Mary Greeley Medical Center

“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: 49842 Based on a review of hospital policies and procedures, patient medical records, and staff interviews, the Acute Care Hospital (ACH)’s administrative staff failed to ensure emergency department (ED) staff provided care in a safe setting for 1 of 10 sampled behavioral health (BH) patients (Patient #4) by failing to provide necessary and appropriate psychiatric treatment for Patient #4 (P4), a patient with acute symptoms of psychosis, bipolar disorder, and paranoid delusions with a history of violent and aggressive behaviors. Staff administered antipsychotic medication, which had previously been demonstrated to be effective at modulating the patient’s symptoms and behaviors, only once during the patient’s hospital stay, despite recommendations from telehealth psychiatric providers to administer said medications as needed, despite multiple documented instances of the patient engaging in violent and aggressive behaviors requiring physical restraints or other interventions by staff. Failure to provide necessary and appropriate interventions in response to violent behaviors related to the patient’s paranoid delusions and psychosis, and as a preventive measure to reduce the risk of violence, resulted in missed opportunities to alleviate acute psychiatric symptoms and modulate aggressive behaviors, the latter of which affected the patient’s ability to transfer to an appropriate inpatient psychiatric facility. Findings include: 1. Review of the policy titled “Patient Rights & Responsibility,” last updated 9/26/2024, revealed in part: a. “You have the right: To care, treatment, and services within [the hospital’s] capability ... and applicable law and regulation. To provide safe, effective, considerate, and respectful care regardless of ... mental disability ... expression...” b. “...You have the right: To an assurance of reasonable safety and security within [the hospital]...” 2. Review of the policy titled “Restraints and Seclusion,” approved 4/28/26, revealed in part: a. “[The hospital] is committed to preventing, reducing, and eliminating the use of restraint and seclusion except in emergencies when there is an imminent risk of the individual harming himself/herself or others and to assume the immediate physical safety of the patient, staff, or others ...” b.. “Restraint or seclusion will only be used when the least restrictive interventions are ineffective. Restraint/seclusion therapy shall be discontinued as soon as possible based on the individual’s patient assessment that determines there is no longer an imminent risk of injury to the patient or others. Regardless of the expiration of the order.” c. “The use of the drug/medication to treat a specific patient’s clinical condition is based on the patient’s symptoms, overall clinical situation, and licensed providers’ knowledge of the patient’s expected and actual response to the medication.” d. “The component of “standard treatment or dosage” for a drug/medication is the expectation that the standard use of a drug/medication to treat the patient’s condition enables the patient to function in the world more effectively or appropriately around them, then would be possible without the use of the drug/medications, is to reduce the patient’s ability to interact with the world effectively or appropriately around the patient, then the drug/medication is NOT being used as standard treatment or dosage for the patient’s condition. e. “Drugs/Medications, such as the following, are NOT considered restraints when used to meet the patient’s assessed needs, with careful monitoring to minimize adverse effects: Therapeutic doses of psychotropic medication for patients who are suffering from serious mental illness are used to improve their level of functioning so they can more actively participate in their treatment. Therapeutic doses of anti-anxiety medication to calm the patient who is anxious ...” 3. Review of Patient #4 (P4)’s 12/15/2025 medical record revealed the following. a. On 12/15/2025 at 3:26 PM, P4 presented to the ED, accompanied by Sheriff’s deputies under a court order filed by their outpatient psychiatric provider. The court report noted deterioration in the patient’s psychiatric condition, including paranoid delusions and severe agitation. The patient’s medical history included bipolar disorder with prior inpatient psychiatric hospitalizations for psychosis, aggression, threatening behavior, and agitation. The outpatient psychiatric provider documented that P4 was evaluated on 12/10/2025 during a crisis appointment and continued to deteriorate, expressing paranoid delusions of being poisoned. b. Upon ED presentation, staff documented the patient appeared agitated and restless, required frequent redirection, and verbalized homicidal ideations toward a family member. c. On 12/15/2025 at 3:30 PM, Staff A (ED Provider) evaluated P4 and ordered a telehealth psychiatric consultation and diagnostic laboratory testing, which were grossly unremarkable (not clinically significant), revealed negative results for blood alcohol (EtOH) and illicit substances, and revealed a subtherapeutic level of serum lithium, indicating possible nonadherence to the patient’s prescribed lithium therapy. d. On 12/15/2025 at 3:57 PM, Staff B (ED RN) completed triage documentation, identifying the patient as resistant to care and noting the patient displayed inappropriate sexual behaviors, verbalized homicidal ideations (HI) toward their father, and required assistance from multiple staff members to change into Behavioral Health (BH) safety attire. Staff completed a violence risk assessment tool and documented a score of 7, indicating a very high risk for violence. Staff B collected vital sign (VS) measurements, which were within normal limits (wnl), with the exception of an elevated systolic blood pressure (SBP) of 163/85 mmHg. e. Staff A (ED Provider) documented the following diagnoses: psychosis, bipolar disorder, and medication noncompliance. Staff A noted the patient presented with an unstable psychiatric condition requiring transfer to an inpatient psychiatric facility. f. ED medication reconciliation notes listed the patient’s current medications as Olanzapine 5 mg PO (by mouth) HS (at bedtime), Cogentin 1 mg PO HS, and Lithium 300 mg PO HS. However, court documentation and the outpatient psychiatric provider’s report listed the current prescribed medications as Olanzapine 5 mg PO HS, Caplyta 42 mg PO HS, and Lithium ER 1200 mg PO HS. This discrepancy was not reconciled by staff in the patient’s medical record. g. On 12/15/2025 at 4:25 PM, Staff K (Telehealth Provider) completed a psychiatric evaluation and identified the patient as uncooperative, yelling throughout the assessment, refusing to answer questions, attempting to move the iPad out of view, and grabbing the arm of a staff member. Staff K reviewed the patient’s psychiatric history, recent medication adjustments, and documented risk factors, which included a history of aggression, threats, and violent behavior. Staff K listed current medications as Olanzapine 5 mg PO HS, Caplyta 42 mg PO HS, and Lithium ER 1200 mg PO HS. Recommendations for the current state of psychosis in the ED include inpatient psychiatric hospitalization. PRN (as needed) medication recommendations included the following: Olanzapine 5 mg PO/IM every 6 hours as needed to target delusions, paranoia; Lorazepam 2 mg PO/IM every 6 hours as needed for agitation to calm the patient; and a recommendation to consider long-acting injections (LAI) for longer-term management. h. On 12/15/2025 at 6:08 PM, P4 declined to participate in the mental health evaluation, but demanded to speak to the psychiatric telehealth provider. When this request could not be granted, P4 became agitated and slammed their elbow against the glass separating the unit from the 1-1 sitter monitoring the BH. P4 then took chocolate milk and poured it through the slats of the safety glass onto the computers and desk, and let the rest run down the wall inside the unit. Staff S (Patient Care Technician (PCT)) entered the unit to clean up the spill, and P4 approached Staff S and attempted to strike them. A public safety officer (PSO) entered the unit and verbally de-escalated the situation before P4 could attempt to strike Staff S again. i. On 12/15/2025 at 9:15 PM, Staff Q (RN/ED Nurse) documented P4 became verbally aggressive with the one-to-one (1:1) sitter. Staff noted P4 verbalized delusions about poison coming from the vent in the wall. Staff made multiple attempts at redirection, which they noted were unsuccessful. Staff A (ED Provider) wrote a one-time order for Olanzapine 5 mg PO and provided the medication, but P4 spit the tablet out. Staff A then ordered an intramuscular (IM) dose of the medication, but P4 willingly took it orally instead at 9:37 PM. j. On 12/16/2025 at 11:00 AM, P4 became agitated and requested staff contact the county attorney to contest their court order. At 11:58 AM, P4 approached the 1:1 sitter and threatened to assault staff. k. On 12/16/2025 at 12:31 PM, P4 refused Lithium, stating the formulation was incorrect because P4 was normally prescribed an extended-release formulation. Nursing staff notified the provider and pharmacy, and at 12:42 PM, the Lithium order was changed to the extended-release tablet the patient had been prescribed at home. At 1:22 PM, P4 received their first dose of Lithium since ED arrival (approximately 22 hours after presentation). l. On 12/16/2025 between 12:34 PM and 1:30 PM, P4 verbalized delusions of being raped and poisoned, expressed HI directed about their family, threatened to expose themself, and made increasingly hostile statements toward staff. m. On 12/16/2025 at 1:04 PM, Staff G (RN / ED Nurse) completed a nurse-to-nurse report to Hospital B, where P4 had been accepted. n. On 12/16/2025 at 1:30 PM, Staff G (RN / ED Nurse), Staff J (PCT), and Staff L (Social Worker) entered the locked Behavioral Health Unit (BHU) to discuss P4’s transfer to Hospital B for inpatient treatment. Upon discussion, P4 became highly agitated, repeatedly demanding to speak with the county attorney to contest the court order. P4 verbally lashed out, stated the psychiatric providers were “all schizophrenic,” disclosed past sexual abuse by the patient’s father, and called Staff L “stupid” a number of times. P4’s agitation escalated physically. P4 threw their food tray at Staff J and punched Staff J in the face. Staff J initiated AVADE (Awareness, Vigilance, Avoidance, Defense, and Escape)-style contact with the patient. P4 was momentarily stabilized, and staff gradually backed away using a bladed stance. P4 then exposed themself by pulling down their pants. Staff verbally de-escalated P4 and safely exited the locked unit without further physical contact. No new physician orders were obtained following the incident. o. On 12/16/2025 at 1:44 PM, P4 demanded Duodote (an antidote for nerve agent poisoning) and threatened further violence, stating there would be a “boxing match” if the medication was unavailable. p. On 12/16/2025 at 2:39 PM, the accepting psychiatric facility declined transfer of the patient upon receiving notice of the patient’s assault of a staff member in a nurse-to-nurse report. q. On 12/16/2025 at 3:45 PM, P4 ran into the locked unit door with sufficient force to open it and began physically assaulting the assigned 1:1 nurse. A Combative Patient Alert was initiated, to which multiple staff members responded. P4 continued to kick and punch staff and was placed in a restraint chair following a take-down procedure. Staff obtained an order for a physical restraint chair; however, no medications changes were made following the incident. r. On 12/16/2025 at 5:24 PM, Staff D (ED Provider) ordered Olanzapine 10mg IM; however, at 5:25 PM, nursing documentation indicated the medication was not administered due to a change in the patient’s condition. P4 remained in the restraint chair for approximately 2 hours and 15 minutes without administration of medications to help target the symptoms of Psychosis. s. On 12/16/2025 at 5:45 PM, the ED provider documented that, due to repeated physical assaults on staff and safety concerns, transfer to the psychiatric facility was no longer appropriate. Criminal charges were filed, and the plan included discharge the patient to jail. t. On 12/16/2025 at 6:12 PM, staff discharged the patient to police custody, and the patient was transported to jail, rather than transferred to an inpatient psychiatric facility. 4. During an interview on 2/17/26 at 11:00 AM, Staff Q (ED RN) reported P4 arrived to the ED via police transport. The patient was brought through the back entrance to the locked ED unit for triage. Staff Q indicated P4 was agitated, uncooperative, refused to change into BH scrubs, and made inappropriate sexual remarks, telling staff they could undress P4 if they wished. During a telehealth psychiatric evaluation, P4 refused to participate, pushed the stand of the tablet aside, and grabbed the RN’s arm. The RN told P4 not to touch staff inappropriately and exited the room. Staff Q reported using verbal de-escalation techniques, which included explaining observed behaviors, setting clear expectations, and redirecting the patient toward safer alternatives. Staff Q reported P4 declined to allow staff to perform and EKG, despite this assessment being a requirement for the patient to be transferred to an inpatient facility, and that refusing the test could delay care. P4 still refused to allow the EKG. The RN reported later in the evening, around 9:30, P4 became verbally abusive to the 1:1 sitter through the glass and was having delusions of poison gas coming out of the vents in the walls. Multiple attempts to redirect were unsuccessful. Staff A (ED Provider) ordered Olanzapine 5 mg orally. P4 took the medication and put it in their mouth, but then spit it out. Staff A then ordered the Olanzapine IM, and P4 then accepted the oral medication. 