Ecu Health North 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,Medical Staff Rules and Regulations, medical record review and staff and physician interviews, the hospital failed to comply with 42 CFR §489.24. The findings included: 1. The hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for three (3) of 28 patients reviewed (Patient #4, Patient #6, and Patient #21).. ~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406. 2. The hospital staff failed to provide stabilizing treatment within the capability of the hospital’s Dedicated Emergency Department (DED) for one (1) of 28 sampled Dedicated Emergency Department patients (Patient #6). ~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag A2407.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 40299 Based on policy review, review of the dedicated emergency department (DED) log, review of the canceled list and staff interviews, the hospital failed to accurately document on its DED central log all patients that presented to the hospital’s DED for treatment. The findings included: Review on 04/30/2025 of the hospital’s “EMTALA Policy” last revised 01/2024 revealed “... The hospital will maintain a central log of individuals presenting to the emergency department seeking assistance. The log will contain at minimum patient name, mode of arrival, date, and discharge disposition. ...” Review on 04/29/2025 of the DED Logs for dates October 2024 through April 26, 2025, were printed and received. During review of the logs the disposition was noted to be discharge, left without treatment (LWOT), eloped, against medical advice (AMA), admitted, transferred, and arrived in error. In further inquiry in the “arrived in error” disposition, it was learned that some patients that present to the ED either request to leave before being seen or they are in the wrong location looking for radiology or the laboratory. In these cases, the patients are canceled out of the ED visit. Review on 04/30/2025 of the list of the “canceled” patients for the time period October 2024 through April 26, 2025, revealed 80 patients had been canceled out of their visits. Of those 80 patients, 52 were patients that had a reason for requesting to be seen in the ED, 12 patients arrived in error; meaning they had radiology or laboratory appointments, 2 patients were medical records that needed to be merged together, 9 patients were labeled as “test” patient, and 5 patients were duplicated on the list. The two logs were compared and the 80 patients on the canceled list were not on the DED EMTALA Log presented. Interview on 04/29/2025 at 1458 with Patient Access (PAS) #10 and PAS #11 revealed the patient comes to the emergency department and gets registered. The patient is added to the tracking board and asked to sit in the lobby. When the patient decides to leave prior to triage and they tell the patient access staff at the registration desk, the patient access staff cancels the appointment which removes the patient off the tracker board. PAS #10 and PAS #11 were unsure if the patient once canceled appears on the DED EMTALA log. Interview on 04/30/2025 at 1313 with Director #12 revealed patients that are on the cancellation list are not on the DED EMTALA Log. Staff are working on it currently and those patients are being put on the log now and going forward all patients that present to the ED will be on the log. Education has gone out to the staff. Monitoring of the change has been going on since the education has gone out. Review of the education sent out via email on 04/29/2025 at 1917 revealed a new process for removing patients from the ED Tracker Board. The new process was effective immediately.”

“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: 33790 Based on policy review, medical record review and staff and physician interviews, the hospital failed to provide a thorough medical screening examination, including ancillary services routinely available, to determine whether an emergency medical condition existed for 3 of 28 patients reviewed (Patient #4, Patient #6, and Patient #21). The findings included: Review of the hospital’s EMTALA Policy last revised 01/2024 revealed “ ... provide to any individual who is not a patient of the hospital and who ‘comes to the emergency department’ an appropriate medical screening evaluation within the capability of the hospital’s emergency department to determine whether an Emergency Medical Condition is determined to exist ... .” 1. Medical record review on 04/30/2025 revealed Patient #4, a 34-year-old, arrived to the hospital on 11/29/2024 at 0042. The arrival complaint was “vomiting.” Review of triage revealed “...PT REPORTS THAT SHE HAS BEEN VOMITING FOR X 3 DAYS AND HAS NOT BEEN ABLE TO EAT.” Review of the ED Provider Note, at 0143, revealed “... comes in with nausea and vomiting of 3 days duration, unable to keep any fluids down....Medical Decision Making....patient will be given IV fluids and medicines for the nausea and be reevaluated ....Patient also states ....has had a therapeutic abortion by taking medications about 4 days ago. ...” Record review revealed Patient #4 received fluids and medications for pain and nausea and departed the ED at 0702 with a diagnosis of nausea and vomiting unspecified. Although there was mention in the provider note of an abortion 4 days ago, no evidence was found that an ultrasound was done or whether the patient was evaluated for bleeding. Telephone interview with MD #13, on 05/01/2025 at 0923, revealed if the patient’s complaints were about a lot of pain or vaginal bleeding it would have changed the approach. Interview revealed the patient’s labs were okay, vital signs were reviewed and Patient #4 was not tachycardic, so based on what the physician saw, Patient #4 was stable for discharge. Bleeding with some pain was to be expected as long as it was not excessive and passing clots. Record review revealed Patient #4 returned to the ED on 11/30/2024 at 1432. Review of the ED Care Timeline at 1433 revealed an updated complaint of “Vaginal Bleeding.” The Triage Note at 1442 indicated “Pt states that she had an abortion 4 days ago and is still having vaginal bleeding and N/V (nausea, vomiting), Pt was seen here two days ago for the same thing and sent home with nausea meds. She states that she wants someone to tell her why she is still bleeding. She called her phys (physician) .... and they told her to come to the ER.” Review of the ED Provider Note, at 1617, revealed “......PMH (past medical history)...HERE FOR INTERMITTENT VAGINAL BLEEDING X 2 DAYS S/P (status post) ELECTIVE ABORTION. PT. STATES SHE WAS TOLD SHE WILL HAVE BLEEDING BUT SHE WAS NOT SURE IF SHE IS BLEEDING TOO MUCH OR NOT.... PT. HAS CHANGED 7 PADS SINCE 8 AM TODAY. ...” A Review of Systems indicated “....Genitourinary: Positive for pelvic pain and vaginal bleeding. ...” The Physical Exam indicated “...Abdominal: General: Abdomen is flat. Palpations: Abdomen is soft. ...” At 1624 the disposition was selected, “ED Disposition set to Home.” The ED Care Timeline noted an ED Note at 1700 which indicated “PA (Name) informed that the patient was refusing to leave, Spoken by PA (Name) and patient decided to go to other facility.” Record review did not reveal any documentation of a genitourinary exam, of the amount of bleeding observed in the hospital or of a vaginal ultrasound being performed. Interview on 05/01/2025 at 1305 with PA #14 revealed the PA reviewed the notes and recalled Patient #4. Patient #4 came in with vaginal bleeding. The PA got blood work and the Quant HCG was at an expected level. PA #14 stated Patient #4 said she had changed 7 pads since the morning, which was not a lot over that timeframe. Interview revealed if the patient said “soaked” through the pads, that would have been documented that “soaked” was a key word. PA #14 stated he examined the patient’s abdomen and it was not tender. PA #14 indicated he did not do a pelvic exam because she told him her bleeding was not excessive and blood work and vital signs were good. Further, the HCG quant (blood test) was expected to be high, and Patient #4 said she had an appointment for follow-up with OB in 48 hours. “There was no need for a pelvic ultrasound,” the PA stated, “she was very stable.” Related to the patient not wanting to leave the ED, PA #14 indicated she wanted to know why she was still bleeding and was told “that was expected.” The patient started to get loud and said she would go somewhere else, interview revealed. Interview with MD #17, on 05/01/2025 at 1340, revealed MD #17 was the attending ED physician on the day of Patient #4’s second visit. The interview revealed he heard about the case after the fact by the PA. The PA stated he went back to try and talk with Patient #4 but she stated she was leaving. MD #17 indicated the patient’s vital signs were stable, she had capacity to decide and was told to go see OB/GYN. Interview revealed outpatient follow-up felt reasonable. DED record review revealed Patient #4 returned to the Emergency Department again on 12/03/2024 at 0103 and was admitted, received antibiotics, a D&C (surgical procedure) and blood transfusion. 40299 2. Closed medical record review on 04/30/2025 for Patient #6 revealed a 62-year-old male that presented to the DED on 03/02/2025 at 0844 with a chief complaint of “Gout”. The Nursing Triage note at 0850 revealed “Leg Pain (Pt [patient] c/o [complain of] left lower leg pain since Thursday night. Pt stated ‘It is a gout flare up. I have them every now and again.’)” Patient #6 was discharged home ambulatory at 1113 with an e-script (prescription sent electronically) for Prednisone (steroid medication) 20 mg tablets and Tramadol (pain medication) 50 mg tablets. Review of the ED Provider Note documented at 1122 revealed “... here for left ankle gout exacerbation with hx (history) of same. He denies trauma or calf pain. ... Medical Decision Making Here for gout flare up. Dx (diagnosis). Gout of left ankle Dc (discharge) home w. rx (with prescription) ED COURSE Clinical Impressions Acute idiopathic gout of left ankle ...” Review of the medical screening exam failed to reveal documentation of which limb or joint was tender, no documentation of the presence or absence of joint effusion, edema, warmth, induration, crepitus or assessment of pulses. Request to interview the Medical Provider involved in Patient #6’s care during this visit revealed they were not available for interview. Request to interview the Registered Nurse (RN) who triaged Patient #6 and the Discharging Nurse for Patient #6 revealed they were not available for interview. Interview on 05/01/2025 at 1027 with Medical Doctor (MD) #2 revealed he was the Emergency Department Medical Director and he was not involved with the care for Patient #6. Interview revealed if a patient who is diabetic comes in with a foot injury/problem, the patient would be registered, then triaged. During the triage MD#2 would expect the nurse to test the patient’s blood sugar, assess the foot pain/injury, and verify pulses in the extremity. Protocol orders can be used for example if the injury can use the pain order set. Once the patient gets into a room in the ED, expect the nurse to put the patient on a monitor depending on what the patient complained of. The provider would assess the patient, order any radiology, immunizations or medications as needed (i.e.: tetanus and antibiotics). If a patient returns to the ED after being seen recently, the patient would be seen. “A day later would be too early to see an improvement, however certainly we would see the patient.” 