Roseland Community Hospital

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 50411 Based on document review, video surveillance review, and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services. Findings include: 1. The hospital failed to ensure that a patient (Pt #1) who presented to the emergency department (ED) with suicidal ideation was triaged and assessed for suicidal ideation, taken directly to the treatment area and monitored to ensure patient safety. (A-1104) The immediate jeopardy (IJ) began on 10/3/2025, due to the hospital’s failure to ensure that a patient (Pt #1) who presented to the emergency department (ED) with suicidal ideation was triaged and assessed for suicidal ideation, taken directly to the treatment area, and monitored to ensure patient safety. Subsequently, Pt #1 had absconded from the ED prior to any assessment and treatment. The IJ was identified on 10/9/2025 at 42 CFR 482.55, Emergency Services. The IJ was announced on 10/9/2025 at 4:25 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, and Chief Quality and Nursing Officer, and was not removed by the survey exit date of 10/9/2025.”

“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: 32741 Based on document review, video surveillance review, and interview, for 1 of 3 clinical records (Pt. #1) reviewed for patients who presented to the emergency department (ED) with suicidal ideation, the Hospital failed to ensure that the patient was triaged and assessed for suicidal ideation, taken directly to the treatment area and monitored to ensure patient safety. Subsequently, Pt. #1 had absconded from the ED prior to any assessment and treatment. This lack of assessment and monitoring of patients with suicidal ideation is likely to cause serious harm, injury or death to patients presenting with suicidal ideation, as well as others at large. Findings include: 1. On 10/9/2025, the Hospital’s policy titled, “Triage Protocol (5/2021)” was reviewed on 10/8/2025 and included, “The ED lead RN will evaluate all ambulance runs and law enforcement patients at ‘Station A’ upon arrival to ED and then notify triage staff of patient arrival. ...The RN assigned to the area will complete the triage procedure. If there are limited bays open, the ED RN will obtain the chief complaint and categorize each patient using the ESI [emergency severity index] levels 1 thru 5 [1 being more severe]. ... The triage staff will initiate interventions as guided by protocol. ... Level 2: Emergent/immediate: Patients are at High-risk: their condition can easily deteriorate, or the condition requires time sensitive treatment. Patients require immediate attention and care and are sent directly to the treatment area. Examples: ... suicidal or homicidal ...” 2. The “Emergency Triage Technician Job Description (8/15/2025)” was reviewed on 10/9/2025 and included, “Essential Functions: Take and record vital signs, assist with other patient assessment and remains as directed. ...” 3. The ED Meeting Minutes, dated 7/18/2025, were reviewed and included, “All members present agreed that the practice of contraband checks on psychiatric, substance abusing, and intoxicated patients should be continued. ... Multiple members noted that at other institutions, all patients are placed in gowns and in that process contraband and weapons are found.” 4. On 10/9/2025, Pt. #1’s clinical record (dated 10/3/2025) was reviewed and indicated: On 10/9/2025, the fire department ambulance run sheet (dated 10/3/2025) noted, “In summary, crew was dispatched to residence for a psych[iatric] eval[uation]. Upon arrival, crew was met by [Pt. #1] outside of residence, was alert, oriented x3 and complaint of wanting to hurt himself. Vitals obtained and [Pt. #1] checked for weapons by local police. [Pt. #1] assisted into ambulance for further assessment and transport. Report called into the Hospital ER with no further orders given to EMS. Upon arrival to ER, report given to staff and care transferred without incident. [Pt. #1] placed in triage area per charge nurse due to no beds available. Pt. #1 care was transferred without incident.” -ED Assessment written by E #2 (ED Triage Technician) - “time of arrival 8:19 PM, mode of arrival - ambulance, condition on arrival. Stated complaint - Pt. #1 seeks psych eval due to suicidal ideations. Pt. #1 admits to ETOH (alcohol) abuse prior to arrival to ED. ESI score 2.” Vital signs were blood pressure 125/77 (normal blood pressure is considered to be less than 120/80), pulse 86 (normal pulse ranges from 60-100), respirations 16 (normal respiratory rate is between 10-20), temperature 97.5 (normal temperature is between 97 and 99 degrees) and pulse ox 93% (normal pulse oximeter is between 95% and 100%). -MD #1’s (Emergency Physician) orders (dated 10/3/2025 at 8:27 PM) included, “Alcohol stat, EKG, CBC, CMP, Drug Screen urine and urinalysis” There was no documentation of any labs drawn or results in Pt. #1’s clinical record. Pt #1 was placed in the ED waiting room, where Pt #1 was not monitored for safety, and the hospital did not call for Pt #1 from the waiting room for approximately 3 hours. -E#2’s notes (dated 10/3/2025 at 11:11 PM, 11:23 PM and 11:36 PM) indicated, “Pt. # 1 was not seen in waiting room or in the hallway.” [This was approximately 3 hours after Pt #1 arrived to the ED. - MD #1’s note, dated 10/3/2025 at 11:22 PM included, “Continuity of Care Note - Pt. #1 apparently presented for alcohol intoxication and psychiatric evaluation. Pt. #1 was visualized on arrival in no distress noted normal vital signs. Psychiatric workup ordered however Pt. #1 absconded from the ED prior to its completion. Pt. #1’s location in the ED is listed as “ED hallway.” -Discharge Summary: absconded Pt. #1’s clinical record did not include a suicide assessment or any monitoring of Pt #1 for safety. 