St Marys Medical Center

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 43434 Based on medical record review, facility policies and procedures and staff interviews, the facility failed to follow their triage policy for reassessing patients at least every two (2) hours to determine any changes in triage level for one (1) (Patient #1) out of ten (10) patients reviewed. This failure has the potential to negatively affect all patients receiving services at the facility. Findings are as follows: A medical record review was completed on 4/21/25, for patient #1. Patient #1 arrived at the emergency department on 3/25/25, at 11:33 a.m., complaining of chest pain and elevated blood pressure. At 11:40 a.m., the patient was triaged and given an acuity level of 3. The patient was returned to the lobby area to wait to see a doctor. The patient remained in the lobby area until leaving against medical advice (AMA) and without seeing the doctor (LWOT) at 8:41 p.m. The medical record produced no documented evidence that reassessments were completed per the facility’s triage policy and procedures. Review of document titled, “Emergency Department, Triage Decision Algorithm” reveals the levels of acuity. Level 3 is labeled danger zone vitals. Review of document titled, “ED Triage Adult and Peds Form” dated 3/25/25 at 11:40 a.m., completed by staff #5 states in part, “...ED Vital Signs, systolic blood pressure was 161 (one hundred sixty-one) mm Hg (milliliters of mercury), and diastolic blood pressure was 79 (seventy-nine) mm Hg. Objective Assessment, Alert and oriented x 3 [three]...” Review of document titled, “Vital View” indicates the following: On 3/25/25 at 11:40 a.m. “Temperature Oral 99.1 N, Peripheral Pulse Rate H 108 N, Respiratory Rate 18 N, Systolic Blood Pressure NBP H161 N, Diastolic Blood Pressure NBP 79 N, SpO2 99 N.” On 3/25/25 at 2:00 p.m. Vitals were as follows: “Peripheral Pulse Rate 81 N, Respiratory Rate 18 N, Systolic Blood Pressure NBP 111N, Diastolic Blood Pressure NBP 74 N, SpO2 98 N.” Review of the document titled, “Flowsheet, Vitals View” indicates that the patient’s vitals were taken on 3/25/25 at 11:40 a.m., then again at 14:00 (2:00 p.m.). There is no documented evidence that within the nine (9) hours the patient was waiting in the lobby, that vitals were taken. A review of “ED Nursing Narrative” completed by staff #4 states, “Patient reports low blood pressure [BP] on home BP monitor on wrist while in lobby. Patient brought back for new vitals at this time. Visual Snow Syndrome [VSS].” Review of the policy titled, “Assessment of Patient” date unknown, states in part, “...V. Reassessment A. Patients will be reassessed as designated intervals throughout the course of his/her care to determine the patient’s response to treatment/care; B. Reassessments are completed, as necessary, based on his/her plan of care or changes in his/her condition. Reassessments may also be based on the following: 1. Patient diagnosis 2. Desire for care, treatment, and services 3. Response to previous care, treatment, and services 4. Setting requirements; C. Additional reassessments will be completed when there is a significant change in a patient’s condition, and/or when a patient’s diagnosis warrants a reassessment; D. Time frames for reassessment are discipline/care setting specific and will depend upon the complexity of the patient’s condition...” Review of policy titled, “Triage 4 - Tier System” last reviewed 7/24, states in part, “...Procedure: The process of triage is used to establish priorities and determine urgency of need for emergency care of patients presenting to the Emergency Department. The goals of triage are to identify life-threatening conditions and determine acuity level for each patient. Patients presenting to Triage will be placed into 1 [one] of 4 [four] triage categories based upon the objective and subjective assessment findings of the triage nurse....3. URGENT: Conditions that involve a significant risk of significant complications or disabilities or impairment of bodily functions. Patient must be, but does not require rapid intervention, however, should be reassessed at least every hour to determine any change in triage level...The triage nurse will note in the triage assessment the assigned acuity of the patient. The triage nurse will complete and document a focused assessment on the patient in a clinical notes...” Review of the policy titled, “Patient Rights” last reviewed 10/21, states in part, “...B. PATIENT RIGHTS: Patients have the right to: 1. Reasonable access to care; 2. considerate care, provided by competent staff, that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values, as these impact their care...20. expect that patients treated in the hospital will receive the most appropriate care within the scope of services available at this hospital. If it is determined that the patient needs services not available at this hospital arrangements will be made to transfer the patient to an appropriate facility which provides the needed services...” An interview was conducted on 4/22/25, at 2:15 p.m., with staff #2. Staff #2 stated, in part, “I concur that the patient received no diagnosis. There is no medical screening or documentation in the medical record. There are only two sets of vitals recorded and no documentation in the medical record.” An interview was conducted