F F Thompson 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: 49205 Based on policy review, medical record review, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1 of 20 medical records reviewed. Specifically, the emergency department (ED) staff failed to provide oversight of care and an appropriate medical screening examination within the capability of the hospital’s emergency department, to determine whether an emergency medical condition existed (Patient #1). Reference: 489.24(a) & 489.24(c): Medical Screening Examination”

“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: 49205 Based on policy review, medical record review, document review, and interview, in 1 of 20 emergency medical records reviewed, emergency department (ED) staff failed to provide oversight of care and an appropriate medical screening examination within the capability of the hospital’s ED, prior to the arrest and removal from the waiting room by police (Patient #1). Findings include: Review of the policy “Emergency Medical Treatment, Screening, Stabilization and Transfer (EMTALA), “ effective 09/22/21, revealed each individual presenting to the dedicated ED requesting an emergency examination or treatment shall be offered a medical screening examination (MSE) to determine if the individual has an emergency medical condition (EMC). The MSE must be sufficient to determine if an EMC exists. If a patient refuses to consent to examination, treatment or transfer deemed medically appropriate, the Hospital must inform the patient or his or her legal representative of the risks and benefits of the decision to the patient. The Hospital must take all reasonable steps to secure the individual’s written informed consent to refuse such examination, treatment or transfer. If the patient refuses to sign the informed consent to refuse examination, treatment or transfer, it must be documented in the medical record. Review of the policy “Emergency Department Medical Screening Examination and Qualified Personnel,” effective 10/23/24, revealed all patient presenting to the ED for evaluation will receive a MSE to determine if an EMC exists. The MSE will be performed by a physician, physician’s assistant, or nurse practitioner under the direct supervision of a physician. The MSE will consist of an appropriate history and physical examination, and if pertinent, ancillary tests, procedures and/or consults. Review of the policy “Emergency Department Triage and Waiting Room Guidelines,” effective 10/28/24, revealed the purpose of triage in the ED is to gather information on the patient’s overall condition, prioritize incoming patients based on acuity, and identify those who need to be immediately evaluated, and those who can safely wait to be seen. The triage nurse performs a brief review of what brings the patient to the ED and assigns the patient an ESI acuity level. This is a proxy measure and national standard of how long an individual can safely wait for a medical examination and treatment in the ED. There is a process for making decisions which patient may safely wait for evaluations. Reasons patients may wait to be seen include patient volume, acuity, or safety. At triage, patients identified as having non-critical problems will have a complete set of vital signs taken. The decision to keep a patient in the waiting room is made based upon the chief complaint, vital signs, and judgment of the triage nurse and/or provider. The nurse should notify a provider for evaluation of a patient if there is any concern that the patient in triage or in the waiting room needs their evaluation expedited. Review of the policy “Against Medical Advice (AMA),” effective 10/28/24, revealed for emergency department (ED) left without being seen (LWBS) patients, staff will document the circumstances surrounding the departure. Review of the emergency department (ED) medical record for Patient #1, dated 07/31/25, revealed the following: - At 02:54 PM, Patient #1 arrived, ambulatory (walked in) at the ED. - At 03:05 PM, Patient #1’s vital signs were a temperature of 97.3 degrees (normal range 96-99 degrees) Fahrenheit, a heart rate of 83 (normal range 60-100) beats per minute, respirations of 18 (normal range 12-20) breaths per minute, a blood pressure of 130/94 (normal range 90-140/60-90) millimeters, an oxygen saturation (percent of oxygen carrying blood cells that contain oxygen) of 97 (normal range 93-100) percent, and a weight of 200 pounds. - At 03:18 PM, an ED triage note by Staff (R), Registered Nurse (RN), revealed Patient #1 complained of having scratches to both legs and foot pain after walking outside for the past two days. Patient #1 stated “I don’ t want to talk to you, I want to talk to a priest.” Patient #1 reported being homeless and