3. DED Logs for dates October 2024 through April 26, 2025 were received and reviewed on April 29, 2025. Patient #21 was listed on the DED Log with an arrival date and time of 04/20/2025 at 2234 and a disposition date and time of 04/21/2025 at 1428. The disposition was “Arrived in Error”. Closed medical record review on 05/01/2025 for Patient #21 revealed an 11-year-old male that presented to the DED on 04/20/2025 at 2234 with a chief complaint of “behavioral, psych”. Review of the ED Care Timeline at 2245 revealed documentation by the Registration staff that Patient #21 was “dismissed”. Review of the medical record failed to have an AMA (against medical advice)form or a note to show a reason Patient #21 left the ED before being evaluated and having a medical screening exam performed. Review of the ED record revealed Patient #21 had no triage, vital signs, or history and physical examination completed. Interview on 04/30/2025 at 1549 with Medic #13 revealed he looks at the log the next day to verify the disposition was entered and entered correctly. If the disposition is missing, Medic #13 enters the disposition. If the disposition is wrong, Medic #13 changes the disposition to the correct disposition. Medic #13 did not remember Patient #21, he changed or corrected the disposition when he did his review of the log. Interview revealed Medic #13 looks at the logs and makes changes or corrections to the disposition after the patients have left. Interview on 05/01/2025 at 1335 with a Hospital Police Officer (HP) #5 revealed he “kind of” remembered Patient #21. HP #5 talked with the female, Patient #21’s “aunt maybe”, that brought the patient in. Per the female she was told by WCD (County Deputy) #9 to bring the patient here because the patient tried to set fire to the house. HP #5 asked the female why she did not get IVC (involuntary commitment) papers prior to coming to the hospital. HP #5 explained the IVC papers would give the facility “more authority to hold the kid here”. Interview on 05/01/2025 at 1630 with a Registered Nurse (RN) #8 revealed she did not remember Patient #21. Interview revealed she would have the patient sign an AMA form if they wanted to leave and if the patient refused to sign the form, she would have a second witness and put a note in the medical record.”

“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: 40299 Based on hospital’s policy, medical record reviews and staff interviews, hospital staff failed to provide stabilizing treatment within the capability of the hospital’s Dedicated Emergency Department (DED) for one (1) of 28 sampled Dedicated Emergency Department patients (Patient #6). The findings included: Review on 04/30/2025 of the hospital’s “EMTALA Policy” last revised 01/2024 revealed “... provide to any individual who is not a patient of the hospital and who ‘comes to the emergency department’ an appropriate medical screening evaluation within the capability of the hospital’s emergency department to determine whether an Emergency Medical Condition exists. ...If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ...” Closed medical record review on 04/30/2025 for Patient #6 revealed a 62-year-old male that presented to the DED on 03/05/2025 at 1816 with a chief complaint of “foot pain”. The Nursing Triage note at 1823 revealed “PT (patient) REPORTS THAT HE STEPPED ON A NAIL ON HIS LEFT FOOT LAST NIGHT THROUGH HIS SHOE. PT IS NO (sic) UP TO DATE ON HIS TETANUS”. Review of the ED Care Timeline at 1824 revealed the chief complaint was updated to “Foot injury (STEPPED ON NAIL LAST NIGHT).” Patient #6’s left foot x-ray resulted at 1926 revealed “Impression: Normal left foot.” Patient #6 was administered the tetanus vaccine at 1926. Review of the ED Care Timeline at 1949 revealed “ED Disposition set to Home.” Patient #6 was administered ciprofloxacin 500 mg by mouth at 1959. Review of the ED Provider Note documented at 2018 revealed “62-year-old male patient with a history of hypertension (high blood pressure), diabetes (high blood sugar), COPD (chronic obstructed pulmonary disease - lung disease ), asthma (condition where your airways narrow and swell and my produce extra mucus), sleep apnea (breathing stops and starts during sleep) and gout (a form of arthritis that causes pain and swelling in your joints mostly your big toe) presents to the ED with a chief complaint of stepping on a nail through his shoe. Unsure of his last tetanus. Onset- 3/5/25 Location- left foot ... Characteristics- left foot injury ... Review of Systems ... Musculoskeletal: Negative for arthralgias (xxx), back pain, gait problem, joint swelling, myalgias, neck pain and neck stiffness. Left foot injury ... Physical Exam ... Skin ... Comments: Puncture wound to bottom of foot. ... ED COURSE Clinical Impressions Puncture wound of left foot, initial encounter Xray neg. (negative) Given tetanus, pain meds (medications) and ABT (antibiotics) Follow up with wound center. DIAGNOSIS: 1. Puncture wound of left foot, initial encounter ... MEDICATIONS: ... START taking these medications ciprofloxacin (CIPRO) 500 mg Oral Tablet Details Take 1 Tablet by mouth twice a day for 7 days., Disp (dispense)-14 Tablet ...” Patient #6 was discharged home at 2123. Review failed to reveal evidence of irrigation or cleaning of the left foot puncture wound prior to Patient #6 leaving the ED. Request to interview the Medical Provider involved in Patient #6’s care during the second visit revealed they were not available for interview. Interview on 04/30/2025 at 1738 with Nurse Practitioner (NP) #1 revealed she could not remember Patient #6. In reviewing the medical record NP #1 recalled Patient #6 came in complaining he had stepped on a nail the night before. He had x-rays of his foot and they were normal. Patient #6 was given a tetanus booster shot and the first dose of antibiotic prior to discharge. Patient #6 was instructed to follow up with the wound clinic to keep a close watch on the wound on his foot. Interview on 05/01/2025 at 1027 with Medical Doctor (MD) #2 revealed he was the Emergency Department Medical Director and he was not involved with the care for Patient #6. Interview revealed if a patient who is diabetic comes in with a foot injury/problem, the patient would be registered, then triaged. During the triage MD#2 would expect the nurse to test the patient’s blood sugar, assess the foot pain/injury, and verify pulses in the extremity. Protocol orders can be used for example if the injury can use the pain order set. Once the patient gets into a room in the ED, expect the nurse to put the patient on a monitor depending on what the patient complained of. The provider would assess the patient, order any radiology, immunizations or medications as needed (i.e.: tetanus and antibiotics).”

“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 reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings included: Based on policy review, medical record review and staff and physician interviews, the hospital failed to perform a timely and complete medical screening exam including explaining the risks of refusals of exam or treatment when patients left AMA (against medical advice) for 3 of 29 sampled Dedicated Emergency Department (DED) patients reviewed (Patient #1, #7, and #19) ~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 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: 49003 Based on policy review, medical record review and staff and physician interviews, the hospital failed to perform a timely and complete medical screening exam including explaining the risks of refusals of exam or treatment when patients left AMA (against medical advice) for 3 of 29 sampled Dedicated Emergency Department (DED) patients reviewed (Patients #1, #7, and #19) The findings included: 1. Review of the Emergency Medical Treatment and Labor Act (EMTALA) policy, effective 11/2022, revealed “...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who comes to the emergency department an appropriate medical screening evaluation within the capability of the hospital’s emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer...” The “Refusal of Care Leaving the Hospital AMA Leaving the Hospital ED WOT [Without Treatment]...”, effective 10/2022, revealed “...Definitions...B. AMA....1. Patient who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure prior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ...” 33790 2. DED medical record review revealed Patient #19 arrived to the emergency department on 05/07/2024 at 0003. Review revealed an arrival complaint of “possible miscarriage.” Vital signs at 0008 were abdominal pain score of 8 - severe pain. Review of the ED Triage Note at 0009 revealed “Pt c/o abd pain, cramping, and vaginal bleeding. Pt had OB urine confirmed pregancy (sic) ....EDD 1/3/25 ....Pt states bleeding started today but states abd pain and cramping started after she was hit in the stomach yesterday around 1330.” Review of the ED Provider Note, service time 0157, revealed “ ...HPI [space] 27-year-old female with no medical history presents to the ED with a chief complaint of threatened labor and vaginal bleeding that started at 11PM on 5/6/2024. Patient reports that she was assaulted yesterday and points to her belly. She reports that her ex-boyfriend assaulted her and he is now along. She denies any dizziness chest pain shortness of breath but reports abdominal cramping and vaginal bleeding. She has tissue noted in his (sic) lower back and it shows some moderate amount of blood. Patient is gravida 3 para 2 no abortions ....Physical Exam .... Constitutional: She is not in acute distress. Appearance: She is not ill-appearing, toxic-appearing or diaphoretic ....Abdominal ....Palpations: Abdomen is soft. Tenderness: There is abdominal tenderness .....CBC WITH DIFFERENTIAL ....WBC ....11.83 (H) .... MPV ....11.5 (H) ....Absolute Neutrophils .... 8.29 (H).... Absolute Immature Granulocytes.... 0.03 (H) .... URINALYSIS ....Color ....Amber (A) .... Clarity .... Turbid (A) ....Hemoglobin ....3+ (A) .... Ketones .... 1+ (A) .... Protein ....1+ (A) .... RBC .... >182 (H) .... WBC ....85 (H) ....Squamous Epithelial Cells ....Few (A) ....Medications Ordered/Administered .... Acetaminophen ....650 mg .... Oral . ...” Further review of the ED Provider Note revealed “....ASSESSMENT / MEDICAL DECISION MAKING .... ED COURSE ....1527: Patient informed the nurse that she is not waiting until the morning for her ultrasound. She reports that she is going. Patient left AMA. [space] DIAGNOSIS 1. Left against medical advice ....” Review of an ED RN Note, at 0328, revealed “Patient states that she does not want to stay for the U/S in the morning. Patient states that she will follow up with her OBGYN today.” Timeline review at 0329 revealed “Patient discharged.” Review did not reveal an AMA form or evidence of explaining the risks of leaving to Patient #19. Telephone interview on 10/01/2024 at 1029 with NP #26 revealed the NP did not recall Patient #19. Interview revealed the statement that the ex-boyfriend was “now along” was a typo. NP #26 stated “100% the ex-boyfriend was not there....would have called hospital police. ...” Interview revealed no recollection of the “tissue” documented and indicated a “moderate” amount of bleeding was more than scant/small but not saturating multiple pads and no clots. Interview revealed Hospital A did not have ultrasound 24/7 and the NP explained to patients they would there between 7:00 and 8:00 am. NP #26 stated the majority of times patients did not wait, they had already left by the time the NP got notified. NP #26 indicated “If I saw her before she left I would have documented ....I go over risks of leaving and benefits of staying.” 