Denver Springs

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48269 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0144: The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure a patient’s home medications were continued or substitution medications were provided to meet the needs of their medical condition in one of one patients reviewed who was transferred out of the facility for acute medical care.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48269 Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure a patient’s home medications were continued or substitution medications were provided to meet the needs of their medical condition in one of one patients reviewed who was transferred out of the facility for acute medical care. (Patient #2) Findings include: Facility policies: The Patient Bill of Rights policy read, you will be evaluated to decide your mental health condition and find the best direction for your care. You have the right to receive care that is provided safely, by a skilled professional who will treat you humanely. The Teen’s Bill of Rights policy read, you have the right to be treated with respect and dignity in a place that is clean and where you are protected from harm. Reference: The naproxen manufacturer’s instructions for use (IFU) read, may cause ulcers, bleeding, or holes in the esophagus (tube between the mouth and stomach), stomach, or intestine. These problems may develop at any time during treatment, may happen without warning symptoms, and may cause death. The risk may be higher for people who take naproxen for a long time or at high doses. If you experience any of the following symptoms, stop taking naproxen and call your doctor: stomach pain, heartburn, or blood in vomit or stools. 1. The facility failed to ensure a patient continued to receive medication they had been taking for their medical condition before admission to the facility. A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 was a 14-year-old voluntarily admitted on 3/24/26 for care of suicidal ideation with multiple suicide attempts. The provider’s history and physical revealed Patient #2 had a history of PANDAS (pediatric condition where the immune system attacked healthy brain tissue after an infection and caused sudden onset of psychiatric issues like obsessive compulsive disorder (OCD), tics, or severe mood changes). The record revealed Patient #2’s home medications included azithromycin (an antibiotic used to treat bacterial infections) 250 mg on Monday, Wednesday, and Friday, naproxen (used to relieve inflammation) 250 mg four times a day, and omeprazole (used to reduce stomach acid) 20 mg before bedtime to treat PANDAS. Additional record review revealed the facility made a therapeutic substitution of pantoprazole (used to reduce stomach acid) in place of omeprazole while Patient #2 was hospitalized. The record also revealed on the evening of 3/25/26, after the second dose of pantoprazole was given at 8:09 p.m., Patient #2 experienced a rash and burning sensation on their arms and chest. The physician on-call was notified of the symptoms and discontinued the order for pantoprazole. There was no evidence of a substitution ordered to replace the pantoprazole. Review of nursing documentation on 3/27/26 revealed Patient #2 began to complain of increased abdominal pain. At 5:33 p.m., the patient had a pain level of two (1-10 scale), and at 8:12 p.m., the patient reported a pain level of five. Documentation on 3/27/26 also revealed Patient #2 had no breakfast and ate only 25% of lunch. On 3/28/26, during lunch in the cafeteria, Provider #1 documented they had responded to a staff assist (call for additional staff to help) for Patient #2, who was in the bathroom and refused to leave because they had severe abdominal pain. Provider #1 documented Patient #2 reported they had increased abdominal pain for approximately 24 hours, which was worse after taking naproxen. Further, Provider #1 documented Patient #2 had left upper quadrant abdominal pain, which was most likely related to chronic naproxen use and minimal food intake. Finally, the record revealed on 3/28/26 at 9:00 p.m., Patient #2 was sent by ambulance to the emergency department for medical clearance. The record revealed Patient #2 reported their left upper quadrant stomach pain had worsened throughout the day and was now at an eight out of ten. Patient #2’s nurse called the provider on-call and received an order to send the patient to the emergency department for medical evaluation. The nurse’s note read, Patient #2 had been refusing to eat the past few days and had been given naproxen for their autoimmune condition, which caused neurologic inflammation. Further, the nurse documented they were worried about a possible stomach bleed. This medical record review was in contrast to the Patient Bill of Rights, which read patients had the right to receive care that was provided safely, by skilled professionals. This medical record review was also in contrast to the Teen Bill of Rights, which read patients had the right to be treated with respect and dignity in a place where they were protected from harm. B. Interviews i. On 6/9/26 at 2:45 p.m., an interview was conducted with physician assistant (Provider) #1. Provider #1 stated Patient #2 had been taking naproxen 250 milligrams (mg) four times a day when they were admitted to the hospital. Provider #1 stated a typical dose would have been one or two times each day. Provider #1 stated they had spoken with Patient #2’s mother about the unusually high dose of naproxen. Provider #1 stated Patient #2’s mother told Provider #1 the medication was necessary to reduce inflammation around the spinal cord from their PANDAS condition. Provider #1 stated they continued patients on their home medications after they were admitted. Provider #1 then reported Patient #2 developed a rash after taking pantoprazole, and it was discontinued. Provider #1 stated Patient #2 had been having belly pain from naproxen and thought they had developed a stomach ulcer. ii. On 6/20/26 at 11:17 a.m., an interview was conducted with staff pharmacist (Pharmacist) #2. Pharmacist #2 stated naproxen 250 mg four times a day was a higher than normal dose. Pharmacist #2 stated naproxen was usually taken every 12 hours. Pharmacist #2 stated if a patient was taking that much without medication like omeprazole to protect the stomach lining, the patient would be at risk of developing stomach pain, an ulcer, or bleeding. Additionally, Pharmacist #2 explained Patient #2 had been on omeprazole 20 mg at bedtime at home. Pharmacist #2 stated omeprazole was a medication the facility did not supply, so the facility provided a therapeutic substitution, pantoprazole, which had been approved by the Pharmacy and Therapeutics committee. Pharmacist #2 stated Patient #2 had an adverse reaction to pantoprazole on the second day of their admission, and the medication was discontinued. Pharmacist #2 then stated the facility failed to request Patient #2’s home medication, omeprazole, be brought into the facility so Patient #2 could continue with their home medication regimen. iii. On 6/11/26 at 8:30 a.m., an interview was conducted with attending physician (Physician) #3. Physician #3 stated PANDAS was an autoimmune condition which led to psychiatric symptoms. Physician #3 stated Patient #2 was being cared for by a specialist at another facility who managed their medication regimen. Physician #3 stated the facility’s practice was to keep patients on their same home medication regimen. Provider #3 stated Patient #2’s adverse reaction to pantoprazole occurred after hours, so the on-call medical provider gave the order to discontinue the medication. Provider #3 stated it was an oversight caused by miscommunication amongst the care team that another medication needed to protect the stomach from the high doses of naproxen was not ordered. Additionally, Physician #3 stated high doses of naproxen changed the acid level in the stomach, which would have been harmful to the patient without the protection of a medication to reduce stomach acid. This interview was in contrast to the Patient Bill of Rights, which read patients had the right to receive care that was provided safely, by skilled professionals. This interview was also in contrast to the Teen Bill of Rights, which read patients had the right to be treated with respect and dignity in a place where they were protected from harm.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52761 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews, and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure patients in the adolescent unit who presented with suicidal ideation (SI) were provided therapeutic activities according to their individualized treatment plans. This failure was identified in three of four adolescent patients who presented with SI. Additionally, the facility failed to ensure the physical milieu fostered a therapeutic environment. This failure was identified in two of two observations of the adolescent group therapy room. Finally, the facility failed to ensure patients were provided compassionate, trauma-informed care tailored to patient-specific stressors. This failure was identified in one of one patients who were presented with a behavioral plan.