Providence St Peter 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: 42740 . Based on interview, document review, and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients seeking or requiring emergency medical care while on hospital property in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to ensure that individuals who request or require emergency medical treatment while on hospital property receive a comprehensive medical screening examination and stabilizing treatment prior to transfer or discharge risks poor patient care outcomes, injury, and death. Findings included: 1. The hospital failed to ensure that 1 of 20 patients requesting medical treatment (Patient #1) received a medical screening exam. 2. The hospital failed to implement policies and procedures that ensure staff obtain emergency medical assistance for individuals experiencing medical emergencies while on hospital property. Cross-reference: Tag A2406 .”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42740 . Based on interview, document review, and review of hospital policies and procedures, the hospital failed to provide an appropriate medical screening exam (MSE) for 1 of 20 patients (Patient #1) requesting, or appearing in need of, emergency services on hospital property. Failure to provide a MSE to patients requesting, or appearing in need of, emergency services risks poor health outcomes, injury, and death. Findings included: 1. Review of the hospital’s policy titled “Emergency Medical Treatment & Labor Act (EMTALA),” policy number 13340714, last approved 03/21/23, showed the following: a. If an individual comes onto hospital property and requests treatment for an emergency medical condition (EMC), a medical screening exam (MSE) must be provided. b. If an individual comes onto hospital property and a prudent layperson observer would believe that the individual is suffering from an EMC, an MSE must be provided. c. Hospital employees will comply with the EMTALA requirements. 2. On 02/12/25 at 5:27 PM, Patient #1 was brought to the hospital by ambulance with complaints of abdominal pain and shortness of breath. Document review showed: a. Patient #1 had a history of diabetes mellitus II (a chronic condition resulting in high blood sugar), hypertension (high blood pressure) and congestive heart failure. b. Patient #1 was diagnosed with Rhinovirus/Enterovirus and discharged by the provider (Staff #3). The nurse (Staff #2) documented that the patient was aggressive in his wheelchair as evidenced by using curse words repeatedly after being asked not to. Staff #2 called for a security escort off hospital property. c. At 10:02 PM, audio and video document review showed security (Staff #13) wheeled the patient to the main ED entrance. At the entrance, the patient began asking for his shoe. At 10:03 PM, the patient stood up and turned around and began explaining that he needed his shoe and his belongings. Two security officers (Staff #13, Staff #12) were observed holding the patient under his arms and escorting him outside the building. Three additional security officers (Staff #30, Staff #14, Staff #20) arrived to assist with the escort off the property. d. At 10:04 PM, audio and video document review showed that Patient #1 stumbled to the ground in the parking lot next to the emergency department. The patient yelled out for help, placed his hand on his chest, and stated that he couldn’t breathe. The patient began audibly wheezing (high-pitched, whistling sound in the lungs) and visibly using his accessory muscles (using muscles beyond the diaphragm and intercostal muscles to aid in breathing, often seen during increased respiratory effort or distress). Staff #13 and Staff #12 lifted the patient under his arms and continued to drag him at a brisk pace. e. The patient continued to cry out for help and verbalized that he couldn’t breathe as he was carried away from the hospital ED. The patient’s pants fell from his body, leaving him naked from the waist down and still missing a shoe. f. Less than one minute later, video showed Patient #1 stumbling while being escorted, and defecating on himself while calling for help. At 10:05 PM, audio and video documentation showed security staff releasing the patient from their grasp after noticing the patient’s feces. g. Once security staff released their hold, Patient #1 was observed stumbling for 5 seconds before collapsing to a hands and knees position on the sidewalk. The patient continued to ask for help and tell security that he couldn’t breathe and needed a doctor. Staff #14 responded to the patient’s pleas for help by telling the patient that he was discharged and had been seen by a doctor. h. At 10:06: PM, video observation showed the patient sitting on the curb without pants, covered in feces, and missing a shoe and sock. The patient asked for help again and an officer responded by telling the patient that he’s “been discharged, stop the show, put on your pants”. From 10:04 PM to 10:07 PM, the patient articulated that he couldn’t breathe 16 times and asked for help 19 times. The last recorded cry for help occurred at 10:10 PM. i. At 10:14 PM, a community member called 911 to report that they drove by the hospital and saw a man laying face down on the sidewalk. The caller stated that the man was naked from the waist down and appeared to need medical attention. j. At 10:20 PM, an emergency medical technician (EMT) was leaving the hospital and saw the patient lying face down on the sidewalk. Law enforcement arrived at the same time and cardiopulmonary resuscitation was initiated. The patient was taken back to the hospital and declared dead at 10:38 PM. 3. Document review showed that the hospital interviewed and obtained a statement from Staff #14 on 02/13/25. Staff #14 stated that the index patient was stating that he couldn’t breathe and stating that he needed help. They did not bring the patient back to the ED because he was seen in the ED and medically cleared for discharge. 4. On 03/18/25 at 1:45 PM, Investigator #1 interviewed the Director of Quality (Staff #16). Staff #16 stated that it was their expectation that hospital security would bring a patient back to the ED if they were asking for help. 5. On 03/25/25 at 2:00 PM, Investigator #1 and Investigator #2 interviewed the Regional Director of Quality (Staff #18). Staff #18 confirmed that security staff receive EMTALA training but the training did not address patients who required a readmission after an ED discharge. