Camden Clark Medical Center

“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: 42792 Based on document reviews, medical record review, and staff interviews, it was determined the facility failed to provide an appropriate Medical Screening Exam (MSE) to rule out an Emergency Medical Condition (EMC) in one (1) out of twenty (20) Patients, (Patient #1). This failure has the potential to negatively affect all patients receiving a medical screening from the facility. Findings include: A policy titled, “Emergency Medical Treatment and Labor Act (EMTALA)” revised on 02/01/2023 was reviewed. This policy states in part, “ ...Policy: ... will comply with the requirement of the Emergency Medical Treatment and Active Labor Act (EMTALA) by ensuring that when an individual come by him or herself or with another person to [Facility] or it premises and a request is made by the individual or on the individual’s behalf for medical examination or treatment, [Facility] or a department thereof will provide for an appropriate Medical Screening Examination within the capability of the Emergency Department, including ancillary services routinely available to the Emergency Department, to determine whether or not an emergency medical condition exists or, with respect to a pregnant woman having contraction whether the woman is in labor. If it is determined that the individual has an emergency medical condition, stabilizing treatment will be provided and they will be either admitted, discharged, or transferred as appropriate ... 3. How to Provide the Medical Screening Examination [MSE] C. Individuals coming to the Emergency Department will be provided a MSE beyond initial triage. Triage is not equivalent to an MSE. Triage is to determine the sequence in which Patients will be seen, not the presence or absence of an emergency medical condition. G. Depending on the Patient’s presenting symptoms, the MSE may range from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. H. A MSE is not an isolated event. It is an ongoing process. The medical record must reflect continuous monitoring according to the Patient’s needs and must continue until he/she is stabilized or appropriately transferred. There will be evidence of this evaluation documented in the medical record to discharge or transfer. Stabilization: Purpose: To ensure that all Patients determined to have an emergency medical condition shall be stabilized prior to being transferred or discharged as required under EMTALA. Procedure: 1. To stabilize or be stabilized means, with respect to an emergency medical condition, that the individual is provided such medical treatment as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition ... 2. A Patient will be deemed stabilized if the treating physician attending to the Patient in the [Facility] Emergency Department or other designated areas has determined within reasonable clinical confidence that the emergency medical condition has resolved ...” A review was conducted of the “Medical Staff Bylaws, Policies and Rules and Regulations,” adopted 11/28/17. Section “Rules and Regulations” states in part, “...Article X Emergency Services ...10.1 General: (a) Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care ...10.2. Medical Screening Examinations: (a) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (1) Emergency Department physicians; (2) Emergency Department physician assistants; (3) Emergency Department nurse practitioners; and (4) Obstetrical Registered Nurses (only in the case of women in labor.) (b) The results of the medical screening examination must be dictated within 48 (forty-eight) hours of the condition of an Emergency Department visit.” A review was conducted of a document titled “Triage of the Antepartum/labor Patient in Special Delivery Unit Maternal Fetal Triage Index,” no date listed. The Maternal Fetal Triage Index revealed in part, “ ...Urgent /Priority 2 (Two): Does the woman or fetus have urgent/priority 2 (Two) vital signs? Or is the woman being in severe pain without complaint or contractions? Or is this a high-risk situation? Or will this woman and/or newborn require a higher level of care than institution provide ... Examples of High-Risk signs ... Difficulty breathing ...” A medical record review was conducted for Patient #1. Patient #1 was presented to the hospital on 07/20/24, due to the chief complaint for tachycardia. The patient endorsed that [he/she] was experiencing tachycardia for a few days. The patient stated that they had been experiencing tachycardia [a fast heart rate] accompanied by palpitation, chest pain, shortness of breath (SOB) and dizziness. The patient confirmed issues with palpitation and syncope in the past and was seen by a cardiologist for it with no etiology identified. The patient is currently twenty-nine (29) weeks pregnant and is a status G5P2AB2 [G=Gravida the number of times the patient has been pregnant, P=Para the number of children the patient has given birth to, AB=abortion/miscarriage the number of abortions/miscarriages the patient has had] and denies any pregnancy complaints. There was no abdominal pain/trauma, vaginal bleeding or leakage or did the patient voice any other concerns or complaint at the time of the initial emergency department (ED) provider evaluation. This patient was triaged at the level three (3) acuity and was assigned to the regular emergency department. A review of Emergency Department Triage Process Emergency Severity Index (ESI) Algorithm. The ESI revealed that Acuity #3 was a danger zone vital. Staff # 6 ’ s “Initial evaluation” of Patient #1 dated 7/20/24 at 7:12 p.m. describes [Patient #1] presented with irregular heartbeat. Staff #6 evaluation continues in part, “ ...Medical Decision Making: The patient is a twenty-two [22] year [gender] who presents with tachycardia and fatigue in the context of a twenty-nine [29] week pregnancy. Patient is persistently tachycardic, sinus on the monitor/EKG, but maintaining