St Tammany Parish Hospital

“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: 48051 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals to comply with 42 CFR §489.24, Special Responsibilities of Medicare Hospitals in emergency cases as evidenced by the failure to ensure the physician certifications and patient transfer consents were completed prior to the transfer of a patient in 6 (#5, #8, #12, #13, #15, #18) of 12 medical records reviewed for an appropriate transfer (See Tag A2409).”

“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: 48051 Based on record review and interview, the hospital failed to ensure the physician certification and the consent for transfer were completed prior to the patient being transferred in 6 (#5, #8, #12, #13, #15, #18) of 12 medical records reviewed for an appropriate transfer. Findings: A review of facility policy, “EMTALA and Patient Transfers,” PolicyStat ID: 20389920, and had a last revised, approved and effective date of 05/2026, revealed in part: “1. POLICY 1. As relates to patient care and transfers under the domain of the Emergency Medical Treatment and Labor Act or EMTALA, St. Tammany Health System (“STHS”) provides an appropriate Medical Screening Examination to individuals who present to its main campus hospital Emergency Department (ED) or OBED or STHS’s Offsite Campus Emergency Department (OSCED) and request or require examination or treatment of an Emergency Medical Condition. A. If the healthcare team determines that an Emergency Medical Condition exists, STHS will provide treatment to the patient until the condition is stabilized or if necessary, transfer the individual to another healthcare facility in compliance with the standards of patient care and legal and regulatory requirements. 4. PROCEDURE PATIENTS WITH AN EMERGENCY MEDICAL CONDITION 2. If STHA is not capable of providing the necessary treatment, STHS colleagues will arrange for an appropriate transfer to a facility that has the physical and clinical capability to provide the treatment as further explained in the following sections. 3. In the event a specific medical specialty is not available at STHS for a patient who presents with an Emergency Medical Condition, then STHS will initiate a transfer. 5. GUIDELINES TRANSFER OF PATEINTS FROM THE STHS UNDER 1. Any transfer of an individual with an Emergency Medical Condition must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf or by a physician order with the appropriate physician certification required under EMTALA. A. To state another way, patients may be transferred under EMTALA according to either of the following: -The patient or legally responsible person acting on behalf of the patient requests a transfer after STHS has informed the individual of its obligations to treat patients. The request must be in writing and indicate the reasons for the request as well as indicate that he/she is aware of the risks and benefits of the transfer. -A physician, or other qualified person in consultation with the physician when a physician is not physically present, signs a certification of transfer stating the risks and benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual’s (including the unborn child) medical condition from the transfer. 3. The Patient Transfer Form is available in PolicyStat and must be completed prior to any patient transfer under EMTALA.” A review of medical records revealed the following: Patient #5 A review of Patient #5’s medical record dated 04/13/2026 revealed the patient being transferred to Provider E at approximately 8:09 p.m. A review of the provider’s orders revealed orders initiated by S19MD at 5:18 p.m. for: “Transfer - PFC Facilitated Request” and “ED Disposition set to Transfer to Another Facility.” The medical record failed to reveal the type of transfer being requested - physician certification versus patient/legally responsible individual request. A review of the document titled, “PATIENT TRANSFER FORM” revealed the following sections of this document incomplete: -Subheading “PATIENT CONDITION,” the provider failed to indicate if the patient was stable or unstable and failed to document the time the document was signed; -Subheading “PROVIDER CERTIFICATION,” the provider failed to document the time the document was signed; and -Subheading “TRANSFER CONSENT,” the facility failed to indicate whether the patient had agreed to transfer or had refused transfer. Patient #8 A review of Patient #8’s medical record dated 04/13/2026 revealed the patient being transferred to Provider B on 04/14/2026 at approximately 9:21 a.m. A review of the provider’s orders revealed an order initiated by S9MD at 10:06 p.m. for: “ED Disposition set to Transfer to Another