hungry. Patient #1 was assigned an acuity level of 4 or “less urgent” (1-immediate life-saving intervention, 2-emergent, 3-urgent, 4-less urgent, 5-non-urgent). - At 03:23 PM, the violence risk screening assessment by Staff (R), RN, revealed Patient #1 was at risk for violence based on their behaviors (staring and eye contact, tone, anxiety, mumbling, and pacing). The “Violence Assessment Tool (0 = low risk, 6-10 = high risk) indicated a score of 9, Patient #1 was at high risk for violence and/or danger. Patient #1 scored one point each for the following categories: history of violence, irritable, boisterous, verbal threats, agitated/impulsive, paranoid/suspicious, substance intoxication/withdrawal, socially inappropriate/disruptive behavior, and body language. Patient #1 was not confused, was not physically threatening, and was not attacking objects. Hunger was listed as a contributing factor. - At 03:50 PM, an ED note by Staff (J), Patient Care Technician (PCT), revealed Patient #1 was laying on the floor of the waiting room blocking the path of other patients. Staff (J) asked Patient #1 to get up from the floor and Patient #1 refused. Patient #1 became extremely agitated. Staff (J) called security to assist with getting Patient #1 off the floor. Security arrived. Patient #1 continued to refuse to get off the floor and made verbal threats of harming the staff members. Local law enforcement officers were called. - At 04:00 PM, Patient #1’s disposition was as left without being seen-before triage, “procedure and treatment not carried out due to patient leaving prior to being seen by health care provider.” (There was no documentation by the medical and/or nursing staff of the patient event in the waiting room including instructing staff to contact security and the police; the monitoring of Patient #1’s condition while the event was occurring; if a medical screening examination was conducted or why it could not be performed; when Patient #1’s care was transferred to law enforcement; and what Patient #1’s final disposition was despite being arrested and removed by police from the ED waiting room. No ED provider had contact with Patient #1). Review of the medical record for Patient #1 at another facility, dated 07/31/25 at 04:37 PM, revealed Patient #1 arrived at the ED in the custody of a law enforcement officer under a Mental Hygiene Law 9.41 status (a law which allows law enforcement officers the authority to take into custody any person who appears to be mentally ill and is acting in a way that presents a “likelihood of serious harm” to themselves or others). The law enforcement officer reported that Patient #1 had been laying on the floor at Hospital #1 who stated they were angry, and they were going to hurt people. Patient #1 was evaluated by Comprehensive Psychiatric Emergency Program Emergency Room (CPEP) provider who determined that Patient #1 needed psychiatric hospitalization but there were no inpatient psychiatric beds available at the facility. On 08/01/25, Patient #1 was transferred to a third hospital (Hospital #3) on a 9.37 Mental Hygiene Law 9.37 (emergent involuntary admission) status. Review of an incident report, dated 07/31/25, revealed the following: - (On 07/31/25), hospital security officers were called to respond to the ED waiting room because Patient #1 was laying on the floor. Staff (O) and Staff (S) approached Patient #1 and asked Patient #1 to sit in a chair or wheelchair. Patient #1 became aggressive and threatened to “kill” the security officers. Local law enforcement officers were called. As soon as law enforcement officers arrived, Patient #1 was taken into law enforcement officers’ custody under Mental Hygiene Law 9.41. Patient #1 was cooperative with law enforcement officers while being escorted out of the facility. Patient #1 was transported to an ED at another facility by law enforcement. - On 08/01/25 at 09:12 AM, Staff (P), ED Director of Nursing, revealed they were present at the time of the incident after being advised that there was a patient who would “kill” anyone who touched them. Staff (P) observed Patient #1 lying on the ED waiting room floor, verbally threatening the security officers, and using other obscenities. Staff (P) spoke with the triage RN who reported Patient #1 was flagged as a violence risk. Staff (P) spoke with the provider assigned to the triage area, who reported they would complete a medical screening exam once it could safely be done. Staff (P) went back into the ED and updated the Charge Nurse. Staff (P) then returned to the ED waiting room and Patient #1 had already been removed from the facility. Staff (P) was notified by security officers that Patient #1 had been arrested under mental health arrest by law enforcement officers who were