16369 3. DED review on 09/25/2024 of Patient #7 revealed a 70-year-old-male that presented to the emergency department on 03/29/2024 at 1747 with a chief complaint of suicide intentions. Review of a triage note at 1757 recorded vital signs that included a pain level of 6, moderate pain. Review of the triage note revealed the patient reported suicide ideations with a plan of walking out in front of oncoming traffic and abdominal pain that started around one hour ago. The patient denied nausea, vomiting or diarrhea. Review revealed the patient was triaged with an Emergency Severity Index (ESI) level of 2 (scale of 1 - 5 with 1 the most emergent). Review of the record revealed the patient was roomed at 1809 with a patient safety observer in place for safety monitoring beginning at 1810. Review revealed laboratory studies were ordered and completed. At 1847 a Columbia Suicide Severity Rating Suicide Risk Assessment was completed with a total score of 7 or moderate risk identified. Review of nursing notes recorded at 1936 stated the patient endorsed suicide ideations but denied homicidal ideations or audio or visual hallucinations. Review revealed the patient had a plan to walk out in front of traffic. The patient stated he had some stomach pain on the right side and reported he was hungry. Review of a medical screening examination initiated on 03/29/2024 at 1947 revealed the patient presented to the DED with complaints of suicide ideations and abdominal pain. Review revealed the patient had a past medical history of depression, substance abuse, and suicide ideations. Review of the note stated that the patient had a plan to walk into traffic due to his depression. Review revealed the patient reported a momentary abdominal pain which he believed was due to being hungry. A review of systems was done and positive for suicide ideations. A physical exam was completed showing the patient was alert and oriented with no acute distress. The patient’s attention and perception were recorded as normal, mood and speech were normal, with cooperative behavior. “... Medical Decision Making 70-year-old M (male) with significant psychiatric history presenting for SI (suicide ideations) with plan. Labs ordered and reviewed, unremarkable. Patient medically cleared for tele psych consultation for further evaluation and treatment of psychiatric problems. ED COURSE Clinical Impressions as of 03/30/2024 at 0029 Suicidal ideation, Depression, unspecified depression type, Cannabis use disorder.” A tele psych consult was requested at 1950. Record review revealed hourly rounding by nursing staff was documented beginning on 03/30/2024 at 0121 showing the patient was resting at that time. Review of the DED record revealed ongoing safety monitoring and review of vital signs. A Suicide Assessment was recorded by nursing at 0719 that documented a low suicide risk level. Review of a tele psych consult electronically signed on 03/30/2024 at 1421 revealed, “... RECOMMENDATIONS Assessment and Plan 70 yo (year old) male with SI and plan to walk into traffic. Lives with his son and states they were arguing yesterday and this made him have thoughts of killing himself. He states he gets lonely and depressed at his son’s house. He has been to the ED several times recently for the same complaint. He was recently at (name of outpatient facility) for the same complaint. He continues to state that if he is discharged he will hurt himself. Currently calm and cooperative, no psychomotor agitation or retardation, speech wnl (within normal limits), good eye contact. Thoughts appear linear and directable. Mood and affect appropriate. Insight and judgement appear fair, and age-appropriate. Recommend IVC (involuntary commitment) be continued and inpatient hospitalization ... IVC Status Recommended Initiate IVC ... ADDENDA Mr. (patient name) was reporting SI. In the note, it says that he was reporting SI but at the end of the note it says No SI/HI noted. The note should have read No HI noted but reporting SI.” Review of a nursing note dated 03/31/2024 at 1406 revealed, “Patient stated that he was no longer suicidal and no longer wanted to be at the hospital. Patient asking to leave AMA (against medical advice). (Emergency department physician MD #6) notified and patient signed AMA form. Review of the “Notice of Treatment and Implications for Care Eligibility Act (NOTICE Act) Leaving Against Medical Advice (AMA)” form revised 10-22 revealed, “As a result of being notified of my rights under the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) I, _______________, a patient at (name of hospital system), at my own insistence and without the authority of and against advice of my personal physician(s) am informing you that I am refusing to be admitted as an observed patient. I have been fully counseled of the risks to my health due to my refusal of examination and/or treatment and unadvised discharge. ... I hereby release (hospital system name), its officers, agents, employees, and my personal physician(s) from any responsibility for all consequences caused as a result of me leaving the hospital.” Review of the form revealed it was signed by Patient #7 on 03/31/2024 at 1400 and signed by a nurse as the witness. There was no signature of a provider on the form. Review of a nursing note recorded the patient left ambulatory by himself on 03/31/2024 at 1413. Review of the DED record revealed no discharge instructions were documented in the medical record. Review of the DED record revealed no documentation of a discussion of the risks of leaving or the benefits of staying. Review of the record revealed the only provider notes were documented on 03/29/2024 at 1947 when the medical screening examination was initiated and on 03/30/2024 at 1421 when the tele psych evaluation was completed. Review revealed no provider documentation of a reassessment of the patient’s condition and no documentation of risks and benefits. Telephone interview on 09/26/2024 at 1450 with the DED physician (MD #6) that was notified of Patient #7’s request to leave AMA on 03/31/2024 revealed he remembered this patient as Patient #7 was in the emergency department frequently. He stated if he sent a patient out AMA he usually included the risks and benefits in the discharge instructions. Interview on 09/27/2024 at 0850 with RN #7 revealed there were no discharge instructions or after visit summary found in Patient #7’s DED record for the visit on 03/29/2024. Interview revealed there was no documentation of a discussion with Patient #7 of the risks of leaving AMA. 50111 4. Review of the medical record for Patient#1 (Pt) revealed a 29 year old female that presented to the DED (Dedicated Emergency Department) on 09/24/2024 at 1532 by private vehicle for a chief complaint of vaginal bleeding. The nursing triage assessment was initiated at 1558. Pt#1 indicated that the onset of symptoms began at 0700 on 09/23/2024. Triage vital signs, completed at 1600, revealed Pt#1 reported a pain level of 6/10 on a numerical pain scale. The triage notes at 1602 revealed Pt#1 came to the DED complaining of vaginal spotting associated with lower abdominal cramping that started the day prior. Pt#1 reported no bleeding on 09/24/2024. The triage note revealed Pt#1 was “Gravida 5, Para 2, Miscarriage 1, Abortion 1.” Pt#1 was triaged at an acuity level “3” (scale of 1 - 5 with 1 the most emergent). Pt#1 was placed in an ED room at 1641. A urine pregnancy screen, urinalysis, and chlamydia/gonorrhea microbiology labs were ordered at 1708. Review of the DED Provider Note dated 09/24/2024 at 1738 revealed, “ ... Patient came to the ED complaining of vaginal spotting associated with lower abdominal cramping that started yesterday. No vaginal bleeding today as claimed ... Vaginal Bleeding ... Pain quality: Aching ... Pain Severity: Mild ... Onset quality: Sudden ... Duration: 1 day ... Timing: Intermittent ... Progression: Resolved ... Chronicity: New ... Worsened by: Nothing ... Review of Systems ... Genitourinary: Positive for vaginal bleeding. Negative for flank pain and vaginal discharge... Results: ... Pregnancy Screen, Urine ... HCG (human chorionic gonadotropin) Positive ... Urinalysis, Complete (notable for the following components) ... Leukocyte Esterase, Urine: 3+, Protein, Urine: Trace, RBC (Red Blood Cells), Urine: 6, WBC (White Blood Cells), Urine: 21, and Squamous Epithelial Cells, Urine: Few ... Medical Decision Making ... 29-year-old female currently pregnant did not want to wait for full evaluation and lab work as well as ultrasound she left AMA (against medical advice). Urinalysis positive for WBCs, RBCs, leukocytes. Pregnancy positive. Patient was clinically stable prior to leaving AMA ... Clinical Impressions ... Threatened Abortion ...” Review of the AMA form revealed two sections of the form “To be completed by a physician:” were not completed by the provider. The sections were as follows: “A. The examination and/or treatment recommended and refused:” and “B. The likely dangers of refusal of such examination and/or treatment may include, but are not limited to the following:” Review revealed the AMA form was signed by the patient, by a nurse as a witness, and by the provider at 1742 on 09/24/2024. Review of the ED Notes at 1756 revealed, “Patient refused treatment and signed AMA form. Patient ambulated to the ed lobby with family and left via private vehicle.” Pt#1 was discharged at 1759. Review of the medical record failed to reveal evidence that the risks of leaving AMA were discussed with Pt#1. Interview on 09/27/24 at 0925 with the ED Manager (Manager#3) revealed the ED provider should discuss the risks of leaving AMA with patients. Interview revealed the ED provider was responsible for documenting the discussion. Telephone interview on 09/27/2024 at 1101 with the ED Medical Director (MD#1) revealed the risks of leaving should be discussed with patients that request to leave AMA. Interview revealed providers were expected to document the conversation in a provider note or in the history and physical examination note.