on 4/22/25, at 1:05 p.m. with staff #5. Staff #5 stated, in part, “...If a patient is on the chest pain protocol, they could be in the lobby, but you can’t do monitoring and reassessments every hour in the lobby. So, if patients self-report we have brought them back to reassess them. It could be around the corner or behind a curtain, not necessarily a triage bay. The chest pain protocol is standing orders we do if a patient is complaining of chest pain. You can’t do everything that is marked on the protocol. If a patient needs nitro, you can’t give that unless we can monitor. Protocol reassessments can be hourly or every ten [10] minutes. Documentation is part of the protocol process. You would expect charting on that.” An interview was conducted on 4/22/25, at 10:40 a.m., with staff #4. Staff #4 stated, in part, “...If the patient is stable and doesn’t need immediate care, they would come back to the waiting room. They get labs and a full work up and go back to the waiting room. It’s the triage nurse’s responsibility to do reassessments and get vitals. We try to go back and forth. We use our best judgement. The providers review labs and test to determine where people should go. The physician’s assistant [PA] can put orders in but most of the time we do protocols. The tech will pull patients back to get troponin levels and look at cardiac enzymes. That’s a six [6]-hour process. We check every two [2] hours. Yes, in a perfect world there should be notes but that’s health care now days. It’s not how you want to run a hospital but that’s how it’s done. I probably did the 2:00 p.m. vitals but I didn’t document them. You can’t do cardiorespiratory monitoring in the triage waiting room. They would have to be in a room first before some of the things could be done...We try to have two [2] RNs [Registered Nurses] in triage. We may not be doing vitals, but we are reassessing the results of labs, specific cardiac troponins and diagnostic indicators. That’s still a level of care...” An interview was conducted on 4/22/25, at 2:00 p.m., with staff #3. Staff #3 stated, “I can’t remember the patient. If I have time I will help in triage. I might do labs or vitals on a patient. Reassessments are done if we can get the patient back in a room. If a patient comes up to the window and tells us something is wrong, we can get them back for an assessment or try. We can do narrative notes now, so there should be notes in the chart.” An interview was conducted via telephone on 4/22/25, at 3:20 p.m. with staff #7. Staff #7 stated, in part, “Policy for reassessment is every two [2] hours. There should be evidence in the record that services were performed. There is potential for patients to fall through the cracks but that is not what we strive for. There are pit providers in the triage, and they can see the patients. No patient should be waiting for nine [9] hours to see a provider. The RN in triage should be doing vitals and reassessing the patients. There should be opportunities to pull the patients back and complete reassessments...””

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 40269 Based on policy review, document review, and staff interviews, it was determined the facility failed to ensure grievance policy and procedures were followed in one (1) out of five (5) grievances reviewed, filed on behalf of patient 1. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A review was conducted of the policy titled, “Customer (Patient/Family/Visitor) Concern/Complaints/Grievance Process,” last revised 03/12/21. The policy states in part, “...Procedure ...C.Grievances: 1. When a grievance is filed, initiate actions to achieve resolution involving other members of medical team as appropriate. a. Acknowledge receiving the grievance by a face to face visit to the patient or his/her representative if he or she is in the facility or by a telephone call or letter if the complaint is received after discharge. b. Make face to face visits to patient and family members with permission. c. Interview the complaint and document the interview. d. Confer with the nursing staff, social worker, physician, or other medical team members involved with the complaint. e. Review the necessary documents. f. If applicable, discuss a potential solution with a complaint and other parties involved. g. Attempt to reach a resolution to the complaint that is satisfactory to all parties involved. h. Conduct necessary follow-up and document in the grievance file. 2. Situations or practices that place the patient in immediate danger are to be promptly referred to the VP [Vice President] of Medical Affairs or VP of Patient Services. After hours, these should be referred to the Patient Care Coordinator who may contact the Administrator On Call. 3. Complete the appropriate documentation and forward to the Patient Advocate. 4. Management will, in coordination with a Patient Advocate, write a formal letter within 7 [seven] business days of receipt of the grievance to inform the appropriate individual of follow-up action and closure. If investigation is not complete within 7 [seven] business days, the response should inform the complaint the medical center is still working to resolve the complaint and that a written resolution is forthcoming. 