Onslow 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: 26622 Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. Specifically, the hospital did not provide Patient #1 an appropriate medical screening exam prior to allowing the individual to leave the hospital campus. Findings included: The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 1 of 25 sampled DED patients (Patient #1). Cross Refer to A2406.”

“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: 26622 Based on medical record reviews, incident report review and staff interviews, the hospital failed to ensure a thorough medical screening exam (MSE) was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition (EMC) existed for one (1) of 25 sampled DED patients (Patient #1). The findings include: Review on 02/17/2026 of the medical record for Patient #1 revealed a 41-year-old female that presented to the Emergency Department (ED) under Involuntary Commitment via Probation Officers on 09/09/2025 at 1853. Patient #1 was placed in ED room #43 at 1900. Review of nursing note documented at 1955 revealed “This nurse assumed charge duties at 1930, informed per Pod 4 nurse that this pt (patient) had been brought in per Onslow county probation officers with IVC (involuntary commitment) papers from Raleigh/Wake county. IVC papers were issues (sic) at 1117 this morning and state pt was brought to our facility at 1240pm. Pt did not arrive to this facility until 1900. This nurse informs probation officers that the IVC papers are invalid, SW (social worker) also contacted Wake county magistrate who states the women’s facility pt was transported from was informed earlier today that the paperwork was invalid at this point as well. Probation officers informed that pt is not IVC’d per our facility and with papers presented being invalid pt would be an at will patient, meaning if pt refused psychiatric evaluation she could not be held in the facility. (Name) SW confirmed this nurses statement, (Name) HS [house supervisor] to Pod 4 as well. Pt asked if she would like a psychiatric eval (evaluation), pt states no. Pt’s shackles removed per probation officers and this nurse advised pt of how to get to the ED exit, pt ambulatory per self from ED.” Review of a mental health social worker note documented at 2012 revealed “Writer was notified at approximately 14:30 that patient was currently an inmate at North Carolina Correctional Institute for Women. Today was her anticipated release date. IVC petition and first exam, along with documentation from patient’s incarceration was faxed to (Name) hospital. fax was reviewed. Writer contacted LCSW (Licensed Clinical Social Worker) on IVC. Call was not answered, message left requesting call back. Writer contacted Wake county Magistrate (telephone number) and spoke with Ms. (Name). She confirms she processed the IVC with the understanding that patient being (sic) transferred to (Name) hospital was a coordinated plan and that (Name) hospital had a bed waiting for her arrival. Writer denied that there was any coordinated plan and (Name) hospital was unaware of this patient until very recently. Writer explained that if patient met IVC criteria, she needed to be evaluated at the closest 24 hr facility to where she is currently at. Ms. (Name) asked for call back phone number, stated she was going to speak with supervisor and call this writer back. Writer received call back from (Name), LCSW. Writer explained the proper steps to getting patient evaluated. IVC was initiated before correctional release. Several hours later, writer was notified that Onslow County probation officers showed up with patient and IVC papers. Review on 02/18/2026 of an email sent from the Director of Corrections Social Workers to the Hospital Compliance officer on 10/03/2025 at 1523 revealed the sender wished to file a complaint. The complainant indicated in the email that a prisoner was released on IVC per the prison psychiatrist who felt the prisoner was not safe to release to the community. The complainant indicated that information was received that probation officers were with the offender in the ED of (Name) hospital and the hospital refused to see the patient for evaluation. The complainant called the hospital and asked to speak with a nurse in charge in the ED. The complainant spoke with a nurse in the ED who the complainant alleges was argumentative and reported that the patient needed to return to Wake County. The complainant alleged the nurse refused to honor the orders for petition even though it had been authorized by the magistrate. The complainant requested to discuss the details of the incident. Review of the hospital incident report provided on 02/19/2026 at 1010 revealed the incident report was completed on 10/07/2025 from the email received on 10/03/2025 and the telephone conversation between the