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42740 . Based on document review, medical record review, and interview, the hospital failed to promote and protect patient rights. Failure to promote and protect each patient’s rights risks loss of personal dignity and physical and psychological harm, including death. Findings included: 1. Failure to protect patients from abuse, neglect, or harassment by implementing effective systems to ensure a safe environment. Cross-reference: A145 2. Failure to discontinue restraints at the earliest opportunity. Cross-reference: A0174 3. Failure to ensure that patients placed in violent restraints receive a 1-hour face-to-face assessment from a trained provider. Cross-reference: A178 4. Failure to ensure all staff members who apply restraints to patients have training in cardiopulmonary resuscitation. Cross-reference: A 206 5. Failure to ensure timely reporting of patient safety and security events. Cross-reference: A 286 Due to the scope and severity of deficiencies cited under 42 CFR §482.13, the Condition of Participation: Patient Rights was NOT MET. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 42740 . Based on observation, interview, document review, and review of hospital policies and procedures, the hospital failed to develop and implement an effective system to ensure a safe environment that prevented patient abuse, neglect or harassment for 1 of 5 patients reviewed (Patient #1). Failure to implement effective systems to ensure a safe environment risks violation of patient rights, serious physical and psychological harm, and death. References: www.weather.gov. “Temperatures for 02/12/25” - “High 42, low 12, average 27.” www.intercitytransit.com. “Bus schedule for St Peter Hospital 02/12/25.” - “Final departure from St Peter Hospital on 02/12/25 at 6:50 PM.” Findings included: 1. Document review of the hospital’s patient handout titled, “Patient Rights and Responsibilities,” last revised 01/27/25, showed that patients have the right to care in a safe environment, free from neglect, physical or emotional abuse, harassment, or discrimination. Patients have the right to have their pain managed while receiving care. Patients have the right to discuss their care and ask questions about the treatment they’re receiving. Document review of the hospital’s policy titled, “Use of Force,” last revised 09/21/23, showed that a use of force could be necessary to protect oneself or others from a reasonably apparent threat of imminent danger, which may result in serious bodily injury or death. Staff should consider the physical condition and abilities of the patient and quantity of officers present. Document review of the hospital’s policy titled, “Trespassing Individuals,” last revised 03/28/24, showed that if a patient refuses to leave, security officers are allowed to physically remove the patient from hospital property. If security decides it’s unsafe, law enforcement may be called. Security officers are allowed to use reasonable force to control a non-compliant individual and detain them until law enforcement arrives. 2. On 02/12/25 at 5:27 PM, Patient #1 was brought to the hospital by ambulance with complaints of abdominal pain and shortness of breath. Document review showed: a. Patient #1 had a history of diabetes mellitus II (chronic condition resulting in high blood sugar), hypertension (high blood pressure) and congestive heart failure. The patient arrived by ambulance and did not have transportation home. b. At 10:03 PM, the nurse’s note indicated that the provider was at bedside to review laboratory and diagnostic test results with the patient. Staff #2 repeatedly documented that the patient was aggressive as evidenced by use of curse words and refusing to leave the hospital. The provider documentation showed that the patient was angry with staff because he did not have a ride to get back downtown. The patient’s listed place of residence was located downtown. c. Documentation, interview, or surveillance of the patient verbally or physically threatening others could not be found. The temperature outside was below freezing and the last bus left the hospital for downtown at 6:50 PM. Evidence that the patient’s concern for getting back home was addressed could not be found. Evidence of a safe discharge plan could not be found. d. Patient #1 was diagnosed with Rhinovirus/Enterovirus and discharged by the provider (Staff #3). The nurse (Staff #2) documented that the patient was aggressive in his wheelchair as evidenced by using curse words repeatedly after being asked not to. Staff #2 called for a security escort off hospital property. e. Video review showed Patient #1 sitting in a wheel chair in the ED hallway at 10:02 PM. The patient was clothed and wearing a face mask. The patient was holding onto his discharge paperwork with his left hand. Two security officers (Staff #12, Staff #13) escorted the patient to the main ED entrance via wheelchair. At the entrance, the patient began asking for his shoe. His shoe was noted to be missing in the later video. At 10:03 PM, the patient stood up and turned around and began explaining that he needed his shoe and his belongings. Immediately after the patient turned around, Staff #12 and Staff #13 were observed reaching out and holding the patient under his arms and escorting him outside of the building. The patient’s verbalized concern of a missing shoe was not addressed, and verbal de-escalation techniques were not observed. Three more secuirty officers (Staff #14, Staff #20, Staff #30) arrive at the scene to assist with Patient #1. f. At 10:04 PM, the patient’s pants began to fall off and he verbalized that he was trying to get his pants back on before falling to the ground in the ED parking lot. The patient yelled out for help, placed his hand on his chest, and stated that he could not breathe. The patient began audibly wheezing (high-pitched, whistling sound that occurs when air flows through narrowed or obstructed airways in the lungs) and visibly using his accessory muscles (using muscles beyond the diaphragm and intercostal muscles to aid in breathing, often seen during increased