Parkwood Behavioral Health System

“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: 47684 This standard is not met based on staff interviews, medical record review, and facility policy review. The facility failed to provide an appropriate Medical Screen Exam (MSE) to determine if an emergent medical condition existed for an individual who presented to the emergency department (ED) and failed to appropriately communicate with the receiving facility or arrange an appropriate transport for one (1) of 20 patients charts reviewed, Patient #1. Findings Include: Review of medical record documentation for Patient #1 from Facility #2, (the original transferring facility) revealed Patient #1 presented to Facility #2 by ambulance for psychiatric evaluation due to acting strange and not taking medications. Patient #1 was triaged, received a medical screening exam (MSE) and laboratory testing. A Physician/Psychologist Emergency Certificate was completed by the provider at Facility #2 determining the patient is unable to care for self by virtue of mental illness. Facility #2 notified Facility #1 for the transfer and the Patient was accepted; transfer was arranged with a non-medical transport service after medical clearance. Review of Patient #1’s medical record from transport service, dated 03/08/2026, revealed on arrival to Facility #1 at 12:30 p.m., Patient #1 ambulated from stretcher to chair and patient care was transferred to Registered Nurse (RN) #3. Further review revealed the nursing staff instructed the transport service to return Patient #1 to Facility #2 due to patient refusing to cooperate with Emergency Medical Service (EMS) transport and nursing staff. Facility #1’s nurse provided assessment of patient including a sternal rub and ammonia inhalant with little to no response from Patient #1. Document review revealed nurse declared a medical emergency due to patient being lethargic and not responding. While in the parking lot of Facility #1, the transport services called 911 for an EMS medical transport to Facility #3’s Emergency Department because they were a non-medical transport service for medically cleared patients only. Review of Patient #1’s medical record from Facility #3 revealed patient arrived at the ED at 2:13 p.m. by Fire Department ambulance service with a diagnosis of altered mental status, unspecified and acute schizophrenia. Facility #3 attempted to contact Facility #1 on patient’s arrival with no answer and again at 3:42 p.m. speaking with the Nursing Supervisor. The Nursing Supervisor said she was not in the facility at the time of the event and would call them back in 30 minutes. Documentation further reveals the Nursing Supervisor asked about status of Patient #1 while at Facility #3 and was told, “ ...patient is the same, assisted with getting himself undressed, flutters his eyes when you call his name and rolls himself in bed ...” Facility #3 explained there was no reason for the transfer and Patient #1 was not having a medical emergency, labs were repeated with no change and that they would be reporting Facility #1 for an Emergency Medical Treatment and Labor Act (EMTALA) violation. Facility #3 reported Facility #1’s physician agreed to accept the patient back. Transport was arranged and Patient #1 was transferred and admitted to Facility #1 at 8:15 p.m. for psychiatric treatment. An interview with the Facility #1’s Psychiatric Physician #1 on 4/15/2026 at 3:00 p.m. confirmed that Facility #2 “ ...notified him at 3:00 to 4:00 a.m. about the patient who was supposed to be psychotic and accepted him ...But when he got here the patient was unresponsive, catatonic, dead weight, can’t get off stretcher and they called me and I told them to send him to the ED for medical clearance ... we know nothing about him ... we needed to make sure he was ok. The Psychiatric Physician also stated, “ ...I didn’t call the ED when we sent him”. An interview with Registered Nurse (RN) #1 on 04/15/2026 at 3:30 p.m. confirmed Patient #1 presented to the emergency department and was not taken to triage and did not receive a medical screening exam. RN #1 reported Patient #1 was referred for admission from Facility #2 and arrived at Facility #1 on 03/08/2026 12:30 p.m. after being accepted by Psychiatric Physician #1. An interview with the Director of Intake (DI) on 4/13/2026 at 3:15 p.m. confirmed the patient arrived but was not accepted for admission because Patient #1 “ ...was not speaking to the staff and would not get off the ambulance stretcher upon arrival and was transferred to Facility #3 for medical evaluation. Review of Parkwood Behavioral Health System’s central Emergency Department (ED) log revealed Patient #1 was logged and arrived at the Facility at 12:30 p.m. on 03/08/2026. No documented medical record was provided for review for the visit. Patient #1 was not admitted to the facility and was transferred to Facility #3. Review of medical record for Patient #1 from Facility #2, transferring facility, dated 03/07/2026 to 03/08/2026, revealed Patient #1 arrived at Facility #2 on 03/07/2026 at 11:05 p.m. via Emergency Medical Services (EMS) with a chief complaint of psychiatric evaluation (acting strange, not taking medications) with a history of drug abuse. ED Provider #2 documented the patient kept his arms crossed and would respond to pain and did not speak. Lab work was completed. Patient is resting comfortably after Zyprexa and due to no psychiatric beds available at the facility, the plan is to transport the patient by EMS to another facility. A Physician/Psychologist Emergency Certificate was completed by ED Provider #2 on 03/07/2026 at 11:10 p.m. and revealed the patient is unable to care for self by virtue of mental illness. Patient stable and report was called to Registered Nurse #4 at Facility #1 at 8:45 a.m. The patient was transferred from Facility #2 on 03/08/2026 at 9:47 a.m. by EMS with qualifying documentation - Danger