Intermountain Health St Vincent Regional 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: 45448 Based on interview, record review, review of a motor vehicle accident report and policy review, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at §489.24: (refer to Appendix V). The facility failed to provide an appropriate MSE within the capacity and capability of the hospital to determine whether or not an emergency medical condition existed for one patient (Patient #15) of 20 sampled patients. Findings include: Patient #15 presented to the ED via ambulance on 4/14/24, following a motor vehicle accident. Patient #15’s triage assessment contained complaints of pain in the jaw, knee, and pain in both the right and left leg. The ED Physician’s examination did not include documented evidence that the hospital provided the necessary testing to rule out whether an emergency medical condition existed, and there was no documented assessment of the patient’s tetanus vaccination status. As the patient was being discharged, he complained of inability to bear weight and severe lower leg pain. The patient was placed in a wheelchair, transferred into a cab, and discharged to his home. Upon the patient’s arrival, he was unable to ambulate from the cab into his home without extensive assistance. Patient #15 was taken to urgent care later in the afternoon on 4/14/24, evaluated, and diagnosed with a left ankle fracture. Investigation revealed that there was x-ray and CT imaging available at the time of Patient #15’s presentation. Review of a facility policy, “Emergency Medical Treatment and Labor Act (EMTALA)”, dated 12/19/22, showed: “ ...Medical Screening Examination (MSE)- the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition exists or a woman is in Labor. Such a screening must be done within the Capability of the Hospital’s Dedicated Emergency Department, including on-call physicians. The Medical Screening Examination is an ongoing process that includes continued monitoring based on the individual’s needs and must continue until the individual is either stabilized or appropriately transferred.”

“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: 45448 Based on interview, record review, review of a motor vehicle accident report and policy review, the facility failed to provide an appropriate MSE within the capacity and capability of the hospital for one patient (#15) of 20 sampled patients. Findings include: Review of a document, “Motor Vehicle Crash Report”, dated 4/14/24, showed patient #15 was unable to maintain his lane and drove into an impact attenuator (a roadway device intended to reduce the damage to structures and vehicles should a collision occur). The vehicle sustained heavy front-end damage and was high centered on the impact attenuator. Review of patent #15’s EMR (electronic medical record) ambulance report, showed patient #15 arrived at the ED via ambulance on 4/14/24 at 3:27 a.m. Patient #15 was involved in a single car motor vehicle accident. Patient #15 stated he was going 60 mph (miles per hour) when he struck a guard rail. He was wearing a seat belt but, his vehicle did not contain an airbag. Patient #15 was noted to have a significant amount of blood on his face, arms and the front of his shirt. Review of patient #15’s EMR, dated 4/14/24, showed patient #15 was triaged at 3:28 a.m. by staff member I. Triage documentation indicated patient #15 was complaining of jaw, knee, and right and left leg pain, with a pain score of 3 out of 10. Patient #15 was seen and examined by staff member L at 3:45 a.m. The physician documented the patient had facial trauma, including a nasal fracture, two lacerations and an avulsion (severe wound where tissue bursts open due to force), as well as a couple superficial abrasions to his knees. At 7:06 a.m., staff member L documented patient #15 was ready for discharge. At 7:15 a.m., the ED adult assessment documented by nursing, showed patient #15 was complaining of knee, head, and left and right leg pain. Patient #15 was discharged at 7:29 a.m. to home, by self, and transported by a private vehicle. During an interview on 5/21/25 at 7:41 a.m., patient #15 confirmed he had been involved in a motor vehicle accident on 4/14/24. Patient #15 remembered waking up after the accident, was unable to open the car door, and had to crawl into the passenger seat to get out of the vehicle. He was transported to the hospital via ambulance, but remembered few details about the hospital visit until he was being discharged. He stated he remembered telling the nurse that he could not walk and was in a lot of pain. Patient #15 said the nurse got him a wheelchair and told him the hospital was getting him a ride home. During an interview on 5/21/25 at 7:53 a.m., staff member K said he remembered receiving report from staff member I and being told patient #15 was, “good to go,” for discharge. Staff member K stated he recalled getting patient #15 out of bed and having to assist him to the restroom. Staff member K stated patient #15 was complaining of leg pain and said he could not walk. Staff member K stated he got a walker to assist patient #15 to the restroom and then assisted him to the car with a wheelchair. Staff member K stated he did not look at patient #15’ record to determine if the patient’s ankle pain was assessed. Staff member K said he assumed everything had been evaluated based on the report provided by the previous nurse, and patient #15 was cleared to be discharged. Staff member K said he should have investigated further but the facility had contacted the cab driver to pick up patient #15, and he had been discharged. The medical record did not contain evidence that the hospital provided any further appropriate screening to determine the source of the patient’s lower extremity pain and inability to walk, or evaluate the patient’s tetanus vaccination status. Investigation showed that the hospital had x-ray and CT capabilities at the time the patient presented to the hospital. During an interview on 5/29/25 at 4:00 p.m., staff member L said he was a physician at the ED who evaluated patient #15. Staff member L stated he was able to review patient #15’s ED visit on 4/14/24. Staff member L stated the documentation of a patient’s triage assessment was generally available for his review, and he usually quickly reviews the information prior to seeing a patient. Staff member L said, based on his notes, he may not have been aware of patient #15’s lower extremity pain, other than patient #15 complained of knee pain and had some minor abrasions over the knees. Staff member L said he should have paid more attention, asked more specific questions, or documented better if the information related to the patient’s lower extremity pain was mentioned in the triage notes. During an interview on 5/21/25 at 7:00 a.m., NF2 stated that when patient #15 arrived at home by cab on 4/14/24 at about 7:30 a.m., patient #15 complained of pain in both of his lower extremities (legs) and was unable to get himself out of the vehicle and walk into the house without significant assistance. NF2 stated she phoned the hospital and asked if patient #15’s lower extremities had been evaluated. NF2 stated she informed the nurse over the phone that both lower extremities (legs) were swollen and that patient #15 could not walk. NF2 stated the nurse responded that the lower extremities (legs) had not been evaluated, and the hospital was not aware patient #15 had a concern. NF2 stated that on 4/14/24 at 4:35 p.m., patient #15 was seen in urgent care for pain and inability to bear weight on his left foot and ankle and severe pain to his right heel. NF2 said patient #15 was found to have an ankle fracture. NF2 stated she took patient #15 to an orthopedic clinic for evaluation, and it was determined the ankle fracture did not require surgical intervention. Record review of patient #15’s urgent care record, dated 4/14/24 at 4:35 p.m. showed: “ ... Visual examination of the left foot reveals significant swelling of the foot and ankle. There is bruising over the lateral malleolus (the bony bump on the outside of the ankle joint). Patient is unable to bear weight. ...” Record review of patient #15’s urgent care left ankle x-ray report, dated 4/14/25, showed patient #15 had a left ankle fracture. Review of patient #15’s orthopedic clinic visit, dated 4/16/24, showed patient #15 had nasal bone fractures, bruising on his right heel, a right wrist sprain, swelling in lower extremities, and a left ankle fracture. The plan for care was documented as, “Plan: Ace wrap and boot brace immobilization left with partial weight bearing. Follow-up in 10 days for recheck with standing x-ray of the left ankle. ...” [sic] During an interview on 5/21/25 at 12:03 p.m., staff member J said the medical director from the ED conducted a review of patient #15’s presentation, and a gap in care was identified with a result of “high harm.” Review of a letter addressed to patient #15, dated 8/4/24, showed: “ ...We reviewed your medical records and included the appropriate clinicians to review your care. Our review was completed on the date of this letter. We determined that the ankle fracture was not evaluated at your emergency room visit. ...” Review of a facility policy, “Emergency Medical Treatment and Labor Act (EMTALA)”, with a review date of 1/21/25, showed: “ ...Medical Screening Examination (MSE)- the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition exists or a woman is in Labor. Such a screening must be done within the Capability of the Hospital’s Dedicated Emergency Department, including on-call physicians. The Medical Screening Examination is an ongoing process that includes continued monitoring based on the individual’s needs and must continue until the individual is either stabilized or appropriately transferred.”

“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: 44770 Based on interview, record review, and review of facility video surveillance footage, the facility failed to mitigate environmental safety risks when facility staff placed a suicidal patient next to an unlocked exit door without 1:1 observation; and failed to follow their policy for suicidal patients who present to the ED for 1 (#2) of 1 sampled patients. This deficiency had the potential for the patient to escape the facility and follow through with his plan to commit suicide. Findings include: Review of patient #2’s EMR (Electronic Medical Record), dated 3/6/24 at 1:43 a.m., showed patient #2 presented to the ED and reported he was suicidal. Patient #2 told the triage nurse he was going to drink himself to the point of death, or he was going to overdose on drugs. The triage nurse assigned the patient an ESI (Emergency Severity Index) score of 2 (Emergency: could be life threatening). Patient #2 was escorted into the Emergency Department at 1:51 a.m. Patient #2 was placed on 1:1 observation at 1:56:18 a.m., although review of facility video surveillance footage showed there was no 1:1 provided until 2:35:51 a.m. Review of patient #2 ’ s physician note showed the patient stated he had a gun hidden in the bushes in town and he was going to shoot himself with it. Patient #2 ’ s blood alcohol level was documented as 340 mg/dl. Observation of a facility surveillance video titled, “ED North Nurses Station East,” dated 3/6/24, showed: 1:51:03- Patient #2 entered the ED hallway with staff member M. The ambulance bay doors were observed at the end of the hall (these doors did not lock and exited the building to the outside. The doors were operated by a push button located on the wall). 1:51:36- Patient #2 was placed in a chair in the hallway approximately five feet from the ED ambulance bay doors. The patient was left unsupervised. 1::53:17- 1:55:16- Patient #2 was unsupervised. 1:55:35-2:04:14 Patient #2 was unsupervised. 2:04:40-2:18:53- Patient #2 was unsupervised. 2:18:53-2:21:59- Staff member K, the emergency department physician, was observed talking to patient #2 in the hallway. Staff member K was not observed with the patient for the remainder of the patient ’ s stay in the Emergency Department. 2:21:59- 2:27:59- Patient #2 was unsupervised. The doors to the ambulance bay opened and closed when an ambulance brought another patient into the ED. 2:33:00- A security staff member escorted patient #2 to ED room #6. 2:35:51- A 1:1 provider arrived outside ED room #6 and remained outside the room until patient #2 was taken to his inpatient hospital room. 4:02:00- Patient #2 was observed being wheeled out of ED room #6 by the transporter. The 1:1 staff member followed. Patient #2 was left alone next to the ambulance exit doors for a total of 29 minutes without a dedicated 1:1 staff member. The time stamp on the surveillance video coincided with the time stamp in the EMR for patient #2 ’ s entrance to the ED and for the time patient #2 was transported out of the ED. Review of a facility document titled, “High Risk Patient Room Checklist”, not dated or timed, showed ED room #6 had unsafe contents removed from the room. The document had a patient label affixed to the lower right corner showing patient #2’s name and the label was dated 3/6/24. Review of a facility document titled, “15 Minute Patient Safety Check”, dated 3/6/24 at 2:00 a.m., showed a patient label for patient #2 in the lower right corner. This was a handwritten document that had been scanned into the EMR. The document showed ED room #6 was cleared at 2:00 a.m., despite video surveillance footage showing security arrived at 2:25:39 a.m. to clear the room. The document showed documentation of the patient being in bed, calm and cooperative, with his hands visible every 15 minutes starting at 2:00 a.m.; however, video surveillance footage showed the patient was sitting in a chair in the hallway and was not in the room until 2:33:00 a.m. The 1:1 staff member was not outside the room until 2:35:51 a.m. During an interview on 3/13/24 at 5:21 p.m., staff member D (ED physician) stated it would not be safe to place a patient who stated they were suicidal, next to an exit door, without 1 to 1 supervision. Staff member D stated she would expect a suicidal patient who presented to the ED to be taken out of their personal clothing, placed in a hospital gown, and have their personal property removed from their possession until the ED physician was able to assess the patient. During an interview on 3/15/24 at 8:04 a.m., staff member L (Facility Security staff member) stated, “From the second a patient says they are suicidal, we need to treat them like an E-hold (emergency hold.) We need to try to stop them from leaving to keep them safe. The ED can always call us to stand by with a patient if they need someone right away. We stand by as the 1:1 until a 1:1 provider can arrive. That usually happens if they have to put the patient in the hallway because there are no rooms available. We usually do the room clear to make sure any hazardous items are removed from a room.” Staff member L stated, “It would not be safe to leave a fully dressed suicidal patient next to an exit door without a dedicated person watching them.” During a telephone interview on 3/18/24 at 9:47 a.m., staff member K (ED physician) said he remembered examining patient #2 on 3/6/24. Staff member K said he knew patient #2 very well. Staff member K stated he did not know who made the decision to put patient #2 by the ambulance bay doors, but he thought the staff might have put the patient there because they see that patient frequently and they do not always believe him. Staff member K said he decided to refer patient #2 to the hospitalist and admit him to the hospital because the patient did not usually report wanting to kill himself. Staff member K stated he was also concerned because patient #2 had a history of being abusive to staff, verbalizing profanities, and using obscene hand gestures, but this time the patient was not doing those things and seemed more subdued. Staff member K said it would not be safe to put a fully clothed suicidal patient next to an exit door. Staff member K said his expectation for a suicidal patient would be to put the patient on 1 to 1 observation right away and if possible, place the patient in a patient room right after triage. Staff member K stated when patients report they are suicidal, staff should take the patient seriously, no matter what their previous interaction with staff had been. Staff member K stated that did not occur on this occasion and, “That probably wasn’t a good thing.” During a telephone interview on 3/20/24 at 10:23 a.m., staff member M (ED RN) stated she remembered patient #2 from the 3/6/24 visit when he reported he was suicidal. Staff member M said she filled in the Columbia suicide Severity Rating Scale questions for the patient because he would not answer her. When given a scenario from the surveyor using patient #2 ’ s stated chief complaint, the answers she gave for the Columbia Suicide Severity Rating Scale differed in question #1, “Have you wished you were dead or wished you could go to sleep and not wake up?” She documented “No” in patient #2’s chart but stated the question should have been answered “yes.” For question Number 3, “Have you been thinking about how you might do this?” she documented, “No” in patient #2’s chart but stated the answer should have been “yes” as the patient had given a plan in triage. For question #4, “Have you had these thoughts and had some intention of acting on them?” she documented “No” in patient #2’s chart but stated the patient would not answer her at the time. For question #5, “Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?” she documented “No” despite the patient giving a plan in triage. Staff member M stated patient #2 did not answer her but she documented “No” in the EMR. Staff member M stated she did not believe patient #2 was suicidal. Staff member M stated placing patient #2 next to the ambulance bay doors, “Might not have been the best place for him.” She stated if it had been any other patient complaining of suicidal ideation, she most likely would not have placed the patient in that chair next to the exit without a 1 to 1 staff member assigned to the patient. Review of a facility policy titled, “Identification and Care of Patients at Risk for Suicide”, dated 2/14/24, showed: “7. 