Logan Health Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, Logan Health Medical Center failed to meet the Conditions of Participation for Patient Rights at 42 CFR 482.13. Based on observation, interview, record review, and policy review, Logan Health Medical Center failed to: -Ensure patients were free from seclusion unless necessary to ensure the immediate physical safety of the patient, staff, or others for 4 (#s 17, 18, 25, and 26) of 6 sampled behavioral health patients placed on mental health holds in the Emergency Department. (A-0154). -Ensure seclusion orders were appropriately time-limited and renewed in accordance with regulatory requirements for 4 (#s 17, 18, 25, and 26) of 6 sampled behavioral health patients placed on mental health holds. (A-0171). -Ensure a face-to-face evaluation was completed within one hour following the initiation of seclusion for violent or self-destructive behavior for 1 (#25) of 6 sampled behavioral health patients placed on mental health holds. (A-0178). -Ensure the medical record evaluated the patient’s reaction to seclusion and the need to continue or discontinue seclusion for 4 (#s 17, 18, 25, and 26) of 6 sampled behavioral health patients placed on mental health holds. (A-0179).”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 47752 Based on observation, interview, record review, and policy review the hospital failed to ensure patients were free from seclusion unless necessary to ensure the immediate physical safety of the patient, staff, or others for 4 (#s 17, 18, 25, and 26) of 6 sampled behavioral health patients placed on mental health holds in the Emergency Department. Findings include: During an observation of the secure area in the Emergency Department on 4/20/26 at 2:00 p.m., showed two double doors leading to the secure area. These double doors are locked and require badge access to enter. Upon entry there was a door off to the left. Behind the door was where security was stationed and the security officer was monitoring patients via video. There was no common area noted in the secure area. 1. Review of patient #17’s electronic medical record dated 10/31/25, showed the patient arrived at the Emergency Department via law enforcement at 1:41 p.m., with suicidal ideation without documented violent or self-destructive behavior. Review of patient #17’s Emergency Department Note dated 10/31/25, revealed no documentation the patient was exhibiting behaviors that posed imminent danger to himself, staff or others that would require initiation of patient’s seclusion. The medical record contained no documentation that less restrictive interventions were attempted prior to placement in a restrictive environment. 2. Review of patient #18’s electronic medical record dated 3/20/26, showed patient #18 presented to the emergency department via the CAT (Crisis Assessment Team) at 1:36 p.m., with suicidal ideation. Patient #18 was seen by staff member S at 1:50 p.m. Patient #18 had been placed in a safe room prior to the provider’s evaluation. Review of Patient #18’s Emergency Department record dated 3/20/26, showed patient #18 had a history of “passive” suicidal ideation related to his living situation, and contained no documented evidence that the patient posed an imminent danger to himself, staff, or others to support initiation of seclusion. The medical record contained no documentation that less restrictive interventions were attempted or determined ineffective prior to placement in the restrictive environment. 3. Review of patient #25’s electronic medical record dated 4/21/26, showed patient #25 arrived at the Emergency Department via ambulance at 10:33 a.m., with a complaint of alcohol intoxication, and a request for a mental health evaluation. Patient #25 was seen by staff member X at 10:36 a.m. Patient #25 had already been placed in a safe room prior to the provider’s evaluation. Review of patient #25’s Emergency Department triage assessment dated 4/21/26, showed the patient was brought in by ambulance and did not present with any suicidal or homicidal ideation. Review of patient #25’s physician’s note dated 4/21/26, showed, “ ... She states she is not suicidal and has no plans or thoughts to harm herself. ...” There was no documented evidence the patient exhibited behaviors that posed imminent danger to herself, staff, or others and would require initiation of patient’s seclusion. The medical record contained no documentation that less restrictive interventions were attempted prior to placement in the restrictive environment. 4. Review of patient #26’s electronic medical record dated 4/21/26, showed patient #26 arrived at the emergency department via ambulance at 12:15 a.m., with witnessed seizures after drinking alcohol. Patient #26 was evaluated by staff member Y at 12:19 a.m. Review of staff member Y’s physician’s Emergency Department note, dated 4/21/26, showed just prior to discharge patient #26 had told nursing staff he was suicidal. Review of nursing documentation dated 4/21/26 at 12:26 p.m. showed, “This RN spoke with [Staff member Z] regarding new pt report of suicide attempt last night ... Verbal order for MH hold received. Security was called for standby and pt was moved ...” Patient #26 was moved to a secure area 12 hours and 6 minutes after he arrived at the Emergency Department. Review of patient #26’s Emergency Department record dated 4/21/26, revealed no documentation the patient was exhibiting behaviors that posed imminent danger to himself, staff, or others requiring the initiation of patient seclusion. The medical record contained no documentation that less restrictive interventions were attempted prior to placement in the restrictive environment and contained no documentation that patient #26 was evaluated by staff member Z after the mental health hold was placed. During an interview on 4/20/26 at 1:50 p.m., staff member B stated concerns had been identified with the facility mental health holds and patient seclusion within the ED. Staff member B stated the purpose of the secure area was to provide a secure area for patients who were considered a “true harm” to themselves or others. During an interview on 4/21/26 at 1:45 p.m., staff member G stated patients were placed in the secure area if there was a direct suicidal or homicidal ideation. Staff member G stated the providers were the ones who would order the mental health holds and they ultimately decide if the patient needed to be assessed by a mental health provider. Staff member G stated seclusion was when a patient was placed in a secure area, the doors were locked to the unit, and even if the patient wanted to, the patient could not leave on their own. Staff member G stated she was not aware of other less restrictive interventions being tried prior to being placed in the secure area. During an interview on 4/22/26 at 9:15 a.m., staff member I stated patients had to be an imminent threat to themselves for a mental health hold and placement in the secure area. Staff member I stated patients who were not behavioral health patients had also been placed in the secure area and. This required security personnel to be contacted for the patients to leave, and the area remained locked. Staff member I stated the physicians were the only individuals who could determine if a patient had appropriate mental capacity and there may or may not be documentation of it in the medical record. During an interview on 4/22/26 at 3:39 p.m., staff member M stated mental health hold orders had been placed prior to the patient being evaluated indicating a need for seclusion. Staff member M stated nursing staff sometimes place patients in the secure area prior to a provider evaluation. The patients would remain in the secure area until assessed and cleared by a provider. Staff member M stated she was not aware of alternative, less restrictive, interventions being attempted prior to mental health holds being ordered. During an interview on 4/22/26 at 9:20 a.m., staff member O stated the secure area was considered seclusion because the patients were unable to leave on their own and the doors remained locked. Review of a facility policy titled, “Retired Restraint of Patients,” with a revision date of 12/2025, showed: “To provide safety to patients and staff in cases where the patient is at risk of injuring him/herself or others, while protecting the patient’s health and safety preserving the patient’s dignity, rights, and well-being ...” “ ... Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving for any period of time. Seclusion is a form of restraint used only to manage violent or destructive behaviors ...” The “Retired Restraint of Patients” policy was in effect during patient #’s 17 and 18’s Emergency Department Visit. Review of a facility policy titled, “Restraint/Seclusion Policy,” unapproved, showed: “It is the policy of [Facility Name] that patients have the right to be free from any sort of restraint unless medically necessary. In the event that restraint or seclusion is necessary and after alternatives have been attempted, the least restrictive method of restraint that meets the patient’s assessed need will be used. ...” Review of a facility policy titles, “Patient Rights and Responsibilities,” effective 4/2026, showed: “ ... 10. Restraint and Seclusion: The patient has the right to be free of restraint or seclusion that is not necessary for medical immobilization for the safety of patients, staff, or visitors.” A request was made on 4/22/26 for a mental health hold policy and a policy was not provided for the facility. The regulations for the Montana Code Annotated were provided.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the Logan Health Medical Center failed to ensure seclusion orders were appropriately time-limited, four hours for adults 18 years of age and order, for 4 (#s 17, 18, 25, and 26) of 6 sampled behavioral health patients placed on mental health holds. Findings include: 1. Review of patient #17’s electronic medical record dated 10/31/25, showed the patient presented to the emergency department via law enforcement at 1:41 p.m. The patient was evaluated by staff member X at 2:04 p.m., placed in the Emergency Department secure unit, and the following orders were initiated for a mental health hold, search and separate belongings, security on standby, and suicide precautions. The physician’s orders dated 10/31/25 at 2:04 p.m., showed the order for the mental health hold failed to include a time limit for the patient’s placement in the secured unit within the ED. 2. Review of patient #18’s electronic medical record dated 3/20/26, showed the patient presented to the Emergency Department via the CAT (Crisis Assessment Team) at 1:36 p.m., with suicidal ideation. The patient had been placed in a room on the secured unit within the ED, prior to a provider evaluation. At 1:57 p.m., orders were placed for a mental health hold, search and separate belongings, security on standby, and suicide precautions were initiated. The physician’s order failed to contain a time limit for placement in the secured unit within the ED. 3. Review of patient #25’s electronic medical record dated 4/21/26, showed the patient presented to the Emergency Department via ambulance at 10:33 a.m., for alcohol intoxication and a mental health evaluation. The patient was placed in a room on the secure unit prior to a provider evaluation. At 10:40 a.m., orders were placed for a mental health hold, search and separate belongings, security on standby, and suicide precautions were initiated. Review of patient #25’s Emergency Department triage assessment dated 4/21/26, showed, “pt (patient) BIBA (brought in by ambulance) for etoh (alcohol) resources/MHE (Mental Health Evaluation) eval, not SI/HI (suicidal ideation/homicidal ideation).” [sic] The physician’s order failed to contain a time limit for placement in the secured unit within the ED. 4. Review of patient #26’s nursing documentation dated 4/21/26 at 12:26 p.m. showed, “This RN spoke with [Staff member Z] regarding new pt report of suicide attempt last night ... Verbal order for MH hold received. Security was called for standby and pt was moved ...” The patient was moved to the secured unit within the ED, 12 hours and 6 minutes after he arrived at the Emergency Department. The physician’s order failed to contain a time limit for placement in the secured unit within the ED. During an interview on 4/20/26 at 1:50 p.m., staff member B stated there had been concerns regarding mental health holds, and seclusion. Staff member B stated secured area was intended to be used for patients who were considered a “true harm” to themselves or others. During an interview on 4/22/26 at 3:39 p.m., staff member M stated she entered mental health hold orders, but they were not time limited. During an interview on 4/23/26 at 9:35 a.m., staff member P stated she did not believe there were time limits on the mental health holds in the secure area. Review of a Logan Health Medical Center policy titled, “Retired Restraint of Patients,” with a revision date of 12/2025, showed no information regarding the timeline of seclusion orders. The “Retired Restraint of Patients” policy was in effect during patient #’s 17 and 18’s Emergency Department Visit. Review of a Logan Health Medical Center policy titled, “Restraint/Seclusion Policy,” not yet approved by the board, showed: “ ... Seclusion follows the Violent Restraint process for orders, observation, and assessment ... ... Violent Restraints- Obtain a renewal order for the following: Adults, Ages 18 and order: Q4hrs ...” [sic].”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review Logan Health Medical Center failed to ensure a face-to-face evaluation was completed within one hour following the initiation of seclusion for violent or self-destructive behavior for 1 (#26) of 6 sampled behavioral health patients placed on mental health holds. Review of patient #26’s nursing documentation dated 4/21/26 at 12:26 p.m. showed, “This RN spoke with [Staff member Z] regarding new pt report of suicide attempt last night ... Verbal order for MH hold received. Security was called for standby and pt was moved ...” Patient #26’s electronic medical record showed no documentation the patient was evaluated by staff member Z or another staff member within one hour of the initiation of the mental health hold. During an interview on 4/20/21 at 1:50 p.m., staff member B stated patients placed on a mental health hold need to be evaluated by a provider within an hour of the order. Review of a Logan Health Medical Center policy titled, “Restraint/Seclusion Policy,” not yet approved by the board, showed: “ ... Seclusion follows the Violent Restraint process for orders, observation, and assessment ... ... Face to face: Violent restraints-within 1 hour every 24 hours. A Qualified Provider or Qualified Behavioral Health RN conducts an in-person, face-to-face assessment of the patient in Seclusion/Restraint with in 1 hour after initiation ...” [sic]”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, Logan Health Medical Center failed to ensure a qualified medical provider evaluated the patient’s response to being placed in seclusion and failed to evaluate the need to continue or discontinue seclusion for 4 (#s 17, 18, 25 and 26) of 6 sampled behavioral health patients placed on mental health holds. Findings include: 1. Review of patient #17’s electronic medical record dated 10/31/25, showed the patient presented to the emergency department via law enforcement at 1:41 p.m. The patient was evaluated by staff member X at 2:04 p.m., placed in the secured unit within the ED, and orders were placed for a mental health hold, search and separate belongings, security on standby, and suicide precautions. There was no documentation of an evaluation for the need to continue or discontinue seclusion. 