5. On 10/8/2025, a policy regarding the care and monitoring of psychiatric patients and suicide risk assessment in the ED was requested. Per the Manager of Risk (E #11), the Hospital does not have a policy related to care/oversight of the psychiatric patients in the ED. 6. On 10/8/2025 at 1:05 PM, video surveillance review was conducted with the Chief Quality and Nursing Officer (E #1) and the Director of Security (E #3). The video footage was from the ED’s EMS ambulance doorway; the patient walk-in entrance; the exterior ED roundabout; and the patient care interior (back ED). The following was observed from the video on 10/3/2025: - 8:07:45 PM: Pt #1 arrived through the Hospital’s ED ambulance bay, escorted by the (local fire department EMS/Z #1 and Z #2). Pt #1 was taken to the main ED’s back hallway, via wheelchair, by the EMS crew (Z #1, Z #2). - 8:10:21 PM: The Triage technician (E #2) approached Pt #1 in the main ED hallway. Vital signs taken by E #2, with verbal interaction observed between E #2 and Pt #1. Z #1 and Z #2 remain with patient while E #2 interacting with Pt #1. E #2 walks away from Pt #1 at 8:12 PM. - 8:12:33 PM: Z #1 and Z #2 transported Pt #1 to the ED nurse’s station. Z #1 and Z #2 interacting with a staff member at the nurse’s station, while Pt #1 remained in the wheelchair, in the hallway. - 8:17:05 PM: Registration Clerk (E #16) interacting with Pt #1 in the hallway, placing a wristband on the patient. Pt #1 signing papers presented by the registration clerk. - 8:20:35 PM: Pt #1 transported to the waiting room, from the back ED, via wheelchair by Z #1 and Z #2. Pt #1 stood up from the wheelchair and sat in the waiting room chair. - From 8:20:35 PM-9:17:14 PM (approximately 57 minutes), Pt #1 remained in the waiting room (unattended by staff). At 9:17:14 PM, Pt #1 walked out of the front “walk-in” doorway. The Greeter (E #15), and the Security Officer (E #14 ), were stationed at the front when Pt #1 walked out the door. - From 9:17:14 PM-9:41:27 PM (approximately 24 minutes), Pt #1 remained in front of the ED’s car roundabout entrance (unaccompanied). - 9:41:50 PM: A car drives up to the ED’s roundabout. Pt #1 enters the car and is driven away. Pt #1 was not seen returning to the ED. 7. On10/8/2025 at 11:45 AM, an interview was conducted with the Lead ED RN (E #4). E #4 stated that when patients present to the ED, the triage nurse initiates the screening. E #4 stated that the screening includes suicidal screening (SAD). On 10/9/2025 at 10:30 AM, an interview was conducted with the ED Medical Director (MD #2). MD #2 stated that MD #2 is aware of the incident regarding Pt. #1. MD #2 stated that a psychiatric patient who is suicidal should immediately be brought back into a room with a sitter for 1:1 monitoring. MD #2 stated that triage needs to be completed, and physician evaluation needs to be done. 8. On 10/9/2025 at 10:50 AM, an interview was conducted with the Director of Nursing (E #8). E #8 stated that the ED tech (E #2) should have communicated that Pt. #1 was suicidal to the charge nurse (E #9). E #8 stated that the charge nurse makes the decision where the patient should be placed. E #8 stated that a suicide assessment is completed on each patient in the ED. 9. On 10/9/2025 at 11:00 AM, an interview was conducted with the ED Charge Nurse (E # 9). E # 9 was the ED Charge Nurse on the day of Pt. #1’s ED visit. E #9 stated that E #9 was not told by the ED tech (E #2) that Pt. #1 was suicidal. E #9 stated that if E #9 knew that Pt. #1 was suicidal, Pt. #1 would have been moved to a room or hallway with a 1:1 sitter. 10. On 10/9/2025 at 11:25 AM, an interview was conducted with the ED Technician (E #2). E #2 stated that E #2 does not remember Pt. #1. E #2 stated that the ED sees a lot of drunk and suicidal patients so E #2 cannot remember Pt. #1. E #2 stated that if a patient is suicidal, E #2 would communicate this information to the charge nurse. E #2 stated that if a patient is suicidal, the patient is placed on 1:1 monitoring with a sitter. 11. On 10/9/2025 at 10:05 AM, an interview was conducted with the Manager of Risk and Compliance (E#11). E#11 stated that E#11 became aware of the incident involving Pt.#1 on 10/7/2025. E#11 stated that E#11 started the investigation, but it has not yet been completed. E#8 stated that there was no security report filed involving Pt.#1. 12. On 10/9/2025 at 10:51 AM, an interview was conducted with the ED Charge Nurse (E#12). E#12 stated that when patients are brought by ambulance, a report is given at the nurse’s station by EMS personnel to the ED Charge Nurse. E#12 stated that a triage technician will perform a basic triage assessment on the patient and assign an ESI (Emergency Severity Index). Patients assigned an ESI of 2 will be immediately brought to the back and placed in a room. E#12 stated that patients with suicidal thoughts will be roomed right away with a sitter assigned and never brought to the waiting area. E#12 stated that if all ED rooms are occupied, a suicidal patient will be placed in the hallway in the ED, never in the waiting area. 13. On 10/9/2025 at 11:05 AM, an interview was conducted with an ED Triage Technician (E#13). E#13 stated that E#13 performs triage assessments for patients presenting to the ED. E#13 stated that E#13 will assign ESI (Emergency Severity Index) for patients triaged. E#13 stated that patients with suicidal thoughts will not be brought to the waiting area. E#13 stated that E#13 will inform the charge nurse so that these patients can be roomed right away.”