taking Patient #1 to another hospital. (No documentation of the event was found in the medical record by Staff (P). - The incident report was closed by the security department (unknown date). Security had no way of knowing if Patient #1 had been medically evaluated or not. Patient #1 was in the waiting room where discharged patients commonly sit to wait for transportation. Communication should have been provided to security officers upon their arrival to the waiting room. Interview on 09/04/25 at 09:36 AM and on 09/04/25 at 03:10 PM, Staff (J), Patient Care Technician, revealed triage technicians are staffed 24/7 in the ED and are there to obtain vital signs on patients after the registration process. Patients are triaged by the RN and assigned an acuity score. Some patients are placed back into the waiting room according to the acuity score until a room or provider is available. Patients in the waiting room will have their vital signs taken at different times until they are seen. Staff (J) was working in triage when Patient #1 presented to the ED for leg pain. Staff (J) performed vital signs on Patient #1 prior to being seen by the triage nurse. The triage nurse saw Patient #1 and asked for them to wait in the waiting room. Patient #1 became agitated and making threats. At some point, Patient #1 laid down on the floor in the middle of the waiting room and refused to get up. Staff (J) asked Patient #1 to get up from the floor with assistance for their safety and safety of others in the waiting room. Patient #1 refused to get off the floor, so security was called for assistance. Patient #1 continued to threaten to kill everyone, so security called law enforcement to respond. The law enforcement officers arrived within minutes, entered the waiting area, spoke with Patient #1 for a very brief period, and placed Patient #1 in handcuffs. Patient #1 was removed from the ED in the custody of law enforcement officers. Staff (J) was advised by one of the Security Officers that Patient #1 was placed under Mental Hygiene 9.41 arrest and was being taking to another ED. Interview on 09/04/25 at 01:20 PM, Staff (O), Security Officer, revealed they just arrived on shift when they were requested to respond to the ED waiting room for a potential violent patient who was laying on the floor. Patient #1 was lying on the floor blocking access for staff and patient to get to the treatment area. Staff (O) asked Patient #1 to get off the floor and offered to get a wheelchair if Patient #1 did not feel comfortable sitting in a waiting room chair. Patient #1 refused the offer and refused to get off the floor. Patient #1 became verbally aggressive by threatening to harm and kill the security officers. There were several other patients in the waiting room that day who appeared visibly shaken by the actions of Patient #1. The other security officer called local law enforcement to respond to help de-escalate the situation. While waiting for law enforcement officers to arrive, Staff (O) helped ensure the safety of the other patients by assisting them away from Patient #1. Law enforcement officers arrived within minutes of being called. Law enforcement officers walked to Patient #1 and told them to get up off the floor. Patient #1 continued to refuse to get off the floor and started threating to kill the law enforcement officers. Law enforcement officers then assisted Patient #1 from the floor to a standing position, before placing handcuffs on Patient #1. Law enforcement officers told Patient #1 that they were under mental health arrest and immediately removed Patient #1 from the facility. Staff (O) did not recall advising any of the medical staff as to what transpired with Patient #1. Staff (O) filed an incident report documenting what took place. Staff (O) was unaware at the time if Patient #1 had received a medical screening exam or not. Interview on 09/04/25 at 01:50 PM, Staff (S), Security Officer, revealed they responded with Staff (O) to the waiting room of the ED for Patient #1. Patient #1 was asked to remove themselves from the floor numerous times for safety. Patient #1 began to make death threats and verbally harass everyone in the waiting room; therefore, the non-emergency law enforcement office number was called for assistance. The law enforcement officers arrived and arrested Patient #1 under a mental health arrest. Patient #1 was distressed and agitated. Staff (S) and Staff (O) did not notify the medical staff Patient #1 was leaving the premises. Interview on 09/09/25 at 09:55 AM, Staff (W), ED Provider, revealed they were working as the provider in triage. Staff (W) was notified there was a patient in the waiting room, who had been flagged as a potential violence risk, and had been triaged. When Staff (W) was ready to see Patient #1, they were advised that Patient #1 was being aggressive, threatening to kill staff, and that law enforcement had been called to ensure staff and patient safety. Staff (W) continued to see other patients, as there were approximately 20 other patient who still needed medical screening exams. Staff (W) was advised that when law enforcement showed up, they immediately placed under Mental Hygiene 9.41 arrest and removed Patient #1 from the hospital. Staff (W) was under the impression that law enforcement officers were called to ensure the safety of the patients and staff in the waiting room, as well as to de-escalate Patient #1 so Staff (W) could safely provide an MSE.