Skagit Valley 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: 42597 . Based on interview, review of hospital policies and procedures, and document review, the hospital failed to implement policies and procedures for the evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to ensure patients receive a comprehensive medical screening examination (MSE) by a qualified medical professional and stabilizing treatment places patients at risk for deteriorating conditions, poor patient oucomes, and death. Findings included: 1. The hospital failed to ensure that the hospital’s medical staff bylaws, approved by the governing body, defined the qualified medical personnel (QMP) permitted to perform medical screening exams in the hospital’s emergency and obstetrical departments. Cross reference Tag A2406 2. The hospital failed to provide a comprehensive MSE within the capabilities of the staff and facilities available at the hospital. Cross-reference Tag A2406 3. The hospital failed to provide stabilizing treatment within the capabilities of the staff and the facilities available at the hospital. Cross reference Tag A2407 Due to the scope and severity of the deficiencies found, the hospital remains out of compliance with the Responsibilities of Medicare Participating Hospitals in Emergency Cases set forth in 42 CFR § 489.20 (l), (m),(q),(r) and 42 CFR § 489.24. .”

“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: 42597 . Item 1: Qualified Medical Personnel Based on interview and document review, the hospital failed to define in the medical staff bylaws, approved by the governing body, those individuals qualified to perform medical screening exams (MSEs) to rule out emergency conditions. Failure to define the individuals qualified to perform medical screening exams (MSEs) to rule out emergency conditions risks sub-standard and inconsistent care. Findings included: 1. Review of the hospital policy titled, “Emergency Patients, Screening, and Mental Health Patient Transfer,” document ID 13472, revised 01/24, showed that individuals authorized to perform MSEs were qualified medical personnel (QMP) as determined by hospital bylaws or rules and regulations. QMP permitted to perform emergency medical screening examinations include qualified members of the medical staff who are Doctors of Medicine or osteopathy, physicians’ assistants or advanced registered nurse practitioners. 2. On 07/31/25, the investigator reviewed the document titled, “SVH/SRC Medical Staff Bylaws,” revision 31, dated 01/24. The review showed that the bylaws did not define the individuals qualified to perform medical screening exams (MSEs). 3. On 07/30/25 at 11:10 AM, the investigator interviewed the Chief Medical Officer (Staff 6). Staff #6 stated that the definition of those individuals qualified to perform MSEs was contained in the hospital’s EMTALA policy, but had inadvertently been left out of the current Medical Staff Bylaws. Item 2: Appropriate Medical Screening Examination (MSE) Based on interview, document review, and medical record review, the hospital failed to ensure that all patients presenting to the Emergency Department (ED) received an appropriate medical screening exam 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, for 2 of 2 patient records reviewed (Patient #1 and Patient #2). Failure to provide an appropriate medical screening exam 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 may result in patient harm and death. Findings included: 1. Review of the hospital policy titled, “Emergency Patients, Screening and Mental Health Patient Transfer (EMTALA),” policy 13472, approved 01/24, showed that a mental health professional will be available at all times to provide a mental health screening for emergency department (ED) patients who have conditions that may indicate a psychiatric emergency. Psychiatric emergency conditions include reported suicidal or homicidal tendencies, history of recent assault, self-mutilation or destructive behaviors, patients who may indicate a danger to self or others, and/or depression with feelings of suicidal hopelessness. In addition to a mental health screening exam, a complete medical screening exam (MSE) must be documented. Patient #1 2. The investigator reviewed Patient #1’s medical record. The record showed: a. The Officer Mental Health Contact Report showed that on 02/25/25 at 8:49 PM, police were dispatched to Patient #1’s residence for a suicide attempt