Barnes-Jewish St Peters Hospital

“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: 40189 Based on policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#13) of 21 Emergency Department (ED) records reviewed from 12/22/25 through 06/22/26. 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, “EMTALA,” dated 12/16/25, showed: - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE (beyond medical triage [process of determining the priority of a patient’s treatment based on the severity of their condition]) by qualified personnel. - To perform an MSE, the hospital should utilize all ancillary services routinely available to determine if an EMC exists. - No patient will be discharged or transferred without an MSE. - MSE is an examination sufficient to reasonably indicate the presence of an EMC for an individual. Please refer to A-2406 for further details.”

“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: 40189 Based on interview, record review, and policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#13) of 21 Emergency Department (ED) records reviewed from 12/22/25 through 06/22/26. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “EMTALA,” dated 12/16/25, showed: - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE (beyond medical triage [process of determining the priority of a patient’s treatment based on the severity of their condition]) by qualified personnel. - To perform an MSE, the hospital should utilize all ancillary services routinely available to determine if an EMC exists. - No patient will be discharged or transferred without an MSE. - MSE is an examination sufficient to reasonably indicate the presence of an EMC for an individual. Review of Patient #13’s Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 04/19/26, showed: - At 4:57 PM, EMS staff arrived to Patient #13’s nursing home and found her in bed, alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation). She had fallen out of her wheelchair when she reached for something that fell to the floor and hit her head on the edge of a dresser. She complained about head and left upper leg pain. - The nursing home staff reported that the patient had been hallucinating (seeing or hearing things which are not there) and there was nothing on the floor. Staff reported she had been experiencing hallucinations for the past month, ever since she started dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions). - At 5:25 PM, she arrived at the ED, was transported to the triage area by stretcher. Verbal report was given to Staff I, RN, and care was transferred to the hospital. Review of Patient #13’s medical record, dated 04/19/26, showed: - At 5:28 PM, Patient #13, a 78-year-old female, arrived at the ED via EMS with a chief complaint of a fall with head injury. Her past medical history included morbid obesity (body weight that is greater than or equal to twice their ideal body weight and/or 100 pounds or more overweight), kidney failure with dialysis, osteoarthritis (when the flexible tissue at the end of bones wear down and cause pain), urinary retention, urinary tract infections (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood) and depression. - At 5:33 PM, the triage note documented that Patient #13 was reaching for something on the floor and fell out of her wheelchair. She hit her head and cut her forehead above her left eyebrow. She complained of some pain in her left upper leg. Patient #13 was A&O x 4.and denied any hallucinations. - At 5:42 PM, on a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) she rated her pain four out of 10. The location of her pain was not documented. - ED provider documentation indicated the patient was “complaining of pain mostly in her left lower extremity.” Staff J’s physical exam documentation indicated the patient only had tenderness with palpation (using one’s hands to assess the body) to the left lower leg. Staff J noted that the patient had five out of five strength of her bilateral upper extremities and four out of five strength to her bilateral lower extremities. The patient had a three-centimeter cut above the left eyebrow that was treated. - At 6:07 PM, an x-ray (test that creates pictures of the structures inside the body-particularly bones) of the left lower leg and a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of the head and neck were ordered. Both were negative. - At 7:06 PM, the patient’s daughter called and informed Staff I, RN, that the patient had been hallucinating and she wanted her checked for an infection. - At 7:19 PM, new orders for a urinalysis (UA, a laboratory examination of a person’s urine), a chest x-ray, complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) were placed. - At 7:59 PM, the patient reported that she did not make urine any longer. - At 8:10 PM, the order