Rush Oak Park Hospital

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 9 patients’ (Pt #1) emergency department clinical records reviewed for assessment/reassessment, the hospital failed to ensure that a reassessment was conducted within the timeframe required per hospital’s policy. Findings include: 1. The hospital’s policy titled, “Triage Policy” (reviewed 05/27/2025) was reviewed and required, “Emergency Severity Index (ESI): Five-level triage algorithm that provides clinically relevant stratification of patients into five groups ... Level 1-resuscitative ... 3-Urgent ... 5-nonurgent.” 3. ... For level 3, 4, & 5, care will be expedited as treatment space becomes available. 4. Patients waiting longer than 2 hours in the waiting room will be reassessed by medical staff.” 2. The clinical record of Pt. #1 was reviewed on 08/01/2025. Pt. #1 presented to the Hospital via ambulance on 06/23/2025 at 12:05 PM. The clinical record included the following: - 12:05 PM, (Pt. #1) arrived in ED, arrival complaint - MG (Myasthenia Gravis - a chronic, autoimmune disorder that causes weakness in the voluntary muscles and fatigue). -12:10 PM, ED Note - Medical Screening Exam (E #1/Physician Assistant) Chief Complaint; weakness, generalized. Alert and oriented (person, place, time, situation), arrived via FD (fire department) reporting several episodes of general weakness x2 days. History of MG since 2016, and states this seems like a typical flare-up. Denies cp (chest pain) sob (shortness of breath) dizziness, fever, chills, pain. Compliant with medications Vss (vital signs stable) BP 141/68 (blood pressure, ref range 90/60 - 140/90) Pulse 78 (ref range 60-90) O2 99% on room air (oxygen - ref range 95% or greater). Stable awaiting further evaluation and treatment. A full evaluation will be performed when a treatment room becomes available. -12:12 PM, ED ESI Calculator Urgency, (E #2/RN) 3; Requires Immediate life-saving attention? No. ED Pain Assessment: No pain. -3:21 PM, ED Vitals Re-Assessment; BP 134/71, Pulse 71, Respirations 16, O2 100 % room air. (3 hours and 11 minutes after arriving in triage). The clinical record lacked documentation of a vital signs re-assessment while waiting longer than 2 hours in the waiting room. 3. An interview was conducted with the Assistant Unit Director (E #5) on 08/01/2025 at 2:15 PM. E #5 stated that for patients that are required to wait in the waiting room because there are no beds available, staff (PCT or RN) are required to re-assess vital signs every two hours and report any change in their condition to a provider or the charge nurse.”

“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: 30461 Based on document review and interview, it was determined that for 1 (Pt. #1) of 5 psychiatric clinical records reviewed for individuals that presented to the Emergency Department (ED), the hospital failed to determine whether or not an emergency medical condition existed, appropriate to the individual’s presenting signs and symptoms. Findings include: 1. On 12/22/2023, the hospital’s “Non-Discrimination in Providing Emergency Medical Care” (updated 12/14/2022) included, “ ...IV. Attachments ...Emergency Medical Treatment and Active Labor Act (EMTALA) ... 1. A medical screening exam must be performed ...2. If an emergency medical condition exist, treatment must be provided and continue until the patient is stabilized ...Tips for Avoiding EMTALA violations: 1. ...when treatment is provided, document what was done and why. If it was not documented, it did not happen ...3. Document the stability of the patient before discharge ...A psychiatric patient is not stable unless they are protected and prevented from harming themselves or others ...” On 10/20/2023, the hospital’s “Medical Staff Rules and Regulations” (2021) included, “ ...E. Admission, Discharges and Transfer ...1. A medical screening examination is required for any patient who presents to the Emergency Department for treatment.” 