Caldwell Memorial 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: 33790 Based on policy review, on-call physician schedule review, medical record review, and physician and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings included: 1. The hospital failed to ensure an on-call physician was available and responded to a call from the Dedicated Emergency Department requesting an on-call physician response to evaluate and treat a patient in the emergency department for 1 of 27 records reviewed (Patient #3) ~ Cross refer to On Call Physicians 489.20 (r)(2) and 489.24 (j)(1-2)- Tag A2404 2. The hospital failed to provide an appropriate transfer when an on-call physician failed to respond to the Emergency Department to evaluate a patient and the patient subsequently was transferred for 1 of 27 patients reviewed (Patient #3). ~ Cross refer to Appropriate Transfer 489.24 (e)(1)-(2) - Tag A2409”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 33790 Based on policy review, on-call schedule review, medical record review and interviews, the hospital failed to ensure an on-call physician was available and responded to the Dedicated Emergency Department (DED) when the on-call physician was needed to evaluate a patient in the DED for 1 of 27 records reviewed (Patient #3) The findings included: Review of the policy “EMTALA Guidelines”, date 09/2024, revealed “...(Name of Hospital) shall provide an on-call physician specialty list which includes all specialties privileged at the hospital. Review of the “Rules and Regulations of the Bylaws”, dated 08/2023, revealed “...Response time for on call physicians to provide emergency Medical Screening Exam or treatment will be a reasonable response time not to exceed 30 minutes. Response time is considered to be a telephone call or presenting to the department where the emergency is present. ...” An updated “Rules and Regulations of the Bylaws was effective 03/06/2025 and indicated the same “... Response time for on call physicians.... will be a reasonable response time not to exceed 30 minutes. ...” Review of the on-call schedule for March 2025 showed MD #2 was on call 03/05/2025 when Patient #3 presented to the DED. DED medical record review, on 06/11/2025, revealed Patient #3, a 66 year old, arrived to the DED 03/05/2025 at 2237 with a chief complaint of “Leg Injury.” Review of the “Emergency Department Provider Note,” date of service 03/05/2025 at 2326, revealed Patient #3 presented to the DED after a fall with left lower leg pain. The patient’s past medical history included COPD (chronic obstructive pulmonary disease) and in DED was on 4 liters oxygen with oxygen saturations now in the “low 90s.” Review revealed notable swelling and bruising to the “anterior tibial plateau” (flat top surface of tibia, bone in lower leg) with concern for a fracture. Further review of the Provider Note revealed “...ED Course Thu Mar 06, 2025 IMPRESSION: 1. Comminuted, angulated and impacted fracture (bone is broken in multiple pieces, at an angle, with one piece driven into another) of the proximal tibial diaphysis (shaft of tibia) 2. Comminuted, angulated and impacted fracture of the proximal fibular diaphysis (upper portion of shaft of fibula, bone in lower leg)... .” On 03/06/2025 at 0012 the Provider Note indicated “paging ortho” and at 0018 “Swelling progressive in LLE (left lower extremity).... now notable fullness. No pain out of proportion currently and NV (neurovascular) intact.... Potential developing compartment (emergency condition from pressure buildup caused by bleeding or swelling in the tissues). ...” At 0043, the documentation noted “repaging”, at 0056 “Still awaiting call back from ortho”, and at 0118 (1 hour, 6 minutes after the first page) “Will transfer given unable to reach ortho. Have attempted calling and paging. Supervisor aware and unable to reach as well....” Record review revealed the patient was accepted by a physician at Hospital B at 0138 with the note indicating “Dr. (Name) at (Hospital B) accepts. ...” The EMTALA Transfer Certification revealed the reason for transfer was “Qualified clinical personnel or service unavailable” and the certifying physician signed the certification 03/06/2025 at 0140. The transport team arrived at 0227 and Patient #3 departed Hospital A at 0228. No documentation was found to indicate the on-call physician ever responded. Interview with the facility survey coordinator on 06/12/2025 at 1330 revealed MD #1, who did the MSE on Patient #3, was no longer on staff at this hospital. Telephone interview with MD #2, an orthopedic surgeon, on 06/12/2025 at 1130, revealed MD #2 was on-call the night Patient #3 was in the ED (03/05-06/2025) but did not realize it at the time. Interview revealed “It