to self or others. Review of the Facility #1’s “Emergency Plan of Services policy” (serves as the facility’s Emergency Medical Treatment and Labor Act [EMTALA] policy) dated 06/1996, revealed “ ...1. The patient or other individual should immediately be assessed to determine whether an emergent condition exists. Emergency Medical Services (EMS) (9-911) should be activated in cases involving life threatening medical emergencies or as deemed appropriate ... “4. The registered nurse should report the medical/psychiatric emergency to the Nurse Executive and the CEO or admission designee” ... “6. Transfer is defined as any movement of a patient or other individual out of this facility to another facility. A transfer agreement exists with ... for management of medical emergencies. EMS (9-911) should be contacted for transfer of persons in medical or ...psychiatric crisis ...9. Documentation 1. The emergency should be fully documented in the clinical record in a timely manner by the charge nurse or his/her designee and should include the following: 1. Signs-symptoms. 2. Treatment interventions and response. 3. Condition at time of transfer ... 9. Documentation: 1. The emergency situation should be fully documented in the clinical record in a timely manner by the charge nurse or his/her designee and should include the following: 1. Signs/symptoms, 2. Treatment and interventions, 3. Condition at time of transfer ...”. Review of the facility’s “Assessment in Triage” Policy, dated 10/2009, Revised 06/2025, reviewed 04/2026, next review 04/2027 reveals “ ...Each patient shall be observed by an intake Assessor who conducts direct visual monitoring to assure safety of the individual awaiting admission or transfer. 2. This process is to be accomplished at a minimum of every 15 minutes and documented on the Patient Risk Sheet in the space provided. 3. Any changes to the patient’s condition may require a rapid response for clinical or medical interventions ...” Exit conference held on 04/16/2026 at 1:15 p.m. with the Chief Executive Officer (CEO) to discuss survey findings with no further information submitted. Cross Refer to A-2406 and A-2409 for additional findings.”

“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: 47684 This standard is not met based on staff interviews, medical record review, and facility policy review. The facility failed to provide an appropriate Medical Screening Exam (MSE) within the capability of the facility to determine if a medical emergency exits when a patient arrived by non-medical ambulance transport for admission to the psychiatric facility for one (1) out of 20 medical records reviewed, Patient #1. Findings Include: An interview with Registered Nurse (RN) #1 on 04/15/2026 at 3:30 p.m., confirmed Patient #1 presented to the emergency department and was not taken to triage and did not receive a medical screening exam. RN #1 reported Patient #1 was referred for admission from Facility #2 and arrived at Facility #1 on 03/08/2026 12:30 p.m., after being accepted by Psychiatric Physician #1. An interview with the Director of Intake (DI) on 4/13/2026 at 3:15 p.m. confirmed the patient arrived but was not accepted for admission because “ ...the Patient #1 was not speaking to the staff and would not get off the ambulance stretcher upon arrival and was transferred to Facility #3 for medical evaluation. An interview with Psychiatric Physician #1 on 4/15/2026 at 3:00 p.m. confirmed the nurse reported on arrival Patient #1 was unresponsive, catatonic, dead weight, can’t get off stretcher and I told them to send him to the Emergency Department (ED) for medical clearance, “ ... we know nothing about him ... we needed to make sure he was ok ...”. Review of Patient #1’s medical record revealed the only documentation for Patient #1 at 12:30 a.m. was the time of arrival in the Central ED Log. No documentation of triage or a medical screening was available for review. Review of the facility’s “Emergency Plan of Services policy” (serves as the facility’s Emergency Medical Treatment and Labor Act [EMTALA] policy) dated 06/1996, revealed “ ...Medical/Psychiatric emergencies involving other individuals should be directed by the on-call physician, Medical Director or any available physician ...1. The patient or other individual should immediately be assessed to determine whether an emergent condition exists ...”. 5. Medical Emergencies (1). A medical emergency is a medical condition with acute/severe symptoms in which failure to provide immediate medical services could result in one or more of the following outcomes: 1) death; 2) serious impairment; 3) substantial risk to bodily functions; or 4) serious risk of compromising the function of any body part or organ. (2) Stabilization is defined as treatment of the condition necessary to assure, within reasonable medical probability and within the capacity of the hospital to do so, that no material deterioration of the person’s condition is likely. Stabilization includes, but is not limited to, the implementation of cardiopulmonary resuscitation and use of oxygen. 6. Transfers (1) Transfer is defined as any movement of a patient or other individual out of this facility to another facility”. Review of the facility’s “Assessment in Triage” Policy, dated 10/2009, last revised 06/2025, “...Each patient shall be observed by an intake Assessor who conducts direct visual monitoring to assure safety of the individual awaiting admission or transfer. 2. This process is to be accomplished at a minimum of every 15 minutes and documented on the Patient Risk Sheet in the space provided. 3. Any changes to the patient’s condition may require a rapid response for clinical or medical interventions ...”. Exit conference was held on 04/16/2026 at 1:15 p.m. with the Chief Executive Officer (CEO) to discuss survey findings with no further information submitted. Cross Refer to A-2400 and A-2409 for additional information.”