respiratory effort or distress). Staff #13 and Staff #12 lifted the patient under his arms and continued to walk and drag him through the parking lot toward the street at a brisk pace. g. By 10:04 PM, the patient, naked from the waist down, stumbled and defecated himself while yelling for help. At 10:05 PM, security released the hold of the patient. The patient stumbled for 5 seconds before collapsing to a hands and knees position on the sidewalk and continued to ask for help and tell the security officers that he couldn’t breathe and needed a doctor. Staff #14 responded to the patient’s pleas for help by telling the patient that he was discharged and had been seen by a doctor. Staff #14 also told the patient to put his pants back on before someone called the police for indecent exposure. h. At 10:05 PM, the surveillance video showed Staff #12, Staff #13, Staff #14, Staff #20, and Staff #30 escorting Patient #1 from the ED to the sidewalk near the ED parking lot. The video also showed a flashlight shining on the patient’s buttock and then audible laughing. A conversation was heard on the video. Security officers stated, “do I have shit on me?” and “he has poop on his nut-sac”. Laughing and cursing were heard in relation to these comments. During that time, the patient continued to ask for help and was told that he was discharged and had already seen a doctor. j. At 10:06 PM, the patient was seen sitting on the curb without pants, covered in feces, and missing a shoe and sock. The patient asked for help and an officer responded by telling the patient that he was “discharged, stop the show, put on your pants”. Over a 3-minute period, the patient articulated that he couldn’t breathe 16 times and asked for help 19 times. The last audible cry for help occurred at 10:10 PM. k. At 10:14 PM, a community member called 911 to report that they drove by the hospital and saw a man laying face down on the sidewalk and wasn’t moving. The caller stated that the man was naked from the waist down and appeared to need medical attention. l. At 10:20 PM, an ambulance crew was leaving the hospital and saw the patient lying face down on the sidewalk. Law enforcement arrived at the same time and started cardiopulmonary resuscitation (CPR). The patient was taken back to the hospital and declared dead at 10:38 PM. 3. Document review showed that the hospital interviewed and obtained a statement from Staff #13 on 02/13/25. Staff #13 stated that they were planning on helping the patient get resources, but the patient began cursing at him. That’s when they decided to escort him off the property. 4. On 03/18/25 at 2:55 PM, Investigator #1 interviewed the Director of Quality (Staff #16). Staff #16 confirmed that the temperature was below freezing, and the bus line was not running at the time the index patient was discharged and escorted from property. 5. On 03/25/25 at 1:40 PM, Investigator #1 and Investigator #2 interviewed the Regional Director of Quality (Staff #18). Staff #18 confirmed that attempts to verbally deescalate the patient were not observed on the surveillance video. Staff #18 also confirmed the inappropriate comments made by the security officers and Patient #1’s condition. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 42599 . Based on interview and document review, the hospital failed to ensure that restraints were discontinued at the earliest possible time for 3 of 4 patient records reviewed (Patients #21, #22, and #23). Failure to ensure that patients are removed from restraints as soon as possible places patients at risk of serious physical and psychological harm. Findings included: 1. Review of the hospital policy titled, “Restraint and Seclusion,” PolicyStat ID 11573879, revised 07/19/22, showed the following: a. Restraint will only be used when other less restrictive clinical interventions have been ineffective to ensure the immediate physical safety of the patient, staff, or others and must be discontinued at the earliest possible time. b. Limit restraint use to emergencies in which there is an imminent risk of a patient physically harming himself, staff, or others c. A restraint order must include the criteria for release, “originating behavior no longer evident.” d. The registered nurse (RN) is authorized to discontinue restraints following an assessment of the patient and determination that release criteria have been met. Patient #21 2. A review of medical records showed on 02/28/25 at 5:40 PM, staff placed Patient #21 in 4-point restraints for violent behavior. Nursing documentation showed that at 7:00 PM, 7:15 PM, 7:30 PM, 7:45 PM, and 8:00 PM, Patient #21 was sedated and asleep, but remained in restraints until 8:12 PM. The investigator found no evidence that staff attempted to remove the restraints or use less restrictive alternatives while the patient was sedated and asleep. Patient #22 3. A review of medical records showed that on 03/07/25 at 6:15 PM, staff placed patient #22 in 4-point restraints for violent behavior. Nursing documentation completed every 15 minutes between 6:45 and 8:00 PM described the patient’s behavior as “calming down,” and documentation at 6:45 PM, 7:15 PM, and 8:00 PM showed that that the patient was asleep. Nursing documentation showed the restraints were removed at 8:05 PM when staff escorted the patient to the restroom. The investigator found no evidence that staff attempted to discontinue the restraints or use less restrictive alternatives while the patient was calm and asleep. Patient #23 4. A review of medical records showed that on 03/05/25 at 10:53 AM, the medical provider signed an order for the application of 2-point restraints for non-violent behavior. Nursing staff documentation showed that Patient #23 was placed in 4-point soft restraints. On 03/06/25 between 9:30 AM and 12:05 PM, staff documentation of observed behaviors showed the patient was calm, but Patient #23 remained in 4-point restraints. Nursing documentation showed that at 12:05 PM, staff discontinued the 4-point restraints, and at 12:07 PM, staff initiated 2-point soft wrist restraints. Nursing documentation described the patient’s observed behavior as calm and asleep at 3:00 PM, 4:07 PM, and 5:00 PM. The investigator found no documentation showing that staff attempted to remove the restraints or use less restrictive measures while the patient was calm and asleep. 