was our mistake,” stating an error was made on the office on-call schedule. Interview revealed that on the night in question, MD #2 was in clinic all day, left at the end of the day, went home feeling physically ill, took some medicine and went to sleep not realizing the physician was on call. Interview revealed the call schedule was completed 2-3 months in advance and added to the physicians’ electronic calendars. Interview revealed the hospital on-call schedule was accurate to list MD #2, but MD #2 was not listed on the office on-call calendar which was used in creating the provider’s calendars. Interview revealed the phone was not turned off but MD #2 went to sleep after taking the medicine and never heard the phone ring. MD #2 stated on-call had actually started at 0800 that morning but MD #2 got no calls during the day. If anyone had called earlier, the MD stated, the error would have been discovered while at work. Interview revealed “It was a perfect storm.” There were no calls while in the office, then MD #2 went home, took medicine, went to sleep and did not hear the phone ring. MD #2 stated the orthopedic PA’s (Physician Assistant) name and number had in the past also been on the call schedule, but at that time their names did not appear on it. Interview revealed “it was our fault.” Interview revealed work was done afterwards and the calendar was changed where a PA phone number was now included. In addition, on-call schedules were now mounted on the wall and a new system was put in place where the schedule was double checked before it was posted to physicians calendars. A scheduler, a CMA (Certified Medical Assistant) and the Office Manager were all involved in ensuring that the on-call schedule posted to the physicians calendar was correct. Interview further revealed that MD #2 participated in the review after this incident occurred to determine how the error happened and prevent a future occurrence. Interview with the ED Manager (Manager #3) on 06/12/2025 at 1340 revealed Manager #3 became aware of the issue when the incident (“Safe”) report was completed. Interview further revealed the manager was not aware of any new incidents occurring after the RCA. Telephone interview on 06/12/2025 at 1650 with Supervisor #4, the Patient Care Coordinator (PCC) who was on duty the night Pt #3 was in the ED, revealed the ED physician called Supervisor #4 to say the doctor could not get in contact with MD #2. Interview revealed Supervisor #4 called the Administrator-on-call to make them aware of the concern. Interview with Administrator (Admin) #5 on 06/12/2025 at 1710 revealed Admin #5 was Administrator-on-call when this event occurred. Interview revealed the patient was safe, which was the most important issue at the time. In the morning, the follow-up began and a thorough review was done. Interview revealed Admin #5 was not aware of any reports of lack of on-call response since the incident in March involving Patient #3.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 33790 Based on review of Rules and Regulations, policy review, medical record review and staff and physician interviews, the hospital failed to provide an appropriate transfer when the on-call physician failed to respond to evaluate a patient and the patient subsequently was transferred for 1 of 27 patients reviewed (Patient #3). The findings included: Review of the “Rules and Regulations of the Bylaws”, dated 08/2023, revealed “...Response time for on call physicians to provide emergency Medical Screening Exam or treatment will be a reasonable response time not to exceed 30 minutes. Response time is considered to be a telephone call or presenting to the department where the emergency is present. ...” An updated Rules and Regulations effective 03/06/2025 indicated the same, “...Response time for on call physicians....will be a reasonable response time not to exceed 30 minutes. ...” Review of the “EMTALA Guidelines” policy, effective 09/2024, revealed “...(Hospital) may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity. ...” Dedicated Emergency Department record review, on 06/11/2024, revealed Patient #3, a 66 year old, arrived to the DED 03/05/2025 at 2237 with a chief complaint of “Leg Injury.” Review of the “Emergency Department Provider Note”, date of service 03/05/2025 at 2326, revealed Patient #3 presented to the DED after a fall with left lower leg pain. Review revealed notable swelling and bruising to the “anterior tibial plateau” with concern for a fracture. Further review revealed tibia and fibula fractures. On 03/06/2025 at 0012, the Provider Note indicated “paging ortho” and at 0018 noted “Swelling progressive in LLE (left lower extremity).... now notable fullness. No pain out of proportion