“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: 36774 Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital (Hospital A/transferring hospital) failed to appropriately stabilize the patient’s emergency medical condition to ensure proper assessment, monitoring and interventions were provided. See A-2407. 2. The hospital failed to ensure that the medical record included documentation about the risks and benefits of transfer. See A-2409-A. 3. The hospital failed to ensure that the receiving facility accepted the transfer.See A-2409-B. 4. The Hospital failed to ensure that the medical records were sent to the receiving hospital. See A-2409 -C. The immediate jeopardy (IJ) began on 2/16/2025, due to the hospital’s failure to properly address Pt. #1’s medical and obstetrical needs while in the OB (Obstetric) triage area. Subsequently, Pt. #1 had diabetic ketoacidosis (acid build-up in the blood) and intrauterine fetal death, and was identified on 5/07/2025. The IJ was announced on 5/07/2025 during a meeting with the Chief Executive Officer, Chief Medical Officer, and Chief Quality and Nursing Officer, and was not removed by the survey exit date of 5/13/2025.”

“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: 32741 Based on document review, and interview, it was determined that for 1 of 4 patients’ (Pt. #1) clinical records reviewed for transferred OB (obstetrics) patients, Hospital A (transferring hospital) failed to appropriately stabilize the patient’s emergency medical condition to ensure proper assessment, monitoring and interventions were provided. Subsequently, Pt. #1 was transferred to Hospital B (receiving hospital) and found to be in DKA (diabetic ketoacidosis/acid in the blood that can lead to significant maternal and fetal morbidity and mortality) and IUFD (intrauterine fetal death). Findings include: 1. The hospital’s policy, “Emergency Medical Treatment (EMTALA)” (dated 12/2023) was reviewed and indicated, “Emergency medical condition” refers to both a labor and non-labor related emergency medical condition. Labor related emergency medical condition means a pregnant woman who is having contractions: when there is inadequate time to affect a safe transfer to another hospital before delivery, or when transfer may pose a threat to the health or safety of the woman or the unborn child ...placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy ...Stabilize - with respect to a labor-related emergency medical condition, the term “stabilize” means for a woman to deliver (including the placenta) as clinically determined ...If the patient has an emergency medical condition, the patient is to be treated in the ED [emergency department] or as an inpatient until the condition is stabilized or die. Patient is to be transferred appropriately.” 2. The hospital’s policy, “Triage” (dated 2020) was reviewed and indicated, “Purpose - to outline the care and evaluation for obstetrical patients presenting to the OB Triage ...Fetal status is assessed and documented at least 30 minutes on the OB Triage form ...” 3. On 5/5/2025, Pt. #1’s clinical record (dated 2/16/2025) was reviewed and indicated: -At 8:20 AM, Pt. #1 arrived at the Hospital A ED . -At 8:28 AM, E #2 (ED Triage Nurse) noted, “Chief complaint - 28 weeks pregnant, complained of nausea, vomiting and body aches. Vital signs - blood pressure 136/88 (low blood pressure is below 90/60, high blood pressure is 130/80 and above), pulse 126 (Normal 60-100), respirations 21 (normal 12-20), temperature 98.4 (normal 97-99) and oxygen saturation 97% (Normal 92%-100%). No bleeding, no leaking. ED pain assessment - pain intensity (0-10) 6, pain present now, yes, pain onset gradual and duration -intermittent. Triage services - fetal heart monitor used -yes. There was no documentation of fetal heart rate in the ED. Pt. #1 seen by MD #2 (ED Physician). MD #2 spoke with MD#1 (OB Physician) who accepted Pt. #1. -At 8:28 AM - ED MD #2 notes indicated, “-Physical exam - no apparent distress, general physical exam -normal inspection, conscious, alert, coherent - disposition: discharge to OB/gyn[obstetrics/gynecology], clinical impression - abdominal pain affecting pregnancy.” -At 8:50 AM - Pt. #1 had ultrasound. The ultrasound results noted, “Findings - there is a single live intrauterine pregnancy ...fetal heart rate is 130 (range from 120 to 160 beats per minute). - At 9:50 AM, E #2’s (OB Triage Nurse) note indicated, “(Pt. #1) on the unit, endorses that (Pt. #1) feels weak.” -At 9:55 AM - E #2 noted “(Pt. #1) had a large emesis of bile colored fluid. (Pt. #1) noted has had multiple episodes of vomiting. (Pt. #1) has general sickly appearance and malaise (weakness). Skin is pale, and mucous membranes very dry.” - At 10:00 AM - E #2 noted, “(Pt. #1) notes that (Pt. #1) is having back pain. Pain scale - 8, contractions intermittent, pain location -back. Uterine activity - external toco (refers to a tocodynamometer, a device used to monitor uterine contractions).” -At 10:10 AM - E #2 noted, “FHR (fetal heart rate) baseline rate - 130.” - At 10:25 AM - E #2 noted, “FHR 130. Uterine activity -external toco -frequency 3-4 per minute, duration 80 seconds.” -At 10:35 AM - E #2 noted, “Unable to accurately monitor FHT[fetal heart tone], adjusting toco.” -At 10:47 AM - E #2 noted, “Contacted ambulance for transport to Hospital B (receiving hospital). Ambulance company noted ambulance would be at Hospital A in approximately 1 hour.” -At 11:07 AM - E #2 noted, “(E #2) notified (MD #1) that (E #3/OB nurse) was having difficulty keeping the baby on the monitor and that (E #2) will attempt to obtain fetal heart tones.” -At 11:25 AM - E #2 noted, “(E #2) having difficulty sustaining fetal heart tones on the external monitor. (E #2 and E #3) at the bedside and is able to audibly hear the fetal heart tones via the monitor ranging in the 125 -130s. (Pt. #1) endorses that (Pt. #1) is feeling fetal movement.” There was no documentation of fetal heart rate