Blue Ridge Healthcare Hospitals, Inc.

“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: 50403 Based on policy review, medical record review, physician and staff interviews, the nursing staff failed to notify the provider that a patient with a guardian was being discharged home unaccompanied without transportation to walk to their place of residence for 1 of 3 patients with a guardian (Patient #4), and failed to complete a Wound Consultation for pressure injury for 1 of 2 patients (Patient #1). The findings include: Review of hospital policy on 02/11/2026 titled Patient Assessment and Reassessment, effective 09/2025 revealed “ ...All patients discharging to home or to another facility will have a discharge reassessment ...” 1. Closed medical record review on 02/10/2026 revealed Patient #4 was a 48-year-old who presented to the ED (Emergency Department) on 11/15/2025 at 2114 via EMS (Emergency Medical Services) with a complaint of ‘popping chest pain’. The Triage RN (Registered Nurse) Nursing Note revealed the patient’s PMH (Past Medical History) included “deaf-mutism” and Schizoaffective Disorder. The ED determined Patient #4 was stable for discharge and the disposition was set to discharge. A Nursing Note dated 11/16/2025 revealed a nurse attempted to call patient’s residence for transportation, a woman answered the phone and stated nobody could come get the patient until the morning. A Nursing Note indicated “...patient was refusing to wait in the lobby and wanted to walk home...spoke with caregiver and she stated that she can not come...and patient states that he is walking home. Patient left hospital ambulatory. Caregiver shows up to the hospital around 0115 to get patient, informed her that patient had already left and is walking home...” Record review failed to reveal notification to the physician of the patient leaving or an attempt to arrange transportation for the patient home. Interview with RN #3 on 02/11/2026 at 1107 revealed that Patient #4 was “deaf”. Interview revealed that RN #3 was not aware Patient #4 had a guardian. Interview revealed “my main concern was that he couldn’t hear cars and (I) was not comfortable with him walking the distance. However, patient was adamant to leave.” Interview revealed that RN #3 did not notify the provider of patient’s transportation issues or that patient walked out in the middle of the night towards the patient’s residence. Telephone interview with MD #1 on 02/11/2026 at 1400 revealed that MD #1 was not aware that the patient had a guardian. Interview revealed that “had I known ....would have made a stronger attempt to keep patient there (in ED) until coordination of transportation could have been arranged.” Interview revealed that the provider was not made aware that the patient was discharged and was ambulating home. 53482 2.Closed medical record review revealed that Patient #1, a 76-year-old, arrived to the hospital via EMS on 10/17/2025 for complaints of left hip and left shoulder pain. The patient was diagnosed with shoulder and hip fractures. Physician admission History and Physical on 10/17/2025 at 0316 noted skin physical exam as “no rash observed: on chest, abdomen and lower extremities”. Nursing documentation on 10/17/2025 at 0522 revealed a Braden skin score of 15 (scale used to assess risk of developing pressure ulcers, with a score below 19 indicating a higher risk). Nursing skin assessments were documented as “Integumentary WDL” (Within Defined Limits) with “bruising.” Physician orthopedic consult addendum note 10/17/2025 at 0646 physical exam documented, “Integumentary: Warm, Dry ...Left lower extremity: Skin is grossly intact ...limited range of motion of left leg due to hip pain”. Medical record review revealed no indication of a pressure ulcer on admission. On 10/21/2025 at 1816 nursing assessment by RN #7 indicated “Exceptions to WDL wound discovered to bottom, RN to place wound consult...Wound covered with [dressing] tape 4x4s at this time...”. Review revealed a wound consult was ordered 10/21/25 at 1819. Review of the order revealed “Inpatient Consult to Wound Nurse: Patient Communication Evaluate and Treat? Yes, Reason Wound ...Pressure Injury....Wound to bilat bottom discovered. Photo uploaded to chart. Appears to be possible pressure injury that has opened. ...” Record review revealed the wound consult was completed 10/22/25 at 1301 by RN #11. The Consult Note documented initial consult assessment completed for the surgical wound incision only. Review of the Consult Note revealed no assessment of the buttock/sacral wound in the consult or in subsequent nursing notes through discharge. Patient #1 was discharged on 10/23/2025. The Discharge Summary and Discharge Instructions did not note an evaluation of the wound or wound care instructions for the buttock/sacral wound. Staff interview with RN #8 on 02/12/2026 at 1220 revealed the 10/22/2025 documentation for the wound was bilateral buttocks wound near the sacral area. Staff interview of RN #11, a wound nurse, on 02/12/2026 at 1250 reported she did not see the comment on the notes for the wound that the patient had a wound on the buttocks, so RN #11 looked at the surgical site wound. The buttocks/sacral wound was not evaluated. Manager #13 in-person interview on 2/12/26 at 1445 reported the sacral ulcer was not assessed during hospitalization of 10/17/2025 - 10/23/2025 by the wound care nurses. RN #7 was unavailable for interview. NC00235111, NC00234748”

“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: 40299 Based on event/visit review, medical record review and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The hospital’s Dedicated Emergency Department [DED] failed to provide an appropriate Medical Screening Examination [MSE] within the capability of the hospital’s DED, for a minor patient that walked into their emergency department and guardian requesting an evalutation for 1 if 30 patients (Patient #3). Findings include: ~ Cross refer to Medical Screening Examination - Tag A2406.”

