Based on interviews, document reviews, review of video, and review of 22 open and closed medical records, it was determined that there was a delay in performing a medical screening examination for one patient (P1) seen in February, 2019. P1 was brought the hospital ED via EMS in early February complaining of a two day history of nausea, vomiting, and diarrhea. According to EMS documentation, P1 was alert and oriented and neurologically intact upon arrival at the ED. The hospital medical record indicated P1 was triaged as an ESI 3 approximately 5 minutes after arrival. Approximately 5 minutes after triage, P1 is seen on the video to slump over to the left side. At the 15 minute mark, the patient is transferred by EMS to a hospital bed in the hall. P1 is clearly minimally responsive and has very little response to noxious stimuli as one of the EMS provider squirted aerosolized saline up P1's nose. Again, no hospital staff assisted or assessed P1. After the transfer into the hospital bed, the patient was placed back against the wall in the hall, where P1 remained for approx. 25 minutes. P1 started seizing after about 10 minutes. Multiple staff are seen walking past P1 but no assessment is done, and no monitoring or vital signs were checked. P1 had at least three seizures while staff walked past. Following the seizure activity, P1 was not responsive at all. After being in the hall a total of approx. 35 minutes, P1 was taken to a room by a staff person who pulled the back of the stretcher and did not look at or interact with the patient. According to documentation in the record, P1 continued to exhibit seizure activity and resuscitation efforts started immediately after P1 was placed in the ED room and a Code Blue was called approx. 10 minutes later when P1 lost the heart rate. After an hour of resuscitation efforts, the code was terminated with P1 never regaining a viable heart rhythm. The investigation confirmed that P1 suffered a delay in the MSE when P1's change in condition was not acted upon by the staff and no physician was notified of P1's condition until the patient was in a room.

Based on a review of hospital policy "Emergency Medical Treatment and Transfer (EMTT) (revised 06/16); 3 open and 24 closed emergency department records it was revealed that no statement of stability, risk to benefit, or consent was found for patient #13 who was voluntarily transferred for treatment to a psychiatric hospital. Review of hospital policy EMTT revealed in part, "C. 1. When it is determined that the individual has an emergency medical condition, the Hospital shall: ...b ...transfers of unstabilized individuals are permitted only if the patient requests it after being informed of the risks and benefits, or when a physician, or other Qualified Medical Person in consultation with a physician certifies that the expected benefits to the transfer outweigh the risks of transfer." Patient #13 was a middle-aged patient who presented in November 2016 with auditory and visual hallucinations and chest pain. Patient #13 had a recent history of psychiatric hospitalization , but had been non-compliant with medications following discharge. Additionally, patient #13 had a positive toxicology screen inclusive of anti-anxiety medications, and narcotics. A medical screening examination inclusive of electrocardiogram revealed that the chest pain was likely related to panic attacks. The psychiatric assessment by a social worker described paranoia, confusion, and the patient report of not feeling safe in the community. The social worker further documented in part, "Pt requires an inpatient psychiatric admission to provide a safe environment and medication stabilization." The plan for disposition included, "Voluntary admission." Based in the fact that the hospital did not have an inpatient psychiatric unit, the social worker located an appropriate bed for placement at a second hospital. A Licensed Clinical Professional Counselor (LCPC) wrote in part, "Pt has been accepted at (hospital #2). Pt remains calm and cooperative, and is awaiting transport within the hour." For each patient transferred, the hospital used a "Patient Transfer Documentation Form (PTDF)" to document the patient acknowledgement of the risk to benefit of transfer, the patient consent for transfer, and the stability of each patient at the time of transfer. The required form was not found in patient #13's record. While record documentation indicated that patient #13 was stable and knew of the impending transfer, no statement in the record revealed that patient #13 was made aware of the risk to benefit of transfer, and no consent was obtained from voluntary patient #13. Therefore, the hospital failed to meet requirements for the transfer of patient #13.