complainant and Patient Advocacy Manager (PAM #5). The incident occurred on 09/09/2025 in the Emergency Department. Documentation on 10/06/2025 by PAM #5 revealed “Spoke with (Name). She states that (Name) hospital ‘refused’ to see the pt (patient). They released the pt from prison, however she was IVC’d by Wake County Magistrate. (Name) said they do these things all the time and they try to get patient back to their own area/environment. (Name) hospital staff told (Name) that the IVC paperwork was invalid. (Name) said that she spoke with Wake County Magistrate and that is not true. I have read (Name) SW’s note and I am still confused on whether the IVC paperwork was invalid. The note referenced that she was IVC’d prior to her release from DAC (Department of Adult Corrections) and she cannot be in the custody of two entities. (Name) said that the nurse told the patient since the IVC paperwork was invalid, she was essentially being kidnapped. Per (Name), patient ‘slipped out the back door’. The note references that patient was asked if she wanted to be mentally evaluated and she did not, so she was marked as a LWBS (left without being seen). Reported that probation found the patient the following day and is back in the custody of the DAC. I am not sure what to do with this concern. I explained to (Name) that if it was a patient making a grievance, my role would be to follow up in writing with the patient. I advised her that I was not sure of the correct track, but we would review the concerns.” Review of the corrective action documented by Director #1 on 11/19/2025 revealed “Pt was not on a custody order. There is documentation from charge nurse that the patient did not elect to have a psychiatric evaluation completed. This was with the assistance social work and house supervisor. There was not a MSE (medical screening examination) completed. The patient LWBS (left without being seen). Education will be provided to the staff related to MSE requirements for any pt that may not have decision making abilities.” Note documented in the incident report on 11/19/2025 at 1300 by Director #1 revealed “Have not been (patient) arrived with probation at 1853 and they presented an IVC petition that had been rescinded to the staff, meaning the patient able to make contact with the reporter (complainant). Review of the resolutions and outcomes of the event revealed “Referred to ED Director and CNO (chief nursing officer) for review of event and for f/u (follow-up) with DOC (Department of Corrections). ED Director will be f/u with involved staff to review the process and the importance of documentation of d/w (discussions with) providers, patient and findings.” Review of the IVC paperwork revealed the petitioner was the psychiatric provider at the correctional institute. The first examination was completed by the psychiatric provider at the correctional institute on 09/09/2025 at 0800. The IVC paperwork custody order was signed by the Wake County Magistrate on 09/09/2025 at 1117. IVC paperwork indicated that the respondent was taken into custody on 09/09/2025 at 1213 and signed by a NC State Capital Police (NCSCP). Section B. For Use When 24-Hour Facility Not Immediately Available or Medically Appropriate was dated 09/09/2025 and time timed at 1213 by the NCSCP with documentation of the examining facility as (Name) Hospital. Interview on 02/17/2026 at 1535 with the Director #1 (Emergency Department Nursing Director) revealed the director was notified by the SW #2 (ED Social Worker) via telephone of the incident. A follow-up interview on 02/18/2026 at 0850 revealed the ED Director received a telephone voice mail message from (Name) from the prison. Interview revealed there was no communication between the ED provider and the prison staff and/or psychiatric provider at the prison in reference to Patient #1. The Wake County Magistrate indicated that information was received that the (Name) hospital had a bed on hold for the Patient. Interview on 02/17/2026 at 1620 with SW #2 revealed the SW received a call from Wake County/Raleigh reference a discharge from jail to hospital for psychiatric evaluation. SW #2 explained to the caller that the patient need to go to the closest hospital. The patient arrived at the hospital with probation officers and IVC papers with no evidence that the IVC was rescinded.” Interview on 02/18/2026 at 0835 with RN #3 revealed that patients presenting with law enforcement officers were brought in through the ambulance entrance. Patient #1 was placed in Pod #4 by two probation officers and social worker. Interview revealed that when this nurse arrived in the patient’s room there were two (2) social workers and two (2) probation officers present. Interview indicated a conversation was held between the social worker and the probation officers concerning the validity of the