“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: 40299 Based on policy review, event/visit review, medical record review, public safety report, and staff interviews, the hospital failed to provide an appropriate Medical Screening Examination [MSE] as requested by Patient #3’s legal guardian for a minor patient that walked into their emergency department for one (1) of 30 sampled patients (Patient #3). Findings included: Review of the EMTALA policy dated 12/2023 revealed “Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who ‘come to the Hospital’s Emergency Department’ ... and request examination or treatment of a medical condition ... A Medical Screening Examination will be performed to determine if an Emergency Medical Condition exists. If the individual has an Emergency Medical Condition, the Hospital will either stabilize the medical condition within its available staff, facilities, and resources, or, if stabilization at the Hospital is not possible, appropriately transfer the individual to a qualified receiving facility ... PROCESS I. Medical Screening Examination: A. Request for MSE: An appropriate Medical Screening Examination will be performed on any individual who ‘comes to the emergency department,’ which means: 1. The individual presents to the Hospital’s dedicated Emergency Department, and, either personally or through someone else, requests examination or treatment for a medical condition. 2. The individual presents anywhere on the Hospital Property and, either personally or through someone else, requests examination or treatment for what may be an Emergency Medical Condition. In either situation, even if there has been no formal request for treatment, a request is considered to have been made if a prudent layperson observer would believe that the individual needs emergency examination or treatment ...” Review of the electronic log of emergency department encounters for Patient #3 revealed Patient #3 had a visit entered on 01/10/2024 at 1630 [3 hours and 6 minutes after discharge from the hospital’s (Hospital A Campus A) emergency department. The patient was transported via law enforcement. Review of the Hospital A Campus A Case Management Note on 01/10/2024 at 1649 revealed “01/10/2024 @ [at] 1630 - Social Worker [SW #4] (hospital employee) received a call from ED (emergency department) RN (registered nurse) stating pt (patient #3) just walked past her and into the hospital. SW #4 found patient in ED lobby with no guardian. Pt stated she walked on foot from [DSS D] office to ED by herself after getting into a fight with her SW. Pt stated when she got to DSS, they went through and took her belongings, including her computer. Pt got upset about this and stated she was going to leave, and did. [SW #4] did not receive a call from [DSS D] (DSS county office staff) regarding this, and [DSS D] did not arrive to the ED with pt. [SW #4] asked pt if she is having feelings of harming herself or others, pt denied this. [SW #4] asked if pt is not feeling well and needs to be checked in, pt denied this as well. PS [#1] (Public Safety Officer) arrived at the ED and met with [SW #4] and pt in SW office. [SW #4] attempted call to [DSS Appointed #5] (County DSS employee) cell phone, who did not answer. [SW #4] called [Guardian #2], pt’s guardian. [Guardian #2] advised she does not know what to do and will ask supervisors/program managers ... all got on the call with [SW #4], stating pt has been displaying ‘behavioral issues’ within the ‘first four minutes’ of pt being at their office. DSS representatives stated pt walking to ED also shows impulsivity, and they would like pt to be evaluated. [SW #4] advised this is not a reason to IVC (Involuntary Commitment) or telepsych pt, and [SW #4] will reach out to Hospital administration on what to do from here. [SW #4] advised by [PS #1] Public Safety that they were told to bring pt back to DSS. Pt went willingly to LE [law enforcement] car and left [Hospital A Campus A] with [PS #1] ...” Review on 08/05/2024 of Hospital B’s open medical record for Patient #3 contained a form “PARENT OR GUARDIAN’S APPLICATION FOR A MINOR’S ADMISSION TO [Hospital B] AND CONSENT TO TREATMENT FOR MENTAL ILLNESS” on 01/10/2024 at 1804 filled out with Patient #3’s name and signed by [DSS D] (DSS county) social