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 16369 Based on facility policy review, medical record review, and staff and physician interviews, the hospital’s governing body failed to provide oversight and have systems in place to ensure organized and effective emergency services were in place to meet the needs of patients that presented to the Emergency Department. The findings include: The hospital’s emergency department (ED) staff failed to ensure an organized and effective emergency services by failing to provide care and treatment including failing to evaluate, monitor and provide treatment to emergency department patients to prevent delays; failing to implement laboratory and EKG orders; and/or failing to explain the riks of leaving and benefits of staying to patients who were leaving the ED against medical advice for 7 of 21 sampled emergency department patients (#4, #9, #19, #7, #1, #14, and #13) Cross refer to §482.55: Emergency Services Standard Tag A 1101.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 16369 Based on facility policy review, medical record review, and staff and physician interviews, the facility staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department. The findings included: The hospital’s emergency department (ED) staff failed to ensure an organized and effective emergency services by failing to provide care and treatment including failing to evaluate, monitor and provide treatment to emergency department patients to prevent delays; failing to implement laboratory and EKG orders; and/or failing to explain the riks of leaving and benefits of staying to patients who were leaving the ED against medical advice for 7 of 21 sampled emergency department patients (#4, #9, #19, #7, #1, #14, and #13) Cross refer to §482.55 Emergency Services Standard: Tag 1101.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 51294 Based on policy review, medical record review and staff interview the hospital staff failed to notify a patient’s legal guardian of patient treatment decisions and discharge disposition. Findings include: Review of the hospital’s policy “Patient Rights and Responsibilities, ECUH-PFE7” - PolicyStat ID 15129086, last revised 02/2024, revealed “Purpose ...All team members, medical team members and contracted agency team members shall observe these patient rights ...H. Be informed (or have your representative informed) about the outcome of your care ...Section E- Additional rights of mental health patients ...D. You are considered legally competent unless a court decides that you are incompetent ...” Review of the hospital policy “Guardianship, ECUH-CS35” - PolicyStat ID 15213026, last revised 04/2024, did not address the procedure for involving a patient’s legal guardian in their care. No specific hospital policy was provided by staff when requested that specifically addressed contact with an adult patient’s legal guardian for treatment decisions or discharge disposition for an adult patient. Review of family notification process education entitled “Family Notification, Go Live Date: 05/20/2024”. Per education, “ ...with the patient’s consent, a family member or designated representative MUST be notified as this is a new requirement for Patient Access Services (registration) (PAS), Emergency Department (ED) nurse, and/or IP (Inpatient) Nurse. It is important to respect patient privacy and autonomy by seeking their approval before sharing any personal health information ...When PAS (registration staff) attempts to contact a patient’s family or representative is unsuccessful, it is the responsibility of the ED Nurse to take over this task. The Family Notification section has been added to the Triage and ED Navigator”. This new process was put in place after there were identified problems with family notifications. Review of the closed medical record for Patient # 5 on 09/25/2024 revealed a 57-year-old male that presented to the ED on 06/02/2024 accompanied by law enforcement (LE). He was admitted at 1910 as an Involuntary Commitment (IVC) with a chief complaint of psychosis (a mental health disorder characterized by a disconnection from reality) and a history of schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves). Review of the medical record revealed Patient # 5 had a legal guardian with guardianship papers scanned into the system on 05/03/2024. Guardianship papers were dated 11/16/2023. Review of the EPIC system (electronic medical record) revealed a flag prominently displayed on the left side of the patient record showing that patient # 5 has a legal guardian. Per closed medical record review in regard to the 06/02/2024 admission, EPIC field “Notify Family or Rep on Admission?” the response was “unable to ask”. The field “Family or Representative Notified” and “Family or Rep Contact Comments” are both blank. Patient # 5 remained in the ED until he was transferred to an inpatient psychiatric facility (without legal guardian notification) on 06/06/2024. Comprehensive review of closed medical record (including ED flowsheets, psychiatric consult and progress notes, psych triage notes, registration records and nursing and medical progress notes) did not reveal any documentation of contact with patient # 5’s legal guardian from admission to discharge. Facility staff failed to notify legal guardian of treatment decisions, continuing care or discharge disposition. Patient #5 was accepted to the referring inpatient psychiatric facility on 06/05/2024 at 1302 and was subsequently discharged there on 06/06/2024 at 1040. There was no documentation of notification to the patient’s legal guardian of the location where the patient was sent. On 09/26/2024 at 1048, previous admission closed medical records were reviewed for patient # 5. He was admitted from 04/16/2024 to 04/19/2024 and no family contact (or legal guardian contact) was found in that record but there was a behavioral health triage note which stated, “Guardianship documents in Media tab”. An interview was conducted on 09/25/2024 at 1145 with ED Nursing Manager #3 in regard to notification of legal guardian for named patient # 5. After thorough review of the record, she stated “It does not look like we called the guardian but it looks like we called the court”. RN note dated 06/03/2024 revealed that the writer “called the clerk of the court office Halifax county & verified [ ...] is pt legal guardian, information given to registration @ this time, plan of care ongoing, charge nurse [ ...] made aware, interim ED director [ ...] made aware, plan of care ongoing.” Writer was not able to be interviewed as they no longer work at the facility. On 09/26/2024 at 1048, closed medical record was reviewed (including previous admissions) with Quality RN #13. Pt #5 was admitted from 04/16/2024 to 04/19/2024 and no family contact (or legal guardian contact was found). In regard to admissions in April 2024 and June 2024, per Quality RN #13, “I don’t see where anyone was talked to”. “If they did, they aren’t documenting”. An interview was conducted with Corporate Quality Manager #19 on 09/26/2024 at 1610 in which she was asked for the policy that addresses notification of legal guardian in regard to care and treatment. Policies that were provided were “Informed Consent”, ECUH-CS4- PolicyStat ID 15998577, last revised 09/2024 and “Family Presence and Visitor Policy and Guidelines”, ECUH-PFE2- PolicyStat ID 15693199. Per Corporate Quality Manager #19, “I think what you are looking for is a combination of these”. Neither policy addressed notification of guardian with treatment decisions or discharge disposition. Both policies were in effect after patient #5’s admission. An interview with Psych ED (locked section of ED for psychiatry patients) RN #19 on 09/27/2024 at 0845 revealed that “it was the RN’s responsibility to contact the POA upon presentation to the Psych ED, especially if IVC’d”. He stated that he would confirm with the provider and/or charge RN first to make sure there were no legal reasons (suspected abuse, etc.) that would preclude him from contacting first. Once the patient was to be admitted and/or ready for transfer “the water gets a little muddy” and he usually leaves that up to the CM (Case Manager) working the case to complete all those calls. An interview was conducted with Quality Director #12 on 09/27/2024 at 1042 in regard to family notification process education. Per Quality Director #12, “new process (family notification) go live was 05/20/2024 systemwide. Now we have Patient Access Screen (PAS). They (registration) verify legal guardian is accurate. Goes to ED triage nurse automatically. They are still asking permission to contact the guardian. The nurse would pick up off the list that there is a guardian.” “If there is a guardian, they are supposed to notify them.” If patient is in the ED, the ED nurse would go into the record. “It should be documented in the nurse’s note who they talked to and information they gave.” “Guardian should be kept up with everything going on.” When asked if patient’s legal guardian should be informed of disposition and if it should be documented, Quality Director #12 stated, “Yes, the primary nurse would need to hand off to the facility and to the guardian”. An interview was conducted with Patient Access Services Manager #14 with Patient Access Services Manager #15 present on 09/27/2024 at 1145. When asked when the legal guardian flag on the left side of the EPIC screen was added, he stated, “It does not tell you”. In regard to the person that completes registration when a patient presents to the ED, he stated “They (registration) should notify the legal guardian, the registrar would have to notify them to verify the registration information.” A telephone interview was conducted with Risk Management Manager #16 on 09/27/2024 at 1318 who stated that “I don’t have any record of a (risk management) consult with this patient’s name, I don’t have anything for a (risk management) consult on that date from North (named hospital)” when asked if risk management was consulted about this patient for his admission on 06/02/2024 through 06/06/2024. When asked about the protocol for a psychiatric patient under IVC with a legal guardian transferred to an outside facility she stated, “In general terms, IVC or not, before we transfer a patient anywhere, typically we notify the legal next of kin”. When asked who would take ownership of notifying the legal next of kin, she stated, “It may be case management, ED should have someone who supports”. An interview was conducted with Corporate Quality Manager #17 on 09/27/2024 at 1343 in regard to documentation on patient #5’s record showing that patient’s legal guardian was contacted during his admission. She states, “I don’t think we had one in here”. “I can’t find anything”. “I am not saying we didn’t do it”. When asked who is responsible for notifying a patient’s legal guardian of admission, ongoing care and disposition she stated, “It is supposed to be the bedside people”. She stated that she had received an email from the System Administrator for Behavioral Health who told her it’s at the local level to do the notification. A telephone interview was conducted on 09/27/2024 at 1418 with Behavioral Health Triage Manager #18. When asked about the procedure from patient consult to disposition she stated, “My team (Behavioral Health Triage) does not do the actual assessment. They call the hospitals (they cover) each morning. They are asked can they locate a bed. They will make referrals to facilities. Once they get an acceptance and the accepting physician’s name, they let the team (inpatient hospital team) know who the facility is and the number to call report. They are done with the case.” “The nurse and the doctor arrange transport, contact guardians, whatever they need to do to get them transferred”. When asked if they speak to the patient she stated “no, typically the nurse will let them know if they (the patient) say that don’t want to go somewhere”.