...has a history note since 2012 of suicidal ideation with multiple visits to facilities in Georgia and Ohio. He was homeless and had a significant history of alcoholism. He was triaged and screened and placed in PES [Psychiatric Emergency Services], the Grady Health System psychiatric emergency department. He was seen by a resident and an attending physician and cleared for discharge with after care plan. According to video surveillance he left the hospital at 4:00 P.M., he came back in the ED at 4:08 P.M. without speaking to anyone and entered the bathroom at which time he used his belt as a ligature and hung himself. Another patient attempted to use the bathroom at 5:45 P.M. and the door was forced open. CPR (cardiopulmonary resuscitation) was started and continued till time of death at 6:11 P.M.”. Further review revealed the County Medical Examiner was notified and involved. The facility took steps to prevent further incidents by assigning a RCA (Root Cause Analysis- the process of discovering the causes of problem in order to identify appropriate solutions) team on 2/22/2024. The Ambulance report (Patient Care Record) dated 2/21/24 at 1:55 P.M. for Patient #1 was reviewed. The report revealed the patient’s “Chief Complaint” SUICIDAL IDEATIONS BY HANGING.” The patient’s level of distress was listed as “Mild.” The patient’s signs and symptoms were documented as “Depression (Primary), Hyperglycemia (elevated blood pressure sugar levels), and Suicidal ideations,” patient #1 vital signs were listed as 160/74 (Normal blood less than 120), Heart Rate 90, Respiratory rate -16, oxygen level was 98 % on room air, blood glucose level was 351 (normal blood glucose level-80 to 100 mcg/dl); Pain level of 3. The patient was noted to be awake, alert and oriented to name, person, and date, and was moving all extremities. Review of the Narrative section of the report revealed in part the following, “66-year-old male behavioral disorder, upon arrival we found ...sitting on a bench outside this location. He states he is under a lot of stress; he is very depressed and is now suicidal with a plan of hanging himself. He C/O (complains of) mild chest pains secondary to 2 broken ribs from a month ago ... He was able to walk over to the ambulance ... we started an 18 GA (gauge) INT (intermittent needle therapy) in the left forearm and started Normal Saline ...gave Grady report ...got him in the ED (Emergency Department) ...registered and triaged ...and turned him over to staff for further evaluation.” A review of Patient (P) #1’s medical record revealed that he arrived at the facility’s emergency department on 2/21/24 at 2:24 P.M., via ambulance. Review of the ED notes the ED Nurse documented in part, “Chief Complaint: Patient presents with Suicidal + (positive) SI (Suicidal ideation) w (with)/ plan to hang himself. He has had an attempt previously where he tried hanging and stabbing himself over a year ago.” Further review the patient was triaged as a level of 2, emergent, (requires an immediate nursing assessment and rapid treatment and includes patients who are in a high-risk situation). A review of an Emergency Medicine Rapid Medical Examination Note for Patient (P) #1 dated 2/21/24 at 3:17 p.m. by medical doctor (MD) BB revealed that P#1’s blood glucose level (level of glucose found in the blood) was 351 (normal was 80-100 mcg/dl) with EMS and the blood glucose level was 275 in triage. P#1 reported polydipsia (thirst) and urinary frequency. P#1 reported that he had been out of insulin (medication used to treat diabetes) for three weeks. There was no documentation in the medical record to indicate that the hospital made use of its capabilities and services routinely available to the emergency department (such as but not limited to, laboratory tests) to further assess whether Patient #1’s abnormal glucose level was a manifestation of an emergency medical condition. Documentation by the ED Physician in the “Narrative” section revealed in part, “Patient was initially found to have a BG (Blood glucose) of 351 so was brought the zones for fluids before being medically cleared and brought to PES for psychiatric evaluation.” Continued review of the Emergency Medicine Rapid Medical Examination Note revealed, “Patient said that he is “not good” because his depression and suicidal thoughts have been bad for 3 (three) days. Patient said that he called for help today because the thoughts were getting stronger, but God doesn’t want him to hurt himself. Patient noted that faith is very important to him. Patient endorses his last alcoholic drink to be a couple of weeks ago and denies any other recent substance use ...Patient says that he has been staying at a group home where he pays rend on the 3rd each month. However, 2 (two) days ago patient was not able to reach his money account. When asked if he can return to this group home, he said that he can’t because if he does he will kill himself. Patient went this morning to get a new ID (identification) after losing his but needed a birth certificate, so he ordered one online. Patient has a sister ...that he talks to regularly (most