for UA was discontinued. - Her chest x-ray was negative. - At 9:04 PM, Patient #13 received oxycodone (synthetic pain medication with a high risk for misuse) for pain rated six out of 10. The location of her pain was not documented. - At 9:08 PM, the CBC results showed a white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal range between 3.80 and 9.90) of 12.86 and the CMP showed no acute indication for dialysis. - At 9:55 PM, Patient #13 received no reassessment of her pain and was discharged back to her nursing home by EMS. Review of Patient #13’s Hospital B medical record, dated 04/24/26, showed she arrived at the ED on 04/24/26 for a chief complaint of a headache. She reported her headache pain was over the injury above her left eyebrow, which she sustained after a fall on 04/19/26. She was A&O x 4. She was found to have pain in her left lower extremity. Hospital B was informed that she had been seen at Barnes Jewish St. Peters Hospital a week prior and had an x-ray of her left lower leg and a CT of her head and neck that were negative. She had blood work drawn and was found to have a high WBC count of 16.2. She started on an IV antibiotic empirically. The patient was admitted for further management. A UA showed significant pyuria (high levels of WBCs or pus in urine) with an elevated WBC count, which indicated a UTI. She had a second IV antibiotic added. The patient reported continued constant left leg pain. On 04/25/26, a left hip x-ray and CT showed a fracture in two places. On 04/26/26, Patient #13 underwent an open reduction internal fixation (ORIF, surgery to fix severely broken bones) and a hemi-arthroplasty (partial hip replacement, as surgical procedure that replaces only the damaged femoral head [ball] of the hip joint with a metal prosthesis, leaving the natural acetabulum [socket] intact) to repair the fracture. On 04/28/26, she was discharged back to her nursing home. During a telephone interview on 06/25/26 at 11:30 AM, Staff L, Paramedic, stated that the patient’s chief complaint was head pain after a fall. Patient #13 was A&O x 4. The nursing home staff reported the patient had been hallucinating. No hallucinations were observed. The patient complained of left hip pain. She gave report to Staff I, RN, and informed her that the patient had pain in her head and the left hip area. During a telephone interview on 06/24/26 at 9:15 AM, Staff I, RN, stated that Patient #13 came in by EMS for a fall out of her wheelchair. She was A&O x 4. There were no hallucinations or confusion noted. The patient complained of left upper leg pain and rated her pain four out of 10. To assess pain in the left upper leg versus left hip pain, she palpated from the knee to the hip. Unless her exam showed specifically hip pain, she only documented upper leg pain. She recalled that she gave the patient pain medication at the end of her shift and was unable to reassess her. The provider added blood work, chest x-ray and UA after the daughter called worried about an infection. The UA was ordered and later discontinued after the patient reported that she no longer made urine. If the patient reported she did not make urine, they would not have straight catheterized (straight cath or “in-and-out” cath, a catheter [a small flexible tube] inserted into the patient’s bladder to drain the urine and then removed) her due to increased risk of infection when there was possibly no urine to obtain. During a telephone interview on 06/24/26 at 1:00 PM, Staff J, Resident, stated that she performed a physical exam which consisted of pressing down the spine, hips, extremities, testing strength in the upper and lower extremities and listening to lung and heart sounds. The patient verbally complained of pain to her lower extremity, specifically her lower leg upon palpation. She palpated her upper thigh and documented lower extremity which would have consisted of the hip down. Even if she knew the patient had reported pain in the upper leg, she would do imaging only if pain was found on her physical exam as well. If her exam was inconsistent with what the nurse reported, she would only go off what the patient reported to her personally at the time of exam. She did not recall if she performed range of motion of the extremities, but she tested the patient’s strength, therefore her leg was moved. Confusion and hallucinations could be caused by a UTI in an elderly patient. The patient had those symptoms for months and was seeing a psychiatrist, so a UTI was less likely. The patient was A&O x 4 and showed no signs of hallucinations. A WBC result of 12.86 did not necessarily indicate an infectious process. The UA was discontinued because the patient showed no signs of a UTI and no longer made urine, therefore a straight cath would not have been performed. During a telephone interview