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 52761 Based on observations, interviews, and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure patients in the adolescent unit who presented with suicidal ideation (SI) were provided therapeutic activities according to their individualized treatment plans. This failure was identified in three of four adolescent patients who presented with SI (Patients #2, #4, and #8). Additionally, the facility failed to ensure the physical milieu fostered a therapeutic environment. This failure was identified in two of two observations of the adolescent group therapy room. Finally, the facility failed to ensure patients were provided compassionate, trauma-informed care tailored to patient-specific stressors. This failure was identified in one of one patients who were presented with a behavioral plan (Patient #3). Findings include: Facility policies: The Specialized Therapy Services policy read, the purpose is to restore, remediate, and rehabilitate a person’s level of functioning and independence in life activities, to promote health and wellness, and to reduce or eliminate the activity limitations and restrictions to participation in life situations caused by an illness or disabling condition. Daily therapeutic activities shall be offered to each patient. One-to-one therapeutic activities shall be offered to those patients who are not physically or emotionally able to tolerate group activities. The Program Overview/Scope of Care policy read, people in an acute psychiatric crisis urgently require a safe environment, a structured and supportive social milieu, and intensive psychiatric and psychological therapeutic intervention. The Inpatient Program combines these elements into a unique and effective treatment program. The program’s physical design provides a safe and sensory stimulating environment for all patients and a space for therapeutic activities. Daily involvement in therapy groups and community meetings helps to develop a sense of independence and mutual support that is important in treatment of all patients in the program. Through this coordinated effort, the program provides support, structure, and therapeutic expertise needed to help patients stabilize their condition and achieve a more appropriate level of functioning. The Safe and Functional Environment policy read, the goal is to develop and implement plans, programs, and processes to promote a safe and functional environment. The organization designs, constructs, and maintains features of the environment to promote patient safety while providing diagnosis, treatment, and care for the appropriate needs of the patient. To provide the appropriate environment, the organization conducts planning activities and inspections of the following items: interior spaces shall meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. The Patient Violence Mitigation Program policy read, positive behavioral plans shall use interventions that explicitly avoid the use of punishment and use positive behavioral strategies to manage dangerous and serious interpersonal problems. The plans are developed to support the safety of the patient with a patient-specific plan. 1. The facility failed to ensure patients in the adolescent unit who presented with suicidal ideation were provided therapeutic activities according to their individualized treatment plans. A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 presented to the facility on 12/6/24 for suicidal ideation. The Treatment Planning Problem Sheet revealed Patient #2 was to receive psychotherapy (talk therapy) group sessions twice daily for one hour. This was in contrast to a review of Patient #2’s therapy treatment record, which failed to reveal psychotherapy provided to Patient #2 on 12/7/24, 12/9/24, and 12/11/24, and revealed psychotherapy was provided once on 12/10/24. Patient #2 was discharged on 12/11/24 after five days of inpatient psychiatric hospitalization, at which point they had received three psychotherapy sessions. This was in contrast to the Specialized Therapy Services policy which read, daily therapeutic activities were offered to each patient to restore, remediate, and rehabilitate a person’s level of functioning and independence in life activities, promote health and wellness, and reduce or eliminate the activity limitations and restrictions to participation in life situations. This was also in contrast to the Program Overview/Scope of Care policy which read, people in an acute psychiatric crisis urgently required intensive psychiatric and psychological therapeutic intervention. Daily involvement in therapy groups and community meetings helped patients develop a sense of independence and mutual support. The program provided the support, structure and therapeutic expertise necessary for patients to stabilize their condition and achieve a more appropriate level of functioning. ii. Review of Patient #4’s medical record revealed Patient #4 presented to the facility on 12/10/25 following a suicide attempt. The Treatment Planning Problem Sheet revealed Patient #4 was to receive psychotherapy group sessions twice daily for one hour and activity therapy once or twice daily for one hour. This was in contrast to a review of Patient #4’s therapy treatment record, which failed to reveal psychotherapy provided on 12/11/25 and 12/13/25, and revealed psychotherapy was provided once on 12/12/25, 12/14/25, and 12/15/25. Furthermore, activity therapy was only offered once on 12/11/25 and 12/12/25. As of 12/15/25, Patient #4 had been at the facility for five days and received psychotherapy three times and activity therapy twice. iii. Review of Patient #8’s medical record revealed Patient #8 presented to the facility on 8/27/25 for suicidal ideation. The Treatment Planning Problem Sheet revealed Patient #8 was to receive psychotherapy group sessions twice daily for one hour. This was in contrast to a review of Patient #8’s therapy treatment record, which revealed psychotherapy was provided once rather than twice on 8/31/25 and 9/1/25. B. Interviews i. Between 12/15/25 to 12/22/25, interviews were conducted with facility staff. a. In an interview conducted with clinical director (Director) #1, Director #1 stated patients at the facility typically presented for problems associated with maladaptive behaviors and thought processes. Director #1 explained behavioral therapies were essential in helping patients alter maladaptive thought processes, prevent impulse behaviors such as self-harm, and improve interpersonal relationships. Additionally, Director #1 stated patients were provided both behavioral therapy and activity therapy to ensure they were therapeutically engaged while stabilizing. Furthermore, Director #1 explained both forms of therapy were offered to patients in order to maximize their resources for self-regulation following discharge. This was in contrast to a review of the records for Patients #2, #4, and #8. b. In an interview conducted with lead therapist (Therapist) #2, Therapist #2 stated both psychotherapy and activity therapy groups were to be provided to patients twice each day. However, Therapist #2 stated neither form of therapy had been offered consistently in recent months due to a lack of staffing. Therapist #2 explained patients may not receive adequate psychoeducation or develop sufficient coping skills if they were not provided with consistent therapy. Additionally, Therapist #2 stated it was important to provide patients with therapy during their hospitalization to equip them with the emotional regulation skills necessary for optimal post-discharge management. c. In an interview conducted with Patient #4, Patient #4 stated they had been infrequently offered therapy sessions during their hospitalization. Rather, a majority of their inpatient stay was spent watching television, doing puzzles, and engaging in unstructured peer socialization. This was in contrast to the Specialized Therapy Services policy which read, daily therapeutic activities were offered to each patient. This was also in contrast to the Program Overview/Scope of Care policy which read, people in an acute psychiatric crisis urgently required a structured and supportive social milieu, and an intensive psychiatric and psychological therapeutic intervention. 2. The facility failed to ensure the physical milieu fostered a therapeutic environment. A. Document Review i. Review of the daily schedule for the adolescent unit for the week of 12/14/25 revealed group therapy was scheduled every day at 11:00 a.m. and 2:30 p.m. B. Observations i. Observations of room #102 on the adolescent unit were conducted on 12/15/25 at 12:40 p.m. Profane writing was observed on the walls of the room, including on the right side of the back wall, on the back wall under the window, on the left wall under the whiteboard, and on the left wall to the right of the whiteboard. This was in contrast to the Safe and Functional Environment policy which read, the organization maintained features of the environment to promote patient safety while providing treatment, and care for the appropriate needs of the patient. Interior spaces met the needs of the patient population and were safe and suitable to the care, treatment, and services provided. During this observation, chief nursing officer (CNO) #3 stated group therapy was conducted in room #102. Additionally, CNO #3 stated a work order would be entered to have the writing removed from the walls that day. This was in contrast to observations of room #102 conducted the following day, 12/16/25 at 3:05 p.m., which revealed the profane writing remained on the walls. C. Interviews i. In an interview conducted with Therapist #2, Therapist #2 stated behavioral health technicians assessed rooms following group therapy sessions to monitor for graffiti. Any identified graffiti was to be cleaned up or painted over immediately. This was in contrast to observations conducted on 12/15/25 at 12:40 p.m., which failed to reveal interventions to remove graffiti from the walls of room #102 following a group therapy session conducted at 11:00 a.m. Additionally, this was in contrast to observations conducted on 12/16/25 at 3:05 p.m., which failed to reveal interventions to remove graffiti from the walls following group therapy sessions the day prior at 2:30 p.m., and group therapy sessions that day at 11:00 a.m. and 2:30 p.m. Therapist #2 also explained it was important to remove graffiti to maintain a safe and therapeutic environment that fostered healing. Therapist #2 stated profane graffiti could evoke a trauma response in patients, affect their self esteem, or cause them to engage in self-destructive or harmful behaviors. 