complaint. Patient #1 told the caller they were going to commit suicide by jumping off the bridge. When law enforcement officers (LEOs) arrived, Patient #1 had returned to the residence. Patient #1 told LEOs that they had been standing on the bridge for 45 minutes, decided not to jump, and returned home. After discussion with LEOs, Patient #1 stated that everything was fine and going to the hospital was unnecessary. After further discussion, Patient #1 agreed to go to the hospital with police for a mental health/involuntary treatment act (ITA) evaluation. b. On 02/25/25 at 9:56 PM, Patient #1 arrived in the ED for an involuntary treatment act (ITA) evaluation for suicidal ideation, escorted by law enforcement officers (LEOs). c. On 02/25/25 at 10:10 PM, a registered nurse (RN) completed a Columbia Suicide Severity Rating assessment that showed “yes” to “suicidal thoughts with method without specific plan or intent to act”, “no” to “suicide intent with specific plan,” and “no” to “suicide intent with preparatory steps or actions taken.” d. On 02/25/25 at 10:36 PM, an ED physician note stated: No SI, No HI. Normal mood and affect. After discussing with the patient, Patient #1 is expressing no suicidal ideation. Patient #1 states that this was a brief episode, has no concerning history, and states there are no firearms at home, and has a safe place to go. Patient #1 does not wish to speak with the social worker at this time and wishes for outpatient resources. Based on my evaluation, I do not think that he is in imminent risk of harm to himself, do not think he requires involuntary detention. No labs or other testing are indicated. e. On 02/25/25 at 10:40 PM, an RN note documented that the RN showed the police report to the physician with concerns that patient was not telling all of the information to him. The physician reviewed the LEO note and felt that the patient was able to be safely discharged with the resources provided. f. On 02/25/25 at 11:02 PM, Patient #1 was discharged, 66 minutes after arrival. Resources provided included instructions to “read the attached information about suicide prevention and depression”, to call Patient #1’s primary care provider to schedule an appointment, to go to the hospital’s emergency department in 3 days if symptoms worsened, and to contact and goto a crisis triage and stabilization facility which was located in another town. 3. The investigator found no evidence that Patient #1 received an evaluation conducted by a mental health professional. 4. The investigator reviewed law enforcement records. The records showed that on 02/27/25 at 4:46 PM, LEOs were dispatched to a bridge after a caller reported witnessing someone jump off the bridge. A body was recovered from the water and identified as Patient #1. Patient #2 Encounter #1 5. The investigator reviewed Patient #2’s medical record. The record showed: a. On 07/12/25 at 2:24 AM, Patient #2 arrived to the ED escorted by LEOs for an ITA evaluation for suicidal ideation. b. On 07/12/25 at 2:28 AM, a nursing suicide severity rating scale showed that Patient #2 told law enforcement that she had access to a firearm and was going to the mountains and blow her brains out. Patient #2’s suicide risk level was scored as “high”. c. On 07/12/25 at 2:34 AM a nursing note showed that at 2:24 AM, Patient #2 accompanied by LEOs, was brought back to a seclusion room in handcuffs. Patient #2 immediately began swearing at staff and a Code Gray (hospital security officer response to potentially dangerous or harmful event) was called. A physician came to the bedside when the Code Gray was called. At 2:34 the physician stated that Patient #2 could leave the department, and Patient #2 loudly exited the department, yelling at staff. d. On 07/12/25 at 2:39 AM, Patient #2 was discharged to the street. e. On 07/12/25 at 2:40 AM a physician note showed that during the initial ED encounter assessment, Patient #2 was brought in by PD due to a concern of suicidal ideation with a plan to shoot herself. The provider evaluated Patient #2 in a mental health safe room immediately following a code gray. The provider assessment showed Patient #2 expressed significant frustration with the hospital and an explicit desire for discharge, denied acute medical concerns, had no physical complaints and denied suicidal ideation. Patient #2 was agitated but intermittently verbally redirectable, and endorsed alcohol use. Patient #2 was