1:1 Sitter/Safety a. Patients with suicidal ideations must be placed under demonstrably reliable monitoring (1:1 continuous monitoring by trained associates who can provide immediate intervention when called for).” Review of a facility document titled, “Emergency Department Suicide Risk Process- SVH- Supporting Document”, dated 10/2021, showed: “Patient arrives in the ED, Active/Stated Suicide, Escort back to the ED (Must have 1:1 sitter with patient at all times until pt. is placed in ED w/staff, Implement Suicide Precautions: Place patient in room visible to nurse’s station (if no open rooms, pt to sit on gurney or chair in ED hallway) with 1:1 sitter. Contact Department of Public Safety (DPS) for assistance, RN/Tech assist patient into a gown and DPS to remove all patient belongings, Examine room carefully and remove anything (that can be removed) that may potentially cause harm (including but not limited to : sharp items, belts, glass, electrical cords, metal eating utensils), RN completes assessment as pertinent to chief complaint, ED physician completes assessment, Note: ED physician to determine need to continue or discontinue 1:1 sitter, initiate Emergency Hold process, and Behavioral Health consult...The patient is not free to leave the Emergency Department until evaluated by a physician...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 44770 Based on interview, record review, and review of facility video surveillance footage, the facility failed to maintain an accurate medical record for 1 (#2) of 3 sampled patients. This deficiency has the potential to affect all patients who receive care in the ED. Findings include: Review of patient #2’s ED Provider Note, dated 3/6/24 at 5:05 a.m., showed patient #2 presented to the Emergency Department for suicidal ideations. Staff member K documented, “ ... Physical Exam ... Cardiovascular: ... No Murmurs, No rubs, No gallops. Thorax and Lungs: Normal breath sounds ... No wheezing ... Abdomen: Soft, nontender, nondistended ...” Observation of facility video surveillance footage titled, “ED North Nurses Station East”, dated 3/6/24, showed: -1:51:03- Patient #2 entered the ED hallway with staff member M. -1:51:36- Patient #2 was placed in a chair in the ED hallway. -2:18:53-2:21:59- Staff member K (ED physician) was observed talking to patient #2. Staff member K’s stethoscope remained around his shoulders, and he did not physically touch patient #2. Staff member K was not seen with the patient for the remainder of the patient ’ s stay in the Emergency Department. -2:33:00- Security escorted patient #2 into a room (ED room #6). -4:02:00- Patient #2 was observed being wheeled out of ED room #6 by the patient transporter. Staff member K was not observed entering ED room #6 at any time. During a telephone interview on 3/18/24 at 9:47 a.m., staff member K stated he was a physician at the facility and assigned to work in the ED on 3/6/24. Staff member K stated he recalled seeing patient #2 on 3/6/24. Staff member K said he occasionally used a documentation template when he documented his physical assessments for patients. Staff member K stated the template included a review of systems showing everything being within normal limits. Staff member K stated he should delete the items he doesn ’ t complete. Staff member K stated if a patient presented to the emergency department for a laceration of the finger, it would not be necessary to listen to the patient ’ s lung sounds, and he would delete those portions on the premade template. Staff member K said it was entirely possible he documented heart sounds, lung sounds and an abdominal assessment he did not perform for patient #2. He said he would not typically listen to lungs, heart, and assess a patient’s abdomen for a patient who presents for suicidal ideation, unless the patient had specific complaints. Staff member K stated he found another patient chart a week prior where he realized he had documented a full assessment on a patient, although the assessment was not performed. Staff member K stated he knew it was not best practice to utilize the premade template, and he was trying to decrease his use of it. Staff member K stated it could be dangerous to document a patient assessment that was not performed.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 44770 Based on interview, record review, policy review, and review of digital video surveillance recordings, the hospital’s Governing Body failed to ensure that: -Medical staff were accountable to the governing body for quality care that met the needs of five patients (#s 27, 28, 30, 32, and 33), of 33 patients reviewed. (A-0049) -The Chief Executive Officer (CEO) effectively managed the hospital to meet applicable regulatory requirements. (A-0057) These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. The severity and cumulative effect of these systemic practices resulted in the hospital’s noncompliance with 42 CFR 482.12 Condition of Participation: Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44770 Based on interview, record review, policy review and review of digital video surveillance recordings, the facility failed to provide a safe environment, free from abuse, when they failed to: -Ensure one patient #6 was identified as being suicidal and then subsequently failed to ensure patient #6 was kept from eloping after he was determined to be suicidal. (A-0144); -Remove three staff members (AA, BB, and AAA) from patient contact, who had not received abuse training, after Security Supervisor staff member CC, reviewed video that showed the three staff members were involved in the abuse of patient #27, which resulted in injury it the patient. (A-0145); -Ensure staff were competent to prevent, identify, and respond to all forms of abuse, when hospital staff failed to recognize abuse of or intervene on behalf of one patient (#27) of two patients reviewed for abuse. (A-0145); and -Ensure a thorough investigation was completed to accurately determine whether abuse had occurred for patient #27 after staff member EE reported the abuse. (A-0145) These failures created an unsafe environment and had the potential to place all hospital patients at risk for their safety. The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights, which resulted in a condition of Immediate Jeopardy (IJ). Immediate Jeopardy was announced to the facility on 11/8/23 at 3:30 p.m., hospital members present included: Interim President Senior Director of Human Resources Senior Director of Service Lines Senior Director of Emergency and Critical Care Senior Director of Surgical Services CNO Regulatory Manager CMO Director of Quality The facility submitted an acceptable plan to remove the immediacy on 11/9/23 at 11:47 a.m. PLAN TO REMOVE IMMEDIACY 1) Emergency department staff, Emergency Department providers, Administration and Security staff will receive immediate just in time training on the recognition of abuse and de-escalation tips as well as the appropriate use of force (‘Use of Force’ Policy). This training will take place prior to their next shift start. A roster will be kept identifying those receiving the training and all staff will receive this. The content of the training will also be emailed to all house wide staff on November 8, 2023. There will be a form to attest to their review of these items. This will include: -‘Use of Force Policy’ -‘Patient Abuse and Neglect SVH Policy’ (Update in process on November 9, 2023 to align this policy with current practice that any staff member that is suspected of abuse will be placed on leave pending further investigation) -AVADE De-escalation techniques 2) A Roster for in-person attendance will be provided and a list of acknowledgements by all staff and providers will be provided- from the email of above referenced documents. Full Compliance with the acknowledgement will be complete by November 30, 2023, and the current status will be provided to surveyors at 0930 on November 9, 2023. 3) Additional training will immediately begin to all staff: - Intermountain Healthcare protocol ‘Law Enforcement Protocol’ (with special attention to page 12 ‘Clarifications About When a Patient is Considered in Lawful Custody’) will be adopted as a site policy through our ongoing integration -Forensic Patient Security Checklist -‘Security Management of Inmates and Prisoners -SVH’ 4) The above training will be sent to all staff on November 9, 2023. An acknowledgment of these documents will be required and compliance list will be maintained and full compliance in place by November 30, 2023. 5) The security officers involved in the patient encounter listed were placed on administrative leave on November 8, 2023. An RCA (root cause analysis) and gap analysis (a process of comparing a company’s current performance with it’s desired performance) will be completed as well as mandatory attendance to the Avade course that is already in process. 6) Administration, Leadership and nursing will receive additional training on the recognition of abuse and the investigation of a concern for abuse with a roster completed. 7) There will be a leadership stand up on November 9th at 1:45 to ensure that all leaders understand the importance of this urgent re-education and ongoing monitoring. 8) The current plan to provide house wide AVADE training on de-escalation will be prioritized and completed. 9) The hospital will also reinforce just culture and the need to report concerns for patient care, abuse, and safety. 10) Any concern about patient abuse that is caused by a staff member or occurs on our premises will result in an immediate investigation up to and including removal from duty for any staff members involved. The removal of the immediacy was verified on 11/9/23 at 3:35 p.m.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 44770 Based on observation, interview, record review, policy review, and review of digital video surveillance recordings, the hospital failed to ensure that medical staff were accountable to the governing body for quality of care that met the needs of five patients (#s 27, 28, 30, 32 and 33), of 33 reviewed. This had the potential to affect the quality of care provided to patients and could affect all patients who received care in the hospital. Findings include: Review of the hospital’s document titled, “Medical Staff Bylaws,” dated 4/20/23, showed, the medical staff’s purposes and responsibilities included: - “Report to and be accountable to the Governing Body for matters within its responsibilities. - To provide oversight of quality and safety of care, treatment, and services provided by Practitioners for patients of the Hospital during the entire length of stay. - To provide a structure for a uniform quality of patient care, treatment, and services. - To provide for a level of professional performance that is consistent with generally accepted standards attainable within the Hospital’s means and circumstances ... - Provide compassionate, appropriate and effective patient care for the promotion of health, prevention of illness, treatment of disease and at the end of life ... -Demonstrate a commitment to continuous professional development, ethics and sensitivity to diversity, and responsible attitudes toward patients, the medical profession and society ...” 1) Patient #27 complained of chest pain. He presented to the emergency department 3 times on 9/16/23. His second emergency department visit was 3 minutes in total and upon discharge, felt he needed to check back in because he continued to have chest pain. Patient #27 was not allowed to return to the ED to be seen again, was subsequently injured on the premises by police and facility security personnel, and taken to another hospital for care. Review of patient #27’s EMR showed patient #27 presented to the emergency department for a second visit of the day by ambulance, for chest pain after smoking marijuana. The physician spent 23 seconds with the patient and had discharge orders written for the visit, prior to the triage assessment being started. Patient #27 was registered again for the third visit to the emergency department again seeking care for chest pain, and was told to leave by the ED nurse before he had been seen by the physician. Observation of facility video footage and police body camera video footage recordings from 9/16/23 showed patient #27 being escorted out of the facility by staff member BBB. When the patient returned and requested to be seen again, he was again ushered out of the facility by staff member BBB. Patient #27 was observed exiting the facility, then came back inside the facility and sat down in the entrance area in one of the chairs. The police arrived on scene. Police officers were observed removing the patient from the chair he was sitting in, and on two occasions the patient was observed being taken to the ground. During the first encounter, patient #27 sustained a laceration to his chin. Blood from the patient was observed pooling on the ground. Once the police officers and facility security personnel were able to place handcuffs on the patient, he was observed being escorted to a police car which was parked outside the facility entrance. Review of facility document titled, “Interview with [BBB],” dated 9/21/23, showed: Staff member BBB heard patient #27 was coming back to the ED via ambulance. Staff member BBB stated she and the physician [staff member S], “made a plan” to discharge patient #27 as quickly as possible. As soon as patient #27 arrived via ambulance, BBB got patient #27’s vitals, and documented her triage note. Patient #27 was complaining of chest pain after smoking marijuana. BBB stated they did not do an EKG. BBB stated staff member S asked registration to get patient #27 registered so he could be discharged as quickly as possible. BBB stated she printed the discharge paperwork for patient #27 and walked the patient