3. The facility failed to ensure patients were provided compassionate, trauma-informed care tailored to patient-specific stressors. A. Document Review i. Review of Patient #3’s medical record revealed Patient #3 presented to the facility on 10/4/25 for major depressive disorder and polysubstance use. Patient #3 had a history of post-traumatic stress disorder (an anxiety disorder caused by traumatic events), reactive attachment disorder (a condition in which children struggle to form emotional bonds with caregivers due to neglect or abuse), autism spectrum disorder, and polysubstance abuse. Further review of Patient #3’s medical record revealed Patient #3 engaged in frequent assaultive behaviors towards staff members, intentionally damaged facility property, and verbally threatened the safety of both staff and other patients. The facility determined a behavioral plan (a structured, individualized plan designed to promote patient safety, guide staff responses, and support therapeutic care when a patient exhibits behaviors that interfere with treatment, safety, or the care environment) was required in order to manage Patient #3’s challenging behaviors. Review of Patient #3’s discharge summary revealed Patient #3 escalated and assaulted a staff member upon being informed of the behavioral plan. Emergency intramuscular (IM) medication was required to subdue Patient #3, and law enforcement was contacted to ensure the safety of all parties present at the facility. Ultimately, the decision was made to discharge Patient #3 into police custody. B. Interviews i. In an interview with registered nurse (RN) #4, RN #4 provided an account of the circumstances surrounding the presentation of the behavioral plan to Patient #3. RN #4 stated a staff member, with whom Patient #3 had a prior altercation with, and an RN woke Patient #3 up from their sleep to present the plan. RN #4 explained behavioral plans should be presented to patients by their inpatient therapist because the therapist could provide effective verbal support and coping skills. Additionally, RN #4 stated Patient #3 had a known history of reacting with physical aggression and verbal threats when faced with boundaries and expectations. RN #4 stated a therapist’s presence would have been beneficial in assisting Patient #3 to de-escalate following the presentation of an emotional trigger. This was in contrast to the Program Overview/Scope of Care policy which read, people in an acute psychiatric crisis urgently required a safe environment and intensive psychiatric and psychological therapeutic intervention. The Inpatient Program combined these elements into a unique and effective treatment program. Through this coordinated effort, the program provided support and therapeutic expertise needed to help patients stabilize their condition and achieve a more appropriate level of functioning. ii. In an interview conducted with Therapist #2, Therapist #2 stated behavioral plans were presented by a patient’s therapist and included a discussion of boundaries, short-term and long-term goals for the patient, and a reward or motivator. This was in contrast to the event recounted by RN #4, which revealed the behavioral plan was not presented by Patient #3’s therapist. Therapist #2 explained Patient #3 was never placed in seclusion because isolation triggered them to escalate. However, Patient #3’s behavioral plan involved isolating Patient #3 to an empty unit to prevent them from agitating or upsetting other patients. This was in contrast to the Patient Violence Mitigation Program policy which read, positive behavioral plans used interventions that explicitly avoided the use of punishment and used positive behavioral strategies to manage dangerous and serious interpersonal problems. The plans were developed to support the safety of the patient with a patient-specific plan. iii. In an interview conducted with Therapist #5, Therapist #5 stated trauma-informed care involved considering a patient’s total history and past experiences when determining the type of treatment to provide. It was important providers were aware of a patient’s past trauma in order to better anticipate triggers and understand why a patient might react negatively to certain stimuli. Moreover, it was important to provide trauma-informed care in order to adjust treatment approaches and ensure the delivery of competent care. This was in contrast to the interview conducted with Therapist #2, during which it was revealed the behavioral plan failed to consider Patient #3’s triggers and failed to adjust the treatment approach during the development or presentation of the plan.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44751 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient Rights was out of compliance. A-0131 STANDARD: (b)(2) INFORMED CONSENT The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. Based on interviews and document review, the psychiatric emergency department (PED) failed to ensure a patient’s discharge disposition complied with their court-ordered involuntary commitment order. In addition, the facility did not obtain approval from the legal custodian, the Colorado Behavioral Health Administration (BHA), in accordance with the Colorado Revised Statutes (CRS) before discharging the patient to an unsupervised setting. This occurred in one of one records reviewed of a patient who presented to the PED on an IC hold. (Patient #4)”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 44751 Based on interviews and document review, the psychiatric emergency department (PED) failed to ensure a patient’s discharge disposition complied with their court-ordered involuntary commitment order. In addition, the facility did not obtain approval from the legal custodian, the Colorado Behavioral Health Administration (BHA), in accordance with the Colorado Revised Statutes (CRS) before discharging the patient to an unsupervised setting. This occurred in one of one records reviewed of a patient who presented to the PED on an IC hold. (Patient #4) Findings include: Facility policies: The Alcohol and Drug Involuntary Commitments section of the Mental Health Hold for Involuntary Treatment policy read, the Department (Colorado Behavioral Health Administration) shall be the legal custodian of individuals involuntarily committed to treatment. Requests for early discharge and/or transfer to other treatment programs shall be submitted to the Colorado Behavioral Health Administration for approval. The Informed Consent policy defined capacity as a person’s ability to Understand the nature and consequences of a proposed treatment, including benefits, risks, side effects, and alternatives to the proposed treatment, and make a decision whether to undergo the proposed treatment. Informed Consent is consent given by a person or the person’s legally authorized representative. The policy defined a patient’s personal representative as the person with the right to make informed decisions regarding the patient’s care. The Facility will obtain consent for admission and treatment to all programs except when the patient has been involuntarily admitted for treatment under state law. References: The Screening Assessment and Level of Care (LOC) forms, identified by staff as a psychiatric assessment/evaluation, determine the level of care needed for the patient, read, the psychiatric assessment/evaluation assists in acquiring information about a patient’s immediate psychiatric needs and any psychiatric care and treatment the patient has received. The screening and LOC assessments contain patient background information, medical history, medication history, associated psychiatric conditions, and any collateral patient information from external facilities, friends, and family. According to the Department of Human Services 2 CCR 502-1, Behavioral Health, Section 21.270 -Alcohol and Drug Involuntary Commitments, (C), the Department shall be the legal custodian of individuals involuntarily committed to treatment and (G) Requests for early discharge and/or transfer to other treatment programs shall be submitted to the Department for approval. According to the Department of Human Services 2 CCR 502-1, Behavioral Health, Chapter 5 -Behavioral Health Residential and Level 3, Including ASAM 3.5 - Withdrawal Management Services, Part 5.9.1 Section Service Delivery and Setting (A) American Society of Addiction Medicine (ASAM) 3.5 - Residential Services are for individuals who have multifaceted treatment needs requiring a twenty-four (24) hour treatment environment, and who are unable to be properly treated at a lower level of residential care and (B)(2) the individual engages in behaviors and/or thought processes that contribute to impaired social, interpersonal, and/or vocational functioning, necessitating this highly structured twenty-four (24) hour treatment environment. According to the Colorado Behavioral Health Administration (BHA) website https://bha.colorado.gov/for-people-in-colorado/involuntary-treatment/substance-use-commitment#substance-use-emergency-commitment, an Involuntary Commitment (IC) is a process in which a person is placed in substance use treatment for up to 270 days without their consent. During this period, they are enrolled in a treatment program that aligns with their needs and placed under the custody of the BHA. The BHA monitors their treatment progress and reports to the court as necessary. An IC follows an emergency commitment and is considered a last resort for individuals who refuse all voluntary substance use treatment, pose a danger to themselves or others due to their substance use, and can benefit from treatment once sober. A person must have refused voluntary treatment and meet one of two criteria: either they pose a danger to themselves or others, demonstrated through threats or acts of physical harm, or they are incapacitated to the extent that they present a danger to themselves or others. 1. The facility failed to receive and review a patient’s IC hold order. Specifically, it did not ensure the patient’s discharge disposition complied with the court-ordered IC hold and failed to obtain approval from the patient’s legal custodian before they discharged the patient to an unsupervised setting, placing the patient’s safety at risk and increasing their risk of relapse. A. Document review revealed despite being on a court-ordered IC hold and having a documented inability to make safe decisions, Patient #4 was discharged to an unsupervised setting. i. A review of the referral documents provided to the PED from a residential recovery center (an inpatient substance use disorder and mental health treatment center) for Patient #4 revealed the following: a. On 12/4/24 at 11:00 a.m., the residential recovery center admitted Patient #4 for substance use treatment. A review of Patient #4’s Admission Assessment at the recovery center revealed Patient #4 required continuous 24-hour care and was placed in a Level 3.5 ASAM treatment program (structured residential setting with 24-hour care and monitoring, which falls under inpatient treatment), which provided structured, intensive residential care based on patient needs. According to the Medical Evaluation performed on 12/4/24 at 11:30 a.m., Patient #4 was on a court-ordered IC hold due to substance use and had recently relapsed while on the IC hold. b. On 12/5/24 at 7:30 p.m., emergency medical services (EMS) transported Patient #4 to an acute care emergency department (ED) for a medical evaluation. According to the Provider Note, recovery center staff told EMS not to leave Patient #4 unattended or discharge them since the court-mandated IC hold required them