IVC papers. The patient when asked, denied suicidal and homicidal thoughts. RN #3 indicated that Patient #1 did not display any psychiatric crisis and did not want a psychiatric evaluation. Interview revealed that the IVC papers were invalid and the hospital staff could not hold the patient. The probation officers removed the shackles from the patient as the patient had declined the medical evaluation and just wanted to know where the exit was. The patient was discharged. Interview on 02/19/2026 at 0905 with CS #4 (Compliance Specialist), PAM #5 (Patient Advocacy Manager) and RM #6 (Risk Manager) revealed the complaint was received by CS #4, who forwarded to the VPN of Compliance and PAM #5. Concerns were determined to not be a grievance after speaking with the complainant and PAM #5 reached out to RM #6. Incident report was filed for Risk Management. RM #6 revealed that an investigation was conducted but there was still some uncertainty about the validity of the IVC as to whether another 1st examination was being requested and whether or not the patient was presenting under IVC or voluntarily and wanting to be seen. After reviewing with staff and obtaining additional information, the hospital leadership determined that the ED provider should have been included in the conversations to determine if the patient had the capacity to make decisions about being seen. The review did not reveal that an ED provider had been contacted in reference to the patient. Interview revealed that regardless of the time the patient presented with probation officers, the staff should have notified the ED provider to evaluate the patient prior to discharge. Interview on 02/19/2026 at 1135 with Director #1 and CNO #7 revealed the investigation included conversations with the staff involved in the incident on 09/09/2025. Interview revealed that Director #1 had follow-up conversations with Probation staff leaders on 02/19/2026. Interview revealed that education related to patients who may lack decision making capabilities cannot decline or refuse a MSE and a provider should be notified to assess the patient. The interview revealed 119 of 141 ED staff completed the huddle education between 11/21/2025 and 11/28/2025. In summary, review of the medical record revealed no documentation of a medical screening examination completed by a provider.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 26622 Based on review of hospital policy, medical records and interview, the nursing staff failed to assess vital signs per physician orders for 2 of 2 sampled ambulatory surgical patients. Findings include: Review on 06/04/2025 of the hospital policy titled “Vital Sign Assessment” effective date 05/2022, revealed “Blood pressure, pulse, respirations, and temperature will be taken on all patients as ordered by the provider. ...” 1. Review on 06/03/2025 of the medical record for Patient #11 revealed a 38-year-old female that presented to the ambulatory surgical center on 04/10/2025 at 0745 for a “Robot Assisted Total Laparoscopic Hysterectomy”. Review of the physician post-operative orders to follow the post-op cesarean section order set, dated 04/10/2025 at 1128 revealed an order to obtain vital signs every hour times 4 (1128-1528) and then obtain every 4 hours beginning at 1528. Review of the nursing vital signs documentation flowsheet revealed vital signs to include temperature, pulse, respirations and blood pressure were obtained at 1131, 1201 and 1202. Vital signs documented at 1232, 1332 and 1432 failed to include the patient’s temperature. Record review failed to reveal a complete set of vital signs was documented every hour times four from 1131 - 1432. Review of the vital signs flowsheet revealed the first set of every 4 hours vital signs was documented at 1532 and failed to include a temperature. Vital signs documented at 1935 included temperature, pulse, respirations and blood pressure. Review of the medical record revealed that Patient #11 returned to the operating room at 2052 for surgical complications. Review of the physician post-operative orders to follow the post-op cesarean section order set, dated 04/10/2025 at 2206 revealed an order to obtain vital signs every hour times 4 (2206-0206 [4/11/25]) and then obtain every 4 hours beginning at on 04/11/2025 at 0206. Review of the nursing vital signs documentation flowsheet revealed vital signs to include temperature, pulse, respirations and blood pressure were obtained at 2210, 2240 and 2252. Vital signs documented at 2215 and 2220 failed to include the patient’s temperature. Vital signs flowsheet review revealed the next complete set of vital signs was obtained at 0343. Record reviews failed to reveal that a complete set of vital signs was documented every hour times four from 2206-0206. Review of the vital signs flowsheet revealed there was no