5. During an interview on 2/17/26 at 10:15 AM, Staff A (ED Provider) reported the following information: Medication selection depends on the patient’s symptom profile. Olanzapine, also known as Zyprexa, is commonly used to target psychosis, delusions, hallucinations, paranoia, and agitation. Lorazepam, known as Ativan, may be considered for severe agitation or anxiety-driven escalation. These medications are commonly used in acute psychiatric crises and are generally well-tolerated when appropriately dosed and monitored. IM medication would generally be considered when there is an immediate or urgent risk to the patient or others, escalating agitation that does not respond to verbal interventions, or continued refusal of oral medication after repeated attempts. Efforts are typically made first to encourage voluntary oral medication, monitor behavior closely, and attempt multiple engagement strategies before proceeding with IM administration. Staff A reported that Olanzapine was ordered for P4 as a one-time dose in the evening of 12/15/25, which was effective, and P4 was calm and able to rest. 6. During an interview on 2/18/16 at 4:00 PM, Staff K (ARNP / Contracted Telehealth Psychiatric Provider) reported the following information: P4 was yelling throughout the attempted evaluation. Even when a patient is not cooperative, Staff K reported that they are still required to attempt to ask all assessment questions. It was evident that P4 was highly agitated, paranoid, and exhibiting signs consistent with psychosis. During the evaluation, P4 attempted to grab the iPad. P4 would not look at the screen, covered their face with their hands, and refused to engage. Staff K noted P4’s agitation escalated during the session. When visible, P4’s eye contact and facial expression suggested paranoia. Staff K reported making a recommendation for inpatient psychiatric care and for the following medications: Olanzapine 5 mg, which P4 was already taking at home to target delusions, paranoia, and thought disorganization; and Ativan 2 mg to reduce agitation and help to calm the patient. Both could be administered orally if the patient was cooperative, or IM if necessary. These medications are commonly used in ED behavioral health settings, and while they can cause some mild degree of sedation, the patient had previously been prescribed olanzapine at home. At the recommended dosages, the medications would be considered standard and generally safe, assuming appropriate monitoring and dosing. They are generally well tolerated by patients and are not considered chemical restraints at the recommended doses. 7. During an interview on 2/19/26 at 8:45 AM, Staff O (ED Provider) reported the following information: Staff O recalled receiving a report from a colleague that the patient had been aggressive earlier. Staff O did not recall significant issues with P4 during the overnight shift. Staff O reported staff monitored P4 closely through camera surveillance and had no incidents during the overnight shift. Staff O reported that, typically, when dealing with a dangerous patient and staff safety, it would typically be reasonable to consider PRN medications, especially if the patient is noted to be escalating. Staff O reported some of the medications used for mental health patients have a sedation risk. If a patient requires significant sedation, they may need to be transferred to a medical bed for monitoring, which would remove the added security of the locked BHU and change the risk profile for staff and other patients. Therefore, while PRN medication would be worth considering, the decision would depend on the real-time behavioral presentation, safety assessment, available resources, and the medication’s specific sedation risk. Staff O reported many medications, particularly at low oral doses, are generally quite safe, but each decision must be individualized to the circumstances at hand. 8. During an interview on 2/18/26 at 8:00 AM, Staff G (ED RN) reported staff delayed informing P4 of the transfer to Hospital B inpatient psychiatric unit until transport was on the way, anticipating P4 would be upset and not want to go. On 12/16/25 at 1:30 PM, Staff G, accompanied by Staff J (PCT) and Staff L (Social Worker), entered the locked BH unit of the ED to inform P4 of the transfer. P4 became agitated, threw their meal tray, and struck Staff J in the head, and Staff J raised their arms to block it. Staff J secured P4 against the wall to control the situation while Staff G and Staff L stepped back to create space. P4 continued yelling and pulled down their pants, exposing themself. A Security Officer then entered the unit. Several individuals were nearby, including paramedics and both ED Providers, and all staff exited the unit safely. After the incident, Staff G contacted Hospital B for an update and learned they could no longer accept P4 due to the assault on staff. Although P4 had been somewhat redirectable earlier, frustration appeared to build, and notification of the transfer precipitated the incident. P4 began to calm after staff left the unit. P4 did not receive any medications following the assault on the staff member, and the Provider did not write any additional or new orders. 9. During an interview on 2/18/26 at 9:30 AM, Staff L (ED Social Worker) reported the following information: When P4 was informed on 12/16/25 at 1:30 PM that transport was on the way, P4 became upset and stated they did not need inpatient treatment. Staff L explained the assessment process and that, based on Psychiatry recommendations and the outpatient provider’s report of deterioration, inpatient placement was appropriate. P4 yelled that they had never had an evaluation, claimed the outpatient provider was “schizophrenic,” and called Staff L derogatory names. P4 became more agitated and threw food at the Staff G (ED RN) and the Staff J (PCT) in the room. P4 then lunged at the Staff J (PCT) with a closed fist and struck them at least twice. After the ED Nurse updated Hospital B about the assaultive behavior toward staff, they rescinded their acceptance for inpatient transfer. No PRN medications were given. 10. During an interview on 2/18/26 at 1:00 PM, Staff B (RN) recalled being assigned to provide 1:1 observation for P4 at approximately 3:00 PM. At that time, P4 was pacing and appeared agitated. Staff B was informed that P4 had been scheduled for transfer for inpatient psychiatric care; however, the receiving hospital declined the transfer after P4 assaulted a staff member earlier that day. Staff B observed P4 pacing frequently and repeatedly approaching the window. P4 displayed flight of ideas, disorganized and nonsensical speech, and impaired orientation. P4 accused staff, including Staff B, of being on methamphetamine, referenced poison coming through the vents, and made multiple unusual accusations. Staff B attempted therapeutic interaction and offered to order lunch as a de-escalation effort. After placing the order, P4 approached the window and whispered, “I’m going to thump you.” At approximately 3:45 PM, P4 quickly approached the window again and made threats about killing their father and referenced killing a cat. The patient’s statements were incoherent and illogical. Without warning, P4-wearing only their underwear, ran toward the locked door and forced it open with full body weight. P4 ran directly toward Staff B, punched Staff B in the head, and knocked off Staff B’s glasses. Staff B yelled for help, and staff responded immediately. Staff assisted in performing a controlled takedown. Once P4 was on the floor and under control, staff assisted P4 up, placed the patient in a restraint chair, and returned the patient to the locked unit. Based on observations, Staff B believed P4 displayed symptoms consistent with acute psychosis, including disorganized thought processes, delusions, and escalating agitation. During the approximately 45 minutes of observation, P4 was unable to engage in coherent conversation, and verbal de-escalation attempts were ineffective. Staff B stated that, from a clinical standpoint, P4 appeared to be a candidate for antipsychotic medication to reduce agitation and psychotic symptoms. Staff B reported no medications were given to P4 following the incident. 11. During an interview on 2/19/26 at 11:00 AM, Staff D (ED Provider) reported that the ED Providers can view the locked Behavioral Health (BH) unit through cameras at the ED front desk and receive updates from 1:1 sitters and nursing staff. Staff would communicate any behavioral changes, escalation, or safety concerns directly to them. Staff D Provider reported, when the telehealth psychiatric service makes treatment or medication recommendations, they are considered, but not automatically implemented. Staff D reported Telehealth Psychiatry providers do not have prescribing authority in the ED, and the attending physician retains responsibility for all medical decisions. Staff D reported Providers may decline recommendations if they disagree clinically and are generally reluctant to initiate new routine or scheduled psychiatric medications in the ED, particularly those that require time to reach therapeutic effect or when patients are already taking multiple psychotropic medications. Staff G reported P4 was in the locked BH unit awaiting transfer for inpatient psychiatric care. Staff G reported familiarity with the patient from prior encounters and described the patient as having extremely unpredictable and explosive violent behavior. Staff G confirmed the patient assaulted a staff member after being informed of a transfer to another hospital, and reported not ordering medication following the first assault because the patient de-escalated and became calm. Staff G also stated sedation prior to transfer can increase the risk of oversedation during transport, and the plan at that time was to facilitate transfer. After the receiving hospital declined admission due to the assault, Staff G reported the patient again appeared calm enough that medication was not clinically indicated prior to the second incident. Following the second assault at approximately 3:45 PM, the patient was placed in restraints. Staff G reported ordering 10 mg IM olanzapine at 5:24 PM, but the medication was not administered because the patient was being transferred to jail. Staff G reported not wanting to sedate the patient prior to transfer due to the potential risk and associated responsibility if complications occurred. When asked whether the patient’s mental health was adequately treated in the ED, Staff G reported the patient’s behavior represented extreme violence rather than a psychiatric condition. Staff G stated the patient’s shifts from calm to violent behavior occurred without warning and that medication would likely not have prevented the assault, though it may have delayed it. Staff G reported they believed transfer to jail was appropriate, given the level of violence P4 had exhibited. Staff G reported not conducting a direct face-to-face evaluation of the patient in the locked unit due to safety concerns and the patient’s repeated violent behavior toward staff. Staff G reported that typically, if a patient needs to be placed in physical restraints, medication would also be ordered. 12. During an interview on 2/17/26 at 12:15 PM, Staff N (Inpatient BHU Psychiatrist) reported It is important to distinguish between standard symptom-management medications and chemical restraints. Medications administered within accepted therapeutic dosing ranges for symptom control are not considered chemical restraints. For example, lorazepam (Ativan) given at a typical adult dose of 1-2 mg for anxiety or agitation is considered appropriate symptom management. Medications are frequently offered within standard dosing guidelines to manage symptoms safely. Patients are involved in treatment decisions whenever possible. If a patient refuses prescribed medication and there is no emergency, staff cannot force administration unless the patient is court-ordered and the court documentation authorizes treatment over objection. However, in an emergency situation where the patient could harm themself or others, IM medication can be given. Physical restraints are used only when there is an immediate safety risk to the patient or others, and less restrictive interventions have failed. The objective is always to use the least restrictive intervention necessary and to discontinue restraints as soon as it is clinically safe to do so. The cumulative effect of these deficient practices, including failures to administer antipsychotic medications deemed appropriate by P4’s psychiatric provider, resulted in an increased risk of harm to the patient, hospital staff, and others.”

