Wright Memorial 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: 51264 Based on policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized and an appropriate tranfer was arranged for one patient (#2) of 22 Emergency Department (ED) records reviewed from 01/01/26 through 06/29/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: The hospital’s policy titled, “Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA),” revised 09/13/24, showed: - Patients receive an appropriate medical screening exam (MSE) within the hospital’s capability to determine whether or not an EMC exists. If an EMC is found to exist, the hospital stabilizes or transfers the patient in accordance with EMTALA. - A Psychiatric (relating to mental illness) EMC means an individual presents an immediate threat to himself or others, for example, the individual has attempted suicide (to cause one’s own death) or is violent. - The individual is stable for discharge when the physician determines they are not a threat to themselves or others. - Patients with emergency psychiatric conditions are stable for transfer when they are protected and prevented from injuring themselves or others during the transfer. - Transfer means the movement, including discharge, of an individual outside the hospital’s facilities at the direction of any person employed by or affiliated with the hospital. - Requirements for an appropriate transfer include: treatment within the hospital’s capability is provided to the patient; the receiving hospital must have available space and a qualified medical personnel (QMP) for the treatment and must have agreed to accept the transfer; the hospital must send copies of all available records pertaining to the patient’s EMC; the transfer must be carried out through the use of QMPs and transportation equipment. The physician at the hospital has the responsibility of determining the appropriate mode, equipment and attendants for the transfer, and the Certificate of Transfer should be completed. Review of the hospital’s policy titled, “Missouri Involuntary Admission,” last revised 04/20/22, showed: - Under the Police Powers Doctrine, law enforcement personnel (LEP) may detain a person if an individual suffers from a mental disorder and is imminently harmful to themselves or others and transports the person to an appropriate facility for evaluation and treatment. The patient may be detained if the individual remains in their custody. Once the LEP relinquishes their custody and control to a hospital, the hospital assumes responsibility for the patient. - Once a patient receives medical clearance and a behavioral health assessment, and the involuntary detention is pursued, placement proceedings will begin. When the patient has been accepted, the legal paperwork and EMTALA Certificate of Transfer form will be completed. - Nursing staff will call report to the receiving facility and arrange requested health information and transport. Please refer to 2407 and 2409 for further details.”

“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: 51264 Based on interview, record review and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#2) of 22 Emergency Department (ED) records reviewed from 01/01/26 through 06/29/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: The hospital’s policy titled, “Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA),” revised 09/13/24, showed: - Patients receive an appropriate MSE within the hospital’s capability to determine whether or not an EMC exists. If an EMC is found to exist, the hospital stabilizes or transfers the patient in accordance with EMTALA. - A Psychiatric (relating to mental illness) EMC means an individual presents an immediate threat to himself or others, for example, the individual has attempted suicide (to cause one’s own death) or is violent. - The individual is stable for discharge when the physician determines they are not a threat to themselves or others. - Patients with emergency psychiatric conditions are stable for transfer when they are protected and prevented from injuring themselves or others during the transfer. Review of the document titled, “Order for 96-Hour Detention, Evaluation and Treatment and Warrant,” filed 06/02/26, showed: - Patient #2 had a court ordered 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) related to his mental health status; he was likely to seriously harm himself or others. He needed evaluation and treatment. - The court ordered him to be taken into custody and transferred to Hospital B, General Acute Care Hospital, or another available psychiatric facility. - Affidavits (a written statement confirmed by oath, for use as evidence in court) from staff and the patient’s father were attached as supporting statements. Review of Patient #2’s medical record, dated 06/01/26, showed: - At 3:54 PM, Patient #2 arrived in the ED screaming at his father, complaining of suicidal thoughts (SI, thoughts of causing one’s own death) over the last month. - He was an 18-year-old with a history of depression, undifferentiated schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly), and anger issues who did not want to go to a psychiatric appointment, so he broke the truck’s back window with his head. He also cut his left arm on the broken glass. - He had been seen several days earlier in the ED after he punched a wall and left against medical advice (AMA). His hand was examined during this visit. - His home medications included Xanax (medication