5. On 03/25/25 at 1:17 PM, the Director of Quality (Staff #16) confirmed Investigator #2’s findings that staff failed to discontinue restraints as soon as possible, and Patients #21, #22, and #23 remained in restraints while sedated or calm and asleep. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 42599 . Based on interview and document review, the hospital failed to ensure that a trained provider completed a face-to-face assessment within 1 hour following the application of violent restraints for 2 of 2 patient records reviewed (Patient #21 and Patient #22). Failure to ensure that patients placed in violent restraints receive a 1-hour face-to-face assessment from a trained provider places patients at risk of serious physical and psychological harm. Findings included: 1. Review of the hospital policy titled, “Restraint and Seclusion,” PolicyStat ID 11573879, revised 07/19/22, showed the following: a. The licensed provider (LP) will evaluate the patient in person (face-to-face) within 1 hour of the application of restraints or seclusion. The findings of the physical and behavioral examination will be documented in the medical record within the 1-hour time period. b. The evaluation will include: i. An evaluation of the patient’s immediate situation ii. The patient’s reaction to the intervention iii. The patient’s medical and behavioral condition. The initial evaluation will include a comprehensive review of systems assessment, behavioral assessment, as well as an assessment of the patient’s history, drugs, and medications, most recent labs, etc. 2. A medical record review of 2 patients restrained in the emergency department showed the following: a. On 02/28/25 at 5:40 PM, staff placed Patient #21 in 4-point restraints for violent behavior. The investigator found no evidence that the LP completed a face-to-face evaluation within 1 hour of the restraint application. b. On 03/07/25 at 6:15 PM, staff placed patient #22 in 4-point restraints for violent behavior. The investigator found no evidence that the LP completed a face-to-face evaluation within 1 hour of the restraint application. 3. On 03/25/25 at 1:17 PM, the Director of Quality (Staff #16) confirmed Investigator #2’s findings of the missing face-to-face assessment documentation. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 42740 . Based on interview and record review, the hospital failed to ensure that staff members who applied restraints to patients were current in cardiopulmonary resuscitation (CPR) training for 5 of 5 staff members reviewed (Staff #30, Staff #13, Staff #14, Staff #12, Staff #20). Failure to ensure all staff members who apply restraints to patients have CPR training risks delayed or inadequate emergency medical responses and death. Findings included: 1. Document review of the hospital’s “Providence Security Officer Job Description,” no date, showed that: a. Application of patient restraints is an essential job function. b. CPR is not a required competency for security officers. 2. Investigator #1 reviewed 5 security officer education files (Staff #30, Staff #13, Staff #14, Staff #12, Staff #20). Each officer had training on applying restraints but no CPR training. 3. On 02/25/25 at 11:00 AM, Investigator #1 and Investigator #2 interviewed the security manager (Staff #29). Staff #29 stated that CPR was not a requirement for security officers. .”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 42740 . Based on interviews, document review, and review of hospital policies and procedures, the hospital failed to ensure that patient safety and security incidents were reported into the incident reporting system according to hospital procedure for 1 of 5 events reviewed. Failure to ensure timely reporting of patient safety and security events limits the hospital’s ability to implement measures that prevent or mitigate future patient harm. Findings included: 1. Document review of the hospital’s policy titled, “Event Reporting and Response,” policy number 15119090, revised 01/26/24, showed that any events that are inconsistent with safe patient care, such as significant harm or death, should be entered into the event reporting system as soon as possible. 2. Review of the hospital documentation showed that on 02/12/25, the Patient #1 was found unresponsive on hospital property and pronounced dead. On 02/19/25, an incident report regarding the patient’s death was entered into the event reporting system. 3. On 03/18/25 at 12:16 PM, Investigator #1 interviewed the Emergency Department Manager (Staff #10). Staff #10 confirmed that the charge nurse emailed her regarding the index patient’s death but she did not receive an accompanying incident report. 4. On 03/18/25 at 1:45 PM, Investigator #1 interviewed the Director of Quality (Staff #16). Staff #16 confirmed that the incident report was entered a week after the event occurred. .”

“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: 42740 . Based on interview, record review, document review, and review of the hospital’s policies and procedures, the hospital failed to ensure adequate and qualified staff for the provision of emergency care. Failure to provide adequate and qualified staff for the delivery of emergency care places patients at risk for delays in treatment and suboptimal outcomes. Findings included: 1. Failure to assume care of patients seeking emergency services. Cross-reference A 1112 Due to the scope and severity of deficiencies cited under 42 CFR 482.55, the Condition of Participation for Emergency Services WAS NOT MET. .”