“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: 47335 Based on document review and staff interviews, the Acute Care Hospital (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 21 emergency patients reviewed (Patient #10, #20, and #21) with an appropriate medical screening exam (MSE) after presenting to the ED requesting emergency medical care. Failure to provide an appropriate MSE and stabilizing treatment places patients at risk for deterioration in their medical condition up to and including death. The ACH’s administrative staff identified an average of 2927 patients per month who presented to the dedicated emergency department and requested emergency medical care. Findings include: 1. Review of Hospital policy number IPC005, “Transfer Emergency Medical Treatment and Labor Act (EMTALA) Policy ...,” Last Reviewed 10/23, revealed in part: a. “ ...This policy applies to anyone who requests or requires care related to an emergency medical condition who presents on the Medical Center property ...” b. “ ...It is the policy of [ACH] to provide an appropriate medical screening examination to individuals presenting to the dedicated Emergency Department requesting examination or treatment of a medical condition, and to individuals presenting on hospital property requesting examination or treatment of an emergency medical condition. If an emergency medical condition exists, [ACH] will stabilize and treat the emergency condition or transfer the individual appropriately ...” c. “ ...Emergency Medical Condition --- acute symptoms of sufficient severity (including severe pain, psychiatric cdisturbances and/or symptoms of substance abuse) that without immediate medical attention could reasonably be expected to result in: placing health in serious jeopardy; serious impairment to body function; and/or serious dysfunction of any bodily organ or part. If an individual presents to the hospital expressing suicidal or homicidal thoughts or gestures, or if determined dangerous to self or others, they are considered to have an emergency medical condition ...” d. “Medical Screening Examination: All individuals who come to [ACH’s] Emergency Department for examination or treatment ... requesting examination or treatment of an emergency medical condition, shall receive an appropriate medical screening examination. The scope of the medical screening exam will provide all necessary testing and on-call services within the capability of the hospital to reach a diagnosis that excludes the presence of an emergency medical condition ... If the individual has an emergency medical condition, further examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition ...” e. “Psychiatric patients are considered stable when they are protected and prevented from injury or harming self/others (i.e., initiation of 1:1 monitoring, seclusion, physical or chemical restraints, etc.), along with stabilizing of a medical condition as needed ...” f. “Personnel qualified to perform an emergency medical exam include ... Practitioners - Any physician medical staff member or physician assistant or advanced practice nurse with appropriate privileges providing emergency services is authorized to perform medical screening examinations in any location on the Medical Center premises. Registered Nurses - Any registered nurse employed by [ACH] who has completed the competency-based orientation checklist for the Emergency Department is authorized to perform a nursing assessment which will form the basis for a medical screening examination. Upon completion of the nursing assessment, the registered nurse will describe the results to the appropriate physician who will determine whether the individual is in an emergency medical condition and will give orders for any further treatment. Treatment may include testing to exclude an emergency medical condition and use of on-call physicians as needed for diagnosis. g. “Refusal of Examination/Treatment: If the individual, or a person acting on the individual’s behalf, refuses further examination and treatment, the individual must be informed of the benefits of the examination and treatment and the risks of refusal of such examination and treatment. If consent to further examination and/or treatment is still withheld, an Against Medical Advice (AMA) form must be completed and placed in the medical record to document the individual’s written informed refusal of examination and treatment. Documentation should include a description of the examination and/or treatment refused by or on behalf of the individual, and the fact that the individual has been informed of the benefits of the examination/treatment and risks of refusing examination, treatment or both ...” 2. Review of the policy “Emergency Department: Environmental Safety and Security ...,” Last Reviewed 2/22, revealed in part: a. “Purpose: The Emergency Department is committed to providing a safe environment for all staff, patients, and visitors ...” b. “ ...Behavioral Health area may be used per physician and staff discretion for patients who are belligerent, psychotic, exhibiting behavioral problems, suicidal, homicidal ...” 3. Review of Patient #10’s medical record from the ACH revealed: a. On 1/3/24 at 9:46 AM, Patient #10 presented to the ED by private vehicle for a chief complaint of an alcohol problem. b. On 1/3/24 at 10:03 AM, an alcohol screening completed and revealed that Patient #10 drank ten or more units of alcohol daily or almost daily. c. On 1/3/24 at 10:21 AM, Patient #10’s neurological assessment completed by RN E revealed Patient #10 had tremors to both arms and legs. d. On 1/3/24 at 10:26 AM, Patient #10 had a blood alcohol level of 163 (high; normal level is less than ten). Physician A noted Patient #10 had a drink since their report, of a day and a half ago. Physician A noted the hospital Social Worker (SW) would meet with Patient #10 to assist in looking for a “detox” facility for Patient #10’s request. e. On 1/3/24 at 11:38 AM, Social Worker (SW) L met with Patient #10 in the ED to discuss options of support for withdrawal management or treatment of acute alcohol intoxication. Patient #10 had returned from deployment overseas four months prior. Patient #10 had requested the hospital proceed in an attempt to secure a “detox” inpatient treatment option for them, and a referral was placed to a rehab facility. f. On 1/3/24 at 2:22 PM, Physician A ordered Chlordiazepoxide (medication used to treat acute alcohol withdrawal) cap 25 milligrams (mg) for Patient #10. g. On 1/3/24 at 2:25 PM, Patient #10 received Chlordiazepoxide cap 25 mg by mouth. h. On 1/3/24 at 3:36 PM, Patient #10 left without their discharge paperwork, or having their discharge vital signs reassessed. Patient #10’s diagnosed with chronic alcohol abuse. 4. The evidence in Patient #10’s medical record showed the hospital failed to provide an appropriate MSE and stabilizing treatment as required by hospital policy number IPC005. The ED physician failed to reassess Patient #10 prior to discharge to determine if Patient #10 was no longer clinically intoxicated and/or experiencing signs and symptoms of alcohol withdrawal. ED staff failed to address why Patient #10 wanted to leave the hospital or determine if Patient #10 had the capacity to make an informed decision about leaving. Hospital staff failed to address the outcome of the referral sent to the inpatient treatment facility for Patient #10. 5. During an interview on 1/24/24 at 9:15 AM, RN E reported Patient #10 had been drinking heavily. Patient #10 had been seen a day or two before at another ED, but was sent home due to not being ready for “detox.” Patient #10 received an order for medication, but didn’t pick it up. RN E recalled Patient #10 had tremors. 6. During an interview on 1/24/24 at 10:10 AM, RN C recalled hospital staff trying to find placement for Patient #10 at a rehab center, but Patient #10 decided not to go due to “money issues.” RN C recalled Patient #10 left the ED after talking with the SW. RN C recalled Patient #10 demonstrated symptoms of sweating, anxiety, and overall not feeling good. 7. During an interview on 1/24/24 at 10:40 AM, Physician A recalled Patient #10 being an alcohol abuser who left without getting placed in rehab. Physician A reported the ED SW was working on placement for Patient #10, was unaware if the SW found placement for Patient #10 prior to their discharge from the ED, and verbalized inpatient rehab placement can take days to find. Physician A recalled Patient #10 reported not being intoxicated, but Patient #10’s blood alcohol level didn’t support Patient #10’s report. Physician A reported Patient #10 was “stable”, had “stable” vital signs, and their potassium level was “stable”, but denied seeing Patient #10 prior to their discharge from the ED. Physician A also reported Patient #10 left the ED prior to receiving their discharge instructions or having another full set of vital signs completed. 8. During an interview on 1/24/24 at 2:45 PM, SW L recalled sending a referral to a rehab facility for Patient #10. SW L reported they secured a bed for Patient #10 at a rehab facility, but Patient #10 left the ED. SW L reported Patient #10 had a blood alcohol level of 163, and recalled Patient #10 as being intoxicated, but able to have a conversation. 9. Review of Patient #21’s ambulance report from the ACH revealed: a. On 11/14/23 at 10:36 PM, emergency medical services (EMS) arrived on scene with Patient #21. Police reported to EMS, Patient #21 had an altercation with multiple people, and got struck in the head multiple times by a golf club. EMS noted Patient #21’s had multiple assaults toward random public entities, and innocent bystanders. Patient #21 demonstrated uncooperative and combative behavior, and signs of extreme hostility toward EMS and law enforcement. Patient #21 sustained injuries to the left side of the head, with two lacerations, and swelling and contusions around the two lacerations. Patient #21 appeared to be in some form of hostile psychosis. Patient #21 demonstrated intermittent cooperativeness, along with unpredictable hostility and aggressive behaviors. 10. Review of Patient #21’s medical record from the ACH revealed: a. On 11/14/23 at 10:38 PM, Patient #21 presented to the ED by law enforcement for multiple facial lacerations, and medical clearance prior to being taken to jail. Upon Patient #21’s arrival to the ED, physician P noted they were swearing and stated, “I refused medical care.” Physician P attempted assess Patient #21’s alertness and orientation when Patient #21 spit in Physician P’s mouth, and kick Physician P in the face. ED staff applied a pressure dressing to Patient #21’s facial lacerations and they were cleared to be taken to jail. Physician P asked ARNP (Advanced Registered Nurse Practitioner) I to assess and offer treatment to Patient #21. b. On 11/14/23 at 10:54 PM, ARNP I offered medical attention to Patient #21, and they refused. c. On 11/14/23 at 11:06 PM, RN O noted Patient #21 arrived at the ED by emergency medical services (EMS) with lacerations to their head. Patient #21 immediately reported they did not want to be at the ED, and refused care. Patient #21 allowed RN O to place a pressure dressing to their laceration. d. On 11/14/23 at 11:11 PM, the ED staff discharged Patient #21. 11. Review of law enforcement bodycam video of Patient #21’s ED visit at the ACH revealed: a. On 11/14/23 at 10:36 PM, Patient #21 arrived at the ED by law enforcement. As law enforcement took Patient #21 out of the police car and placed them in a wheelchair, Patient #21 made threatening statements toward the officer, swearing, and referring to the officer’s gun. b. On 11/14/23 at 10:37 PM, upon entering the ED Patient #21 stood up from the wheelchair and became confrontational with paramedics and law enforcement, swearing, and making life threatening statements several times. c. On 11/14/23 at 10:39 PM, Patient #21 transferred to an ED bed, remaining in police handcuffs with hands behind their back. Patient #21 stated “I’m refusing medical attention.” Physician P attempted to ask Patient #21 for the day, and Patient #21 verbalized they were not going to answer any questions and spit Physician P’s face. Physician P raised a fist at Patient #21, then turned to walk away, and Patient #21 kicked Physician P in the face. Physician P engaged in a physical altercation with Patient #21. Law enforcement, nursing staff, and paramedics were in the room, immediately responded, removed Physician P from Patient #21’s exam room, and physically restrained Patient #21 down on the exam bed at the head, shoulders, and legs. Patient #21 remained handcuffed with both hands behind their back. Someone is then heard saying take him to jail. ED staff is heard saying Patient #21 is medically clear to go with discussion about Patient #21 being medically cleared for discharge, then RN O verbalized Patient #21 was not medically cleared. d. On 11/14/23 at 10:40 PM, ED staff asked Patient #21 about letting staff clean them up, and putting sutures in the laceration. Patient #21 continued to talk and swear at ED staff. e. On 11/14/23 at 10:41 PM, Patient #21 is heard asking law enforcement and ED staff to stop, as they are assessing Patient #21’s injuries, and discussing treatment options. f. On 11/14/23 at 10:42 PM, ED staff again are heard offering medical care, and Patient #21 is heard stating “I refuse medical attention.” Then Patient #21 stated “if you want to put a towel on it, then fine, but I’m refusing medical attention.” ED staff offered to wrap the lacerations, and Patient #21 verbalized they did not want anyone touching it. ARNP I is then seen at the foot of Patient #21’s bed, just inside the exam room, and is heard introducing self to Patient #21, stating “sir, my name is [ARNP I], I am the nurse practitioner on, do you want medical treatment?” Patient #21 stated “no, I do not.” ARNP I stated “okay,” walked away from Patient #21’s exam room with Physician P, and stated “he is refusing medical treatment.” g. On 11/14/23 at 10:43 PM, RN O told Patient #21 they had to help Patient #21 a little bit, and Patient #21 said, “no, I’m good, bud.” h. On 11/14/23 at 10:45 PM, Patient #21 allowed ED staff to assess the head lacerations. Patient #21 started talking to staff, asking if “we’re good?” “You good, [random name]?” ED staff asked again about cleaning Patient #21 up, and they again refuse, but are heard asking “can you help me?” ED staff continued to assess, clean, and then bandaged Patient #21’s head and facial lacerations. i. On 11/14/23 at 10:51 PM, RN O applied a pressure dressing to Patient #21’s head. j. On 11/14/23 at 10:53 PM, law enforcement placed Patient #21 in the back of their patrol car, and Patient #21 continued to be verbally aggressive, making verbal threats. 