out of the hospital. During a phone interview on 11/14/23 at 8:56 a.m., patient #27 stated he had wanted to be seen in the emergency department on 9/16/23. He stated the doctor did not want to help him, and a nurse was yelling at him during his visit. Patient #27 could not remember the police taking him to the ground, being arrested, or going to another hospital for treatment. During an interview on 11/8/23 at 11:20 a.m., staff member S stated he was the physician assigned to work in the ED on 9/16/23, and he was assigned to patient #27 for his visits to the ED. Staff member S stated he did not recall “making a plan” with the nurse to discharge patient #27 as quickly as possible. Staff member S agreed the marijuana patient #27 had used could have had been laced with another drug or chemical which may have caused the patient’s chest pain. 2) Patient #28 presented to the ED two times with complaints of high blood pressure anxiety and paranoia. On patient #28’s first visit, he had one set of vital signs taken. Patient #28’s vital signs showed he was hypertensive and tachycardic. He did not have a repeat set of vital signs taken before being discharged. Patient #28’s second visit was 7 minutes total and he continued to be tachycardic at the time of his discharge. Review of patient #28’s EMR showed, patient #28 was seen in the emergency department on 11/3/23 at 5:01 a.m. Patient #28 was complaining of high blood pressure and anxiety. His vital signs were BP 164/110, HR 141, RR 20 and SpO2 of 96%. An EKG was performed that showed sinus tachycardia at a rate of 134 bpm. No other tests were performed. There were no other vital signs documented. Patient #28 was discharged six minutes after the physician examined him. The consent to treat, and the notice of privacy practices was signed by registration staff because the “patient appears confused.” Review of patient #28’s medical record showed the patient returned to the ED on 11/3/23 at 8:35 a.m. Patient #28 was seeking care because he was having weakness and feeling dizzy. The patient was triaged at 8:36 a.m. and his vitals were BP 136/87, HR 122, RR 18, and SpO2 94%. Review of patient #28’s medical record showed he was ready for discharge at 8:40 a.m., and was discharged at 8:42 a.m. No nurse was assigned to patient #28 Observation of facility video surveillance footage from 11/3/23 at 8:35 a.m. showed patient #28 came to the registration area and was taken to the triage area. Staff member S approached the patient at the triage desk in the lobby. The video showed staff member S and patient #28 entering the emergency department door. Staff member S talked to patient #28 next to the door. He did not touch patient #28. At 8:40:05 the video showed patient #28 walking back out of the emergency department. He was not provided discharge instructions. During an interview on 11/9/23 at 10:50 a.m., staff member EE stated, staff member S was notorious for walking patients out of the emergency department. Staff member EE said staff member S takes patients that have come in by ambulance and walks them from the ambulance door straight to the lobby. Staff member EE stated staff member S would watch the tracker in the back, and if he saw a name he recognized, he would come out to the lobby to talk to the patients and discharge them immediately, sometimes not even taking them back in the emergency department. Staff member EE stated she had made complaints about staff member S’s behavior to her supervisors. 3) Patient #30 presented to the ED via ambulance. EMS found the patient down on the ground by a bench and was unarousable. There was one minute between the ED physician assigning himself to the patient and the patient being marked ready for discharge. The nurses’ notes showed the physician examined patient #30 as she was walking out of the emergency department. Review of patient #30’s EMR showed, patient #30 was seen on 6/26/23 at 5:01 p.m. with a complaint of alcohol intoxication. The patient received discharge instructions prior to patient #30 being evaluated by a physician. The nursing notes showed the physician examined the patient when she was on her way out of the ED after she was discharged. The physician documented a complete examination that included, listening to the patients heart, lungs, and abdomen, inspecting the patient’s eyes, ears, nose, throat, and skin, feeling the patient’s neck, chest, and abdomen, checking neurological status, including 10 of the 12 cranial nerves, and the patient’s psychiatric status. Review of patient #30’s, “Consent to treat and notice of privacy practices,” dated 6/26/23 at 5:16 p.m., after the patient was discharged, showed it was signed by registration staff showing, “Patient is physically unable to sign.” 4) Patient #32 complained of nausea during her visit to the ED. During her visit she had multiple vital signs outside of normal limits that were not addressed before she was discharged. She was discharged 5 minutes after receiving an intramuscular injection. Review of patient #32’s EMR showed, patient #32 presented to the emergency department on 10/6/23 at 12:56 a.m. Review of patient #32’s emergency department medical chart showed: -At 1:04 a.m. triage notes showed patient #32 was complaining of her “guts being messed up,” and the nurse noted, “pt was very drowsy at triage, disoriented x 3 (patient #32 did not know who she was, where she was, or what day it was), and not interactive with staff. Pt denies drugs or etoh (alcohol).” Vital signs in triage were BP 169/112, HR 97, RR 19 and SpO2 100%. -At 1:27:07 a.m., patient #32 was placed in room 15. -At 1:28:15 a.m., provider S assigned himself to the patient. -At 2:04 a.m., patient #32’s vital signs were BP 146/126 HR 85 SpO2 98%. -At 2:05 a.m., patient #32 was given Zofran 4 mg orally for nausea. -At 2:19 a.m. patient #32’s vitals sings were 147/97 HR 79 and SpO2 93%. -At 2:33 a.m., discharge orders were placed by staff member S. -At 2:34 a.m., patient #32’s vital signs were BP 163/136 HR 33 SpO2 100%. -At 3:00 a.m., patient #32 was given Compazine 10 mg IM for nausea. -At 3:04 a.m., patient #32’s vital signs were 158/103, HR 46, and SpO2 82%. -At 3:15 a.m., patient #32 was discharged. No other vital signs were recorded. There were no diagnostic studies ordered. Patient #32’s consent to treat and notice of privacy paperwork was signed by registration staff and showed, “pt physically unable to sign.” The physicians note stated patient #32 was difficult to understand, and other than nausea, he was unable to get any significant history from the patient and indicated the patient was taken to a gas station by security after discharge. During a phone interview on 11/15/23 at 2:00 p.m., staff member S stated if a patient presented with abnormal vital signs, he would have the nurse repeat the vital signs to verify their accuracy. Staff member S stated he would not be comfortable discharging a patient with a blood pressure of 158/103, a heart rate of 46 and an SpO2 of 82%. When staff member S was informed he had discharged a patient with those vital signs on 10/6/23, he stated, “It could be one of three things. I forgot to document, or I did not realize the vital signs were not normal. I would expect a nurse to report those vital signs to me or at least retake them.” During a phone interview on 11/13/23 at 1:52 p.m., NF2, a local paramedic, stated, “If [staff member S] is working he tries to discharge patients before we leave. He told us once that he had a challenge to try to discharge someone faster than we can be back in service. I would not be surprised if staff member S discharged her (patient #32) before we even left. That happens on a pretty consistent basis. If a patient can walk, a lot of times, [staff member S] will walk them straight out of the department. If it is someone he sees often; like a homeless person or an alcohol intoxication, he just discharges them as quickly as possible.” 5) Patient #33 arrived to the ED via ambulance with complaints of a dislocated knee. The physician attempted to reduce the dislocation without medication and failed to perform an x-ray prior to attempting to reduce the dislocation. Patient #33 began yelling at the physician and scratched him. Staff member S told the patient to leave. Patient #33 was subsequently taken from St. Vincent’s ED to another hospital via ambulance where her dislocated and fractured patella (kneecap) was reduced with sedation. Review of patient #33’s EMR showed, on 3/30/23 at 6:08 p.m., patient #33 arrived via ambulance, complaining of knee pain. Patient #33 was very anxious and was not very cooperative with staff. Patient #33 appeared to be intoxicated. It took multiple tries and multiple nurses to convince the patient to allow them to cut her pants to expose her knee. -At 6:14 p.m. Physician notes written by staff member S showed, “She was on her phone requesting that we call 911 so she can be taken to [Other local hospital name]. Discussed with the patient that I would not do that but was happy to assess her which she refused, and if she wishes to be seen at [Other local hospital name] that she would at least need to leave the department and could call. Following this I left the room ... when I went back in, I could easily see the patella is dislocated, and therefore just straightened her leg, immediately reducing the dislocation. With this the patient scratched my right forearm drawing blood.” The physician was called away for CPR in progress and when he returned the patient was gone. -At 7:48 patient disposition was listed “elopement.” Review of patient #33’s ambulance report showed, at 6:49 p.m., the paramedics arrived in the facility’s emergency department with a report of a patient (#33) requesting to be taken to [another local hospital]. Pt #33 told the paramedics that the doctor had attempted to put her knee back in place without giving her any pain medication and was being mean to her. The report stated no other information was obtained from St Vincent Hospital because no one would acknowledge him or answer any questions. The report said, “security stated patient was told to leave St. Vincent’s by the doctor due to her behavior.” Patient #33 was transported to another local hospital. Review of patient #33’s medical record from the other local hospital showed, patient #33 was seen in their emergency department on 3/30/23 at 7:07 p.m. The report showed the patient’s patella was still dislocated. An x-ray of her knee showed, the patella (knee cap) was dislocated and had a small fracture. After sedation, the physician was able to successfully reduce her dislocation.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 44770 Based on interview, record review, policy review, and digital video surveillance recordings review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for the management of the entire hospital, including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation CoP: Governing Body and 42 CFR 482.13 CoP: Patient’s Rights. These failures had the potential to affect the quality of care and safety of all patients. Findings include: Review of the hospital’s document titled, “Medical Staff Bylaws,” dated 4/20/23, showed, “The Governing Body has the ultimate authority and responsibility for the oversight and delivery of health care rendered by Practitioners ...” 1. The CEO failed to ensure compliance with the CoP of Governing Body as evidenced by the ineffective management of the hospital that resulted in the failure to meet applicable regulatory requirements. 2. The CEO failed to ensure compliance with the CoPs of Governing Body, and Patient’s Rights, as evidenced by the failure to ensure that patients were provided quality care to meet the patient care needs and patient care was provided in a safe setting and without abuse when: -One patient (#6) was seen in the ED and was identified by the triage nurse as having suicidal ideations. The physician did not recognize the patient was suicidal. Patient #6 was discharged and later returned after attempting to commit suicide. (A-0144); -One patient (#27) complained of chest pain, his emergency department visit was 3 minutes in total, and upon discharge felt he needed to check back in. The patient continued to have chest pain but was not allowed to return to the ED to be seen again. He was subsequently injured on the premises by security and police, and was taken to another hospital for care. (A-0049 and A-0145); -One patient (#28) presented two times with complaints of high blood pressure and dizziness. On patient #28’s first visit he had one set of vital signs taken. Those vital signs showed he was hypertensive and tachycardic. The patient did not have a repeat set of vital signs taken before being discharged. Patient #28’s second visit was 7 minutes total and he continued to be tachycardic. (A-0049); -One patient (#29) arrived via EMS with alcohol withdrawal. He was a known alcoholic that had stopped drinking the day before. Patient #29 had tremors and appeared anxious. His total time in the ED was 12 minutes where he received an oral medication and was discharged 5 minutes after taking the medication. (A-0049); -One patient (#30) was found lying on the ground, unresponsive, and was brought into the ED by EMS. A complete examination was documented by the physician after the physician spent one minute with the patient in the hallway. The physician completed patient #30’s examination while she was on the way out of the ED, following her discharge. (A-0049); -One patient (#32) complained of nausea. During her visit she had abnormal vital signs that were not addressed. Patient #32 was discharged 5 minutes after receiving an intramuscular injection. (A-0049); and -One patient (#33) arrived via ambulance with complaints of a dislocated knee. The physician attempted to reduce the dislocation without medication, or x-ray imaging. The patient began yelling at the physician, and he told her to leave. Patient #33 was subsequently taken to another hospital where her dislocated and fractured patella was reduced with sedation. (A-0049). During an interview on 11/27/23 at 2:56 p.m., staff member A stated he was the interim Hospital President for the facility. Staff member A stated he was appointed to the position during the first week in October of 2023. Staff member A stated the hospital system does not use the term CEO (Chief Executive Officer); they use Hospital President instead. Staff member A stated he was made aware of a concern with an alleged EMTALA violation that was self-reported to CMS upon his appointment as the Hospital President, but he was not made aware of the details of the incident that was reported. Staff member A said he expected to be informed of issues of abuse, patient injury, or EMTALA issues. He stated he was not made aware of abuse concerns until the survey team brought up concerns about abuse of patient #27 while conducting an on-site complaint investigation on November 6, 2023. Staff member A stated he watched the video of the 9/16/23 incident with patient #27, and stated it was “disturbing” to watch. Staff member A stated he had been made aware of a physician that was having some, “short ED times” and there had been some concerns with that physician having, “unsafe discharges.” Staff member A stated he had not watched any of the video footage that was viewed by surveyors during the survey of patient #28 and patient #32. Staff member A stated the physician [staff member S] had been placed on administrative leave when the survey concluded on 11/9/23, but he was reinstated to work on 11/17/23. Although, staff member A said staff member S was still being investigated by the Medical Executive Committee for his “unsafe discharges.” After surveyors explained what was observed on the videos of patient #28 and #32, staff member A stated he felt it was “pretty appalling” he was not made aware of what was observed on the videos. When asked about risk managements duties of keeping him aware of issues, staff member A stated, “Clearly there is a problem there. I do not have all of the information that you have.””