currently and NV (neurovascular) intact.... Potential developing compartment (emergency condition from pressure buildup caused by bleeding or swelling in the tissues). ...” The Provider Note revealed, at 0043, “repaging”, at 0056 “Still awaiting call back from ortho”, and at 0118 (1 hour, 6 minutes after the first page) “Will transfer given unable to reach ortho. Have attempted calling and paging. Supervisor aware and unable to reach as well. ...” At 0138, the Provider Note indicated “Dr. (Name) at (Hospital B) accepts. Clinical concern for developing compartment syndrome. Emergent transfer. ...” Further review revealed at 0151 the ED provider documented “Unable to get air (transport) given now weather conditions....reported snowing in (Location/city of Hospital B).... Patient leaving via ground (ambulance) given limited transport options. Understanding of plan and risk. ...” Review documented clinical impressions of “... Closed fracture of proximal end of left tibia....Closed fracture of proximal end of left fibula.... Traumatic compartment syndrome of left lower extremity... .” The EMTALA Transfer Certification revealed the reason for transfer was listed as “Qualified clinical personnel or service unavailable.” The transport team arrived to the hospital at 0227 and Patient #3 departed Hospital A at 0228 for transfer to Hospital B. Review of the Hospital B “ER Report” dated 03/06/2025 at 0506 revealed “...presents as a transfer.... secondary to left lower leg fractures and concern for swelling that could develop into compartment syndrome....Medical Decision Making.... Patient will be hospitalized at this time by Ortho team for further care.... Diagnosis/Disposition 1. Tibia Fracture 2. Fibula fracture 3. Fall 4. Generalized weakness... .” Review revealed Patient #3 was discharged from Hospital B on 03/12/2025. Interview with the facility survey coordinator on 06/12/2025 at 1330 revealed MD #1, who performed the medical screening on Patient #3, was no longer on staff at Hospital A. Telephone interview with MD #2, an orthopedic surgeon, revealed MD #2 was on-call the night Patient #3 was in the ED (03/05-06/2025) but did not realize it at the time. Interview revealed “It was our mistake,” stating that an error was made on the office on-call schedule and MD #2’s name did not appear on the MD’s schedule that night. MD #2’s name was on the hospital schedule, which was correct. Interview further revealed that on the night in question, MD #2 was in clinic all day, left at the end of the day, went home feeling physically ill, took some medicine and went to sleep, not knowing s/he was on call. Interview revealed MD #2 did not turn off the phone but went to sleep after taking medicine and never heard the phone ring. Telephone interview on 06/12/2025 at 1650 with Supervisor #4, the Patient Care Coordinator (PCC) who was on duty the night Pt #3 was in the ED, revealed the ED physician called the supervisor to say the doctor could not get in contact with MD #2. Interview revealed Supervisor #4 called the Administrator-on-call to make them aware of the concern but did not recall what happened afterward. Interview with Administrator (Admin) #5 on 06/12/2025 at 1710 revealed Admin #5 was the Administrator-on-call when this event occurred. Interview revealed the patient was safe which was the most important issue at the time. The next morning, interview revealed, follow-up began and a thorough review was done. The medical record did not contain the name and address of the on-call physician who failed to appear to provide an evaluation and any necessary stabilizing treatment.”

“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: 33790 Based on policy review, medical record review, and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings included: The hospital’s Dedicated Emergency Department (DED) failed to ensure stabilization prior to discharge for two of 25 sampled patients who presented to the DED seeking care (Patient #2 and Patient #3). ~ Cross refer to Stabilizing Treatment - Tag A2407”