12. During an interview on 1/30/24 at 8:45 AM, Paramedic N recalled Patient #21 being extremely agitated and aggressive, and demonstrated impaired judgment. Paramedic N reported ED staff didn’t follow AMA policy with Patient #21, and Patient #21 should not have been allowed to leave AMA. 13. During an interview on 1/30/24 at 11:00 AM, RN O reported a potential for something very bad to happen. RN O didn’t recall explaining the benefits of an examination and/or treatment, or the risks of refusing examination, treatment, or both. 14. During an interview on 1/30/24 at 11:00 AM, Physician P acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21. Physician P reported an interaction of 45 seconds with Patient #21, and after Patient #21 assaulted Physician P, they asked ARNP I to try and assess Patient #21. Physician P reported Patient #21 adamantly refused care multiple times, and explained Patient #21 had a Glasgow Coma Scale of 15 (13 to 15 means minor brain injury), spoke in full sentences, and felt Patient #21 was competent to make medical decisions and refuse medical treatment. 15. During an interview on 1/30/24 at 12:30 PM, ARNP I recalled Patient #21 being alert, aggressive, and screaming at ED staff. ARNP I recalled when attempting to assess Patient #21, they refused, and reported Patient #21 was able to sit up, look ARNP I in the face, and when asked if they wanted medical treatment, Patient #21 said no. ARNP I reported Patient #21 was medically competent to make medical decisions, but acknowledged ARNP I didn’t do an assessment on Patient #21, and didn’t know what Physician P did prior to ARNP I’s attempt to assess Patient #21. ARNP I acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21. 16. During an interview on 1/30/24 at 2:30 PM, RN G acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21. 17. ED staff failed to follow hospital policy number IPC005 for individuals expressing homicidal thoughts or gestures, or determined to be dangerous to others, should be considered to have an emergency medical condition (EMC). The hospital policy also stated psychiatric patients are considered stable when they are protected and prevented from injuring or harming self or others. The hospital staff failed to complete an appropriate MSE to assure Patient #21 didn’t have any head injuries other than the head lacerations. No laboratory testing or head imaging were obtained. The ED staff failed inform Patient #21 of the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. Patient #21 expressed violent thoughts and gestures toward hospital staff and law enforcement while in the ED from arrival to departure, but Patient #21 was allowed to leave AMA. 18. Review of Patient #20’s medical record from the ACH revealed: a. On 11/7/23 at 4:49 PM, Patient #20 presented to the ED by ambulance with law enforcement with a chief complaint of being physically and sexually assaulted. Patient #20 alleged being hit in the head numerous times. Upon Patient #20’s arrival to the ED, ARNP I noted Patient #20 had a one-centimeter (cm) laceration to the scalp. Patient #20 had bleeding coming from the right ear, with a perforated eardrum, and scratches down the right side of the face. ARNP I noted Patient #21 rated her pain as a 10 out of 10 on the pain scale (tool used to help assess a patient’s pain; 0 being no pain, and 10 being the worst possible pain) to the right side of the head and ear. ARNP I noted they cleansed and irrigated Patient #20’s wounds, applied one staple to the one cm head laceration, and covered it with bacitracin (topical antibiotic ointment) and a dressing. ARNP I notified the sexual assault response team (SART), and diagnosed Patient #20 with a laceration of the scalp. b. On 11/7/23 at 5:51 PM, Patient #20 became verbally aggressive and upset with RN H’s questions about their injuries and reason for their ED visit. Patient #20 felt RN H was putting words in Patient #20’s mouth, and didn’t believed Patient #20. ED staff informed Patient #20 they notified the SART, and were awaiting their arrival. c. On 11/7/23 at 5:56 PM, Patient #20 left against medical advice (AMA). d. On 11/7/23 at 6:18 PM, Patient #20 returned to the ED accompanied by law enforcement for a chief complaint of seizures (a sudden, uncontrolled burst of electrical activity in the brain). Patient #20 held their breath until they turned purple in color and attempted to choke them self with the handcuffs. Patient #20 pulled out the staple from the scalp laceration which was placed approximately an hour prior. Patient #20 again reported pain as 10 out of 10 to the right ear, and right scalp laceration. ARNP I applied two staples to the laceration. e. On 11/7/23 at 6:50 PM, Patient #20 discharged. Law enforcement came to transport Patient #20, and Patient #20 threw them self on the floor. Patient #20 attempted to take the new staples from the scalp laceration, and started hitting their head on the floor. ED staff lifted Patient #20 in handcuffs to a wheelchair, they were taken to the ambulance garage, and placed in the police car. f. The hospital staff failed to provide any further assessment or treatment for Patient #20’s complaints of pain. The hospital failed to complete an appropriate MSE to assure Patient #20 didn’t have further head injuries other than the head laceration and rupture tympanic membrane. No laboratory testing or head imaging were obtained. The hospital also failed to address Patient #20’s self-harm behaviors that could have resulted in further injuries, possible death of Patient #20. They also failed to obtain any imaging or testing to rule out the possibility of seizure activity. 19. During an interview on 1/24/24 at 8:30 AM, RN F recalled Patient #20 came into the ED twice on 11/7/23, once for an assault, and the second time by law enforcement for a possible seizure. RN F reported during Patient #20’s second ED visit, they were observed choking them self with handcuffs. 20. During an interview on 1/24/24 at 12:30 PM, ARNP I reported Patient #20 is seen frequently in the ED for alcohol abuse, drug abuse, and aggressive behavior. ARNP I recalled Patient #20 being hysterical, screaming, flailing around, being aggressive, and not letting anyone touch them during their first ED visit on 11/7/23. ARNP I reported being informed Patient #20 wanted leave after they agreed to wait for the SART. ARNP I reported Patient #20 pulled out the staple that had just been put in, and said they were leaving. ARNP I reported Patient #20 left multiple times before after the SART had been contacted, so they explained to Patient #20 the team was on the way, and Patient #20 needed to stay, but Patient #20 still left AMA. ARNP I reported law enforcement brought Patient #20 back to the ED, and reported they thought Patient #20 had a seizure. ARNP I replaced the staples to Patient #20’s head laceration, and left the room. ARNP I then reported Patient #20 put them self on the floor, and began hitting their head on the floor. ARNP I didn’t recall where Patient #20 was discharged to, because ARNP I didn’t see Patient #20 before they left. 21. During an interview on 1/24/24 at 11:00 AM, RN G reported Patient #20 as someone that is seen in the ED frequently, had some serious medical issues, and serious substance abuse issues. RN G reported Patient #20 can be very volatile toward ED staff and other patients in the ED waiting room. RN G recalled triaging Patient #20 on 11/7/23 during their first ED visit, and notified the SART. RN G reported Patient #20 trying to rip out the staple to the scalp and wanting to leave AMA. 22. During an interview on 1/24/24 at 11:00 AM, RN H recalled Patient #20 coming to the ED twice on 11/7/23. RN H reported when they attempted to assess Patient #20 and ask question, Patient #20 immediately got upset. RN H reported attempting to explain to Patient #20 the SART had been notified and were on their way, but Patient #20 said they were leaving. RN H reported Patient #20 did not sign an AMA form. RN H then recalled law enforcement brought Patient #20 back to the ED for a possible seizure. RN H reported the ED provider went into see Patient #20, said Patient #20 didn’t have a seizure, nothing changed from their previous ED visit, and Patient #20 could discharge. RN H recalled Patient #20 banging their head on the floor. RN H reported law enforcement was called back to the ED, Patient #20 was placed in handcuffs, discharged to law enforcement, and taken to jail. Please refer to C-2406 for additional information.”

“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: 47335 Based on document review and staff interviews, the Acute Care Hospital (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 21 emergency patients reviewed (Patient #10, #20, and #21) with an appropriate medical screening exam (MSE) after presenting to their ED requesting emergency medical care. Failure to provide an appropriate MSE places all patients at risk of an undetected emergency medical condition and potential deterioration of their medical condition. The ACH’s administrative staff identified an average of 2927 patients per month who presented to the dedicated emergency department and requested emergency medical care. Findings include: 1. Review of Patient #10’s medical record from the ACH revealed: a. On 1/3/24 at 9:46 AM, Patient #10 presented to the ED by private vehicle for a chief complaint of an alcohol problem. Patient #10 reported drinking an 18 pack of beer and one pint of fireball daily since August, and had their last drink the previous morning. b. On 1/3/24 at 10:00 AM, Patient #10’s pulse was 87 (normal range 60-100), respirations were 18 (normal range 12-16), blood pressure (BP) was 139/88 (normal range less than 120/80), and pulse oximetry (SPO2) was 98% (normal range is usually 95% or higher). c. On 1/3/24 at 10:03 AM, an alcohol screening revealed that Patient #10 drank ten or more units of alcohol daily or almost daily. d. On 1/3/24 at 10:09 AM, Physician A evaluation noted Patient #10 as alert, nontoxic-appearing, calm and cooperative, and skin was warm and dry. e. On 1/3/24 at 10:21 AM, Patient #10’s neurological assessment completed by RN E revealed they were alert and oriented to time, place, person, and situation. Patient #10 had clear speech and could follow commands. Patient #10 had tremors to both arms and legs. f. On 1/3/24 at 10:26 AM, Patient #10’s abnormal lab results were noted as a white blood count of 4 (low; normal range 4.5-11.0); hemoglobin (Hgb - protein in the blood that carries oxygen) of 12.9 (low; normal range 13.5-17.5); platelets (cell found in the blood to help stop bleeding) were 108000 (low; normal range 150-400); potassium (helps nerves function and muscles contract, helps the heartbeat stay regular) of 2.8 (low; normal range 3.5-5.1); AST (test used to check for liver damage) of 181 (high; normal range 8-34); Bilirubin of 1.4 (high; normal range 0.3-1.2) (Higher levels may indicate different types of liver or bile duct problems). A blood alcohol level of 163 (high; normal level is less than 10). Patient #10 reported drinking a day and a half ago. Physician A noted the hospital Social Worker (SW) would meet with Patient #10 to assist in looking for a “detox” facility. g. On 1/3/24 at 10:45 AM, Physician A ordered potassium chloride 40 Milliequivalents (mEq) by mouth for Patient #10. h. On 1/3/24 at 10:57 AM, RN E administered potassium chloride 40 mEq to Patient #10. i. On 1/3/24 at 11:38 AM, Social Worker (SW) L met with Patient #10 in the ED to discuss options of support for withdrawal management or treatment of acute alcohol intoxication. SW L questioned Patient #10 why they didn’t pick up the prescription for withdrawal management given to them two days ago at Hospital B, and Patient #10 reported they were not aware of the prescription at their pharmacy. Patient #10 returned from deployment overseas four months prior. Patient #10 requested the hospital proceed in an attempt to secure a “detox” inpatient treatment option for them, and a referral was placed to a rehab facility. j. On 1/3/24 at 12:54 PM, Patient #10’s BP was 137/88, and SPO2 was 96%. k. On 1/3/24 at 2:22 PM, Patient #10’s pulse was 105, BP was 147/96, and SPO2 was 97%. Physician A ordered Chlordiazepoxide (medication used to treat acute alcohol withdrawal) cap 25 mg for Patient #10. l. On 1/3/24 at 2:25 PM, Patient #10 received Chlordiazepoxide cap 25 mg by mouth. m. On 1/3/24 at 2:45 PM, Patient #10’s pulse was 107, BP was 142/89, and SPO2 was 96%. n. On 1/3/24 at 2:45 PM, lab obtained a repeat basic metabolic panel (BMP) (test use to check fluid balance, electrolytes, and kidney function) from Patient #10. o. On 1/3/24 at 3:13 PM, Patient #10’s BMP resulted with a potassium level of 3.2 (low). p. On 1/3/24 at 3:15 PM, Patient #10’s BP was 152/95, and SPO2 was 97%. q. On 1/3/24 at 3:36 PM, Patient #10 left without their discharge paperwork, or having their discharge vital signs reassessed. Patient #10’s diagnosed with chronic alcohol abuse. 