2. Review of patient #18’s electronic medical record dated 3/20/26, showed the patient presented to the Emergency Department via the CAT (Crisis Assessment Team) at 1:36 p.m., with suicidal ideation. The patient had been placed in a room on the secure unit within the ED, prior to a provider evaluation. At 1:57 p.m. orders were placed for a mental health hold, search and separate belongings, security on standby, and suicide precautions were initiated. There was no documentation of an evaluation for the need to continue or discontinue seclusion. 3. Review of patient #25’s electronic medical record dated 4/21/26, showed the patient presented to the Emergency Department via ambulance at 10:33 a.m., for alcohol intoxication and a mental health evaluation. At 10:40 a.m., orders were placed for a mental health hold, search and separate belongings, security on standby, and suicide precautions were initiated. There was no documentation of an evaluation for the need to continue or discontinue seclusion. 4. Review of patient #26’s electronic medical record dated 4/21/26, showed the patient had been in the Emergency department for 12 hours and 6 minutes when he reported a suicide attempt the night prior. A verbal order was received for a mental health hold, and the patient was moved to the secured unit within the ED. There was no documentation of an evaluation for the need to continue or discontinue seclusion. During an interview on 4/22/26 at 4:14 p.m., staff member N stated a mental health hold could be discontinued by any physician after an assessment was completed to determine if the patient was safe. If a patient was deemed not safe a continuation of the hold would be documented. Review of a Logan Health Medical Center policy titled, “Restraint/Seclusion Policy,” not yet approved by the board, showed: “ ... Seclusion follows the Violent Restraint process for orders, observation, and assessment ... ... The evaluation incorporates the following: I. The patient’s immediate situation II. The patient’s reaction to the intervention III. The patient’s medical and behavioral condition IV. The need to continue or terminate the restraint or seclusion ...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 45448 Based on observation, interview, and record review, the facility failed to adhere to infection prevention standards by not performing hand hygiene while delivering patient food trays; failed to follow the facility policy for isolation precautions for a resident who was positive for COVID-19. These deficient practices had the potential to affect all staff, patients, and visitors that enter the facility. Findings include: 1. During an observation on 9/24/25 at 11:08 a.m., staff member X was delivering lunch trays to patients in rooms 322 through 332. Staff member X was observed leaning on the tray cart, running his hands through his hair, and then touching his face. He was also observed to have a bandage on his left thumb. Staff member X opened the tray cart, removed a meal tray and delivered it to room 324, placed it on the bedside table, and exited the room. Staff member X then checked the patient listing paper on top of the meal cart, opened the meal cart, removed a meal tray, entered room 326, placed the tray on the bedside table, and exited the room. He repeated these actions for room 332. Staff member X was not wearing gloves, and did not use hand sanitizer prior to entering or exiting patient rooms with meal trays. During an interview on 9/24/25 at 12:00 p.m., staff member X said he had been trained to wash his hands prior to entering a patient room for tray delivery. Staff member X said he had cut his thumb on his left hand four weeks ago and was now covering it with a bandage. Staff member X said the patient trays and tray cart were sanitized prior to leaving the dietary department, and he had washed his hands with soap and water. Staff member X said he did not like to use the hand sanitizer on his hand because it “burned where I had my cut.” During an interview on 9/24/25 at 1:33 p.m., staff member N said dietary staff were expected to sanitize their hands before they enter the patient room and upon exiting the patient room. Staff member N said dietary staff were reminded every day during the 9:00 a.m. huddle. Staff member N said staff member X had cut his thumb in the past and should be wearing gloves to cover the bandage. Review of a facility policy, “Hand Hygiene,” with a revision date of 02/2025, showed: “...Procedure 1. When to perform hand hygiene ... ...B. Immediately after each episode of direct patient contact/care ...D. Immediately after contact with objects and equipment in the immediate patient environment or other activities that could result in hands becoming contaminated ...” 2. During an observation and interview on 9/24/25 at 12:05 p.m., room 346 had a precaution sign posted outside of the room for Airborne/Droplet/Contact precautions. A personal protective equipment (PPE) cart was in place outside of the door. Staff member Y was inside the room, wearing a gown, face shield, and gloves, the room door was fully open. Staff member Y exited the room and doffed her PPE. Staff member Y said she had been concerned about the patient door being open, prior to entering room 346, and called the infection prevention office for direction. Staff member Y said the person in the infection prevention office said the patient in room 346 was set to be taken off precautions the following day and was no longer coughing or showing signs of COVID-19, so the room door could remain open. Review of a facility policy, “COVID-19 Isolation Guidelines,” with a revision date of 9/2024, showed: “1. Airborne/Droplet/Contact Precautions ...C. Patient Placement ...2. If a negative pressure room is not available a regular room will work, but door must remain closed. ...” During an interview on 9/24/25 at 1:22 p.m., staff member M said for COVID-19 isolation precautions, patient doors were to remain closed while the patient was on precautions. Staff member M said the only reason for a room door of a patient on COVID-19 precautions to remain open would be for safety purposes. She was not made aware of any concern for patient safety. Staff member M said the patient room door should have remained closed to prevent possible spread of COVID-19. Staff member M said all staff had been trained to perform hand hygiene prior to entering and when leaving a patient room.”