“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: 47684 This standard is not met based on staff interviews, medical record review, and facility policy review. The facility failed to provide contact/communication with the receiving medical facility for acceptance and treatment, failed to provide medical records related to medical condition, and failed to ensure the patient was transferred through qualified transportation for one (1) out of 20 medical records reviewed, Patient #1. Findings Include: An interview with the transferring facility’s Psychiatric Physician #1 on 4/15/2026 at 3:00 p.m. confirmed that he did not call/communicate with the receiving hospital to report Patient #1’s need for transfer. Psychiatric Physician #1 reported he was contacted for the transfer and acceptance of a psychotic patient to the Psychiatric facility around between 3:00 and 4:00 a.m. and when Patient #1 arrived from Facility #2 he received a report the patient was “unresponsive, catatonic, dead weight, and can’t get off stretcher, and I instructed them to send the Patient to an Emergency Department for medical clearance. ... we know nothing about him ... we needed to make sure he was ok...” An interview conducted with the Nurse Supervisor (NS) on 4/15/2026 at 3:30 p.m. revealed she was in another unit of the facility when Patient #1 arrived. The NS confirmed Patient #1 should have gone to intake and the House Supervisor should have filled out paperwork. The NS further stated when she arrived at the facility she noted the police, the transferring facility’s transport (the non-medical transport), and an ambulance transport from the local area were in the parking lot of the facility. The NS reported that the EMS transport service (non-medical transport) who brought Patient #1 to Facility #1 notified 911 while in Facility #1’s parking lot for medical transport of Patient #1 after Facility #1 refused to accept the patient and instructed them to take the patient to another emergency department. Review of Patient #1’s medical record from Facility #1 revealed no review due to no medical record generated. Facility #1 did not document first encounter with Patient #1. Only documentation of Patient #1 at the facility for the initial presentation was in the Central Emergency Department (ED) Log at 12:30 a.m. Review of Patient #1’s transport service record dated 03/08/2026 revealed on arrival at Facility #1 the nursing staff instructed EMS (non-medical service) to transport Patient #1 back to Facility #2 due to patient refusing to cooperate with EMS and nursing staff at Facility #1. Documentation reveals Facility #1’s nurse initial assessment of Patient #1 included a sternal rub and ammonia inhalant with little to no response. Document review revealed the nurse declared a medical emergency due to patient being lethargic and not responding. 911 called for EMS medical transport to Facility #3 Emergency Department. Review of Patient #1’s medical record from Facility #3 revealed patient was received at 2:13 p.m. with a diagnosis of altered mental status, unspecified and acute schizophrenia. Attempted to contact Facility #1 on arrival with no answer and again at 3:42 p.m. speaking with the NS, who was not in facility at the time of the event and would call them back in 30 minutes. Documentation further reveals the NS asked about status of patient and was told, “ ...patient is the same, assisted with getting himself undressed, flutters his eyes when you call his name and rolls himself in bed ...” Facility #3 explained there was no reason for the transfer and Patient #1 was not having a medical emergency, labs were repeated with no change and that they would be reporting Facility #1 for an EMTALA violation. Facility #3 reported Facility #1’s physician agreed to accept the patient back. Review of the Facility’s “Emergency Plan of Services” policy, dated 06/1996, revealed “6. Transfers (1) Transfer is defined as any movement of a patient or other individual out of this facility to another facility. A transfer agreement exists with [Named Facility] for management of medical emergencies. EMS (9-911) should be contacted for transfer of persons in medical or, if appropriate and in compliance with Parkwood Hospital policies and procedure, psychiatric crisis...(2) A copy of the following information should be given to the EMS team for delivery to the receiving facility: 1) medical record information pertinent to the medical emergency situation including signs/symptoms, initial diagnosis and interventions implemented for the purpose of stabilization and 2) Memorandum of Transfer. “8. Training (2) ...management of the following medical situations through orientation and annual education: 1. Recognition, interpretation and documentation of signs/symptoms of medical situations ... “9. Documentation ... 1. The emergency should be fully documented in the clinical record in a timely manner by the charge nurse or his/her designee and should include the following: 1. Signs-symptoms. 2. Treatment interventions and response. 3. Condition at time of transfer. 4. Instructions given to patient/family member/guest/employee.” Review of the Facility’s Medical Clearance policy, effective 03/2025, revealed, “Procedure: All individuals are triaged prior to their assessment...2. If the physician recommends, the individual will be sent out for medical clearance...4. The emergency medical facility is given the report. 5. An ambulance is called for transport...6. Transportation forms are completed to include the Memorandum Of Transport and the Patient Consent / Request / Refusal of Transport. 7. The individual continues to be monitored until they leave the facility.” Exit conference held on 04/16/2026 at 1:15 p.m. with the Chief Executive Officer (CEO) to discuss survey findings with no further information submitted. Cross refer to A-2400 and A-2406 for additional information.”