“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: 33790 Based on policy review, medical record review and staff interviews, the hospital’s Dedicated Emergency Department (DED) failed to ensure stabilization prior to discharge for two (2) of 25 sampled patients who arrived to the DED seeking emergency care (Patient #3 and Patient #2). The findings included: Review of the “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines” policy, effective 08/2022, revealed “...All patients shall receive a medical screening exam ....that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis ....(Hospital) may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge.” 1. Medical record review, on 04/17/2024, revealed Patient #3 arrived to the DED on 08/16/2023 at 1510 for a mental health evaluation. Review of the ED Triage Note at 1522 revealed “Pt [patient] arrives via LEO [Law Enforcement Officer] for mental health evaluation. Pt denies SI/HI [suicide ideation/homicidal ideation]. Pt states : I don’t know why I am here’.” Patient #3 was assigned an acuity of 2. Review of the Emergency Physician Note, filed 08/16/2023 at 1833, revealed “...HPI [history of present illness]: [Patient #3] is a 34 y.o. [year old] male who presents to the ED [Emergency Department] under an IVC [involuntary commitment order] after reportedly making threats to his (family member). Patient is quite well-known to the department. He has a history of substance use, psychosis, schizophrenia....The IVC reads as follows ‘made threats to chop off his (relative’s) breasts and murdering her. He has knocked on the door of his neighbors and told them that he had a plan to murder his (family members). He has told people that he has a firearm.’...” The Physician Note indicated “...ED Course:...has a history of mental illness....Apparently he made some threats to his (family member) after there was an altercation. He also reportedly threatened that he had a weapon....I will uphold the IVC as he did reportedly make threats. We will have the patient evaluated by the psychiatrist to ensure safety and determine if the IVC should be upheld. ...” An order was placed at 1823 for “Consult - Inpatient consult to Psychiatry (Virtual). Review of the “...Acute Telepsychiatry ED Initial Consult” note filed at 2045, revealed “...Per chart review and initial tele psych evaluation, patient’s presentation is most consistent with juvenile onset Schizophrenia superimposed on Borderline Intellectual Functioning, with current psychotic decompensation exacerbated by medication noncompliance and cannabis abuse. The patient is at acute elevated risk of suicide/dangerous to others and further worsening of psychiatric condition ....Disposition: Recommend inpatient psychiatric hospitalization. Please work with appropriate staff to facilitate this process. IVC Status: This patient DOES meet IVC criteria. ...” Review of “Commitment/IVC” paperwork revealed the involuntary commitment process was started on 08/16/2023. Review of the Criteria for Commitment revealed it included being an individual with a mental illness and dangerous to self and others. The recommendation was inpatient commitment for “7” days. Review revealed starting on 08/17/2023 multiple facilities were sent referrals for admission for Patient #3 with no indication of any acceptance. On 08/21/2023 at 0442, an ED Note revealed “...This RN [Registered Nurse] into room to speak with patient about nicotine and a stimulant and pt has not laid down or slept in the last 2 days. Pt then began to yell at this nurse...Attempted to redirect patient several times ....pt became aggressive and began yelling at RN ....While moving towards RN. This RN shut the door between pt and nurse for safety. Pt then began slamming his fist against the door and continuing to yell obscenities. After about 2 minutes of him slamming his fist against the door, pt decided to take the recliner and slam it against a door. At this time security arrived with [Name] RN to attempt to talk patient down until LPD [local police] arrived. Once LPD arrived and spoke with patient he then got out of his chair and went to bed to lay down.” An ED Note by a Nursing Assistant, at 0445, noted “Pt rang call bell and threatened to ‘tear this place down’ if he did not get a nicotine lozenge. Charge [Name] RN notified. [Name] came over to speak to pt and then pt lunged toward [Name]. LPD was called.” A Nursing Note, on 08/22/2023 at 2127 stated “Patient communicating threats against this nurse that he will ‘beat my [xxx]’ and ‘I will kill you.’...” ED Care Timeline review revealed, on 08/23/2023 at 0054, “Patient called out to staff screaming and demanding to know ‘When he was going home, he was very agitated and contiued [sic] to scream at staff. He said ‘He was going to kick the [expletive] door down.’ Staff tried to calm patient down and he continued to be loud. ...” At 0056, a Timeline note indicated “Pt called over and asked for when he was going home then he proceed to get mad....and threatened to cut RN.... boobs off.” At 0101 the patient was noted as “ ...very aggressive and is kicking the door and yelling ...” and at 0105 “Pt viewed via cameras repeatedly kicking room....door. LPD notified.” The Timeline further noted, at 0106, “Pt covered camera with toilet paper and refused to remove it. Staff asked patient again to remove the paper and he said ‘No and if he didn’t get his medicine he was burning this [expletive] Place down.’ Security called.” At 0112, “Security removed paper from camera.” At 1200 the ED Care Timeline review revealed “Psychosocial: ....Exceptions to WDL Exhibited Unsafe Behaviors: Agitation ....Mood: Anxious ....Motor Activity: Agitation ...Mental Status Thought Processes: Concrete thinking ....Hallucinations: Denies ...Homicidal/Harm to Another Are you Currently Having Homicidal Thoughts/: Denies Aggression/Violence/Anger Do you Have a History of Violence/Aggression?....Denies Destructive Behavior: None observed Ever Find That You Can’t Handle Your Anger?: Denies. ...” A “SOCIAL WORK ASSESSMENT/ CONSULT”, date of service 08/23/2023 at 1456, revealed “... Pt is a 34 year old male ....Current living arrangements: Pt lives alone in an apartment he pays rent for. Pt reports having one dog ....Precipitating Events & Psychosocial Stressors: IVC paperwork reports pt communicated threats towards his (family) stating he intended to harm her, and stated to several neighbors he had a weapon....CONCLUSION: Pt presents with a euthymic affect and calm mood. His speech was clear and effective with communicating his thoughts and emotions. Patient appears fully oriented x4, lucide [sic] and willingly engaged in interview. Pt denies any and all SI/HI, desire to harm self or harm other, paranoid thinking, delusional thinking or thoughts of grandeur. Pt DOES NOT meet criteria for IVC at this time for the following reasons.... ACTT support for follow up/ OP follow up MH [mental health] support.... Future oriented.... No SI/HI.... Medication compliant. ...” Review of a “Progress Note - Non-Provider” dated 08/23/2023 at 1607, revealed a Case Manager note which indicated “4:00PM: Spoke with [Name], pt’s ACT Team Lead and informed her of pt’s dc [discharge] and release from IVC. Team expressed concerns of dc due to reports of pt’s aggressive behavior towards guardian. Explained to Team Lead that pt has been under IVC for a week, and re-assessment was done to determine if IVC needed to be continued. Pt presented with no psychosis, SI/HI, or delusional behavior. Explained pt no longer met IVC criteria thus dc was required. ...” Review of an ED Progress Note by the discharging provider, date of service 08/23/2023 at 1729 revealed, “ED Update Note Summary: The patient was initially seen and evaluated by Dr. [Name], DO. He was initially seen on 08/16/2023 and brought in under IVC after reportedly making threats to his mother. He has been in the emergency department for a week and his IVC expired. I spoke with [Name], one of our case managers noted that the patient was no longer reporting any delusional, psychiatric, or homicidal behavior. He is followed by the ACT team. He believes that the patient was appropriate for discharge. He had not been accepted for transfer. I discussed this with the patient who denies SI/HI. ....He was discharged with instructions return to the emergency department immediately for any thoughts of self-harm, harm to others, or any other new, concerning, worsening symptoms. ...” Medical record review revealed Patient #3 was discharged at 1950. The medical record failed to reveal a tele psych consult reevaluation by a Psychiatrist was obtained prior to allowing the IVC to expire and discharging Patient #3 home, even after the behaviors of the previous night. Interview with Staff #4 on 04/17/2024 at 1540 revealed Staff #4 was a Discharge Planner. Interview revealed Staff #4 assessed psych patients in the emergency room and evaluated to determine if the IVC needed to be upheld. If a patient needed inpatient services, Staff #4 facilitated placement. Interview revealed that in doing the evaluation, Staff #4 did a mental status eval, looking at appearance, communication, eye contact, insight, judgment and thought processes. Staff #4 said “Are they presenting any behaviors that they could be an imminent danger to self or others?” Interview revealed Staff #4 usually reviewed the medical record prior to evaluating a patient but did not recall if he had reviewed it or was aware of behaviors from the previous night on Patient #3. Telephone interview on 04/18/2024 at 0845 with DO #1, the discharging physician, revealed DO #1 revealed DO #1 did not recall Patient #3. Interview revealed DO #1 took the recommendations of the two “social work staff” very seriously and never questioned their skills. DO #1 stated he always saw and evaluated a patient before deciding to discharge. Interview revealed when seeing the patient, DO #1’s standard discussion was to discuss what the DO understood/had been told about the patient, discuss whether the patient agreed it was accurate and question if the patient/others would be safe if the patient was discharged. DO #1 stated it was not common to