documentation of the first set of every 4 hours vital signs (should have been documented on 04/11/2025 at 0606). Vital signs flowsheet review revealed documentation of a temperature at 0716 and 1000 with no pulse, respiration or blood pressure documented. The next set of vital signs was documented at 1445 (time of discharge). The nursing staff failed to document a complete set of vital signs every hour times four and then every 4 hours as ordered by the physician. Interview on 06/04/2025 at 1100 with RN #1 revealed the nursing staff were expected to follow the physician orders for obtaining vital signs. The vital signs should include temperature, pulse, respiratory rate and blood pressure. The interview revealed the staff failed to obtain vital signs per the physician order and failed to follow the hospital policy. 2. Review on 06/04/2025 of the medical record for Patient #20 revealed a 44-year-old female that presented to the ambulatory surgical center on 04/10/2025 at 0516 for a “Robot Assisted Total Laparoscopic Hysterectomy”. Review of the physician post-operative orders to follow the post-op cesarean section order set, dated 04/10/2025 at 0920 revealed an order to obtain vital signs every hour times 4 (0920-1320) and then obtain every 4 hours beginning at 1320. Review of the nursing vital signs documentation flowsheet revealed vital signs to include temperature, pulse, respirations and blood pressure were obtained at 0919, 0949 and 0950. Vital signs documented at 1030, 1230 and 1300 failed to include the patient’s temperature. Record review failed to reveal that a complete set of vital signs was documented every hour times four from 0920 - 1305 (time of discharge). The nursing staff failed to document a complete set of vital signs every hour times four as ordered by the physician. Interview on 06/04/2025 at 1100 with RN #1 revealed the nursing staff were expected to follow the physician orders for obtaining vital signs. The vital signs should include temperature, pulse, respiratory rate and blood pressure. The interview revealed the staff failed to obtain vital signs per the physician order and failed to follow the hospital policy.”

“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: 47421 Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings included: The hospital staff failed to ensure an appropriate medical screening examination that was within the capability of the Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for two (2) of 28 patients that presented to the hospitals’ DED (Patient #12 and Patient #26). ~cross refer to 489.24(a) and 489.24(c) - Tag 2406”

“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: 47421 Based on policy review, medical record review and interviews, the hospital staff failed to ensure an appropriate medical screening examination that was within the capability of the Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for two (2) of 28 patients that presented to the hospitals’ DED (Patient #12 and Patient #26). The findings included: Review of the hospital’s policy Emergency Medical Treatment and Labor Act (EMTALA) last revised 12/2021 revealed “ ... PROCEDURE: A: Patient Evaluation with Treatment 1. EMTALA is triggered when a person ‘comes to the emergency department’ and a request is made by that individual or on their behalf for an examination or treatment of ‘a medical condition.’ ... This request includes treatment for a possible emergency medical condition that occurs on Hospital Property outside of a Dedicated Emergency Department. Onslow Memorial Hospital shall provide an appropriate medical screening examination to determine (i) if the individual has an emergency medical condition, or (ii) in the case of pregnant person, if they are in labor. 2. The medical screening exam will be provided within the capability of the Hospital’s Dedicated Emergency Department and will include ancillary services routinely available to the emergency department. In addition, a pregnant person may receive a medical screening exam in Labor and Delivery. 3. The individual shall be evaluated by qualified medical personnel that have been designated by the Hospital in its medical staff by laws. 4. If it is determined that an Emergency Medical Condition exists or that a pregnant person is in labor, the Hospital shall either a. Stabilize the patient by providing further medical examination and treatment within the capabilities of the Hospital, or b. Appropriately transfer of the individual to another medical facility, EMTALA permits transfer of an unstable patient for only two reason medical indication and patient requests ...” 