Carolinas Medical Center/Behav Health

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 39307 Based on review of the hospital policy and grievance log, the hospital staff failed to identify and follow the grievance policy for 1 of 2 reviewed grievance (Patient #2). The findings included: Hospital Patient Complaint and Grievance Management Policy dated 11/02/2023 revealed “PURPOSE This policy sets forth the procedure for appropriately identifying and promptly resolving patient and/or patient representative complaints and grievances and requires each patient and/or patient representative be informed about how to file a grievance ...GRIEVANCES Complaints meeting any of the following criteria are considered a grievance and require a written response ...2. Complaints regarding patient’s care or with the allegation of abuse, neglect, patient harm or failure of the hospital to comply with one or more CoPs, or other CMS requirements ...” Review on 11/05/2025 of the Grievance Log for the past 6 months failed to reveal documentation of Patient #2 for the 08/18/2025 through 08/29/2025 admission included on the log. Closed medical record review on 11/04/2025 revealed Patient #2 was a 17-year-old-female who presented as an Involuntary Commitment (legal obligation for hospital admission process) to the hospital on 08/18/2025 for Suicidal Ideation (feelings of harm to self). Review revealed 3 of 11 days with documentation to note on 08/20/2025 at 1209 hygiene “Independent”, on 08/21/2025 at 0745 “face washed, brushed teeth”, on 08/26/2025 at 1127 the Registered Nurse (RN) noted “Pt presents calm and cooperative ...bathroom door locked.” on 08/28/2025 at 0815 “face washed”. ... On 08/28/2025 at 2105 the RN noted “ ...Patient was irritable ...Patient was asked to sit in hallway so that her roommate could shower and patient refused .... Writer told patient that she should give her roommate the same privacy that she is given to complete hygiene time. SW (Social Worker) came to speak with patient, and she was able to get out of room for roommate to shower ...” Record review revealed the nursing staff were monitoring Patient #2 for signs and symptoms of purging associated with medication noncompliance in the setting of the Behavioral Health Unit (BHU). Record review revealed on 08/29/2025 at 1635 Patient #2 was discharged to the prior living (Named) Group home with a staff member with a documented 09/02/2025 scheduled follow up appointment. Interview on 11/05/2025 at 0845 with the Hospital Leadership: Assistant Vice President (AVP), Director of Nursing, Director of Inpatient Therapy, Administrative Supervisor, Accreditation Coordinator, Quality, Nurse Manager revealed the reviewed video of the hallway on the BHU was only accessible for 15 days unless the facility staff saved a specific incident. As per AVP, the leadership was notified of the allegation of sexual inappropriate touch by a Health Care Technician toward a patient during a shower. If an event was found to be substantiated the video would have been saved by the facility. The hospital was notified on 09/04/2025 at 1000 by way of a County Detective appearance to the facility. The hospital completed the investigation on 09/10/2025 with the conclusion of unsubstantiated allegation. On 09/15/2025 the hospital was notified by the Health Care Registry that they would not investigate. The hospital system automatically taped over the timed video as per usual process. Interview with the Hospital Leadership found the allegation of a Patient Care Technician having inappropriate sexual contact with Patient #2 to be unsubstantiated. Interview revealed that the Hospital Leadership had investigated the allegation, however did not process the reported incident as a Grievance as per policy. Interview on 11/05/2025 at approximately 0850 with the RN Administrative Supervisor revealed the BHU adolescents were provided hygiene time at 0800 at time of wake up, on Saturday/Sunday shower time was 1600 and Monday through Friday 1430 was shower time. Interview revealed a Patient Care Technician would remain on the hallway outside of patient rooms to monitor for patient safety during shower time. Interview on 11/05/2025 at 1655 with the Central Division Grievance Coordinator revealed a work history in the role for 8 years at the facility. Interview revealed that the notification of the alleged abuse of Patient #2 should have been processed as a formal grievance as per policy. Interview revealed the hospital staff did not process and follow the policy as expected. NC00233403”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 34065 Based on review of policy, review of medical records, and interviews with staff, the facility staff delayed printing and documenting telemetry strips to show telemetry monitoring on patients with telemetry orders for 2 of 4 telemetry patients reviewed (Patient #28 and Patient #1). The findings include: Review of policy titled “Nursing Telemetry ECG (Electrocardiogram) Monitoring” with effective date of 04/12/2024 revealed “Policy: Telemetry and Hardwired monitoring will be initiated and maintained per provider order. Summary: This policy provides guidelines for Telemetry and Hardwired monitoring to assess patients for dysrhythmias on a continuous timeframe, or emergency situation.... Documentation/Interpretation: A. Record/print a telemetry monitor strip: 1. Upon admission to the unit. 2. At least every shift. 