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 42740 . Based on observation, interview, and document review, the hospital failed to accept care of patients arriving by ambulance and provide a triage and continual monitoring at the time of arrival on hospital property in 5 of 32 patients reviewed (Patients #1, #17, #26, #27, #32). Failure to ensure timely triage, monitoring, and prioritization of the MSE risks delays in treatment and suboptimal outcomes. Findings included: 1. Review of the hospital’s policy titled, “Emergency Medical Treatment & Labor Act (EMTALA),” policy number 13340714, last approved 03/21/23, showed that the triage, MSE, or necessary stabilizing treatment are not to be delayed. The record must reflect continued monitoring according to the patient’s needs and must continue until they are stabilized or appropriately transferred or discharged. Review of the hospital’s policy titled, “Triage - Emergency Center,” policy 8478585, last revised 09/08/20, showed that upon presenting to the ED, patients shall be evaluated to determine the appropriate priority in which they will be seen for an emergency medical exam (MSE). A patient may be triaged either as a walk-in at triage or at the bedside. The hospital uses the 5 category Emergency Severity Index (ESI) triage system to prioritize resources. The levels include: Level 1 - Life threatening Level 2 - Emergent Level 3 - Urgent Level 4 - Routine Level 5 - Non-Urgent 2. The investigator reviewed medical records and prehospital patient care records (PCRs) for patients who received care in the ED with the Director of Quality (Staff #9). The documentation showed the following: PATIENT #1 a. Emergency medical service (EMS) documentation showed that Patient #1 arrived at the hospital via ambulance on 11/21/23 at 2:56 PM. The hospital documentation showed that hospital staff acknowledged Patient #26’s ED arrival at 2:59 PM. Patient #1 complained of a ground-level fall and subsequent left shoulder pain. The patient remained on the emergency medical services (EMS) gurney without nursing care, hospital monitoring, triage, or MSE until 4:03 PM, 1 hour and 4 minutes after arrival at the hospital. Patient #1 was assigned an initial ESI of 3. After the patient’s MSE, the patient’s listed diagnosis was a shoulder dislocation and fracture. b. The investigator selected additional patients to review from the same date and timeframe as Patient #1’s encounter. The 2 additional medical records showed the following: On 11/21/23 at 3:01 PM, Patient #14 arrived by private vehicle and entered the ED waiting area with the primary complaint of abdominal pain. The hospital immediately assumed care and the patient was triaged by a nurse at 3:02 PM and assigned an ESI 3 by 3:04 PM. The patient was prioritized by ESI, per hospital protocol and received a medical screening exam at 3:50 PM. By contrast, Patient #1 had arrived 2 minutes earlier but was not triaged and assigned a priority until 4:03 PM. The patient’s ESI priority was evaluated as equivalent to Patient #14 (both ESI 3). However, Patient #1 received her triage and ESI approximately an hour later than Patient #14 and subsequently was prioritized for MSE after Patient #14 and did not receive an MSE until 4:15 PM. Additionally, on 11/21/23 at 3:17 PM, Patient #15 arrived by private vehicle and entered the ED waiting area with the primary complaint of wrist pain after a fall. The hospital immediately assumed care and the patient was triaged by a nurse at 3:18 PM and assigned an ESI of 4. During this time, Patient #1 continued to wait in the breezeway of the hospital without being prioritized for a MSE or monitored for change in condition. PATIENT #17 c. EMS documentation showed that Patient #17 arrived at the hospital via ambulance on 01/12/24 at 10:27 AM. The hospital documentation showed that hospital staff acknowledged Patient #17’s ED arrival at 10:32 AM. Patient #17 complained of a fall on ice and a subsequent ankle injury. The patient remained on the emergency medical services (EMS) gurney without nursing care, hospital monitoring, triage, or MSE until 11:12 AM, 40 minutes after arrival at the hospital. Patient #17 was assigned an ESI of 3. The MSE was completed, and the patient was diagnosed with a fractured lower extremity. The investigator selected an additional patient to review from the same date and timeframe as Patient #17’s encounter. The additional medical record showed that on 01/12/24 at 10:31 AM, Patient #18 arrived by private vehicle and entered the ED waiting area with the primary complaint of heart palpitations. The patient was triaged and prioritized as an ESI 3 at 10:36 AM, 5 minutes after arrival. In contrast, Patient #17 arrived within a minute of Patient #18 but care was not assumed or prioritized for 40 minutes. PATIENT #26 d. EMS documentation showed that Patient #26 arrived at the hospital via ambulance on 01/21/24 at 4:34 PM. The hospital documentation showed that hospital staff acknowledged Patient #26’s ED arrival at 4:38 PM. Patient #26 complained of a recent fall and subsequent head injury. By 5:37 PM, 59 minutes after the initial request for emergency services, the patient remained in the hospital breezeway and continued to wait to be triaged and prioritized for an MSE. The patient told ambulance staff that her pain was increasing, and she was also having pain on the right side of her chest. The patient requested to be taken to a hospital that could provide care. The ambulance staff checked-in with the charge nurse again to verify that they couldn’t assume care for Patient #26. Upon confirmation, the ambulance staff transported the patient to another hospital in the area to receive care. The hospital and ambulance documentation both indicated that the patient was at the hospital but that the hospital did not assume care, triage to prioritize the MSE, or provide monitoring for changes in condition. PATIENT #27 e. EMS documentation showed that Patient #27 arrived at the hospital via ambulance on 01/24/24 at 1:04 PM. The hospital documentation showed that hospital staff acknowledged Patient #27’s ED arrival at 1:06 PM. Patient #27 arrived at the ED via ambulance with the primary complaint of a witnessed seizure (disrupted brain activity that leads to involuntary movements or loss of consciousness) and fall. The ambulance documentation showed that the ambulance staff held the patient in the breezeway until 1:41 PM, 35 minutes. The ambulance documentation also showed that the patient’s condition improved while she awaited care and the ambulance staff handed over care to the charge nurse and the hospital assumed care at that time. Hospital documentation of a triage, monitoring, or MSE could not be found. The patient’s disposition was updated to left without being seen and before triage at 9:43 PM by an ED nurse, 8 hours and 37 minutes after patient arrived. PATIENT #32 f. On 01/30/24 at 2:50 PM, the investigator conducted observations in the ED and reviewed the medical record and prehospital PCR of Patient #32. The