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 49003 Based on policy review, medical record reviews and staff and provider interviews, the hospital’s emergency department (ED) staff failed to ensure an organized and effective emergency services by failing to provide care and treatment including failing to evaluate, monitor and provide treatment to emergency department patients to prevent delays; failing to implement laboratory and EKG orders; and/or failing to explain the riks of leaving and benefits of staying to patients who were leaving the ED against medical advice for 7 of 21 sampled emergency department patients (#4, #9, #19, #7, #1, #14, and #13) The findings include: 1. Review of the EMTALA policy, effective 11/2022, revealed “...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who ‘comes to the emergency department’ an appropriate medical screening evaluation within the capability of the hospital’s emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ...” The “Refusal of Care Leaving the Hospital AMA Leaving the Hospital ED WOT...”, effective 10/2022, revealed “...Definitions...B. AMA....1. Patient who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ...” Closed medical record review on 09/25/2024 revealed Patient #4 (Pt#4) was a 59-year-old-female who presented to the Emergency Department (ED) on 07/28/2023 at 1618 with complaints of a possible kidney infection. The triage vital signs at 1735 revealed temperature 98.7, heart rate 117, respirations 18, blood pressure 110/69, room air pulse oximetry 98%, pain rated 9, severe pain. Triage documentation revealed Pt#4 was assigned an Emergency Severity Index (ESI) level of 3 (scale of 1 - 5 with 1 the most emergent). The medical record revealed that lab tests were ordered by the triage nurse at 1738 and Pt#4 was placed in the lobby waiting room. Review of the Patient Care Timeline revealed the laboratory staff called RN#8 (ED nurse) at 1933 to report a critical Potassium level of 2 (normal 3.5 to 5.1) which was reported to MD #6 (ED physician) at 1933. Pt #4 remained in the lobby waiting room with no orders for potassium supplement until Pt #4 was seen by the PA #7 (Physician Assistant) at 0147. Review of the Patient Care Timeline revealed PA #7 ordered Potassium chloride (KLOR-CON) 40 mEq (milliequivalents) tablet PO (orally) and a fluid bolus of sodium chloride 0.9% 1,000 ml (milliliters) at 0151. Record review revealed Pt #4 was placed on a cardiac monitor around 0217 and the RN documented the cardiovascular assessment was within defined limits. Review of the Patient Care Timeline revealed the nurse initiated the IV (intravenous) bolus and medications [Zofran (medication for nausea) 4 mg (milligrams) IV, Cefepime (antibiotic) 1 gram IV, and Klor-Con 40 mEq orally] around 0254 (Potassium replacement administered 7 hours and 21 minutes after critical lab was reported). Medical record review revealed MD #11 (Hospitalist) was consulted to complete a H&P (history and physical) for admission at 0338 and wrote an inpatient admission order at 0431. Record review revealed MD #11 wrote an order for an additional dose of Klor-Con 40 mEq tablet orally at 0434 and a nursing note that the medication wasn’t administered at 0535 because Pt #4 was complaining of nausea. Review of the medical record revealed MD #11 wrote an order for an EKG (electrocardiogram) at 0553. Review of the medical record failed to review completion of the EKG order at Hospital A. Medical record revealed a dose of Flagyl 500 mg IV was ordered at 0806. Record review revealed a second dose of oral Klor-Con 40 mEq tablet administered at 0927 and the Flagyl 500mg IV was administered at 0955. Review of the Patient Care Timeline revealed a repeat potassium level was reported to be 2.1 at 1055. Review of the Patient Care Timeline revealed a downward trend in Pt #4’s blood pressure and Pt#4 subsequently received an additional 1,500 ml of sodium chloride 0.9% fluid bolus and 3 doses of albumin human 25% infusion 12.5 g (grams) IV. The medical record revealed an IV infusion of Levophed (life-threatening low blood pressure medication) 4 mg/250 ml at 16 mcg/ml (micrograms per milliliter) for low blood pressures (79/47 to 102/63) was initiated at 1351. Record review revealed an IV dose of potassium chloride in water 10 mEq/100 ml was administered at 1425. Review of the medical record revealed that Pt #4 was transferred to an outside tertiary care center (Hospital B) on 07/29/2023 at 1540 where she was treated for sepsis from a complicated UTI (urinary tract infection) with severe hydronephrosis (excess urine in the kidneys), hydroureter (blockage of one or both tubes that carry urine from the kidneys to the bladder) and possible colitis (inflammation of the colon). Medical record review of the tertiary care hospital revealed that a repeat potassium level at 1804 was still 2.1. Record review of the EKG completed at the tertiary care hospital at 1747 revealed HR (heart rate) 96, PR 141, QRSD 83, QT 429, and an interpretation of “Sinus rhythm, prolonged QT, and nonspecific repol (repolarization) abnormality.” The record revealed with further treatment of the low potassium, on 07/30/2023 at 0436 the potassium level was reported as 2.7 and then at 1758 the level was reported to be 5.0. Medical record review of Hospital A failed to reveal treatment of a critical potassium level of 2.0 for over 7 hours and 21 min (reported time 1933 to administration time of a potassium supplement at 0254) while Pt #4 was sitting in the lobby waiting area. Medical record review failed to reveal completion of an EKG order during Pt #4’s stay with Hospital A (from order at 0553 to transfer at 1540). The Triage RN was unavailable for interview. Interview on 09/26/2024 at 1025 with MD #6 revealed no recollection of Pt #4. MD #6 revealed no recollection of being told of the critical potassium level for Pt #4. MD #6 revealed “there were many times over the summer of 2023 where the ED was full and there were multiple patients with no treatment rooms available and patients were waiting in the lobby.” MD #6 revealed the decision to move a patient to the treatment area was left up to the charge nurse and the nurse in the triage area. MD #6 revealed that he was unsure of the delay in getting Pt #4 into a treatment room. MD #6 revealed the potassium level of 2.0 would be something to treat, typically with IV potassium. MD #6 revealed that the patient volumes and wait time were much better currently. Interview on 09/26/2024 at 1050 with the admitting Hospitalist (MD #11) revealed no recollection of Pt #4, but a review of the H&P had been completed prior to the interview. MD #11 revealed there were a large number of patients during the summer of 2023, “especially at night.” “As the Hospitalist on call, there were many times where the patient needed to go to another hospital, but there were no beds to send them to so we had to admit them and hold them in the ED.” MD #11 revealed that the ED physicians would contact the hospitalist to admit and assume care of patients and then the ED MD’s would go back to focusing on the ED patients. MD #11 revealed feeling “overwhelmed at times,” but that “everyone was doing the best they could.” MD #11 revealed that while she may still have admit privileges at Hospital A, MD #11 hasn’t worked or admitted a patient in over six months. Interview 09/26/2024 at 1645 with PA #7 (Physician Assistant - Certified) revealed Pt #4 was a “hot potato” that was picked up on 07/29/2023 after having been in the lobby for many hours. PA #7 revealed that upon examination the priority of care was treating the patient’s sepsis with fluid resuscitation and IV antibiotics. PA #7 revealed P t#4 was stable from a cardiac standpoint, “yes there was tachycardia (rapid heart rate), but the bigger concern was for the sepsis.” When asked about potassium supplementation being given orally, PA #7 revealed staff having “issues with IV access” and “with a stable cardiac view, the priority needed to be on fluid resuscitation.” Once the fluids were infusing, “the next avenue to deliver the potassium was orally so the order was placed.” PA #7 revealed that Pt #4 needed a transfer out to a tertiary care facility, but there were no beds available so a consultation was placed for the hospitalist to see the patient and admit at Hospital A until transfer could be completed. PA #7 revealed no issues with nursing staff completing orders or getting things done and if it was emergent, PA #7 reported getting the charge nurse to perform the duty. PA #7 revealed there was “no question” in her mind that “sepsis was the primary concern for Pt #4 at the time of assuming care and there were no questions” in her mind that the care provided was the “right care.” 16369 2. The “Refusal of Care / Against Medical Advice.../ Leaving the Clinical Setting” policy, effective 03/2024, revealed “...Definitions...B. AMA....1. Patients who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ...” Medical record review on 09/25/2024 of Patient #7 revealed a 70-year-old-male that presented to the hospital’s emergency department on 03/29/2024 at 1747 with a chief complaint of suicide intentions. Review of a triage note at 1757 recorded vital signs that included a blood pressure of 116/71, temperature 98.4, pulse 103, respirations 18, oxygen saturation of 96% on room air, and a pain level of 6, moderate pain. Review of the triage note revealed the patient reported suicide ideations with a plan of walking out in front of oncoming traffic and abdominal pain that started around one hour ago. The patient denied nausea, vomiting or diarrhea. Review revealed the patient was triaged with an Emergency Severity Index (ESI) level of 2 (scale of 1 - 5 with 1 the most emergent). Review of the record revealed the patient was roomed at 1809 with a patient safety observer in place for safety monitoring beginning at 1810. Review revealed laboratory studies were ordered and completed. At 1847 a Columbia Suicide Severity Rating Suicide Risk Assessment was completed with a total score of 7 or moderate risk identified. Review of nursing notes recorded at 1936 stated the patient endorsed suicide ideations but denied homicidal ideations or audio or visual hallucinations. Review revealed the patient had a plan to walk out in front of traffic. The patient stated he had some stomach pain on the right side and reported he was hungry. Review of a medical screening examination initiated on 03/29/2024 at 1947 revealed the patient presented to the DED with complaints of suicide ideations and abdominal pain. Review revealed the patient had a past medical history of depression, substance abuse, and suicide ideations. Review of the note stated that the patient had a plan to walk into traffic due to his depression. Review revealed the patient reported a momentary