5. Copies of all grievances will be forwarded to the Patient Advocate to assure acknowledgement to the complainant, appropriate communication to all departments involved, investigation by all departments, communication to the complaint of solution and closure ...” A review was conducted of the grievance filed on behalf of patient (pt) 1 on 03/05/25. The grievance was reported in person to staff 4. The grievance, in summary, explains how information as to what happened with pt 1 was not communicated timely to the family, and they had questions as to what happened during the procedure. They also inquired if a sentinel event was reported, and the ICU physician was “negative.” A comment on 03/13/25 at 10:21 a.m. states, “Reviewed. Awaiting additional information. Will review and discuss with [staff 6].” A letter was sent to pt 1 on 03/14/25 and states in part, “...I apologize for the delay in getting a response to you; however, it is important to us that we review your concerns thoroughly prior to sharing our results with you. You should expect a response by letter within 30 days of this letter ...” A comment on 03/31/25 at 5:29 p.m. by staff 5 states, “Aware of situation. [Staff 3] documented air embolism in report. [Staff 3] will need to respond to the questions being asked of by the family. I am not aware of anything missing, and I will discuss staff conversations over patients and families.” A comment on 04/07/25 at 12:06 p.m. states, “Reviewed and discussed reported event with [staff 6] on 03/31/25.” May it be noted, no further documentation was provided in response to the grievance. There is no evidence anyone had any additional conversations with the family, or notified staff 3 of the questions being asked. An interview was conducted with staff 4 on 04/07/25 at 2:45 p.m. Regarding the grievance filed on behalf of pt 1, staff 4 states, “The grievance was just closed today, about an hour ago. I will send out a letter on behalf of the patient to the healthcare surrogate. I initially received the grievance in person from the family a day after the procedure, when the patient was here in the hospital. If the patient’s [adult child] would have asked to talk to the doctor, I would have gotten [her/him] to speak with [her/him]. [She/he] basically just wanted the situation investigated. [She/he] asked about Sentinel events and sentinel events are kept confidential from me, so I would not know if that was filed. About four (4) to five (5) days after the grievance was filed, I went to check on the patient, and the patient’s [spouse] was sleeping in the room, and the patient was unconscious. I never had any further contact with the patient or the family. I didn’t receive any further complaints from the family.” An interview was conducted with staff 5 on 04/08/25 at 9:47 a.m. Regarding pt 1, staff 5 states in part, “...I didn’t know that the family complained and filed a grievance the day after. I did not see that the grievance appeared in my Midas (grievance reporting and response) system to respond to until the end of March. I do rounding on patients in my department, and if I knew about this grievance, I could have gone over and talked to the patient. We could have let the doctor know, and [she/he] would have spoken to the patient and family as well. This doctor is very personable, and if they would have relayed to [her/him] what the family was complaining about, [she/he] would have been happy to speak to them ...” A telephone interview was conducted with staff 3 on 04/08/25 at 11:27 a.m. Regarding pt 1, staff 3 states in part, “...I would have spoken to the family if they had any additional questions but no one told me they had any and they did not express any to me when I spoke with them. Part of my routine rounding is to always ask the family or patients if they have any questions about the care. I always updated the family on the whole situation and all the information I’ve obtained from the whole team taking care of the patient. I would even be happy to speak with them now if they called me and had any questions about what had happened ...The family never asked me about that. I would have been happy to explain it to them ...” An interview was conducted with staff 13 on 04/08/25 at 1:00 p.m. Regarding pt 1, staff 13 states, “I remember this patient very well. The patient had issues during their procedure. The youngest [adult child] was here during the procedure. The doctors had spoken to [her/him] but [she/he] wasn’t medical and didn’t quite understand all the information that was given to [her/him] when [she/he] relayed it to the rest of the family. The rest of the family felt every time a new doctor came in, they were given conflicting information. The one (1) [adult child] who was a nurse, was upset. [She/he] requested to speak with someone because they weren’t being told things clearly. [She/he] said [she/he] wanted to speak with the advocate. I called the advocate and they came up. The advocate, after they spoke with the family, they didn’t tell me anything that was said. They didn’t complain after that to me. I know the situation was hard and there were a lot of physicians involved in the case.” An interview was conducted with staff 14 on 04/08/25 at 1:34 p.m. Regarding pt 1, staff 14 states, “I remember the patient. I was not aware of a situation with the patient’s family until after all the events occurred. When the patient’s family filed a grievance, the patient advocate put it in the system and