Facility” and at 10:07 p.m., “Transfer - PFC Facilitated Request.” The medical record failed to reveal the type of transfer being requested - physician certification versus patient/legally responsible individual request. A review of the document titled, “PATIENT TRANSFER FORM” revealed the following sections of this document incomplete: -Subheading “PATIENT CONDITION,” the provider failed to indicate if the patient was stable or unstable and failed to document the date and time the document was signed; -Subheading “PROVIDER CERTIFICATION,” the provider failed to document the date and time the document was signed; and -Subheading “TRANSFER CONSENT,” the facility failed to indicate whether the patient had agreed to transfer or had refused transfer. Patient #12 A review of Patient #12’s medical record dated 03/14/2026 revealed the patient being transferred to Provider A on 03/14/2026 at approximately 5:17 p.m. A review of the provider’s orders revealed an order initiated by S12MD at 1:48 p.m. for: “Transfer - PFC Facilitated Request” and at 3:04 p.m. “ED Disposition set to Transfer to Another Facility.” The medical record failed to reveal the type of transfer being requested - physician certification versus patient/legally responsible individual request. A review of the document titled, “PATIENT TRANSFER FORM” revealed the following sections of this document incomplete: -Subheading “PATIENT CONDITION,” the provider failed to document the date and time the document was signed; -Subheading “PROVIDER CERTIFICATION,” for the diagnosis the provider documented, “Kidney Transplant” and did not match the diagnosis of “Fatigue and Anemia, unspecified type (Primary)” as indicated on the ED Provider note completed by S12MD. Further, this section failed to include the physician’s signature, date and time; and -Subheading “TRANSFER CONSENT,” the facility failed to indicate whether the patient had agreed to transfer or had refused transfer. Patient #13 A review of Patient #13’s medical record dated 04/18/2026 revealed the patient being transferred to Provider E at approximately 4:18 p.m. A review of the provider’s orders revealed an order initiated by S14MD at 11:39 a.m. for: “ED Disposition set to Transfer to Another Facility.” The medical record failed to reveal the type of transfer being requested - physician certification versus patient/legally responsible individual request. A review of the document titled, “PATIENT TRANSFER FORM” revealed the following sections of this document incomplete: -Subheading “PATIENT CONDITION,” the provider failed to indicate if the patient was stable or unstable prior to transfer; and -Subheading “TRANSFER CONSENT,” the facility failed to indicate whether the patient had agreed to transfer or had refused transfer. Patient #15 A review of Patient #15’s medical record dated 04/07/2026 revealed the patient being transferred to Provider D at approximately 3:25 p.m. A review of the provider’s orders revealed an order initiated by S16MD at 1:04 p.m. for: “ED Disposition set to Transfer to Another Facility.” The medical record failed to reveal the type of transfer being requested - physician certification versus patient/legally responsible individual request. A review of the document titled, “PATIENT TRANSFER FORM” revealed the following sections of this document incomplete: -Subheading “PATIENT CONDITION,” the provider failed to indicate if the patient was stable or unstable and failed to document the date and time the document was signed; -Subheading “PROVIDER CERTIFICATION,” the provider failed to document the date and time the document was signed; and -Subheading “TRANSFER CONSENT,” the facility failed to indicate whether the patient had agreed to transfer or had refused transfer. Patient #18 A review of Patient #18’s medical record dated 05/01/2026 revealed the patient being transferred to Provider A at approximately 6:21 p.m. A review of the provider’s orders revealed an order initiated by S18MD at 5:11 p.m. for: “ED Disposition set to Transfer to Another Facility.” The medical record failed to reveal the type of transfer being requested - physician certification versus patient/legally responsible individual request. A review of the document titled, “PATIENT TRANSFER FORM” revealed the following sections of this document incomplete: -Subheading “PATIENT CONDITION,” the provider failed to indicate if the patient was stable or unstable and failed to document the date and time the document was signed; Subheading “PROVIDER CERTIFICATION,” the provider failed to document the date and time the document was signed; and Subheading “TRANSFER CONSENT,” the facility failed to indicate whether the patient had agreed to transfer or had refused transfer. In interviews during medical record review on 05/06/2026 from 1:15 p.m. to 4:15 p.m. and on 05/07/2026 from 8:45 a.m. to 11:50 a.m., S2DED confirmed the above-mentioned findings while navigating the electronic medical records for surveyor review.