1. Medical record review for Patient #12 revealed the Emergency Medical Services (EMS) trip report revealed the chief complaint was “AMS [altered mental status] w/Possible Drug Ingestion ... Signs & Symptoms: Alcohol/Drug Exposure-Poisoning by unspecified drugs/substance. Cognitive Functions and Awareness-Altered mental Status ... Patient Admits to Drug Use ... dispatched emergency traffic to the jail in reference to a 52-year-old female overdose. On scene, Pt [patient] is found laying supine in the jail and appears to be mumbling. Pt is responsive to painful stimuli. Pt airway is open and self-maintained. Pt breathing is normal, unlabored but unable to communicate effectively w/crew ... LEO (law enforcement officer) on scene states Pt was upright and talking adequately w/Pt approximately 10 minutes prior to EMS arrival when she had a control fall to the ground assisted by LEO. LEO states that Pt stated ingesting crack cocaine approximately 4 hours in the back of the police car prior to events happening. Pt is able to answer basic questions with yes or no responses following painful stimuli and states she did ingest crack cocaine and no other drug ... Pt vitals are assessed to find no abnormalities. En route, Pt remains responsive to painful stimuli and able to answer to answer basic yes or no questions following stimulation. Pt vitals remain within normal limits ... At destination ...Pt brought to Trauma 2 ...Report given to receiving faculty and nurse signs for transfer of care and for Pt due to AMS. Transfer of care is complete...” Review of the EMS Radio Communication Record revealed at 2220 report was taken by the nurse. The record revealed the chief complaint was “AMS alert (no speak) does not follow commands pupils even”. Closed dedicated emergency department (DED) medical record review of Patient #12 revealed a 52 year old female presented to the DED via EMS and law enforcement on 05/17/2023 at 0017 with a chief complaint of altered mental status. At 0028 a Medical Screening Examination (MSE) was initiated. Review of the DED triage note at 0035 revealed “BIBA (brought in by ambulance) from jail for a witnessed episode of ‘unresponsive’ or seizure like activity, ceased with ammonia salt. Pt (patient) now ao (alert/oriented) when given painful stimuli. Potential crack cocaine use tonight while in custody per pt (patient), per officers, camera do not show her ingesting any substances. At 0048 a neurological exam documented a total score of 4 (0-22), “pt not cooperative with assessment, nods and reacts to verbal”. At 0100 a Glasgow Coma Scale revealed a score of 12. Eye opening: to pain, verbal response: oriented, motor response: localizes to pain. The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. Reporting each of these separately provides a clear, communicable picture of a patient. The findings in each component of the scale can aggregate into a total Glasgow Coma Score which gives a less detailed description but can provide a useful summary of the overall severity. The Glasgow Coma Scale and its total score have since been incorporated in numerous clinical guidelines and scoring systems for victims of trauma or critical illness. This activity describes the use of the Glasgow Coma Scale and reviews the role of using the scale for the interprofessional team to successfully communicate a patients condition. The maximum total score that can be gained is 15. A score of 9 to 12 correlates with moderate injury. ED course: 0133 - Patient re-evaluated, she is now repeating ‘I can’t breath [sic]’, though SpO2 is currently 100%. When I leave the room she is quiet. 0200 - Patient’s repeat chemistry normal. Could have been a pseudoseizure. Not meningitic. Stable for discharge. Final diagnosis: Pseudoseizure. Plan: The patient’s condition remained stable s/p ED observation and serial evaluations. I reviewed the diagnostic test results, which were relayed to the patient, along with diagnosis and treatment plan. Vital signs are stable at time of disposition, and the patient is deemed safe for discharge to police custody.” Patient #12 was discharged at 0230. Review of a physician note at 0257 revealed “Medical Decision Making: ...presents to the ED in police custody after collapsing during booking process at jail. History obtained from police. Officer reports that patient was arrested for multiple charges including possession of heroin and cocaine. She was brought to jail for booking, was conversant and acting appropriately until she was brought to magistrate, at which time she collapsed (was caught before she hit the ground) and flailed her arms and legs. Police gave an ammonia packet and flailing resolved. Patient was then responsive to painful stimuli only. Patient eluded [sic] to crack/cocaine use while in police car while she was having this episode, video from car was reviewed and showed no evidence of this. Patient does not provide any history at this time. No head trauma or other trauma. On exam, the patient is in no distress. She has no evidence of tongue biting. Head is atraumatic. Patient