involve tele psych at discharge, but if the ED physician requested a psych reevaluation they could get one. Interview with Staff #5 on 04/18/2024 at 1448, revealed Staff #5 was a MSW (Medical Social Worker) and LCSWA and the second staff member who evaluated IVC patients in the ED. Interview revealed the two staff gave recommendations to the physicians. When IVCs were about to expire they did a reassessment to determine if the patient still met IVC criteria. Interview revealed patients did not have to be reevaluated by tele psych, but could be if it was thought to be necessary. Telephone interview with MD #6, the Telepsychiatry Medical Director, on 04/18/2024 at 1532, revealed the Telepsychiatry physicians did psych evaluations and gave recommendations on patients with psych needs. Interview revealed the team did not do reevaluations unless requested by the ED. MD #6 stated they saw patients based on a consult from the ED. 2. Medical record review on 04/17/2023 revealed Patient #2 arrived to the DED on 08/16/2023 at 0114 with a chief complaint of “Mental Health Evaluation.” Review of the Triage Note revealed “Patient arrives in LPD custody under an IVC order after ‘running away from a group home.’ Pt states that he has ‘been on the run for three days’ until found by police. Pt denies SI/HI.” Review of the ED Provider Note at 0355 revealed “[Patient] is a 16 y.o. male with a reported past medical history of ADD and OCD presents to the ED by LPD for mental health evaluation. Patient was found after running away from his group home 3 days ago....Per report patient has had a history of attempting suicide. LPD note also states ‘the respondent states that he is also a danger to his family at home’....Will uphold IVC and obtain behavioral health evaluation for placement. ...” Review of a “ ...Acute Telepsychiatry ED Initial Consult” note, dated 08/16/2023 at 0935, revealed “...presented to [hospital] ER on early morning of 8/16/23 for safety evaluation after eloping from group home he had been residing at for the previous several weeks following discharge from long-term treatment facility in [another state]. Per chart review and initial telepsych evaluation, patient’s presentation is most consistent with Adjustment Disorder exacerbated by likely underlying Oppositional Defiant Disorder. Although no collateral information from family or previous hospitalizations is available at time of initial ATS evaluation...patient’s own report suggests a history and behavioral course consistent with ODD/Cluster B traits in an adolescent. Patient’s transition from controlled inpatient-residential setting to outpatient group home setting has been rather difficult, and it appears that this elopement was a culmination of a period of conflict between patient and peers as well as staff at this group home placement.... The patient is at acute and chronic elevated risk of suicide/dangerousness to others and further worsening of psychiatric condition....The patient DOES meet [state] involuntary commitment criteria at this time....Strongly recommend attempting to gain further collateral from patient’s family and/or previous group home and/or any involved DSS agencies. ...” Review of a Collateral note, at 1319, revealed “Spoke to patient’s (family member)....states that he did really well at a PRTF (Psychiatric Residential Treatment Facility) and that he does tend to do well when he has a very structured environment and when he is locked in, because he knows he cannot leave. Hard time with anyone telling him what to do...States that....is concerned for his safety.... thinks that he needs to go to inpatient hospitalization or to a PRTF again as that was the last setting when he was stable. Recommendations: Disposition: Given new information provided....recommend discharge to PRTF or higher level of care ....Going home is not considered an option at this time and would not be recommended give level of dysregulation the patient has demonstrated when outside of structured environments.” On 08/28/2023 at 1126, an Encounter Note stated “CM is continuing to work on placement. CM is looking into [Facility Name], but they currently have a 4-6 week wait.” An Encounter Note on 09/07/2023 at 0859 revealed “...There are three PRTFs that have patient under review. No acceptances have been received. CM is still looking into rapid response respite beds, but these are full at this time. 1350: Spoke with patient again at length. He still does not believe that he needs treatment nor needs to be in a PRTF. Patient states the main issue is that he broke the trust of his (family). He feels that he has done all that he can to regain their trust, but it is not successful. He is fearful that he will be in facilities until he ages