“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: 45448 Based on observation, interview, record review, and review of facility video surveillance recordings, the facility failed to ensure patients were safe in their environment by failing to follow their established policies and procedures for recognizing patients who presented with psychiatric concerns for suicide risk for 1 (#6) of 33 sampled patients. Findings include: A review of a facility policy, “Management of Patients with Emotional Illness or Effects of Alcoholism or Substance Abuse,” dated 3/12/2019, showed: “ ...Patients with emotional Illness Presenting to the Emergency Department ...6. Assist patient into a hospital gown and remove their personal clothing and belongings from the room...” A review of a facility policy, “Identification and Care of Patients at Risk for Suicide,” dated 11/8/21, showed: “ ...7. 1:1 Sitter/Safety a. Patients with suicidal ideation must be placed under demonstrably reliable monitoring (1:1 continuous monitoring by trained associates who can provide immediate intervention when called for)...” A review of a facility document, “Guidelines for Safety Attendants,” not dated, showed: “ ...5. Always keep door/curtain to the patient’s room open with lights on during the day. Sit inside the patient’s room, between the door and the patient... 6. Maintain a line of sight with the patient at all times... 7. Coordinate patient activities with the primary care nurse. Questions, changes in patient condition, and related concerns should be reported to the primary nurse or the charge nurse...” A review of patient #6’s emergency department record, dated 10/11/23 at 1:06 p.m., showed patient #6 arrived at the emergency department by wheelchair from his primary physician’s office for an attempted suicide. Patient #6 had stabbed himself in the neck multiple times with a pen he had taken from a reception desk. Patient #6 was placed on 1:1 observation and taken to an exam room, after the room had been cleared. Patient #6 was attached to continuous monitors and vitals were documented every 15 minutes. At 2:12 p.m., patient #6 made 3 attempts to remove his IV. At 2:19 p.m., patient #6 removed his IV, all monitoring equipment, and stated he was leaving. ED tech and security convinced patient #6 to stay. Patient #6 had his monitoring equipment (BP, SpO2, Cardiac monitor) reapplied and had Coban applied to his IV site. A review of a facility document, “15 Minute Safety Check”, dated 10/11/23, showed patient #6 was in bed with his hands visible, calm, and cooperative, as documented by staff member T. Staff member U took over observations at 3:00 p.m., and documented the patient was in bed and agitated until his elopement at 4:15 p.m. There is no documentation in patient #6’s medical chart which showed the agitation was reported to the physician or nursing staff. Record review of “ED Provider Note,” dated 10/11/23 at 9:18 p.m., showed patient #6 was seen and evaluated by staff member K. Patient #6 was having suicidal ideations, delusions, paranoia, and hallucinations. He had a history of schizophrenia and had been not taking his medication for 6 months. Staff member K assessed patient #6 to be a threat to himself and possibly others. Staff member K placed patient #6 on one-to-one observation. Haldol 10mg was given IM for agitation. Staff member K consulted a facility hospitalist and it was decided patient #6 would be admitted for observation. While awaiting a room assignment, patient #6 “knocked over the elderly one-to-one person” and ran from the building. Security and the police were notified. Observation of facility video surveillance recordings, dated 10/11/23 at 4:15 p.m., showed an older gentleman standing at the end of the hallway, outside of patient #6’s room. The gentleman was standing and was looking down the hallway and into the room of patient #6. The gentleman is observed walking to the doorway of patient #6’s room, and was observed being shoved to the ground by patient #6. Patient #6 was observed running down the hallway, wearing sweatpants, socks, and a patient gown. He was viewed, running out of the facility entrance. During an interview on 11/8/23 at 4:22 p.m., staff member K stated he was the physician assigned to the care of patient #6. Staff member K stated patient #6 was paranoid and had thoughts of hurting himself. Staff member K said he spoke with patient #6 and the patient said he was not going to hurt himself as long as he was in the facility. Staff member K said he did an assessment for an emergency hold for patient #6, but did not file the paperwork and stated, “It was a judgement call.” Staff member K stated an emergency hold would have kept patient #6 in the building. He stated patient #6 was admitted to the facility and eloped from 1:1 observation prior to the admission being completed. During an interview on 11/15/23 at 8:57 a.m., staff member U said he was a sitter assigned to take over 1:1 observation for patient #6. Staff member U said he had only been to the ED twice to perform patient 1:1, and it felt foreign to him. Staff member U stated, “The staff didn’t tell me anything about the patient, only that he was not allowed to leave.” Staff member U stated this assignment was different from ones he was usually assigned, as upon arriving to the ED, two security guards were outside of patient #6’s room. Staff member U stated patient #6 was lying on a gurney and appeared agitated; he still had his clothing on and he was wearing a green gown. Staff member U stated patient #6 was repeating to the staff that he wanted to leave and talk to his girlfriend. Staff member U said security was called from the room and left him with a buzzer to use if he needed any help. Staff member U stated a short time later, a physician came into the room and gave patient #6 his cell phone. He stated patient #6 began making phone calls and he became more agitated. Staff member U stated patient #6 called his girlfriend and asked her to come to the hospital. About 15 minutes later, patient #6 received a phone call that his girlfriend had arrived. Staff member U stated patient #6 approached the door in his room, and he thought patient #6 was going to ask a question but instead, patient #6 was looking for the security guards. Staff member U stated patient #6 then pushed him to the ground and bolted from the building. Staff member U stated he thought it was unusual that patient #6 had his clothing on under his gown, but felt he did not know how much “leeway” he had in the emergency department. Staff member U said the only documentation available to him was the monitoring paper. Staff member U stated he had no “real way” to notify staff of a change in patient #6’s condition. Staff member U said, “Maybe that is what the buzzer was for.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44770 Based on interview, record review, policy review, and review of digital video surveillance recordings, the facility failed to ensure: -Staff were competent to prevent, identify, and respond to all forms of abuse when hospital staff failed to recognize abuse or to intervene on patient #27’s behalf when he was injured in the lobby of the ED while he was a patient of the emergency department; and -Ensure a thorough investigation was completed to accurately determine whether abuse had occurred for one patient (#27), after staff member EE reported the abuse. These failed practices by the facility placed all hospital patients at increased risk for their safety. Findings include: Review of a facility policy titled, “Victims of Abuse or Neglect”, dated 3/14/22, showed: The purpose of the policy was to provide procedures for reporting, investigating, and follow-up when an allegation for patient abuse or neglect was made, or when other information was received indicating that abuse or neglect of a patient may have occurred. The policy only included abuse of a child, older person/dependent adult, or a victim of domestic violence. The policy did not include what staff should do in the event they witnessed abuse of any patient by staff. Review of a facility policy titled, “Use of Force,” dated 5/25/22 showed: “Use of Force is sometimes necessary to ensure the safety and security of the associates, patients, and visitors that are within [Facility name] ...The purpose of handcuffs is to restrain the movements of a subject in a manner that provides a safe means of transportation for officers; or the proper application of distraction techniques, takedowns, or the application of medical restraints, as prescribed by a physician or authorized medical provider ... - The security staff are required to report any use of force immediately to a supervisor. - All use of force events will include assessment by persons affected by the Emergency Department or Emergency Medical Services. - Will be documented in a Safety Event Report (PEARL) and within the Department of Public Safety Event Report. - Any surveillance footage of the event will be retained and cataloged for review and records purposes. - Witness statements should be obtained and submitted as part of the records of the event. - A public safety officer whose use of force results in injury to any person may be placed on administrative leave, pending use of force review. - Associates and security officers involved shall immediately make a verbal notification to Department Manager and Department of Public Safety Manager in all cases in which they use physical force... - Notification to Department Manager and Leadership: ...Where the application of force appears to have caused physical injury. The individual has expressed a complaint of pain ... Any situation requiring law enforcement involvement... - Manager or Supervisor shall respond in-person to the incident where there has been a reported application of force. - The manager and or supervisor is expected to: Obtain the basic facts from the officers involved. Ensure any injuries, or report of injuries, are examined by qualified medical personnel. Identify any witness if not already identified in related reports or related statements. Collect needed information for Use of Force Review, ensure reports are completed and satisfactory...” Review of patient #27’s EMR showed: Patient #27 presented to the emergency department three times. On 9/16/23 at 10:12 p.m., patient #27 presented to the emergency department via ambulance, his second visit, for chest pain after smoking marijuana. At 10:15 patient #27 was discharged home. On 9/16/23 at 10:23 patient #27 registered to be seen in the emergency department again, stating he was still having chest pain. Review of facility video surveillance recordings from 9/16/23 showed: -At 10:20:04 (time stamp from video), patient #27 walked out of the emergency department. He was observed holding paperwork in his hands. -At 10:20:19 patient #27 walked outside. -At 10:20:33 patient #27 returned to the emergency department lobby. -At 10:21:47 patient #27 was observed speaking to the registration clerk and receiving a new arm band. -At 10:24 staff member BBB was observed coming out of the emergency department and walked patient #27 out of the hospital entrance doors. -At 10:24:42 staff member BBB was observed coming back into the hospital entrance doors without patient #27. -At 10:26:02 patient #27 came back into the hospital entrance and sat in a chair by the door in the breezeway. -At 10:26:26 staff member BBB, staff member AA, and staff member AAA came out of the lobby to the chair where patient #27 was sitting. The staff members appeared to be speaking to patient #27. Staff member BBB was observed standing with her arms folded across her chest, shaking her head no. -At 10:30:06 staff member BBB walked back into the ED lobby leaving the two security officers with patient #27. -At 10:32:56 a third security officer, staff member BB entered through the hospital entrance and appeared to be speaking to patient #27. -At 10:35:46 three police officers enter the breezeway and appeared to be speaking to patient #27. -At 10:37:38 two of the police officers walked towards patient #27, who was observed seated in the chair. Patient #27 was not showing any aggressive behaviors at any time leading up to this point; occasionally he crossed his legs. The police officers picked patient #27 up out of the chair and patient #27 appeared to stiffen his body and held his arms close to his sides. - At 10:38:00 the police officers shoved patient #27 into the wall. -At 10:38:17 the police officers and the three security officers took patient #27 to the ground. Patient #27’s head was observed bouncing off the floor when he was taken down. -At 10:39:09 staff member AA put handcuffs on patient #27. -At 10:40:16 one of the police officers stood up and a large amount of blood was observed on the floor next to patient #27’s head. -At 10:41:23 staff member BBB came out into the breezeway doorway and looked toward the officers and patient #27. She did not attempt to assess the patient for injury or intervene on the patient’s behalf. -At 10:41:46 the police picked patient #27 up off the floor. Patient #27 attempted to kick one of the officers and he was again taken to the ground a second time. Staff member BBB did not attempt to assess the patient and kept her distance from the officers and patient #27. -At 10:42:04 staff member BBB left the breezeway toward the emergency department. She did not attempt to assess