Saint Francis Hospital-Evanston

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined for 1 of 2 (Pt. #1) clinical records reviewed for restriction of rights, the hospital failed to ensure that a notice of Restriction of Rights form was completed, when an emergency medication was administered, as required. Findings include: 1. The Hospital’s policy titled “Restriction of Rights Notifications” (Last Revised 9/19/2022) included: “ ...Behavioral Health and Non-Behavioral Health and ED’s - 1. Restriction of Rights form is to be completed in the following instances ...b. Administering psychotropic medication without the patient’s consent ...” 2. The clinical record of Pt. #1, reviewed on 2/18/2025, included that “Pt. #1 presents to the emergency department after asking someone to call the paramedics. Patient is hyperverbal with word salad and unable to have a linear conversation ...Patient is unable to give any meaningful history or answers questions in any kind of linear capacity. Patient unable to give consent, cannot hold a linear conversation, doesn’t answer questions appropriately...ED [Emergency Department] Medical Decision Making ...Presentation concerning for acute psychosis...” The record included the following physician’s orders for medication and administration documentation: - 10/3/2024 at 11:32 AM to give Midazolam (anti-anxiety medication) 2 mg (milligrams) IV (intravenous) once. An entry dated 10/3/2024 at 11:58 AM in the clinical record, indicated that Midazolam 2 mg was administered intravenously to Pt. #1. - 10/3/2024 at 12:02 PM to give Haloperidol Lactate (antipsychotic medication) 5 mg IM (intramuscular) once. An entry dated 10/3/2024 at 12:04 PM in the clinical record, indicated that Haloperidol Lactate 5 mg was administered intramuscularly to Pt. #1. - 10/3/2024 at 11:32 AM to give Haloperidol Lactate 5 mg IV once. An entry dated 10/3/2024 at 1:47 PM in the clinical record, indicated that Haloperidol 5 mg was administered intravenously to Pt. #1. - 10/3/2024 at 8:40 PM to give Droperidol (antipsychotic medication) 2.5 mg IM once. An entry dated 10/3/2024 at 8:46 PM in the clinical record, indicated that Droperidol 2.5 mg was administered intramuscularly to Pt. #1. - 10/3/2024 at 8:40 PM to give Midazolam 5 mg IM once. An entry dated 10/3/2024 at 8:46 PM in the clinical record, indicated that Midazolam 5 mg was administered intramuscularly to Pt. #1. - 10/4/2024 at 11:13 PM to give Haloperidol Lactate 5 mg IM once. An entry dated 10/5/2024 at 12:51 AM in the clinical record, indicated that Haloperidol 5 mg was administered intramuscularly to Pt. #1. The record lacked documentation that a Restriction of Rights form had been completed for the above-mentioned instances when a psychotropic medication was administered. 3. On 2/19/2025 at approximately 2:05 PM, an interview with a Registered Nurse (E#8). E#8 stated that best practice dictates that a Restriction of Rights form be completed for each instance of administering a psychotropic medication.”

“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: 27125 Based on document review, observation, and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to ensure a medical screening exam was performed for a patient on hospital grounds observed by staff to be in need of emergency medical treatment, until EMS (emergency medical services) came and brought the patient into the hospital.”