to receive substance use treatment at the residential recovery center. ii. A review of the facility’s PED screening and LOC assessment for Patient #4 on 12/6/24 revealed the following: a. At 5:38 p.m., the PED received a referral from the residential recovery center, where Patient #4 was an inpatient. The referral requested the PED perform a psychiatric screening and LOC assessment for Patient #4. b. At 6:17 p.m., Patient #4 arrived at the PED with staff from the residential recovery center. Upon arrival, intake specialist (Specialist) #1 asked the residential recovery center staff accompanying Patient #4 to remain during the screening and LOC assessment. However, the recovery center staff left before Specialist #1 completed the assessments. At 7:20 p.m., Specialist #1 documented Patient #4 was on a court-ordered IC hold and obtained collateral information for Patient #4’s screening assessment from the referral and medical records the residential recovery center provided. At 7:42 p.m., Specialist #1 completed the screening and LOC assessment for Patient #4 and reviewed the results with Provider #2, who recommended against admission and referred Patient #4 to intensive outpatient treatment. Additionally, Specialist #1 documented they presented and reviewed the screening and LOC assessments with the PED intake supervisor, the administrator on call (AOC), and the chief executive officer (CEO) before they discharged Patient #4. At 8:33 p.m., Specialist #1 reviewed the recommendation for intensive outpatient treatment with Patient #4, and Patient #4 signed the Screening Assessment and Personalized Treatment Recommendation form. At 8:45 p.m., Patient #4 was discharged to an unconfirmed location without supervision. Upon request, the facility could not provide evidence that it had received and reviewed Patient #4’s court-ordered IC hold, attempted to coordinate the patient’s return to the residential recovery center, complied with the IC hold requirements, or obtained approval from the patient’s legal custodian before discharge. Additionally, the facility could not confirm Patient #4 was discharged to a safe and supervised location. Furthermore, these events and the facility’s failure to provide evidence contrasted with CSR 2 CCR 502-1, Behavioral Health, Section 21.270 - Alcohol and Drug Involuntary Commitments, which stated individuals on an IC hold were under the custody of the BHA and required BHA approval before discharging or transferring a patient to ensure compliance with the court-ordered IC hold and continuity of court-ordered treatment. B. Interviews revealed staff failed to review the court-ordered IC hold and medical records from the recovery center, leaving them unaware Patient #4 was an inpatient with 24-hour oversight for substance use relapse risk. As a result, they discharged the patient to an unsupervised setting. i. On 1/29/25, at 8:00 a.m., Specialist #1 was interviewed. Specialist #1 stated they did not understand how to apply an IC hold at the facility or assess a patient with one. Specialist #1 also stated they did not know what actions to take when a patient on an IC hold did not meet admission criteria. Specialist #1 stated while they believed an IC hold mandated treatment, they did not know whether or how an IC hold would be enforced at the facility. Specialist #1 stated they did not receive or review the court-ordered IC hold for Patient #4. They also stated they did not know Patient #4 was receiving inpatient substance use disorder treatment at the residential recovery center, which led them to discharge the patient unsupervised. ii. On 1/29/25 at 9:11 a.m., assessment supervisor (Supervisor) #3 was interviewed. Supervisor #3 stated an IC hold was a court-ordered hold that required a patient to receive substance use treatment and specified the treatment the patient had to receive. Additionally, Supervisor #3 stated staff should have been provided the IC hold order and reviewed the court-ordered treatment outlined in the IC hold order. Supervisor #3 stated patients who were admitted for inpatient substance use treatment exhibited impaired judgment, engaged in risky behaviors, and had an increased risk of overdose when unsupervised. These interviews conflicted with Patient #4’s medical records from the residential recovery center, which stated Patient #4 had been admitted as an inpatient to an ASAM Level 3.5 treatment program for continuous 24-hour, structured, intensive care based on Patient #4’s substance disorder treatment needs. Additionally, these interviews conflicted with 2 CCR 502-1, Behavioral Health, Chapter 5, which stated individuals with substance use disorders admitted to ASAM Level 3.5 residential care had impaired social behaviors and thought patterns and needed 24-hour highly structured and monitored care.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 42693 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI CONDITION, was out of compliance. A-0286 PATIENT SAFETY (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. Based on interviews and record review, the facility failed to ensure patient events were reported, analyzed and preventative measures were implemented. Specifically, the facility failed to report an adverse patient event in order to investigate causative factors and implement preventative actions (Patient #20). Additionally, the facility failed to implement preventive measures after patient safety concerns were identified however continued to occur in 8 of 26 medical records reviewed. (Patient #1, #2, #3, #4, #12, #17, #19, and #25).”

“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: 42693 Based on interviews and record review, the facility failed to ensure patient events were reported, analyzed and preventative measures were implemented. Specifically, the facility failed to report an adverse patient event in order to investigate causative factors and implement preventative actions (Patient #20). Additionally, the facility failed to implement preventive measures after patient safety concerns were identified however continued to occur in 8 of 26 medical records reviewed. (Patient #1, #2, #3, #4, #12, #17, #19, and #25). Findings include: Facility policies: The Incident Notification Communication policy read, the purpose was to establish a uniform procedure to outline communication expectations for potential events that occur at the facility. The policy defined an adverse event as a patient safety event that resulted in harm to a patient. Adverse events should prompt notification of organization leaders, investigation, and corrective actions. An adverse event may or may not result from an error. The Incident Report Protocol and Patient Safety Events policy read, an incident report was a detailed notice in the information system of a patient safety incident. A patient safety incident was an event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety incident could be, but was not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. A Sentinel Event included an adverse event of a severe and urgent nature, which could result in an unexpected and undesirable patient outcome. Examples included any occurrence, which has resulted in an unanticipated death or major loss of function, not related to the natural course of the individual’s condition; death caused by self-inflicted injurious behavior while in a health care setting; abduction of any individual receiving care, treatment, or services; sexual abuse/assault (including rape); and any elopement (that is, unauthorized departure) of an individual served from a staffed around the clock setting (including the ED) leading to the death, permanent harm or severe temporary harm of the individual served. Patient Safety Incidents must be captured via the incident reporting system. It was the responsibility of all staff to report all patient safety incidents, accidents, or injuries involving patients or visitors and to report such occurrences using the Incident Reporting system along with notifying their supervisor immediately. When a patient safety incident was discovered, the employee making the discovery was required to notify their immediate supervisor and enter the incident in the incident management system. Incident reports were to be filled out for any patient safety incident. The Incident Report Management policy read, the Director of Quality and Risk Management will lead the investigation for all patient-related incidents. Supervisors/Managers must complete additional information within the incident reporting system, related to their review of patient-related incidents. The Director of Quality and Risk Management was responsible for closing out all incident reports within 72 hours of notice of the event. The Risk Management Plan policy read, for further investigation: gather all pertinent facts about the incident including the scene, who was involved, description of the event, and any damages. Continues to communicate with the patient and family through the physician. Enter notification/incident form into the database for trend analysis. Determine, possibly through quality improvement analysis evaluation if changes in processes, in-service education, or other steps were necessary. Risk Management/Quality Improvement completed the following: identified risk and adverse events through incident reporting, patient complaints, and other data resources; identified problems through continuous monitoring or critical indicators or the quality and appropriateness of patient care; assessed incidents, adverse events, and trends through the Quality Improvement Committee and risk management analysis; assessed performance improvement data through peer review; recommended and monitored corrective actions designed to reduce patient risks; monitored effectiveness or corrective actions. The Integration of Risk Management and Education section read, accountability and corrective measures for incidents most often involved educational functions. Once the exposure to loss had been identified and priorities set or new policies developed, the Risk Manager may request that an effective educational program in which training and retraining will be implemented. The Risk Manager would coordinate, plan and implement educational programs to minimize the risk of harm to patients and others through the general orientation and/or handbooks (as available), risk management educational sessions as indicated and coordinate an annual presentation, Hospital wide by the Risk Manager, insurance carrier and/or legal counsel. The Elopement