3. Any time there is a change in rhythm or patient’s condition....” 1. Review of Patient #28’s medical record revealed a 57-year-old female admitted on 07/22/2025 for nonfunctioning nephrostomy tube (tube inserted into the kidney for drainage). Past medical history for Patient #28 was significant for Hydronephrosis (enlargement of the kidneys), AAA repair (abdominal aortic aneurysm repair), Diabetes, and bilateral Nephrostomy tubes. Patient #28 was transferred to the patient care floor on 07/23/2025 at 1340 with telemetry orders. Review revealed no documentation of telemetry strips in Patient #28’s medical record after transfer from the ED. Review revealed documentation of the “telemetry box on” at 2137, approximately 8 hours later. Interview on 07/25/2025 at 1140 with Manager of Operations #1 revealed Patient #28 arrived on patient care floor at 1340. Patient #28’s telemetry box was documented as placed on the patient at 2137. Review revealed there was no telemetry strip placed on the record for review prior to that time. Interview revealed policy was not followed. 2. Review of the medical record of Patient #1 revealed a 35-year-old female presented to the ER (Emergency Room) on 09/28/2024 at 1615 with pleuritic pain (sharp, stabbing pain in the chest that worsened with coughing, breathing or sneezing) with diagnosis of pulmonary embolism (blood clot in the lungs). Patient #28’s past medical history includes liver transplant secondary to alcoholic hepatitis (liver disease related to drinking alcohol) on immunosuppression (medicines that suppressed the immune system to prevent rejection of the new organ), recent fibular fracture (leg bone break) and bipolar (disease of mania and depression episodes). Patient #1 was transferred to the patient care floor on 09/28/2024 at 2311 with telemetry orders. Review of the first telemetry strip placed on Patient #1’s chart was dated 09/29/2024 at 0324, approximately 4 hours after admission. Review revealed the first documentation of the “telemetry box on” was 09/29/2024 at 0749, approximately 8 hours after admission. Interview on 07/23/2025 at 1600 with Nurse Manager #2 revealed Patient #1’s first telemetry strip was reviewed at 0324, several hours after admission. Interview revealed there was a delay in placing the telemetry box on Patient #1 and documentation of the telemetry strip. Interview revealed policy was not followed. NC00201433, NC00232347, NC00230113, NC00230387, NC00226879, NC00230233, NC00225885, NC00228798, NC00231179, NC00220721, and NC00228917”

“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: 41345 Based on review of hospital policy, closed medical record review, and physician and staff interviews, the hospital failed to provide stabilizing treatment within its capability and capacity for one (1) of 29 sampled patients (Patient #3) that presented to the hospital’s dedicated emergency department with an emergency medical condition. The findings include: A policy related to Emergency Medical Treatment and Labor Act (EMTALA) procedures was requested on 07/22/2025. Hospital administrative staff presented an “EMTALA compliance, Including Patient Transfers (Emergency Medical Treatment and Labor Act)” policy that was approved October 28, 2024. revealed “ ...stable ...means that no material deterioration of the individual’s condition is likely, within a reasonable medical probability, to result from or occur during the transfer of the individual ...” Dedicated Emergency Department (DED) record review for Patient [Pt] #3, revealed the 7-year old patient arrived at Hospital A, Campus 4 Emergency Department on 05/05/2025 at 0651 by car with mother with a chief complaint of “shortness of breath” used albuterol 2 [two] hours ago, didn’t help.” Pt #3 was triaged as a level 3 at 0702 and had an a MSE was initiated (medical screening exam) at 0754 with vital signs of T (temperature)-99.2, respirations of 24, bp- (blood pressure) of 126/51, pulse oxygenation of 91 on room air, weight was 50.8 kg (kilograms). Treatment orders: DuoNeb (medication to relax the airway and improve breathing) 2.5 mg (milligram) /3 ml (milliliter) order via nebulizer at 0706, prednisolone phosphate (steroid medication to assist with breathing) 3 mg/ml orders at 0707. Respiratory assessment at 0725 noted with inspiratory wheezing. 0725 chest Xray ordered. Vital signs at 0800 HR-126, bp 129/66, 02 sat on room air 95%. 