out of 18. He does not see the need for treatment and desperately wants to go home to family. ...” An Encounter Note, dated 09/12/2023 at 1147, notes “Spoke to [Name] CM....She received patient’s official acceptance letter from [Facility Name]....was originally told the wait list was 6-8 weeks. The acceptance letter now states 10-12 weeks. Patient will remain on the wait list for [Name] but CM will continue to search for a PRTF that will have a closer acceptance date. ...” An Encounter Note on 09/22/2023 at 1616 documented “MSW has met with child multiple times this week. Each time, patient is focused on how to leave the hospital and avoid treatment facilities. Patient has asked about minor emancipation, inquiring if he would qualify to become his own guardian. Patient also asked if adult siblings can take guardianship from parents. Explained that this would be a court process. Today patient asked if there was any way that anyone can sign him out of the hospital other than his parents. Patient has continued to deny his need for treatment. Patient is asking specific information regarding his accepting facility...started to brainstorm how he could be transferred into the program he preferred.” On 09/28/2023 at 1837, an ED Progress Note revealed “Technician was playing spoons with the patient and others in the behavioral health unit [Zone 3]. Patient #2 and another teenager in the unit grabbed the staff members badge off her chest, they scanned the badge to the pad and ran out of the hospital. County police have been called immediately and they are currently looking for the patient and other teenagers in the unit.” At 1921, an ED Note documented “ ...(family member) was contacted and informed on [Patient #2] eloping from the Emergency Department. ...” An ED Note at 2130 stated “Pt was escorted back into the ER via [City name] police department. Pt placed in hallway D until provider wanted to assess or place in the lock unit. Provider states that pt may go into the lock unit and he will see him in that room. Pt escorted to room 19 via law enforcement.” At 2217 an ED Progress Note indicated “The patient was apprehended and brought back to room 19 by police. He is refusing to exit the bathroom where there were no cameras. I had a collegial discussion with the patient imploring him to exit to his bedroom and cooperate with request, specifically noting that we would engage in no additional modification of his behavior or provide addition request if he were to comply. The patient is refusing to leave the bathroom and is also requesting ‘something to sleep.’ The patient indicates that he will forcibly resist being taken from the bathroom. I have ordered 5 mg [milligram] of intramuscular haloperidol and 1 mg of intramuscular Ativan. [Name] PD is present at bedside with security. ...” At 2250, An ED RN note was documented that “Patient was cooperative with IM medications and transfer to room 6 for 1:1 monitoring.” Review of the ED Care Timeline revealed on 09/29/2023 at 1121, “...Patient is requesting to speak with the psychiatrist of which provider is aware.” Review of MSW Encounter/Progress Note, from 09/29/2023 at 1734, revealed “...MSW spoke to patient about yesterday. Patient states that he is scared that once he is ‘locked’ in another facility, he will not be able to leave until after he is 18. Patient states that he misses his family and wants to be with them....Patient still states that he is unsure if he can make it to Tuesday without trying to run again.” On 10/03/2023 at 0954, Discharge Instructions were noted and Patient #2 was discharged with a parent to go to the Respite facility to await PRTF placement. A note at 1205 revealed “Patient’s (Family member) called stating that patient made it to [Name] Respite safely. ...” ED record review did not reveal any new orders for Telepsychiatry consults after the initial order on 08/16/2023 and did not reveal any additional Telepsychiatry consults documented for evaluation or treatment recommendations either before or after Patient #2’s elopement on 09/28/2023 nor after Patient #2’s 09/29/2023 request to speak with a psychiatrist. Interview on 04/17/2024 at 1420 with Staff #5, revealed patients did not have to be re-evaluated by tele psych during their stay, but they could be if it was thought to be necessary. Telephone interview with MD #6, the Telepsychiatry Medical Director, on 04/18/2024 at 1532, revealed the Telepsychiatry physicians did psych evaluations and gave recommendations on patients with psych needs. Interview revealed the team did not do reevaluations unless requested by the ED. Further interview revealed that just because a patient asked to speak to a psychiatrist did not mean Telepsychiatry would see the patient.”