worker. Review of the EVALUATION FOR ADMISSION /CONTINUAL STAY form revealed “ ... The above named [check box] minor ... was examined on 01/10/2024 at 2000 o’clock ... DESCRIPTION OF FINDINGS: ... Patient requests admission. Has continued to engage in disruptive, aggressive, and some self injuries (sic) behaviors saying to DSS staff she will escalate if not admitted ...” Review of the Provider note dated 01/10/2024 at 2041 revealed “ ... Reason for Admission: ... a 16-year-old Caucasian female ... who presented to the Admissions Office at [Hospital B] as a volunteer (by guardian) walk-in early on the evening of 01/10/2024. She was brought ... by staff from [DSS D]. The patient’s guardian of person is [Guardian #2] ... Because of behavioral problems (arguments, physical aggression, property destruction), the patient was taken to the emergency department at [Hospital A Campus A] on multiple occasions. However, after undergoing telepsychiatry evaluations, it appears that the decision was made not to admit her to the hospital because of a lack of suicidality or sufficient risk of harm to others. The patient has been staying in the [DSS D] offices since then, under staff supervision. After eloping from the [DSS D] offices and walking back to [Hospital A Campus A] earlier today, the patient was brought to [Hospital B] to seek admission ... PLAN: 1. The on-call attending psychiatrist ... made the decision to admit the patient to [Hospital B] this evening. The patient is going to be admitted ...” Review of the “Psychiatric Assessment” at 2025 revealed “ ... 2. Chief Complaint or Patient’s Response to Hospitalization (in patient’s own words): ‘I wanted to come here because the last time, this was the only place where the groups actually helped and I learned to use good coping skills. 3. Present Illness (onset and circumstances leading to admission): 16-year-old female with a long history of psychiatric illness with multiple placements and hospitalizations throughout the years. She is in the custody of DSS. She was admitted as a volunteer and volunteer by guardian for mood stabilization and behavioral stabilization ... Upon seeing her and interviewing her, she is calm, pleasant, cooperative. She tends to minimize her role in all of this, minimizing the degree of aggression and disruptive behaviors she has been engaging in. She tends to externalize things onto others. She blames DSS social workers for either not being attentive or not caring, etc. She blamed her aunt for getting angry that the boyfriend left, etc. She also stated she was put in the hospital by DSS simply because they did not want to babysit her in their office on Christmas. In any case, she has definitely been aggressive, disruptive, and oppositional in these situations. That said, [Patient #3] states plainly that she has been using poor coping skills and recalls how much she learned here and how much she thinks our hospital helped her, and so she desires to come back to relearn, strengthen and refresh her coping skills ... 27. Initial Plan including Pharmacological Formulation (strategies to deal with identified problems, rationale for medication choices): Admit to the unit for safety and stabilization. She will receive a multidisciplinary evaluation and treatment in the unit. She will receive a physical exam addressing any health concerns. Further collateral information will be obtained. Will continue her current medications ... 34. Admission: Approved ...” Review of the PS [Public Safety] #1 report dated 01/10/2024 at 1624 revealed “... JUVENILLE [sic] PROBLEM ... SUBJ [subject] LEFT OF [sic] FOOT ... HEADING TOWARDS HOSPITAL ... CALLER IS WITH DSS AND SAID SUBJ WANTS TO BACK [sic] TO HOSPITAL ... HAS BEEN COMBATIVE ... JUVENILE IS POSSIBLY IN THE HOSPITAL WAITING ROOM ... IM [I am] OUT AT HOSPITAL ... IM OUT WITH THAT FEMALE ... MAKE CONTACT BACK WITH CALLER AND HAVE SOMEONE EN ROUTE TO PICK UP JUVENILE WE WILL BE IN ED DEPT [department] ... CALLER ADVISED THEY ARE ON THE PHONE WITH ER NOW ... I WILL BE ENROUTE BACK TO DSS SHORTLY IF SOMEONE WILL STANDBY ... WAS RETURNED TO [DSS D] AFTER LOCATED AT THE ER LOBBY. DSS WOULD NOT COME TO HOSPITAL TO PICK UP FEMALE THEY HAVE CUSTODY OF WHILE RETURNING FEMALE BACK TO DSS, THE CALLER MET OFFICERS AT THE DOOR AND ADV [advised] TO TAKE