0824 Tylenol (medication for pain, fever) 650mg given by mouth. Discharge prescription for prednisolone given to mother. Patient discharged home with mother at 0847. Review of the provider progress note for 05/05/2025 “7 year old with history of asthma presents with shortness of breath per mom at bedside patient has had 1 [one] day of cough, shortness of breath and worsened overnight, and had an episode of vomiting denies abdominal pain- history of asthma has been using albuterol (medication to help with breathing) with no significant improvement, mild sore throat yesterday, no reported fevers, mom states that family members at home have been sick with viral symptoms”. Exam- mildly uncomfortable appearing tachycardia present- pulmonary- mildly increased work of breathing diffuse expiratory wheezes in bilateral lung fields, no stridor, abdominal- flat, soft, non-distended, no guarding. Discharge disposition- patient report significant improvements of symptoms following breathing treatments- he continues to have very mild extra wheezes, but breath sounds are much clear at this time. He is tolerating po (by mouth) ... Given improvement of symptoms do feel as though patient is safe for discharge. Will discharge with steroid course and strict return precautions. Instructed mom to follow up with primary care physician within the next several days. Interview with Physician #1 on 07/24/2025 at 1015 revealed, “my decision making status is that I look at respiratory rate, work of breathing, breath sound and general appearance, and prior history” after he got breathing treatments, and steroids, was breathing much better, no accessory muscles, no oxygen was room air clinically alright for discharge and follow up with primary care provider”. Patient #3 presented to Hospital B on 05/05/2025 at 0903 in the DED with triage vital signs of blood pressure 127/73, pulse- 146, R-62 02 saturation of 93%, temperature 98.5. ED provider note presents in extreme respiratory distress with an exacerbation that started last night- here in extreme distress, anticipate admission unless he is to make significant improvement and maintain that, will treat aggressively with IV steroids, a 2 gram bolus of magnesium, on normal saline bolus, 20 mg of albuterol and reevaluate-1147 after completion of hour long patient states that he is starting to feel better, he is moving air anteriorly, still very decreased and wheezy posteriorly, second hour long ordered- 1300 patient completed second hour long- hypoxic at 88% on room air, placed on 2 liter nasal cannula. On reevaluation he still has increased work of breathing. Mild flaring around nasal cannula. Very tight posteriorly moving minimal air- third hour long ordered and will admit to pediatric ICU (intensive care unit). Pulmonary consulted and aware of admission- patient remained NPO (nothing by mouth) until respiratory status improved. Weaned albuterol per protocol and was able to space to 10mg/hour by the morning of 5/6/2025. His diet was advanced and transferred to the pediatric floor on the afternoon of 05/06/2025. He was weaned off support the morning of 05/07/2025 and remained stable on room air with comfortable respiratory status since that time- he has been taking po well and remained afebrile. Mother is comfortable with discharge home and close PCP follow up this week. An asthma action plan was completed prior to discharge home on 05/07/2025. In summary, Patient #3 presented to Hospital B with parent on 05/05/2025 at 0903 16 minutes after discharge from Hospital A’s DED in extreme respiratory distress. Review of the DED record from Hospital A, Campus 4 revealed no reassessment of respirations after the initial respirations recorded at 0754 and prior to discharge at 0847. Review of the patient’s respirations from Hospital B at 0903 were 62. Patient #3 was admitted to Hospital B and discharged on 05/07/2025. NC00232546”

“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: 30260 Based on record review, interview, and policy review, the hospital failed to perform a medical screening examination (MSE) for one patient (Patients (P)1) of 20 Emergency Department (ED) records reviewed when the patient presented to the ED on 04/23/23 seeking care. This failure had the potential to harm all patients who present to the ED and request an exam. Findings include: Review of the nursing notes dated 04/23/23 at 10:09 PM located in the medical record revealed,”[P1] is a 19 y.o. [sex] with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall. Patient was riding a motorized skateboard this evening down a hill and tried to slow down and flew off of it. [He/she] was not wearing a helmet and may have hit [his/her] head. +LOC. [He/she] remembers waking up and someone calling EMS. On EMS arrival patient was initially confused. [He/she] states this only lasted a few seconds and [he/she] states [he/she] quickly came back to baseline. [He/she] endorses just abrasions over the right face, left elbow and right leg without any pain in these areas.” Review of the physical examination documented by MD2 located in the medical record dated 04/23/23 at 10:09 PM revealed, “ ...Head: Normocephalic, + superficial abrasions over the right face with hematoma over the right forehead...” Review of the