“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 interview, record review and policy review, the facility failed to comply with the conditions of participation outlined in §489.24(a)(1)(i): The facility failed to provide an appropriate MSE (medical screening examination) by a QMP (qualified medical professional) for 1 (#14), and failed to document continuous monitoring according to the individuals needs until it was determined whether or not the individual had an EMC (emergency medical condition) for 6 (#s 4, 5, 8, 9, 15, and 17) of 20 sampled patients who presented to the ED (emergency department) for emergency care. Findings Include: Review of a facility policy titled, Emergency Medical Treatment and Active Labor Act (EMTALA), A313, dated 6/2024, showed: “ ...Medical Screening Examination 1. When an individual comes to the hospital Campus requesting examination or treatment for an EMC, or who appears to a reasonable observer to need medical treatment for an EMC, or who appears to a reasonable observer to need medical treatment, a MSE will be performed by an individual qualified to perform such an examination, to determine whether an EMC exists, or, with respect to a pregnant woman having contractions, whether the woman is in labor ... 8. The hospital’s EMTALA obligation ends when a provider or QMP has determined: A. no EMC exists (even though the underlying medical condition may persist); B. an EMC exists, and the individual is appropriately transferred to another facility; C. an EMC exists, and the individual is admitted to the hospital for further stabilizing treatment; or D. an EMC exists, and the individual is stabilized and discharged...” Review of a facility policy titled, Patient Assessment and Re-Assessment in the Emergency Department, ED 1531, dated 3/2023, showed: “ ...Patients will be re-assessed at least hourly and/or more frequently as patient condition warrants. ...e. Vital signs: i. Repeated every 5-30 minutes on Level 1 and 2 patients at nurse’s discretion based upon stability of patient. ii. Repeated every 1 hour on Level 3 patients at the nurse’s discretion based upon stability of the patient. iii. Repeated on Levels 4 and 5 at the nurse’s discretion based upon the stability of the patient. iv. Repeated within 30 minutes after the administration of medications with potential side effects. v. Repeated after any change in patient condition. vi. Repeated if any vital signs are outside the normal range ...” Review of a facility policy titled, Patient Elopement from the Emergency Department ER1107, dated 5/2024, showed, “Every patient who arrives to the Emergency Department (ED) and is checked in should be seen by a provider. However, when a patient decides to leave prior to being discharged by a provider, the following procedures will be followed ... Document in [Electronic Medical Record] for an Elopement or LWBS (left without being seen): 1. Time or arrival. 2. Chief complaint. 3. Time or approximate time the patient left. 4. Any other pertinent information. Document in [Electronic Medical Record] for an AMA (against medical advice): 1. Time of triage. 2. Chief complaint. 3. Time seen by the physician. 4. Time patient left Emergency Department. 5. Documentation will include inability/or refusal to obtain signed AMA. If patient refuses to sign, obtain a second witness signature. ED personnel will round on patients regularly, preferably every hour, to provide updates on the expected wait or delay ... AMA- When a patient has been seen by the physician and evaluated, then decides to leave before treatment or disposition is complete. Elopement- When a patient has been seen by the physician and evaluated, then decides to leave without staff notification. LWBS- When a patient has been seen by the triage nurse and leaves prior to being seen by a physician.” 1) Patient #14 arrived at the ED via ambulance for a chief complaint of abdominal pain. The triage nurse called the patient’s caregiver, and the caregiver said she would come pick up the patient. Patient #14 did not receive a MSE by a QMP. 2) Patient #4 was a 94-year-old patient who presented to the ED for a syncopal episode (medical terminology for passing out) and dizziness. The patient waited to be seen for 3 hours and 20 minutes in the waiting room. Patient #4 was assigned an ESI (Emergency Severity Index, a 5-level system based on the level of severity of a patient’s medical condition) level 3, indicating he was stable with multiple types of resources needed to investigate or treat his medical condition. Patient #4’s EMR lacked documentation of continuous monitoring consistent with facility policy. 3) Patient #5 presented to the ED for chest pain with a history of MI (myocardial infarction, commonly known as a heart attack) and cardiac stents (medical devices surgically placed in the arteries of the heart). Patient #5 was assigned an ESI score of 2 indicating she was at high risk of deterioration or showing signs of a time-critical problem. Patient #5’s EMR lacked documentation of continuous monitoring consistent with facility policy. 4) Patient #8 presented to the ED with chest pain. She had an abnormal EKG (electrocardiogram, a test to evaluate the hearts electrical rhythm) in triage. Patient #8 was assigned an ESI score of 2 indicating she was at high risk of deterioration, or showing signs of a time-critical problem. Patient #8’s EMR lacked documentation of continuous monitoring consistent with facility policy. 5) Patient #9 presented to the ED with shortness of breath and abnormal oxygen saturations. She was assigned an ESI score of 2 indicating she was at high risk of deterioration or showing signs of a time-critical problem. Patient #9’s EMR lacked documentation of continuous monitoring consistent with facility policy. 6) Patient #15 presented to the ED with shortness of breath and chest pain. He was assigned an ESI score of 3 indicating he was stable with multiple types of resources needed to investigate or treat his medical condition. Patient #15 had an abnormal EKG and critically low potassium. Patient #15’s EMR lacked documentation of continuous monitoring consistent with facility policy. Patient #15 became unresponsive and without a pulse in the ED waiting area. He required CPR and was admitted to the Intensive Care Unit. 7) Patient #17 presented to the ED with suicidal ideation on 3 separate occasions. She eloped from the ED on 8/1/24, returned on 8/2/24, and eloped again and returned on 8/5/24 following a suicide attempt by ingesting a toxic overdose of Wellbutrin XR, which required a hospital admission. Patient #17’s EMR lacked documentation of continuous monitoring consistent with hospital policy for her first and second presentation to the ED.”

“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 interview and record review the facility failed to provide an appropriate MSE (medical screening examination) by a QMP (qualified medical provider) for 1 (#14), and failed to document continuous monitoring according to the individuals needs, per hospital policy, until it was determined whether or not the individual had an EMC (emergency medical condition) for 6 (#s 4, 5, 8, 9, 15, and 17) of 20 sampled patients who presented to the ED (emergency department) for emergency care. Findings include: 1) Review of patient #14’s EMR (electronic medical record) showed patient #14 presented to the ED via ambulance on 8/17/24 at 2:51 p.m. Review of the ambulance report showed patient #14 called 911 reporting she had abdominal pain. Patient #14 told paramedics she had been having abdominal pain for about one day and she stated she thought it was a bladder infection, as she had a history of bladder infections and had approximately three infections a year. The ambulance report showed patient #14 was oriented to person and time but thought she was in a different state. The ambulance crew were directed to the ED triage area upon their arrival to the ED where she was transferred from the ambulance gurney to a wheelchair. A triage note dated 8/17/24 at 2:54 p.m., showed patient #14 presented complaining of abdominal pain and a history of bladder infections. She was assigned a triage ESI (emergency severity index, a triage tool used to mitigate a patient’s risk and determine which patients need to be prioritized ahead of others) level 3, indicating she was stable with multiple types of resources needed to investigate or treat her medical condition. A nursing note entered on 8/17/24 at 3:23 p.m., authored by staff member Q, showed staff member Q remembered the patient from a previous visit, and she remembered the patient’s niece was her caregiver. Staff member Q contacted patient #14’s niece, and her niece told staff member Q she did not think patient #14 needed to be seen. Staff member Q documented she placed patient #14 in ED