her blood pressure. No pregnancy related complaints and normal fetal heart tones. Given the pronounced tachycardia without clear etiology, after a discussion of the risk/benefits of computed tomography angiography [CTA] to [his/her] /baby, the patient agrees to CTA. Negative for pulmonary embolism [PE] but does show very small pericardial effusion. Urinalysis [UA] shows small bacteriuria/pyuria, but also with significant qualms. No urinary symptoms ...” May it be noted that the patient was twenty-nine (29) weeks pregnant and there was no evidence in the Patient ’ s medical record of an OB/GYN consultation. An interview was conducted on 08/20/24 at 3:03 p.m. with Staff # 3. Staff # 3 stated, “I did the triage for [Patient #1], the triage was done as a regular Patient. The ED providers are the ones who decided consultation with OB/GYN. There is a sheet in the ED department that is a guide for pregnant Patients up to twenty (20) weeks, this how we triage the Patient if there are any alerts indicating the Patient is sent upstairs to the OB/GYN emergency department. In this case the Patient did not meet the criteria to go upstairs.” A phone interview was conducted on 08/20/24 at 3:21 p.m. with Staff #6. Staff #6 stated: “I did not recall [Patient #1]. When asked if it would have been appropriate for Patient #1 to be seen at ER and not by an Obstetric when Patient #1 was twenty-nine (29) weeks pregnant. Staff #6 stated, “Over twenty (20) weeks of pregnancy, Patients would go to the OB (Obstetric) emergency department, but a pregnant woman without pregnancy issues would stay in the ED. If the Patient came to the regular ER, that means the OB is not even involved.” Patient #1 was discharged with first (1st) degree heart blockage because it is not a serious risk.””

“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: 40269 Based on document review, medical record review, observation and staff interview, it was determined the facility failed to ensure procedure was followed for removing ALL of the patient ‘s belongings, in one (1) out of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care in the facility’s Emergency Department (ED). Findings: A policy was reviewed titled “Emergency Department Behavioral Health Unit (BHU) Policy and Procedure”, effective date 2/26/23. The policy has a section titled “Purpose” which states, in part, “To establish guidelines for care of mental health and substance abuse disorder patients in the Emergency Department.” The policy has a section titled “Procedure” which states, in part, “ 8. Maintain the safety of the patient, staff, and others. a. Patient will be placed in paper scrubs. b. Emergency department staff will collect and hand off all belongings to security personnel for inventory of patients belongings as outlined in security procedure. Documented list will be scanned into the medical record under the media tab. c. If patient is being discharged to home and does not require inpatient treatment, patient will be given their belongings along with their discharge paperwork. d. If patient requires admission to an inpatient facility, patient will not be provided their belongings ... 10. Utilize restraints only if patient is an immediate danger to self, staff, or others. Contact local law enforcement if potential danger to staff, or others. See Restraint policy. 13. Encourage patient to remain in ED until the medical and mental health screening and referral is complete. If the patient insists on leaving, the staff member who heard the patient state ’ I want to harm myself or others ’ must initiate the mental hygiene petition.” A medical record review was conducted for patient #1. The patient presented to the facility’s Emergency Department (ED) on 06/09/24 via Emergency Medical Services (EMS) at 11:03 a.m. At 11:17 a.m. a note by Employee (Emp) #5 states, “Pt (patient) placed in paper scrubs, belongings bagged up and given to security. Security at the bedside. Constant monitoring in place. Safety measures maintained.” Emp #1 documented “ED Course” at 11:58 a.m. and it states, “Patient eloped from the emergency department shortly after blood collection. [Patient #1] denies suicidal and homicidal ideation during interview. Attempts were made to contact [other facility] to confirm whether patient reported homicidal or suicide ideation to them.” The patient was listed as eloped at 12:15 p.m. A video review was conducted of the facility ED on 6/12/24 at 11:00 a.m. with Emp #2. The video started on 06/09/24 at 11:00 a.m. and shows the following: Please note Emp #2 explains the camera time is approximately five (5) minutes ahead, so actual time would be five (5) minutes prior to time listed. 11:21 a.m. Patient handed paper scrubs 11:22 a.m. Patient ambulates into BHU pod restroom (ligature free) and closes door 11:24:45 a.m. Patient back to room, put belongings bag on the floor, put shoes on the floor (slip-on shoes, no laces), lays on bed and covers up with personal blanket 11:26:24 a.m. Patient sitting at edge of bed, put shoes back on 11:31:47 a.m. Patient stands at doorway of the room 11:34:05 a.m. ED technician comes into the room with an ECG machine. Pushes belongings bag out of the way, against the wall 11:38:45 a.m. Security personnel obtains belongings bag, leaves the blanket and shoes with patient An interview was conducted with Emp #4 on 6/12/24 at 2:14 p.m. Emp #4 was asked about the process for taking a patient’s belongings if they are found to be suicidal. Emp #4 stated “Well, [Patient #1] denied SI, but our process would be to take the patient’s clothes and give them paper scrubs to put on. Their belongings are inventoried and put in a locker for safety. The patient is searched for weapons. If the patient is suicidal, we will do one (1) to one (1) monitoring.” Emp #4 was asked why Patient #1’s belongings were not taken. Emp #4 stated, “At that point, [Patient #1’s] blanket and shoes should have been taken and put in the locker.””