abdominal pain which he believed was due to being hungry. A review of systems was done and positive for suicide ideations. A physical exam was completed showing the patient was alert and oriented with no acute distress. The patient’s attention and perception were recorded as normal, mood and speech were normal, with cooperative behavior. “... Medical Decision Making 70-year-old M (male) with significant psychiatric history presenting for SI (suicide ideations) with plan. Labs ordered and reviewed, unremarkable. Patient medically cleared for tele psych consultation for further evaluation and treatment of psychiatric problems. ED COURSE Clinical Impressions as of 03/30/2024 at 0029 Suicidal ideation, Depression, unspecified depression type, Cannabis use disorder.” A tele psych consult was requested at 1950. Record review revealed hourly rounding by nursing staff was documented beginning on 03/30/2024 at 0121 showing the patient was resting at that time. Review of the DED record revealed ongoing safety monitoring and review of vital signs. A Suicide Assessment was recorded by nursing at 0719 that documented a low suicide risk level. Review of a tele psych consult electronically signed on 03/30/2024 at 1421 revealed, “... RECOMMENDATIONS Assessment and Plan 70 yo (year old) male with SI and plan to walk into traffic. Lives with his son and states they were arguing yesterday and this made him have thoughts of killing himself. He states he gets lonely and depressed at his son’s house. He has been to the ED several times recently for the same complaint. He was recently at (name of outpatient facility) for the same complaint. He continues to state that if he is discharged he will hurt himself. Currently calm and cooperative, no psychomotor agitation or retardation, speech wnl (within normal limits), good eye contact. Thoughts appear linear and directable. No SI/HI (suicidal ideations/homicidal ideations) or AVH (audio visual hallucinations), and no obvious paranoia or delusions were noted. Mood and affect appropriate. Insight and judgement appear fair, and age-appropriate. Recommend IVC (involuntary commitment) be continued and inpatient hospitalization ... IVC Status Recommended Initiate IVC ... ADDENDA Mr. (patient name) was reporting SI. In the note, it says that he was reporting SI but at the end of the note it says No SI/HI noted. The note should have read No HI noted but reporting SI.” Review of a nursing note at 1715 revealed, “TELE PSYCH RECOMMENDED PT (patient) BE IVC’d (involuntarily committed) & WRITER REPORTED TO MD THE RECOMMENDATIONS & MD SAID THAT IS NOT NECESSARY BECAUSE THE PT IS AGREEING TO STAY & RECEIVE TREATMENT VOLUNTARY (sic).” Review of a nursing note at 2024 revealed, HALIFAX COUNTY MAGISTRATE REFUSES TO IVC THIS PATIENT. (name) STATES “HE MUST BE PROVIDED WITH OUTPATIENT DOCUMENTS FOR DRUG REHAB AND FURNISH HIS OWN TRANSPORTATION TO DRUG REHAB...” Review of a psychosocial assessment note documented by nursing at 2349 recorded the patient appears depressed and “verbalizes suicidal thoughts.” Review of a nursing note at 2352 documented a Suicide Assessment with a risk score of 2 indicating a low risk. Review revealed an emergency department provider was notified of the suicide risk score. Review revealed the patient had hourly rounding done and was calm and cooperative. Vital signs remained stable. Review of a nursing Suicide Assessment documented on 03/31/2024 at 0722 revealed a suicide risk score of 2, low risk and an emergency department provider was notified of the low risk. Review of a nursing note at 1406 revealed, “Patient stated that he was no longer suicidal and no longer wanted to be at the hospital. Patient asking to leave AMA (against medical advice). (Emergency department physician MD #6) notified and patient signed AMA form. Review of the “Notice of Treatment and Implications for Care Eligibility Act (NOTICE Act) Leaving Against Medical Advice (AMA)” form revised 10-22 revealed, “As a result of being notified of my rights under the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) I, _______________, a patient at (name of hospital system), at my own insistence and without the authority of and against advice of my personal physician(s) am informing you that I am refusing to be admitted as an observed patient. I have been fully counseled of the risks to my health due to my refusal of examination and/or treatment and unadvised discharge. ... I hereby release (hospital system name), its officers, agents, employees, and my personal physician(s) from any responsibility for all consequences caused as a result of me leaving the hospital.” Review of the form revealed it was signed by Patient #7 on 03/31/2024 at 1400 and signed by a nurse as the witness. There was no signature of a provider on the form. Review of a nursing note recorded the patient left ambulatory by himself on 03/31/2024 at 1413. Review of the DED record revealed no discharge instructions were documented in the medical record. Review of the DED record revealed no documentation of a discussion of the risks of leaving or the benefits of staying. Review of the record revealed the only provider notes were documented on 03/29/2024 at 1947 when the medical screening examination was initiated and on 03/30/2024 at 1421 when the tele psych evaluation was completed. Review revealed no provider documentation of a reassessment of the patient’s condition and no documentation of risks and benefits. Telephone interview on 09/26/2024 at 1450 with the DED physician (MD #6) that was notified of Patient #7’s request to leave AMA on 03/31/2024 revealed he remembered this patient as Patient #7 was in the emergency department frequently. He stated if he sent a patient out AMA he usually included the risks and benefits in the discharge instructions. The physician stated he had seen this patient multiple times within the last year. He stated he is not suicidal. MD #6 stated “He was not suicidal at the time he left.” Interview on 09/27/2024 at 0850 with RN #7 revealed there were no discharge instructions or after visit summary found in Patient #7’s DED record for the visit on 03/29/2024. Interview revealed there was no documentation of a discussion with Patient #7 of the risks of leaving AMA. 33790 3. Review of the EMTALA policy, effective 01/2024, revealed “...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who ‘comes to the emergency department’ an appropriate medical screening evaluation within the capability of the hospital’s emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ...” The “Refusal of Care / Against Medical Advice.../ Leaving the Clinical Setting” policy, effective 05/2024, revealed “...Definitions...B. AMA....1. Patient who leave an inpatient or outpatient setting or any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ...” DED medical record review, on 09/25/2024, revealed Patient #9 arrived to the emergency department by private vehicle on 09/01/2024 at 1720. The ED Care Timeline noted that triage started at 1724. Vital signs at 1936 were blood pressure (BP) 108/69, temperature 97.5, pulse 81, respirations 16 and oxygen saturation of 100% on room air. A pain score of 10 was documented (on a scale of 0-10, with 10 indicating severe pain). A Triage Note at 1737 documented “Pt is G1P0 (first pregnancy), 12 wks. Was told at 8wks that pregnancy was not viable. Two days ago she started bleeding and this afternoon bleeding became heavy w/ (with) clots. Having severe pelvic pain.” A physical assessment at 1737 noted respiratory, cardiovascular, peripheral vascular and neurological systems as within defined limits. There was no physical assessment noted related to the pregnancy bleeding. Patient #9 was assigned a triage acuity of 3 (on a scale of 1-5, with 1 being most severe). The following lab tests were collected: CBC with Differential, CMP, Type and Screen. The CBC resulted at 1747 with the following abnormal results: White Blood Count (WBC) 11.29 (Reference Range [RR] 4.50-11.0), Absolute Neutrophils 9.53 (RR 1.80-7.70) and Absolute Immature Granulocytes 0.05 (RR 0). The CMP resulted at 1806, with abnormal results of low CO2 of 20 (RR 22-29) and elevated glucose of 111 (RR 70-105). Review of the ED Care Timeline revealed at 1827 (1 hour 7 minutes after arrival) “ ...Patient and significant other (SO) demanded that her IV be taken out so they could leave. The patient and SO was adamant about leaving because they had not been brought to the back yet. An AMA form was obtained. The patient was advised that by leaving she could continue to bleed up to the point of death and by signing the AMA form she takes responsibility for anything that happens after she leaves the hospital. The patient stated that she was going to go somewhere else. The patient signed the AMA form witnessed by RN. IV removed.” At 1908 the ED Care Timeline indicated “Patient dismissed.” Record review failed to reveal any physical evaluation of Patient #’s bleeding and failed to reveal a repeat pain evaluation prior to departure after an initial pain score of 10 on arrival. ED record review revealed a form titled “Leaving AMA-Discontinue Tx-Refuse Tx”. This form noted “ ...This is to certify that I (Name of Patient #9), a patient at Unknown Department at my own insistence and without the authority of and against the advice of my personal physician(s) (First and Last Name), RN demand to leave the hospital. ...” The form included a section labeled “To be completed by a physician: [space] A. The examination and/or treatment recommended and refused: [space] B. The likely dangers of refusal of such examination and/or treatment may include, but are not limited to the following: [space]. ...”These two sections left spaces to document the exam or treatment refused and also the likely dangers of refusal. Both sections were left blank, nothing was written on the form in either of those two areas. The form then indicated “ ...I have been fully counseled of the risk to my health, including, but not limited to, those listed above, due to my refusal of examination and/or treatment and unadvised discharge. I acknowledge that follow-up care with my regularly treating physician has been advised and it is my sole responsibility to seek such follow-up care and a treatment. I hereby release (System name), it’s officers, agents, employees, and my personal physician(s) from any responsibility for all consequences caused by my leaving said hospital. ...” After that last statement, there were lines for the patient to sign, a witness to sign, and a physician to sign as well as a place for date and time. Over the line for the Patient’s Signature was a handwritten statement “too long a wait” with no patient signature noted. There were handwritten signatures over the witness and physician signature lines. The date and time were not filled in. Form review revealed the form was not populated or completed accurately; it inserted “Unknown Department”, inserted the name of a hospital nurse where a physician name was to have been inserted and indicated the patient’s personal provider gave advice to the patient not to refuse the care/treatment even though the patient was in the hospital ED, not in a provider office. The sections for documenting