on Pt. #1’s fetal monitoring strip for this time. -At 11:30 AM - E #2 noted, “(MD #1) notified (E #2) that (Pt. #1’s) glucose is 452 (normal range between 70 and 100) and other labs are grossly abnormal.” (Pt. #1’s) urine ketone was 80/normal is 0. Anion gap was 24.2/normal 10-20. (High level of ketones and anion gap may indicate DKA). -At 11:35 AM - E #2 noted, “(Pt. #1) had diabetes in (Pt. #1’s) last pregnancy. (Pt. #1) stated that since that time, (Pt. #1) has not had any diabetes issues.” -At 11:40 AM - E #2 noted, “(E #2) attempting to adjust toco. (E #2) able audibly to hear heart tones ranging in the 130s but briefly registering on the fetal monitor.” There was no documentation of fetal heart rate on Pt. #1’s fetal monitoring strip for this time. At 12:00 PM - E #2’s noted, “(MD #1) performing bedside ultrasound where (MD #1) reported to (E #2 and E #3) that (MD #1) was able to see cardiac activity on the monitor.” *There was no documentation of Pt. #1’s bedside ultrasound results in Pt. #1’s clinical record. There was no documentation of Pt. #1’s fetal heart rate after 11:25 AM in Pt. #1’s clinical record. -At 12:44 PM - E #2 noted, “(Pt. #1) transported off unit via stretcher accompanied by ambulance staff. Vitals: blood pressure 156/92, heart rate 120, spO2[peripheral oxygen saturation] -99 %.” 4. MD #1’s triage notes (dated 2/16/2025) indicated, “(Pt. #1) came to the ER (emergency room) (gravida[the number of times a woman has been pregnant] 8 para[the number of times a woman has given birth to a baby at or beyond 20 weeks gestation] 7) complaining of abdominal pain with nausea, body aches and pain. (Pt. #1) sent to OB for further evaluation ... (Pt.#1’s) heart rate is 120. Preterm labor?? Vaginal exam - cervix thick and uneffaced. Plan -OB labs, OB ultrasound, IV (intravenous) fluid bolus, IV Zofran (nausea medication), consult for possible transfer MFM (maternal fetal medicine) was done with (MD #3 from Hospital B). (MD #3) accepted for transfer to Hospital B.” 5. On 5/7/2025, Pt. #1’s clinical record (dated 2/16/2025 through 2/20/2025) from Hospital B was reviewed and indicated, “Hospital course -( Pt. #1) presented as a transfer of care with IUFD, found to be in DKA on admission and transferred to MICU (medical intensive care unit). While in MICU, (Pt. #1) underwent treatment for DKA and also had an induction of labor. (Pt.#1) delivered a male infant with no nuchal cord (no cord-around-the neck), demised (dead).” 6. On 5/5/2025 at 11:45 AM, an interview was conducted with MD #1. MD #1 stated that Pt. #1 was transferred to Hospital B due to preterm labor. MD #1 stated that Hospital A could deliver babies 37 weeks and older. MD #1 stated that MD #1 did not know about Pt. #1’s high blood glucose level. MD #1 stated if MD #1 knew about Pt. #1’s high blood glucose level, MD #1 would have treated Pt. #1 prior to discharge. 7. On 5/5/2025 at 12:00 PM, an interview was conducted with the OB Nurse (E #2). E #2 stated that E #2 will never forget Pt. #1. E #2 stated that MD #1 told E #2 about Pt. #1’s high glucose level. E #2 stated that MD #1 stated that Pt. #1 was going to be transferred to Hospital B. E #2 stated that Pt. #1 waited for about 1 hour before the ambulance arrived and the ambulance staff do not monitor fetal heart tones. 8. On 5/5/2025 at 1:00 PM, an interview was conducted with the OB Medical Director (MD #4). MD #4 stated that pregnant patients must be stabilized prior to transfer. MD #4 stated that Pt. #1’s blood sugar should have been stabilized prior to transfer. MD #4 stated that MD #4 reviewed Pt. #1’s fetal monitoring. MD #4 stated that when Pt. #1 had “D cells (decelerations, which temporary decreases in the baby’s heart rate - can be a sign of fetal distress). MD #4 stated that Pt. #1 should have had “resuscitative measures” such as placed on oxygen after the D cells were noted on the fetal monitoring strip. MD #4 stated that MD #3 (from Hospital B) discussed Pt. #1’s case with MD #4. MD #3 suggested to MD #4 that an RCA (root cause analysis) be conducted regarding Pt. #1. MD #4 stated that MD #4 thinks an RCA was initiated but is not completed. 9. On 5/5/2025 at 3:00 PM, an interview was conducted with the Director of Quality & Chief Nursing Officer (E #4). E #4 stated that E #4 does not think this was any incident report for Pt. #1. 10. On 5/6/2025 at 9:30 AM, a confidential interview was conducted with Z#1. Z#1 stated that Pt. #1 should not have been transferred until Pt. #1’s blood glucose was stabilized. Z#1 stated that there was no incident report regarding this incident. Z#1 stated that Pt. #1 was dumped on Hospital B without providing any treatment to stabilize Pt. #1’s condition. 11. On 5/7/2025 at 9:00 AM, an interview was conducted with Pt. #1. Pt. #1 stated that Pt. #1 went to Hospital A’s emergency room for nausea and vomiting. Pt. #1 stated that Hospital A did an ultrasound and sent Pt.#1 to the OB department. Pt. #1 stated that Pt. #1 remembers the nurses telling the doctor to do something, but Pt. #1 can’t remember details. Pt. #1 stated that Pt. #1 kept vomiting while Pt. #1 was at Hospital A. Pt. #1 stated that Pt. #1 was dying and became disoriented. Pt. #1 stated that Pt. #1 was transferred to Hospital B and put into the intensive care unit at Hospital B. Pt. #1 stated that Pt. #1 had no idea that Pt. #1 was in preterm labor. Pt. #1 stated that Pt. #1’s baby boy died.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36774 A. Based on document review and interview, it was determined that for 1 of 4 OB(obstetric) triage (Pt. #2), and 3 of 3 emergency department (Pt. #6, Pt. #7, and Pt. #8) clinical records reviewed for transfers, the hospital failed to ensure that the medical record included documentation about the risks and benefits of transfer. Findings include: 1. On 5/06/2025, the hospital’s policy titled, “Transfer/Referral of a Patient” (reviewed on 5/2021) was reviewed and included, “... It is the policy of (Name of Transferring Hospital) to provide appropriate... transfer of patients who have presented with an emergency medical condition... Explanation... 