“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: 40269 Based on document review, medical record review, observation and staff interviews, it was determined the facility failed to ensure the patient had a appropriate medical screening examination in one (1) out of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care in the facility’s Emergency Department (ED). Findings include: A review was conducted of the “Medical Staff Bylaws, Policies and Rules and Regulations,” adopted 11/28/17. Section “Rules and Regulations” states in part, “...Article X Emergency Services ...10.1 General: (a) Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care ...10.2 Medical Screening Examinations: (a) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (1) Emergency Department physicians; (2) Emergency Department physician assistants; (3) Emergency Department nurse practitioners; and (4) Obstetrical Registered Nurses (only in the case of women in labor.) (b) The results of the medical screening examination must be dictated within 48 (forty-eight) hours of the condition of an Emergency Department visit.” A policy was reviewed titled “Suicide Risk Assessment in the Emergency Department”, effective 7/19/22. The policy has a section titled “Procedure” which states, in part, “Patient presents to the Emergency Department with a chief complaint of Suicidal or Homicidal Ideation. These patients are roomed and changed into paper scrubs by emergency department staff. The patient ’ s personal belongings are inventoried by security and stored in locked cabinet for safety and security ...Ask Suicide-Screening Questions (ASQ) positive screening has two (2) pathways. If the patient answers YES to question one (1) - four (4) and no to question five (5) they should remain in a room that is video monitored or if answering YES to any of the questions one (1) - four (4) and answering Yes to question five (5) the patient is determined to be at high or imminent risk requiring a one (1) : one (1) patient sitter.” A medical record review was conducted for patient #1. The patient presented to the facility’s Emergency Department (ED) on 06/09/24 via Emergency Medical Services (EMS) at 11:03 a.m. The patient signed their consent for treatment. The triage was initiated at 11:09 a.m. by Emp #5 and states, “Pt (Patient) arrives to ED via EMS on RA (room air) from [Patient #1’s crisis center]. Per EMS pt was found with t-shirt around neck and states [Patient #1] was ‘going to jump off a cliff.’ EMS reports withdrawing from ‘75 (seventy-five) ml (milliliters) of Methadone a day.’ Pt reports left arm spasms which EMS reports has caused [Patient #1] to ‘flail around everywhere.’ Pt denies SI/HI (suicidal ideations/homicidal ideations) upon arrival.” The Suicide Monitoring/Prevention was completed at 11:13 a.m. by Emp #5 and is titled, “Ask Suiside-Screening Questions” or ASQ. The patient answered the first four (4) questions yes, and the last one No. Per facility policy, this places the patient initially at moderate risk for attempting suicide, and requires video monitoring, which was already in place. The question the patient answered “No” to states, “Are you having thoughts of killing yourself right now?” The “Emergency Department Provider Note” was started at 11:13 a.m. by Emp #1 and states in part, “HPI (History of Presenting Illness)... It is expressed by EMS that their initial call was for SI (suicidal ideations). Upon [Patient #1]’s arrival the patient denies SI/HI. RN (Registered Nurse) will attempt to contact [Patient #1’s crisis center] in order to verify the exact situation ... there are no other complaints at this time ...Physical Exam:...Musculoskeletal: Patient has intermittent sporadic movement of the BUE and BLE... Psychiatric:Patient appears anxious but cooperative with examination ...Work up: CBC (complete blood count), comprehensive metabolic panel- non-fasting, ethanol- serum, drug screen with confirmation urine, thyroid stimulating hormone with free T4 reflex, urinalysis- macroscopic, Covid-19 screening, urinalysis- microscopic, Suboxone confirmatory\definitive urine, methadone confirmatory/definitive urine, fentanyl confirmatory/definitive urine, ECG (electrocardiogram) 12 (twelve) lead, benztropine (cogentin) 1 mg/ml (one milligram per milliliter) injection.” Additional orders included “ Consult to Psych (psychiatry) Clinical Assessment Coordinator.” May it be noted, the only