on 06/24/26 at 3:30 PM, Staff K, Physician, stated that he oversaw the resident and physically assessed the patient as well. Patient #13 received a hands-on exam. She was A&O x 4. The patient hit her head and had a CT that was negative and complained of leg pain below the knee and had an x-ray of the lower leg that was negative. If there was a fracture at the ball of the hip, there may not have been any shortening of the leg, the patient may have had little discomfort and could have walked on it many times. The patient may have been moved after she was discharged from the hospital which made it worse and may have been why she had increased pain later. A physical exam directed the treatment, not what the patient told other staff. Sometimes triage notes were reviewed prior to physical exam. Patient #13 was able to lift her leg. The pain was in her knee. If the patient had increased pain prior to discharge that required pain medication, that may have triggered more testing. He did not order oxycodone and was unsure who did. If when we moved the patient’s leg and there was no pain in the upper leg or hip, then no x-ray would have been performed. She had a fracture that got missed but if the patient had no displacement, it may not have been seen on x-ray anyway. To test for an infection, orders would have included a UA and blood work. A WBC of 12.86 would not have been worrisome if the patient was without fever. The UA was cancelled because the patient no longer made urine. A straight cath could have been done for urine, but an end stage renal patient always had dirty urine. The exam was considered a complete MSE. During a telephone interview on 06/24/26 at 12:30 PM, Staff F, ED Medical Director, stated that a physical exam consisted of a head-to-toe assessment. An x-ray was dependent on physical exam and palpation of all the long bones. He expected the entire leg to be assessed for any pain or deformity. If it was not displaced, a deformity may not have been seen. Range of motion should have been performed to possibly point in the direction of an injury. A patient could have experienced lower leg pain with a hip fracture. He expected a provider to review nurses’ assessment notes after their exam and before orders were placed. The expectation was to focus the exam at the area where the nurse reported the patient had pain even if the patient did not report it to the provider. If the patient had an increased pain level from four out of 10 to six out of 10 that required oxycodone prior to discharge, that should have triggered further examination on where the pain was coming from. To rule out infection, he would have ordered blood work, a UA since UTIs were common in elderly female patients, a chest x-ray to r/o pneumonia (infection in the lungs) and assessment of the skin for cellulitis (an infection of the skin). A UA was a nice addition if a patient had reports of hallucinations or confusion. If a patient reported they did not make urine and all other tests were negative to rule out the cause of hallucinations, a straight cath was not out of the question. A bladder scan was an option to have seen if there was any urine in the bladder, then a decision could have been made if a straight cath was appropriate. A straight cath would have given a great clean sample. He would have considered it a complete MSE if all parts of the examination were documented, but in retrospect of knowing part of the exam may have been missed, it was incomplete.”

“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 policy review, the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#2) of 20 Emergency Department (ED) records reviewed from 09/09/25 through 03/09/26. 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 Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)” dated 12/16/25, showed: - When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within their capabilities and capacity. - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE, beyond medical triage (process of determining the priority of a patient’s treatment based on the severity of their condition) by qualified personnel. - No patient will be discharged or transferred without an MSE. - MSE is an examination sufficient to reasonably indicate the presence of an EMC for an individual. - The Emergency Severity Index (ESI) is used for priority care with medical screening. Acuity Level Two (emergent) classification are conditions that are a potential threat to life, limb, or function requiring immediate aggressive interventions. Review of the hospital’s document titled, “Standard Work,” dated 08/07/25, showed rounding in the ED waiting room every two hours was to include vital signs (VS, measurements of the body’s most basic functions), pain assessment and updates. Please refer to A-2406 for further details.”

