Southwest Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47233 Based on policy review, record review, and interview, the Hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient’s rights. Findings Include: 1. The hospital failed to ensure the monitoring for 1 of 2 patient in restraints as required per hospital policy. (Refer to Tag A0175) 2. The hospital failed to ensure that a physician or other licensed practitioner performed a face-to-face evaluation within one hour after the initiation of restraint when used for the management of violent behavior for 2 of 2 sampled patient in restraints. (Refer to Tag A0178)”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 47233 Based on policy review, record review, and interview, the Hospital failed to ensure the condition of a patient in restraints was monitored at intervals required by hospital policy for 1 of 2 (Patient 1) patients reviewed with restraints. This deficient practice places any patient in restraints at risk for injury and harm. Findings Include: Review of a policy titled, “Safety Needs: Fall Prevention and Restraint Use,” revised 08/2024 showed, “ ...To guide the staff in using alternative / non-physical interventions to restraints to prevent or minimize the use of restraints. To guide the staff in decision making about least-restrictive methods of restraint use. To establish guidelines to validate and ensure the safe application and removal of restraints by competent staff. To establish guidelines to protect the patient’s health and safety and preserve their dignity, rights and well-being when restraints are in use. To establish guidelines for assessing/collecting data on the patient’s needs for the use or continued use of restraints to facilitate discontinuation as soon as possible. To establish guidelines for monitoring the patient during the use of restraints and meeting their safety and personal needs, including vulnerable patient populations, such as pediatric, emergency, and cognitively or physically limited patients. To establish guidelines for the appropriate ordering of restraints. To establish guidelines for the medical record documentation when restraints are used ... Soft Limb Restraint(s): a. At least every 2 hours, and as needed, the restraint(s) will be loosened/removed to: i. Perform ROM exercise. ii. Monitor skin temperature and color; and to massage skin under restraint. iii. Monitor neurovascular status (cap refill, pulse(s) and movement). b. At least every 2 hours, and as needed: i. Monitor the clinical justification for continued use of the restraint, and for patient readiness from release from restraint. ii. Re-enforce patient and/or family restraint education as needed iii. Monitor effectiveness of restraint and document the type of restraint in use. iv. Attend to the patient’s needs, i.e. toileting, nutrition and hydration, and positioning. v. Monitor the patient’s level of consciousness / mental status. vi. Assure that restraints are applied correctly. vii. Assure the patient call-light is in reach and that patient rights and dignity are maintained viii. Due to the risk associated with restraint use in vulnerable patient populations such as pediatric, and cognitively or physically impaired patients, additional monitoring may be required ...” Patient 1 Review of Patient 1’s 08/14/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:24 PM by EMS and police. Chief complaint “ ...Patient arrives from [home] with c/o aggression. Per EMS, patient became aggressive towards staff and PD [police department] had to be notified. Upon arrival to the ED, patient was extremely aggressive and attempting to hit staff. Patient is screaming “no” repeatedly. Patient has abrasions noted to his nose. Per staff, patient was hitting his head on a van.” Past medical history includes: Intellectual Disability Diagnosis (IDD) (learning disability); Edentulous (toothless); Xerostomia (dry mouth); Obsessive Compulsive Disorder (pattern of unwanted thoughts and fears known as obsessions); Hypertension (elevated blood pressure); and Diabetes (increased blood sugar). Review of a document titled, “Emergency Department Physician Documentation” dated 08/15/24 at 11:10 AM showed, “Chief complaint: Altered Mental Status Time Seen by Provider: 08/14/24 13:40 [1:40 PM] ... male who lives in supervised group home facility ...brought to emergency department by EMS and police department because of acute change of mental status and aggressive behavior according to EMS and facility patient has aggressive behavior towards staff. He was very agitated and loud on arrival required both chemical and physical restraint. Patient given Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM [intramuscular]. Patient has history of similar behavior in the past and he had multiple visits to emergency department for aggressive behavior. No fall or trauma reported by facility. Patient has history of manic depressive disorder. ...” Review of a document titled “Patient Order Summary” dated 08/14/24 at 