used especially in the treatment of mild to moderate anxiety) 0.25 mg three times daily, Prozac (an antidepressant drug) 20 mg each night, and Zyprexa (medication used to treat mental disorders) 20 mg each night. - At 4:21 PM, his blood pressure (BP, normal between 90/60 and 120/80) was 144/98 and his pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 105. - His physical exam showed he had de-escalated (reduce the intensity of a conflict or potentially violent situation), was alert, awake and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). He was cooperative but agitated, and his judgment was impulsive. His head was tender, but he was not actively bleeding. He had a cut to his elbow but no problems with function. His wrists had multiple scrapes but no deep cuts. - Patient #2’s laboratory results showed no significant findings except his white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) was slightly elevated. His urine showed no infection and his comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed no problems. The urine drug screen was positive for benzodiazepines (medication used to relieve anxiety and muscle spasms and reduce seizures; produce sedation). - At 5:24 PM, he received 5 milligrams (mg) of Zyprexa. - A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed no head injury. An x-ray showed no broken elbow. - At 6:14 pm, his elbow was stitched and dressed with soft dressings. - At 6:50 PM, he received a behavioral health consult via their Behavioral Access Center (BAC) telemedicine (telemed, remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication). They recommended placement into an inpatient psychiatric facility. Patient #2 requested Hospital B. - At 8:46 PM, he received a 15 mg tablet of Zyprexa. - On 06/02/26 at 8:13 AM, he received a 20 mg capsule of Prozac, and a 1 mg tablet of Xanax. - At 8:31 AM, notes showed the local police were called. Patient #2 screamed that he wanted to leave and hit the wall with his head and fists. He grabbed the physician and shoved him. The house supervisor was also notified. - At 8:38 AM, he received a 10 mg injection of Zyprexa. Notes showed he spit in the physician’s face. - At 8:40 AM, the police were bedside. - At 8:46 AM, he was in violent restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). - At 10:29 AM, orders were placed to release his restraints. - At 10:43 AM, notes showed he yelled and tried to hit and bite security. He was placed into restraints again. - At 10:59 AM, he received a 5 mg injection of Haldol (a medication used to treat mental disorders by decreasing excitement of the brain). - At 12:32 PM, notes showed LE called and stated they had obtained a 96-hour hold. LE was informed that there was no accepting facility at that time. LE stated they would pick him up and find an appropriate facility per their normal procedures. - At 12:48 PM, documentation showed his vital signs (VS, measurements of the body’s most basic functions) were measured but they were not recorded. - At 12:55 PM, notes showed police “transport” arrived to take him to the “next phase of care”. - At 1:02 PM, he was “released to LE”. Review of Patient #2’s Hospital B medical record, dated 06/02/26, showed: - At 2:41 PM, physician notes showed Patient #2 was brought by LE for a mental health evaluation. He had made SI remarks earlier that day, but he did not feel that way anymore. - At 5:32 PM, nursing notes showed she contacted Hospital A and gathered information about medications they had given, his laboratory results, and the events that took place there. - At 8:00 PM, he arrived at their mental health unit where he was admitted for treatment. During an interview on 07/01/26 at 4:30 PM, Staff H, Risk Manager, stated that the hospital sought placement for him with the two nearest places that provided mental health services. Staff informed the police department that they did not have placement. During an interview on 07/01/26 at 2:33 PM, Staff I, House Supervisor, stated that a 96-hour hold was a legal way to transport a patient to get the care they needed. He wasn’t transferred; he was discharged to police to transport him to a mental health facility per their protocol. He couldn’t remain there in restraints, and they could not treat him appropriately with the resources they had. They didn’t have a locked unit or a psychiatrist (physician who specializes in mental health disorders). “He was out of control, and the BAC had exhausted all their efforts.” Waiting for placement was indefinite and “we didn’t feel we could retain him until that could be done.” During an interview on 07/01/26 at 3:52 PM, Staff J, ED Physician, stated that the court initiated a 96-hour hold and ordered where the patient was to go. Patient #2 was very violent, and for everyone’s safety they thought he should go where the court ordered. The judge made the decision for a place that was safe for him. He was medically cleared to go; he was alert and oriented and his condition was not going to deteriorate. During an interview on 07/01/26 at 1:22 PM, Staff D, RN, stated that Patient #2 was medically stable; his VS were stable, he was alert and oriented the whole time, he was never lethargic, and he never needed supplemental oxygen. BAC never found placement. Police had a 96-hour hold and that meant that they had to allow him to go with police. Police had protocol and chose to take him into their custody. They didn’t want to wait because of his violent behavior.”