discharged in order to “minimize potential harm in the setting of hospitalization.” and denied any further suicidal ideation. Patient #2 endorsed using alcohol. f. The investigator found no evidence that Patient #2 received any breath or blood testing for alcohol levels or was evaluated by a mental health professional as required by hospital policy. Encounter #2 g. On 07/12/25 at 2:42 AM, Patient #2 returned to the ED in the custody of LEOs. LEOs witnessed Patient #2 fall on the sidewalk outside the ED. Patient #2’s head struck the ground and Patient #2 lost consciousness. h. On 07/12/25 at 3:30 AM, an RN note showed that Patient #2 was unstable when standing, and was stumbling and off balance. i. On 07/12/25 at 4:05 AM, an RN note showed that Patient #2 reported, “I just want to kill myself” and requested psychiatric help. j. On 07/12/25 at 5:23 AM, lab results showed a blood alcohol test ordered at 2:46 AM, collected at 4:41 AM, and resulted at 5:23 AM, with results of 233 mg/dL (reference range <= 10). k. On 07/12/25 at 9:02 AM, Patient #2 was assessed by a licensed social worker. l. On 07/12/25 at 2:07 PM, Patient #2 was transferred to a voluntary inpatient behavioral health facility. Final diagnoses included alcohol intoxication, suicidal ideation, closed head injury, and concussion with loss of consciousness of 30 minutes or less. 6. On 07/23/25 between 2:15 PM and 4:15 PM, the investigator interviewed the Regulatory Affairs Manager (Staff #1), the ED Clinical Manager (Staff #2), and the Chief Quality Officer (Staff #3). Staff #2 confirmed that Patient #2 had been discharged on 07/12/25 at 2:38 AM, without receiving an evaluation conducted by a mental health professional or designated crisis responder, and that it was likely that a separate encounter was not created for Patient #2’s second ED visit because the 2 visits were so close together that the first visit had not yet been cleared from the electronic record system. The reason for the extended time period between the blood alcohol order and the blood alcohol result was unclear. Staff #3 stated the ED physicians could be considered mental health professionals, and they treated mental health issues frequently. 7. On 07/23/25 at 10:40 AM, the investigator interviewed the Social Work Manager (Staff #5). Staff #5 stated that the hospital had licensed social workers available 7 days per week, 365 days per year, from 7:30 AM until 9:30 PM. Social workers who have education, training, and licensure may conduct mental health evaluations. The ED had dedicated social workers from 9:00 AM until 9:30 PM. If an emergency department patient needed a mental health evaluation outside of the hours of 7:30 AM-9:30 PM, the patient could wait in the ED until a social worker was available. 8. On 07/28/25 between 10:22 AM and 10:39 AM, the investigator interviewed the ED Assistant Medical Director (Staff #4). During the interview, Staff #4 stated that ED providers are considered mental health professionals and are capable of completing mental health screening evaluations in lieu of a social worker assessment. Staff #4 stated that the hospital does not have a standardized mental health screening evaluation template for ED physicians, and the elements of the patient’s mental health assessment are determined by the individual provider. .”

“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: 42597 . Based on document review, medical record review, and interview, the hospital failed to ensure stabilizing treatment within its capability and capacity and per hospital policy for patients with suicidal ideation or actions for 6 of 22 patient records reviewed (Patient #3, Patient #6, Patient #13, Patient #17) Failure to ensure stabilizing treatment places patients at risk for inconsistent care, adverse outcomes, and death. Findings included: 1. Review of the policy titled, “Management of Patients with Mental Health Concerns or Suicidal Risk in the Emergency Department,” document ID 10756, revision 13, dated 03/25, showed that: Patients at risk for suicidal ideation or mental health complaints must be assigned an Emergency Severity Index (ESI) triage score of 2. The Registered Nurse (RN) must complete the Columbia-Suicide Severity Rating Scale (C-SSRS) at triage. The Charge RN must determine appropriate room placement as soon as possible. If available, the patient should be placed in a designated mental health safe room (P1-P4) when medically appropriate. If