2:14 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/14/24 14:22 [2:22 PM]. Complete 08/14/24 15:11 [3:11 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/14/24 showed, “Restraints: Initiate/Monitor 08/14/24 12:20 [12:20 PM] ... -Date Initiated 08/14/24 -Time Initiated 12:20 ... -Date Restraint Removed 08/14/24 -Time Restraint Removed 15:10 [3:10 PM] ...” Documentation showed restraints were initiated approximately two hours prior to restraint order. Review of a document titled “Patient Order Summary” dated 08/14/24 at 5:32 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/14/24 17:32 [5:32 PM]. Complete 08/14/24 23:28 [11:28 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/14/24 showed, “Restraints: Initiate/Monitor 08/14/24 17:32 [5:32 PM] ... -Date Initiated 08/14/24 -Time Initiated 17:32 [5:32 PM] ...08/14/24 19:00 [7:00 PM] -Patient Response to Restraints remains agitated and restless ...” From 08/14/24 at 7:00 PM through 08/14/24 at 11:28 PM when patient discharged, Patient 1’s medical record failed to show documentation of every two hour restraint monitoring as required per policy. Review of Patient 1’s 08/19/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:50 PM by private vehicle. Chief complaint “ ...[Staff] His behavior has been getting worse, He is hitting and scratching people. He was trying to wrap the seatbelt around his neck today. We want to get him evaluated ...” Review of a document titled, “Emergency Department Physician Documentation” dated 08/19/24 at 3:53 PM showed, “Chief complaint: Mental Health Emergency Time Seen by Provider: 08/19/24 13:15 [1:15 PM] ...male with history of intellectual deficiency and behavior disorder brought to emergency department severe agitation screaming and yelling emergency department. Patient require physical and chemical restraint ...Patient agitation become under control with total 10 mg Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] IM [intramuscular] ...I requested screening with Healthsource and patient signed out to night shift physician on shift change apparently patient apparently screen and discharge ...” Review of a document titled “ED Notes” dated 08/19/24 at 1:19 PM showed, “Pt [sic] assisted in to bed with by x5 asst. [sic] Soft wrist restraints applied per [Staff I] and Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM [intramuscular] given in left: deltoid. Pt [sic] continues to holler out. Lights dimmed to try to help the patient rest.” Review of a document titled “Patient Order Summary” dated 08/19/24 at 2:19 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/19/24 13:00 [1:00 PM]. Complete 08/20/24 02:49 [2:49 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints risk of falling cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/19/24 showed, “Restraints: Initiate/Monitor 08/19/24 13:19 [1:19 PM] ... -Date Initiated 08/19/24 -Time Initiated 13:19 [1:19 PM] ... -Date Restraint Removed 08/20/24 -Time Restraint Removed 02:50 [2:50 AM] ...” From 08/19/24 at 1:19 PM through 08/19/24 at 7:00 PM Patient 1’s medical record failed to show documentation of every two hour restraint monitoring as required per policy. Review of Patient 1’s 08/28/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 5:46 PM by EMS. Chief complaint [community housing] staff brought patient in to for aggression. Patient has a history of these episode [community housing]wishes to have a mental health evaluation. ...” Review of a document titled, “Emergency Department Physician Documentation” dated 08/29/24 at 2:56 AM showed, “Chief complaint: Mental Health Emergency Time Seen by Provider: 08/28/24 18:26 [6:26 PM] ... 57-year-old male with past medical history inclusive of intellectual disability, type 2 diabetes BPH, seizure disorder intermittent explosive disorder urinary incontinence hypertension recurrent behavioral disturbance who presents from [community housing]facility with request for behavioral health evaluation in the setting of increasingly aggressive behavior with patient attempting to assault staff both at his facility and on arrival in the emergency department. Patient without medical complaint but is found to be uncooperative with evaluation. By report patient has history of these violent outbursts ...” Review of a document titled “Patient Order Summary” dated 08/28/24 at 6:15 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/28/24 18:15 [6:15 PM]. Complete 08/29/24 03:22 [3:22 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/28/24 showed, “Restraints: Initiate/Monitor 08/28/24 18:15 [6:15 PM] ... -Date Initiated 08/28/24 -Time Initiated 18:15 [6:15 PM] ... -Date Restraint Removed 08/29/24 -Time Restraint Removed 03:22 [3:22 AM] Patient 1’s medical record failed to show documentation of every two hour restraint monitoring as required per policy from 08/28/24 at 6:15 PM through 08/28/24 at 11:00 PM. During an interview on 09/10/24 at 11:48 AM Staff B, CNO stated, “ ...we use paper charting on the floor so that there is no time