“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: 51264 Based on interview, policy review and record review, the hospital failed to arrange an appropriate transfer for one patient (#2) with a psychiatric (relating to mental illness) emergency of 22 Emergency Department (ED) records reviewed from 01/01/26 through 06/29/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care of a psychiatric Emergency Medical Condition (EMC). Findings included: The hospital’s policy titled, “Patient Transfers and Emergency Medical Treatment and Labor Act (EMTALA),” revised 09/13/24, showed: - Patients receive an appropriate medical screening examination (MSE) within the hospital’s capability to determine whether or not an EMC exists. If an EMC is found to exist, the hospital stabilizes or transfers the patient in accordance with EMTALA. - A psychiatric (relating to mental illness) EMC means an individual presents an immediate threat to himself or others, for example, the individual has attempted suicide (to cause one’s own death) or is violent. - The individual is stable for discharge when the physician determines they are not a threat to themselves or others. - Patients with emergency psychiatric conditions are stable for transfer when they are protected and prevented from injuring themselves or others during the transfer. - Transfer means the movement, including discharge, of an individual outside the hospital’s facilities at the direction of any person employed by or affiliated with the hospital. - Requirements for an appropriate transfer include: treatment within the hospital’s capability is provided to the patient; the receiving hospital must have available space and a qualified medical personnel (QMP) for the treatment and must have agreed to accept the transfer; the hospital must send copies of all available records pertaining to the patient’s EMC; the transfer must be carried out through the use of QMPs and transportation equipment. The physician at the hospital has the responsibility of determining the appropriate mode, equipment and attendants for the transfer, and the Certificate of Transfer should be completed. Review of the hospital’s policy titled, “Missouri Involuntary Admission,” last revised 04/20/22, showed: - Under the Police Powers Doctrine, law enforcement personnel (LEP) may detain a person if an individual suffers from a mental disorder and is imminently harmful to themselves or others and transports the person to an appropriate facility for evaluation and treatment. The patient may be detained if the individual remains in their custody. Once the LEP relinquishes their custody and control to a hospital, the hospital assumes responsibility for the patient. - Once a patient receives medical clearance and a behavioral health assessment, and the involuntary detention is pursued, placement proceedings will begin. When the patient has been accepted, the legal paperwork and EMTALA Certificate of Transfer form will be completed. - Nursing staff will call report to the receiving facility and arrange requested health information and transport. Review of the document titled, “Order for 96-Hour Detention, Evaluation and Treatment and Warrant,” filed 06/02/26, showed: - Patient #2 had a court ordered 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) related to his mental health status; he was likely to seriously harm himself or others. He needed evaluation and treatment. - The court ordered him to be taken into custody and transferred to Hospital B, General Acute Care Hospital, or another available psychiatric facility. - Affidavits (a written statement confirmed by oath, for use as evidence in court) from staff and the patient’s father were attached as supporting statements. Review of Patient #2’s medical record, dated 06/01/26, showed: - At 3:54 PM, Patient #2 arrived in the ED screaming at his father, complaining of suicidal thoughts (SI, thoughts of causing one’s own death) over the last month. - He was an 18-year-old with a history of depression, undifferentiated schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly), and anger issues who did not want to go to a psychiatric appointment, so he broke the truck’s back window with his head. He also cut his left arm on the broken glass. - He had been seen several days earlier in the ED after he punched a wall and left against medical advice (AMA). His hand was examined during this visit. - His home medications included Xanax (medication used especially in the treatment of mild to moderate anxiety) 0.25 mg three times daily, Prozac (an antidepressant drug) 20 mg each night, and Zyprexa (medication used to treat mental disorders) 20 mg each night. - At 4:21 PM, his blood pressure (BP, normal between 90/60 and 120/80) was 144/98 and his pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 105. - His physical exam showed he had de-escalated (reduce the intensity of a conflict or potentially violent situation), was alert, awake and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time). He was cooperative but agitated, and his judgment was impulsive. His head was tender, but he was not actively bleeding. He had a cut to his elbow but no problems with function. His wrists had multiple scrapes but no deep cuts. - Patient #2’s laboratory results showed no significant findings except his