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50453 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the care of each patient. This deficient practice is evidenced by: 1) failure to obtain a physician’s order for sheath removal on 2 (#1, #2) of 3 patient medical records reviewed; and 2) failure of the Registered Nurse to document assessments post sheath removal per hospital policy on 2 (#1, #2) of 3 patient medical records reviewed. Findings: Review of hospital policy titled, “Femoral Arterial and Venous Sheath Removal Protocol,” last revised 06/2024, revealed in part: “PURPOSE: To outline management of patient undergoing removal of femoral/arterial venous sheath. PRE-PROCEDURE ASSESSMENT: 1. Obtain/verify Physician’s Order for sheath removal. POST PROCEDUREAL ASSESSMENT: 1. Assess the peripheral vascular status and neurovascular status of the affected extremity after arterial sheath removal, obtain vital signs and assess puncture Q 15 minutes x4, Q 30 minutes x2, Q 60 minutes x4.” 1) Failure to obtain a physician’s order for sheath removal on 2 (#1, #2) of 3 patient medical records reviewed. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted to ICU on 02/10/2026 for Bilateral Pulmonary Embolism. Patient #1 was admitted following EKOS placement (Endovascular System to treat Pulmonary Embolisms) with insertion sites to right and left femoral arteries. Review of the nursing documentation for Patient #1 revealed that the sheaths were removed by the nurse on 02/11/2026 at 8:45 AM. Review of Patient #1’s physician orders failed to reveal an order for the removal of the sheaths from the right or left femoral arteries. In an interview on 04/21/2026 at 11:35 AM, S1DOC and S2RN confirmed the above-mentioned findings. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted to ICU on 02/13/2026 for Bilateral Pulmonary Embolism. Patient #2 was admitted following EKOS placement, with insertion sites to the right and left femoral arteries. Review of the nursing documentation for Patient #2 revealed that the sheaths were removed by the nurse on 02/14/2026 at 4:18 PM and 02/14/2026 at 4:20 PM. Review of Patient #2’s physician orders failed to reveal an order for the removal of the sheaths from the right or left femoral arteries. In an interview on 04/22/2026 at 3:15 PM, S7CCD and S8RN confirmed the above-mentioned findings. 2) Failure of the Registered Nurse to document assessments post sheath removal per hospital policy on 2 (#1, #2) of 3 patient medical records reviewed. Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted to ICU on 02/10/2026 for Bilateral Pulmonary Embolism. Patient #1 was admitted following EKOS placement (Endovascular System to treat Pulmonary Embolisms) with insertion sites to right and left femoral arteries. Review of Patient #1’s nursing documentation revealed that the sheaths were removed on 02/11/2026 at 8:45 AM. Review of the nursing documentation post sheath removal revealed in part the following documentation on 02/11/2026: 9:00 AM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 9:15 AM- No blood pressure documented. No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 9:30 AM- No blood pressure documented. No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 9:45 AM- No blood pressure documented. No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 10:00 AM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 10:30 AM- No vital signs documented. No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 11:00 AM- Sheath site assessment documented as still infusing on the right. 12:15 PM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 1:00 PM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 2:00 PM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 3:01 PM- Sheath site assessment documented as still infusing on the right. Review of Patient #1’s medical record failed to reveal documented evidence that the patient was assessed Q 15 minutes x4, Q 30 minutes x2, and Q 60 minutes x4 per policy. In an interview on 04/21/2026 at 11:35 AM, S1DOC and S2RN confirmed the above-mentioned findings. S2RN also confirmed that Patient #1 was not assessed per hospital policy post sheath removal. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted to ICU on 02/13/2026 for Bilateral Pulmonary Embolism. Patient #2 was admitted following EKOS placement, with insertion sites to the right and left femoral arteries. Review of Patient #2’s nursing documentation revealed that the sheaths were removed on 02/14/2026 at 4:18 PM and 02/14/2026 at 4:20 PM. Review of the nursing documentation post sheath removal revealed in part the following documentation on 02/14/2026: 5:05 PM- No puncture site assessment documented (no additional documentation prior to this post sheath removal). 5:15 PM- Vital signs documented (first set post sheath removal). 7:01 PM- vital signs and assessments documented. 8:00 PM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 9:00 PM- vital signs and assessments documented. 10:00 PM- No puncture site, peripheral vascular, or neurovascular assessment of extremities documented. 11:00 PM- vital signs and assessments documented. Review of Patient #2’s medical record failed to reveal documented evidence that the patient was assessed Q 15 minutes x4, Q 30 minutes x2, and Q 60 minutes x4 per policy. In an interview on 04/22/2026 at 3:09 PM, S7CCD and S8RN confirmed the above-mentioned findings. S7CCD and S8RN also confirmed that Patient #2 was not assessed per hospital policy post sheath removal.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by: 1. Failure to assess 1 (#17) of 20 (#1-#16, #18-#20) patients’ response to pain following an intervention. 2. Failure to reassess 1 (#12) of 20 (#1-#11, #13-#20) patients’ vital signs at a minimum every 2 hours per policy. 3. Failure to reassess 1 (#8) of 20 (#1-#7, #9-#20) patients’ vital signs within 30 minutes of discharge from emergency department per policy. 4. Failure to document a reassessment 1 (#7) of 20 (#1-#6, #8-#20) patients’ per policy. Findings: Review of hospital policy revised 04/2024 titled “Emergency Department Roles, Assessments, Required Documentation Guidelines” revealed in part: Roles and Responsibilities 2. Bedside Nurse ix. Documentation of Interventions and Patient Contacts 2. Pain Assessment and Reassessment a. 1 HR PO b. 30 min IV or IM. Xi. Ongoing Vital Signs related to ESI, Patient Status, Medication, and procedures. The following are minimums without change in status or medications being administers. Nurses should assess and validate vitals based on treatment and patient condition. 1. ESI Level 1-2 = Vitals @ least every hour 2. ESI Level 3 = Vital @ least every 2 hours 3. ESI 4-5 = Vital @ least every 4 hours 4. Vitals within 30 minutes of discharge. j. Maintain appropriate documentation and ongoing assessment related to restraints and psychiatric patients. 1. Failure to assess 1 (#17) of 20 (#1-#16, #18-#20) patients’ response to pain following an intervention. Review of Patient #17 electronic medical record revealed the last blood pressure was documented on 05/04/2024 at 5:19 p.m. Patient received IV Morphine at 7:26 p.m. and had a pain assessment documented as 7/10. The patient was discharged at 8:39 p.m. on 05/04/2024. Further review revealed no reassessment of Blood Pressure which is not within the 2 hour minimum per policy or within 30 minutes of discharge per policy. There was also not a pain reassessment within 30 minutes of receiving IV pain medication as per policy. In an interview on 05/15/2024 at 12:30 p.m. S1DED confirmed the above mentioned findings. 2. Failure to reassess 1 (#12) of 20 (#1-#11, #13-#20) patients’ vital signs at a minimum every 2 hours per policy. Review of Patient #12 electronic medical record revealed the last set of vital signs were documented on 04/24/2024 at 4:33 p.m. This patient was discharge at 7:13 p.m. on 04/24/2024. Further review revealed no reassessment of vital signs within the 2 hour minimum per policy or within 30 minutes of discharge per policy. In an interview on 05/15/2024 at 11:00 p.m. S1DED confirmed the above mentioned findings. 3. Failure to reassess 1 (#8) of 20 (#1-#7, #9-#20) patients’ vital signs within 30 minutes of discharge from emergency department per policy. Review of Patient #8 electronic medical record revealed the patient received PO Ibuprofen at 1:02 p.m. and had a pain assessment documented as 5/10. The patient was discharged at 2:17 p.m. on 03/26/2024. Further review revealed there was no pain reassessment within 1 hour of receiving a PO pain medication as per policy. In an interview on 05/15/2024 at 9:40 a.m. S1DED confirmed the above mentioned findings. 4. Failure to document a reassessment 1 (#7) of 20 (#1-#6, #8-#20) patients’ per policy. Review of Patient #7 electronic medical record revealed the patient received PO Norco at 3:05 p.m. and had a pain assessment documented as 10/10. The patient was discharged at 3:33 p.m. on 03/23/2024. Further review revealed there was no pain reassessment within 1 hour of receiving a PO pain medication or prior to disposition as per policy. In an interview on 05/15/2024 at 9:20 a.m. S1DED confirmed the above mentioned findings.”