stamp...” During an interview on 09/10/24 at 11:15 AM Staff B, CNO, Staff A, RN, and Staff D, RN acknowledged Patient 1’s medical record was missing every two-hour documentation. During an interview on 09/10/24 at 11:15 AM Staff B, CNO, Staff E, RN, and Staff D, RN acknowledged facility policy does not differentiate violent verse non-violent restraints. During an interview on 09/11/24 at 9:30 AM Patient Representative (PR) 1 stated, “I had my staff verify that they did not take the restraints off at all at any point when he was there so they just left him in the bed and kept giving [Patient 1] medication to sedate [Patient 1] ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 47233 Based on document review, policy review, and security video review, the Hospital failed to ensure a patient in restraints received a face-to-face assessment within one hour of initiating the restraints physician or other licensed practitioner as required for 2 of 2 (Patient 1 and 21) patient reviewed with restraints. This deficient practice places any patient receiving services at this hospital at risk for serious injury and harm. Findings Include: Review of a policy titled, “Safety Needs: Fall Prevention and Restraint Use,” revised 08/2024 failed to address one hour face to face by a physician or other licensed practitioner after the initiation of restraints as required by Centers for Medicare and Medicaid Services (CMS). Patient 1 Review of Patient 1’s 08/14/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:24 PM by EMS and police. Chief complaint “ ...Patient arrives from [home] with c/o aggression. Per EMS, patient became aggressive towards staff and PD [police department] had to be notified. Upon arrival to the ED, patient was extremely aggressive and attempting to hit staff. Patient is screaming “no” repeatedly. Patient has abrasions noted to his nose. Per staff, patient was hitting his head on a van.” Past medical history includes: Intellectual Disability Diagnosis (IDD) (learning disability); Edentulous (toothless); Xerostomia (dry mouth); Obsessive Compulsive Disorder (pattern of unwanted thoughts and fears known as obsessions); Hypertension (elevated blood pressure); and Diabetes (increased blood sugar). Review of a document titled, “Emergency Department Physician Documentation” dated 08/15/24 at 11:10 AM showed, “Chief complaint: Altered Mental Status Time Seen by Provider: 08/14/24 13:40 [1:40 PM] ... male who lives in supervised group home facility ...brought to emergency department by EMS and police department because of acute change of mental status and aggressive behavior according to EMS and facility patient has aggressive behavior towards staff. He was very agitated and loud on arrival required both chemical and physical restraint. Patient given Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM [intramuscular]. Patient has history of similar behavior in the past and he had multiple visits to emergency department for aggressive behavior. No fall or trauma reported by facility. Patient has history of manic depressive disorder. ...” Review of a document titled “Patient Order Summary” dated 08/14/24 at 2:14 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/14/24 14:22 [2:22 PM]. Complete 08/14/24 15:11 [3:11 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/14/24 showed, “Restraints: Initiate/Monitor 08/14/24 12:20 [12:20 PM] ... -Date Initiated 08/14/24 -Time Initiated 12:20 ... -Date Restraint Removed 08/14/24 -Time Restraint Removed 15:10 [3:10 PM] ...” Documentation showed restraints were initiated approximately two hours prior to restraint order. Review of a document titled “Patient Order Summary” dated 08/14/24 at 5:32 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/14/24 17:32 [5:32 PM]. Complete 08/14/24 23:28 [11:28 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/14/24 showed, “Restraints: Initiate/Monitor 08/14/24 17:32 [5:32 PM] ... -Date Initiated 08/14/24 -Time Initiated 17:32 [5:32 PM] ...08/14/24 19:00 [7:00 PM] -Patient Response to Restraints remains agitated and restless ...” Patient 1 was in restraints from 08/14/24 at 7:00 PM through 08/14/24 at 11:28 PM when patient discharged. The medical record failed to show Patient 1 received a one hour face to face assessment by the physician or licensed practitioner on 08/14/24. Review of Patient 1’s 08/19/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:50 PM by private vehicle. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2). Chief complaint “ ...