withdraws to pain. She has no obvious facial droop. Regular heart rate and rhythm and clear lungs.” Review of a Police Report (Reporting Officer Narrative) revealed a traffic stop and arrest report for Patient #12 on 05/16/2023 at 2321 for possession of drugs and drug paraphernalia. Review of the report revealed Patient #12 was found to have drugs and drug paraphernalia in her purse. “I started with the purse (named patient) had handed me. I located 3 marijuana joints in the attached bag on the purse. I then located another small attached bag on the purse. Within the second small bag I located several small yellow bags, I know these bags to be used to contain narcotics. I then located a scale, on the scale I located a white substance which (named patient) advised was cocaine ... While searching the passenger side of the vehicle I located a yellow bag on the ground matching the ones I found in the purse. Within the yellow bag I located a black substance which I was unfamiliar with. I spoke with (named patient) who stated it was cocaine.” Review revealed the substance did not test positive for cocaine but did test positive for heroin. Review revealed “(Named patient) then stated that she had a crack pipe stuffed inside her person ... Once at the Detention Center, Detention staff had (named patient) remove the crack pipe from her body ... Once Magistrate (named) was ready to speak to (named patient), (named patient) stood up and walked to the magistrate window but would not speak. (Named patient) then slowly leaned into me and I placed my hand on her arm at which time she pushed harder into me. (named patient) then started to slowly lower herself to the ground and I assisted in the same. Once on the ground (named patient) appeared to be unresponsive but breathing. I requested Narcan ... When I went to place the Narcan in (named patient) nose she said ‘I’m not overdosing, I ate a big bag of cocaine’ and then started to shake when I asked where she consumed the cocaine (named patient) stated ‘in the back of the police car ’. (It should be noted the watchguard was reviewed later and it does not appear that (named patient) swallowed any narcotics, she was also in handcuffs.) Detention staff nurse was on scene and advised it appeared she was faking but just to be safe wanted her to be checked out since (named patient) stated she ate a bag of cocaine. EMS was requested at 2343 ... While waiting on EMS, the Detention Center Nurse utilized an ammonia tab on (named patient) which made her stop shaking. (Named patient) then just laid on the ground and did not talk or make any sounds after that. But was breathing normally, and did not appear in any distress. Upon arrival of EMS (named patient) continued to not answer questions. I followed (named patient) to the hospital. Upon arrival to the hospital (named patient) was placed into room T2 and evaluated by staff...After some time the doctor advised me that all her lab work was good and discharged her from the hospital. (Named patient) signed her discharge papers and put her shirt back on that ER staff had removed. As soon as I advised (named patient) that she was going back into handcuffs she started to do the same behaviors she was doing in the jail originally ... I placed (named patient) into the wheelchair with the assistance of ER staff. (Named patient) was still talking but only twitching. The same ER doctor came to check on (named patient) by doing a few test with her hands. The ER doctor then stated she was faking and was fine ... Once in the sally port (named patient) refused to listen or walk on her own and had to be carried into the jail. (Named patient) continued talking but just refused to listen to detention staff and started aggressively resisting officers ...” Further review of the Police Report (Case Supplemental Report-Officer #3) revealed the officer responded on 05/17/2023 at 0239 to the named hospital to assist another officer. Review of the report revealed the (named patient) was discharged and cleared to proceed to jail. “(Named officer) and I had to wheel (named patient) to my patrol vehicle because she refused to stand up ... I started my Watch Guard and proceeded to the jail. (Named patient) would mumble and yell incoherent words while kicking the rear seat guard. As we approached the jail she became louder and continued to kick the rear seat guard ... While walking to the intake counter (named patient) dragged her feet and refused to walk under her own power. Once at the intake counter (named patient) got tense and started to pull away from myself, (named officer) and the detention Officers.” Further review of the Police Report (Case Supplemental Report-Officer #4) revealed “(named officer) ...responded to ... at 0732 in regards to CPR (cardiopulmonary resuscitation) in progress ... When I arrived I was motioned