policy read, the purpose was to provide adequate documentation in the patient’s medical record of the elopement. In the patient’s medical record document time, who was notified, efforts made to ensure that the patient was safe, areas searched, and the patient’s behavior and mental status in the progress notes. The Facility Risk Assessment policy read, the assessment would evaluate the risk from a variety of functions including the structure of the environment and performance of everyday tasks. Risks were also identified from internal sources, such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and credible external sources (i.e. Sentinel Event Alerts). The Facility would conduct a risk assessment of the physical environment to evaluate hazards and identify features in the physical environment that could be used to attempt suicide and/or cause harm to patients, staff, and visitors. The facility will use the assessment to take necessary action to minimize the risk(s) and develop protective measures associated with various tasks performed in each area within the Hospital and off-site Facilities. The Facility will conduct a full risk assessment annually or whenever there was a change in the environment and will review the progress of the assessment and action plans related to the assessment at least quarterly at the facility safety committee. The Risk Assessment Team Members will identify the appropriate risk elements in the environment and the activities conducted in the area that could have an impact on patient care. The team will also address any risks reported by staff members in the risk assessment as they were received. The assessment for safety and security-related risk can be completed on the Risk Assessment form. The assessment will be conducted in all areas of the Facility, including the areas conducted in environmental tours. The Risk Assessment Team Members complete the form by identifying the risks related to each area. The team members will evaluate the risk to determine if current mitigation strategies were in place that sufficiently mitigate the risk. Risks that require additional mitigation will require immediate clinical and physical mitigation until a long-term strategy is put in place. The Safety Officer, Risk Assessment Team, and/or EOC Committee will determine if additional changes in process, training, policy, and/or procedure or PPE/Safety equipment will be required to eliminate or minimize the impact of the risk. 1. The facility failed to ensure an adverse patient event was reported and investigated. a. A review of Patient #20’s record and the EMTALA log for 3/7/24 and 3/10/24 revealed the patient overdosed on medication while in the intake area. i. On 3/7/24 at 3:30 p.m., Patient #20 arrived at the facility. ii. The safety assessment form was completed by the patient at 3:34 p.m. The form read the patient was seeking services due to alcohol and drug use. Patient #20 indicated on the form they did not have thoughts to harm themselves and felt safe. iii. The close observation form read at 3:30 p.m. the patient was located in “other” and the patient displayed calm behavior. There was no additional documentation of 15-minute checks performed after 3:30 p.m. There were two sticky notes placed on the form with vital signs written down. Vital signs at 3:50 p.m. read, blood pressure 142/88; heart rate 139 beats per minute (BPM), and a blood alcohol level (BAL) of .069. iv. At 3:41 p.m. the patient’s eligibility insurance was reviewed by the facility. v. At 5:36 p.m., the patient’s urine drug screen revealed they were positive for barbituates, meth, amphetamine, and benzodiazepines. Vital signs at 6:07 p.m., written on the second sticky note, read the patient’s blood pressure was 99/54; heart rate was 125 bpm; and respirations of 11. vi. The EMTALA form read the form was completed at 6:35 p.m. The patient was sent to another hospital due to the need for medical clearance. The patient was incapacitated, unresponsive, and had decreased vital signs. The patient reported ingesting 600 mg of Seroquel and unknown sleeping pills. vii. A review of Patient #20’s record and EMTALA log for 3/10/24 revealed the patient returned to the facility at 12:10 p.m. after receiving medical treatment at an outside facility. The screening assessment form was completed at 12:38 p.m. The note on the screening assessment form read, that the patient was previously at the facility on Thursday and overdosed in the intake bathroom. b. A review of the patient safety event report log revealed there was not a report entered for Patient #20’s event. This was in contrast to the Incident Report Protocol and Patient Safety Events policy which read, that incident reports were to be filled out for any patient safety incident. The incident report should have been filled out as soon as practicable after the incident had occurred. c. A review of the quality committee meeting minutes from 4/25/24 revealed there was no mention of Patient #20’s event. This was in contrast to the Risk Management Plan policy which read, that incident reports should have been entered into the database for trend analysis as the Quality Improvement Committee identified risks and adverse events through incident reporting and assessed and implemented corrective actions. d. Interviews with staff revealed they were unaware of this event and that the event should have been reported. i. On 7/9/24 at 4:16 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated any staff could enter an incident report when an event occurred. RN #1 stated it was important for the event to be entered so it could be reviewed and to prevent a similar event from happening again. ii. On 7/10/24 at 11:40 a.m., an interview was conducted with the director of nursing (DON) #2. DON #2 stated observations of patients were to be completed whenever a patient was at the facility. DON #2 stated the observations started in the front lobby and intake area. DON #2 stated it was important for observations to be done to ensure patient safety. DON #2 explained if an event occurred that caused patient harm, an incident report was to be filed. DON #2 stated once an incident report was entered, it would be investigated to identify concerns. On 7/11/24 at 1:30 p.m., additional documentation regarding the patient safety event for Patient #20 was requested from DON #2. DON #2 stated she was unaware a safety event had occurred with Patient #20. iii. On 7/15/24 at 11:44 a.m., an interview was conducted with the director of quality, risk, and compliance (Director) #3. Director #3 stated an incident report was to be filed whenever an event occurred that was outside of the normal day-to-day activities. Director #3 stated events such as a drug overdose were supposed to be followed up on immediately. At 1:04 p.m., a second interview was conducted with Director #3 in which Patient #20 was discussed. Director #3 stated they were unaware of the event that occurred regarding Patient #20. Director #3 reviewed facility documents and confirmed an incident report was not filed regarding Patient #20’s drug overdose incident. Director #3 stated it was important for events to be reported for opportunities to be identified and to prevent further patient harm. 2. The facility failed to ensure preventative measures were implemented after patient safety concerns were identified and failed to re-evaluate measures for success when implemented. a. A review of Patient #25’s medical record revealed they arrived at the facility on 6/8/24 at 2:16 p.m. for treatment of a suicide attempt by a drug overdose. The patient observation sheet revealed checks on the patient were started at 2:19 p.m. and were to be conducted on the patient every 15 minutes. Further review of the observation sheet revealed the 15-minute observations did not start until 4:30 p.m., over two hours after the patient arrived at the facility. A review of a patient safety event for Patient #25 revealed they had eloped from the intake area at 3:35 p.m. The report read the patient had held down the push bar of the door to elope from the hallway. The patient walked out of the door and was followed by staff. The police department was called and the patient was later returned to the facility at 4:30 p.m. The follow-up for the patient safety event read the patient was placed on elopement precautions once they returned to the facility, however, there was no mention in the safety report that the facility identified the lack of 15-minute observations and implemented measures to ensure continued lapses in 15-minute observations were not recurring at the facility. b. On 7/1/24 at 1:00 p.m., Patient #12 presented to the facility for alcohol detox. On the Safety Assessment form, Patient #12 marked they felt unsafe and concerned. A review of the patient observation sheet revealed one 15 minute check of the patient was completed at 1:00 p.m. There was only one 15 minute check performed until the patient left the facility at 3:29 p.m., two and a half hours after the patient presented to the facility. Similar findings of the lack of every 15-minute observations were found in Patients #2, #3, #4, #17, #19, and #25 intake medical records. c. The facility’s risk assessment last reviewed by the facility on 6/6/24, revealed the push bar doors had been identified as an elopement risk in 2022. The mitigation measure put in place for the identified risk was for assessment staff to monitor the area and patients. The mitigation measures were in contrast to the medical record review which revealed 12 patients were not consistently monitored while in the intake area. Additionally, the facility’s risk assessment and mitigation measures were in contrast to the facility risk assessment policy which read, the team members would evaluate the risk to determine if current mitigation strategies were in place that sufficiently mitigate the risk. The facility was unable to provide evidence the mitigation measures sufficiently mitigated the risk. d. On 7/15/24 at 4:12 p.m., an interview was conducted with DON #2. DON #2 stated intake staff had not consistently performed close observation rounds. DON #2 stated to mitigate this, they implemented real-time compliance audits to ensure continuous patient observations were performed. DON #2 stated since March of 2024, two real-time compliance audits were performed in the intake area which had not identified gaps in compliance. They further stated they were not aware patients in the intake area were not continuously monitored until the survey was conducted.”