observations, interviews, and documentation showed the following: EMS documentation showed that Patient #32 arrived at the hospital via ambulance on 01/30/24 at 2:35 PM. The hospital documentation showed that hospital staff acknowledged Patient #32’s ED arrival at 2:38 PM. Patient #32 arrived at the ED via ambulance with the primary complaint of an unwitnessed fall and head injury. On 01/30/24 at 2:50 PM, the investigator observed Patient #32 on an ambulance gurney in the ED breezeway with an emergency medical service (EMS) staff member (Staff #17). Staff #17 stated that her patient had not been triaged by a nurse. On 01/30/24 at 3:00 PM, the investigator interviewed the charge nurse (Staff #16) on duty regarding Patient #32 observed on a gurney in the breezeway. Staff #16 confirmed that the hospital had not assumed care of Patient #32 in the breezeway because they were waiting for a bed and a nurse to become available. Staff #16 also confirmed that the patient had not been triaged or assigned an ESI number to prioritize his MSE. The investigator asked to interview the triage nurse for the patients arriving by ambulance. Staff #16 informed the investigator that they did not have a position of triage nurse for patients arriving by ambulance. Staff #16 confirmed that the hospital was not currently on diversion status. The EMT stayed with the patient in the breezeway without a triage, monitoring, or MSE until 4:25 PM, 1 hour and 47 minutes after arriving at the hospital. 3. On 01/22/24 at 4:00 PM, the investigator interviewed the registrar (Staff #14). Staff #14 confirmed that the patient arrival time recorded by registration reflected the time the patient arrived in the ambulance bay or entered through the waiting room entrance. 4. On 11/23/24 beginning at 10:30 AM, the investigator interviewed the Quality Manager (Staff #9). Staff #9 confirmed the patient timelines found in the medical record for arrival, triage, ESI, and MSE for Patients #1, #14, #15, #17, #26, #27 and #32. 5. On 01/22/24 at 12:15 PM, the investigator interviewed 2 ED physicians (Staff #7, Staff #8) regarding patient care concerns in the ED. Staff #7 stated that they were concerned about their patients that remained in the ambulances and breezeway because they hadn’t been evaluated and weren’t being monitored by their triage nurse or a provider. Staff #8 verbally agreed with this concern and added that some charge nurses would try to go out to the ambulances to visually assess a patient, but they often had their own patients and weren’t able to go to the ambulances. 6. On 01/22/24 at 12:20 PM, the investigator interviewed the charge nurse (Staff # 12) who verified the concerns presented by Staff #7 and Staff #8 and stated that there wasn’t a nurse available to care for all the patients who came by ambulance. .”

“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: 42740 . Based on observation, interview, and record review, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care via ambulance in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to ensure patients are prioritized to receive a medical screening exam (MSE) by a qualified medical professional risks delay in care, further injury, and death. Findings included: The hospital failed to triage and prioritize patients for medical screening exams (MSEs) upon arrival for 2 of 32 patients reviewed (Patients #26, #27). Cross Reference: 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: 42740 . Based on observation, interview, and document review, the hospital failed to assume care of patients arriving by ambulance and provide a medical screening exam (MSE) in 2 of 32 patients reviewed (Patients #26, #27). Failure to provide a MSE to patients presenting to the emergency department (ED) risks poor health outcomes, injury, or death. Findings included: 1. Review of the hospital’s policy titled, “Emergency Medical Treatment & Labor Act (EMTALA),” policy number 13340714, last approved 03/21/23, showed that the triage, MSE, or necessary stabilizing treatment are not to be delayed. The record must reflect continued monitoring according to the patient’s needs and must continue until they are stabilized or appropriately transferred or discharged. Review of the hospital’s policy titled, “Triage - Emergency Center,” policy 8478585, last revised 09/08/20, showed that upon presenting to the ED, patients shall be evaluated to determine the appropriate priority in which they will be seen for an emergency medical exam (MSE). A patient may be triaged either as a walk-in at triage or at the bedside. 2. The investigator reviewed medical records and prehospital patient care records (PCRs) for patients who received care in the ED. The documentation showed the following: a. Emergency medical service (EMS) documentation showed that Patient #26 arrived at the hospital via ambulance on 01/21/24 at 4:34 PM. The hospital documentation showed that hospital staff acknowledged Patient #26’s ED arrival at 4:38 PM. Patient #26 complained of a recent fall and subsequent head injury. By 5:37 PM, 59 minutes after the initial request for emergency services, the patient remained in the hospital breezeway and continued to wait to be triaged and prioritized for an MSE. The patient told ambulance staff that her pain was increasing, and she was also having pain on the right side of her chest. The patient requested to be taken to a hospital that could provide care. The ambulance staff checked-in with the charge nurse again to verify that they couldn’t assume care for Patient #26. Upon confirmation, the ambulance staff transported the patient to another hospital in the area to receive care. The hospital and ambulance documentation both indicated that the patient was at the hospital but that the hospital did not assume care, triage to prioritize the MSE, or provide monitoring for changes in condition. On 01/30/24 at 12:30 PM, the investigator interviewed the Quality Manager (Staff #9). Staff #9 confirmed that the medical record showed that Patient #26 arrived for emergency care and waited for 59 minutes in the hospital’s breezeway without hospital-provided monitoring, triage, or MSE. On 01/23/24 at 6:50 PM, the investigator interviewed the Fire Lieutenant (Staff #21) responsible for Patient #26’s prehospital care. Staff #21 confirmed the patient’s ED arrival