recently today).” MD BB noted that per a chart review, P#1 had numerous visits to the facility and other hospitals with similar presentations and complaints with history of housing instability and alcohol use. Continued review of the note revealed that a medical screening examination (MSE) was conducted by MD BB that revealed P#1 was alert, calm and cooperative, and engaged with interviewer. P#1 reported that his mood was “not good”. P#1 was documented to be “coherent, organized, and goal directed”. The section of the note titled, “Assessment/Diagnosis(es) MD BB documented in part, “1. Homelessness: Patient is at higher overall risk for suicide given their current homelessness, chronic illness, and ongoing substance use. Patient is also at risk for manipulative self-harm. However, suicide is best addressed with substance treatment and connection with psychotherapy and not short term psychiatric. There may be a component of secondary gain as the patient remains homeless with limited resources and has not followed through with outpatient planning.” P#1 was discharged to self and provided with contact information for outpatient psychiatric resources to the Georgia Crisis and Access Line and Grady Mental Health Clinic. (Access to Crisis Services - provides telephonic crisis intervention services, Dispatch mobile teams, and assist individuals in finding an open crisis or detox bed across the state). Medical record review revealed that on 2/21/2024 at 3:28 P.M. that Licensed Professional Clinician (LPC)-CC was authorized by Physician AA (Attending Medical Doctor) to perform an ED SRA [Suicide Risk Assessment -comprehensive assessment that determines an individual’s risk is for suicide at a given point and time]. Documentation by LPC revealed in part the following SRA questions were asked, “.. Have you actually had any thoughts about killing yourself: Yes; Have you thought about how you might do this?: Yes (“Hang self or stab myself.”); Have you had any intention on acting on these thoughts of killing yourself? Do you intend to carry out this plan: No ...Modifiable risk factors: Current instability in environment/psychosocial factors and Active alcohol/substance use disorder. Protector factors: Future orientee/goal directed, Connection religious beliefs and Connection to family.” The section of note titled “History and Present illness, the LPC-CC documentation, revealed in part, “Patient #1 states he came to the hospital because he was getting “close ...When asked how r to doing it” ...Patient #1 reports faith is absolutely important to him which stopped him from completing suicide. ...When asked how the hospital could help him, he replied, “Keep me safe from harming myself. Send me to a program for mental illness. ... Patient #1 states he has a sister ...that he speaks to often. He reports no other support.” There was no documentation in the medical record to indicate the facility staff attempted to contact the patient’s sister or ask the patient to call his sister, to notify her of the facility’s assessment that Patient #1 was determined a moderate risk for suicide, nor was she notified of Georgia Crisis line as stated in the facility’s policy. Further review of the medical record review revealed the Licensed Professional Clinician (LPC) CC documented in part, “Mental Exam (examination) “Appearance: Unkempt/disheveled; Behavior: Cooperative; Speech: Normal; Mood: “Not Feeling very good.”; Affect: Blunted [a decreased ability to express emotion through facial expressions, tone of voice, and physical movements] ... Thought Process: Linear and Tight; Memory: Intact; Insight” Fair; Judgement: Poor”. The video footage related to Patient #1’s initial visit (2/21/2024) was provided to the survey team during the investigation. Review revealed that that at 4:01p.m., Patient #1 was seen exiting the hospital’s emergency department exterior entry holding paperwork in his hand. A review of the medical record for the subsequent visit revealed that Patient #1 was evaluated un the ED again on 2/21/2024 at 6:02 P.M., and was pronounced deceased at 6:11 P.M. A review of the facility’s policy titled, “Assessment of Suicide Risk and Suicide Prevention,” last revised 12/2023, revealed that the facility would provide guidelines for the assessment of suicide risk for patients receiving behavioral health services. Assessment: 1. The Columbia-Suicide Severity Rating Scale (C-SSRS) or the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) will be completed for individuals. The SAFE-T assessment will solely be used within Psychiatric Emergency Services (PES): o Prior to being discharged from the Psychiatric Emergency Services (PES) in the Emergency Department. ... B. Response to the C-SSRS and SAFE-T: The appropriate level of care is determined based upon the results of the assessments and the determination of imminent risk. Recommended responses are as follows: High Imminent Risk- inpatient hospitalization. Moderate Imminent Risk- refer to higher level of care or outpatient follow-up as appropriate - A Crisis Safety Plan will be developed for individuals deemed to be at