2. During an interview on 1/24/24 at 9:15 AM, RN E recalled caring for Patient #10 for about an hour, then passed care over to another RN. RN E reported Patient #10 had just returned from deployment a few months prior, and had been drinking heavily. Patient #10 had been seen a day or two before at another ED, but due to Patient #10 not being ready for “detox,” they were sent home. RN E recalled Patient #10 received an order for medication, but didn’t pick it up. RN E recalled Patient #10 having tremors during their ED visit. 3. During an interview on 1/24/24 at 10:10 AM, RN C recalled hospital staff trying to find placement for Patient #10 at a rehab center, but Patient #10 decided not to go due to “money issues.” RN C recalled Patient #10 left the ED after talking with the SW. RN C reported encouraging Patient #10 to pick up the previously prescribed medication. RN C recalled Patient #10 demonstrated symptoms of sweating, anxiety, and overall not feeling good. 4. During an interview on 1/24/24 at 10:40 AM, Physician A recalled Patient #10 being an alcohol abuser who left without getting placed in rehab. Physician A reported Patient #10 had recently been evaluated at Hospital A, and given recommendations and a prescription for alcohol withdrawal, but didn’t follow the treatment plan or pick up the prescription provided to them. Physician A reported the ED SW worked on placement for Patient #10, but wasn’t aware if they found placement prior to discharging them from the ED, and verbalized inpatient rehab placement can take days to find. Physician A recalled Patient #10 reported not being intoxicated, but Patient #10’s blood alcohol level didn’t support their report. Physician A reported Patient #10 was “stable”, had “stable” vital signs, and their potassium level was “stable”, but denied seeing Patient #10 prior to their discharge from the ED. Physician A also reported Patient #10 left the ED prior to having another full set of vital signs completed. 5. During an interview on 1/24/24 at 2:45 PM, SW L recalled assessing Patient #10, and sending a referral to a rehab facility. SW L reported they secured a bed for Patient #10 at a rehab facility, but Patient #10 left the ED after talking with SW L. SW L reported Patient #10 had a blood alcohol level of 163, and described Patient #10 as being intoxicated, but able to have a conversation. SW L recalled Patient #10 reported drinking the morning before coming to the ED, almost 24 hours before coming in, but their blood alcohol level was still elevated. 6. Evidence from Patient #10’s medical record showed the hospital failed to provide an appropriate MSE and stabilizing treatment. The ED physician failed to reassess Patient #10 prior to discharge to determine if Patient #10 was no longer clinically intoxicated and/or experiencing signs and symptoms of alcohol withdrawal. ED staff failed to address why Patient #10 wanted to leave the hospital or determine if Patient #10 had the capacity to make an informed decision about leaving. Hospital staff failed to address the outcome of the referral sent to the inpatient treatment facility for Patient #10. 7. Review of Patient #10’s medical record from Hospital B revealed: a. On 1/3/24 at approximately 4:40 PM, Patient #10 presented to Hospital B’s ED. Documentation showed patient #10 reported feeling very shaky, tremulous, nauseous, and anxious. Vital signs were documented as temperature 98.3 F, pulse 110, respiration rate 18, BP 162/118, SpO2 97. Patient #10 tested positive for COVID-19. Patient #10’s white blood cell count increased to 4.2, Hgb increased to 13.1, platelet count increased to 118,000, potassium increased to 3.6, AST decreased to 152, Bilirubin increased to 1.9. b. On 1/3/24 at 6:29 PM, Patient #10 became more tremulous and hypervigilant. BP was 154/109. c. On 1/3/24 at 7:02 PM, Patient #10’s BP was 145/119. The ED provider ordered Valium (medication used to treat anxiety, seizures, muscle spasms, and twitches) IV for Patient #10. d. On 1/3/24 at 7:15 PM, ED staff noted Patient #10 received IV Valium. e. On 1/3/24 at 9:45 PM, Patient #10 was admitted to Intensive Care Unit for stabilizing treatment. 8. Review of Patient #21’s ambulance report from the ACH revealed: a. On 11/14/23 at 10:36 PM, emergency medical services (EMS) arrived on scene with Patient #21. Police reported to EMS, Patient #21 had an altercation with multiple people, and got struck in the head multiple times by a golf club. The EMS documented Patient #21 had multiple assaults toward random public entities, and innocent bystanders. EMS noted Patient #21 as uncooperative and combative, showing signs of extreme hostility toward EMS and law enforcement. Patient #21 sustained injuries to the left side of the head, with two lacerations, and swelling and contusions around the two lacerations. EMS noted Patient #21 appeared to be in some form of hostile psychosis. Law enforcement transport Patient #21 to the ED for further evaluation and care due to unsafe probability of Patient #21 toward EMS. It was unknown whether Patient #21 had taken any illicit drugs or alcohol. EMS documented Patient #21 demonstrated intermittent cooperativeness, along with unpredictable hostility and aggressive behaviors. 9. Review of Patient #21’s medical record from the ACH revealed: a. On 11/14/23 at 10:38 PM, Patient #21 presented to the ED by law enforcement for multiple facial lacerations, and medical clearance prior to being taken to jail. Upon Patient #21’s arrival to the ED, they were swearing, and stated, “I refused medical care.” Physician P attempted to assess Patient #21’s alertness and orientation, but Patient #21 spit at Physician P, and kick Physician P in the face. Physician P noted Patient #21 had a pressure dressing applied to their facial lacerations, and they were cleared to be taken to jail. Physician P asked ARNP (Advanced Registered Nurse Practitioner) I to assess and offer treatment to Patient #21. b. On 11/14/23 at 10:54 PM, ARNP I noted blood to Patient #21’s face. ARNP I offered medical attention to Patient #21, and Patient #21 refused. ARNP documented Patient #21 would be arrested, and leave by law enforcement for assaulting medical staff. c. On 11/14/23 at 11:06 PM, RN O documented Patient #21 arrived at the ED with a laceration to the top of the left side of their head. Patient #21 immediately stated “I don’t know why I’m here, I don’t want to be here,” and they did not want anyone to touch them. Patient #21 allowed RN O to place a pressure dressing to their laceration. d. On 11/14/23 at 11:11 PM, the ED staff discharged Patient #21 with law enforcement. 10. Review of law enforcement bodycam video of Patient #21’s ED visit at the ACH revealed: a. On 11/14/23 at 10:36 PM, Patient #21 arrived at the ED by law enforcement, taken out of the patrol car by law enforcement in the ambulance garage, and placed into a wheelchair. Patient #21’s face, and clothes were covered with blood. Patient #21 made threatening statements to law enforcement as they were assisted to a wheelchair. Patient #21 is heard swearing and talking about the officer’s gun. b. On 11/14/23 at 10:37 PM, upon entering the ED Patient #21 stood up from the wheelchair, became confrontational with paramedics and law enforcement swearing, and made life threatening statements several times before three officers got Patient #21 to sit back down in the wheelchair to be escorted into an ED exam room. c. On 11/14/23 at 10:39 PM, Patient #21 transferred from the wheelchair to an ED exam bed. Patient #21 remained in police handcuffs with hands behind their back. Physician P presented to Patient #21’s bedside, and asked “what happened to you?” Patient #21 stated “I’m refusing medical attention,” while swearing at ED staff. DO P then attempted to ask Patient #21 for the day, and Patient #21 verbalized they were not going to answer any questions and spit in Physician P’s face. Physician P raised a fist at Patient #21, then turned to walk away, and Patient #21 kicked Physician P in the face. Physician P engaged in a physical altercation with Patient #21. Law enforcement, nursing staff, and paramedics were in the room, immediately responded, removed Physician P from Patient #21’s exam room, and physically restrained Patient #21 down on the exam bed at the head, shoulders, and legs. Patient #21 remained handcuffed with both hands behind their back. Patient #21 continued talking, and swearing at ED staff and law enforcement. Someone is then heard saying take him to jail. ED staff is heard saying Patient #21 is medically clear to go, discussion continued about Patient #21 being medically cleared for discharge, then RN O verbalized Patient #21 was not medically cleared. d. On 11/14/23 at 10:40 PM, ED staff asked Patient #21 about letting them clean them up, and putting sutures in the laceration. Patient #21 continued to talk to ED staff, talking about them hitting him some more, and they might like it. e. On 11/14/23 at 10:41 PM, Patient #21 told RN O to let go of their face, as RN O applied pressure to Patient #21’s facial laceration. RN O explained to Patient #21, they were bleeding. ED staff were heard asking for medication for Patient #21, but told by another ED staff they didn’t think the provider would. ED staff were then heard asking about the lacerations to Patient #21’s face and head. Law enforcement reported a golf club being involved, and Patient #21 verbalized that is what they got hit with. Patient #21 then asked police and ED staff to stop, as they are assessing Patient #21’s injuries, and discussing treatment options. f. On 11/14/23 at 10:42 PM, ED staff again are heard offering medical care, and Patient #21 is heard stating “I refuse medical attention.” Then Patient #21 stated “if you want to put a towel on it, then fine, but I’m refusing medical attention.” ED staff offered to wrap the lacerations, and Patient #21 verbalized they did not want anyone touching it. ARNP I is then seen at the foot of Patient #21’s bed, just inside the exam room, and is heard introducing self to Patient #21, stating “sir, my name is [ARNP I], I am the nurse practitioner on, do you want medical treatment?” Patient #21 stated “no, I do not.” ARNP I stated “okay,” walked away from Patient #21’s exam room with Physician P, and stated “he is refusing medical treatment.” g. On 11/14/23 at 10:43 PM, RN O told Patient #21 they had to help Patient #21 a little bit, and Patient #21 said, “no, I ’ m good, bud.” h. On 11/14/23 at 10:45 PM, Patient #21 allowed ED staff to assess the head lacerations. Patient #21 started asking if “we’re good?” “You good, [random name]?” ED staff asked Patient #21 if they could clean off around Patient #21’s face, and Patient #21 stated “I don’t want you touching me.” Then Patient #21 asked “can you help me?” ED staff explained they were trying to help Patient #21, and are heard continuing to assess, clean, and bandage Patient #21’s head and facial lacerations. i. On 11/14/23 at 10:48 PM, Patient #21 allowed the ED staff to clean some of the dried blood off their face, but is heard saying “there is no blood.” ED staff are also heard reporting a tear in Patient #21’s ear. j. On 11/14/23 at 10:51 PM, RN O applied a pressure dressing to Patient #21’s head. k. On11/14/23 at 10:52 PM, ED staff and law enforcement assisted Patient #21 to a sitting position, as Patient #21 asked “are you done?” Law enforcement responded, informing Patient #21 they were done, and Patient #21 stated “alright just making sure.” As law enforcement escorted Patient #21 back toward the ambulance garage, Patient #21 reached for law enforcement’s gun. Patient #21 remained handcuffed. l. On 11/14/23 at 10:53 PM, law enforcement placed Patient #21 in the back of their patrol car, and Patient #21 continued to be verbally aggressive, making verbal threats. 