ordered test that had resulted at the time of elopement was the ECG. At 11:17 a.m. a note by Emp #5 states, “Pt placed in paper scrubs, belongings bagged up and given to security. Security at the bedside. Constant monitoring in place. Safety measures maintained.” At 12:05 p.m. a note by Emp #8 states, “Patient reports [Patient #1] is unable to stay in the room. Patient reports I just want to leave. Patient ambulated out of ED without difficulty, patient deniesSI/HI. Provider-aware.” At 12:07 p.m. a note by Emp #8 states, “Patient denies SI and HI. patient reports withdrawing, States I just need help.” At 12:38 p.m. a note by Emp #8 states, “attempted to call [Patient #1’s crisis center] multiple times to notify patient eloping, no answer. unable to notify [Patient #1’s crisis center]. provider aware.” A 12:54 p.m. a note by Emp #11 states, “alerted for substance use. patient came to Ed from [Patient #1’s crisis center] .Patient left ED AMA.” At 3:09 p.m. a note by Emp #3 states, “Pt walked out of BHU (Behavioral Health Unit) with security guard stating [Patient #1] wanted to go outside and get some air. Patient escorted back to [Patient #1]’s room.” Emp #1 documented “ED Course” at 11:58 a.m. and it states, “Patient eloped from the emergency department shortly after blood collection. [Patient #1] denies suicidal and homicidal ideation during interview. Attempts were made to contact [Patient #1’s crisis center] to confirm whether patient reported homicidal or suicide ideation to them.” The patient was listed as eloped at 12:15 p.m. A video review of the facility’s Emergency Department (ED) was conducted on 6/12/24 at 11:00 a.m. with Employee (Emp) #2. Emp #2 states camera is two (2) minutes fast. 11:59:55 a.m. Patient into the waiting room, then outside ED main entrance 12:00 p.m. Patient sitting on bench outside ED entrance, security with the patient 12:01:24 p.m. Patient ambulates back into waiting room followed by security, sits in chair 12:01:52 p.m. Emp #8 arrives with patient, removes IV access 12:02:38 p.m. Patient walks out main ED entrance 12:04:16 p.m. Patient ambulating out of ED, uses crosswalk to cross main road, into parking lot across the street from ED entrance 12:05:37 p.m. Patient out of camera sight An interview was conducted with Emp #4 on 6/12/24 at 2:14 p.m. Emp #4 was asked about their involvement with the events surrounding Patient #1. Emp #4 was asked about the process for taking a patient ’ s belongings if they are found to be suicidal. Emp #4 stated “Well, Patient #1 denied SI, but our process would be to take the patient’s clothes and give them paper scrubs to put on. Their belongings are inventoried and put in a locker for safety. The patient is searched for weapons. If the patient is suicidal, we will do one (1) to one (1) monitoring.” Emp #4 was asked why Patient #1 ’ s belongings were not taken. Emp #4 stated, “At that point, [Patient #1 ’ s] blanket and shoes should have been taken and put in the locker.” An interview was conducted with Emp #5 on 6/12/24 at 3:02 p.m. Emp #5 was asked about their interaction with Patient #1 on 6/9/24. Emp #5 stated in part, “I was in charge of triage, and I took report from the EMS personnel. EMS reported that [Patient #1] was at the detox facility and was found with a t-shirt around [Patient #1 ’ s] neck..” A telephone interview was conducted with Emp #1 on 6/12/24 at 3:40 p.m. Emp #1 was asked about their interaction with Patient #1 on 6/9/24. Emp #1 stated in part, “I came to the room to see the patient. [Patient #1] was having a lot of spontaneous movements of [Patient #1]’s extremities, especially the arms. [Patient #1] was complaining about arm pain since receiving Suboxone earlier that morning. [Patient #1] was having trouble sitting still but was not complaining of pain anywhere other than in the arms. The behavioral health unit (BHU) protocol was started, and blood work was started for medical clearance. [Patient #1] let them get blood and started intravenous access (IV). Sometime later, the nurse told me that [Patient #1] wanted some fresh air and had eloped.” Emp #1 was asked what interventions had been prescribed for Patient #1. Emp #1 stated, “[Patient #1] could not remember the name of their blood pressure medication, but I had written an order for a medication to help with the involuntary movements.” Emp #1 was asked about Patient #1’s demeanor. Emp #1 stated, “[Patient #1] was nice, I did get report regarding SI, but I did not get any impression that [Patient #1] was suicidal.” An interview was conducted with Emp #8 on 6/12/24 at 4:58p.m. Emp # 8 was asked about their interaction with Patient #1 on 6/9/24. Emp #8 stated in part, “...