[Staff] His behavior has been getting worse, He is hitting and scratching people. He was trying to wrap the seatbelt around his neck today. We want to get him evaluated ...” Review of a document titled, “Emergency Department Physician Documentation” dated 08/19/24 at 3:53 PM showed, “Chief complaint: Mental Health Emergency Time Seen by Provider: 08/19/24 13:15 [1:15 PM] ...male with history of intellectual deficiency and behavior disorder brought to emergency department severe agitation screaming and yelling emergency department. Patient require physical and chemical restraint ...Patient agitation become under control with total 10 mg Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] IM [intramuscular] ...I requested screening with Healthsource and patient signed out to night shift physician on shift change apparently patient apparently screen and discharge ...” Review of a document titled “ED Notes” dated 08/19/24 at 1:19 PM showed, “Pt [sic] assisted in to bed with (sic) by x5 asst. [sic] Soft wrist restraints applied per [Staff I]...” Review of a document titled “Patient Order Summary” dated 08/19/24 at 2:19 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/19/24 13:00 [1:00 PM]. Complete 08/20/24 02:49 [2:49 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints risk of falling cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/19/24 showed, “Restraints: Initiate/Monitor 08/19/24 13:19 [1:19 PM] ... -Date Initiated 08/19/24 -Time Initiated 13:19 [1:19 PM] ... -Date Restraint Removed 08/20/24 -Time Restraint Removed 02:50 [2:50 AM] ...” Patient 1 was in restraints from 08/19/24 at 1:19 PM through 08/19/24 at 7:00 PM when patient discharged. The medical record failed to show Patient 1 received a one hour face to face assessment by the physician or licensed practitioner on 08/19/24. Review of Patient 1’s 08/28/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 5:46 PM by EMS. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2). Chief complaint [community housing] staff brought patient in to for aggression. Patient has a history of these episode [community housing] wishes to have a mental health evaluation. ...” Review of a document titled, “Emergency Department Physician Documentation” dated 08/29/24 at 2:56 AM showed, “Chief complaint: Mental Health Emergency Time Seen by Provider: 08/28/24 18:26 [6:26 PM] ... 57-year-old male with past medical history inclusive of intellectual disability, type 2 diabetes BPH, seizure disorder intermittent explosive disorder urinary incontinence hypertension recurrent behavioral disturbance who presents from [community housing] facility with request for behavioral health evaluation in the setting of increasingly aggressive behavior with patient attempting to assault staff both at his facility and on arrival in the emergency department. Patient without medical complaint but is found to be uncooperative with evaluation. By report patient has history of these violent outbursts ...” Review of a document titled “Patient Order Summary” dated 08/28/24 at 6:15 PM, showed, “Order Restraints: Initiate/Renewal ...Start 08/28/24 18:15 [6:15 PM]. Complete 08/29/24 03:22 [3:22 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Care Assessments” dated 08/28/24 showed, “Restraints: Initiate/Monitor 08/28/24 18:15 [6:15 PM] ... -Date Initiated 08/28/24 -Time Initiated 18:15 [6:15 PM] ... -Date Restraint Removed 08/29/24 -Time Restraint Removed 03:22 [3:22 AM]. Patient 1 was in restraints from 08/28/24 at 6:15 PM through 08/28/24 at 6:15 PM when patient discharged. The medical record failed to show Patient 1 received a one hour face to face assessment by the physician or licensed practitioner on 08/28/24. Patient 21 Review of Patient 21’s medical record showed, a 26-year old, presented to the ED on 07/06/24 at 7:38 PM via Emergency Medical Services. Patient 21 presented with a chief complaint “ ...Seizures x 2 then combative ...” Past medical history includes: Seizures. Review of a document titled, “Emergency Department Physician Documentation” dated 07/06/24 at 7:47 PM showed, “Chief complaint: Seizure ...Patient arrived after having a seizure via EMS Patient was combative with EMS and the police had to help with transfer per. Patient is unable answer questions. Patient did move to the gurney from the EMS cot. Patient is sane letter words without making since ...” Review of a document titled “Patient Order Summary” dated 07/06/24 at 8:48 PM, showed, “Order Restraints: Initiate/Renewal ...Start 07/06/24 20:48 [8:48 PM]. Stop Request 07/07/24 00:14 [12:14 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Patient Order Summary” dated 07/06/24 at 10:46 PM, showed, “Order Restraints: Initiate/Renewal ...Start 07/06/24 22:46 [10:46 PM]. Complete 07/08/24 10:15 [10:15 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ...” Review of a document titled “Physician Order for Restraint” dated 07/07/24 at 00:00 [12:00 AM], showed, “Clinical Justification for use of Restraint To Promote Safety/Healing ...To Prevent Patient Injury ...Type of Restraint Soft Limb Restraint-Right Wrist Soft Limb Restraint- Left Wrist Soft Limb Restraint - Right Ankle Soft Limb Restraint - Left Ankle 3. Patient to be Restraint for 24 hours ...” Electronically signed by physician 08/01/24 at 2:31 PM 25 days, 14 hours, 31 minutes after restraints applied. Review of a document titled “Physician Order for Restraint” dated 07/08/24 at 00:00 [12:00 AM], showed, “Clinical Justification for use of Restraint To Promote Safety/Healing ...To Prevent Patient Injury ...Type of Restraint Soft Limb Restraint-Right Wrist Soft Limb Restraint- Left Wrist 3. Patient to be Restraint for 24 hours ...” Electronically signed by physician 08/01/24 at 2:31 PM 24 days, 14 hours, 31 minutes after restraints applied. Review of the medical record failed to show a one-hour face to face was completed for Patient 21. During an interview on 09/10/24 at 11:48 AM Staff B, CNO stated, “ ...we use paper charting on the floor so that there is no time stamp...” During an interview on 09/10/24 at 11:15 AM Staff B, CNO, Staff E, RN, and Staff D, RN acknowledged missing one hour face-to-face in facility policy.”