room 31 so the “tech could keep an eye on her.” The EMR showed patient #14’s niece picked up patient #14 at 3:55 p.m. Patient #14 did not receive a MSE from a QMP. The discharge paperwork showed patient #14 left without being seen at 4:27 p.m. There was no documentation showing patient #14 was advised of the risks of leaving without having an examination by a QMP. The EMR also lacked documentation of hourly rounding or vital signs. During an interview on 10/22/24 at 7:58 a.m., staff member Q stated patient #14 did not have an evaluation by a physician in the ED. Staff member Q said patient #14 presented to the emergency department via ambulance. Staff member Q said the ambulance brought patient #14 to triage because there was not a bed available or because there was not a nurse available to take her in the ED. Staff member Q stated she recognized patient #14 from a previous visit and knew patient #14’s niece was her caregiver. Staff member Q stated she looked in the EMR and found the niece’s phone number and contacted her. The niece told staff member Q she was frustrated with patient #14 and felt patient #14 did not need to be seen in the ED. Staff member Q said she did not know if patient #14’s niece was her POA (power of attorney, a legal designation that gives the person legal authority to act on the persons behalf.) Staff member Q said she did not know how to look in the EMR to see if patient #14’s niece was her POA. Staff member Q said a doctor or mid-level provider (nurse practitioner or physician assistant) is required to provide an MSE, she stated a nurse cannot provide an MSE. Staff member Q said if a patient came to the ED in an ambulance, a reasonable person would assume the person in the ambulance was seeking medical care. Staff member Q said patient #14 said she came to the facility because she was having abdominal pain. Staff member Q said patient #14 returned to the ED on 8/21/24 and was admitted to the hospital after having a ground level fall and was treated for a UTI (urinary tract infection). 2) Review of patient #4’s EMR showed patient #4 was a 94-year-old male who presented to the ED on 7/29/24 complaining of having a syncopal episode (medical terminology for passing out). He reported he was at a hardware store when he passed out and hit his head. Patient #4 arrived in triage at 1:38 p.m. The triage note showed patient #4 was dizzy and did not remember falling. Patient #4 said he had a lawn mower fall on him about 10 days prior. His vital signs were obtained in triage and an EKG (electrocardiogram, a medical test that shows the electrical conduction of the heart, it can help determine if a patient is having a cardiac emergency) was performed. The vital signs showed patient #4 was bradycardic (low heart rate) and his blood pressure was high 142/93. The EKG was read as normal sinus rhythm. Patient #4 was assigned a triage level 3, indicating he was stable with multiple types of resources needed to investigate or treat his medical condition. The EMR showed patient #4 told the nurse he did not want to wait any longer at 5:05 p.m. The nursing note showed his IV was removed and patient #4 left. There was no documentation showing there was an attempt by staff to convince him to stay to be examined by the QMP. The record lacked documentation the patient was informed of the risks of leaving without being examined by the QMP. There were no hourly vital signs documented during the time the patient was waiting to be seen from 1:38 p.m. to 5:05 p.m. per hospital policy for an ESI level 3 patient and there were no notes documenting patient #4’s condition during the time he was waiting to be seen by the QMP. During an interview on 10/22/24 at 1:00 p.m., staff member X stated she worked in triage at the facility and the expectation for taking vital signs and rounding (a term used for checking on a patient’s condition and needs) on patients waiting to be seen by a provider was to round and take vitals hourly, unless a patient’s condition was requiring more frequent vital signs. Staff member X explained the ED would occasionally be too busy to meet that expectation. Staff member X said she was in triage when patient #4 presented to the ED after his syncopal episode. Staff member X looked in the patient’s EMR and stated there was only one set of vital signs taken during the time patient #4 was in the ED waiting room on 7/29/24 from 1:38 p.m. through 5:05 p.m. Staff member X stated the boarders (patients who were finished with emergency treatment and were waiting for rooms in the hospital) in the ED were the reason they could not get critical patients back into rooms in the ED. 3) Review of patient #5’s EMR showed patient #5 presented to the ED on 8/5/24 at 10:49 a.m., with a complaint of chest pain since 10:00 p.m. the night before. Patient #5 had a history of MI (myocardial infarction, commonly referred to as a heart attack) and cardiac stents (medical devices surgically implanted inside the arteries to the heart to allow proper blood flow). She was triaged an ESI level 2, indicating high risk of deterioration, or signs of a time-critical problem. Patient #5 had blood drawn for laboratory testing and an EKG while she was in triage. The EKG was read as a normal EKG. She was sent to the waiting room to wait for a room in the ED. A nursing note dated 8/5/24 at 3:57 p.m., showed patient #5 told the nurse she received a notice on her phone showing she had lab results in “Myhealth” (an online health application to receive communications from the facility). Patient #5 told the nurse she could see that her Troponin (a lab result used to help diagnose a heart attack) was negative, so she was going to leave. There was no documentation showing there was an attempt by staff to convince her to stay to be examined by the QMP. The record lacked documentation the patient was informed of the risks of leaving without being examined by the QMP. There were no vital signs taken every 5 to 30 minutes per hospital policy for an ESI level 2 patient and there was no documentation of rounding on patient #5 while she waited in the waiting room from 10:49 a.m. to 3:57 p.m. During an interview on 10/17/24 at 10:48 a.m., staff member D, the Clinical Nurse Manager of the Emergency Department, stated it was expected for triage nurses and ED techs to round on patients and take vital signs every hour at a minimum while awaiting a room in the ED. Staff member D stated she was unsure if there was a policy regarding how often vitals signs should be completed for a patient waiting to be seen by the physician. During an interview on 11/27/24 at 9:10 a.m., patient #5 stated that when she presented to the ED, her blood pressure had been very high, and she was having chest pain. Triage staff drew her blood, and then placed her in the waiting room. Patient #5 reported no one checked on, or took vital signs on, anyone in the waiting room while she was there. When she saw her lab results through the patient portal (online access to a patient’s medical record and testing results), and saw that her troponin was negative, she told one of the ED staff that she was leaving. No one reviewed her labs or asked her to stay to be seen. They said, “OK, goodbye,” and she left. Patient #5 reported she had experienced a similar situation approximately two years before, when she went into anaphylactic shock (severe life-threatening allergic reaction). She was administered epinephrine and Benadryl (medications used to treat allergic reactions) by ambulance staff, and then sat in a room in the ED for four hours, no one checked on her, and she left. Patient #5 stated, “I am so afraid to have to go there...You just sit there, and no one checks on you...With my history, I could have been having another heart attack.” During an