P1-P4 rooms are unavailable or the patient is not medically stable, the patient must be assigned a sitter and placed in an alternative room cleared of ligature risks. For patients with behavioral health complaints RN documentation should consist of complete comprehensive psychosocial and violent risk assessments every 8 hours and behavioral reassessments every 2 hours or sooner if changes occur. Review of the document titled, “Emergency Services Outpatient Minimum Charting Standards: ED Patients,” document ID 170712, revision 4, dated 12/23, showed that behavioral health patients should have a a focused assessment, a daily psychosocial assessment, suicide and alcohol withdrawal risk assessments when applicable, and documentation of updates and comfort measures. Patient #3 Encounter #1 2. The investigator reviewed Patient #3’s medical record. The review showed: a. On 06/13/24 at 3:04 PM, Patient #3 arrived to the Emergency Department (ED) accompanied by local law enforcement crisis responders for mental health evaluation and repair of self-inflicted right forearm lacerations. Patient #3 was taken to a Room 18, a main ED treatment room. b. On 06/13/24 at 3:09 PM, an RN showed a suicide risk score of 0, and documentation of “no” for the categories Wish to be Dead, Suicidal Thoughts, Suicidal Thoughts with Method Without Specific Plan or Intent to Act, Suicidal Intent Without Specific Plan, Suicide Intent with Specific Plan, and Suicide Intent with Preparatory Steps or Actions Taken. d. On 06/13/24 at 5:00 PM, a physician note showed that Patient #3 was seen at this ED last night after self-inflicting three lacerations to her right forearm which were repaired with skin adhesive. The physician closed a new 4 cm laceration with 7 sutures. Patient #3 reported thoughts of killing themselves with fentanyl but does not think they would. The physician discussed the situation with the social worker who stated that they were going to dispatch the DCR (designated crisis responder). e. On 06/13/24 at 4:33 PM, a nursing note showed that Patient #3 was found outside of their ED treatment room (room #18). Staff called a code gray, but the team was unable to reach the patient, and Patient #3 left the facility. Staff called a Code Gray but the team was unable to reach Patient #3 and Patient #3 left the facility f. The investigator found no evidence that room 18 was cleared of ligature risks, or that Patient #3 was assigned a 1:1 mental health assistant (MHA) (sitter), or that RNs performed a focused assessment, or a head to toe assessment, or a behavioral health assessment per policy. 3. On 07/25/25 between 9:00 AM and 3:00 PM, the investigator interviewed the ED Clinical Manager (Staff #2) during medical record review. Staff #2 confirmed the missing documentation. Encounter #2 g. On 06/13/24 at 4:57 PM, LEOs (law enforcement officers) returned Patient #3 to the ED. Patient #3 was taken to a secure mental health safety room to await DCR evaluation. h. On 06/13/24 at 5:03 PM, an ED Physician ordered 5 mg of haloperidol, 2 mg of lorazepam, and 25 mg of diphenhydramine for IM (intramuscular) injection. i. On 06/13/24 at 5:15 PM, a sitter note showed that Patient #3 was swearing, pacing, and restless. j. On 06/13/24 at 5:21 PM, an RN administered 5 mg of haloperidol, 2 mg of lorazepam, and 25 mg of diphenhydramine in the right deltoid by IM injection. k. On 06/13/24 at 6:00 PM, a social worker note shows that the social worker was going to contact the designated crisis responder to evaluate Patient #3 for involuntary treatment. l. The investigator found no evidence that a nurse performed a complete comprehensive psychosocial and a violent risk assessment or behavioral reassessments every 2 hours per policy. No evidence was found that an RN assessed Patient #3’s response the medications administered at 5:21 PM. Patient #3 did not receive a comprehensive head to toe assessment until 8:40 PM, 1 minute prior to discharge. 