time, the patient’s change in condition, and the ambulance crew rerouting to another hospital. Staff #21 also stated that hospital staff were notified of the patient’s change in condition and her request to go to another hospital if they could not care for her. Staff #21 stated that the patient continued to wait in the breezeway without hospital care until she was transported to another hospital. b. EMS documentation showed that Patient #27 arrived at the hospital via ambulance on 01/24/24 at 1:04 PM. The hospital documentation showed that hospital staff acknowledged Patient #27’s ED arrival at 1:06 PM. Patient #27 arrived at the ED via ambulance with the primary complaint of a witnessed seizure (disrupted brain activity that leads to involuntary movements or loss of consciousness) and fall. The ambulance documentation showed that the ambulance staff held the patient in the breezeway until 1:41 PM, 35 minutes. The ambulance documentation also showed that the patient’s condition improved while she awaited care and the ambulance staff handed over care to the charge nurse and the hospital assumed care at that time. Hospital documentation of a triage, monitoring, or MSE could not be found. The patient’s disposition was updated to left without being seen and before triage at 9:43 PM by an ED nurse, 8 hours and 37 minutes after the patient arrived. On 01/30/24 at 3:05 PM, the investigator interviewed the ED Manager (Staff #15) and also reviewed the medical record of Patient #27 with Staff #15. Staff #15 stated that the ambulance record didn’t align with their processes. The charge nurse would not have assumed care. The investigator asked how we could verify if this patient was brought to the waiting area since her condition improved. Staff #15 stated that patients who were brought to the waiting area and then leave against medical advice or without being seen were documented as such in the medical record. Staff #15 confirmed that the medical record did not indicate the disposition of the patient or if a triage or MSE occurred. 3. On 01/22/24 at 4:00 PM, the investigator interviewed the registrar (Staff #14). Staff #14 confirmed that the ED’s registration process was to document the patients’ arrival time when the patient presented for care at the ambulance bay or the waiting room entrance. Staff #14 also stated that the time a nurse documents that they are assuming care does not necessarily reflect the time the patient arrived for care. 4. On 01/22/24 at 12:00 PM, the investigator interviewed the ED Assistant Manager (Staff #11). Staff #11 stated that the hospital process was to receive reports from the ambulance staff. Based on that report, some patients were to wait in the breezeway or ambulance until a bed became available. The investigator asked how the patients were prioritized to receive an MSE. Staff #11 stated that patients in the breezeway or ambulance were not considered hospital patients and remained the responsibility of the ambulance staff. 5. On 01/30/24 at 3:05 PM, the investigator interviewed the manager of the ED (Staff #15). Staff #15 stated that patients remained the responsibility of EMS until hospital staff were available to assume care and begin the triage process. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49702 . Based on interview and document review, the hospital failed to ensure that patients were provided care in a safe environment, free from abuse or neglect. Failure to protect patients from neglect places patients at risk for serious physical and/or psychological harm and death. Findings included: The hospital failed to implement interventions to prevent patient elopement. Due to the severity of deficiency under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET. Cross reference: Tag A-145 .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49702 . Based on observation, interview, and record review, the hospital failed to develop and implement an effective system to prevent patient elopement for 1 of 1 patients reviewed (Patient #1). Failure to protect patients and to ensure care in a safe environment by preventing patient elopement risks violation of patient rights, serious injury, or death. Findings included: 1. Document review of the hospital’s policy titled, “Patient Rights and Responsibilities,” PolicyStat ID 8769890, last revised 01/21, showed that patients are made aware of their rights and responsibilities prior to receiving hospital care or services. 2. Document review of the hospital’s patient handout titled, “Patient Rights and Responsibilities,” last revised 11/22, showed the following: a. Patients will be treated with dignity, and be free from neglect, exploitation, abuse, harassment, racism, or discrimination. b. Patients have the right to receive care in a safe setting. 3. Document review of the hospital’s policy titled, “Inpatient Elopement - Adult,” PolicyStat ID 8569682, last revised 05/22, showed the following: a. Elopement is defined as a patient leaving the facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. b. Patient assessment for elopement risk includes a patient history of elopement, wandering, or becoming disoriented; cognitive changes or symptoms of anxiety, depression, or agitation that may lead to erratic behavior. c. Preventative measures for patients determined to be at elopement risk include but are not limited to bed alarm or egress alarm use, placing the patient in a view room, placing the patient as a close observation assignment, placing the patient in clothing that identifies them as an elopement risk, documenting elopement risk in the medical record, and communicating elopement risk at daily bed huddles. 