interview on 10/22/24 at 9:00 a.m., staff member M stated she was the SUS (shift unit supervisor) and was covering triage when patient #5 presented to the ED on 8/5/24. Staff member M stated she would not usually leave an ESI level 2 triaged patient in the waiting room. She said there was either not enough nurses or not enough beds to take patient #5 back to a room in the ED. Staff member M said she started the chest pain protocol from triage by doing an EKG, starting an IV (intravenous line) and drawing blood for laboratory testing. She said, “Technically I would have a patient like that on a monitor, and with the history of stents I would want her back sooner than later. We saw 97 patients that day with several boarders. These boarders completely clog up our ED. We are space limited. It greatly limits my ability to move emergent patients from the lobby to the ED. When the boarders don’t have a med/surg (medical surgical unit) nurse assigned to them, I have to use my ED nurses to care for boarders and the beds are full. I had nowhere to put her.” Staff member M stated there was no official protocol for rounding on patients waiting in the ED waiting room. She said the ED techs try to take vitals and round on patients hourly while they are waiting. Staff member D stated, “There were several high acuity patients that came in around the same time that day (8/5/24). It would still be expected that her vitals would be checked every hour at least.” During an interview on 10/22/24 at 11:40 a.m., staff member U stated, “Someone who is an ESI level 2, we would put that patient on the monitor and get them O2 (oxygen) or whatever was needed right away ... We try to get vitals every hour and sooner if we can ... We sometimes will have 14 patients boarding and that takes up half of our rooms. It is usually when we have boarders when we can’t get critical patients back into the ED. I was always told it is every hour for rounding and vital signs. I don’t know if there is a policy. The tech usually does the rounding and vitals ... Registration will also let us know if someone is not looking well in the waiting room.” 4) Review of patient #8’s EMR showed she presented to the ED on 9/12/24 at 1:09 p.m. Patient # 8’s triage note authored by staff member W, showed patient #8 reported heavy chest pain since 9/11/24 and felt like something was obstructing her throat. Patient #8 told the triage nurse she had a history of having a MI in 2023. She was triaged an ESI level 2. An EKG was completed in triage that showed, “supraventricular rhythm (an irregular heart rate that begins above the ventricles, or lower chambers of the heart), atypical EKG.” Blood was collected in triage and sent to the laboratory for testing. A nursing note dated 9/12/24 at 3:49 p.m., showed patient #8 LWBS (left without being seen). The nursing note showed the patient left with her IV in place. A nurse attempted to call patient #8, but there was no answer. The EMR lacked documentation of vital signs every 5 to 30 minutes for an ESI level 2 patient per hospital policy or rounding when patient #8 was waiting to see the physician between 1:09 p.m. and 3:49 p.m. 5) Review of patient #9’s EMR showed, patient #9 presented to the ED on 9/23/24 at 2:15 p.m. with a complaint of pain and swelling in both of her feet. The triage note showed she had recently been admitted for pneumonia and low potassium in her blood. Patient #9 normally wore oxygen at 1.5L using a nasal cannula, but she told triage she had been requiring 3L. The triage note showed, “Pt lethargic during triage.” Vital signs were taken in triage, and the vital signs were within normal limits. Patient #9 was assigned a triage ESI level 2. At 3:11 p.m., her pulse oximetry (a measurement of oxygen attached to hemoglobin in the blood) was low at 86% (normal is 92-100%) and her heart rate was 97 (normal 60-90 beats per minute). She was placed on oxygen at that time. No other vital signs were recorded. At 4:27 p.m., the record showed patient #9 left without being seen. The EMR lacked documentation showing why or how patient #9 left and lacked documentation of vital signs every 5 to 30 minutes per hospital policy for a patient with an ESI level 2. During an interview on 10/22/24 at 11:40 a.m., staff member U stated he was the nurse who triaged patient #9 on 9/23/24. He said patient #9 was complaining of her feet being red and swollen. He said he triaged her at an ESI level 2, per hospital protocol. Staff member U stated, “In a perfect world I would notify the SUS if I felt they were high enough acuity to be roomed right away. Someone who is a 2 ESI, we would put that patient on the monitor and get them on O2 or whatever they needed right away.” Staff member U said he attempted to start an IV on patient #9 four times unsuccessfully. He said she came into the facility without her oxygen. He did not put her on oxygen while she waited to be seen by a physician. During an interview on 10/22/24 at 9:36 a.m., staff member V stated she was covering in triage to provide a break for the assigned triage nurse on 9/23/24. She stated patient #9’s caregiver came to triage to tell her she thought patient #9’s oxygen level was low. Staff member V went to the lobby and checked patient #9’s oxygen saturation and found patient #9’s oxygen saturation was low at 86%. Staff member V stated she put oxygen on patient #9 at 2L/min using a nasal cannula. Staff member V stated, “The hard part is that when there are constant patients walking in and we are triaging, it is just hard to go back and document or recheck vitals.” She stated she did not see any follow up vital signs documented in patient #9’s EMR and did not know why there was no documentation for patient #9 leaving without being seen by a provider. During a telephone interview on 12/26/24 at 2:03 p.m., NF1 stated she brought patient #9 to the ED in Kalispell. She stated she and patient #9 lived in a different town but due to patient #9’s complicated health issues, they would usually drive the hour drive to Kalispell for her care. She said when they arrived at the ED they were taken to the triage area quickly. NF1 stated they were sent to the lobby to wait. She said she kept checking with the ED staff about every half an hour to see how much longer the wait was going to be. NF1 said patient #9 kept falling asleep in the lobby. At one point she said she was worried about patient #9’s oxygen level, and she did not have her oxygen monitor with her, so she went to get hospital staff to check it. NF1 said the nurse came out and checked her oxygen level and it was low. NF1 said the staff did not check patient #9’s vital signs while she was in the waiting room other than when she asked them to check patient #9’s oxygen level. NF1 said she was so worried about patient #9’s condition she decided to take her back to the town where they live to the hospital there. NF1 said patient #9 was admitted to the hospital there with pneumonia, COPD (chronic obstructive pulmonary disease), and problems with the electrolytes in her blood. NF1 said patient #9 was discharged on hospice and died a week later. 