“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: 44751 Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20, and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2406: (a)(c) Appropriate Medical Screening Examination. Based on interviews and document review, the facility failed to ensure patients who presented to the facility for emergency psychiatric services received an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for the patient in 11 of 20 medical records reviewed. (Patients #1, #2, #3, #5, #7, #8, #12, #16, #17, #20, and #21). Additionally, the facility failed to ensure qualified medical personnel (QMP) performed an MSE for patients who presented to the facility to determine the presence of an EMC in 10 of 20 medical records reviewed. (Patients #4, #6, #9, #10, #11, #13, #14, #15, #17, and #19) Tag 2409: (e) Restricting Transfer Until the Individual Is Stabilized. Based on interviews and document review, the facility failed to ensure patients were assessed and transported for medical clearance as deemed safe by a provider. The failure was identified in six of eight medical records reviewed in which patients were transferred out for medical clearance. (Patient #3, #7, #8, #14, #16, and #17)”

“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: 44751 Based on interviews and document review, the facility failed to ensure patients who presented to the facility for emergency psychiatric services received an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for the patient in 11 of 20 medical records reviewed. (Patients #1, #2, #3, #5, #7, #8, #12, #16, #17, #20, and #21). Additionally, the facility failed to ensure qualified medical personnel (QMP) performed an MSE for patients who presented to the facility to determine the presence of an EMC in 10 of 20 medical records reviewed. (Patients #4, #6, #9, #10, #11, #13, #14, #15, #17, and #19) Findings include: Facility policies: The EMTALA policy defined a QMP as an individual designated to perform the MSE by the hospital’s governing board (GB) through the medical staff and/or hospital bylaws. An MSE is defined as a general and focused assessment based on the patient’s chief complaint with the intent to determine the presence or absence of an EMC. A psychiatric MSE will include a screening assessment by a QMP. Triage or the completion of a medical/psychiatric triage form alone does not satisfy the MSE requirement. The facility will maintain medical and other records related to individuals transferred or discharged to or from the Hospital for six (6) years. Hospitals will maintain a log of patients presenting to the hospital for treatment along with documentation indicating whether he or she refused treatment, was denied treatment, or whether the patient was treated, admitted, stabilized, and/or transferred or discharged. The Screening Assessment and/or Level of Care/ Psychosocial Assessment policy read every patient must have a Screening Assessment. No section of the assessment should be left blank without an explanation. If the patient doesn’t meet the admission criteria for inpatient, partial hospitalization program (PHP), or intensive outpatient program (IOP) then the Screening Assessment will be staffed with a provider and signed. The Screening Assessment and the Level of Care Assessments will be completed by Assessment Coordinators (intake specialists) in the Assessment Department. The Assessment Department department is staffed with Masters level therapists; registered nurses and/or licensed individuals (as required by state licensure). An Assessment Coordinator will assess the patient and complete the assessments by gathering the necessary information from the patient, the patient’s family, other informants, and or the patient’s referring provider/therapist. The assessments are completed for every patient who comes to the facility seeking psychiatric services. References: The Medical Staff Rules and Regulations read the Medical Staff Rules and Regulations are a component of the Hospital Medical Staff Bylaws. Section 21, Emergency Services of the Medical Staff Rules and Regulations read the hospital provides services to evaluate, stabilize, and transfer when necessary and appropriate, individuals who present to the hospital with conditions of an emergent or urgent nature. These services include the provision of an appropriate “medical screening examination” by a Physician or other “qualified medical personnel” for individuals who present with an “emergency medical condition” and request examination or treatment to determine if the individual is experiencing an “emergency medical condition” and shall further include appropriate treatment to stabilize the patient or transfer the patient to another facility if medically necessary. Qualified medical personnel (QMP) may include any provider acting within the scope of their licensure and medical staff/allied health professional staff privileges. The Governing Board Bylaws, Article IV, Section 3, read the Governing Body shall have the following duties and responsibilities: Approve Medical Staff bylaws, rules, and regulations. Additionally, Article IV, Section 4, read the Governing Board shall approve, in writing, the qualified medical personnel (“QMP”) who may perform the medical screening examinations (“MSE”) for EMTALA purposes. The Screening Assessment form, identified by staff as a psychiatric assessment/evaluation form used when performing an MSE, was provided by the facility. The Screening Assessment form assisted staff at the facility in acquiring information about a patient’s immediate psychiatric needs and information related to the care needed by the patient. The form obtained background information, medical history, medication history, and the psychiatric concern the patient had and was completed to assist staff in determining the psychiatric services needed for the patient. 1. The facility failed to ensure patients who presented to the facility for emergency psychiatric services received a medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for the patient. A. Patient Safety Assessment forms, Personalized Treatment Recommendations, and the facility’s EMTALA logs (a list of patients who sought emergency medical treatment from the facility) were reviewed and revealed from 1/30/24 through 7/4/24 patients who presented to the facility for psychiatric emergency services were not provided an MSE. i. Medical record review revealed Patient #20 was admitted to the facility on 3/10/24. A review of Patient #20’s Screening Assessment for 3/10/24 revealed Patient #20 had a diagnosis of substance use disorder (SUD - excessive use of alcohol, medications, and or illegal drugs) and had presented to the facility three days earlier on 3/7/24. According to the chief complaint/current symptoms section of the Screening Assessment documented on 3/10/24, while in the intake assessment area (the designated area where new patients received medical screening exams) on 3/7/24, Patient #20 overdosed on Seroquel (an anti-psychotic medication to control mood) and sleeping pills. A review of the EMTALA log for 3/7/24 revealed at 3:30 p.m., Patient #20 presented to the facility, and three hours later at 6:30 p.m., Patient #20 had been transferred out for immediate medical interventions and treatments. Upon request, the facility failed to show how the patient was assessed on 3/7/24 during the three hours they were at the facility to determine if an EMC existed for Patient #20. Additionally, the facility was unable to provide evidence a psychiatric MSE had been performed for Patient #20 to determine if an emergent psychiatric condition existed before the patient overdosed. ii. According to the EMTALA log, Patient #17 presented on 5/26/24 at 5:42 p.m. one hour and 21 minutes later at 7:03 p.m. Patient #17 was transferred out for medical evaluation. Upon request, the facility was unable to provide evidence Patient #17 received an MSE to determine if they had an emergent psychiatric condition. Additionally, the facility was unable to provide evidence the patient had been assessed by staff while at the facility. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #17 had received an MSE to determine if the patient had an emergent psychiatric condition. iii. Patient #7 presented to the facility on 4/2/24 at 7:00 p.m. According to the EMTALA log, 35 minutes later at 7:35 p.m. Patient #7 was transferred out for further medical evaluation. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #7 had received an MSE to determine if the patient had an emergent psychiatric condition. iv. Patient #8 presented to the facility on 4/11/24 at 1:47 p.m. According to the EMTALA log Patient #8 was transferred out for medical evaluation nine minutes later at 1:55 p.m. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #8 had received an MSE to determine if the patient had an emergent psychiatric condition. v. On 7/4/24 at 1:00 p.m., Patient #3 presented to the facility for alcohol detox services. Review of the Safety Assessment completed by Patient #3 revealed they were experiencing tremors, impaired cognitive thinking (confusion, forgetfulness, and or lack of focus), and increased sweating when they presented to the facility. According to the Personalized Treatment Recommendation Patient #3 was instructed to get a medical evaluation at the nearest emergency department (ED) and was discharged from the facility. A review of the EMTALA log revealed on 7/4/24 at 2:00 p.m. one hour after Patient #3 had presented to the facility, Patient #3 was transferred out for further medical evaluation. However, upon request, the facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #3 had received an MSE to determine if the patient had an emergent psychiatric condition. vi. On 7/4/24 at 3:00 p.m. Patient #16 presented to the facility for alcohol detox services. A review of the Safety Assessment form completed by Patient #16 revealed Patient #16 was experiencing alcohol withdrawal symptoms. However, a review of the Personalized Treatment Recommendation for Patient #16 revealed Patient #16 had been instructed to undergo a medical evaluation at the closest ED and, once medically cleared, Patient #16 was to request the ED send a referral to the facility for them to be admitted. A review of the EMTALA log revealed at 3:42 p.m., 42 minutes after Patient #16 had presented to the facility, Patient #16 was transferred out. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #16 had received an MSE to determine if the patient had an emergent psychiatric condition. vii. Patient #5 presented to the facility on 1/30/24 at 4:55 p.m. According to the EMTALA log Patient #5 was discharged, one hour and 40 minutes later at 6:35 p.m. Upon request, the facility failed to show how the patient was assessed during the time Patient #20 was at the facility. Additionally, the facility was unable to provide evidence Patient #5 had received an MSE to determine if the patient had an emergent psychiatric condition. viii. Patient #1 presented to the facility on 5/2/24 at 1:55 p.m. According to the EMTALA log two hours and five minutes later at 4:00 p.m., Patient #1 was discharged. Upon request, the facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #1 had received an MSE to determine if the patient had an emergent psychiatric condition. ix. On 5/11/24 at 9:45 a.m. Patient #2 presented to the facility. According to the EMTALA log one hour and 48 minutes later Patient #2 was discharged. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #2 had received an MSE to determine if the patient had an emergent psychiatric condition. x. On 6/26/24 at 5:25 p.m., Patient #21 presented to the facility. According to the EMTALA log for 6/26/24, Patient #21 was discharged one hour and 20 minutes later at 6:45 p.m. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #21 had received an MSE to determine if the patient had an emergent psychiatric condition. xi. On 7/1/24 at 1:00 p.m., Patient #12 presented to the facility. According to the EMTALA log for 7/1/24, Patient #12 was discharged two hours and 29 minutes later at 3:29 p.m. The facility was unable to provide evidence the patient had been assessed by staff while at the facility. Additionally, the facility was unable to provide evidence Patient #12 had received an MSE to determine if the patient had an emergent psychiatric condition. These medical record reviews were in contrast to the Screening Assessment and or Level of Care/ Psychosocial Assessment policy which stated every patient was required to have a completed Screening Assessment performed. Additionally, according to the EMTALA policy, a psychiatric MSE would include a screening assessment to determine the presence of an EMC. B. Interviews with staff revealed the Screening Assessment form was the psychiatric MSE and was required for each patient who presented for emergency psychiatric services. i. On 7/15/24 at 2:33 p.m., an interview was conducted with Specialist #6. Specialist #6 stated the Screening Assessment forms were used to evaluate the psychiatric crisis level of patients who present to the facility. Additionally, Specialist #6 stated the Screening Assessment forms reviewed the patient’s risk for self-harm and harm to others. Specialist #6 stated the Screening Assessment was required to be completed by intake specialists at the time the patients were assessed. Specialist #6 stated the Screening Assessment form was completed by intake specialists to ensure patients were not actively experiencing an emergent psychiatric condition and also to ensure the patient was not a danger to themselves or others. This interview was in contrast to the medical records reviewed which lacked evidence a screening assessment had been performed. ii. On 7/9/24 at 3:49 p.m., an interview was conducted with intake assessment specialist (Specialist) #7. Specialist #7 stated the screening assessment was the psychiatric assessment. Specialist #7 stated all screening assessments were performed by an intake assessment specialist or intake director (Director) #5. Specialist #7 stated a screening assessment was performed for every patient who presented to the facility and requested emergent psychiatric services. Specialist #7 stated the intake assessment specialists were required to complete a Screening Assessment form when a psychiatric assessment was performed for patients who presented to the facility seeking emergent psychiatric services. iii. On 7/9/24 at 9:34 a.m., an interview was conducted with Director #5. Director #5 stated the Screening Assessment form was completed for all patients who presented to the facility. Director #5 stated the Screening Assessment form was to be completed by the intake staff member who assessed the patient. Director #5 stated the Screening Assessment form ensured that patients requesting psychiatric services were not at risk of harming themselves or others and determined if they were experiencing a psychiatric or medical emergency. iv. On 7/10/24 at 9:47 a.m. an interview was conducted with director of nursing (DON) #11. DON #11 stated the screening assessment served as the MSE for the patient. According to DON #11, the screening assessment assisted in identifying if the patient was experiencing a psychiatric emergency. 2. The facility failed to ensure patients who presented for emergency psychiatric services received an MSE by qualified medical personnel (QMP). A. Document review revealed Governing Board Bylaws and Medical Staff Rules and Regulations had not designated intake assessment specialists as QMPs to perform MSEs. According to the Governing Board Bylaws, a QPM was any provider who worked within their license and the privileges granted by the medical staff. The bylaws did not state the intake director and intake assessment specialists were considered medical staff or privileged staff at the facility. B. Medical record review revealed intake specialists performed the MSE for patients who presented for emergency psychiatric services, even though intake specialists were not designated as QMPs by the governing board. i. On 1/25/24 at 11:05 a.m. Patient #14 presented to the facility after the patient had attempted suicide. A review of the Screening Assessment form for Patient #14 revealed Patient #14 had endorsed having thoughts of self-harm and also endorsed a plan to commit suicide by “jumping into traffic or strangling” themselves. Additionally, Patient #14 had walked into traffic before presenting to the facility. According to the Screening Assessment form the MSE for Patient #14 had been conducted by intake specialist (Specialist) #2. ii. On 2/2/24 at 5:25 p.m. Patient #13 presented to the facility. According to the Chief Complaint/Current Symptoms section of the Screening Assessment, Patient #13 did not meet the inpatient criteria for medical detox. Additionally, the MSE for Patient #13 was performed by Specialist #3 on 2/2/24 and subsequently signed by Specialist #4 on 2/3/24. iii. On 1/8/24 at 1:28 p.m. Patient #11 presented to the facility. A review of Patient #11’s Screening Assessment form revealed Patient #11 had requested inpatient detox services. The MSE was conducted by Specialist #2. iv. On 2/20/24 at 4:20 p.m. Patient #15 presented to the facility. According to Patient #15’s Screening Assessment form, Patient #15, requested inpatient detox services for alcohol after the patient relapsed earlier in the day. The MSE for Patient #15 was performed by intake director (Director) #5. v. On 3/30/24 at 10:15 p.m. Patient #6 presented to the facility. According to Patient #6’s Screening Assessment form, Patient #6 had requested inpatient detox services. The MSE was conducted by Specialist #12. vi. On 4/28/24 at 8:00 p.m., Patient #9 presented to the facility. According to the Screening Assessment form for Patient #9, the patient presented for inpatient detox services. Patient #9 endorsed continuous alcohol consumption daily and a history of shakes, tremors, seizures, nausea, and vomiting when detoxing from alcohol. The MSE for Patient #9 was performed by Specialist #10. vii. On 4/29/24 at 2:04 p.m. Patient #4 presented to the facility and requested inpatient detox services for alcohol. According to the Screening Assessment form for Patient #4, the patient reported continuous alcohol consumption daily and a history of shakes, tremors, sweats, chills, nausea, and vomiting when detoxing from alcohol. At 3:30 p.m. Patient #4 was discharged from the facility. The MSE for Patient #4 was performed by Specialist #3 and Specialist #6. viii. A review of the June 2024 EMTALA log revealed Patient #19 presented to the facility on 6/23/24 and 6/24/24. On 6/24/24 at 12:03 p.m., Patient #19 presented to the facility for inpatient detox services. A review of the Screening Assessment for Patient #19 revealed the Screening Assessment form and MSE were completed by Specialist #7. ix. On 5/26/24, Patient #17 presented to the facility at 9:00 p.m. for inpatient detox services for alcohol. A review of the Screening Assessment form for Patient #17 revealed the MSE was completed by Specialist #6. x. On 6/3/24 at 9:13 a.m. Patient #10 presented to the facility for inpatient detox services for alcohol. A review of the Screening Assessment form for the patient revealed the MSE was completed by Specialist #6. C. Interviews with facility staff revealed the facility was unaware