“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: 47233 Based on document review, record review, policy review and interview the Hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide stabilizing treatment to a patient who presented to the emergency department seeking medical care for an emergency medical condition (EMC). Failure to provide stabilizing treatment places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death. Findings Include: The hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking emergency medical care. (Refer to tag A2407)”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47233 Based on record review, document review and interview the Hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death. Findings Include: Review of a document titled, “Medical Staff Rules and Regulations” revised on 04/14/2011 showed, “ ...Patients discharged from the ER will be provided with discharge instructions and, as needed, advised to obtain follow-up care with their primary care physician. If the patient does not have a primary care physician, the patient will be referred to the on-call physician. The patient shall be advised that, if he or she cannot obtain follow-up care or his or her condition worsens, the patient may return to the Emergency Room for care ...Emotionally ill / alcohol abuse / drug abuse patients shall receive: i. Medical Screening ii. Evaluation by Southwest Guidance Center or a Psychiatric consult, as ordered ...” Review of a hospital policy titled, “EMTALA” revised 11/2022 showed, “ ...To Stabilize” or “Stabilize” or “Stabilized” means: 1. With respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the Hospital ... 2. The hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below ...E. Individuals Who Have An Emergency Medical Condition 1. If, after a medical screening examination, it is determined that an individual has an emergency medical condition, the Hospital must a. Within the capability and capacity of the staff and facilities available at the hospital (including coverage available through the hospital’s on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or b. Admit the individual to the hospital in order to stabilize the individual; or c. If stabilization of the individual is beyond the capabilities or capacity of the hospital, arrange for appropriate transfer of the individual to another medical facility in accordance with this policy ...” Patient 1 Review of Patient 1’s, medical record showed, a 57-year-old, presented to the Emergency Department (ED) on 08/19/24 at 12:50 PM by private vehicle. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2). Chief complaint “ ...[Staff] His behavior has been getting worse, He is hitting and scratching people. He was trying to wrap the seatbelt around his neck today. We want to get him evaluated ...” Review of a document titled, “Emergency Department Physician Documentation” dated 08/19/24 at 3:53 PM showed, “Chief complaint: Mental Health Emergency Time Seen by Provider: 08/19/24 13:15 [1:15 PM] ...male with history of intellectual deficiency and behavior disorder brought to emergency department severe agitation screaming and yelling emergency department. Patient require physical and chemical restraint ...Patient agitation become under control with total 10 mg Zyprexa IM [intramuscular] ...I requested screening with [Community Mental Health agency] and patient signed out to night shift physician on shift change apparently patient apparently screen and discharge ...” Review of a document titled “ED Notes” dated 08/19/24 at 1:19 PM showed, “Pt [sic] assisted in to bed with by x5 asst. [sic] Soft wrist restraints applied per [Staff I] and Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM given in left: deltoid. Pt [sic] continues to holler out. Lights dimmed to try to help the patient rest.” Review of a document titled “ED Notes” dated 08/20/24 at 4:03 PM showed, “ ... Patient was screened by [Community Mental Health agency] and a safetly [sic] plan was made. This nurse went to speak with the [Patient Representative] about the patient and his safetly [sic] plan...