11. During an interview on 1/30/24 at 8:45 AM, Paramedic N recalled Patient #21 being extremely agitated and aggressive, and demonstrated impaired judgment, but aware of their name and where they were. Paramedic N reported Patient #21 would become agitated then de-escalate, but nothing triggered them. Paramedic N reported when a patient has violent mood swings like Patient #21, something else is going on, and a CT is needed to rule out potential causes. Paramedic N reported Patient #21 attempted to reach for the officer’s gun as they were being escorted from the ED. Paramedic N reported Patient #21 didn’t have an appropriate assessment. Paramedic N recalled the ED staff mindset as getting Patient #21 out of the ED. 12. During an interview on 1/30/24 at 11:00 AM, RN O recalled Physician P attempted to ask Patient #21 questions, but Patient #21 didn’t allow Physician P to ask anything. RN O couldn’t recall what questions ARNP I asked Patient #21. RN O reported seeing Patient #21 reaching for the officer’s gun as they were walking Patient #21 out of the ED, and a potential for something very bad to happen. RN O didn’t recall explaining the benefits of an examination and/or treatment, or the risks of refusing examination, treatment, or both. 13. During an interview on 1/30/24 at 11:00 AM, Physician P recalled Patient #21 as uncooperative, speaking in full sentences, and being neurologically intact (nervous system is working, which involves things like balance, memory, and strength). Physician P reported Patient #21 refused medical treatment to law enforcement prior to being brought to the ED. Physician P reported if a violent patient is brought to their ED, they are typically assessed for competency, and there are numerous opportunities for treating a patient depending on their competency. Physician P acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as Physician P was “just kicked in the head.” Physician P reported an interaction of 45 seconds with Patient #21, and after Patient #21 assaulted Physician P, they asked ARNP I to try and assess Patient #21. Physician P reported Patient #21 assaulted other people prior to coming to the ED, had a laceration to their head, adamantly refused care multiple times, and explained Patient #21 had a Glasgow Coma Scale (GCS) of 15 (13 to 15 means minor brain injury), spoke in full sentences, and felt Patient #21 was competent to make medical decisions and refuse medical treatment. Physician P then reported they were comfortable discharging Patient #21 to jail, because nurses were available to monitor Patient #21 at the jail. 14. During an interview on 1/30/24 at 12:30 PM, ARNP I recalled Patient #21 being alert, aggressive, and screaming at ED staff. ARNP I recalled when attempting to assess Patient #21, they refused, and reported Patient #21 was able to sit up, look ARNP I in the face, and Patient #21 said no. ARNP I reported ED staff attempted to do a medical screening on Patient #21, but Patient #21 refused. ARNP I reported Patient #21 was medically competent to make medical decisions, but acknowledged ARNP I didn’t do an assessment on Patient #21, didn’t know what Physician P did prior to ARNP I’s attempt to assess Patient #21, and ARNP I didn’t even get close to Patient #21. ARNP I acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21. 15. During an interview on 1/30/24 at 2:30 PM, RN G recalled Patient #21 called them by a random name, and would ask for help, but then said no when ED staff tried to help. RN G reported Patient #21 wouldn’t let ED staff suture the laceration, but did allow ED staff to clean it, and apply a dressing. RN G recalled three or four law enforcement officers, two paramedics, two nurses, and a tech caring for Patient #21 during their ED visit, and Patient #21 being held down for ED staff to treat them. RN G recalled it being reported to them that Patient #21 reached for law enforcement’s gun when they were leaving the ED, and prior to Patient #21 arrived at the ED, they had been attacking people in the community. RN G acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as they were not Patient #21’s primary nurse. 16. The hospital failed to provide an appropriate MSE to Patient #21 while in their ED to fully assess Patient #21 for concern of a closed head injury, or the cause of Patient #21’s combativeness, which if not related to a head injury could have been from a countless number of causes. The ED staff failed to inform Patient #21 of the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. Patient #21 expressed violent thoughts and gestures toward hospital staff and law enforcement while in the ED from arrival to departure, but Patient #21 was allowed to leave against medical advice (AMA). 17. Review of Patient #20’s medical record from the ACH revealed: a. On 11/7/23 at 4:49 PM, Patient #20 presented to the ED by ambulance with law enforcement with a chief complaint of being physically and sexually assaulted. Patient #20 alleged being hit in the head numerous times. Upon arrival to the ED, ARNP I assessed Patient #20, and noted they had a one-centimeter (cm) laceration to their scalp. Patient #20 denied loss of consciousness, lightheadedness, dizziness, vision change, nausea, vomiting, or fainting. Patient #20 had bleeding coming from the right ear, with a perforated eardrum, and scratches down the right side of the face. ARNP I noted Patient #21 rated their pain as a 10 out of 10 on the pain scale (tool used to help assess a patient’s pain; 0 being no pain, and 10 being the worst possible pain) to the right side of the head and ear. ARNP I cleansed and irrigated Patient #20’s lacerations, applied one staple to the one cm head laceration, and covered it with bacitracin (topical antibiotic ointment) and a dressing. ARNP I notified the sexual assault response team (SART) and diagnosed Patient #20 with a laceration of the scalp. b. On 11/7/23 at 4:49 PM, ARNP I ordered an antibiotic for Patient #20 for the ruptured tympanic membrane, and sent a prescription to Patient #20’s pharmacy. ARNP I educated Patient #20 on the medication prescribed and wound care. c. On 11/7/23 at 5:12 PM, Patient #20 received the antibiotic. Patient #20’s GCS assessment was 15. d. On 11/7/23 at 5:51 PM, Patient #20 became verbally aggressive and upset with RN H’s questions about their injuries and reason for their ED visit. Patient #20 felt RN H was putting words in Patient #20’s mouth, and didn’t believed Patient #20. ED staff informed Patient #20 that they notified the SART, and were awaiting their arrival. e. On 11/7/23 at 5:56 PM, Patient #20 left AMA. f. On 11/7/23 at 6:18 PM, Patient #20 returned to the ED accompanied by law enforcement for a chief complaint of seizures (a sudden, uncontrolled burst of electrical activity in the brain). ARNP I assessed Patient #20 upon their arrival to the ED. Patient #20 held their breath until they turned purple in color and attempted to choke them self with their handcuffs. Patient #20 pulled the staple out of the scalp laceration placed approximately an hour prior. Patient #20 again reported pain as 10 out of 10 to the right ear, and right scalp laceration. ARNP I cleansed and irrigated the laceration, applied two staples, and covered it with antibiotic ointment and a dressing. g. On 11/7/23 at 6:22 PM, RN H assessed Patient #20’s GCS, which remained 15. h. On 11/7/23 at 6:24 PM, Patient #20 told RN H “it feels better to not breathe.” i. On 11/7/23 at 6:35 PM, Patient #20 pulled their pants down, and intentionally peed through the bedrails onto the floor. j. On 11/7/23 at 6:50 PM, Patient #20 discharged. When law enforcement came to transport Patient #20, and Patient #20 threw them self on the floor, attempted to take out the new staples from the scalp laceration, and started hitting their head on the floor. ED staff lifted Patient #20 in handcuffs to a wheelchair, took Patient #21 to the ambulance garage, and place them in the police car. k. The hospital staff failed to provide further assessment or treatment for Patient #20’s complaints of pain. The hospital failed to complete an appropriate MSE to rule out Patient #20 didn’t have any significant head injuries other than the head laceration and rupture tympanic membrane. No laboratory testing or head imaging were obtained. The hospital also failed to address Patient #20’s self-harm behaviors that could have resulted in further injuries, or possible death of Patient #20. Hospital staff failed to obtain any imaging or testing to rule out the possibility of seizure activity. 18. During an interview on 1/24/24 at 8:30 AM, RN F recalled Patient #20 coming to the ED often, and had a history of alcohol and drug abuse. RN F recalled Patient #20 came to the ED twice on 11/7/23, once for an assault, and the second time by law enforcement for a possible seizure. RN F reported ED staff notified SART during Patient #20’s first ED visit, but Patient #20 became upset with another nurses’ questions, and decided to leave. RN F reported Patient #20’s second ED visit, they were reported as not breathing well by law enforcement, and were observed choking them self with their handcuffs. RN F recalled Patient #20’s skin color being a different color. RN F reported when ARNP I presented to Patient #20’s room, RN F left because they were not the primary nurse for Patient #20. 19. During an interview on 1/24/24 at 12:30 PM, ARNP I recalled Patient #20, and reported they are seen frequently in the ED for alcohol abuse, drug abuse, and aggressive behavior. ARNP I recalled Patient #20 being seen in the ED twice on 11/7/23. ARNP I reported Patient #20 being hysterical, screaming, failing around, being aggressive, and not letting anyone touch them during their first ED visit on 11/7/23. ARNP I recalled barely being able to get staples into Patient #20’s laceration ARNP I reported being informed Patient #20 wanted to leave after they agreed to wait for SART. ARNP I reported Patient #20 pulled out the staple they had just been put in, and said they were leaving. ARNP I reported Patient #20 left multiple times before after SART had been contacted, so they explained to Patient #20 the team was on the way, and Patient #20 needed to stay, but Patient #20 still left AMA. ARNP I reported law enforcement brought Patient #20 back to the ED, and reported they thought Patient #20 had a seizure. ARNP I reported replacing the staples Patient #20 had removed from the head laceration, and left the room. ARNP I reported Patient #20 wanted to leave. ARNP I then reported Patient #20 urinated and defecated on the floor, put them self on the floor, and began hitting their head on the floor. ARNP I was unable to recall where Patient #20 was discharged to, or what happened to Patient #20, because ARNP I didn’t see Patient #20 before they left. 20. During an interview on 1/24/24 at 11:00 AM, RN G reported Patient #20 as someone that is seen in the ED frequently. RN G reported Patient #20 had some serious medical and substance abuse issues. RN G reported Patient #20 being very volatile toward ED staff and other patient in the ED waiting room, and there being complaints about Patient #20 assaulting people in the ED waiting room. RN G recalled triaging Patient #20 on 11/7/23 during their first ED visit, and notifying SART. RN G reported Patient #20 trying to rip out the staple to the scalp and wanting to leave AMA. RN G denies seeing Patient #20 during their second ED visit on 11/7/23. 21. During an interview on 1/24/24 at 11:00 AM, RN H reported Patient #20 comes to the ED frequently. RN H reported Patient #20 comes into the ED drunk, aggressive, and abusive. RN H recalled Patient #20 coming to the ED twice on 11/7/23. RN H reported attempting to assess Patient #20, asking questions, and Patient #20 immediately got upset, thinking RN H didn’t believe them. RN H reported attempting to explain to Patient #20 the SART had been notified and were on their way, but Patient #20 said they were leaving. RN H reported Patient #20 did not sign an AMA form. RN H then recalled law enforcement bringing Patient #20 back to the ED for a possible seizure. RN H recalled the ED provider went to see Patient #20, said Patient #20 didn’t have a seizure, nothing changed from their previous ED visit, and Patient #20 could discharge. RN H recalled Patient #20 banging their head on the floor. RN H reported law enforcement was called back to the ED, Patient #20 was placed in handcuffs, discharged to law enforcement, and taken to jail.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47335 Based on document review and staff interviews, the Acute Care Hospital (ACH) administrative staff failed to ensure the Emergency Department (ED) staff provided 3 of 21 emergency patients reviewed (Patient #10, #20, and #21) with an appropriate stabilizing treatment for their emergency medical condition (EMC) after presenting to the ED requesting emergency medical care. Failure to provide appropriate stabilizing treatment places all patients at risk for deterioration of their emergency medical condition up to and including death. The ACH’s administrative staff identified an average of 2927 patients per month who presented to the dedicated emergency department and requested emergency medical care. Findings include: 1. Review of Patient #10’s medical record from the ACH revealed: a. On 1/3/24 at 9:46 AM, Patient #10 presented to the ED by private vehicle for a chief complaint of an alcohol problem. Patient #10 reported drinking an 18 pack of beer and one pint of fireball daily since August, and had their last drink the previous morning. b. On 1/3/24 at 10:00 AM, Patient #10’s pulse was 87 (normal range 60-100), respirations were 18 (normal range 12-16), blood pressure (BP) was 139/88 (normal range less than 120/80), and pulse oximetry (SPO2) was 98% (normal range is usually 95% or higher). c. On 1/3/24 at 10:03 AM, an alcohol screening revealed that Patient #10 drank ten or more units of alcohol daily or almost daily. d. On 1/3/24 at 10:09 AM, Physician A evaluation noted Patient #10 as alert, nontoxic-appearing, calm and cooperative, and skin was warm and dry. e. On 1/3/24 at 10:21 AM, Patient #10’s neurological assessment completed by RN E revealed they were alert and oriented to time, place, person, and situation. Patient #10 had clear speech and could follow commands. Patient #10 had tremors to both arms and legs. f. On 1/3/24 at 10:26 AM, Patient #10’s abnormal lab results were noted as a white blood count of 4 (low; normal range 4.5-11.0); Hgb of 12.9 (low; normal range 13.5-17.5); platelets were 108000 (low; normal range 150-400); potassium of 2.8 (low; normal range 3.5-5.1); AST of 181 (high; normal range 8-34); Bilirubin of 1.4 (high; normal range 0.3-1.2). A blood alcohol level of 163 (high; normal level is less than 10). Patient #10 reported drinking a day and a half ago. Physician A noted the hospital Social Worker (SW) would meet with Patient #10 to assist in looking for a “detox” facility. g. On 1/3/24 at 10:45 AM, Physician A ordered potassium chloride 40 mEq by mouth for Patient #10. h. On 1/3/24 at 10:57 AM, RN E administered potassium chloride 40 mEq to Patient #10. i. On 1/3/24 at 11:38 AM, Social Worker (SW) L met with Patient #10 in the ED to discuss options of support for withdrawal management or treatment of acute alcohol intoxication. SW L questioned Patient #10 why they didn’t pick up the prescription for withdrawal management given to them two days ago at Hospital B, and Patient #10 reported they were not aware of the prescription at their pharmacy. Patient #10 returned from deployment overseas four months prior. Patient #10 requested the hospital proceed in an attempt to secure a “detox” inpatient treatment option for them, and a referral was placed to a rehab facility. j. On 1/3/24 at 12:54 PM, Patient #10’s BP was 137/88, and SPO2 was 96%. k. On 1/3/24 at 2:22 PM, Patient #10’s pulse was 105, BP was 147/96, and SPO2 was 97%. Physician A ordered Chlordiazepoxide (medication used to treat acute alcohol withdrawal) cap 25 mg for Patient #10. l. On 1/3/24 at 2:25 PM, Patient #10 received Chlordiazepoxide cap 25 mg by mouth. m. On 1/3/24 at 2:45 PM, Patient #10’s pulse was 107, BP was 142/89, and SPO2 was 96%. n. On 1/3/24 at 2:45 PM, lab obtained a repeat basic metabolic panel (BMP) (test use to check fluid balance, electrolytes, and kidney function) from Patient #10. o. On 1/3/24 at 3:13 PM, Patient #10’s BMP resulted with a potassium level of 3.2 (low). p. On 1/3/24 at 3:15 PM, Patient #10’s BP was 152/95, and SPO2 was 97%. q. On 1/3/24 at 3:36 PM, Patient #10 left without their discharge paperwork, or having their discharge vital signs reassessed. Patient #10’s diagnosed with chronic alcohol abuse. 