intake specialists needed designation as QMPs by the Governing Board to perform the MSE. i. On 7/15/24 at 2:33 p.m. an interview was conducted with intake specialist (Specialist) #6. Specialist #6 stated they performed psychiatric MSEs. Specialist #6 stated screening assessment forms were completed by intake specialists to determine if an emergent psychiatric condition existed for the patient. ii. On 7/10/24 at 3:40 p.m., Director #5 was interviewed. Director #5 stated they were not aware intake specialists had to be designated as QMPs to perform the MSE. Director #5 also stated the facility determined the intake staff would perform the psychiatric MSE for patients who presented and requested emergent psychiatric services. iii. On 7/15/24 at 3:54 p.m., chief executive officer (CEO) #9 was interviewed. CEO #9 stated they were unaware intake specialists and the intake director were not designated as QMPs to perform MSEs. CEO #9 further stated at the 3/27/24 Governing Board meeting, the board reviewed and approved QMP designations. However, the facility was unable to provide evidence upon request that the board had designated intake specialists and the intake director as QMPs. The medical record reviews and interviews contrasted with the Governing Board bylaws, Medical Staff Rules and Regulations, and EMTALA policy. The Governing Board bylaws and EMTALA policy required the Governing Board to approve QMPs in writing, defining a QMP as someone designated by the board through the medical staff rules and regulations. According to the Medical Staff Rules and Regulations, intake specialists were not designated as medical staff or allied health professionals, who alone could serve as QMPs within the scope of their licensure and privileges.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44751 Based on interviews and document review, the facility failed to ensure patients were assessed and transported for medical clearance as deemed safe by a provider. The failure was identified in six of eight medical records reviewed in which patients were transferred out for medical clearance. (Patient #3, #7, #8, #14, #16, and #17) Findings include: Facility policies: The Emergency Medical Treatment and Active Labor Act (EMTALA) policy read, transfer means the movement (including discharge) of an individual outside the hospital’s facilities at the direction of any qualified medical personnel employed by the hospital. When a patient is being transferred from the facility to another facility, staff shall discuss transfer and risks with the patient. If the patient consents for transfer, call EMS for transfer. The facility will call EMS or the local sheriff’s department for the patient’s transfer to the receiving hospital. If the patient refuses to be transferred and is not at imminent medical risk, complete a copy of the Consent to Transfer EMTALA Form noting the patient’s refusal, and complete the assessment process. The Transfer to Another Facility policy read, if there is a medical emergency or medical clearance is required for a patient in assessment who has not been admitted, an appropriate hospital transfer will take place. The RN assesses and determines if the patient has an unstable medical condition. The RN will contact the physician and they will provide orders to transfer the patient. The physician will contact the emergency department physician and provide clinical information about the patient. The assessment staff will arrange for the transfer. The assessment staff will complete the EMTALA transfer form and send the original with the patient. When transportation arrives, i.e. ambulance, give the sealed envelope to the attendant. 1. The facility failed to ensure patients who needed medical clearance were transported by ambulance to ensure patient safety. A. Medical Record Review i. On 7/4/24 at 1:00 p.m., Patient #3 presented to the facility for alcohol detox treatment. The personalized treatment recommendation form read the patient needed to seek medical clearance via the nearest emergency department (ED). After seeking clearance, the facility would review the ER records for admission consideration at the facility. The patient was transported in a private vehicle by a sobriety sponsor. Upon request the facility was unable to provide evidence of a medical screening exam (MSE) completed by a qualified medical professional (QMP) and an RN assessment was performed to determine if the patient had an unstable medical condition. Additionally, there was no evidence the appropriate level of transfer and the risks of transportation by private vehicle were discussed with the patient by a QMP. Also, there was no evidence of the emergency department being contacted by the physician to provide clinical information about the patient. ii. On 7/4/24 at 3:00 p.m., Patient #16 arrived for alcohol detox treatment. The personalized treatment recommendation form read the patient needed to seek medical clearance at the local ER and that once the patient was medically cleared, the hospital could send a referral to the facility for review. The EMTALA log revealed Patient #16’s disposition was marked as private transport. Upon request the facility was unable to provide evidence of a medical screening exam (MSE) completed by a qualified medical professional (QMP) and an RN assessment was performed to determine if the patient had an unstable medical condition. Additionally, there was no evidence the appropriate level of transfer and the risks of transportation by private vehicle were discussed with the patient by a QMP. iii. On 4/2/24 at 7:00 p.m., Patient #7 arrived for alcohol detox treatment. Patient #7 reported they had been experiencing hallucinations and felt shaky. The EMTALA log showed Patient #3 was a medical send-out. There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer. iv. On 4/11/24 at 1:47 p.m., Patient #8 arrived for detox treatment. At 1:55 p.m. the EMTALA log read Patient #8 was a medical send-out. There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer. v. On 1/25/24 at 11:05 a.m., Patient #14 arrived for treatment after a suicide attempt. Five hours later at 4:05 p.m., Patient #14 was transferred out for further medical evaluation. There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer. vi. On 5/26/24 at 5:41 p.m., Patient #17 presented to the facility. According to the disposition noted on the EMTALA log, one hour and 22 minutes later Patient #17 was transferred out for further medical evaluation. There was no documentation to indicate how the patient was transferred. Additionally, the facility was unable to provide evidence an RN had performed an assessment to determine if the patient had an unstable medical condition prior to the patient being transferred out. Also, there was no evidence in the medical record an MSE had been completed by a QMP to determine the appropriate level of transfer. B. Interviews i. On 7/15/24 at 2:33 p.m., an interview was conducted with intake specialist (Specialist) #6. Specialist #6 stated when the EMTALA log stated medical send out by 911 it meant intake staff called 911 and the patient was transferred out by ambulance to an ED for further medical evaluation. Specialist #6 stated when private transport was listed on the EMTALA log, it meant the patient needed additional medical evaluation but 911 was not called, and a friend or family member transported the patient to an ED for further medical evaluation. Specialist #6 stated an EMTALA form should have been completed for patients who were transferred by ambulance and by private transport. This was in contrast to the review of the EMTALA log which was lacked evidence of whether the patient was sent out by ambulance or by private transport for Patients # 7, #8, #14, #17. This was also in contrast with the review of Patients #3, #7, #8, #14, #16, and #17, which showed no evidence of an EMTALA form to verify that the patient was transferred appropriately and in accordance to the facility’s policies. ii. On 7/11/24 an interview was conducted with director of nursing (DON) #11. DON #11 stated they were unable to locate an EMTALA form for Patient’s #7, #8, #14, and #17. DON #11 stated an EMTALA transfer from would not have been completed for Patient #3 and Patient #16 since the disposition for both patients was medical send out, private transport. DON #11 stated “medical send” out meant the patient required further medical evaluation for acute medical symptoms the facility could not treat. Additionally, DON #11 stated “private transport” meant the patient transported themselves or had another person transport them. iii. On 7/9/24 at 9:34 a.m. an interview was conducted with intake director (Director) #5. Director #5 stated patients in intake who needed additional medical evaluation were transferred out by ambulance. Director #5 stated intake staff would call 911, and EMS will transport the patient. Director #5 stated how the patient was transported out would be listed on the EMTALA log under the disposition. Director #5 stated an EMTALA transfer form was completed for patients transferred out by ambulance. The medical record reviews and interviews contrasted with the EMTALA policy and the Transfer to Another Facility policy which stated for patients who have not been admitted to the facility and required medical clearance a transfer to an external facility should be conducted under the guidance and approval of a QMP. The facility should complete an EMTALA transfer form for the patient. Additionally staff should discuss the transfer and associated risks with the patient before the patient has been transferred. Lastly, EMS or local law enforcement should be called to transfer the patient.”