Northeast Regional Medical Center

“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: 49404 Based on record review and policy review, the hospital failed to follow their policy to provide within its capability and capacity, an appropriate medical screening examination (MSE) for two patients (#3 and #6) and failed to appropriately transfer one patient (#2) of 21 Emergency Department (ED) records reviewed from 06/01/23 to 07/31/23 and 09/01/23 to 02/13/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” dated 07/2021 showed: - When an individual comes to the ED requesting medical treatment, an appropriate MSE, within the capabilities of the ED, shall be performed to determine whether an EMC exists. - If the patient informed the ED staff that they are leaving the hospital prior to receiving a MSE, staff should attempt to persuade the patient to stay until they can be screened. - The ED physician or Qualified Medical Professional (QMP) should discuss the risks of leaving the ED prior to receiving a MSE or prior to receiving stabilizing treatment for an EMC. - If the patient refuses to stay ED staff should obtain the patient’s signature, date and time on an Against Medical Advice (AMA) form. - If it is determined through a MSE that an EMC exists, ED personnel shall provide further medical evaluation and treatment as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital or transfer the individual to another appropriate facility that can meet the patient’s needs. - Transfer of an individual with an EMC must be initiated by a physician’s order and the individual being transferred must be informed of the risks versus benefits of the transfer. - Transfer procedures require the hospital to provide stabilizing medical treatment within its capabilities to minimize risks of transfer, acceptance of the patients by the receiving hospital that has the available space and qualified personnel to treat the individual and has agreed to provide appropriate medical treatment. The hospital will provide the receiving hospital with all medical records that are available of the time of transfer and relevant to the EMC. - Transport is carried out through qualified personnel and appropriate transportation and equipment, as required. The transferring physician will determine and order the life support measures, personnel and equipment that are medically appropriate to sustain the individual during transfer. - Appropriate transport for an emergent patient would be an ambulance or medical helicopter with an emergency medical service (EMS, emergency response personnel, such as paramedics, first responders, etc.) crew, but never a private vehicle or taxi; personal vehicles are not considered “appropriate transportation” because they do not include equipment or life support measures and they are not driven or staffed by trained emergency professionals. - Generally, ED patients are not transferred, and stabilization of the patient ends the hospital’s EMTALA obligations. If a patient needs follow up care, they are discharged with instructions. - Transfer to another medical facility by appropriate means may occur after stabilization if the individual requires specialized treatment not available at the hospital and another hospital with specialized facilities has space and personnel available in the specialized facility. Under those circumstances, the transfer of the patient is not governed by EMTALA. Instead, the hospital should follow applicable policies and procedures relating to non-emergency transfers. Review of the hospital’s policy titled “Suicide (to cause one’s own death) Risk Assessment and Interventions,” dated 10/2019 showed all adult patients who present for care and services will be screened for suicide ideation (SI, thoughts of causing one’s own death) and behavior using the Columbia Protocol, also known as the Columbia Suicide Severity Rating Scale (CSSRS, a scale to evaluate a person’s risk to self-inflicted hard and the desire to end one’s life). Based on the severity and immediacy of the suicide risk assessed by the Columbia Protocol, patient safety measures and interventions will be implemented to keep patients safe from inflicting harm to self. Patients assessed as high suicide risk were to be placed on one-to-one (1:1, continuous visual contact with close physical proximity) continuous observation, the Registered Nurse (RN) notifies the physician, and the physician orders a mental health professional referral. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” dated 02/2023, showed the Emergency Medicine Physician or their qualified designee will see, evaluate, and treat all persons presenting themselves to the hospital ED for emergency medical care. Even though requested, the hospital failed to provide an elopement (when a person makes an intentional, unauthorized departure from a medical facility) policy. Review of Patient #3’s ED record, dated 06/07/23 showed the following: - She was a 16-year-old female who presented to the ED at 4:57 PM with her counselor, who was concerned that the patient was dehydrated (condition caused by excess loss of water from the body). - Laboratory tests were drawn and showed she had a low potassium (a mineral needed for your body to function properly). - She was given intravenous (IV, in the vein) fluids and a potassium supplement. - At 7:20 PM, she was discharged home. - A urinalysis (a laboratory examination of a person ’ s urine) was not ordered. Review of Patient #6’s medical record, dated 09/02/23, showed: - She presented to the ED at 12:33 PM accompanied by her boyfriend with a chief complaint of intoxication and SI. - She reported she was intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) and her last drink was 20 minutes before going to the ED. A nursing assessment was completed, and blood was drawn for laboratory tests, which included a complete blood count (CBC, a blood test performed to determine overall health including inflammation and infection), comprehensive metabolic panel (CMP, a blood test performed to a variety of diseases and conditions), and blood alcohol level. - At 12:39 PM, her nurse recorded her CSSRS as high risk for suicide and that Staff K, physician, was notified. - At 12:41 PM, Staff K saw the patient. She later had a discussion with the patient regarding her alcohol intoxication, and informed the patient she could not be assessed by psychiatric (relating to mental illness) services until her alcohol level was decreased. - At 1:09 PM, the patient was in her exam room with her significant other in line of sight of an RN. - At 2:16 PM Staff J, RN, discovered that the patient had left with her boyfriend. The police and Staff K were notified. Staff K spoke to the patient by phone, the patient said she felt better, wanted to sleep and was not suicidal. She agreed to return to the ED, but did not. Review of the hospital’s policy titled “Transfer Protocols,” dated 03/28/23 showed the referring physician consults with the receiving physician regarding arrangements, transportation and acceptance of the patient assuring the facility is capable of assuming care of the patient. The Trauma Team Leader decides to transfer and chooses the most expedient and appropriate route of transfer to provide for the care of the patient. Review of Patient #2’s medical record, dated 07/16/23, showed: - She presented to the ED by personal automobile at 12:23 PM for a left arm cut that occurred at home prior to arrival. - A tranexamic acid (a medication that blocks the breakdown of blood clots, preventing bleeding) soaked sterile gauze dressing was applied to a 3.5 centimeter (CM, a unit of measurement) laceration (a deep cut or tear in skin) on her left wrist, profuse bleeding was noted. Intravenous (IV, in the vein) access was obtained and laboratory tests were drawn. - The ED physician assessed the patient and contacted Hospital C at 1:58 PM for a vascular surgery (surgery that can be used to treat a wide range of heart and blood flow issues) consultation. Hospital C agreed to see the patient in their ED. - The physician cleansed the wound, applied sutures, and dressed the wound with a gauze pressure dressing. The patient tolerated it well and the bleeding stopped. - The physician and the receiving physician agreed that it was appropriate for the patient to be transferred by personal automobile. - The physician discussed the plan of care with the patient, all questions and concerns were addressed prior to disposition and the patient was agreeable to the plan. - The patient left the ED at 3:56 PM accompanied by her husband. - There was no documentation that Patient #2 was offered transportation via EMS and no documentation that Patient #2 refused to be transferred via ambulance. Review of Patient #2’s Hospital C medical record, dated 07/16/23, showed: - She presented to the ED at 6:30 PM for an evaluation of a laceration to her left wrist. - The physician’s assessment noted a three cm laceration to the left forearm with a single figure eight suture and no active bleeding. The patient’s left arm strength was normal with subjective numbness and tingling to her left hand. An x-ray (test that creates pictures of the structures inside the body, particularly bones) of her arm was negative. - The wound was opened, washed out, and reclosed with a single layer of sutures. The tendons were intact, and the post-procedure examination showed her affected hand’s circulation, sensation and motor ability were intact. - The patient was discharged home with instruction to follow up with plastic surgery in about a week.”