“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 follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#2) of 20 Emergency Department (ED) records reviewed from 09/09/25 through 03/09/26. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” dated 12/16/25, showed: - When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within their capabilities and capacity. - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE, beyond medical triage (process of determining the priority of a patient’s treatment based on the severity of their condition) by qualified personnel. - No patient will be discharged or transferred without an MSE. - MSE is an examination sufficient to reasonably indicate the presence of an EMC for an individual. - The Emergency Severity Index (ESI) is used for priority care with medical screening. Acuity Level Two (emergent) classification are conditions that are a potential threat to life, limb, or function requiring immediate aggressive interventions. Review of the hospital’s document titled, “Standard Work,” dated 08/07/25, showed rounding in the ED waiting room every two hours was to include vital signs (VS, measurements of the body’s most basic functions), pain assessments and updates. Review of Patient #2’s Ambulance report, dated 01/20/26, showed: - On 01/20/26 at 2:00 PM, Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) staff encountered Patient #2 at his employers. He complained of chest pain, headache, nausea and dizziness. - EMS staff obtained his VS. They were normal except for a blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) of 200/91. It was rechecked with a more appropriately sized BP cuff and was 148/88. - EMS staff administered nausea medication and aspirin (blood thinner that can also treat pain, fever, headache and inflammation) and transported him to the ED. - At 2:27 PM, they arrived at the ED, transported the patient to triage by stretcher, gave verbal report to a Registered Nurse (RN), and transferred care to the hospital. Review of Patient #2’s medical record, dated 01/20/26, showed: - At 2:32 PM, Patient #2 arrived at the ED via EMS and his arrival complaint was documented as headache and nausea. - At 3:28 PM, a nursing assessment was initiated, and his chief complaint was updated to include chest pain. He reported chest pain that radiated to his right neck and arm. - At 3:31 PM, his BP was 199/97. - He complained of a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) of nine for a headache. - At 3:32 PM, triage was completed, and orders were placed for a chest x-ray (test that creates pictures of the structures inside the body-particularly bones), electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) and a blood draw for labs, including a Troponin I High Sensitivity (a blood test that measure whether or not a person is experiencing a heart attack, normal result is between 0 and 15). Cardiac and respiration (breathing, breaths) monitoring was ordered when available. - The Troponin level, and another Troponin level drawn two hours later were normal. - The EKG showed abnormalities but was negative for a ST-Elevation Myocardial Infarction (STEMI, heart attack). - The chest x-ray was negative. - He received no reassessment of his pain or VS. - His ESI acuity level was documented as two - emergent. - At 7:06 PM, he left without being seen (LWBS). Review of Patient #2’s medical record from Hospital B, dated 01/20/26, showed: - At 11:08 PM, he presented to the ED with a complaint of acute chest pain and shortness of breath. - An EKG showed no heart attack, and his Troponin level was not elevated. - A chest computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed multiple right-sided pulmonary emboli (PE, blood clot in the lung). - He was admitted for treatment of the PE with blood thinning medication. - On 01/22/26, he was discharged. During a telephone interview on 03/10/26 at 11:35 AM, Staff K, Physician, stated that he did not see Patient #2. Based on the patient’s complaint, nurses followed protocols for placing orders. The EKG, x-ray and labs were appropriate for chest pain. He reviewed the EKG when it was completed, and it did not show a STEMI. He did not know the reason for the interval between the patient’s arrival and triage, but the ED experienced high volume during that time. If beds were unavailable in the ED, patients would wait in the waiting room. Ideally patients would be monitored by nursing staff while in the waiting room and were encouraged to stay for treatment instead of leaving. He was unaware of the patient’s elevated BP. During an interview on 03/10/26 at 12:20 PM, Staff F, RN, stated that she triaged Patient #2. She was not originally assigned to triage but was reassigned due to a surge in patient volume. The information she had prior to speaking with the patient was that his chief complaints were a headache and nausea. She did not speak with EMS when the patient arrived as she was not acting as triage nurse then. Once he told her he had chest pain, she placed orders per the ED’s chest pain protocol. The EKG was reviewed immediately by the physician. She did not know why the patient’s pain or VS were not reassessed while he waited in the waiting room. During an interview on 03/10/26 at 12:20 PM, Staff M, Nurse Manager, stated that: - The patient would have been prioritized if the chief complaint was listed as chest pain. The chief complaints were entered by registration staff according to information provided by the patient, if the patient was able to provide it. - EMS provided report prior to arrival and when care was transferred to the ED nurse. She did not know how the miscommunication about the patient’s chest pain occurred, but the triage nurse would normally have been informed by EMS. - She expected that patients in the waiting room would be reassessed, including VS, every two hours per the ED’s standard work. She noted the patient was seen around 5:30 PM when his blood was drawn and his Troponin level was rechecked. - The chest pain orders when the patient was triaged were appropriate. - The ED experienced a high volume that day, and multiple patients arrived around the same time as Patient #2. During an interview on 03/10/26 at 1:00 PM, Staff N, RN, stated that her shift began at 6:00 PM, but she had no recollection of the patient or speaking with him before she left. She expected that patients in the waiting room would have VS checked every two hours. When patients left against medical advice (AMA) or LWBS, the charge nurse and physician were notified so an attempt could be made to convince them to stay, and a final set of VS was offered to the patient. She could not say if either occurred for Patient #2.”