2. During an interview on 1/24/24 at 9:15 AM, RN E recalled caring for Patient #10 for about an hour, then passed care over to another RN. RN E reported Patient #10 had just returned from deployment a few months prior, and had been drinking heavily. Patient #10 had been seen a day or two before at another ED, but due to Patient #10 not being ready for “detox,” they were sent home. RN E recalled Patient #10 received an order for medication, but didn’t pick it up. RN E recalled Patient #10 having tremors during their ED visit. 3. During an interview on 1/24/24 at 10:10 AM, RN C recalled hospital staff trying to find placement for Patient #10 at a rehab center, but Patient #10 decided not to go due to “money issues.” RN C recalled Patient #10 left the ED after talking with the SW. RN C reported encouraging Patient #10 to pick up the previously prescribed medication. RN C recalled Patient #10 demonstrated symptoms of sweating, anxiety, and overall not feeling good. 4. During an interview on 1/24/24 at 10:40 AM, Physician A recalled Patient #10 being an alcohol abuser who left without getting placed in rehab. Physician A reported Patient #10 had recently been evaluated at Hospital A, and given recommendations and a prescription for alcohol withdrawal, but didn’t follow the treatment plan or pick up the prescription provided to them. Physician A reported the ED SW worked on placement for Patient #10, but wasn’t aware if they found placement prior to discharging them from the ED, and verbalized inpatient rehab placement can take days to find. Physician A recalled Patient #10 reported not being intoxicated, but Patient #10’s blood alcohol level didn’t support their report. Physician A reported Patient #10 was “stable”, had “stable” vital signs, and their potassium level was “stable”, but denied seeing Patient #10 prior to their discharge from the ED. Physician A also reported Patient #10 left the ED prior to having another full set of vital signs completed. 5. During an interview on 1/24/24 at 2:45 PM, SW L recalled assessing Patient #10, and sending a referral to a rehab facility. SW L reported they secured a bed for Patient #10 at a rehab facility, but Patient #10 left the ED after talking with SW L. SW L reported Patient #10 had a blood alcohol level of 163, and described Patient #10 as being intoxicated, but able to have a conversation. SW L recalled Patient #10 reported drinking the morning before coming to the ED, almost 24 hours before coming in, but their blood alcohol level was still elevated. 6. Acute alcohol intoxication can lead to altered mental status which can lead to hypoventilation (breathing too shallow and too slow to meet the bodies oxygen need) and excessive drowsiness, leading to airway compromise. Acute alcohol withdrawal can lead to electrolyte abnormalities, and life-threatening seizures. Treatment for acute alcohol intoxication and acute alcohol withdrawal are metabolizing, hydration, rechecking the blood alcohol level, admission to the hospital, and medications. Evidence in Patient #10’s medical record showed the ED physician failed to reassess Patient #10 prior to discharge to determine if Patient #10 was no longer clinically intoxicated and/or experiencing signs and symptoms of alcohol withdrawal. ED staff failed to address why Patient #10 wanted to leave the hospital or determine if Patient #10 had the capacity to make an informed decision about leaving. Hospital staff failed to address the outcome of the referral sent to the inpatient treatment facility for Patient #10. 7. Review of Patient #10’s medical record from Hospital B revealed: a. On 1/3/24 at approximately 4:40 PM, Patient #10 presented to the ED with their mother for an unknown complaint. Patient #10 reported feeling very shaky, tremulous, nauseous, and anxious. Vital signs were documented as temperature 98.3 F, pulse 110, respiration rate 18, BP 162/118, SpO2 97. Patient #10 tested positive for COVID-19. Patient #10’s white blood cell count increased to 4.2, Hgb increased to 13.1, platelet count increased to 118,000, potassium increased to 3.6, AST decreased to 152, Bilirubin increased to 1.9. b. On 1/3/24 at 6:29 PM, Patient #10 became more tremulous and hypervigilant. BP was 154/109. c. On 1/3/24 at 7:02 PM, Patient #10’s BP was 145/119. The ED provider ordered Valium (medication used to treat anxiety, seizures, muscle spasms, and twitches) IV for Patient #10. d. On 1/3/24 at 7:15 PM, Patient #10 received IV Valium. e. On 1/3/24 at 9:45 PM, Patient #10 was admitted to Intensive Care Unit for stabilizing treatment. 8. Review of Patient #21’s ambulance report from the ACH revealed: a. On 11/14/23 at 10:36 PM, emergency medical services (EMS) arrived on scene with Patient #21. Police reported to EMS, Patient #21 had an altercation with multiple people, and got struck in the head multiple times by a golf club. The EMS documented Patient #21 had multiple assaults toward random public entities, and innocent bystanders. EMS noted Patient #21 as uncooperative and combative, showing signs of extreme hostility toward EMS and law enforcement. Patient #21 sustained injuries to the left side of the head, with two lacerations, and swelling and contusions around the two lacerations. EMS noted Patient #21 appeared to be in some form of hostile psychosis. Law enforcement transport Patient #21 to the ED for further evaluation and care due to unsafe probability of Patient #21 toward EMS. It was unknown whether Patient #21 had taken any illicit drugs or alcohol. EMS documented Patient #21 demonstrated intermittent cooperativeness, along with unpredictable hostility and aggressive behaviors. 9. Review of Patient #21’s medical record from the ACH revealed: a. On 11/14/23 at 10:38 PM, Patient #21 presented to the ED by law enforcement for multiple facial lacerations, and medical clearance prior to being taken to jail. Upon Patient #21’s arrival to the ED, they were swearing, and stated, “I refused medical care.” Physician P attempted to assess Patient #21’s alertness and orientation, but Patient #21 spit at Physician P, and kick Physician P in the face. Physician P noted Patient #21 had a pressure dressing applied to their facial lacerations, and they were cleared to be taken to jail. Physician P asked ARNP (Advanced Registered Nurse Practitioner) I to assess and offer treatment to Patient #21. b. On 11/14/23 at 10:54 PM, ARNP I noted blood to Patient #21’s face. ARNP I offered medical attention to Patient #21, and Patient #21 refused. ARNP documented Patient #21 would be arrested, and leave by law enforcement for assaulting medical staff. c. On 11/14/23 at 11:06 PM, RN O documented Patient #21 arrived at the ED with a laceration to the top of the left side of their head. Patient #21 immediately stated “I don’t know why I’m here, I don’t want to be here,” and they did not want anyone to touch them. Patient #21 allowed RN O to place a pressure dressing to their laceration. d. On 11/14/23 at 11:11 PM, the ED staff discharged Patient #21 with law enforcement. 10. Review of law enforcement bodycam video of Patient #21’s ED visit at the ACH revealed: a. On 11/14/23 at 10:36 PM, Patient #21 arrived at the ED by law enforcement, taken out of the patrol car by law enforcement in the ambulance garage, and placed into a wheelchair. Patient #21’s face, and clothes were covered with blood. Patient #21 made threatening statements to law enforcement as they were assisted to a wheelchair. Patient #21 is heard swearing and talking about the officer’s gun. b. On 11/14/23 at 10:37 PM, upon entering the ED Patient #21 stood up from the wheelchair, became confrontational with paramedics and law enforcement swearing, and made life threatening statements several times before three officers got Patient #21 to sit back down in the wheelchair to be escorted into an ED exam room. c. On 11/14/23 at 10:39 PM, Patient #21 transferred from the wheelchair to an ED exam bed. Patient #21 remained in police handcuffs with hands behind their back. Physician P presented to Patient #21’s bedside, and asked “what happened to you?” Patient #21 stated “I’m refusing medical attention,” while swearing at ED staff. DO P then attempted to ask Patient #21 for the day, and Patient #21 verbalized they were not going to answer any questions and spit in Physician P’s face. Physician P raised a fist at Patient #21, then turned to walk away, and Patient #21 kicked Physician P in the face. Physician P engaged in a physical altercation with Patient #21. Law enforcement, nursing staff, and paramedics were in the room, immediately responded, removed Physician P from Patient #21’s exam room, and physically restrained Patient #21 down on the exam bed at the head, shoulders, and legs. Patient #21 remained handcuffed with both hands behind their back. Patient #21 continued talking, and swearing at ED staff and law enforcement. Someone is then heard saying take him to jail. ED staff is heard saying Patient #21 is medically clear to go, discussion continued about Patient #21 being medically cleared for discharge, then RN O verbalized Patient #21 was not medically cleared. d. On 11/14/23 at 10:40 PM, ED staff asked Patient #21 about letting them clean them up, and putting sutures in the laceration. Patient #21 continued to talk to ED staff, talking about them hitting him some more, and they might like it. e. On 11/14/23 at 10:41 PM, Patient #21 told RN O to let go of their face, as RN O applied pressure to Patient #21’s facial laceration. RN O explained to Patient #21, they were bleeding. ED staff were heard asking for medication for Patient #21, but told by another ED staff they didn’t think the provider would. ED staff were then heard asking about the lacerations to Patient #21’s face and head. Law enforcement reported a golf club being involved, and Patient #21 verbalized that is what they got hit with. Patient #21 then asked police and ED staff to stop, as they are assessing Patient #21’s injuries, and discussing treatment options. f. On 11/14/23 at 10:42 PM, ED staff again are heard offering medical care, and Patient #21 is heard stating “I refuse medical attention.” Then Patient #21 stated “if you want to put a towel on it, then fine, but I’m refusing medical attention.” ED staff offered to wrap the lacerations, and Patient #21 verbalized they did not want anyone touching it. ARNP I is then seen at the foot of Patient #21’s bed, just inside the exam room, and is heard introducing self to Patient #21, stating “sir, my name is [ARNP I], I am the nurse practitioner on, do you want medical treatment?” Patient #21 stated “no, I do not.” ARNP I stated “okay,” walked away from Patient #21’s exam room with Physician P, and stated “he is refusing medical treatment.” g. On 11/14/23 at 10:43 PM, RN O told Patient #21 they had to help Patient #21 a little bit, and Patient #21 said, “no, I ’ m good, bud.” h. On 11/14/23 at 10:45 PM, Patient #21 allowed ED staff to assess the head lacerations. Patient #21 started asking if “we’re good?” “You good, [random name]?” ED staff asked Patient #21 if they could clean off around Patient #21’s face, and Patient #21 stated “I don’t want you touching me.” Then Patient #21 asked “can you help me?” ED staff explained they were trying to help Patient #21, and are heard continuing to assess, clean, and bandage Patient #21’s head and facial lacerations. i. On 11/14/23 at 10:48 PM, Patient #21 allowed the ED staff to clean some of the dried blood off their face, but is heard saying “there is no blood.” ED staff are also heard reporting a tear in Patient #21’s ear. j. On 11/14/23 at 10:51 PM, RN O applied a pressure dressing to Patient #21’s head. k. On11/14/23 at 10:52 PM, ED staff and law enforcement assisted Patient #21 to a sitting position, as Patient #21 asked “are you done?” Law enforcement responded, informing Patient #21 they were done, and Patient #21 stated “alright just making sure.” As law enforcement escorted Patient #21 back toward the ambulance garage, Patient #21 reached for law enforcement’s gun. Patient #21 remained handcuffed. l. On 11/14/23 at 10:53 PM, law enforcement placed Patient #21 in the back of their patrol car, and Patient #21 continued to be verbally aggressive, making verbal threats. 