the exam or treatment refused and the likely dangers of refusal were not filled in, nothing was written in either section. The date and time the form was signed was not completed. Telephone interview with RN #21, on 09/26/2024 at 1345, revealed the nurse remembered Patient #9. Interview revealed at the time of the patient’s arrival, “we were pretty backed up.” Interview revealed Patient #9 said “we called ahead and thought you would be ready.” Interview revealed Patient #9 was brought in and triaged but “...all of our rooms were full ...there was no room to put her in .... she was stable.” Interview revealed RN #21 talked with the charge nurse and discussed the situation to see if they could get her out of the waiting room into the back but the Charge Nurse thought there might not be adequate staff to keep fast track open during the night. In asking how Patient #9 looked in the car, RN #21 stated “(she) looked like she was in pain, she was not diaphoretic, was not pale. When asked how the RN evaluated the patient, RN #21 indicated she asked the patient how much bleeding there was, the patient was still in the car and the nurse could not assess her in the car. In response to a question about visible blood in the car, the RN stated there was not obvious blood visible in the car. As they got into the waiting area, RN#21 stated the patient’s husband went to registration and RN#21 thought there was another patient in triage so the RN went back to finish that triage. Interview revealed “there is always 1 nurse in triage plus I had a new grad nurse ... was there to learn, not to do tasks.” In triage, the RN indicated, she asks patients what brought them in, checks vital signs, looks at the computer record to check for ultrasound history. The RN stated she did not usually physically evaluate for bleeding, she asked patients how much bleeding they had, were they soaking through a large pad every hour or so; in this specific case RN#21 indicated she did not recall what was asked of this patient. When asked if it would be documented if the nurse asked the amount of bleeding, RN#21 stated “I’m not sure I would write that down ... can’t write everything down.” Patient #9, the RN stated, was “tearful, crying, very emotional, seemed very frustrated, thought she would go from the vehicle to a private room. ...” RN #21 stated she started an IV and drew labs and went back and spoke to the Charge Nurse again to see if she could get the patient back. RN #21 stated the patient and husband wanted the IV out, wanted to leave and agreed to sign the AMA form. “They said they were going to another hospital.” Interview revealed RN #21 did not go over the AMA form, the RN in orientation (RN #22) was the one who physically signed the AMA form and wrote a note about it. When asked what happened when patients stated they wanted to leave, RN #21 indicated they tell them about the form acknowledging they are leaving AMA.... That they haven’t seen a doctor ....encourage them to stay and see the doctor ....if they leave it is at their own risk.” Interview revealed physicians were not involved in the AMA process if they had not seen the patient. Interview with the orienting nurse, RN #22, on 09/26/2024 at 1530, revealed the RN recalled Patient #9. Interview revealed the patient arrived with vaginal bleeding and was pregnant. Interview revealed “day was very busy, had a lot of people in the waiting room at that time ...hadn’t stopped triaging patients all day ... all the beds in the back were full and no one was moving at the time.” There were “holds for placement” the RN stated. When asked if the RN saw Patient #9 when she first came in, RN #22 stated “yes”. When asked how she appeared, the RN answered “normal skin tone, not pale, believe in pain, did not appear to be in severe distress.” Interview revealed RN #21 triaged Patient #9, and after triage the patient sat right outside the triage door the whole time, in a wheelchair, most waiting room chairs were full. Interview revealed the patient and significant other were both upset that they were not going to the back yet. The RN stated they were informed multiple times that beds were not available, when they were available they would be taken back. When asked if RN#22 thought the patient needed to be in the back, the answer was “yes, with bleeding she is at higher risk.” Interview revealed Patient #9’s vital signs were in normal range and this RN never saw bleeding/blood on the patient. Further interview revealed RN #22 took the patient out to the car and did not remember any blood on the wheelchair. Interview revealed the RN thought he would have remembered because he would have needed to wipe the wheelchair down with bleach wipes rather than regular wipes. The RN stated Patient #9 wrote too long a wait on the form and did not sign her name. Interview revealed the form used with Patient #9 was printed out of the computer system, possibly by the Charge Nurse, for the RN to use with this patient. Interview revealed RN #22 had not been taught to use that form, stating “It is not the one we usually use.” RN #22 stated “They said multiple times if they didn’t get a bed in the back were going to leave. We advised them multiple times that it was not recommended ... needed to be seen by a doctor ... leaving could continue to bleed up until death.” Interview revealed Patient #9’s significant other stated “If we continue to sit here would bleed out anyway.” RN #22 stated they reiterated they were trying to get a bed in the back as soon as possible and again the risks of bleeding/death. The RN stated “I felt she needed to be seen but due to circumstances could not bring her back yet.” RN #22 did not recall if anyone spoke to a physician about Patient #9. Request to interview the Charge Nurse on duty when Patient #9 was in the ED revealed the Charge Nurse was not available for interview. Telephone interview on 09/27/2024 at 1030 with MD #23 revealed MD #23 did not see Patient #9. Interview revealed blood work and IV were done while the patient was waiting on a room. Interview revealed the MD would not go out to talk with a patient in triage who wanted to leave, stating “... I haven’t seen the patient.” MD #23 indicated nursing did the right thing, started labs and IV, discussed the risks or leaving and got the AMA form. “If a patient in triage wants to leave and not see a doctor, think it’s very appropriate to get the paperwork and explain the risks/ you might die.” 4. DED medical record review revealed Patient #19 arrived to the emergency department on 05/07/2024 at 0003. Review revealed an arrival complaint of “possible miscarriage.” Vital signs at 0008 were blood pressure 123/82, temperature 98.3, pulse 93, respirations 20, SpO2 98% on room air with abdominal pain pain score of 8 - severe pain. Review of the ED Triage Note at 0009 revealed “Pt c/o abd pain, cramping, and vaginal bleeding. Pt had OB urine confirmed pregancy (sic) ....EDD 1/3/25 ....Pt states bleeding started today but states abd pain and cramping started after she was hit in the stomach yesterday around 1330.” Review of the ED Provider Note, service time 0157, revealed “ ...HPI [space] 27-year-old female with no medical history presents to the ED with a chief complaint of threatened labor and vaginal bleeding that started at 11PM on 5/6/2024. Patient reports that she was assaulted yesterday and points to her belly. She reports that her ex-boyfriend assaulted her and he is now along. She denies any dizziness chest pain shortness of breath but reports abdominal cramping and vaginal bleeding. She has tissue noted in his (sic) lower back and it shows some moderate amount of blood. Patient is gravida 3 para 2 no abortions ....Physical Exam .... Constitutional: She is not in acute distress. Appearance: She is not ill-appearing, toxic-appearing or diaphoretic ....Abdominal ....Palpations: Abdomen is soft. Tenderness: There is abdominal tenderness .....CBC WITH DIFFERENTIAL ....WBC ....11.83 (H) .... MPV ....11.5 (H) ....Absolute Neutrophils .... 8.29 (H).... Absolute Immature Granulocytes.... 0.03 (H) .... URINALYSIS ....Color ....Amber (A) .... Clarity .... Turbid (A) ....Hemoglobin ....3+ (A) .... Ketones .... 1+ (A) .... Protein ....1+ (A) .... RBC .... >182 (H) .... WBC ....85 (H) ....Squamous Epithelial Cells ....Few (A) ....Medications Ordered/Administered .... Acetaminophen ....650 mg .... Oral . ...” Further review of the ED Provider Note revealed “....ASSESSMENT / MEDICAL DECISION MAKING .... ED COURSE ....1527: Patient informed the nurse that she is not waiting until the morning for her ultrasound. She reports that she is going. Patient left AMA. [space] DIAGNOSIS 1. Left against medical advice ....Patient and I reviewed signs/symptoms of worsening or progressing illness that could develop, and would require seeking urgent or emergent care. Patient expressed understanding. Patient verbalized understanding of instructions and all things reviewed today. ...” Review of an ED RN Note, at 0328, revealed “Patient states that she does not want to stay for the U/S in the morning. Patient states that she will follow up with her OBGYN today.” Timeline review at 0329 revealed “Patient discharged.” Record review did not reveal an AMA form or evidence of explaining the risks of leaving to Patient #19. Telephone interview on 10/01/2024 at 1029 with NP #26 revealed the NP did not recall Patient #19. Interview revealed the statement that the ex-boyfriend was “now along” was a typo. NP #26 stated “100% the ex-boyfriend was not there....would have called hospital police. ...” Interview revealed no recollection of the “tissue” documented and indicated a “moderate” amount of bleeding was more than scant/small but not saturating multiple pads and no clots. Interview revealed Hospital A did not have ultrasound 24/7 and the NP explained to patients they would there between 7:00 and 8:00 am. NP #26 stated the majority of times patients did not wait, they had already left by the time the NP got notified. NP #26 indicated “If I saw her before she left I would have documented ....I go over risks of leaving and benefits of staying.” In regards to assault, NP #26 indicated that while the NP did not typically document it, if she was worried for a patient’s safety NP#26 would 100% take action for the patient up to and including locking down the ED. Interview revealed NP #26 did not recall anything like that happening lately. Telephone interview with RN #27 on 10/01/2024 revealed the RN was a travel nurse who arrived to this hospital in March 2024. Interview revealed RN #27 thought “vaguely recalled” Patient #19 but did not recall any specifics. Interview revealed the RN remembered trying to talk someone into staying, telling the patient they needed the test to receive “definitive care” and explaining the reasons why but could not say if it was this patient. 50111 5. Review on 09/27/2024 of the hospital policy “Vital Signs in the Emergency Department,” effective 12/2022, revealed, “... 