1. on the attending physician’s written certification... the potential benefit of the transfer outweighs the increased risks associate with the transfer...” 2. On 5/06/2025, the clinical record for Pt. #2 was reviewed. On 3/4/2025, Pt. #2 was brought to the hospital’s OB triage with a chief complain of (pregnancy in) labor. On 3/4/2025, Pt. #2 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer. 3. On 5/06/2025, the clinical record for Pt. #6 was reviewed. On 4/26/2025, Pt. #6 was brought to the hospital’s ED (emergency department) due to aggressive behavior. On 4/28/2025, Pt. #6 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer. 4. On 5/06/2025, the clinical record for Pt. #7 was reviewed. On 4/21/2025, Pt. #7 was brought to the hospital’s ED due to abdominal pain. On 4/22/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer. 5. On 5/06/2025, the clinical record for Pt. #8 was reviewed. On 4/18/2025, Pt. #8 was brought to the hospital’s ED due to hand problem. On 4/19/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. The clinical record did not include documentation regarding the risk and benefits of transfer. 6. On 5/06/2025 at approximately 2:18 PM, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that the above patients had emergency medical condition that required higher level of care. MD #5 stated that explanation regarding the risk and benefits of the transfer should have been explained and documented in the clinical records. B. Based on document review and interview, it was determined that for 2 of 3 emergency department (Pt. #7 and Pt. #8) clinical records reviewed for transfers, the hospital failed to ensure that the receiving facility accepted the transfer. Findings include: 1. On 5/06/2025, the hospital’s policy titled, “Transfer/Referral of a Patient” (reviewed on 5/2021) was reviewed and included, “... It is the policy of (Name of Transferring Hospital) to provide appropriate... transfer of patients who have presented with an emergency medical condition...” The policy did not include ensuring availability of qualified personnel at the receiving hospital. 2. On 5/06/2025, the clinical record for Pt. #7 was reviewed. On 4/21/2025, Pt. #7 was brought to the hospital’s ED (emergency department) due to abdominal pain. On 4/22/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. There was no documentation to ensure that the receiving hospital had agreed to accept the transfer. 3. On 5/06/2025, the clinical record for Pt. #8 was reviewed. On 4/18/2025, Pt. #8 was brought to the hospital’s ED due to hand problem. On 4/19/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care... There was no documentation to ensure that the receiving hospital had agreed to accept the transfer. 4. On 5/06/2025 at approximately 2:18 PM, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that there should be documentation in the clinical record to indicate availability of accepting physician. C. Based on document review and interview, it was determined that 1 of 4 OB triage (Pt. #2), and 2 of 3 emergency department (Pt. #6, and Pt. #7) clinical records reviewed for transfers, the hospital failed to ensure that the medical records were sent to the receiving hospital. Findings include: 1. On 5/06/2025, the hospital’s policy titled, “Transfer/Referral of a Patient” (reviewed on 5/2021) was reviewed and included, “... It is the policy of (Name of Transferring Hospital) to provide appropriate... transfer of patients who have presented with an emergency medical condition... 5. A photocopy of patient’s medical record and other documents as required will be sent with the patient...” 2. On 5/06/2025, the clinical record for Pt. #2 was reviewed. On 3/4/2025, Pt. #2 was brought to the hospital’s OB triage with a chief complain of (pregnancy in) labor. On 3/4/2025, Pt. #2 was transferred to another hospital due to a need for higher level of care. There was no documentation to indicate that the patient’s medical record and other document were sent to the receiving hospital. 3. On 5/06/2025, the clinical record for Pt. #6 was reviewed. On 4/26/2025, Pt. #6 was brought to the hospital’s ED (emergency department) due to aggressive behavior. On 4/28/2025, Pt. #6 was transferred to another hospital due to a need for higher level of care. There was no documentation to indicate that the patient’s medical record and other document were sent to the receiving hospital. 4. On 5/06/2025, the clinical record for Pt. #7 was reviewed. On 4/21/2025, Pt. #7 was brought to the hospital’s ED due to abdominal pain. On 4/22/2025, Pt. #7 was transferred to another hospital due to a need for higher level of care. There was no documentation to indicate that the patient’s medical record and other document were sent to the receiving hospital. 5. On 5/06/2025 at approximately 2:18 PM, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that the above patients required higher level of care. MD #5 stated that there should be a documentation to indicate that the medical records were sent to the receiving hospital.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 27125 Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The hospital failed to ensure patients exhibiting elopement behaviors were monitored to ensure safety of the patient. (See A-144) The immediate jeopardy began on 2/13/2024, due to the Hospital’s failure to ensure patients exhibiting elopement behaviors were monitored, allowing a patient to pull the fire alarm and elope from the Hospital; and was identified on 2/22/2024 at 42 CFR 482.13, Patient Rights. The IJ was announced on 2/22/2024 at 1:35 PM during a meeting with the Chief Executive Officer, Chief Quality Officer, Director of Regulatory, Chief Medical Officer and Clinical Services Administrator and was not removed by the survey exit date of 2/22/2024.”