“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: 49404 Based on interview, record review, and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#3 and #6) out of 21 Emergency Department (ED) records reviewed from 06/01/23 to 07/31/23 and 09/01/23 to 02/13/24. This failed practice had the potential to cause harm to all patients who presented to Northeast Regional Medical Center seeking care for an EMC. Findings included: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Policy,” dated 07/2021 showed: - When an individual comes to the ED requesting medical treatment, an appropriate MSE, within the capabilities of the ED, shall be performed to determine whether an EMC exists. - If the patient informed the ED staff that they are leaving the hospital prior to receiving a MSE, staff should attempt to persuade the patient to stay until they can be screened. - The ED physician or Qualified Medical Professional (QMP) should discuss the risks of leaving the ED prior to receiving a MSE or prior to receiving stabilizing treatment for an EMC. - If the patient refuses to stay, ED staff should obtain the patient’s signature, date and time on an Against Medical Advice (AMA) form. - If it is determined through a MSE that an EMC exists, ED personnel shall provide further medical evaluation and treatment as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital or transfer the individual to another appropriate facility that can meet the patient’s needs. Review of the hospital’s policy titled “Suicide (to cause one’s own death) Risk Assessment and Interventions,” dated 10/2019, showed all adult patients who present for care and services will be screened for suicide ideation (SI, thoughts of causing one’s own death) and behavior using the Columbia Protocol, also known as the Columbia Suicide Severity Rating Scale (CSSRS, a scale to evaluate a person’s risk to self-inflicted hard and the desire to end one’s life). Based on the severity and immediacy of the suicide risk assessed by the Columbia Protocol, patient safety measures and interventions will be implemented to keep patients safe from inflicting harm to self. Patients assessed as high suicide risk were to be placed on one-to-one (1:1, continuous visual contact with close physical proximity) continuous observation, the Registered Nurse (RN) notifies the physician, and the physician orders a Mental Health Professional referral. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” dated 02/2023, showed the Emergency Medicine Physician or their qualified designee will see, evaluate, and treat all persons presenting themselves to the hospital ED for emergency medical care. Even though requested, the hospital failed to provide an elopement (when a person makes an intentional, unauthorized departure from a medical facility) policy. Video of the ED exits from 09/02/23 was requested but not provided by the hospital. Review of Patient #3’s ED record showed the following: - She was a 16-year-old female who presented to the ED on 06/07/23 at 4:57 PM with her counselor, who was concerned that the patient was dehydrated (condition caused by excess loss of water from the body). - She had a history of methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) use. - Laboratory tests were drawn and showed she had a low potassium (a mineral needed for your body to function properly) level. - At 5:44 PM, Staff I, ED Physician, documented that Patient #3’s counselor had been concerned about dehydration based on her urine being brown in color. - She was given a liter (L, metric unit of measure) of lactated ringers (intravenous [IV, in the vein] fluid that contains electrolytes) and potassium chloride (medication used to treat and prevent low levels of potassium). - At 7:20 PM, Patient #3 was discharged home. - A urinalysis (a laboratory examination of a person’s urine) was not ordered. Review of Patient #6’s medical record, dated 09/02/23, showed: - She presented to the ED at 12:33 PM accompanied by her boyfriend with a chief complaint of intoxication and SI. - She reported she was intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs) and her last drink was 20 minutes before going to the ED. A nursing assessment was completed, and blood was drawn for a complete blood count (CBC, a blood test performed to determine overall health including inflammation and infection), comprehensive metabolic panel (CMP, a blood test performed to a variety of diseases and conditions), and blood alcohol level. - The patient’s blood alcohol level was 334 mg/dl, with a reference range of 0.0 - 10.0. - At 12:39 PM her nurse recorded her CSSRS as high risk for suicide and that Staff K, physician, was notified. - At 12:41 PM Staff K saw the patient. She later had a discussion with the patient regarding her alcohol intoxication, and informed the patient she could not be assessed by psychiatric services