then I could see it and respond to it. I did not get this grievance.” An interview was conducted on 04/09/25 at 10:51 a.m. with staff 6. Regarding the grievance filed on behalf of pt 1, staff 6 states, “The situation was assigned to peer review regarding the air embolism during the procedure. It would be assigned for another EP provider to review it. It would be presented at quality. This is a risk associated with the procedure, so what we look at is the percentage of occurrences and does this provider fall out of the benchmark for the percentage. Usually a peer review takes thirty [30] to ninety [90] days. This one is scheduled for next Wednesday. Since this outcome was outside of standard, it should have been entered into Midas. The staff is not shy about bringing outcomes forward. Since this patient was a death after a procedure, those are all looked into. I was notified within hours of the air emboli and I sent it to the medical staff review coordinator immediately to make sure it was on the list for peer review. We can then put it in the Midas system if it’s not there.” An interview was conducted with staff 17 on 04/09/25 at 1:33 p.m. Regarding Nursing peer review, staff 17 states in part, “...I was only asked to review the ketamine situation. I did not know the family filed a grievance on behalf of the patient and I was not asked to review anything regarding that.” An interview was conducted with staff 20 on 04/09/25 at 2:30 p.m. Regarding the grievance filed on behalf of pt 1, staff 20 states, “The patient advocate [staff 4] received the grievance. [She/he] pushed it to the provider side for communication. There was a piece of the grievance that was a provider issue. All the grievances would go through the grievance committee which meets bi-weekly. The advocate team puts everything together in a synopsis and then we review the grievance. This would probably be reviewed this week since it just was closed out. [Staff 4] reviews when [she/he] forwards everyone the information in the grievance system to make sure everyone is responding. We push everyone to get them done in seven (7) days. I agree that the nurse manager of the unit should have been aware of the situation even though there were no direct complaints from the ICU. I’m assuming the nurse manager didn’t get it because there were no complaints on this particular unit. There’s obvious opportunities for improvement for real-time communication. I will bring this up in the grievance committee meeting tomorrow.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 40269 Based on policy reviews, medical record reviews, and staff interviews, it was determined the facility failed to follow the policy and procedures for reporting patient safety events in three (3) out of three (3) events involving patient (pt) 1. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A review was conducted of the policy titled, “Patient Safety Event, including Adverse and Sentinel Reportable Events,” last revised 01/21. The policy states in part, “Policy: St Mary’s Medical Center (SMMC) has a procedure for the notification, investigation, and action plan follow-up regarding patient safety events. Definitions: Patient safety event: an event, incident, or condition that could have resulted or did result in harm to a patient. This could be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error ...1. Adverse event: A patient safety event that resulted in harm to a patient ...5. Sentinel event: A patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm. These events are called sentinel because they signal the need for immediate full investigation and response ...Procedure: 1. Identification A. Any persons performing work for SMMC who is aware of an event that may be an adverse or sentinel event is responsible for notifying leadership via the nursing/patient care or medical staff chain of command, as soon as possible. B. The event is to be reported to the Director of Quality and Accreditation as soon as possible, who is responsible to compare the reported event against the Sentinel event criteria. C. The Director of Risk management, Director of Quality and Accreditation, and/or their designee shall report any potential sentinel event to Medical Center Administration. D. The Director of Risk Management, or designee, will notify accounting to place the bill on hold for any event being investigated as sentinel. II. Immediate Response to an Adverse or Sentinel Event ...G. A risk event report should also be completed that includes a brief summary of the event specifying who, what, when, and where of the occurrence ...VI. Disclosure A. Patients and, when appropriate, their family/support person shall be informed about the unanticipated outcomes of care, treatment, and services related to adverse or Sentinel events ...” A review was conducted of a policy titled, “Risk Event Reporting and Management Process,” last revised 08/18. The policy states in part, “Policy: Patient/family/visitor accidents/incidents are to be reported as soon as possible after the event occurs. Definitions: a risk event (‘event’) is any occurrence or situation that is outside the expected course of delivery of hospital care. An event can involve an inpatient, outpatient, visitor, volunteer, employee or other person and may result in loss, damage, or violation of rights. A risk event may result when