“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: 27125 Based on document review, observation, and interview, it was determined that for 1 of 1 (Pt. #1) behavioral health patients involved in an elopement, the hospital failed to ensure patients exhibiting elopement behaviors were monitored to ensure the safety of the patient. Subsequently, Pt. #1 eloped from the hospital. This could potentially affect the current 14 behavioral health patients on census who are on elopement precautions. Findings include: 1. The hospital’s policy titled, “Precaution (9/3/2021)” was reviewed on 2/20/2024 and required, “The patient admitted to Behavioral Health will be placed on elopement precautions as part of standard admission precautions. ... Patients on any special precautions (suicide, elopement, assault, ...) will be monitored every 15 minutes and the patient status will be documented by the staff on the Observation Flow Sheet. ... There will be a staff member assigned to observe the hallways and bathrooms.” 2. The clinical record of Pt. #1 was reviewed on 2/20/2024. Pt. #1 presented to the emergency department on 2/9/2024 with complaints of paranoia, increased auditory hallucinations and medication noncompliance. Pt. #1 was admitted to the locked behavioral health unit and placed on suicide, elopement, and assault precautions, requiring every 15-minute observations. The BHU (behavioral health unit) Observation Record, dated 2/13/2024, indicated that Pt. #1 was not observed from 2:45 PM to the time of elopement at 3:35 PM (50 minutes). A nurse’s note, dated 2/13/2024 at 2:47 PM included, “Patient [Pt. #1] visible in hallway. Patient had to be redirected away from the nurse’s station multiple times. Patient is demanding to see nurse practitioner [NP#1] regarding discharge. [NP#1] talked to [Pt. #1] several times and [Pt. #1] continues to request to see [NP#1] and constantly asks the nurses about discharge. The discharge summary (NP#1), dated 2/14/2024 at 10:03 AM included, “ ... Patient [Pt. #1] was seen by the nurse practitioner [NP] during morning rounds, patient was preoccupied with discharge all day, asking to be discharged home today [2/13/2024] ... Patient was told by the NP that [Pt. #1] will be discharged home when stable. During quiet time, it was reported that patient [Pt. #1] pulled the fire alarm and ran out of the unit and made it out of the hospital building. Patient was not properly discharged from the unit. Patient is safe and is currently at home with family.” 3. The hospital’s incident report dated 2/14/2024 included, “This writer heard alarms and immediately performed nursing rounds, noted Patient [Pt. #1] not in assigned room. Security arrived on site. MHA’s and nursing started searching for patient in and around facility. Staff monitoring exit doors for safety and to prevent other patients from leaving unit and or eloping. Patient unable to be located at this time. Cause: Hallways were not covered.” 4. On 2/20/2024 at 10:00 AM, an observational tour was conducted on the BHU (2nd floor). The BHU census was 14 adults (male and female). There were 14 patients on elopement precautions. There were 2 hallways (one long hallway and one short hallway). Pt #1’s room (2024 -private room) was located on the long hallway. 5. A video review of February 13th from 3:34 PM to 3:37 PM (time of reported elopement) was conducted on 2/20/2024 at 8:50 AM with the clinical services administrator (E#1). The video included: 3:34 PM - staff taking vital signs of a patient outside the nurse’s station, three staff seen in the hallway. 3:35:34 (hour, minute, second) - Pt. #1 seen walking down a hallway (behind nurse’s station) with blanket wrapped around body and head - no staff visible in the hallway. 3:35:50 PM - Pt. #1 at end of hallway, pulled alarm by door and blanket fell to floor, Pt. #1 was gone out the back door. 3:36:03PM - a MHA (mental health associate - E#3) entered the hallway, went to door at end of hallway, turned around and began a room-to-room search. Two additional staff entered hallway and began room to room search. Exit door was left unattended. 3:33:56 PM [Camera time based on different camera settings, but time was after elopement]: - A different camera from outside of the hospital shows Pt. #1 running east down the street in front of the hospital. 6. The MHA (E#8), who was assigned to monitor the short hallway, was interviewed on 2/20/2024 at 12:10 PM. E#8 stated that E#8’s assignment was to watch the short hallway. E#8 stated, “I went on break, told another MHA that I was leaving.” E#8 stated that the other MHA was busy and never went to the short hallway to take E#8’s place. 7. The risk compliance manager (E#9) was interviewed on 2/20/2024 at 12:45 PM. E#9 stated that an incident report was completed, and interviews of the staff were started to determine the cause. E#9 presented the investigation that included: Findings: Patient was released from quiet room and was not monitored by assigned staff. No Code Grey was called for elopement. Staff was not posted in the corridor. Documentation of patient being in quiet room without notes of behavior issue warranted. Minimal MHA documentation on patient behavior changes Recommendations and Corrective Actions: Disciplinary action determined by BHU manager. Education and training regarding coverage of unit. Assign coverage for lunch and breaks. Review and update policy - elopement risk patient process, precaution policy, safety rounds, MHA documentation process, Lunch/break protocol, staffing assignment process. Education and training on policies and procedures listed above. E#9 stated that E#9 was unclear as to what has been completed from the recommendation list as of 2/20/2024. 8. The interim Nurse manager of Behavioral Health (E#4) was interviewed on 2/20/2024 at 11:10 AM. E#4 stated, “When a fire alarm goes off, the exit doors automatically unlock. Staff are required to go to all exits. I heard someone say, ‘A patient eloped’. They found a blanket by the door, looked down the stairs and noticed the outside door was open. Once the staff figured out who was missing, they went back to the stairway with security and went outside to see if they could see the patient. The patient was not found.” E#4 stated that an elopement had never happened before. The staff have been in serviced on environmental rounds [every 15 minute monitoring and documentation] and the requirement to not leave a hallway unattended. No policies have been reviewed or revised yet. E#4 stated, “Approximately 50 % of the staff have been reeducated. I’m also working on redoing the assignment sheet to include and clarify who should cover when breaks are taken. There should have been someone in the hallway and the monitoring rounds should have been completed and documented. That is a requirement.”