patient #27 for injury. Patient #27 was still registered as a patient of the facility during the duration of the video and he was not assessed by a medical provider after hitting his head on the floor. Review of NF6’s body camera footage, dated 9/16/23 showed patient #27 stated he did not want to leave the facility because he, “might die.” Patient #27 told the officer the reason he did not want to leave because he wanted “his heart rate to calm down.” During an interview on 11/14/23 at 8:56 a.m., patient #27 stated he wanted to be seen in the emergency department. He said the doctor did not want to help him and the nurse was yelling at him. Patient #27 could not remember the police taking him to the ground, being arrested, or going to the other hospital. During an interview on 11/9/23 at 10:50 a.m., staff member EE stated she was the registration clerk assigned on 9/16/23, and she heard an ambulance call overhead for patient #27. She stated she saw staff member S go into patient #27’s room. The patient tracking board showed patient #27 came to the ED for chest pain. Staff member EE stated she was concerned when the patient was discharged 6 minutes after he arrived via ambulance. Staff member EE stated patient #27 was escorted out of the hospital by the nurse (BBB). She stated patient #27 came back into the ED with his discharge instructions and said he needed to be seen again because he continued to have chest pain. Staff member EE stated she checked patient #27 back into the system and gave him a new patient ID band. Staff member EE stated the nurse (BBB) came out and told the patient he had already been assessed, there was nothing wrong with him, and he needed to leave. Staff member EE stated she saw security was involved, and the patient was eventually taken down to the ground by police and security. Staff member EE said the whole situation seemed wrong to her, so she reported it anonymously through the hospital PEARL system. During an interview on 11/8/23 at 4:32 p.m., staff member BB stated he was a security guard for the facility. He stated he was called on 9/16/23 to assist staff member AA with a patient that would not leave the property. Staff member BB stated he offered patient #27 a ride somewhere, but the patient did not want to leave because he still wanted to be seen in the ED. Staff member BB stated he was not sure why the patient needed to leave the property. He said the patient did not appear to be a danger to others or himself at the time they were asking him to leave. Staff member BB stated it is common to allow patients to stay in the lobby after they are discharged if they are not causing any problems. Staff member BB said he was not told why patient #27 needed to leave. He said he did notice the patient was injured after he was taken to the ground and handcuffed. Staff member BB stated, “Now knowing that she (staff member BBB) escorted him out, I feel like it could have been handled a lot better. I found out later that the nurse (staff member BBB) told him to leave and that they wouldn’t see him again. I saw his patient’s name band that indicated he was a patient. But I was told by [staff member AA] that he was discharged.” Staff member BB agreed the incident most likely would not have escalated to police being called, or the patient being injured if the security staff would have known he was still a patient of the hospital. Staff member BB stated after the incident the manager watched the video with the officers involved. The manager did not offer any ways things could have been handled differently. Staff member BB said, “When we were reviewing the footage, I was sure there would be more to come of this because of the force that was used.” Staff member BB said he was unsure if he had ever received training in recognizing patient abuse. During an interview on 11/8/23 at 5:18 p.m., staff member AA said he was told by staff member BBB that patient #27 was “playing games” and she wanted him to leave. Staff member AA stated BBB told her patient #27 was going to keep checking in to be seen, so she, “wanted him off of the property.” Staff member AA said the patient was not being disruptive or aggressive to anyone. Staff member AA stated patient #27 would say he didn’t want to leave but he couldn’t remember why the patient did not want to leave. Staff member AA stated a patient of the hospital should remain under security control if they are still a patient. However, if the patient has been discharged they let local law enforcement handle the situation. Staff member AA stated he was not aware patient #27 was still a patient. Staff member AA stated he did not know a patient could not be turned away if they were requesting treatment. When asked about recognizing abuse of a patient, he said, “that was for the nurses,” and as a security guard he did not receive training for recognizing abuse of a patient. When asked if he would report an incident he felt was patient abuse, he said, “well if the patient was bleeding or knocked out by the nurse or something, I might.” Review of a police report, dated 9/16/23, showed NF6 wrote in his report patient #27 told him he did not want to leave the emergency department, as he wanted to let “his heart rate calm down,” and “it was time to go back to a bed” (in the emergency department). NF6 wrote in his report the security officer from the facility told him the patient was discharged from the hospital and he needed to leave. NF6 wrote patient #27 was sitting in a chair in the lobby; when he was asked to leave, he did not, so he and another police officer simultaneously picked patient #27 up from the chair to remove him from the premises, per the facilities security guard request. When NF6 and his partner grabbed patient #27, he stiffened up his body making it difficult to place hand cuffs on him. While they were attempting to get cuffs on the patient, they took him to the ground with the assistance of security personnel. NF6 wrote he saw there was blood on the floor after they took him to floor. NF6 wrote one of the security staff placed hand cuffs on the patient. Review of patient #27’s medical record from the other local hospital, dated 9/16/23 at 10:58 p.m. showed, Patient #27 was seen in the emergency department after an altercation that occurred at St Vincent’s Hospital. The report showed patient #27 sustained a laceration to his chin that required 6 stitches to close. Patient #27 was discharged to police custody. During an interview on 11/7/23 at 1:57 p.m., staff member V said the facility did not recognize any abuse occurred. During an interview on 11/8/23 at 9:30 a.m., staff member CC said he reviewed the video footage of the incident on 9/16/23 the following day, on 9/17/23. He stated he did not feel the security officers acted inappropriately. Staff member CC stated he reviewed the video after he read the security officers report. Staff member CC stated he did not involve anyone else in his investigation other than the officers involved. He stated risk management staff made a request a few days later (9/20/23) for information regarding the incident on 9/16/23. He stated risk management did not request any feedback or his professional opinion of what happened on 9/16/23. Staff member CC stated he did not suspend the security officers during or after the investigation took place. An attempt was made to interview staff member BBB but the phone number was no longer in service.”

“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: 44770 Based on observation, interview, policy review, record review, and review of video surveillance, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at 489.24: (refer to Appendix V). The facility failed to 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 for six patients (#s 6, 27, 28, 29, 32, and 33); and the facility failed to provide stabilizing treatment for one patient (# 27) of 33 sampled patients. Findings include: Review of a facility document titled, Emergency Medical Treatment and Labor Act (EMTALA), with a last review dated 12/19/22, showed, “It is the policy of the Hospital that it shall: 1. Provide an MSE by a physician or other QMP to any individual who comes to the Emergency Department to determine if the individual has an EMC; and 2. If it is determined that the individual has an EMC, provide the individual with such further medical examination and treatment as required to stabilize the EMC within the capability and capacity of the hospital or to arrange for an appropriate transfer of the individual to another medical facility ...” -Patients #s 6, 27, 28, 29, 32 and 33 did not receive an appropriate MSE after seeking care in the emergency department. (Refer to A-2406). -Patients # 27 did not receive stabilizing treatment in the emergency department before being discharged. (Refer to A-2407).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 44770 Based on observation, interview, record review, and review of video surveillance, the facility failed to maintain an accurate emergency department log, whereas the facility deleted 1 (#27) of 33 sampled patients from the ED log. Findings include: Review of the hospital ED log for 9/16/23 showed, patient #27 registered for the ED at 4:31 p.m. and at 10:12 p.m. The facility ED log failed to show patient #27’s registration on 9/16/23 at 10:24 p.m. Review of patient #27’s EMR, “Encounter Status History,” showed staff member EE had deleted the encounter from the ED log on 9/16/23 at 10:24 p.m. During an interview on 11/7/23 at 1:57 p.m., staff member V stated the registration clerk deleted the encounter for patient #27 because she did not know what to do after the nurse told the patient to leave and he could not be seen in the ED. During an interview on 11/9/23 at 10:50 a.m., staff member EE stated she registered patient #27 for his third encounter on 9/16/23 at 10:24 p.m. but a nurse came out and told the patient he had already been seen, there was nothing wrong with him, and he needed to leave. Staff member EE stated she did not know what to do with the registration of the patient after the nurse made him leave. Staff member EE asked the triage nurse what to do with patient #27’s registration, and the triage nurse told her to delete the encounter completely, so she deleted the encounter. Observation of a facility security video of the front desk and triage area, dated 9/16/23 at 10:24 p.m., showed, patient #27 presented the registration clerk in the lobby. Patient #27 was then observed walking over to the triage desk, and a nurse came out of the ED and escorted him out of 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: 44770 Based on observation, interview and record review, the facility failed to provide a appropriate MSE for 6 (#s 6, 27, 28, 29, 32 and 33) of 33 sampled patients. Findings include: 1) Patient #6 was seen in the ED on 10/11/23 at 8:35 a.m. for multiple complaints. Patient #6 was concerned he may have contracted HIV due to his history of drug abuse. Patient #6 was assessed in triage to be having thoughts of harming himself or others for the last several days. Patient #6 was seen and evaluated for his HIV concerns, but he was not evaluated for his psychiatric concerns prior to being discharged. Patient #6 returned to the ED at 1:06 p.m. after attempting suicide at his primary physician’s office when attempting to schedule an appointment. Patient #6’s MSE for his first ED visit psychological evaluation did not assess his suicide risk after admitting to having ideas of self-harm for the previous several days. Emergency department visit #1: A review of patient 6’s emergency department record, dated 10/11/23 at 8:35 a.m., patient #6 arrived at the emergency room reception with multiple complaints. Staff member O performed a triage assessment on patient #6 that showed; distress level as mild. Patient #6 presented to ED for evaluation of possible HIV concerns related to his IV drug use and was requesting lab work to “make sure he doesn’t have anything majorly wrong with him.” The SI/HI portion of the assessment showed patient #6 answered no to thoughts of harming himself or others. A PHQ Depression Assessment was performed by staff member O. Patient #6 responded he had been bothered by feeling down, depressed, and hopeless for the last several days. He also responded He had trouble falling/staying asleep or slept too much more than 50% of the time. Patient #6 said he was feeling tired/low energy for the last several days and had a poor appetite/overate for the last several days. He was feeling bad/failure, letting himself/family down more than 50% of the time with trouble concentration for the last several days. Patient #6 responded he had thoughts of death/hurting himself for the last several days. During an interview on 11/8/23 at 12:36 p.m., staff member O said he triaged patient #6 during his first ER visit. He asked the patient if he was having thoughts of harming himself or others and patient #6 responded, no. Staff member O said when he asked the questions for the PHQ assessment, patient #6 responded that he was having thoughts of death and hurting himself for the last several days. Staff member O said he recognized the discrepancy and called back to the nurse assigned to his care, reporting the discrepancy so it could be discussed with the physician. During an interview on 11/8/23 at 11:56 a.m., staff member P said, staff member O had called to notify her of patient #6’s