2. On 12/20/2023, the hospital’s “Screening and Care of the Suicidal Patient” (8/26/2022) policy was reviewed and included, “ ...purpose of this policy is to identify patients in the emergency department ...who are at high risk for suicide ...and provide protective interventions during their treatment course ...3. One to one constant visual observation can be initiated ...it is required when patient has diagnosis of suicidal ideation ...13. c. completes a follow-up assessments of the patient’s suicidal ideation using the CSSRS to assess the past 48 hours ...d. documents that the above steps have been completed and that the sitter may be safely discontinued.” 3. On 12/20/2023, the clinical record of Pt. #1 was reviewed. On 10/19/2023, Pt. #1 was brought to the Emergency Department (ED/hospital A) by ambulance due to Pt. #1 having homicidal thoughts to hurt others with no plan or intent. Pt. #1was examined and diagnoses included: polysubstance abuse, schizoaffective disorder, passive suicidal ideation, and COVID-19. The clinical record included: -On 10/19/2023, Pt. #1’s Ambulance Run Sheet (to Hospital A) included, “ ... (Pt. #1) walked up to ambulance stating that (Pt. #1) wants to go to the hospital to talk to a therapist because (Pt. #1) wants to hurt himself and hurt other people ...Chief Complaint: Mental Status Change. Behavioral/psychiatric.” On 10/19/2023 at 6:26 PM, Pt. #1 was triaged. At 6:30 PM, (Pt. #1’s) ED Initial Screening: Columbia Suicide Scale indicated that Pt. #1 verbalized suicidal ideation with no plan or intent within the past month. On 10/19/2023 at 6:53 PM, a 1:1 (constant visual monitoring) Safety Assistant was initiated for Pt. #1 for suicidal ideation. The safety assistant intervention remained in place throughout Pt. #1’s hospital course. . -On 10/19/2023 at 8:43 PM, Emergency (ED) first encounter with (Pt. #1) ...Chief complaint: Psychiatric Problem ... (Pt. #1) states (Pt. #1) would like to harm multiple people ...No current plan. (Pt. #1) would like to speak with a therapist. Hx (history) of schizophrenia ... (MD #3) believe based on (MD #3’s) time spent with (Pt. #1) ... (Pt. #1) care meets: HIGH complexity of care. As such (MD #3) have addressed a chronic illness with severe exacerbation that poses a risk of morbidity or mortality to (Pt. #1) ...” -On 10/20/2023 at 6:54 AM, ED Physician’s (MD #2) ‘ED Note’ included, “ ...(MD #2) reviewed the result of the C-SSRS (Columbia Suicide Severity Rating Scale) screening (10/19/2023) ...reported observations include: (Pt. #1) endorsing active suicidal thoughts and ideation ...(MD #2) conducted a suicide risk assessment including the following risk and protective factors: ...recent clinical status: major depressive disorder, command hallucinations to hurt self, highly impulsive behavior, and substance abuse or dependence ...Suicide Risk Assessment: based on this evaluation, (Pt. #1) is at high risk for suicide in the healthcare setting ...Suicide Risk Formulation: (Pt. #1) endorsing active suicidal ideation with plan to run in front of traffic ...Recommendations: Continue 1:1 safety assistant and constant visual observation ...Specific interventions to mitigate future risk: escalate level of care: Inpatient psychiatric hospitalization.” No other C-SSRS screenings for Pt. #1 were available for review. -On 10/20/2023 at 6:54 AM, Attending Physician’s (MD #2) ‘ED Note’ included, “(Pt. #1) is awake, clinically sober. (Pt. #1) continues to endorse active suicidal or homicidal ideation and does not feel safe leaving the emergency department. Will work on inpatient psychiatric transfer ... (Pt. #1) is medically appropriate for inpatient psychiatric care.” On 10/20/2023 at 9:34 AM, Attending Physician’s (MD #1) ‘ED Note’ included, “(Reevaluation: ... (Pt. #1) states that (Pt. #1) is having passive SI thoughts due to wanting to feel better. (Pt. #1) states that (Pt. #1) would prefer to be sent to a detox center to get better. (MD #1) believes that (Pt. #1) is a low risk for any self-harm as some of (Pt. #1’s) smptoms is directly related to (Pt. #1) polysubstance abuse ...