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48506 Based on medical record review, policy review, and interview, in one of one medical records, the hospital failed to ensure that nursing staff documented two unsuccessful attempts of placement of a weighted feeding tube. Specifically, the unsuccessful placement of the weighted feeding tube caused a pneumothorax (air leak into the space between the lung and chest wall). (Patient #1) Review on 02/21/25 of policy “Weighted Feeding Tube”, dated 06/17/09, revealed insertion of the weighted feeding tube documentation should include the size of the tube, placement, insertion site, verification of placement, drainage (if any), x-ray, and the comfort level of the patient. (The policy did not address the need for documentation of a tube that was not placed in the correct position.) Review on 02/21/25 of policy “Assessment and Documentation”, dated 06/14/24, revealed patient care will be governed by the attached standards of nursing care. The nursing standards of care revealed a head-to-toe assessment is required on a change in status and intervention. (The policy did not address the need for documentation of an adverse event of an intervention.) Review on 02/21/25 of the medical record of Patient #1 revealed no evidence of nursing documentation of two unsuccessful placements of a weighted feeding tube on 08/05/24. On 08/05/24 at 07:12 PM, Staff (N), Physician, documented a significant event that revealed a weighted feeding tube was attempted twice and unfortunately it was difficult to place the feeding tube and the x-ray showed the feeding tube tip in the right lung. The tube was pulled out and the next x-ray revealed a small to moderate pneumothorax. Interview on 02/20/25 at 02:15 PM with Staff (O), Registered Nurse, revealed that they were the primary nurse for Patient #1 on 08/05/24. Staff (O) did not recall inserting the weighted feeding tube for Patient #1. If there was difficulty with placement of the weighted feeding tube, they likely would have asked Staff (K), Registered Nurse to assist in the procedure. If there were any complications while attempting to place the weighted feeding tube it would be documented in a free text note in the electronic medical record. Interview on 02/20/25 at 02:25 PM with Staff (K), Registered Nurse, revealed that Staff (K) did not recall the exact events of the weighted feeding tube insertion on 08/05/24 but stated “my guess would be that Staff (O), Registered Nurse, attempted to place the weighted feeding tube and was unsuccessful.” Staff (K) would have made the second attempt of insertion. Staff (K) stated “I assume that I gave the patient (Patient #1) a pneumothorax, but I don’t recall actually placing the tube.” The x-ray showed the weighted feeding tube was in the right lung, and it was removed. Patient #1 ended up with a small pneumothorax in the right lung. The attempted insertion of the weighted feeding tube would be charted in a free text note in the electronic medical record by the bedside nurse. Interview on 02/20/25 at 01:30 PM with Staff (F), Quality Nurse, verified that there was no nursing documentation of the insertion of a weighted feeding tube for Patient #1 on 08/05/24.”

“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: 49203 Based on medical record review, policy review, document review, and interviews, it was determined that clinical staff failed to follow policies and procedures governing the care provided in the emergency department. Medical record review revealed Patients #1, Patient #2, and Patient #3 arrived in the emergency department with the complaint of chest pain, were triaged with an Emergency Severity Index level 2 (emergent-30-minute vital signs required), and sent back to the waiting room. Emergency department staff did not place Patient #1, Patient #2, or Patient #3 on a cardiac monitor, vital signs were not obtained every 30-minutes, an electrocardiogram (EKG) was not obtained (Patient #3 only), blood work including a troponin level was not obtained (Patient #3 only), and an IV access