6) Review of patient #15’s EMR showed, patient #15 presented to the ED on 9/5/24 at 12:06 p.m. Patient #15 was triaged at 12:29 p.m. Patient #15 told the triage nurse he was having difficulty breathing, chest pain, and had a productive cough for the last week. He was assigned an ESI level 3. An EKG was performed in triage which showed “sinus rhythm with occasional ventricular premature complexes, left bundle branch block” (abnormal EKG) and blood was drawn for laboratory testing. The blood test revealed patient #15 had a potassium level of 2.5 mEq/L (Normal range 3.5-5.2 mEq/L. This was a critically low result. Critically low potassium could cause a lethal cardiac arrhythmia). The record showed the critical potassium result was reported to the charge nurse at 1:29 p.m., 33 minutes prior to the patient being found unresponsive in the lobby. Cardiac labs were not obtained in triage. At 2:02 p.m., patient #15 was found in the ED waiting area unresponsive and a Code Blue team was called. CPR (cardiopulmonary resuscitation - attempts to restart an individuals heartbeat and/or breathing) was started at 2:02 p.m. Patient #15’s EMR lacked vital signs or documentation of patient rounding between 12:29 p.m. and when he was found unresponsive at 2:02 p.m. The EMR lacked documentation the ED provider was informed of the abnormal EKG or the low blood potassium level. Review of a cardiology consult for patient #15 showed, “He (patient #15) presented to the emergency department today with several days of chest pain and cough felt to be related to pneumonia, while in the waiting room he underwent VF/VT (ventricular fibrillation/ventricular tachycardia, heart rhythm that does not produce a pulse) cardiac arrest ... Laboratory evaluation demonstrated significant hypokalemia (low potassium) with a potassium of 2.5 ...VF cardiac arrest likely due to severe hypokalemia.” Patient #15 was admitted to the intensive care unit after ROSC (return of spontaneous circulation) was achieved. During an interview on 10/22/24 at 9:00 a.m., staff member M stated, she was the nurse in triage on 9/5/24 when patient #15 presented to the ED. Staff member M stated, said normally she would have placed patient #15 on a monitor. Staff member M said she was unaware of a specific protocol for vital signs or rounding on patients who are waiting to be seen by a physician. She stated, “We have tried to establish a standard of care to recheck vitals every hour, but it isn’t happening right now. The triage nurse is responsible for everyone in the lobby. It puts a big responsibility on our techs and some of them are really new ...We don’t have a protocol we have a loose standard, so it doesn’t always happen.” Staff member M said patient #15 had been worked up in Urgent Care and was sent to the ED from Urgent Care because he required a higher level of care. Staff member M said she did not receive the critical value for the potassium. Staff member M said the critical potassium value was relayed to the SUS at 1:29 p.m., but she was not made aware of the value, and she said she could not see any documentation in the record a physician was informed of the critical value. She said typically a critical value would be relayed to the provider and the nurse. Staff member M said if she had known about the critical lab value, she would have pushed harder for him to be given a room in the ED sooner. She stated, “This patient really needed to be on a monitor. It is very frustrating, we had seven boarders, he would have had a bed if we had not had the boarders.” Staff member M stated she heard people yelling in the lobby, so she went to see what was happening. She stated she found patient #15 unresponsive and without a pulse. She activated a Code team and began CPR. Staff member M looked at patient #15’s EMR and said she could not find any documentation of vital signs or patient rounding for patient #15 between when he was triaged at 12:29 and when he was found unresponsive at 2:05 p.m. During an interview on 11/27/24 at 10:17 a.m., patient #15 stated that he went to the ED on 09/05/24 because he was not “feeling right.” After he was triaged, he sat in a chair in the lobby waiting to be seen, and did not remember anyone checking on him during that time. While he waited, his family member believed he had fallen asleep, however, he had gone into cardiac arrest. 7) Review of patient #17’s EMR showed, patient #17 had presented to the ED three times for suicidal ideation. The first presentation was on 8/1/24 at 12:17 p.m. when she was brought in by ambulance with reports of being suicidal. The EMS (emergency medical systems, ambulance) report from 8/1/24 at 11:38 a.m. showed the ambulance was dispatched for a female patient experiencing suicidal ideations and mental health behavioral issues. The report narrative showed, “Per the patient she had been experiencing an increase in family related stress, SI (suicidal ideation), and believed that people were trying to poison her.” The PHQ2/C-SSRS (patient health question 2, a screening for depression and C-SSRS Columbia Suicide Severity Rating Scale, an assessment of suicide risk) screening in triage showed, “Depression not Indicated” despite the ambulance personnel reporting the patient was suicidal and the patient reporting she had suicidal ideation. Patient #17 had a medical history of previous SI, mental health issues, and chronic back pain. The patient reported she had been non-compliant with her medications. The triage note showed patient #17 complained of her hair falling out, sore throat, upset stomach, nerve pain, fatigue and skin blemishes she developed after eating food given to her by other people. Vital signs were as follows, heartrate 110 bpm (high), blood pressure 133/94 (high), respiratory rate 16 (normal), and SpO2 99% (normal). She was assigned an ESI level 2. Review of an ED note authored by staff member K showed, patient #17 had pertinent history of methamphetamine use, anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, depression, prior suicidality with presentations to the ED with thoughts of self-harm and concern for being poisoned. Patient #17 told staff member K she had briefly voiced thoughts of self-harm which was what prompted EMS to her home. She told staff member K she was not acutely suicidal or homicidal. Patient #17’s EMR showed orders placed on 8/1/24 at 12:46 for crisis consult, search and separate belongings, call security for standby, patient safety plan template, and suicide precautions. There was no documentation of security being called for standby, no documentation to show the patients belongings were searched and separated, no documentation of implementation of suicide precautions and the record showed patient #17 was allowed to elope from the emergency department to the lobby despite these orders. The crisis note showed staff member L arrived to assess patient #17 but she had eloped to the hospital lobby prior to her arrival in the ED. Staff member L brought patient #17 to a family support room from the lobby and interviewed her there. The crisis note showed staff member L found patient #17 to be more concerned with getting a police report and legal matters, and found patient #17 to no longer have suicidal ideation and allowed her to leave the facility. The record lacked evidence security was contacted for standby when patient #17 arrived with reported suicidal ideations, lacked documentation of a search of her belongings or that her belongings were separated from her per hospital policy on her arrival, and lacked documentation of suicide precautions being implemented. Staff member K’s note showed patient #17 became verbally aggressive and stated her needs were not being met and patient #17 eloped from the ED. Patient #17 presented to the ED for a second time on 8/2/24 at 2:04 p.m., approximately 26 hours after her first presentation, and stated she needed to be admitted to Pathways (a facility for mental and behavioral health). The triage note showed patient #17 reported suicidal ideation and said she did not want to talk to anyone except a mental health provider or victim’s advocate. Her suicide assessment showed she was at moderate risk for suicide as she answered “yes” to wishing she were dead within the past month, “yes” to having thoughts of killing herself in the past month, and “yes” to having done something to end her life during her lifetime. The EMR showed patient #17 was taken to an ED room. The