any of these people perceive, rightly or wrongly, that they have been slighted, neglected, mistreated, or injured. Procedure:1.The person involved in an event, witnessing an event, or the first to arrive at an event will initiate the appropriate internal communication process. The on-line computer form, ‘Risk Event Reporting’, is to be used for events involving patients and visitors. The on-line computer form ‘Employee Injury Report/First Report of Injury’ is to be used to report staff injuries.2. Risk management is responsible for coordinating internal notification of an event for appropriate review and event closure. The severity of an event and immediate needs of the patient or visitor are to be evaluated by the charge nurse, patient care coordinator, and any supervisory personnel. Follow up is to begin immediately on serious events per policy ‘Patient Safety Event, Including Adverse and Sentinel Reportable Events’. If the on-line computer forms are not available, plain white paper is to be used for recording the event and forwarded to Risk Management before leaving duty. If the event occurs on an off shift, holiday, or weekend, the risk event report is to be given to the patient care coordinator who will forward the documentation to the Risk Management office. 3. Documentation in the medical record should reflect what occurred. It should not state that a ‘risk event report’ was completed or that risk management or quality was notified. 4. The risk event reporting form and any follow-up investigation are not part of the patient’s medical record ...” A medical record review was conducted for patient (pt) 1. The pt presented to the facility on 03/04/25 for a Watchman ’ s procedure by staff 3. A “Watchman Implant Procedure” note by staff 3 states in part, “...Procedure Note:...During the exchange of the wire into the pigtail catheter, the patient developed a cough, with clear signs of air embolism observed on fluoroscopy. The patient subsequently experienced low blood pressure and ST [ST segment in an ECG (Electrocardiogram)] elevation. Blood was suctioned via the sheath, and high pacing from the pacemaker was initiated. A 4 [four] Fr [French] sheath was placed in the right femoral artery for blood pressure monitoring. Intracardiac echocardiography (ICE) revealed no evidence of pericardial effusion. Blood pressure and heart rate begin to stabilize. However, oxygen saturation remained low, and the patient was intubated. The patient remained clinically stable with normalized ECG changes, stable blood pressure, and improved oxygen saturation. The patient was extubated shortly after. Upon extubation, facial asymmetry and slight changes in pupil size were noted, prompting a stroke alert and an urgent CT [Computed Tomography] scan of the head. The family was notified ...” The “Electrophysiology (EP) Device Report” was reviewed and revealed a stroke alert was called 12:32 p.m., and the stroke team arrived at 12:34 p.m. The pt was transported to CT from the EP lab at 12:37 p.m. The pt time of death was 03/18/25 at 10:48 p.m. The “Certificate of Death” lists the “Cause of Death” as 1. Air embolism, 2. PEA [pulseless electrical activity] arrest, 3. Kidney failure. An interview was conducted with staff 5 on 04/08/25 at 9:47 a.m. Regarding pt 1, staff 5 states in part, “The patient had a Watchman’s procedure. During the procedure, the doctor thought [he/she] visualized an air embolism. After the patient was extubated, the patient had signs and symptoms of a stroke. They called a stroke alert. The stroke team came to the EP lab. The stroke alert team is trained in assessment. They immediately started the assessment and took the patient straight to the CT scanner and then to the ED. All patients go to the ED to be evaluated if an unexpected outcome happens after the procedure, especially signs and symptoms of a stroke ...I did not file any incident report based on what happened during the procedure or after.” A telephone interview was conducted with staff 3 on 04/08/25 at 11:27 a.m. Regarding pt 1, staff 3 states in part, “The patient presented for a Watchman procedure. During the procedure, the patient had a big cough and became unstable. I visualized what was a possible air embolism. I aborted the procedure, and initiated supportive management. [She/he] stabilized and was extubated. After [she/he] was off anesthesia, there was a concern for the patient not responding appropriately. We called a stroke alert, and the stroke team took over care ...” An interview was conducted on 04/09/25 at 10:51 a.m. with staff 6. Regarding pt 1, staff 6 states in part, “...Since this outcome was outside of standard, it should have been entered into Midas (patient safety event reporting system). The staff is not shy about bringing outcomes forward. Since this patient was a death after a procedure, those are all looked into. I was notified within hours of the air emboli and I sent it to the medical staff review coordinator immediately to make sure it was on the list for peer review. We can then put it in the Midas system if it’s not there.” An interview was conducted with staff 1 on 04/09/25 at 3:20 p.m. Staff 1 confirmed there was no incident report or safety event report filed on behalf of pt 1 having an aborted procedure, having a potential air embolus during their procedure or having stroke-like symptoms post procedure.”