white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) was slightly elevated. His urine showed no infection and his comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed no problems. The urine drug screen was positive for benzodiazepines (medication used to relieve anxiety and muscle spasms and reduce seizures; produce sedation). - At 5:24 PM, he received 5 milligrams (mg) of Zyprexa. - A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed no head injury. An x-ray showed no broken elbow. - At 6:14 pm, his elbow was stitched and dressed with soft dressings. - At 6:50 PM, he received a behavioral health consult via their Behavioral Access Center (BAC) telemedicine (telemed, remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication). They recommended placement into an inpatient psychiatric facility. Patient #2 requested Hospital B. - At 8:46 PM, he received a 15 mg tablet of Zyprexa. - On 06/02/26 at 8:13 AM, he received a 20 mg capsule of Prozac, and a 1 mg tablet of Xanax. - At 8:31 AM, notes showed the local police were called. Patient #2 screamed that he wanted to leave and hit the wall with his head and fists. He grabbed the physician and shoved him. The house supervisor was also notified. - At 8:38 AM, he received a 10 mg injection of Zyprexa. Notes showed he spit in the physician’s face. - At 8:40 AM, the police were bedside. - At 8:46 AM, he was in violent restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). - At 10:29 AM, orders were placed to release his restraints. - At 10:43 AM, notes showed he yelled and tried to hit and bite security. He was placed into restraints again. - At 10:59 AM, he received a 5 mg injection of Haldol (a medication used to treat mental disorders by decreasing excitement of the brain). - At 12:32 PM, notes showed LE called and stated they had obtained a 96-hour hold. LE was informed that there was no accepting facility at that time. LE stated they would pick him up and find an appropriate facility per their normal procedures. - At 12:48 PM, documentation showed his vital signs (VS, measurements of the body’s most basic functions) were measured but they were not recorded. - At 12:55 PM, notes showed police “transport” arrived to take him to the “next phase of care”. - At 1:02 PM, he was “released to LE”. Review of Patient #2’s Hospital B medical record, dated 06/02/26, showed: - At 2:41 PM, physician notes showed Patient #2 was brought by LE for a mental health evaluation. He had made SI remarks earlier that day, but he did not feel that way anymore. - At 5:32 PM, nursing notes showed she contacted Hospital A and gathered information about medications they had given, his laboratory results, and the events that took place there. - At 8:00 PM, he arrived at their mental health unit where he was admitted for treatment. During an interview on 07/01/26 at 4:30 PM, Staff H, Risk Manager, stated that the hospital sought placement for him with the two nearest places that provided mental health services. Staff informed the police department that they did not have placement. Since the unit was not locked, it was common for LEP to remove violent patients. Those patients could not stay until placement was found, so they could take them somewhere safely. The hospital executed the instructions on the 96-hour hold. During an interview on 07/01/26 at 2:33 PM, Staff I, House Supervisor, stated that a 96-hour hold was a legal way to transport a patient to get the care they needed. He wasn’t transferred; he was discharged to police to transport him to a mental health facility per their protocol. He couldn’t remain there in restraints, and they could not treat him appropriately with the resources they had. They didn’t have a locked unit or a psychiatrist (physician who specializes in mental health disorders). “He was out of control, and the BAC had exhausted all their efforts.” Waiting for placement was indefinite and “we didn’t feel we could retain him until that could be done.” Police had a 96-hour process to find facilities, and she knew they helped those individuals get the help they needed. During an interview on 07/01/26 at 3:52 PM, Staff J, ED Physician, stated that the court initiated a 96-hour hold and ordered where the patient was to go. Patient #2 was very violent, and for everyone’s safety they thought he should go where the court ordered. The judge made the decision for a place that was safe for him. He was medically cleared to go; he was alert and oriented and his condition was not going to deteriorate. There was no transfer involved because they could not find a place for him to go. During an interview on 07/01/26 at 1:22 PM, Staff D, RN, stated that Patient #2 was medically stable; his VS were stable, he was alert and oriented the whole time, he was never lethargic, and he never needed supplemental oxygen. BAC never found placement. Police had a 96-hour hold and that meant that they had to allow him to go with police. Police had protocol and chose to take him into their custody. They didn’t want to wait because of his violent behavior. During an interview on 07/02/26 at 8:00 AM, Staff K, Social Worker, stated that the availability of psychiatric rooms went from 42 to 16, so waiting sometimes took days. Normally hospitals held those patients until placement, and they usually went in an ambulance.”