“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: 37971 Based on observation, document review, and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to conduct a thorough re-assessment as required and medical screening examination by the licensed medical practitioner to determine if an emergency medical condition existed. (A-2406) The Immediate Jeopardy began on 05/29/2023 due to the hospital’s failure to conduct a complete a medical screening examination to determine if an emergency medical condition existed. Subsequently the patient was found unresponsive and died. The IJ was identified on 12/8/2023 at 42 CFR 489.24 (a) (c). The IJ was announced on 12/08/2023 at 10:30 AM during a meeting with the Director of Regulatory, Clinical Services Administrator, Chief Medical Officer, Chief Quality Officer, Chief Executive Officer, and Risk Manager. The IJ was not removed by the survey exit date of 12/08/2023.”

“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: 40079 Based on document review and interviews, it was determined that for 1 of 25 (Pt. #1) clinical records reviewed for emergency medical services, the hospital failed to complete an appropriate medical screening exam to determine whether or not an emergency medical condition existed prior to discharge. Subsequently Pt.#1 expired. 1. On 12/05/23, the hospital’s policy titled, “Emergency Medical Treatment (EMTALA)” (revised 5/2021) was reviewed and required, “ ... all persons seeking emergency care at hospital shall receive an appropriate medical examination and evaluation (‘screening to determine whether an emergency condition exists ...’) If the patient has an emergency medical condition, the patient will receive treatment within the hospital’s capabilities until the condition is stabilized ...” 2. On 12/05/23, the hospital’s policy titled, “Emergency Management of Narcotic Overdose/Substance Abuse: Guidelines” (revised 05/2021) was reviewed and included, “Substance Abuse, signs & symptoms: A. Examples ...1. Opiates (Heroin) ... 5. Cocaine, Amphetamines ... Clinical Manifestations -acute intoxication/overdose ... 1. Slurred speech ... 3. Decreased Vital signs ... 6. Tachycardia ... Emergency Management per Physician Order: 1. Monitor vital signs, cardiac and respiratory monitoring ... 3. Send urine for urinalysis with toxicology screen ... Opioid Withdrawal - Signs and Symptoms 1. Lethargy ... 4. Irritability/Agitation ... Emergency Management ... 1. Intravenous fluids. 2. Assess for Associated Medical problems and comorbidities. 3. Place patient in protective environment under proper medical supervision. 4. Continuous Monitoring of Vital Signs and Reassessment ...” 3. On 12/05/23, the hospital’s policy titled, “Reporting Critical or Panic or there Results” (revised 3/8/23) was reviewed and required, “A. Critical Values: Denoting a morbid condition in which death is possible. Critical or Panic Values: A=Urgent Action-notify the ordering physician or designated service immediately, all hours ... Troponin - I POS > 0.03 (positive greater than) = Urgent Action required ... It is the responsibility of the technologist who performs the test to initiate notification of such results to physicians or RNs ...” 4. Pt. #1’s clinical record was reviewed and indicated that on 05/29/2023 Pt. #1 was brought to the Emergency Department (ED) by ambulance with a chief complaint of drug ingestion. The clinical record included the following: -Ambulance Care Report, dated 5/29/23 at 12:30 PM, included “Called for overdose.” Pt. #1 was found on the porch stating that Pt. #1 had been “on a weeklong crack binge”. -Triage Note dated 5/29/23 at 12:34 PM, vital signs were the following: Temperature 98.5 (normal 95.9-99.6); Blood Pressure 96/62 (normal systolic 100-140); Pulse 95 (normal 60-90); Respirations 15 (12-24); O2 Sat 93% (normal oxygen saturation 95-100); ... Psychosocial History: Schizophrenia; Substance use: Yes Cocaine, heroin ... Triage Acuity Level: ESI-3 (emergency severity level-1 requiring immediate care; 3-emergency care).” -EKG (electrocardiogram/shows electrical activity of the heart) report dated 05/29/23 at 1:47 PM, included, “Ventricular rate 113 bpm (beats per minute/normal range 60 - 100) Sinus tachycardia.” - History and physical (entered by MD #1) dated 05/29/23 at 12:59 PM, “ ... Chief Complaint: Drug ingestion ... Mentioned cocaine use heavily. Physical Exam: Conscious (appears drowsy) ...cardiovascular/Chest: Sinus tachycardia (irregular rapid heartbeat at 110 beats per minute/normal 60-90) ... (Pt. #1) is more alert, (Pt. #1) is refusing all further treatment and evaluation in their workup, noncooperative, will be discharged home, the nurse, and the ER (emergency room) physician both tried to encourage him to allow evaluation and treatment and/or observation (Pt. #1) is refusing everything. Disposition: Discharge to home, self-care at 12:59 PM. Clinical Impression: cocaine abuse. Condition: Fair.” -Nursing note (E #10/Registered Nurse) dated 05/29/23 at 2:53 PM, “(Pt. #1) becomes angry and screams at staff stating (Pt. #1) does not want any more services. Security is called, (Pt. #1) is d/c’d (discharged) after showing (Pt. #1) is stable for d/c, security wheels pt to waiting area to wait for bus card.” -Pt. #1 was escorted to warming area (area adjacent to the emergency department [ED] where people come to warm up or to cool down from the weather) at 2:59 PM. -Laboratory report dated 05/29/23 at 14:00 (2:00 PM), included the following: K level (potassium) at 6.2 high (normal range is 3.5-5.1; high levels-can cause heart problems that require immediate medical attention); Troponin at 0.170/high (normal level 0.000-0.034/value greater than 0.120 has a 95% positive predictive value for positive acute myocardial infarction). Pt. #1’s clinical record lacked documentation regarding the abnormal lab results being reviewed, reported, or assessed by laboratory staff, ED physician, and ED registered nurse. 