“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: 27125 Based on document review, observation and interview it was determined that for 1 of 1 (Pt. #1) clinical records reviewed for a patient on hospital grounds observed to be in need of emergency medical treatment, the hospital failed to ensure a medical screening exam was performed, until EMS (emergency medical services) came and brought the patient into the hospital. Findings include: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy (12/21/2022)” was reviewed on 5/14/2024 and included, “Comes to the Emergency Department” means an individual: ... Has presented on hospital property, other than dedicated emergency department, and requests examination or treatment for what may be an Emergency Medical Condition. ... In the absence of such request ... a request will be considered to exist if a prudent layperson (common sense) observer would believe, based on individual’s appearance or behavior, that an individual needs emergency examination or treatment. ... Hospital Property means the entire main campus of the Hospital, including sidewalks, parking lots and driveways or hospital departments, including any buildings owned by the hospital that are within 250 yards of the hospital.” 2. The security log from 1/20/2024 to 1/27/2024 was reviewed on 5/14/2024. A report, dated 1/22/204 at 6:30 AM described an event that matched the complaint about Pt. #1. The report included: “On the morning of January 22, 2024, at around 6:00 AM, the lead security officer (E#2) and another security officer (E#3) were cleaning up the waiting room of homeless people who the ED staff had allowed to stay. ... We came across [Pt. #1] who had been in the waiting room for 24 hours and kindly asked [Pt. #1] to leave. ... [Pt. #1] ended up going outside around 6:45 AM. E#3 saw Pt. #1 outside smoking what he thought was a cigarette. [Pt. #1] was standing out there for about 15 minutes and then laid down on the ground. E#3 came to inform me [E#2] that [Pt. #1] was laying down outside and may need help. I told the charge nurse (E#4) what was happening and explained to [E#4] the situation. (E#4) said ’[Pt. #1] is probably ‘just playing possum trying to get back in’. E#3 had already placed a call to the police to come help escort [Pt. #1] off the property. Multiple nurses and doctors walked by [Pt. #1] and 2 or 3 ambulances drove by [Pt. #1] as well, never checking on [Pt. #1]. The police arrived and went to try to get [Pt. #1] off the ground, but found [Pt. #1] to be unresponsive, so the officer came in and told me (E#2) that [Pt. #1] was unresponsive. ... So, I (E#2) went back into the ED and found (E#4) in a huddle and explained what we had discovered, and E#4 told me that if [Pt. #1] needed to be checked in, then we will check [Pt. #1] in. I returned to post 1[area in ED] to discover that the police had called the fire department, and they arrived around maybe 7:15 AM or so and they also found [Pt. #1] unresponsive, so they brought [Pt. #1] into the ED and placed [Pt. #1] into trauma room #2. 3. The clinical record of the 1/22/2024 encounter was reviewed on 5/14/2024. Pt. #1 presented to the Hospital via ambulance on 1/22/2024 at 7:09 AM with the diagnosis of altered mental status. - A nurses note (E#8), dated 1/22/2024 at 7:10 AM included, “Patient found laying out in parking lot in front of ED not responding; EPD [police department] and EFD [fire department] brought patient into ED. Patient minimally responsive on arrival. - The emergency department note - history and physical (H&P) (MD#1), dated 1/22/2024 at 7:19 AM included that Pt. #1 had a history of seizure disorder and presented with a chief complaint of altered mental status. Pt. #1 was found unresponsive in the parking lot and the police department called EMS. Pt. #1 had been discharged from the ED on 1/21/2024 and was allowed to stay in the waiting room overnight. Pt. #1 had been asked to leave and was escorted out by security about 15 minutes prior to arrival on 1/22/2024. Pt. #1 was subsequently admitted to the hospital. 4. A video of the alleged event was reviewed on 5/14/2024 at 12:45 PM with the Director of Security (E#5). The video dated 1/22/2024 included the following: There was a light layer of snow on the ground and the ED ramp was wet. - 6:30 AM - Pt. #1 was seen walking out of the hospital ED exit onto the ambulance ramp. Pt. #1 was wearing winter coat and sweatpants. - 6:32 AM - Pt. #1 started talking to a male visitor outside on the ramp. Pt. #1 and male appeared to be smoking (unknown substance). - 6:37 AM - The male visitor leaves to return to hospital. - 6:39 AM - Pt. #1 begins wobbling (still on ambulance ramp), appears to lose balance and falls (approximately 25 - 30 yards from ED door - still on ambulance bay ramp). Pt. #1 was laying on back, face up tilting to the right side. This was witnessed by a security officer (E#3). E#3 was visualized approximately 15 yards from Pt. #1, closer to hospital doors. - 6:40 AM - The security officer (E#3)walks quickly into the hospital. - Between 6:40 AM and 6:51 AM - 1 ambulance drives out of the ambulance bay and two staff (per E#5, identified as hospital staff, but E #5 unable to identify names) walk up to hospital past Pt. #1. - 6:51 AM - The police arrive. The police officer approaches Pt. #1 and kicks Pt. #1 on the arm lightly - no response from Pt. #1. - 6:52 AM - The police officer and two staff (per E#5, identified as hospital staff, but E #5 unable to identify names) members go into the hospital. - 6:54 AM - The police officer returns to Pt. #1 and shines a light in Pt. #1’s eyes. No response from Pt. #1. The police officer enters the police car. - Between 6:54 AM and 6:57 AM - 3 staff walk past Pt. #1 when entering the hospital and 1 staff walks past Pt. #1 when leaving the hospital (per E#5, identified as hospital staff, but E #5 unable to identify names). - 6:58 AM - An ambulance, fire truck an additional police officer arrives. The ambulance blocks the view of Pt. #1. - 7:00 AM - Pt. #1 is on a stretcher and taken into the hospital by EMS (emergency medical services). 5. The charge nurse (E#4), on duty when Pt. #1 was found outside, was interviewed on 5/15/2024 at 8:00 AM. E#4 stated that E#4 had spoken to Pt. #1 in the morning when security was clearing the ED of people that had stayed overnight. E#4 stated, “I asked [Pt. #1] if [Pt. #1] needed help with transportation to a shelter. [Pt. #1] used the bathroom and denied need for additional resources. [Pt. #1] walked outside independently.” E#4 stated that a little while later security told E#4 that Pt. #1 needed medical assistance. E#4 was preparing for the end of shift huddle and said would be available shortly. E#4 stated, “I was told that [Pt. #1] was laying on the ground, I did say that maybe [Pt. #1] was playing possum to get back inside. I just needed to wrap up a couple of things and was planning on going outside.” E#4 stated that E#4 never escalated the situation to anyone or ask anyone else to go check on Pt. #1. E#4 stated, “I probably should have sent someone else, but I had a rapport with [Pt. #1] and thought I could take care of it.” E#4 stated that staff can assist someone in need anywhere on hospital property or can call 911 if unable to get person into the hospital by themselves. 6. The ED medical director/chief medical officer (MD#2) was interviewed on 5/15/2024 at 9:30 AM. MD#2 stated, “I was not aware of this situation until yesterday when you [surveyors] arrived. I am embarrassed that I was not made aware. It is not only policy to help someone in need on hospital property, and our responsibility, but it’s the humane thing to do.” MD#2 stated that all of administration should have been made aware and investigated right after event occurred.”