response of having thoughts of harming himself or others. Due to the varied discrepancies in patient #6’s responses during triage, the patient’s suicide information did not trigger an electronic notification to the ED provider, and staff member P failed to notify the provider of the patient’s suicide risk or the discrepancy in the patient’s responses. During an interview on 11/8/23 at 1:05 p.m., staff member L said she was not made aware of patient #6’s triage assessment and was only aware of his HIV concerns. Staff member L said the patient was acting “odd” and was a little anxious, but she did not see anything that was concerning and did not investigate further. She does not usually go through a psychological evaluation unless the patient tells her something that would indicate a need or if it was reported to her by nursing staff. Staff member L said she tested patient #6 for HIV and he waited in the department for his results. She answered all his questions, he was discharged and instructed to schedule a follow-up appointment with his primary physician. A review of an “ED Provider Note,” dated 10/11/23 at 9:06 a.m., showed patient #6 had a chief complaint of abnormal lab results and addiction problem. Patient #6’s past medical history showed, alcoholism in recovery, history of methamphetamine abuse, schizophrenia, shellfish allergy and tobacco abuse. Patient #6 was not currently using alcohol or drugs (IV, marijuana, heroin, methamphetamines). His current medication was Trazadone 50mg, 1-2 every night. Patient #6’s psychiatric evaluation showed his affect normal, judgement normal, and anxious mood. Patient #6 tested negative for HIV and was advised to contact his primary physician by phone today to schedule a follow up appointment. Patient #6 was discharged from visit at 10:42 a.m. A review of patient #6’s emergency department record, dated 10/11/23 at 1:06 p.m., 2 hours and 24 minutes after his first ED visit, patient #6 arrived in ED by wheelchair for attempted suicide. Staff member O performed a triage assessment on patient #6 that showed; distress level as severe and no vital signs were documented for the triage assessment. Patient #6 presented to the ED for evaluation of attempting to “kill himself” with a pen. He went to his primary physician’s office building to schedule an appointment, grabbed a pen from the reception desk, and proceeded to stab himself in the throat numerous times. Patient #6 was verbalizing that he “should have done it with the razor blade that he had yesterday.” Staff member O notified ED staff and held patient #6 at the triage desk until a room was made available in the ED. 2) Patient #27 arrived at the emergency department on 9/16/23 seeking care for chest pain and palpitations on three separate occasions. During the patient’s first visit, the physician completed a history and physical and ordered a single troponin test (elevation can indicate a heart attack). The physician did not ensure that a second troponin level or chest x-ray was completed prior to the patient’s discharge. Review of patient #27’s EMR dated 9/16/23, showed: -4:31 p.m. Patient #27 presented to the emergency department for chest pain. -4:48 p.m., triage was started. Patient #27’s vital signs were BP 158/83, P 80 bpm, R 18, and Spo2 98%. (Normal vital signs include BP <120/<80, P 60-100, R 12-18 and Spo2 >90%.) -4:49:33 p.m., Patient #27 was placed in room 12 -4:49:56 p.m. Staff member S assigned himself as the provider of the MSE for patient #27. -5:10 p.m., Staff member S performed an examination on patient #27. The physician’s documentation showed the patient was “Awake, alert, in no acute distress.” The physician documented the patient’s heart rate was 75 and indicated when the patient stands, his heart rate will increase to 100 then begin to decrease. -5:11 p.m., Staff member S placed an order for a single troponin -6:01 p.m. Staff member S made the patient “ready for discharge.” -6:22 p.m. Patient #27’s triage documentation was complete, vital signs were BP 144/86, P 84, R 15, and Spo2 of 100%. -6:25 p.m. patient #27 was discharged. The EMR did not indicate that a second troponin level or chest x-ray was completed to ensure the patient was not experiencing a heart attack, pneumonia, or collapsed lung. Patient #27 arrived at the emergency department via ambulance, his second visit, seeking care for chest pain and palpitations on 9/16/23. The patient’s second visit for complaints of chest pain and palpitations lasted approximately three minutes from arrival to discharge, and the patient was determined ready for discharge by the ED physician prior to staff documenting the patient’s vital signs. Patient #27 was registered again for the third visit to the emergency department, again seeking care for chest pain, and was told to leave by the ED nurse before he had been seen by the physician. Patient #27 was subsequently injured in the facility entryway and transported to a nearby facility ED for care. Review of patient #27’s EMR dated 9/16/23, showed: -10:12 p.m. Patient #27 presented to the emergency department for a second visit of the day by ambulance, for chest pain after smoking marijuana. -10:13 p.m. Staff member S assigned himself as the provider of the MSE for patient #27. -10:13:06 p.m. Patient 27 was placed in ED room 23. -10:13:23 p.m. Staff member S made the patient “ready for discharge.” -10:15 p.m. Patient #27’s triage documentation was complete, vital signs were BP 171/83, P 72, R 14, and Spo2 of 98%. -10:15 p.m. patient #27 was discharged. The EMR did not indicate that an EKG, chest x-ray, or troponin were completed to ensure the patient’s ongoing chest pain was not a result of the patient suffering from an acute myocardial infarction (heart attack), pneumonia, collapsed lung, or other serious illness. -10:23 p.m. patient #27 registered to be seen in the emergency department, again. -10:24 p.m. staff member EE deleted the encounter on the ED log. Observation of facility video surveillance footage from 9/16/23, showed: -10:20 p.m. Patient #27 was seen walking out of the emergency department carrying paperwork. He exited the building. -10:21 p.m. Patient #27 was seen returning to the emergency department registration desk and speaking with the registration clerk. The registration clerk was seen removing patient #27’s wrist band and placing a new wristband on patient #27’s wrist. -10:24 p.m. Staff member BBB was seen coming out of the emergency department and escorted patient #27 out of the hospital entrance door, and was seen gesturing while speaking to the patient, before BBB reentered the hospital without patient #27. -10:26 p.m. Patient #27 was seen reentering the hospital and taking a seat in a chair in the hospital entrance area. -10:26 p.m. Staff member BBB, staff member AA, and staff member AAA were observed speaking to patient #27. Staff member BBB was standing near patient #27, with her arms folded across her chest, and shaking her head no. -10:35 p.m. Three police officers were seen entering the facility and appeared to be speaking to patient #27. -10:37 p.m. Two of the police officers walked toward patient #27, who was still seated in the chair, occasionally crossing and uncrossing his legs. Patient #27 did not appear to be showing any aggressive behavior at any time. The police officers were observed picking patient #27 up out of the chair, and patient #27 appeared to stiffen his body and resist. -10:38 p.m. The police officers were observed shoving patient #27 into a nearby wall and down to the ground. Patient #27’s head was observed bouncing off the floor while he was taken down. -10:40 p.m. One of the police officers stood up and a large amount of blood was observed on the floor next to patient #27’s head. -10:41 p.m. The police were observed picking patient #27 up from the floor. Patient #27 attempted to kick one of the officers and he was again taken to the ground, a second time. Staff member BBB was present and at no time was observed to attempt to assess or provide care for patient #27’s injury. -10:42 p.m. Staff member BBB exited the area toward the emergency department lobby. Patient #27 was escorted to a patrol car by police. Patient #27 was still a registered patient of the facility during the incident and was not provided an MSE by a provider prior to or following the injuries he sustained. During an interview on 11/14/23 at 8:56 a.m., patient #27 stated he had wanted to be seen in the emergency department. He stated the doctor did not want to help him and the nurse was yelling at him. Patient #27 could not remember the police taking him to the ground, being arrested, or going to another hospital for care. Review of a facility document titled, “Interview with [BBB],” dated 9/21/23, showed: BBB said she was made aware of patient #27 returning to the ED for a second time via ambulance. BBB said she and staff member S “made a plan” to discharge patient #27 “as quickly as possible.” When patient #27 arrived via ambulance, BBB got patient #27’s vitals and entered them into her triage note. Patient #27 was complaining of chest pain after smoking marijuana. BBB stated an EKG was not done. BBB said staff member S brought a registration clerk back as quickly as possible to get patient #27 registered, so the EMR system would allow patient #27 to be marked as discharged. BBB then printed the discharge paperwork and walked patient #27 out of the hospital. BBB stated, “10 minutes later” staff member S came to her stating patient #27 had registered again to be seen. BBB said she then went out to the lobby to speak with patient #27 and walked him outside of the building, where she pointed the patient in the direction of the other local hospital nearby. Staff member BBB had noticed patient #27 had returned inside the entrance and was seated in a chair. BBB reported to security the patient would not leave. BBB, staff members AA, and AAA went to the entrance to speak to patient #27. Patient #27 was complaining of his legs not working and that he did not want to leave. BBB said security called local police to assist, things escalated, and the patient was injured. BBB stated the police decided to transport the patient to another local hospital to be seen and treated for his injuries. Review of a facility document titled, “Interview with [staff member Z],” dated 9/21/23, showed: staff member Z stated patient #27 told her he wanted to be seen again in the ED. The registration clerk cut off the old arm band and placed a new one for the visit. Staff member Z said the RN (staff member BBB) came out and began yelling at patient #27 saying, “No, no, no, no. You were just seen and there is nothing wrong with you.” Staff member Z said she knew it was an EMTALA violation, but due to the RN that was involved she, “didn’t want to get in the way of her.” Staff member Z said the registration clerk did not know what to do with the registered encounter after the nurse told the patient he could not be seen, so the visit was canceled and patient #27 was deleted off the ED log. During an interview on 11/8/23 at 11:20 a.m., staff member S said he did not recall “making a plan” with the nurse to discharge patient #27 as quickly as possible on his second visit. He agreed the marijuana could have been laced with other drugs or chemicals, which may have caused the patient’s chest pain. Staff member S stated he spoke to the patient briefly, and he did not remember if cardiology was ever consulted. Staff member S said he was not aware the patient had checked in to be seen for a third visit. Staff member S said the patient should have been seen when he checked in the third time. During a phone interview on 11/9/23 at 10:50 a.m. staff member EE stated she was working the night patient #27 came in for his second and third visit to the ED. Staff member EE said she was working triage and saw staff member S go in the examination room with the patient #27. Staff member EE said the patient was having chest pain and his entire visit was only six minutes in duration. The patient left the hospital, turned around and walked back into the facility and went to the reception desk, wanting to be evaluated. Staff member EE said patient #27 was reading his discharge notes and it said “if you have any of these symptoms to come back to the ED.” Staff member EE said BBB came out from the ED department yelling “No, no, no” at patient #27, grabbed him by the arm, and walked him outside of the hospital entrance. Staff member EE stated, staff member S “is notorious for walking patients out of the emergency department. He takes patients that have come in by ambulance and he walks them from the ambulance door straight to the lobby.” Staff member EE stated, staff member S “will watch the tracker board in the back, and if he sees a name he recognizes, he will come out to talk to them, and discharge them immediately.” Staff member EE stated she has made complaints about his behavior to her supervisors. During an interview on 11/9/23 at 1:31 p.m., Staff Z, Patient Access Supervisor, stated when a patient presented to the ED for emergency care, during the registration process, Staff S, EDP, would collect the patient and physically escort the patient through the ED and outside to the ambulance bay, where the patient was left by the physician without a MSE. Staff Z stated that she had personally witnessed this occur approximately five or six times over the past three years, that her staff