medical record revealed a “Medical Decision Making” documented by MD2 that revealed, :”4/23/2023 10:32 PM-Medical Decision Making: Medical Decision-Making (P1) is a 19 y.o. male with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall off of a motorized skateboard with +LOC. On arrival normal vitals, blood pressure here is 163/80. Primary exam negative for acute life threat...According to Canadian CT head rules, patient does not require a CT of his head at this time. Although patient has abrasions over his face and hematoma over his right forehead, he has no significant tenderness in these areas, and I have low suspicion for facial fracture. Patient does not require further work-up at this time...At this time, he may have a concussion, and I have given referral to the concussion at work.” Cross Refer to 2406.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 30260 Based on observation and staff interview, the facility failed to post in the emergency department (ED) or in a place or places likely to be noticed by all individuals entering the ED, and individuals waiting for examination and treatment in areas other than traditional ED an EMTALA (Emergency Medical Treatment and Labor Act) sign specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor. Findings include: During a tour of the ED on 11/04/24 at 1:55 PM with the ED Nurse Manager (EDNM2), observation failed to identify EMTALA signage in the patient entrance to the ED. Upon entering the ED waiting area, observation did not reveal EMTALA information was posted. Interview at the time EDNM2 stated the sign used to be on the wall in the ED waiting room. After some looking the EMTALA sign was found behind a vertical electronic signboard. EDNM2 had to remove the vertical electronic signboard before the EMTALA sign could be visualized. EDNM2 confirmed the EMTALA sign was completely covered by the signboard and was not visible to patients coming into 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: 30260 Based on record review, interview, and policy review, the hospital failed to perform a medical screening examination (MSE) for one patient (Patients (P)1) of 20 Emergency Department (ED) records reviewed when the patient presented to the ED on 04/23/23 seeking care. This failure had the potential to harm all patients who present to the ED and request an exam. Findings include: Review of the policy titled, “EMTALA Compliance, Including Patient Transfers (Emergency Medical Treatment and Labor Act) (GC Market)” dated 10/28/24 revealed, “ ... ‘Emergency Medical Condition’ or ‘EMC’ means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: o Placing the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. o Serious impairment to bodily functions. o Serious dysfunction of any bodily organ or part. ‘Medical Screening Exam’ or ‘MSE’ means examinations, tests, studies, monitoring, and procedures that are appropriate given the individual’s presenting signs and symptoms and reasonably calculated to determine if an EMC is present, including ancillary services routinely available to the emergency department ...’Stable’ or ‘Stabilized’ means that no material deterioration of the individual’s condition is likely, within a reasonable medical probability, to result from or occur during the transfer of the individual. In other words, the EMC that caused the individual to seek care is Stable, even though the underlying condition may still exist ...” Review of the “Canadian CT Head Rule” revealed, “ ...CT of head is only required for minor head injury patients with any one of these findings ...dangerous mechanism (pedestrian occupant ejected fall from elevation.) ...” Review of P1’s medical record revealed P1 arrived at the hospital ED on 04/23/23 at 9:34 PM with a chief complaint of falling. P1 was triaged at 9:46 PM. Review of the nursing note dated 04/23/23 at 9:46 PM located in the medical record revealed,” Chief Complaint: Trauma (Riding skateboard this evening without helmet, crashed on concrete, - helmet. + LOC [loss of consciousness], initially confused on EMS [Emergency Medical Services] arrival and hypertensive @ 200/100 [blood pressure]. GCS [Glasgow Coma Scale- a clinical tool that measures a patient’s level of consciousness by assessing their eye, verbal, and motor responses also used to guide medical care and monitor patients after a brain injury, such as a car accident] was 15, Trauma cleared, and c-collar [cervical collar] removed on arrival to ED.” Review of the nursing notes dated 04/23/23 at 10:09 PM located in the medical record revealed,”[P1] is a 19 y.o. [sex] with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall. Patient was riding a motorized skateboard this evening down a hill and tried to slow down and flew off of it. [He/she] was not wearing a helmet and may have hit [his/her] head. +LOC. [He/she] remembers waking up and someone calling EMS. On EMS arrival patient was initially confused. [He/she] states this only lasted a few seconds and [he/she] states [he/she] quickly came back to