was not started per facility policy. On 03/20/24 at 01:41 PM, an Immediate Jeopardy was identified for the CoP of Emergency Services. The facility implemented immediate interventions that included updating policies & procedures with staff education related to the monitoring of patients who must wait in the waiting room before being placed in the emergency department treatment area. Vital sign frequency audits were implemented and will be reviewed by the Nursing Quality Office and presented at the Nursing Practice Quality and Safety Steering Committee. On 03/20/24 at 06:41 PM, the Immediate Jeopardy was removed based on onsite surveyor verification of the immediate actions implemented by the facility through observations, policy review, document review, and interviews. Cross Reference: 482.55 (a) (3) Emergency Services.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 49203 Based on medical record review, policy review and interview, the facility failed to follow policies governing the care provided in the emergency department: 1.Staff are not providing ongoing and continuing assessment of the care provided in the emergency department for cardiac patients. 2.Staff did not follow the policy for patients who leave without being seen for Patient #1. Failure to follow established policies has the potential for a delay and/or lack of identification of an adverse patient event. Findings #1: Review of the policy “ Emergency Department Triage and Documentation “dated 11/15/12 indicated that all patients presenting to the emergency department for care will be triaged and seen by medical providers according to the severity of their illness/injury. A triage severity category will be assigned to each patient using the five-level “Emergency Severity Index (ESI),” after the initial nursing assessment and interview. If the patient’s medical status changes, the assigned triage category will change. Category level two: (Unstable) is a life-threatening condition that may deteriorate or with symptoms requiring time sensitive interventions. An example is a patient with chest pain, age 25 and greater, with severe shortness of breath and severe pain. -All patients in these categories (category 2) will be taken immediately to the treatment area. A registered nurse is directly responsible for care of all category one and two patients, including assessments and reassessments. -All patients placed on the cardiac monitor will have an initial rhythm strip read and attached to the patient’s medical record. -Vital signs (blood pressure, apical pulse, respiratory rate) and patient assessment for all category level one and level two patients must be documented at least every one-half hour unless less frequently ordered by the physician. Vital signs and reassessment will be documented more frequently than every one-half hour at the nurse’s discretion or physician order depending on the patient’s physical condition. Review of the policy “Cardiac Monitoring” dated 07/27/18, indicated that cardiac monitoring is required in the emergency department based on presenting symptoms. Review of the policy “Specific Treatment Guidelines-Emergency Department,” dated 09/22/21 indicated that any patient who presents with suspicious chest pain or an abnormal rhythm, the nursing staff will do the following: -Monitor the ABC’s (airway, breathing and circulation). -Immediately contact the emergency department physician. -Establish an IV (intravenous access). -Begin oxygen therapy, only if oxygen saturation is below 90%. -Do an EKG (electrocardiogram). -Establish cardiac monitoring. Review of the emergency department medical record dated 01/09/24 for Patient #1 revealed the following: -At 11:05 AM, Patient #1 presented to the emergency department with the complaint of chest pain. -At 11:13 AM, vital signs were completed. The blood pressure was 173/88 with an oxygen saturation (percent of oxygen in the blood) of 98%. Patient #1’s pain level was reported at five out of ten (one indicating no pain, 10 indicating the worst pain). -At 11:22 AM, Staff (I), Triage Nurse documented that Patient #1 presented with chest pain which radiated into the neck and down both arms. Patient #1 denied shortness of breath, vomiting, fever and chills however reported nausea. Patient #1 took chewable aspirin, 324 mg prior to arriving to the emergency department. Patient #1 was assigned an Emergency Severity Index (ESI-measurement of illness severity) of two. -At 12:45 PM, Staff (H), Nurse Practitioner documented that 30 minutes prior to arrival to the emergency department, Patient #1 noted sudden onset of centralized chest pain with heaviness that radiated to both the right and left arm. Patient #1 denied recent illness, was not coughing and/or did not have hemoptysis (cough producing blood). Patient #1 did not have a history of cardiac disease but identified a family history of cardiac disease. Orders were placed for an electrocardiogram (EKG-test to check heart rhythm), chest x-ray, and bloodwork including a troponin level (test to determine a cardiac attack). - At 12:45 PM, the electrocardiogram revealed minimal inferior ST elevations (possible indication of a heart attack). -At 12:55 PM, the chest x-ray revealed that Patient #1’s lungs were clear and there was no sign of pleural effusion (accumulation of fluid in the cavity surrounding the lungs), pneumothorax (collection of air outside of the lung but within the cavity surrounding the lung) or acute osseous abnormalities (bone abnormalities). No definite acute cardiopulmonary disease was identified. -At 03:12 PM, Patient #1 was discharged from the system with a discharge disposition of left without being seen. -At 03:15 PM, a troponin result of 34 (normal range per facility criteria) was documented. (Patient #1 was not placed on a cardiac monitor, vital signs were not obtained every 30 minutes, and an IV access was not started per facility policy). Review of the emergency department medical record for Patient #2 dated 03/19/24 revealed the following: -At 09:16 AM, Patient #2 presented to the emergency department with complaints of dizziness, chest pain, and nausea. Patient #2 has a history of depression, hypertension (high blood pressure), Multinodular Goiter (an enlarged thyroid caused by multiple thyroid nodules), Sickle Cell Trait (an inherited blood disorder), Migraine, Iron Deficiency, and Hashimoto’s Thyroiditis (the immune system causes the death of the cells in the thyroid that make hormone). -At 09:45 AM, an electrocardiogram (EKG-test to record the electrical signals in the heart) was performed. -At 09:46 AM, Patient #2 was triaged. Vital signs were obtained with a blood pressure of 122/77, respirations of 18 breaths per minute, a temporal (side of the head) temperature of 97.7 Fahrenheit, oxygen saturation (amount of oxygen in the blood) of 97%, a heart rate of 87 beats per minute, and chest pain of eight out of ten (score of one the least pain, 10 the worse pain). An emergent or an Emergency Severity Index of two (emergency: could become life threatening) was assigned. Patient #2 was returned to the emergency department waiting room. -At 11:09 AM, repeat vital signs were obtained with a blood pressure of 131/73, respirations of 14 breaths per minute, oxygen saturation of 98%, and a heart rate of 79 beats per minute. -At 12:43 PM, Patient #2 was moved from the waiting room to emergency department hallway bed five. -At 12:45 PM, a medical screening examination was completed on Patient #2. The physician ordered continuous telemetry (cardiac monitoring), a covid/influenza test, and a blood work, including a troponin level (test to determine a cardiac attack). -At 01:03 PM, the nursing documented that Patient #2 had mid chest pain that radiated to the left side and under the breast. -At 02:00 PM, Patient #2’s lying blood pressure was 127/66. -At 02:02 PM, Patient #2’s sitting blood pressure was 122/78. -At 02:03 PM, Patient #2’s standing blood pressure was 119/76. -At 02:31 PM, an electrocardiogram was performed. -At 02:38 PM, Patient #2 was moved from the waiting room to emergency department hallway bed 12. At 03:21 PM, Patient #2’s vital signs were obtained with a blood pressure of 125/70, respirations 20 breaths per minute, a temperature of 98.2 Fahrenheit, oxygen saturation (amount of oxygen in the blood) of 98%, and a heart rate of 72 beats per minute. -At 04:00 PM, Patient #2’s vital signs were obtained with a blood pressure of 138/79, oxygen saturation of 98%, and a heart rate of 77 beats per minute. -At 04:55 PM, Patient #2 was discharged from the emergency department with an after-visit summary report and was instructed to follow-up with their primary medical provider as soon as possible or return to the emergency department for any worsening or concerning symptoms. (Patient #2 was not placed on a cardiac monitor, vital signs were not obtained every 30 minutes, and an IV access was not started per facility policy). Review of the emergency department medical record for Patient #3 dated 03/19/24 revealed the following: -At 12:36 PM, Patient #3 arrived in the emergency department with a complaint of chest pain, flank pain, and blood in the urine. Patient #3 had a history of atrial fibrillation (irregular heart rhythm) status post cardioversion (returns heartbeat to normal rhythm), aortic aneurysm (a balloon-like bulge in the aorta, the large artery that carries blood from the heart through the chest and torso), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Patient #3 was anticoagulated (a substance used to prevent and treat blood clots in the blood vessels and heart). -At 12:55 PM, Patient #3 was triaged. An emergent or an Emergency Severity Index of two (emergency: could become life threatening) was assigned. Vital signs were obtained with a blood pressure of 141/101, respirations of 20 breaths per minute, a temporal temperature of 97.5 Fahrenheit, oxygen saturation (amount of oxygen in the blood) of 95%, a heart rate of 91 beats per minute, and four out of 10 chest pain. Triage was completed and Patient #3 was returned to the emergency department waiting room. -At 01:55 PM, Patient was taken from the waiting room to emergency department room five. -At 02:13 PM, a medical screening examination was conducted by the physician with a differential diagnosis of decompensated heart failure (a structural or functional change in the heart leading to the inability to pump blood) from atrial fibrillation (abnormal heartbeat). The physician also ordered bloodwork and urine laboratory studies for Patient #3, including obtaining a troponin level, and an electrocardiogram. (There is no indication in the medical record that this was completed or reviewed by a physician). -At 02:44 PM, blood was collected for labs. -At 03:34 PM, urine was collected via straight catheterization, for an urinalysis. -At 03:30 PM, vital signs were obtained with a blood pressure of 117/85, respirations of 24 breaths per minute, oxygen saturation of 93%, and a heart rate of 112 beats per minute. -At 03:56 PM, vital signs were obtained with a blood pressure of 125/82, respirations of 21 breaths per minute, oxygen saturation of 91%, and a heart rate of 104 beats per minute. -At 06:00 PM, vital signs were obtained with a blood pressure of 118/79, oxygen saturation of 93%, and a heart rate of 92 beats per minute. -At 07:19 PM, Patient #3 was discharged from the emergency department with an after-visit summary report instructing Patient #3 to follow-up with primary medical provider as soon as possible or return to the emergency department for any worsening or concerning symptoms. (Patient #3 was not placed on a cardiac monitor, vital signs were not obtained every 30 minutes, an EKG was not obtained, blood work including a Troponin level was not obtained per physician order, and an IV access was not started per facility policy). Interview on 03/18/24 at 02:08 PM with Staff (I), Triage Nurse, revealed that patients presenting with chest pain are triaged and electrocardiogram is done. An Emergency Severity Index (ESI) level 2 requires additional resources of care which include assessments to be done every hour to two hours and to quickly hook a patient on to a cardiac monitor. Interview on 03/20/24 at 09:51 AM with Staff (M), Nurse Practitioner, revealed that quick examinations are done on patients on cardiac monitor to decide what to order. Patients seen by the triage nurse who has chest pains will have an electrocardiogram set up before being seen by a provider. Findings #2: Review of the policy “Signing Out Against Medical Advice,” dated 10/18/23 indicated that patients may not be detained in the hospital against their wishes. The patient must be asked by the provider to sign the “Refusal of Care” form. If the patient does not wait for the physician, or the patient refuses to sign the form, the physician, and a witness, or two witnesses (Thompson Health Associates) will sign the form. When a patient leaves against medical advice, the nurse manager/nursing supervisor must be notified immediately. Patient will be discharged from computer system with a reason code of against medical advice. Review on 03/20/24 of the emergency department medical record dated 01/09/24 for Patient #1 revealed the following: -At 11:05 AM, Patient #1 presented to the emergency department with complaint of chest pain. -At 03:12 PM, Patient #1 was discharged from the electronic medical record system with a discharge disposition of left without being seen. (The medical record had no indication of when the patient left the hospital. No leave without being seen or leaving against medical advice documentation was found in the medical record). Interview on 03/18/24 at 02:19 PM with Staff (G), Attending Emergency Department Physician, revealed that staff speak to patients that may want to leave against medical advice about the implications and the need to stay to receive medical care. If they still insist on leaving, they are given a form to sign denoting that they have opted to leave against medical advice. Staff (G) stated that staff would follow up and call a patient who had an elevated troponin level who left without being seen by a provider, after test is conducted, to convince them to come back in or to seek immediate medical care somewhere else.”