moderate risk. Patient Education on the Crisis Safety Plan will be documented in the electronic medical record (EMR) to include patient’s expressed likelihood to use the Safety Plan ...C. Monitoring: o Individuals served in the community, who are at moderate or high risk for suicide must address the treatment of suicidality in their treatment plans. D. Provision of Suicide Prevention Information o When an individual at risk for suicide leaves the care of the organization (whether at discharge from a program or after the provision of a service), suicide prevention information, such as the contact information for the Georgia Crisis and Access Line, is provided to the individual and his or her family. Provision of this information is documented in the patient record. The facility’s policy titled, “EMTALA Policy - Medical Screening Examination, Central Log, On-call coverage, and Signage,” last reviewed 9/2023, “It is the policy of the facility to provide an appropriate Medical Screening Examination (MSE) when an individual comes to its Dedicated Emergency Department (DED) and: 1. The individual or representative acting on the individual’s behalf requests and examination or treatment for a medical condition .... Procedure: When an MSE (medical Screening examination) is Required: Grady must provide an appropriate MSE within the capability of the hospital’s DED (Dedicated Emergency Department) including ancillary services routinely available to the DED, to determine whether or not an EMC (Emergency Medical Condition) exists: (i) any individual ...who requests such an examination ... An MSE shall be provided to determine whether or not the individual is experiencing an EMC ...Extent of the MSE...b. Definition of MSE ...As MSE is the process required to reach, within reasonable clinical confidence, the point at which it can be determine whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of Grady. C. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer ...e. Extent of MSE varies by presenting symptoms. The MSE varies by presenting symptoms and may vary depending on the individual’s signs and symptoms: i. Depending on the individual’s presenting symptoms, an appropriate MSE can involve a wide spectrum of actions ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures ... iii. Individuals with psychiatric symptoms: The medical record should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicate danger to self or others.” During an interview on 3/4/24 at 2:19 p.m. in the conference room, Medical Doctor (MD) BB said that she has been a general psychiatric medical resident for almost one year. MD BB said that once patients are triaged, a psychiatric complaint is identified and deemed medically stable, then are then sent to the ED’s psychiatric emergency services (PES) area where staff formulate a treatment plan for the individual and decide on the disposition of the patient. MD BB recalled that a chart review was performed on P#1 before the plan of care was discussed, and MD BB noted that P#1 was a high utilizer at multiple emergency departments (EDs) in the past for the same complaint and was discharged numerous times. MD BB recalled that P#1’s housing status was unclear as he reported he was staying in a group home (GH) but was not living in the GH for a couple of days due to financial issues. MD BB recalled that a list of shelter resources was given to P#1 along with OP (Outpatient) resources for housing assistance. MD BB recalled that P#1 sat in the hall spot chair and did not require the use of a room in the PES prior to discharge. During an interview on 3/5/24 at 9:35 a.m. in the conference room, MD AA said that he has been practicing psychiatric medicine for four years and has been an Attending for almost nine months. MD AA recalled reviewing P#1’s chart who had a history of chronic alcohol and substance usage and multiple ED visits due to SI. MD AA recalled P#1 presenting to the PES after receiving medical treatment for hyperglycemia (high-blood sugar) and intravenous (IV) fluids with an RN. MD AA recalled that he wrote an addendum the night of the event to summarize what was done in the PES that day for P#1. During an interview on 3/5/24 at 1:57 p.m. in the conference room, Licensed Professional Clinician (LPC) CC said that she has been an LPC since 2013. LPC CC said that LPCs assess and assist with determining along with the physician if a patient should be admitted to the facility or discharged. LPC CC recalled P#1 that he presented to the PES for a SI complaint after being treated for hyperglycemia. LPC CC recalled that P#1 reported that he was not doing well because he was depressed and suicidal. LPC CC recalled that P#1 reported that he was staying at a group home (GH) but got put out because he could not pay rent. LPC CC recalled that P#1 reported that he had been staying at the GH for at least two days. LPC CC recalled asking P#1 if he could stay with his sister and P#1 told her that he could not. LPC CC recalled asking P#1 if he would do anything to hurt himself and P#1 reported that if he would hurt himself, it would be to hang himself or