4. Medical record review showed the following: a. On 4/25/23 at 3:10 PM, Patient #1 was admitted for bilateral forearm abscesses (skin infections), substance use disorder, and schizophrenia after being detained in the field by the Designated Crisis Responder (DCR). On 04/26/23, Patient #1 underwent an incision and drainage procedure to treat her bilateral forearm wounds. b. On 04/28/23 at 5:06 PM, provider documentation showed a plan for DCR consultation if Patient #1 attempted to leave the facility against medical advice. c. On 04/29/23 at 4:45 PM, security documentation showed that Patient #1 eloped from the facility without receiving a DCR consultation. d. On 04/30/23 at 8:59 PM, Patient #1 was detained for grave disability by the DCR at her residence. Patient #1 was transported to St. Peter Hospital and readmitted. e. On 05/06/23 at 5:07 PM, Patient #1 eloped from the facility again. Patient #1 was on an involuntary hold for grave disability at the time of the elopement. f. On 05/07/23 at 11:45 AM, Patient #1 returned to St. Peter Hospital by ambulance for treatment of her bilateral forearm wounds and DCR evaluation for involuntary detainment. An Unavailable Detention Facilities Report showed that Patient #1 was unable to be transferred to a psychiatric care facility due to two large abscesses requiring IV antibiotics until 05/10/23. g. On 05/08/23 at 8:48 PM, the DCR evaluated Patient #1. The evaluation showed that Patient #1 was in imminent danger because of being gravely disabled and was in danger of serious physical harm resulting from a failure to provide for health and safety. Patient #1 had admitted to injecting heroin into her wound sites after her elopement on 05/06/23. As a result, Patient #1 was involuntarily detained. h. On 05/15/23, Patient #1 remained gravely disabled and was placed on a court-ordered a 14-day involuntary hold. i. On 05/16/23, Patient #1 underwent surgical debridement, skin grafting, and wound vacuum placement for wounds on both forearms. j. On 05/21/23, Patient #1 was being watched by in-person and virtual (by camera) staff members due to her high risk for elopement. Another staff member requested that the in-person staff watching Patient #1 assist with patient care in another room. During the caregiver’s absence, Patient #1 eloped from the facility. At 3:01 PM, staff reported the elopement to security, but they were unable to locate the patient on hospital property. 5. On 02/28/24, investigators received a copy of the coroner’s report that showed that 2 community case workers found Patient #1 deceased in her residence on 05/30/23. The report showed that the patient died from an accidental drug overdose. 6. On 02/27/24 at 3:24 PM, Investigator #1 and Investigator #2 interviewed Staff #1. Staff #1 stated that in-person or virtual (camera) sitters could be used to keep detained patients from eloping. Staff #1 stated that staff assigned as 1:1 patient sitters for reasons other than suicidal ideation might be asked to step away to provide temporary assistance with other patients depending on the 1:1 patient’s recent behavior. 7. On 02/27/23 at 3:40 PM, Investigator #1 and Investigator #2 interviewed Staff #2. Staff #2 stated that if they were assigned as a 1:1 for a patient for a reason other than suicidal ideation and were asked to provide care for a patient in another room, they would go help the other patient “if the 1:1 had been behaving.” .”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 49702 . Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that adverse events were recognized and reported for 2 of 2 events reviewed (Patient #1). Failure to ensure patient safety and adverse events are recognized and reported limits the hospital’s ability to enact measures that prevent or mitigate patient harm. References: National Quality Forum. List of Serious Reportable Events - Patient Protection Events - Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person. Findings included: 1. Document review of the hospital’s policy titled, “Sentinel / Adverse Events,” PolicyStat ID 10525436, last revised 10/21, showed the following: a. Events identified as actual or potential sentinel or adverse events as defined in the policy’s attachment should be immediately reported to the Director or Manager for Quality Services, the Administrator on Call, or their designee. b. The attachment titled, “PSPH Attachment Definitions of Adverse and Sentinel Events Adverse Events (Washington State Department of Health (DOH): October 2012,” last revised 10/21, showed that discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person was listed as a reportable event. c. The Director of Quality Services, or designee, has the ultimate responsibility to determine if an event is a sentimental or adverse event that requires reporting. d. The facility is required to submit a report to the Department of Health within 45 days of confirmation of the adverse event, including a root cause analysis and corrective action plan if one is determined to be necessary. 2. Medical record review showed the following: a. On 4/25/23 at 3:10 PM, Patient #1 was admitted for bilateral forearm abscesses (skin infections), substance use disorder, and schizophrenia after being detained in the field by the Designated Crisis Responder (DCR). b. On 04/28/23 at 5:06 PM, provider documentation showed a plan for DCR consultation if Patient #1 attempted to leave the facility against medical advice. c. On 04/29/23 at 4:45 PM, security documentation shows that Patient #1 eloped from the facility without receiving a DCR consultation. d. On 04/30/23 at 8:59 PM, Patient #1 was detained for grave disability by the DCR at her residence. Patient #1 was transported to St. Peter Hospital and readmitted. e. On 05/06/23 at 5:07 PM, Patient #1 eloped from the facility again. Patient #1 was on an involuntary hold for grave disability at the time of the elopement. f. On 05/07/23 at 11:45 AM, Patient #1 returned to St. Peter Hospital by ambulance for treatment of her bilateral forearm wounds and DCR evaluation for involuntary detainment. g. On 05/08/23 at 8:48 PM, the DCR evaluated Patient #1 and involuntarily detained Patient #1 for grave disability. h. On 05/15/23, Patient #1 remained gravely disabled and was placed on a court-ordered a 14-day involuntary hold. i. On 05/21/23, Patient #1 eloped from the facility. At 3:01 PM, staff reported the elopement to security, but they were unable to locate the patient on hospital property. 3. On 02/29/24 at 3:01 PM, Investigator #1 interviewed the Director of Quality and Risk (Staff #3), who confirmed that Patient #1’s elopement events were not reported to the Washington Department of Health because the hospital did not know that Patient #1 had expired after eloping. Staff #3 confirmed that involuntary detainment for grave disability would indicate that a patient was unable to make decisions, making the event reportable regardless of whether the event caused a patient harm. .”