[Patient Representative] explained that they couldn’t take him back due to him being a safety risk to himself and safe [sic]. This nurse explained to the worker that this was understood but placement to [Mental Health Hospital] would not be appropriate due to his IDD [Intellectual disability] diagnoses per [Community Mental Health agency]. [Patient Representative] stated “[Mental Health Hospital] said that we were not to take him back until his mental health needs were met.” This nurse explained to [Patient Representative] that this was not a mental health facility and that we have done everything we can to the best of our ability ...” Review of a document titled “Mental Health Screening Form” dated 08/20/24 at 4:25 PM showed “ ...III. Presenting Problem. Client is a 57-year-old male who was brought to the ED yesterday for physical aggression and self-abusive behavior. At the ED, client had to be chemically and physically restraint. Client was seen in the ED on 08/14/24 for verbal and physical aggression and self-abusive behavior and also required restraint however for a shorter duration. He was diverted back to [home] with a safety plan. Client has been unable to maintain with a safety plan. Yesterday, client wrapped a seat belt around his neck. Client has superficial abrasions on his face due to his self-abusive behavior. He scratched and hit staff members and hospital workers. Client has been throwing items and has been destructive to property. Client’s current presentation is a change in his baseline level of functioning ...” Further review of the “Mental Health Screening Form” showed, “ ... both reports a significant change in clients functioning and symptoms. Client’s current behaviors are outside of his baseline level of functioning. They expressed significant concern about the ability to maintain client safety and the safety of others. A safety plan has not been successful in maintaining client at a lower level of care. Client does meet criteria for inpatient hospitalization as client presents as current risk of harm to self, current risk of harm to others, and current destruction of property. Client does pose an imminent risk of harm to self or others as evidenced by clients acting out, physically aggressive behaviors directed towards self and others. Client will be referred for involuntary inpatient hospitalization as client lacks capacity to make an informed decision regarding care and treatment and is likely to cause harm to themselves or others in the foreseeable future. Written report will be provided to the ED for their records ...” Review of a document titled, “State Hospital Application for Emergency Admission (for Observation and Treatment)” dated 08/20/24 at 4:25 PM showed, “ ...I will file a petition seeking involuntary commitment of this person with the District Court of no later than close of business day on 08/21/24. I believe this patient to be a mentally ill person subject to involuntary commitment for care and treatment as defined in KSA 59-2946 (F) and is likely to cause harm to self or others if not immediately detained ...” During an interview on 09/10/24 at 4:30 PM Staff B, CNO stated, “ ...I wasn’t aware of the court hold. Our gap here is we didn’t read the paperwork from the Mental Health screener, and patient was already discharged ...” During an interview on 09/10/24 at 6:25 PM Patient Representative (PR) 2, Licensed Masters Social Worker (LMSW) stated, “ ...I had pulled a safety plan from a previous chart in case we were going to go that way just to be prepared to and that’s not the way we went so the safety plan wasn’t used ... and the last I knew we were waiting for placement at [Mental Health Hospital] the form was sent to the County Attorney and the County Attorney decided not to file the because [Patient 1] had been released back to his home ... the hospital didn’t want to keep him there while they waited placement because it was a pretty long wait list ...the evaluation was faxed to the hospital at 5:34 PM ...” During an interview on 09/11/24 at 9:30 AM PR 1, stated, “ ...the client was in active psychosis not at baseline he was being very aggressive violent verbally explosive and so his provider recommended that we send him to the emergency room for evaluation so that they could get him into [Mental Health Hospital] so we did that we took him to the emergency room and they sedated him with medication he was sedated with medication and also physically restrained in four point restraints ... so he was sedated couldn’t answer questions for the screener ... we were told that there was a waiting list and [Mental Health Hospital] confirmed that they received the referral and that he was 13th on the list and the emergency room told us we had to come get him so they discharged him ...” Although there was significant concern about Patient 1’s ability to maintain safety and the safety of others, safety plan had not been successful in maintaining at a lower level of care and Patient 1 met criteria for inpatient hospitalization as he posed an imminent risk of harm to self or others as evidenced by acting out, physically aggressive behaviors directed towards self and others, Patient 1 was discharged home on 08/20/24 at 5:53 PM.”