(MD #1) also believes that (Pt. #1) is no immediate threat to any other individuals ...case was discussed with social worker who evaluated (Pt. #1), states that (Pt. #1) can be discharged to (hospital B) for detox intake as they also have accommodations for COVID positive patients. (MD #1) discussed this plan with (Pt. #1), agrees that (Pt. #1) would like to be sent to (hospital B) for detox. Will discharge (Pt. #1) at this time.” The clinical record did not include Social Worker notes or social worker assessments. -On 10/20/2023 at 9:40 AM, Hospital A’s ‘After Visit Summary’ included, “ ... (Pt. #1) stated that (Pt. #1) is most interested in going to a detox center, (Pt. #1) was sent to (hospital B) for polysubstance detox intake ...Follow-up with Substance Use Intervention Team Clinic ...” 4. On 12/20/2023, the clinical record of Pt. #1 was reviewed. On 10/20/2023, Pt. #1 was brought to the Emergency Department (hospital B) by taxi from (hospital A) for detoxification program. Pt. #1was examined and diagnoses included: schizophrenia, covid positive and polysubstance abuse. The clinical record included: -On 10/20/2023 at 10:29 AM, the Registered Nurse’s (E #/Hospital B) ‘Nurses Note’ included, “ ...AOx3 (alert and oriented) (Pt. #1) sent from (Hospital A) ER (Emergency Room) via taxi for SI (suicidal ideation), HI (homicidal ideation), polysubstance abuse. (Pt. #1) states that (Pt. #1) has been feeling these feeling for two days. Positive plan to poison self. (Pt. #1) states that he wants to hurt people on the North side. Positive THC (marijuana), ETOH (alcohol intoxication), Cocaine (stimulant drug), Meth. (methamphetamine/stimulant drug) (Pt. #1) is cooperative and sleepy.” 5. On 12/21/2023 at approximately 10:03 AM, an interview with the Attending physician (MD #1) was conducted. MD #1 stated that (MD #1) received (Pt. #1) from (MD #4). MD #1 stated that (MD #4) reported that (Pt. #1) presented to Emergency Department for questionable SI/HI concerns. MD #1 stated that (MD #4) reported that (Pt. #1) was positive for polysubstance intoxication and that plan is to re-evaluate (Pt. #1) when clinically sober with possible inpatient psychiatric placement. MD #1 stated that (MD #1) re-evaluated (Pt. #1) when clinically sober and (Pt. #1) expressed thoughts of not wanting to live were due to (Pt. #1’s) polysubstance use. MD #1 stated that (MD #1) and (Pt. #1) discussed detox program, with (Pt. #1) wanting to voluntarily attend program upon discharge. (MD #1) stated that (Pt. #1) was not a harm to self or others and was medically appropriate for discharge. MD #1 stated that (MD #1) did not use a specific assessment form to complete re-assessment of Pt. #1, rather (MD #1) asked (Pt. #1) suicide screening questions and documented (Pt. #1’s) assessment in a provider’s note. 6.On 12/21/2023 at approximately 10:36 AM, an interview with the Attending Physician (MD #4) was conducted. MD #4 stated (Pt. #1) was at (Hospital A) due to endorsing vague suicidal and homicidal ideation along with polysubstance abuse. MD #4 stated when (Pt. #1) was reassessed, (Pt. #1) continued to state active suicidal thoughts. (MD #4) stated that (MD #4) will not discharge a patient who states such thoughts, even with no plan or intent. MD #4 stated that (MD #4’s) recommendation/plan for (Pt. #1) was to admit to an inpatient psychiatric facility if (Pt. #1’s) suicidal thoughts continued. E #4 stated suicide risk assessments are completed on patients to determine safety and plan of care. 7. On 12/21/2023 at approximately 1:45 PM, an interview with the Attending Physician (MD #3) was conducted. MD #3 stated that (Pt. #1) was brought to the ED for suicidal and homicidal ideations. E #3 stated that (Pt. #1) was assessed and plan was to evaluate, complete labs, observe patient due to polysubstance intoxication and re-evaluate. MD #3 stated that (Pt. #1’s) care was handed off to (MD #4). 8. On 12/22/2023 at approximately 9:44 AM, an interview with the Director of Case Management (E #7) was conducted. E #7 stated that initially (Pt. #1) was identified as a psychiatric patient that would need to be transferred to a medical floor with psychiatric consult due to being COVID positive. E #7 stated that (Pt. #1’s) attending physician (E #1) re-evaluated (Pt. #1) and (Pt. #1) wanted detox treatment. E #7 stated that patients requesting detox programming would be seen by the hospital’s social worker for evaluation. E #7 stated that there is no documentation that Pt. #1 was seen and evaluated by a social worker.”