by another method. LPC CC said that she was not sure why the team did not ask more about where P#1 would go once discharged and felt that the team could have asked more on this matter when thinking about it now. LPC CC said that she did perform a suicide risk assessment on P#1 and that he was a moderate risk, but this is based on his chronic history and risk factors. LPC CC said that per facility policy patients with a moderate risk can be discharged. The facility failed to ensure that patient #1 was provided an appropriate medical screening examination during his initial ED visit on 2/21/2024 at 2:36 P.M. The facility failed to follow its “Assessment of Suicidal Risk and EMTALA policies failing to make use of the hospital’s capability (including diagnostic testing to determine whether the patient’s observed abnormal glucose upon arrival in the setting of being out of insulin for 3 (three) weeks, was a manifestation of an emergency medical condition), and failed to obtain collateral information from Patient #1’s identified family member to determine whether or not there was an emergency medical condition.”

“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: 45841 Based on record review, interview, and policy review, the facility failed to ensure nursing care for each patient was properly evaluated for 1 (Patient #1) of 3 records reviewed. Findings included: Review of a facility policy titled, “[Facility name] Prevention and Management of Pressure Injury [PI] Policy,” last revised 04/2023, revealed, “Assess the patient’s skin for any alteration in skin integrity and perform a Braden Scale pressure injury risk assessment Q [every]-shift. Pay special attention to patients who are critically ill and patient [sic] with hip fracture for early signs of pressure injury of heels. Document assessment findings and interventions implemented each shift in Epic [healthcare software company]” and: “i. Reposition the patient every two hours while in bed using the foam wedge as needed ii. Apply skin barrier or sacrum foam dressing iii. Apply skin barrier and heel foam dressing iv. Float bilateral heels with offloading boots v. Nutritional referral for Braden Scale score less than 10 vi. Utilize nursing care plans in Epic for care of patients at risk for PI development or with skin breakdown and the patients’ specific interventions from Braden scale vii. Remove any equipment, clothing, or dressings such as but not limited to: Splint, Sequential Compression Device (SCDs) and heel booty every shift to evaluate the condition of the skin.” A review of a “Patient Information” document revealed Patient #1 was admitted on 01/21/2023 with a diagnosis of a gunshot wound. A review of “H&P [History and Physical] Notes,” dated 01/22/2023, indicated Patient #1 was admitted to the facility with a gunshot wound to the head and was admitted to the surgical intensive care unit (SICU). A review of “Calculated Braden Risk Scale” documentation within “Braden Intervention Level” sections of Patient #1’s medical record revealed the patient was assessed as high risk from 01/22/2023 to 01/25/2023, on 01/31/2023, 02/02/2023, 02/04/2023, and 02/09/2023, from 02/12/2023 to 02/14/2023, on 02/19/2023, and 02/20/2023; moderate risk on 01/26/2023 to 01/30/2023, on 02/10/2023 and 02/11/2023, and from 02/15/2023 to 02/18/2023; and severe risk on 02/01/2023 and 02/03/2023. A review of “Positioning per patient’s condition” flowsheet documentation revealed staff documented consistent turning and repositioning of Patient #1. A review of “Hygiene” flowsheet documentation revealed staff documented no protective barrier application for Patient #1 on 01/25/2023, 01/26/2023, 01/28/2023, 01/29/2023, 01/30/2023, 02/05/2023, 02/06/2023, 02/07/2023, or 02/08/2023, or from 02/10/2023 to 02/20/2023. A review of a “[Facility initials] Enterstomal [sic]/Wound Care Services Consult Note,” dated 02/20/2023, revealed Patient #1 had a stage 2 pressure injury to their buttocks. During an interview on 09/13/2023 at 2:50 PM, Vice President (VP) of Critical Care #26 revealed all patients in the SICU were to be turned every two hours, except for some patients with head injuries and/or spinal cord injuries. VP of Critical Care #26 stated a Braden Scale score was used to determine skin risk factors; however, VP of Critical Care #26 noted that protective interventions were to be implemented for any Braden Scale risk level because patients in the SICU were immobile. VP of Critical Care #26 stated other skin precautions used were protective barrier lotion and keeping a patient clean and dry. An interview conducted on 11/16/2023 at 1:40 PM with Director of Wound Care #5 revealed interventions were to be applied for an at-risk patient. Per Director of Wound Care #5, the facility used the Braden Scale for Predicting Pressure Ulcer Risk to determine a patient’s level of risk. An interview conducted on 11/16/2023 at 2:10 PM with Clinical Informatics #4 revealed skin barrier application was not consistently documented by staff in January 2023 for Patient #1 and were even less consistently documented from 02/10/2023 to 02/20/2023.”