had reported they too had witnessed Staff S escort patients out without an MSE, and that both she and her staff had reported this to her manager and director during a staff meeting, sometime around March 2023. Review of patient #27’s medical record from [local hospital name], dated 9/16/23 at 10:58 p.m., showed, patient #27 was treated in that hospital’s emergency department after sustaining an injury to his face at St Vincent Hospital. The physician notes showed patient #27 arrived with an actively bleeding wound that required 6 stitches on his chin. 3) Patient #28 arrived to the ED and was registered on 11/3/23 at 5:01 a.m. for high blood pressure, anxiety, chest pain, and paranoia, with findings that included an elevated blood pressure of 164/110 (normal is less than 120/80) and a heart rate of 141 (normal is less than 100). The ED physician documented that he did not feel the patient needed further workup, and discharged the patient. Patient #28 presented to the ED a second time at 8:40 a.m. with complaints of weakness and dizziness. His heart rate was elevated at a rate of 122. The physician documented that he informed the patient that the ED was not a place for him to sleep, and discharged the patient without diagnostic studies. The patient’s second visit for complaints of weakness and dizziness with an elevated heart rate lasted approximately seven minutes from arrival to discharge. Review of patient #28’s EMR, dated 11/3/23, showed: -5:01 a.m. Patient #28 arrived to the emergency department, ambulatory, with complaints of anxiety and paranoia. The triage nurse noted the patient was paranoid in triage. -5:01 a.m. triage was started. Patient #28’s vital signs were BP 164/110, P 141 bpm, R 20, and Spo2 96%. (Normal vital signs include BP <120/<80, P 60-100, R 12-18 and Spo2 >90%.) -5:18 a.m. Patient #28 was placed in room 15 (non-emergent care). -5:23 a.m. An EKG was performed and showed sinus tachycardia with a rate of 134 bpm. -5:35 a.m. Patient #28 was moved to room 3 (cardiac/trauma room) by the assigned nurse. -5:37 a.m. The nurse’s assessment showed the patient was fearful, impulsive, and agitated, appeared tense, exhibited poor judgment and his coping behaviors were impaired. -5:49:54 a.m. Staff member S performed an examination on patient #28. The physician’s documentation showed the patient was “alert and oriented x 3.” There was no documentation related to the triage nurse assessment the patient was “paranoid” or the patient was fearful, agitated or impulsive. The physician documented the patient’s heart rate was normal, despite the elevated pulse rate of 141 bpm and did not mention the EKG showing sinus tachycardia at a rate of 134 bpm. -5:53 a.m. Patient #28 was discharged to home and was escorted out of the department by hospital security officers. -5:56 a.m. Discharge instructions were entered into the EMR for patient #28. -5:57 a.m. Patient #28 was removed from the ED system. No laboratory tests, or other diagnostic tests were ordered. -8:35 a.m. Patient #28 returned to the emergency department, ambulatory, with complaints of weakness and feeling dizzy. -8:36 a.m. Patient #28’s triage was performed. The triage nurse documented the patient was anxious in triage. His vitals were BP 136/87, P 122, R 18, and Spo2 94%. -8:37 a.m. Staff member S examined patient #28 in the north hallway. The physician’s examination documentation showed the patient was alert and oriented, and did not indicate the patient was anxious, as assessed and documented by the triage nurse. There was no documentation that the physician examined the patient’s cardiovascular system. The physician did note the patient’s heart rate as 122 beats per minute, but there is no comment about the patient’s heart rate being elevated. No labs, EKG, or imaging was completed for the patient during this visit, despite the patient’s consistent tachycardia (rapid heartbeat). -8:40 a.m. Patient #28 was documented as ready for discharge. -8:42 a.m. Patient #28 was discharged, and no discharge instructions were printed. Observation of facility video surveillance footage, dated 11/3/23, showed: -8:35 a.m. Patient #28 was seen entering the emergency department registration area. -8:36 a.m. Patient #28 was seen entering the triage desk area. -8:39 a.m. Staff member S was seen coming out of the ED door. Staff member S escorted patient #28 through the door, into the ED. -8:40 a.m. Patient #28 was seen leaving the ED and walking though the emergency room lobby. No paperwork was observed in his possession. Patient #28 walked out of the hospital entrance. Patient #28 appeared to turn around to go back into the facility, then shook his head, and he turned around and walked away. An attempt was made to interview patient #28. His phone went to voicemail, and he did not return the call. 4) Patient #29 was seen on 5/3/23 at 3:45 a.m. for complaints of nausea, vomiting, diarrhea and abdominal pain rated at nine (on a 1-10 scale). The patient admitted that he had been drinking too much and believed he was experiencing problems with his liver, yet there were no diagnostic studies or medications ordered for the patient prior to his discharge. Patient #29 returned to the emergency department to be seen on 5/4/23 at 5:41 a.m. for nausea and was documented by nursing, to smell strongly of alcohol. The ED physician documented that the patient “seems to be malingering,” and informed the patient he could go to a crisis center, but could not come to the ED for a “place to sleep.” The patient was discharged without diagnostic studies, medications, or discharge instructions related to his alcohol abuse or nausea. Review of patient #29’s EMR, dated 5/3/23, showed: -3:45 a.m., Patient #29 presented to the emergency department with complaints of nausea, vomiting and diarrhea. -3:46 a.m., Patient #29’s triage assessment was completed. His vital signs were BP 125/78, P 81, R 18, and Spo2 of 94%. -3:49:46 a.m., Staff member DDD documented an MSE examination for patient #29. -3:50:11 a.m., Patient #29 was documented as ready to discharge. -3:56 a.m., Discharge instructions were printed for patient #29. -4:02 a.m., Patient #29 was discharged. Patient #29’s EMR did not include a past medical history or social history, despite the patient being a frequent patient at the ED and an admitted alcohol user. The EMR did not show any medication, laboratory studies, or diagnostic imagining were ordered by the physician to evaluate the reason for the patient’s nausea and abdominal pain. Review of patient #29’s medical record, “Physician Notes,” dated 5/3/23, showed: “[Patient #29] is a 22 year old male who presents to the emergency department complaining of abdominal pain and vomiting ... He frequently comes in with a complaint like this and then just wants to sleep and not be bothered ... He says that he has pain all over his abdomen, that he has been drinking too much and he thinks his liver is acting up ... Final impression: homelessness.” Review of patient #29’s EMR, dated 5/4/23, showed: -5:41 a.m., Patient #29 returned to the emergency department with complaints of nausea. -5:45 a.m., Patient #29 was taken to an ED exam room. -5:48 a.m., Patient #29’s triage documentation was completed. The triage note stated the patient had a very strong odor of alcohol. Patient #29’s vital signs were BP 144/78, P 62, R 16, and Spo2 98%. -5:50 a.m., Staff member DDD examined patient #29. -5:50 a.m., Patient #29 was marked ready for discharge. -5:54 a.m., Patient #29 was discharged. Patient #29’s EMR did not show any medication, laboratory studies, or diagnostic imagining were ordered by the physician to determine the reason for the patient’s persistent nausea, or to determine if the patient was intoxicated. There is no description of the patient’s past medical history or social history, despite the patient’s frequent visits to the ED and suspected alcohol intoxication. Further, the patient was not provided with discharge instructions related to the patient’s alcohol abuse or nausea. Review of patient #29’s medical record, “Physician Notes,” dated 5/4/23, showed: “I explained to [patient #29] that he can go to the crisis center somewhere else but that he could not just come here as a place to sleep ... Final impression: homelessness.” Patient #29 presented to the emergency department via EMS on 11/1/23 at 9:02 a.m., complaining of alcohol withdrawal. He was a known alcoholic that had stopped drinking the day before; he had tremors and appeared anxious. His total time in the ED was 12 minutes, where he received an oral medication and was discharged 5 minutes after taking the medication. Review of patient #29’s EMR, dated 11/1/23, showed: -9:02 a.m.,. Patient #29 presented to the ED via ambulance with complaints of alcohol withdrawal, shortness of breath, anxiety, abdominal pain, and heartburn. The patient stated he stopped drinking the day before. Initial vital signs were; BP 140/86, HR 74, and Spo2 98%. The patient stated his pain was a 9 out of 10. -9:03 a.m., staff member S assigned himself to the patient. -9:08 a.m., Patient #29 was marked ready for discharge. -9:09 a.m., Patient #29 was given Ativan 1 mg orally. -9:14 a.m., Patient #29 was discharged. Patient #29’s EMR did not show a past medical history or social history was reviewed by the physician, despite the patient’s frequent visits to the ED and complaint of alcohol withdrawal. No laboratory studies, or diagnostic imagining were ordered by the physician to determine the reason for the patient’s abdominal pain or heartburn. No neurologic or psychologic examination was completed. Following the administration of Ativan to patient #29 no repeat vital signs were taken. 5) Patient #32 arrived at the ED and registered on 10/6/23 at 12:56 a.m., for “guts being messed up.” Patient #32 had multiple vital signs outside of normal limits that were not addressed before she was discharged. On 10/6/23 at 4:54 a.m., patient #32 returned with cold exposure. According to video review, the patient’s time in the ED was approximately six minutes, of which the physician spent 30 seconds with patient. The ED physician then documented portions of an examination that based on video review, did not occur. Review of patient #32’s EMR showed, patient #32 presented to the emergency department on 10/6/23 at 12:56 a.m. -At 1:04 a.m. triage notes showed patient #32 was complaining of her “guts being messed up.” The nurse noted, “pt was very drowsy at triage, disoriented X 3 (patient #32 did not know who she was, where she was or what day it was), and was not interactive with staff. Pt denies drugs or etoh (alcohol).” Vital signs in triage were BP 169/112 (normal range is less than 120/80), HR 97, RR 19 and Spo2 100%. -1:27:07 a.m., patient #32 was placed in room 15. -1:28:15 a.m., provider S assigned himself to provide the MSE for patient #32. -2:04 a.m., vital signs were BP 146/126 HR 85 Spo2 98%. -2:05 a.m., patient #32 was given Zofran 4 mg orally for nausea. -2:19 a.m., patient #32’s vital signs were 147/97 HR 79 and Spo2 93%. -2:33 a.m., discharge orders were placed. -2:34 a.m., patient #32’s vital signs were BP 163/136 HR 33 Spo2 100%. -3:00 a.m., patient #32 was given Compazine 10 mg IM for nausea. -3:04 a.m., patient #32’s vital signs were 158/103, HR 46, and Spo2 82%. -3:15 a.m., patient #32 was discharged. There was no neurological examination or diagnostic studies related to the patient’s altered mentation, no diagnostic studies related to the patient’s complaint of nausea, and no reassessment of the patient’s high blood pressure and low blood oxygen reading. The consent to treat and notice of privacy paperwork was signed by registration staff and showed “pt physically unable to sign.” The physicians note stated the patient was difficult to understand, other than nausea he was unable to get any significant history from the patient and indicated the patient was taken to a gas station by security after discharge. Review of an ambulance report for patient #32, dated 10/6/23, showed, “upon arrival PD stated patient was just dropped off by St Vincent security approx. 20 minutes ago ... patient states that she is cold and unable to walk and requests transport to St. Vincent Hospital. ...found patient laying on sidewalk...”