4. Patients who are waiting to be roomed in the ED (Emergency Department) should have vital signs assessed at a minimum of every (2) hours until a treatment room is available ...” Review of the medical record for Patient #1 (Pt) revealed a 29 year old female that presented to the ED on 09/24/2024 at 1532 by private vehicle for a chief complaint of vaginal bleeding. The nursing triage assessment was initiated at 1558. Pt #1 indicated that the onset of symptoms began at 0700 on 09/23/2024. Triage vital signs, completed at 1600, revealed Blood Pressure (BP) 102/60, oral temperature 36.9 degrees Celsius, heart rate 74, respiratory rate 18, oxygen saturation 99% on room air, height 165.1 centimeters and weight of 123.4 kilograms. Pt #1 reported a pain level of 6/10 on a numerical pain scale. The triage notes at 1602 revealed Pt #1 came to the ED complaining of vaginal spotting associated with lower abdominal cramping that started the day prior. Pt #1 reported no bleeding on 09/24/2024. The triage note revealed Pt #1 was “Gravida 5, Para 2, Miscarriage 1, Abortion 1.”(five pregnancies with 2 living) Pt #1 was triaged at an acuity level “3” (scale of 1 - 5 with 1 the most emergent). Pt #1 was placed in an ED room at 1641. A urine pregnancy screen, urinalysis, and chlamydia/gonorrhea microbiology labs were ordered at 1708. Review of the ED Provider Note dated 09/24/2024 at 1738 revealed, “ ... Medical Decision Making ... 29-year-old female currently pregnant did not want to wait for full evaluation and lab work as well as ultrasound she left AMA (against medical advice). Urinalysis positive for WBCs, RBCs, leukocytes. Pregnancy positive. Patient was clinically stable prior to leaving AMA ... Clinical Impressions ... Threatened Abortion ...” Review of the AMA form revealed two sections of the form “To be completed by a physician:” were not completed by the provider. The sections were as follows: “A. The examination and/or treatment recommended and refused:” and “B. The likely dangers of refusal of such examination and/or treatment may include, but are not limited to the following:” Review revealed the AMA form was signed by the patient, by a nurse as a witness, and by the provider at 1742 on 09/24/2024. Review of the ED Notes at 1756 revealed, “Patient refused treatment and signed AMA form. Patient ambulated to the ed lobby with family and left via private vehicle.” Pt#1 was discharged at 1759. Review of the medical record failed to reveal evidence that the risks of leaving AMA were discussed with Pt #1. Interview on 09/27/24 at 0925 with the ED Manager (Manager #3) revealed the ED provider should discuss the risks of leaving AMA with patients. Interview revealed the ED provider was responsible for documenting the discussion. Telephone interview on 09/27/2024 at 1101 with the ED Medical Director (MD #1) revealed the risks of leaving should be discussed with patients that request to leave AMA. Interview revealed providers were expected to document the conversation in a provider note or in the history and physical examination note. 6. Review on 09/27/2024 of the hospital policy “Vital Signs in the Emergency Department,” effective 12/2022, revealed, “... 4. Patients who are waiting to be roomed in the ED (Emergency Department) should have vital signs assessed at a minimum of every (2) hours until a treatment room is available ...” Review of the EMTALA policy, effective 11/2022, revealed “...(Hospital A) is committed to complying with the Emergency Medical Treatment and Labor Act....and the implementing regulations....EMTALA requires that a hospital with an emergency department provide to any individual who is not a patient of the hospital and who ‘comes to the emergency department’ an appropriate medical screening evaluation within the capability of the hospital’s emergency department to determine whether an Emergency Medical Condition exists....If an Emergency Medical Condition is determined to exist, the hospital must provide any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or an appropriate transfer. ...” The “Refusal of Care Leaving the Hospital AMA Leaving the Hospital ED WOT...”, effective 10/2022, revealed “...Definitions...B. AMA....1. Patient who leave any area of the ED prior to planned discharge and who have been examined by a clinician ....or have received any evaluation or treatment via nurse-implemented protocol.... It should be used if the patient receives any tests including FSBS (Fingerstick blood sugar).... ED Team members will make every reasonable effort to prevent departure pirior to discharge...Efforts will be documented in the medical record....If possible, risks of leaving and benefits of remaining to complete discharge will be discussed with the patient....Patient who leave from the lobby will be called multiple times prior to changing status to LWOT or AMA....The medical record should reflect all attempts. ...” Review of the closed medical record for Patient #14 (Pt) revealed a 19-year-old male that presented to the ED (Emergency Department) on 12/29/2022 at 1206 by private vehicle for a chief complaint of vomiting. The nursing triage assessment was initiated at 1221 with documentation that Pt #14 presented with back pain, chest pain, and abdominal pain when vomiting. The patient indicated that the onset of symptoms began at 0700 on 12/28/2022. Vital signs, completed at 1222, revealed Blood Pressure (BP) 117/77, oral temperature 37.5 degrees Celsius, heart rate 87, respiratory rate 18, oxygen saturation 98% on room air, and weight of 68 kilograms. Review revealed no documentation of pain assessment for Pt #14 during triage. Pt #14 was triaged at an acuity level of “2” (scale of 1 - 5 with 1 the most emergent) at 1227. A chest x-ray, EKG (electrocardiogram), and Troponin every 3 (three) hours for 3 occurrences were ordered at 1228. Review of the EKG performed at 1231 and revealed, “Borderline ECG ... Sinus rhythm ... normal P axis ... Borderline T wave abnormalities ...” Review of the chest x-ray performed at 1237 revealed, “No acute cardiopulmonary disease.” The Troponin level resulted at 1318 and was within normal range. Record review failed to reveal evidence that the ordered subsequent Troponin levels were collected. Review revealed Pt #14 was called in the ED lobby with no answer at 2304 (10 hours and 58 minutes after arrival) and at 2315 (11 hours and 9 minutes after arrival). Pt #14’s disposition was set to AMA (Against Medical Advice) at 0135. Pt #14 was discharged at 0136 (13 hours, 15 minutes after arrival). Review failed to reveal evidence of a discharge order or that discharge instructions were given to Pt #14. Medical record review failed to reveal evidence of ongoing assessment of Pt #14 while in the ED waiting room. Interview on 09/27/24 at 0925 with the ED Manager (Manager #3) revealed patients assigned an acuity level of “2” would ideally be taken into an ED room within 30 minutes of arrival if a room was available; however, the ED Charge Nurse (RN) made the decision to room patients based on acuity, vital signs, and the chief complaint. Interview revealed the Charge RN would room the patients who presented as the “sickest” first. Manager #3 stated that patient should have vital signs assessed every 2 hours in the waiting room to monitor the patient for a change in condition or worsening status. Interview revealed ordered labs should have been drawn for Pt #14 and patient care should have been continued in the waiting room. Interview on 09/26/2024 at 1543 with the Nursing Director for Critical Care (Director #2) revealed the triage nurse was responsible for obtaining a complete set of vital signs during triage, including a pain assessment. Director #2 revealed the Triage RN was responsible for obtaining all ordered Troponin levels and the ongoing evaluation of patients in the ED waiting room. The Triage RN (RN#4) was unavailable for interview. The Charge RN (RN#5) was unavailable for interview. #7. Review of the closed medical record for Patient # 13 (Pt) revealed a 72-year-old female that presented to the ED on 12/29/2022 at 1256 by EMS (Emergency Medical Services) for a chief complaint of pain. The nursing triage assessment was initiated at 1325 with documentation that Pt #13 presented with pain all over the body “since Sunday” (4 days prior to arrival to the ED). The patient indicated that the pain was worse in the chest and radiated to her back and reported shortness of breath. Vital signs, completed at 1325, revealed Blood Pressure (BP) 120/80, oral temperature 36.8 degrees Celsius, heart rate 82, respiratory rate 18, oxygen saturation 97% on room air, and weight of 81.6 kilograms. Review revealed no documentation of pain assessment for Pt #13 during triage. Review revealed the chief complaint was updated to chest pain and pain (non-specific) at 1327. Pt #13 was triaged at an acuity level of “2” (scale of 1 - 5 with 1 the most emergent) at 1329. A chest x-ray, EKG (electrocardiogram), and Troponin every 3 (three) hours for 3 occurrences were ordered at 1330. Review of the EKG performed at 1333 revealed abnormal findings of “Borderline right axis deviation ... QRS axis (81,90) ... Minimal ST depression, inferior leads ... When compared with ECG of 22-Dec-2022 15:52:23, Sinus Rhythm ...” The chest x-ray performed at 1338 revealed, “Interval small left pleural effusion with mild adjacent atelectasis and or consolidation in the left lung base. An infectious process to be excluded.” The Troponin level resulted at 1412 and was within normal range. Record review failed to reveal evidence that the ordered subsequent Troponin levels were collected. Review revealed Pt #13’s disposition was set to AMA (Against Medical Advice) at 1841. Pt #13 was discharged at 1842 (5 hours, 46 minutes after arrival). Review failed to reveal evidence of a discharge order, discharge instructions were given, or the patient was called multiple times in the waiting room prior to changing Pt #13’s status to AMA. Medical record review failed to reveal evidence of ongoing assessment of Pt #13 while in the ED waiting room. Interview on 09/27/24 at 0925 with the ED Manager (Manager #3) revealed patients assigned an acuity level of “2” would ideally be taken into an ED room within 30 minutes of arrival if a room was available; however, the ED Charge Nurse (RN) made the decision to room patients based on acuity, vital signs, and the chief complaint. Interview revealed the Charge RN would room the patients who presented as the “sickest” first. Manager #3 stated that patient should have vital signs assessed every 2 hours in the waiting room to monitor the patient for a change in condition or worsening status. Interview revealed ordered labs should have been drawn for Pt#13 and patient care should have been continued in the waiting room. Interview on 09/26/2024 at 1543 with the Nursing Director for Critical Care (Director #2) revealed the triage nurse was responsible for obtaining a complete set of vital signs during triage, including a pain assessment. Director #2 revealed the Triage RN was responsible for obtaining all ordered Troponin levels and the ongoing evaluation of patients in the ED waiting room. Interview revealed nurses should attempt to call patients at least two times and document the attempts in a nursing note if it was believed that a patient departed the ED waiting room. The Triage RN (RN#4) was unavailable for interview. NC00217803; NC00217901; NC00206503; NC00205442; NC00196576; NC00196517; NC00196564”