4. On 07/25/25 between 9:00 AM and 3 PM, the investigator interviewed Staff #2 during medical record review. Staff #2 stated the expectation that nurses perform a comprehensive head to toe assessment and behavioral health assessment within 1-2 hours of arrival and approximately every 2 hour updates for patients presenting with mental health complaints, and that RNs are expected to document the patient’s response to interventions. Encounter #3 5. The investigator reviewed Patient #3’s medical record. The record showed: a. On 07/11/25 at 10:25 AM, Patient #3 arrived by ambulance to the ED. b. On 07/11/25 at 10:25 AM, an RN triage note showed that Patient #3 was a “bounceback” from yesterday with suicidal ideation now with suicidal attempt where she took approximately 20 150 mg trazodone pills. Patient #3 had written a suicide note. Patient arrived alert and oriented, drowsy, vital signs stable. Ambulance staff called poison control. Patient #3 was assigned an ESI of 2. c. On 07/11/25 at 10:28 AM, documentation showed vital signs of: heart rate 86, respirations 20, blood pressure 113/80, and oxygen saturation of 95%. No further vital signs were documented until 9:56 PM, 17 minutes prior to patient discharge at 10:13 PM. d. On 07/11/25 at 10:42 AM, an electrocardiogram (EKG) was performed and reviewed as sinus rhythm, rate 72 with normal axis. No ST or T wave abnormalities. e. On 07/11/25 at 12:05 PM, an RN note showed that the RN spoke with poison control at 1200 hours (12:00 PM) and poison control recommended monitoring for lethargy, QTc prolongation, and use of benzodiazepines for seizure activity. f. The investigator found no evidence that cardiac monitoring was ordered or initiated, or that a repeat EKG was ordered or performed. g. On 07/11/25 at 1:55 PM, an RN note showed that the RN contacted poison control again to tell them that the trazodone pills ingested appeared to be standard release. Poison control recommended monitoring Patient #3 for 4-6 hours or until symptoms had completely resolved. h. On 07/11/25 at 4:00 PM, an RN note showed that the provider considered the patient medically cleared at this time. i. On 07/11/25 at 5:40 PM, the ED timeline showed that Patient #5 was transferred to a secure mental health safe room. 6. On 07/25/25 between 9:00 AM and 3:00 PM, the investigator interviewed the Staff #2 during medical record review. Staff #2 confirmed that poison control is usually consulted promptly for patients presenting with overdoses, usually by an RN but sometimes by a physician. The delay in contact for Patient #5 was possibly because EMS had already called poison control. Staff #2 confirmed that there was no evidence that Patient #5 was placed on a cardiac monitor, and Patient #3 had just two sets of vital signs recorded between arrival and departure. Patient #6 7. The investigator reviewed Patient #6’s medical record. The record showed: a. On 02/24/25 at 4:14 PM, Patient #6 walked into the ED. b. On 02/24/25 at 4:20 PM, a physician note showed that Patient #6 stated that he needed help and just wanted to die. Patient #6 had not had anything to eat or drink over the last three days. Patient #6’s personal continuous glucose monitor reading was 270. Patient #6 did not have a discrete plan for suicide other than to “just do a bunch of fentanyl.” Patient #6 was acutely ill appearing, frail to the point of cachexia (a complex metabolic syndrome characterized by significant, involuntary weight loss, muscle wasting, and fatigue), smelled strongly of alcohol and was somewhat tremulous. c. On 02/24/25 at 4:23 PM, an RN triage note showed that Patient #6 stated “I hate myself. I wish I wouldn’t wake up. I just want to die.” Patient #6 stated that they did not know how much alcohol they had consumed today and stated that they woke up on their garage floor while trying to seek fentanyl. Patient #6’s medical history included Type 1 diabetes. Patient #6’s CIWA-AR (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised) was 9 (mild withdrawal). d. On 02/24/25 at 5:30 PM, an ethyl alcohol level result showed 117 mg/dL (reference level <= 10) e. On 02/24/25 at 6:09 PM, CMP (complete metabolic panel) showed a serum glucose level of 241 mg/dL (reference range 65-99). f. On 02/24/25 at 6:20 PM, an RN note showed that Patient #6 requested fluids by mouth and snacks. No evidence of blood sugar checks or provision of food or beverages was documented. g. On 02/24/25 at 9:47 PM, a physician note showed that Patient #6 was reevaluated and was feeling somewhat better but remained profusely diaphoretic and was believed to also be withdrawing from narcotics. Patient #6 was not quite sure what to do at this point as they were no longer significantly despondent or actively suicidal. Patient #6 was given the option of discharge home or staying the night to talk with a social worker in the morning. Patient #6 opted to stay the night. h. On 02/24/25 at 10:03 PM, 8 units