[Emp #5] did not say that the patient mentioned anything about events that happened at the detox facility.” Emp #8 was asked about their assessment of Patient #1. Emp #8 stated, “I asked [Patient #8] if they were suicidal or trying to harm themselves and [Patient #1] said ‘no, they were not.’ I did get the patient’s labs and start an IV. I did not give any medication. The patient did express that they wanted to leave the ED.” Emp #8 was asked about the provider that saw the patient. Emp #8 stated, “I was not in the room when the physician came to assess the patient.” Emp #8 was asked about how Patient #1 left the facility. Emp #8 stated, “One of the security guards told me that [Patient #1] wanted to leave, so I went and told [Emp #1] that [Patient #1] wanted to leave. [Emp #1] said that if [Patient #1] ‘wanted to leave and is not suicidal, then [Patient #1] can leave.’ I then went and removed [Patient #1’s} IV. [Patient #1] wanted to leave and [Emp #1] was not able to talk to the patient about leaving against medical advice (AMA).” A telephone interview was conducted with Emp #9 on 06/13/24 at 11:13 a.m. Regarding Patient #1, Emp #9 states in part, “We responded to the call of the patient trying to commit suicide with a t-shirt ...” A telephone interview was conducted with Emp #12 on 06/13/24 at 11:38 a.m. Regarding Patient #1, Emp #12 states in part, “... I would have given the same report I gave to medcom (medical command) to the employee at the hospital. I gave a report verbally to [Emp #5]. Yes I did tell [Emp #5] the patient tried to open the door of the ambulance. I worded it exactly [Patient #1] tried to open up the ambulance door while we were going down Route Fifty (50). The [Patient #1] said they weren’t trying to jump out, just trying to get air. I did ask the patient directly if they were suicidal with a plan as required by medcom and [Patient #1] told me no.” A telephone interview was conducted with Emp #3 on 06/13/24 at 2:42 p.m. Regarding Patient #1, Emp #3 states, “The patient walked out of the behavioral health unit (BHU) with security. I looked at [Patient #1] and spoke with [Patient #1] and [Patient #1] said [Patient #1] just wanted to get some air. At that time [Patient #1] agreed to go back into [Patient #1]’s room. I did not talk to [Patient #1] when [Patient #1] came back out and left. After [Patient #1] left, [Emp #8] told me [Patient #1] left and [Emp #8] took [Patient #1]’s IV out. [Patient #1] was not currently endorsing suicide or homicidal ideations. We aren’t allowed to keep them unless they’re actively endorsing it. The only time we can hold someone is with a hold order and they have to be actively suicidal.” An interview was conducted with Emp #13 on 06/13/24 at 2:07 p.m. Regarding Patient #1, Emp #13 states, “We went by the EMS report that the patient was suicidal. Anytime we get a patient from a detox unit they are placed in the behavioral health unit pod. They are not specific to suicidal or homicidal patients. Even detox patients will get the video monitoring. The patient was placed in paper gowns. When the patient said they wanted to leave, their belongings were given back to [Patient #1] and [Patient #1] declined changing back into [Patient #1]’s clothes before [Patient #1] left. If a patient elopes, we only call the police if the patient is having active suicidal ideations, had an alcohol level greater than 100 (one hundred) or had an IV in place. I can’t answer as to why the provider didn’t have time to go talk to the patient. We had tried to talk to [Patient #1’s crisis center] but the patient had already walked out.” An additional telephone interview was conducted with Emp #8 on 06/13/24 at 2:30 p.m. Regarding Patient #1, Emp #8 states, “I don’t know exactly what the patient said for the reason [Patient #1] was leaving. [Patient #1] just told me [Patient #1] was leaving. The charge nurse [Emp #3] had already talked to [Patient #1] and I’m not sure what [Patient #1] told [Emp #3]. The provider said as long as [Patient #1] wasn’t actively suicidal [Patient #1] could leave. I asked [Patient #1] again [Patient #1] said no. I took [Patient #1]’s IV out and [Patient #1] left.””