record lacked documentation of being separated from her belongings, security being summoned for standby, or suicide precautions being implemented. The EMR showed, at 2:27 p.m. staff member J, an ED physician, arrived in the room . Review of patient #17’s EMR reflected the medical chart lacked ED provider notes for the visit. Orders to call security for standby, provide a patient safety plan template, to search and separate belongings, and place the patient in suicide precautions were entered at 2:28 p.m. The record lacked evidence the orders were completed. The record showed patient #17 eloped at 3:05 p.m. Patient #17 presented to the ED for a third time on 8/5/24 at 7:45 a.m., she was brought into the ED via EMS. The EMS report showed patient #17 was found lying on the concrete outside of her apartment. Patient #17 had vomited prior to EMS arrival, her speech was slurred, and EMS personnel discovered patient #17 had taken 20-30 Wellbutrin XL 300mg tablets (an antidepressant) along with a pint or more of whiskey. The triage note showed patient #17 was found by a neighbor. Patient #17 admitted to taking a pint of whiskey, and ingested Wellbutrin to kill herself. Her suicide assessment showed she was at high risk for suicide. Suicide precautions were ordered and initiated. Vital signs were documented every 30 minutes. Patient #17 was treated medically for her overdose and was admitted as an inpatient at 9:00 a.m. for continued care for the diagnosis of a suicide attempt and toxic overdose with Wellbutrin. During an interview on 10/22/24 at 10:00 a.m., staff member O stated she was the nurse when patient #17 presented on 8/1/24. She said suicidal patients were typically taken to the secure rooms that are specifically designed for patients with suicidal ideation or behavioral health needs. She said patients with suicidal ideations would be changed out of their clothing and put in a hospital gown on arrival. She said security was responsible for taking the patient’s belongings for patient safety. She said they would call security to help watch the patients. Staff member O said she did not think they could hold a patient if the physician had not seen them yet. She said the doctor was the only person who could put an emergency hold on a patient. Staff member O said sometimes the ED was so busy the physician would not get in the room for a while. She said if the patient tried to leave, she would try to get the doctor to come in sooner, but if they couldn’t she could not make the patients stay, even if they were suicidal. She stated she tried to get patient #17 to come back into the ED, but patient #17 would not stay. Staff member O said she could not remember if patient #17 was ever changed into a gown or if suicide precautions were ever started. She looked at the EMR and was not able to find documentation of patient #17 being placed on suicide precautions. During an interview on 10/22/24 at 8:23 a.m., staff member P said he was working on 8/2/24 when patient #17 presented to the ED. The EMR showed he was assigned to patient #17 but he stated he never saw the patient. Staff member P said patients who come in through triage who endorse suicidal ideations would be brought back to the secure unit right away. Staff member P stated, “Once they get back to the unit, we won’t let them go until the physician sees them. If they are endorsing SI or HI, they must be seen before they leave. I know for sure I didn’t see this patient. I would not have ever let her just walk out, even if she says she changed her mind.” During an interview on 10/22/24 at 12:04 p.m., staff member Y said he was the SUS on 8/1/24 and on 8/2/24 when patient #17 presented to the ED. Staff member Y looked at patient #17’s record and stated he failed to document what occurred with patient #17, so he was unsure what transpired. Staff member Y said he was unsure if patient #17 was ever taken to a room in the ED, whether she was examined by the physician, or if she had been under a psychiatric hold. Review of a facility policy titled, Depression and Suicide Risk Screening, AGN 490, dated 8/2023, showed: “...For the Emergency Department (ED) and Acute Inpatient Services: A. Clinical staff will use the PHQ2 as the baseline screen for depression and the C-SSRS as the baseline screen for suicide risk ... B. Certain responses may prompt further action. This screening process will be completed each visit...” For individuals with a high risk for suicide, the facility shall call the Crisis Interventionist, initiate suicide precautions, and engage a sitter or use a designated safe room if a sitter is not available. Review of a facility policy titled, Emergency Medical Treatment and Active Labor Act (EMTALA), A313, dated 6/2024, showed: “ ...Medical Screening Examination 1. When an individual comes to the hospital Campus requesting examination or treatment for an EMC, or who appears to a reasonable observer to need medical treatment for an EMC, or who appears to a reasonable observer to need medical treatment, and MSE will be performed by an individual qualified to perform such an examination, to determine whether an EMC exists, or, with respect to a pregnant woman having contractions, whether the woman is in labor ... 8. The hospital’s EMTALA obligation ends when a provider or QMP has determined: A. no EMC exists (even though the underlying medical condition may persist); B. an EMC exists, and the individual is appropriately transferred to another facility; C. an EMC exists, and the individual is admitted to the hospital for further stabilizing treatment; or D. an EMC exists, and the individual is stabilized and discharged...” Review of a facility policy titled, Patient Assessment and Re-Assessment in the Emergency Department, ED 1531, dated 3/2023, showed: “ ...Patients will be re-assessed at least hourly and/or more frequently as patient condition warrants. ...e. Vital signs: i. Repeated every 5-30 minutes on Level 1 and 2 patients at nurse’s discretion based upon stability of patient. ii. Repeated every 1 hour on Level 3 patients at the nurse’s discretion based upon stability of the patient. iii. Repeated on Levels 4 and 5 at the nurse’s discretion based upon the stability of the patient. iv. Repeated within 30 minutes after the administration of medications with potential side effects. v. Repeated after any change in patient condition. vi. Repeated if any vital signs are outside the normal range ...” Review of a facility policy titled, Patient Elopement from the Emergency Department ER1107, dated 5/2024, showed, “Every patient who arrives to the Emergency Department (ED) and is checked in should be seen by a provider. However, when a patient decides to leave prior to being discharged by a provider, the following procedures will be followed ... Document in [Electronic Medical Record] for an Elopement or LWBS: 1. Time or arrival. 2. Chief complaint. 3. Time or approximate time the patient left. 4. Any other pertinent information. Document in [Electronic Medical Record] for an AMA: 1. Time of triage. 2. Chief complaint. 3. Time seen by the physician. 4. Time patient left Emergency Department. 5. Documentation will include inability/or refusal to obtain signed AMA. If patient refuses to sign obtain a second witness signature. ED personnel will round on patients regularly, preferably every hour, to provide updates on the expected wait or delay ... AMA- When a patient has been seen by the physician and evaluated, then decides to leave before treatment or disposition is complete. Elopement- When a patient has been seen by the physician and evaluated, then decides to leave without staff notification. Left without being seen (LWBS)- When a patient has been seen by the triage nurse and leaves prior to being seen by a physician.””