of Lantus (long acting insulin) was ordered for Patient #6. i. On 02/24/25 at 10:04 PM, an RN note showed that Patient #6 refused the insulin. j. On 02/25/25 at 7:22 AM, a physician ordered an adult diet for Patient #6. k. On 02/25/25 at 7:33 AM a physician ordered 12 units of Lantus for Patient #6. The insulin was administered at 9:00 AM. l. The investigator found no evidence of a blood glucose check ordered or performed prior to insulin administration. m. From 02/24/25 at 10:33 PM until 02/25/25 at 5:48 AM, the investigator found no evidence that a full set of vital signs or any alcohol or narcotic withdrawal assessments were performed. n. On 02/25/25 at 11:35 AM, Patient #6 was moved to a secure mental health safe room. o. On 02/25/25 at 12:39 PM, vital signs were ordered. The investigator found no evidence that vital signs were completed prior to Patient #6’s transfer to the inpatient mental health unit at 2:18 PM. p. On 02/25/25 at 1:15 PM, a sitter note showed that Patient #6 was eating lunch. No documentation of a blood glucose check or insulin administration was found or provided. 8. On 07/25/25 between 9:00 AM and 3:00 PM, the investigator interviewed the Staff #2 during medical record review. Staff #2 stated confirmed the missing information and stated that Patient #6 was medically cleared prior to be transfer to a mental health safety room. Patient #13 9. The investigator reviewed Patient #13’s medical record. The record showed: a. On 02/24/25 at 6:59 PM, Patient #13’s mother brought Patient #13 to the ED for evaluation of increasing delusional and bizarre behaviors. b. On 02/24/25 at 7:24 PM, Patient #13’s vital signs were heart rate 110, blood Pressure 150/86, respirations 18, and oxygen saturation 98%. c. On 02/25/25 at 2:08 AM, a physician placed an order for vital signs. Vital signs were not completed until 8:37 AM, approximately 6 hours later. d. On 02/25/25 at 11:50 AM, a comprehensive behavioral health assessment was completed, approximately 16 hours after arrival. 10. On 07/25/25 between 9:00 AM and 3:00 PM, the investigator interviewed Staff #2 during medical record review. Staff #2 confirmed that vital signs were ordered but not performed within the expected 1 hour time period, and that nurses should complete behavioral health assessments when applicable within approximately 2 hours of a patient’s arrival to the ED and daily. Patient #17 11. The investigator reviewed Patient #17’s medical record. The record showed: a. On 05/10/25 at 1:21 PM, an RN triage note showed that Patient #17 arrived to the ED by ambulance for evaluation of a suicide attempt by overdose. Patient #17 had felt suicidal for awhile. Patient #17 had a bag of suboxone and maybe took 2 suboxone and one hydroxyzine. Patient #17 reported feeling diaphoretic (sweaty) and short of breath. Patient #2 was classified as ESI 2. b. At 1:23 PM, a physician note showed that Patient #17’s medical history included depression, suicidal ideation, and seizure due to alcohol withdrawal. Patient #17 reported taking 2 pills of suboxone, and 1 pill of hydroxyzine with the intention to kill himself. Patient #17 reported drinking 112 shots of liquor per week. Patient #17 was unsure of when their last alcohol intake was. c. At 1:37 PM, a physician ordered an ethyl alcohol level. d. At 4:08 PM, the ethyl alcohol level result was <10 mg/dL (normal range <= 10). e. At 4:30 PM, a sitter note showed that the patient appeared to be asleep f. At 4:33 PM, a physician ordered lorazepam 1mg by injection. g. At 5:15 PM, a sitter note showed that the patient appeared to be asleep h. At 5:20 PM, the lorazepam order was changed to administration by mouth and was administered at 5:31 PM. i. The investigator found no nursing documentation of Patient #17’s response to the lorazepam administration. A suicide risk assessment was not documented until 5:31 PM, approximately 4 hours after triage. No evidence was found of a comprehensive head to toe or behavioral health assessment per policy, or any ongoing RN assessments for alcohol withdrawal. From 05/10/25 at 4:30 PM and 05/11/25 at 9:15 AM no vital signs were documented. 12. On 07/25/25 between 9:00 AM and 3:00 PM, the investigator interviewed Staff #2 during medical record review. Staff #2 confirmed the expectation that RNs should perform and document behavioral health and comprehensive head to toe assessments, and patient response to medication and CIWA assessments as applicable. .”