to the interior cell inside the jail. I immediately went inside, where I observed jail staff doing CPR on a unconscious female. I then assisted with life saving measures prior to EMS arrival. Jail staff advised they already administered two doses of narcan. I continued doing CPR and EMS took over. I was advised that the female which was later identified as (named patient) came into the jail this morning and was cleared by the hospital prior to being booked into (named jail).” Review of the Sheriff report revealed “Crime Incident(s) Death” of Patient #12. Date reported 05/17/2023 at 0730. Review of the Death Certificate revealed Patient #12 was pronounced by the medical examiner on 05/17/2023 at 0803. The immediate cause was pending. Review revealed the Death Certificate was “UNCERTIFIED.” Interview on 04/25/2024 at 0955 with MD #2 revealed he was not the physician that completed the MSE for Patient #12. Interview revealed there was not a standard protocol for a patient with altered mental status. Xray’s and a drug screen were not routine workups. The workup was dependent on the patient’s presentation, history and physical and the findings. Interview revealed a urine drug screen may or may not be ordered. The test only gave positive or negative results, no levels. Interview revealed if a patient had already stated they did drugs, then a drug screen was not information to act on due to the test not giving valuable information other than a positive or negative. Interview revealed that treatment for a heroin overdose, if the patient was asymptomatic, was further observation. If the patient was symptomatic then more treatment would be needed dependent upon presentation. Interview revealed that treatment for a crack cocaine overdose had no specific treatment unless the patient had other symptoms. If the patient had no other symptoms upon presentation, then the physician may not have done more. Interview revealed that if a patient had done a large amount of drugs, then that may warrant additional observation and tests. Interview revealed the symptoms of a patient with a crack cocaine overdose were tachycardic, febrile, distress, chest pain, and decompensation. Interview revealed that crack cocaine was absorbed rapidly. Further interview revealed that if a patient were a drug mule (packing) then we would need to determine how much they ingested. Treatment for a drug mule would be prolonged observation, Xray, CT scan, EKG, and a GI consult. Interview revealed that if a physician was not informed of the large amount of ingested drugs/being a drug mule, then the physician would not know to do that type of workup. Interview revealed that once a patient was stabilized, vital signs were good and the patient was not in distress, then they were good for discharge. An additional interview on 04/25/2024 at 1500 with MD #2 revealed he was able to review the medical record of Patient #12 for the interview. Interview revealed “By review I can’t say anything different would be done.” Interview revealed that if the patient was not in acute distress the patient would get a workup and observation, but if the patient was recovering, they would be discharged. Interview revealed that if the patient was smuggling drugs, then LEO should provide a report or EMS would relay that to the physician. Interview revealed we would treat the signs and symptoms and there would be a period of observation. Interview revealed that if LEO or the patient wanted to be checked for smuggling it would need to be stated, we would not do it without a reason. Interview revealed that Patient #12 had labs and an EKG done. Interview revealed the ED Medical Director did not see anything inappropriate or any red flags with the treatment provided. Interview request on 04/24/2025 with the MD that performed the MSE on Patient #12 revealed the physician was no longer available. Interview request on 04/24/2025 with the RN that triaged Patient #12 revealed the nurse was no longer available. Telephone interview on 06/05/2024 at 1400 with a staff member at the Chief Medical Examiner’s office revealed the Death Certificate for Patient #12 remained “uncertified” with the cause of death “Pending” at the time of the call. In summary, Patient #12 presented to the hospital DED with concerns for altered mental status. The Medical Screening Exam (MSE) did not include an evaluation of orientation or sensation of extremities. Patient #12’s Glasgow Comma Scale score was documented as 12 (twelve), which is abnormal. There was no documentation of a repeat neurological examination prior to discharge. Additionally, the limited exam provided did not including testing to fully assess Patient #12’s altered mental status presenting complaint. 