11. During an interview on 1/30/24 at 8:45 AM, Paramedic N recalled Patient #21 being extremely agitated and aggressive, and demonstrated impaired judgment, but aware of their name and where they were. Paramedic N reported Patient #21 would become agitated then de-escalate, but nothing triggered them. Paramedic N reported when a patient has violent mood swings like Patient #21, something else is going on, and a CT is needed to rule out potential causes. Paramedic N reported Patient #21 attempted to reach for the officer’s gun as they were being escorted from the ED. Paramedic N reported Patient #21 didn’t have an appropriate assessment. Paramedic N recalled the ED staff mindset as getting Patient #21 out of the ED. 12. During an interview on 1/30/24 at 11:00 AM, RN O recalled Physician P attempted to ask Patient #21 questions, but Patient #21 didn’t allow Physician P to ask anything. RN O couldn’t recall what questions ARNP I asked Patient #21. RN O reported seeing Patient #21 reaching for the officer’s gun as they were walking Patient #21 out of the ED, and a potential for something very bad to happen. RN O didn’t recall explaining the benefits of an examination and/or treatment, or the risks of refusing examination, treatment, or both. 13. During an interview on 1/30/24 at 11:00 AM, Physician P recalled Patient #21 as uncooperative, speaking in full sentences, and being neurologically intact (nervous system is working, which involves things like balance, memory, and strength). Physician P reported Patient #21 refused medical treatment to law enforcement prior to being brought to the ED. Physician P reported if a violent patient is brought to their ED, they are typically assessed for competency, and there are numerous opportunities for treating a patient depending on their competency. Physician P acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as Physician P was “just kicked in the head.” Physician P reported an interaction of 45 seconds with Patient #21, and after Patient #21 assaulted Physician P, they asked ARNP I to try and assess Patient #21. Physician P reported Patient #21 assaulted other people prior to coming to the ED, had a laceration to their head, adamantly refused care multiple times, and explained Patient #21 had a Glasgow Coma Scale (GCS) of 15 (13 to 15 means minor brain injury), spoke in full sentences, and felt Patient #21 was competent to make medical decisions and refuse medical treatment. Physician P then reported they were comfortable discharging Patient #21 to jail, because nurses were available to monitor Patient #21 at the jail. 14. During an interview on 1/30/24 at 12:30 PM, ARNP I recalled Patient #21 being alert, aggressive, and screaming at ED staff. ARNP I recalled when attempting to assess Patient #21, they refused, and reported Patient #21 was able to sit up, look ARNP I in the face, and Patient #21 said no. ARNP I reported ED staff attempted to do a medical screening on Patient #21, but Patient #21 refused. ARNP I reported Patient #21 was medically competent to make medical decisions, but acknowledged ARNP I didn’t do an assessment on Patient #21, didn’t know what Physician P did prior to ARNP I’s attempt to assess Patient #21, and ARNP I didn’t even get close to Patient #21. ARNP I acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21. 15. During an interview on 1/30/24 at 2:30 PM, RN G recalled Patient #21 called them by a random name, and would ask for help, but then said no when ED staff tried to help. RN G reported Patient #21 wouldn’t let ED staff suture the laceration, but did allow ED staff to clean it, and apply a dressing. RN G recalled three or four law enforcement officers, two paramedics, two nurses, and a tech caring for Patient #21 during their ED visit, and Patient #21 being held down for ED staff to treat them. RN G recalled it being reported to them that Patient #21 reached for law enforcement’s gun when they were leaving the ED, and prior to Patient #21 arrived at the ED, they had been attacking people in the community. RN G acknowledged they didn’t explain the benefits of an examination and/or treatment, or the risks of refusing examination and/or treatment to Patient #21, as they were not Patient #21’s primary nurse. 16. The hospital failed to provide an appropriate MSE to Patient #21 while in their ED to fully assess Patient #21 for concern of a closed head injury, or the cause of Patient #21’s combativeness, which if not related to a head injury could have been from a countless number of causes. The ED staff failed to inform Patient #21 of the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. Patient #21 expressed violent thoughts and gestures toward hospital staff and law enforcement while in the ED from arrival to departure, but Patient #21 was allowed to leave against medical advice (AMA) without being explained the benefits of an examination/treatment and the risks of refusing examination, treatment, or both. 17. Review of Patient #20’s medical record from the ACH revealed: a. On 11/7/23 at 4:49 PM, Patient #20 presented to the ED by ambulance with law enforcement with a chief complaint of being physically and sexually assaulted. Patient #20 alleged being hit in the head numerous times. Upon arrival to the ED, ARNP I assessed Patient #20, and noted they had a one-centimeter (cm) laceration to their scalp. Patient #20 denied loss of consciousness, lightheadedness, dizziness, vision change, nausea, vomiting, or fainting. Patient #20 had bleeding coming from the right ear, with a perforated eardrum, and scratches down the right side of the face. ARNP I noted Patient #21 rated their pain as a 10 out of 10 on the pain scale (tool used to help assess a patient’s pain; 0 being no pain, and 10 being the worst possible pain) to the right side of the head and ear. ARNP I cleansed and irrigated Patient #20’s lacerations, applied one staple to the one cm head laceration, and covered it with bacitracin (topical antibiotic ointment) and a dressing. ARNP I notified the sexual assault response team (SART) and diagnosed Patient #20 with a laceration of the scalp. b. On 11/7/23 at 4:49 PM, ARNP I ordered an antibiotic for Patient #20 for the ruptured tympanic membrane, and sent a prescription to Patient #20’s pharmacy. ARNP I educated Patient #20 on the medication prescribed and wound care. c. On 11/7/23 at 5:12 PM, Patient #20 received the antibiotic. Patient #20’s GCS assessment was 15. d. On 11/7/23 at 5:51 PM, Patient #20 became verbally aggressive and upset with RN H’s questions about their injuries and reason for their ED visit. Patient #20 felt RN H was putting words in Patient #20’s mouth, and didn’t believed Patient #20. ED staff informed Patient #20 that they notified the SART, and were awaiting their arrival. e. On 11/7/23 at 5:56 PM, Patient #20 left AMA. f. On 11/7/23 at 6:18 PM, Patient #20 returned to the ED accompanied by law enforcement for a chief complaint of seizures (a sudden, uncontrolled burst of electrical activity in the brain). ARNP I assessed Patient #20 upon their arrival to the ED. Patient #20 held their breath until they turned purple in color and attempted to choke them self with their handcuffs. Patient #20 pulled the staple out of the scalp laceration placed approximately an hour prior. Patient #20 again reported pain as 10 out of 10 to the right ear, and right scalp laceration. ARNP I cleansed and irrigated the laceration, applied 2 staples, and covered it with antibiotic ointment and a dressing. g. On 11/7/23 at 6:22 PM, RN H assessed Patient #20’s GCS, which remained 15. h. On 11/7/23 at 6:24 PM, Patient #20 told RN H “it feels better to not breathe.” i. On 11/7/23 at 6:35 PM, Patient #20 pulled their pants down, and intentionally peed through the bedrails onto the floor. j. On 11/7/23 at 6:50 PM, Patient #20 discharged. When law enforcement came to transport Patient #20, and Patient #20 threw them self on the floor, attempted to take out the new staples from the scalp laceration, and started hitting their head on the floor. ED staff lifted Patient #20 in handcuffs to a wheelchair, took Patient #21 to the ambulance garage, and place them in the police car. k. The hospital staff failed to provide further assessment or treatment for Patient #20’s complaints of pain. The hospital failed to complete an appropriate MSE to rule out Patient #20 didn’t have any significant head injuries other than the head laceration and rupture tympanic membrane. No laboratory testing or head imaging were obtained. The hospital also failed to address Patient #20’s self-harm behaviors that could have resulted in further injuries, or possible death of Patient #20. Hospital staff failed to obtain any imaging or testing to rule out the possibility of seizure activity. Hospital staff also failed to provide prophylaxis treatment for the sexual assault or behavioral health treatment for the self-harm behaviors. 18. During an interview on 1/24/24 at 8:30 AM, RN F recalled Patient #20 coming to the ED often, and had a history of alcohol and drug abuse. RN F recalled Patient #20 came to the ED twice on 11/7/23, once for an assault, and the second time by law enforcement for a possible seizure. RN F reported ED staff notified SART during Patient #20’s first ED visit, but Patient #20 became upset with another nurses’ questions, and decided to leave. RN F reported Patient #20’s second ED visit, they were reported as not breathing well by law enforcement, and were observed choking them self with their handcuffs. RN F recalled Patient #20’s skin color being a different color. RN F reported when ARNP I presented to Patient #20’s room, RN F left because they were not the primary nurse for Patient #20. 19. During an interview on 1/24/24 at 12:30 PM, ARNP I recalled Patient #20, and reported they are seen frequently in the ED for alcohol abuse, drug abuse, and aggressive behavior. ARNP I recalled Patient #20 being seen in the ED twice on 11/7/23. ARNP I reported Patient #20 being hysterical, screaming, failing around, being aggressive, and not letting anyone touch them during their first ED visit on 11/7/23. ARNP I recalled barely being able to get staples into Patient #20’s laceration ARNP I reported being informed Patient #20 wanted to leave after they agreed to wait for SART. ARNP I reported Patient #20 pulled out the staple they had just been put in, and said they were leaving. ARNP I reported Patient #20 left multiple times before after SART had been contacted, so they explained to Patient #20 the team was on the way, and Patient #20 needed to stay, but Patient #20 still left AMA. ARNP I reported law enforcement brought Patient #20 back to the ED, and reported they thought Patient #20 had a seizure. ARNP I reported replacing the staples Patient #20 had removed from the head laceration, and left the room. ARNP I reported Patient #20 wanted to leave. ARNP I then reported Patient #20 urinated and defecated on the floor, put them self on the floor, and began hitting their head on the floor. ARNP I was unable to recall where Patient #20 was discharged to, or what happened to Patient #20, because ARNP I didn’t see Patient #20 before they left. 20. During an interview on 1/24/24 at 11:00 AM, RN G reported Patient #20 as someone that is seen in the ED frequently. RN G reported Patient #20 had some serious medical and substance abuse issues. RN G reported Patient #20 being very volatile toward ED staff and other patient in the ED waiting room, and there being complaints about Patient #20 assaulting people in the ED waiting room. RN G recalled triaging Patient #20 on 11/7/23 during their first ED visit, and notifying SART. RN G reported Patient #20 trying to rip out the staple to the scalp and wanting to leave AMA. RN G denies seeing Patient #20 during their second ED visit on 11/7/23. 21. During an interview on 1/24/24 at 11:00 AM, RN H reported Patient #20 comes to the ED frequently. RN H reported Patient #20 comes into the ED drunk, aggressive, and abusive. RN H recalled Patient #20 coming to the ED twice on 11/7/23. RN H reported attempting to assess Patient #20, asking questions, and Patient #20 immediately got upset, thinking RN H didn’t believe them. RN H reported attempting to explain to Patient #20 the SART had been notified and were on their way, but Patient #20 said they were leaving. RN H reported Patient #20 did not sign an AMA form. RN H then recalled law enforcement bringing Patient #20 back to the ED for a possible seizure. RN H recalled the ED provider went to see Patient #20, said Patient #20 didn’t have a seizure, nothing changed from their previous ED visit, and Patient #20 could discharge. RN H recalled Patient #20 banging their head on the floor. RN H reported law enforcement was called back to the ED, Patient #20 was placed in handcuffs, discharged to law enforcement, and taken to jail.”