{sic} Review of patient #32’s EMR showed, on 10/6/23 patient #32 returned to the emergency department via ambulance with complaints of cold exposure. -4:54 a.m., patient #32 arrived in the ED. -4:57 a.m., staff member S documented a physical examination that included: - listening to the patient’s heart, lungs and abdomen - inspecting the patient’s range of motion to be intact - feeling the patient’s neck and abdomen - neurological status to be normal - the patient’s psychiatric status to be oriented to person, place and time The clinical impression found patient #32 to be nauseated, homeless, suffering from polysubstance abuse, and a mental health disorder. -4:59 a.m., triage showed, Temp 98.4 F, BP 148/80, HR 72, RR 18 and Spo2 of 98%. -5:00 a.m., patient #32 was shown ready for discharge. -5:02 a.m., patient #32 was discharged. No laboratory studies were completed for the patient, despite the patient having ongoing nausea and weakness. Additionally, no neurologic exam was completed by the ED physician. ED notes showed, “AVS (discharge instructions) discussed with patient at discharge. Patient wheeled out of department in wheelchair. Instructed to follow-up with PCP and to return with any concerns.” Review of a hospital video surveillance footage showed, on 10/6/23 at 4:53:16 a.m. patient #32 was removed from the ambulance. She was on the gurney hunched over and not sitting up. Ambulance personnel were all wearing jackets and two were wearing stocking caps. -4:54:10 a.m., the ambulance personnel wheeled patient #32 down the hall into the ED. Staff member QQ was seen getting a wheelchair. -4:55:06 a.m., patient #32 was placed in the wheelchair and EMS left the ED. -4:55:30 a.m., registration placed a patient ID band on the patient. -4:56:24 a.m., staff member S placed a fan on the counter and aimed it in patient #32’s direction. Staff member QQ started taking vital signs. -4:56:45 a.m., staff member S walked over to patient #32 and appeared to be speaking to her. He did not touch the patient. -4:57:15 a.m., staff member S walked away from patient #32. At 4:58:31 a.m., staff member QQ finished taking patient #32’s vital signs. -4:59:01 a.m., staff member QQ wheeled patient #32 into the lobby. Patient #32 was hunched over in the wheelchair and appeared unable to sit up. -5:01:00 a.m., staff member QQ brought out another wheelchair full of patient #32’s belongings. -5:06:25 a.m., a security officer was seen checking on patient #32. The patient appeared to try to lift her head up to look at him, but remained hunched over, turning her head to the side to look up at the officer. During a phone interview on 11/13/23 at 1:52 p.m., NF2 stated his crew picked up patient #32 that morning (6/10/23). He stated she was right where [facility] security left her laying on the sidewalk. He stated patient #32 told them she could not walk. NF2 stated when staff member S was working in the ED, “he tries to discharge the patients before we leave. He told us once that he has a challenge to try to discharge someone faster than we can be back in service. I would not be surprised if he discharged her (patient #32) before we even left. That happens on a pretty consistent basis.” NF2 said frequently, if the patient is able to walk, staff member S would walk them straight out of the department without being seen. If it is a patient they see frequently, like a homeless person, or a patient with alcohol intoxication, they would be discharge as quickly as possible. NF2 said, “I had a patient one time that I brought in complaining of a headache and he (staff member S) walked out to the ambulance bay and asked him if he wanted Tylenol or Motrin. He went inside the ED, retrieved Tylenol for the patient, and told him to leave. Sometimes he doesn’t even talk to them.” During a phone interview on 11/14/23 at 11:03 a.m., staff member QQ stated she did not remember patient #32’s visits on 10/6/23. She said sometimes the doctor will listen to the patient’s complaint and then they will discharge the patient straight away. Staff member QQ stated, “If they come in a couple of times for the same thing and haven’t been worked up yet, we might do some tests. You have to understand, a lot of these people we know already. They are often intoxicated ... I have been a nurse for 35 years and have been doing this a long time. It isn’t uncommon to discharge someone right away if they keep coming in with the same problem.” 6) Patient #33 presented to the emergency department via EMS on 3/30/23 at 6:08 p.m. with complaints of a dislocated knee. The physician failed to complete an appropriate MSE for patient #33; as the physician did not order imaging of the knee and did not provide the patient with medication prior to attempting to reduce the dislocation. The patient began yelling at the physician, and the physician told the patient to leave the facility. The patient was subsequently taken to another hospital where her dislocated and fractured patella was reduced with sedation. Review of patient #33’s EMR, dated 3/30/23, showed: -6:08 p.m., Patient #33 presented to the ED via ambulance with complaints of a dislocated knee. Patient #33 was very anxious and was not very cooperative with staff. Patient #33 appeared to be intoxicated. It took multiple tries and multiple nurses to convince the patient to allow them to cut her pants to expose her knee. The only vital sign documented was a blood pressure of 119/92. -6:14 p.m., Physician notes written by staff member S showed, “She was on her phone requesting that we call 911 so she can be taken to Billings clinic. Discussed with the patient that I would not do that but was happy to assess her which she refused, and if she wishes to be seen at Billings clinic that she would at least need to leave the department and could call. Following this I left the room ... when I went back in, I could easily see the patella is dislocated, and therefore just straightened her leg, immediately reducing the dislocation. With this the patient scratched my right forearm drawing blood.” The physician was called away for CPR in progress and when he returned the patient was gone. -7:48 p.m., patient disposition is listed as elopement. Review of patient #33’s ambulance report showed, at 6:49 p.m., the paramedics arrived in the facility’s emergency department with a report of a patient (#33) requesting to be taken to [another hospital]. Pt #33 told the paramedics that the doctor had attempted to put her knee back in place without giving her any pain medication and was being mean to her. The report stated no other information was obtained from St. Vincent Hospital because no one would acknowledge him or answer any questions. The report said, “security stated patient was told to leave St Vincent Hospital by the doctor due to her behavior.” Patient #33 was transported to another local hospital. Review of patient #33’s medical record from the other hospital showed, patient #33 was seen in their emergency department on 3/30/23 at 7:07 p.m., the report showed the patient’s patella was still dislocated. An x-ray of her knee showed patient #33 had a small fracture and dislocation of the patella (knee cap). After sedation the physician was able to successfully reduce her dislocation. 29047 45448”

“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: 44770 Based on interview, record review, and video surveillance review, the facility failed to provide stabilizing treatment for one patient (#27), who was visibly injured during an altercation with law enforcement and hospital security officers, after he presented to the ED. A sample of 33 patient records were reviewed. Findings include: 1) Patient #27 arrived at the emergency department on 9/16/23 seeking care for chest pain and palpitations on three separate occasions. On the first visit, the patient arrived at the ED at 4:31 p.m., and the physician completed a history and physical and ordered a single troponin test. The patient was discharged at 6:25 p.m. The patient presented to the ED a second time at 10:12 p.m. for chest pain and the patient was discharged at 10:15 p.m. At 10:23 p.m., patient #27 was registered for his third visit to the emergency department, again seeking care for chest pain, and was told to leave by the ED nurse before he had been seen by the physician. Patient #27 was subsequently injured in the facility entryway during an altercation with law enforcement and hospital security officers, and transported to a nearby ED for care of his injury sustained at St. Vincent Hospital. During a phone interview on 11/9/23 at 10:50 a.m. staff member EE stated that the patient left the hospital (second ED discharge for 01/14/23), turned around and walked back in to the reception desk, wanting to be evaluated. Staff member EE said patient #27 was reading his discharge notes and it said “if you have any of these symptoms to come back to the ED.” Staff member EE said BBB came out from the ED department yelling “No, no, no” at patient #27, grabbed him by the arm, and walked him outside of the hospital entrance. Review of a facility document titled, “Interview with [staff member Z],” dated 9/21/23, showed: staff member Z stated patient #27 told her he wanted to be seen again in the ED. The registration clerk cut off the old arm band and placed a new one for the visit. Staff member Z said the RN (staff member BBB) came out and began yelling at patient #27 saying, “No, no, no, no. You were just seen and there is nothing wrong with you.” Staff member Z said she knew it was an EMTALA violation, but due to the RN that was involved she, “didn’t want to get in the way of her.” Review of a facility document titled, “Interview with [BBB],” dated 9/21/23, showed: BBB said that after patient #27 was discharged (second ED discharge for 01/14/23), he registered again to be seen (third ED presentment). BBB said she went out to the lobby to speak with patient #27 and walked him outside of the building, where she pointed the patient in the direction of the other local hospital nearby. Staff member BBB had noticed patient #27 had returned inside the entrance and was seated in a chair. BBB reported to security the patient would not leave. BBB, staff members AA, and AAA went to the entrance to speak to patient #27. Patient #27 was complaining of his legs not working and that he did not want to leave. BBB said security called local police to assist, things escalated, and the patient was injured. BBB stated the police decided to transport the patient to another local hospital to be seen and treated for his injuries. During an interview on 11/14/23 at 8:56 a.m., patient #27 stated he had wanted to be seen in the emergency department. He stated the doctor did not want to help him and the nurse was yelling at him. Patient #27 could not remember the police taking him to the ground, being arrested, or going to another hospital for care. During an interview on 11/8/23 at 11:20 a.m., staff member S said he was not aware the patient had checked in to be seen for a third visit. Staff member S said the patient should have been seen when he checked in the third time. Review of patient #27’s medical record showed: -10:23 p.m. patient #27 registered to be seen in the emergency department for his third visit for chest pain -10:24 p.m. staff member EE deleted the encounter on the ED log. Observation of facility video surveillance footage from 9/16/23, showed: -10:20 p.m. Patient #27 was seen walking out of the emergency department (this correlated with the discharge from his second visit to the ED on 09/16/23) carrying paperwork. He exited the building. -10:21 p.m. Patient #27 was seen returning to the emergency department registration desk and speaking with the registration clerk. The registration clerk was seen removing patient #27’s wrist band and placing a new wristband on patient #27’s wrist. -10:24 p.m. Staff member BBB was seen coming out of the emergency department and escorted patient #27 out of the hospital entrance door, and was seen gesturing while speaking to the patient, before BBB reentered the hospital without patient #27. -10:26 p.m. Patient #27 was seen reentering the hospital and taking a seat in a chair in the hospital entrance area. -10:26 p.m. Staff member BBB, staff member AA, and staff member AAA were observed speaking to patient #27. Staff member BBB was standing near patient #27, with her arms folded across her chest, and shaking her head no. -10:35 p.m. Three police officers were seen entering the facility and appeared to be speaking to patient #27. -10:37 p.m. Two of the police officers walked toward patient #27, who was still seated in the chair, occasionally crossing and uncrossing his legs. Patient #27 did not appear to be showing any aggressive behavior at any time. The police officers were observed picking patient #27 up out of the chair, and patient #27 appeared to stiffen his body and resist. -10:38 p.m. The police officers were observed shoving patient #27 into a nearby wall and down to the ground. Patient #27’s head was observed bouncing off the floor while he was taken down. -10:40 p.m. One of the police officers stood up and a large amount of blood was observed on the floor next to patient #27’s head. -10:41 p.m. The police were observed picking patient #27 up from the floor. Patient #27 attempted to kick one of the officers and he was again taken to the ground, a second time. Staff member BBB was present and at no time was observed to attempt to assess or provide care for patient #27’s injury. -10:42 p.m. Staff member BBB exited the area toward the emergency department lobby, and reentered carrying towels, dropping a towel over one of the bloody areas on the floor. - 10:44 p.m. One of the hospital security officers shined a flashlight on the patient’s face, and staff member BBB peered over to observe the patient’s face. Staff BBB left and then reentered the vestibule and placed gloves on her hands. - 10:48 p.m. Patient #27 is wheeled out of the vestibule exit by police, while staff member BBB exited the vestibule to the ED waiting room, and security officer staff clean up the blood on the floor with towels. Patient #27 was still a registered patient of the facility during the incident and was not provided stabilizing treatment following the injuries he sustained. Review of patient #27’s medical record from [local hospital name], dated 9/16/23 at 10:58 p.m., showed, patient #27 was treated in that hospital’s emergency department after sustaining an injury to his face at St Vincent Hospital. The physician notes showed patient #27 arrived with an actively bleeding wound that required 6 stitches on his chin.”