“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: 46199 Based on medical record review, staff interviews and document reviews, it was determined the facility failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases by refusing to accept a patient from a referring hospital that was an appropriate transfer.This failure has the potential to negatively affect all patients receiving care from the facility. Cross reference - 489.24 (f) A participating hospital that has specialized capabilities or facilities may not refuse to accept from a referring hospital an appropriate transfer of an individual who requires such specialized capabilities or facilities.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 46199 Based on medical record review, staff interviews and document reviews, it was determined the facility failed to accept a patient from a referring hospital an appropriate transfer of an individual who required specialized care of one (1) out of twenty (20) patients, patient #1. This failure has the potential to negatively affect all patients receiving care from the facility. Findings include: A review of the facilities Emergency Departments (ED) Central Log revealed Patient #1 was not listed in the log. A review was conducted of a document titled “Patient Name (Last, First Middle)” time: 9:43pm, date: 8/5/24. The document contains a section titled “Comments: 8/5/24” which states, in part, “Patient was brought in by [significant other] as a walk in for assessment. [Significant other] reports that (Patient #1) has consumed an unknown amount of Ethyl Alcohol (ETOH) and sedatives (Xanax) ...Tried to call report to SMMC ED, the nurse (EMP #8) said (Patient #1) has a no trespassing there so is not allowed to go there. Report called to [other facility RN] at [other facility] at 9:35p.m.; also advised that SMMC unable to take [Patient #1] due to no trespassing order (concerned that patient may be violent and wanted them to be wary of that).” A review was conducted of a policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” last reviewed 06/20. The policy states in part, “Policy: as required under the emergency medical treatment and labor act 42 USC section 1395 and all federal regulations and interpretive guidelines promulgated thereunder any patient who comes to St. Mary’s Medical Center requesting emergency services, regardless of diagnosis or financial status, is entitled to and will receive a medical screening examination within the capabilities of the hospital ‘s emergency department, performed by individuals qualified to perform such examination, to determine whether an emergency medical condition exists.” An interview was conducted on 8/8/24 at 9:00a.m. with Emp #8. Emp #8 was asked about the phone call they received from [Psychiatric Hospital]. Emp #8 stated, “They called me about wanting to send a patient here. The patient was drunk and had hit their head. I told them this patient had just been ‘no trespassed’ so they can go to [other local acute facility].” Emp #8 was asked about receiving calls from [Psychiatric Hospital]. Emp #8 stated, “If it is their admitted patient, they give us the complaint and tell us they are sending. I clarified that [Patient #2] showed up at their door with their significant other, was intoxicated and had fallen in their lobby. [Psychiatric Hospital caller] said the patient’s name is [Patient #2] and I said [Patient #2] been no trespassed and can go to [other facility].” Emp #8 was asked the name that she was given and Emp #8 states in part, I heard [Patient #2’s name] but I know now it was [Patient #1’s] name. It should be noted that Patient #1 did not have a no trespassing order against them. A telephone interview was conducted on 8/8/24 at 9:35a.m. with [Psychiatric Hospital] Staff #1. [Psychiatric Hospital] Staff #1 was asked about the events of 8/5/24 that occurred at their facility. [Psychiatric Hospital] Staff #1 stated, “A person showed up in our lobby and was heavily intoxicated and fell in our lobby, striking their head. [Psychiatric Hospital Staff #2] contacted our physician, and they advised sending the patient to the ER. [Psychiatric Hospital Staff #2] called St. Mary’s and told them about the patient. The person at St. Mary’s said that the patient had a no trespassing order on them, and they could not take the patient. That person advised them to go to [other local acute facility]. [Psychiatric Hospital Staff #2] contacted [other local acute facility] and they took report on the patient.” [Psychiatric Hospital] Staff #1 was asked if there was documentation as to who was contacted at St. Mary’s. [Psychiatric Hospital] Staff #1 stated, “I am attempting to contact [Psychiatric Hospital Staff #2] to see if they remember the name because it is not in the documentation.” A second telephone interview was conducted on 8/8/24 at 1:25p.m. with [Psychiatric Hospital] Staff #1. [Psychiatric Hospital] Staff #1 states in part, [Emp #8] was the person that was contacted and told them to take the patient to [other local acute facility]. [Psychiatric Hospital] Staff #1 was asked if they were told St, Mary’s was on diversion at the time. [Psychiatric Hospital] Staff #1 stated, “There was no diversion that we were aware of.” An interview was conducted on 8/8/24 at 1:30p.m. with Emp #4. Emp #4 was asked about the events of 8/5/24. Emp #4 stated, ‘I agree one hundred percent (100%) there needs to be additional education. I’m not sure what [Emp #8] was thinking in terms of this being a transfer versus a non-patient being sent to us.””