“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: 48050 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide an appropriate medical screening exam with a complete psychiatric evaluation for 1 (#12) of 1 (#12) patients who presented to the emergency department with suicidal ideation. (see findings tag A-2406).”

“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: 48050 Based on record reviews and interviews, the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice is evidenced by failing to provide an appropriate medical screening exam with a complete psychiatric evaluation for 1 (#12) of 1 (#12) patients who presented to the emergency department with suicidal ideation. Findings: Review of Policy titled Medical Staff Obligations for Emergency Services, dated 05/21/2019, revealed in part: All individuals who present to emergency requesting a medical examination or treatment shall receive care outlined by EMTALA and other appropriate regulations and standards for patient care. A review of Patient #12’s medical record revealed the 6 year old female presented to the ED on 04/24/2024 at 4:09 p.m. Patient #12 was triaged at 4:27 p.m. as a level 2 Emergent for a swallowing staples in an attempt to harm self. RN performed Suicide Risk Assessment at 4:36 p.m. which patient scored as high risk for suicide and this was only suicide risk assessment done during the 04/24/2024 visit. Patient #12 was seen by S7MD at 4:58 p.m. and an x-ray was ordered for swallowing staples at school to harm self. S7MD consulted the social worker and the consult was completed on 04/24/2024 at 5:02 p.m. On 04/24/2024 at 6:52 p.m. the ED MD ordered Patient #12 to be discharged home with mother to follow up with mental health appointment on 04/25/24 at 11:00 a.m. At 7:09 p.m. Patient #12 stated to the nurse “then can I have another staple to put in my mouth”. It was documented that nurse notified ED MD and ED MD was at Patient #12’s bedside, but no further documentation was noted related to Patient #12’s comments. Patient #12 was discharged at 7:13 p.m. on 04/24/24. Patient #12 had an appointment with her mental health provider on 04/25/2024 at 11:00 a.m. The Physician’s Emergency Certificate (PEC) exam date and time was 04/25/2024 at 11:00 a.m. The PEC was signed at 11:53 a.m. on 04/25/2024 by the mental health provider documenting that Patient #12 was a danger to self and others. Patient #12 returned to the ED on 04/25/2024 at 12:30 p.m. on a Physician’s Emergency Certificate (PEC) after seeing mental health provider. Patient #12 was transferred on 04/25/2024 at 6:33 p.m. to another facility on a PEC for psychiatric care. On 05/15/2024 at 11:30 a.m. S1DED verified that Patient #12 did not have a psychiatric evaluation while in the ED on 04/24/2024 and returned to the ED on 04/25/2024 on a PEC. S1DED also verified the ED physicians at the facility routinely perform their own psychiatric examination and will place patients under a PEC if they feel it is required for the safety of the patient.”