40299 2. Review on 04/25/2024 of the closed medical record for Patient #26 revealed a 45-year-old male presented to the DED on 03/11/2024 at 0144 with a chief complaint of “bloody stools.” Pivot assessment at 0148 revealed “Pt (patient) recently had colonoscopy were (sic) cancerous polyps were removed. Pt is c/o (complaining of) generalized abdominal pain with blood stools. Priority Level: 3 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute).” Review of the Provider note at 0248 revealed “Patient states that he is having loose stool with dark red blood. He notes his stools have been loose, and mixed with blood states that this has been an ongoing issue. States that he has not had a solid bowel movement for some time stating he was treated previously for H. pylori and that had endoscopy and multiple polyps removed. States was told last month that of (sic) his polyps were precancerous, and have started (sic) seeing the dark blood in his stool. States that there is no formed stool, as he has not had any formed bowel movements in quite some time since being treated for H. pylori but does not note any fever or unusual abdominal discomfort. States that the bleeding has been relatively small amounts and not large amounts of blood. He notes that the stool is not black or extremely dark but he would not describe it as bright red either... States that he had his colonoscopy at the (Hospital B) hospital. ... Re-evaluation: Patient presents here with persisting rectal bleeding, have not been large amounts. Patient has good coloration, red palpebral conjunctiva, and is hemodynamically stable. We do not have any GI specialist here to do a colonoscopy and see where he is bleeding from, nor does patient appear unstable. Had his workup and is a patient of the nearby (Hospital B) Hospital where it is appropriate for him to go to have this problem reinvestigated as he had recent colonoscopy there and multiple polypectomy (sic). As this is not an acute problem but rather an ongoing issue after his colonoscopy and not associated with any acute hemodynamic instability or pain, feel it is appropriate for him to follow-up in the morning with his physicians/GI specialist who did the colonoscopy at (Hospital B) later this morning. As he is clearly not anemic or hemodynamically unstable do not see any advantage in doing testing here that we will be unable to follow-up on as we do not have anybody here that could follow-up with colonoscopy or other testing, even where they willing to do so as he recently had colonoscopy at (Hospital B), where his GI issues have been managed recently. Discharging him to home with follow-up and return precautions ... Discharge: Clinical Impression: Lower gastrointestinal bleed ... Patient Disposition: HOME, SELF-CARE ... Activity Restrictions/Additional Instructions: Follow-up with your doctor at (Hospital B) this morning. I would specifically recommend that you call the doctor that did your colonoscopy and let him know that you are having bleeding, to schedule recurrent colonoscopy or evaluation ...” Review of the ED Nursing note at 0300 revealed “In room to introduce self and role. Pt states that he has been having bright red blood in stools and diarrhea. (MD #3) in room to assess pt at this time. Verbal orders to discontinue orders for bloodwork and urine. (MD #3) states to patient, ‘you need to call your GI (gastrointestinal) doctor in the morning, we do not have a GI specialist in this hospital.’...” Review of the medical record revealed Patient #26 was discharged home on 03/11/2024 at 0314. Telephone interview on 04/25/2024 at 1642 with MD #3 revealed he remembered Patient #26 came in complaining of bright red blood per rectum. Patient #26 was “already plugged in with GI” and MD #3 did not see anything concerning, no massive hemorrhage, nothing life threatening about his presentation. Interview revealed there was no benefit to get hemoglobin or hematocrit or to perform a guaiac test (test to check for blood in stool) as the patient reported he was having bleeding. Interview revealed Patient #26 did not say he was in the bathroom and blood was everywhere, nothing to suggest a large bleed or that Patient #26 was unstable. MD #3 stated the “reasonable thing to do was to have him see GI in the morning”. His conjunctiva, vital signs, and heart rate were all normal. Interview on 04/26/2024 at 0858 with MD #2 revealed he was not involved in the care of Patient #26. Interview revealed Patient #26 had a low-grade bleed. It is “all about the History and Physical (H&P)” when performing the medical screening exam. “Every medical schoolteacher will tell you a good H&P is acceptable to evaluate a patient.” MD #3 is very skilled and performed an appropriate MSE. In summary, Patient #26 presented to the DED with complaints of blood in his stool. The hospital record did not document a MSE was performed to evaluate causes of bleeding or diagnostic studies within their capability and capacity.”