until her alcohol level was decreased. - At 1:09 PM the patient was in her exam room with her significant other in line of sight of an RN. - At 2:16 PM Staff J, RN, discovered that the patient had left with her boyfriend. The police and Staff K were notified. Staff K spoke to the patient by phone. The patient said she felt better, wanted to sleep and was not suicidal. She agreed to return to the ED, but did not. - There was no documentation or order for a 1:1 patient observer. During an interview on 02/15/24 at 8:35 AM, Staff J, RN, stated that Patient #6 appeared to be intoxicated upon admission. She completed an admission assessment and notified Staff K of the patient’s CSSRS high risk suicide assessment. She stated that patients with high suicide risk were to be placed on 1:1 observation, the patient rooms were cleared of safety hazards, and the patients were placed in paper scrubs. The patient was accompanied by her boyfriend and was in an exam room in sight of the nurse’s station. Following her assessment Staff J needed to transfer another patient. She notified other staff of her absence, and when she returned, she discovered that the patient had left with her boyfriend. She notified the physician and law enforcement. Law enforcement were unable to locate the patient. During an interview on 02/15/24 at 8:55 AM, Staff K, Physician, stated that she assessed Patient #6 but did not find her at high risk for suicide. She ordered labs necessary for medical clearance and did not order suicide precautions. When the patient was discovered missing, she called the patient and asked her to return. The patient agreed to return but didn’t return until the following day. During an interview on 02/14/24 at 2:20 PM, Staff A, Chief Nursing Officer (CNO), stated that suicide precautions required 1:1 observation, if patients on suicide precautions attempted to leave staff were to attempt to convince the patient to stay, notify the physician, and then notify law enforcement if the patient did leave. During a telephone interview on 02/22/24 at 8:30 AM, Staff Q, Former Agency RN, stated that if a patient was determined to be low risk for suicide, no interventions were put in place. Northeast Regional Medical Center “has been very lax when it comes to psych patients.” Staff Q stated that at other hospitals, when a patient indicated that they were suicidal, they would have all the precautions put in place (put in paper scrubs, removal of their belongings, 1:1 observation, etc.). At Northeast Regional Medical Center, it was different every time, and very confusing. Sometimes patients were put on a 1:1, sometimes they weren’t. Security was not allowed to touch patients and “if a psych patient wants to leave, they just let them go” and call local law enforcement.”

“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: 49404 Based on interview, record review, and policy review, the hospital failed to provide safe transfer with qualified personnel and equipment for one patient (#2) out of 21 Emergency Department (ED) records reviewed for 06/01/23 to 07/31/23 and 09/01/23 to 02/13/24. This failure placed all patients being transferred at risk for their safety during transport. Findings include: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” dated 07/2021, showed: - When an individual comes to the ED requesting medical treatment, an appropriate medical screening examination (MSE), within the capabilities of the ED, shall be performed to determine whether an emergency medical condition (EMC) exists. - If it is determined through a MSE that an EMC exists, ED personnel shall provide further medical evaluation and treatment as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital or transfer the individual to another appropriate facility that can meet the patient’s needs. - Transfer of an individual with an EMC must be initiated by a physician’s order and the individual being transferred must be informed of the risks versus benefits of the transfer. - Transfer procedures require the hospital to provide stabilizing medical treatment within its capabilities to minimize risks of transfer, acceptance of the patients by the receiving hospital that has the available space and qualified personnel to treat the individual and has agreed to provide appropriate medical treatment. The hospital will provide the receiving hospital with all medical records that are available at the time of transfer and relevant to the EMC. - Transport is carried out through qualified personnel and appropriate transportation and equipment, as required. The transferring physician will determine and order the life support measures, personnel and equipment that are medically appropriate to sustain the individual during transfer. - Appropriate transport for an emergent patient would be an ambulance or medical helicopter with an emergency medical service (EMS, emergency