baseline. [He/she] endorses just abrasions over the right face, left elbow and right leg without any pain in these areas.” P1 received ibuprofen (Motrin) 800 milligrams (mg) per physician orders at 9:55 PM. There was no pain assessment related to this medication administration in the medical record. Review of the physical examination documented by MD2 located in the medical record dated 04/23/23 at 10:09 PM revealed, “ ...Head: Normocephalic, + superficial abrasions over the right face with hematoma over the right forehead...” Review of the medical record revealed a “Medical Decision Making” documented by MD2 that revealed, :”4/23/2023 10:32 PM-Medical Decision Making: Medical Decision-Making (P1) is a 19 y.o. male with a past medical history of anxiety and depression, who presents to the emergency department for evaluation of fall off of a motorized skateboard with +LOC. On arrival normal vitals, blood pressure here is 163/80. Primary exam negative for acute life threat...According to Canadian CT head rules, patient does not require a CT of his head at this time. Although patient has abrasions over his face and hematoma over his right forehead, he has no significant tenderness in these areas, and I have low suspicion for facial fracture. Patient does not require further work-up at this time...At this time, he may have a concussion, and I have given referral to the concussion at work.” Review of the medical record revealed P1 was discharged from the facility on 04/23/23 at 10:59 PM. The ED attending physician documented the following attestation in P1’s medical record, “4/24/23 at 6:27 PM I have seen the patient concurrently with the resident. I agree with their history, physical, medical decision making, and plan as documented.” During an interview with MD1 on 11/07/24 at 9:15 AM MD1 stated he/she had reviewed P1’s medical record to refresh his/her memory. He/she was attending at the time and the resident (MD2) saw the patient. There was some question about the history, whether the patient actually lost consciousness or not. P1 was doing well. We discussed whether P1 needed a CT (computed tomography, - a type of x-ray that produces detailed images of the inside of the body, often used to diagnose head injuries. CT can identify evidence of bleeding, swelling, or skull fractures) or not, and MD2 elected not to perform a CT. We discharged P1 when it was determined that he/she needed no further evaluation. When asked if he/she or his/her resident made the right call in not doing the CT, MD1 stated that in retrospect the MD2 applied her clinical judgement using the Canadian head CT rule (a medical scale used to determine if a patient with a minor head injury needs a CT scan of their head) and that was what informed her decision. MD1 stated he was aware of what subsequently happened to P1 but that “in real time, right in front of us, we had a patient that looked good in front of us and met the criteria per MD2’s application of the Canadian head CT rule.” MD2 stated the ED does not CT everyone that comes in with a head injury, and the rule is designed to limit unnecessary radiation exposure. MD1 stated in retrospect, would have done a CT knowing what happened with a bad outcome. MD1 reiterated that P1 looked good, and we did not think he needed the head CT. When asked what the criteria is used for determining whether to perform a head CT, MD1 stated a lot of it is based on “clinical gestalt,” but criteria include if there was an abnormal neurological examination, if there was a very high-risk mechanism (i.e. the cause of the accident), if there was persistent vomiting, if the wound looks bad, coupled with the history and physical exam findings. MD1 stated part of the ED’s general discharge instructions would be to return to the ED if the patient experiences persistent vomiting. During an interview on 11/07/24 at 9:45 AM, the Accreditation Liaison stated MD2 was no longer employed by the facility. During an interview on 11/07/24 at 4:17 PM, Family Member (FM) stated he/she received a call on a Sunday night around 8:00 PM that P1 was taken to the facility’s ED by a friend from P1’s college campus. FM was unable to reach the hospital ED before P1 was discharged and had returned to the college campus. FM was at the dormitory entrance when P1 arrived in a car driven by a friend. When P1 got out of the car he/she was disoriented, had a huge gash on the head, looked awful, and started immediately vomiting. P1 almost fell when trying to walk toward FM, and FM had to grab him/her to prevent a fall. FM stated P1 reported he/she started vomiting on the trip back from the hospital to the campus. FM stated when driving from the campus to their home, P1 was very disoriented and vomited several times. FM stated P1 was not getting any better, so FM brought P1 to Hospital 2’s ED. While at Hospital 2, P1 had a CT scan done that revealed brain hemorrhaging and fractures. P1 was transferred to the hospital (Intensive Care Unit) for a few days and then discharged to home with therapy.”