5. Pt. #1 was readmitted to the ED on 5/29/2023 at 7:43 PM (4 hours and 44 minutes after first ED visit). The clinical record included the following: History dated 05/29/23 at 8:12 PM, “(Pt. #1) ...was sitting in the waiting area and (Pt. #1) was found to be unresponsive and was brought to the main ED ...” At 7:43 PM Cardiopulmonary resuscitation (CPR) was initiated, and emergency medication were administered. CPR was discontinued and patient was pronounced dead at 8:09 PM. 6. On 12/05/23, the hospital provided a “Quality Management Occurrence Report (QMOR)” dated 05/30/23 at 3:02 PM and included, “Date of Occurrence; Time 14:25 PM (2:25 PM) ... with (Pt.#1), Security reported; the ED physician (MD#1) on duty and nurse (E#10) requested to have the patient mentioned escorted out of the building, stating the patient refused care. When public safety officers arrived, (Pt. #1) appeared to be unstable, (Pt. #1) was unable to stand or walk and his eyes were rolling different directions per responding officers. (MD #1) was very adamant directing security to escort (Pt. #1) out of the building. Security informed the nurse and doctor of the patient’s current state, however, instructed security to escort (Pt. #1) outside. Security did not feel comfortable escorting (Pt. #1) out of the building therefore they assisted (Pt. #1) into a wheelchair and allowed (Pt. #1) to wait in the waiting area. At approximately 20:25 (8:25 PM) hours, it was reported the (Pt. #1). in question was found without a pulse ... What Caused this Occurrence? (MD#1) ended treatment and requested to have patient escorted out of the building.” 7. On 12/05/2023 at 2:00 PM, the hospital’s quality department timeline for the sentinel event was reviewed and included, Staff members (anonymous) stated: The [Pt. #1] stated (Pt. #1) could not walk and complained of chest pains ...” 8. On 12/05/23 at 12:45 PM, an interview was conducted with a Security Officer (E #7), E #7 stated a nurse (E #10) called E #7 to the back to take a patient out of the ED because the patient wanted to leave. E #7 stated that the patient (Pt.#1) did not look well and needed help getting up from the bed because he could not stand or walk, (Pt.#1) stated his legs were wobbly. The patient was calm and cooperative when speaking with E #7. E #7 and another Security Officer helped (Pt.#1) into a wheelchair and took him out to the warming center. (Pt.#1) had to be assisted out of wheelchair to another chair. The patient stated (Pt. #1) needed a few minutes to get self together. E #7 stated that the nurse and physician were present when the patient stated (Pt. #1) could not walk and had to be assisted to the wheelchair. 9. On 12/05/23 at 2:15 PM, an interview was conducted with the Chief Medical Officer (MD #2). MD #2 stated that a patient can be discharged before stat (immediately) lab results are obtained, based on their clinical presentation. In the case of (Pt.#1) it was the right of the patient to refuse treatment. However, if a patient is unresponsive, we will proceed with the necessary care and interventions. MD #2 was asked if based on the RCA findings, was (Pt.#1) safe to be discharged from the ED. MD #2 stated that the RCA findings indicated that (Pt.#1) was not wanting to stay, (Pt.#1) was belligerent and did not want any treatment and did not want to be there, this patient was not safe to discharge. MD #2 stated that the RCA should have identified other concerns such as the lab results were not reported or followed up, and if there was a concern that the patient was not adequate for discharge, (Pt.#1) should have been reassessed. 10. On 12/06/23 at 2:05 PM, an interview was conducted with MD #1 (ED Physician/ED Medical Director). MD #1 stated that any patient in the ED with a change in condition should be re-evaluated prior to discharge. MD #1 stated that based on his evaluation (Pt.#1) did not have a change in medical condition and was appropriate for discharge. MD #1 stated that MD #1 did not recall any staff voicing concern about escorting the patient (Pt.#1) off the premises. MD #1 stated that he ordered cardiac enzymes and other labs because the patient reported cocaine and heroin abuse. The patient was discharged before these lab results were reported. MD #1 stated that the laboratory did not call on any abnormal lab results and that he did not look at the lab results because the patient was already discharged.”