response personnel, such as paramedics, first responders, etc.) crew, but never a private vehicle or taxi; personal vehicles are not considered “appropriate transportation” because they do not include equipment or life support measures and they are not driven or staffed by trained emergency professionals. - Generally, ED patients are not transferred, and stabilization of the patient ends the hospital’s EMTALA obligations. If a patient needs follow up care, they are discharged with instructions. - Transfer to another medical facility by appropriate means may occur after stabilization if the individual requires specialized treatment not available at the hospital and another hospital with specialized facilities has space and personnel available in the specialized facility. Under those circumstances, the transfer of the patient is not governed by EMTALA. Instead, the hospital should follow applicable policies and procedures relating to non-emergency transfers. Review of the hospital’s policy titled “Transfer Protocols,” dated 03/28/23, showed the referring physician consults with the receiving physician regarding arrangements, transportation and acceptance of the patient assuring the facility is capable of assuming care of the patient. The Trauma Team Leader decides to transfer and chooses the most expedient and appropriate route of transfer to provide for the care of the patient. Review of Patient #2’s medical record, dated 07/16/23, showed: - She presented to the ED by personal auto at 12:23 PM for a left arm cut that occurred at home prior to arrival. - A tranexamic acid (a medication that blocks the breakdown of blood clots, preventing bleeding) soaked sterile gauze dressing was applied to a 3.5 centimeter (CM, a unit of measurement) laceration (a deep cut or tear in skin) on her left wrist, profuse bleeding was noted. Intravenous (IV, in the vein) access was obtained, and a complete blood count (CBC, a blood test performed to determine overall health including inflammation and infection) and comprehensive metabolic panel (CMP, a blood test performed to a variety of diseases and conditions) were drawn. - The ED physician assessed the patient and contacted Hospital C at 1:58 PM for a vascular surgery (surgery that can be used to treat a wide range of heart and blood flow issues) consultation. Hospital C agreed to see the patient in their ED. - The physician cleansed the wound, applied sutures, and dressed the wound with a gauze pressure dressing. The patient tolerated it well and the bleeding stopped. - The physician and the receiving physician agreed that it was appropriate for the patient to be transferred by personal automobile. - The physician discussed the plan of care with the patient, all questions and concerns were addressed prior to disposition and the patient was agreeable to the plan. - The patient left the ED at 3:56 PM accompanied by her husband. - There was no documentation that Patient #2 was offered to be transferred via ambulance and no documentation that Patient #2 refused to be transported via ambulance. Review of Patient #2’s Hospital C medical record, dated 07/16/23, showed: - She presented to the ED at 6:30 PM for an evaluation of a laceration to her left wrist. - The physician’s assessment noted a three cm laceration to the left forearm with a single figure eight suture and no active bleeding. The patient’s left arm strength was normal with subjective numbness and tingling to her left hand. An x-ray (test that creates pictures of the structures inside the body, particularly bones) of her arm was negative. - The wound was opened, washed out, and reclosed with a single layer of sutures. The tendons were intact, and the post-procedure examination showed her affected hand’s circulation, sensation and motor ability were intact. - The patient was discharged home with instruction to follow up with plastic surgery in about a week. During an interview on 02/14/24 at 2:15 PM, Staff B, RN, stated that Patient #2 was bleeding upon admission but following the application of a pressure dressing and sutures the bleeding stopped. The patient’s vital signs (body temperature [degree of hotness or coldness of the body, normal is 98.6 °F], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heart beat, normal is approximately 90/60 to 120/80], heart rate [the number of times the heart beats within a certain time period, usually a minute]and breathing rate) were normal and her pain was controlled. She stated that the patient was agreeable to having her husband transport her to Hospital C, and that they didn’t express any objections about transporting themselves. Multiple attempts to interview Patient #2 were unsuccessful. An interview with Staff S, ED Physician, was requested but he was on leave and unavailable. An interview with Staff T, Hospital C Vascular Surgeon, was requested but he was unavailable.”