HER TO [Hospital B]. THE CALLER VERBALLY TOLD OFFICERS THAT DSS HAD CUSTODY OF THE FEMALE AND OFFICERS STILL HAD TO EXPLAIN WHY FEMALE HAD TO BE LEFT AT DSS ...” Interview on 08/01/2024 at 1305 with SW #4 revealed she was notified by the ED Nurse Manager that Patient #3 had just walked past the nurse in the ED. SW #4 met Patient #3 in the ED waiting room. SW #4 called DSS Appointed #5 (County DSS employee) and Guardian #2 and while SW #4 was on the telephone with DSS, Patient #3 left the ED with law enforcement. Telephone interview on 08/01/2024 at 1441 with Guardian #2 revealed Patient #3 was driven to Hospital B (psychiatric hospital) on the day she returned (01/10/2024) to the DSS office because Patient #3’s behaviors had escalated. Interview on 08/02/2024 at 1220 with Provider #6 revealed Patient #3 should have been seen and evaluated on the the 01/10/2024 walk-in visit. Provider #6 was not aware of Patient #3 walking into the ED on 01/10/2024. He was notified a couple of weeks later. Interview revealed the note (SW #4 01/01/2024 at 1649) is different than what Provider #6 was told. Provider #6 was told Patient #3 came in asking to stay here as the people were nicer.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 40299 Based on review of medical records and staff and provider interviews, the hospital failed to provide a safe discharge from the emergency department for 1 of 30 patients reviewed (Pt #3), a minor behavioral health patient, and failed to reevaluate the patient after return to the ED the same day. The findings included: Review on 07/31/2024 of the closed medical record for Patient #3 revealed the patient presented to the ED (Emergency Department) via EMS (Emergency Medical Services) on 12/10/2023 at 1940 with an arrival complaint of “Psychiatric Evaluation.” Review of the ED Provider Note at 2006 revealed “Patient is a 16-year-old female with past medical history of aggressive behavior, disruptive mood dysregulation disorder, major depression, PTSD (Post Traumatic Stress Disorder) .... suicidal ideations reporting from DSS (Department of Social Services) ... .” Provider Note review revealed Patient #3 had also been in the ED in November 2023 and at that time was discharged to DSS. Further review of the provider note revealed “ ...Patient was reportedly refusing her medications over the last 2 (two) days and becoming very agitated and aggressive, barricading herself in DSS office .... EMS was called ... .” Patient #3 was placed under involuntary commitment (IVC) due to her behaviors. Record review revealed Patient #3 had been residing at the DSS office building while they tried to find placement at the time she refused to take her medications and barricaded herself in her room. Review revealed telepsychiatry recommended “inpatient psychiatry for safety, stabilization, medication adjustments and determination of appropriate long term disposition. ...” Review revealed efforts to secure inpatient placement were not successful; Patient #3 was declined admission for inpatient psychiatry due to behaviors or placed on a wait list that could last 1-2 months. Review revealed Patient #3 exhibited violence on 12/22/2023 at 1100 and required restraints. Review of a Case Management Note dated 12/27/2023 at 1818 revealed “... SW met with pt at bedside to discuss physical violence episode that occurred this week. Pt stated ‘I was mad and I was not on my medications’. Pt advised she has been taking her medications and realizes that they help her feel better .... Pt asked if she can be dc (discharged) back to DSS now since she is feeling better. Pt stated she will continue to take her medications when she discharges and would go to therapy. Pt behaved well today and was active, talking with staff, coloring, reading, and watching TV. Meeting with DSS and Local Management Entity (LME) scheduled for tomorrow, 12/28, at 8:30 am for placement updates. ...” Review of the Case Management Note on 12/28/2023 at 1003 revealed “ ... SW completed Disposition/Placement meeting with DSS and LME .... SW Provided hospital update ....DSS did not provide any updates but advised they will be reaching out ... for ... recommendations and formal assessment ....LME advised all crisis facilities in NC and PRTFs (Psychiatric Residential Treatment Facilities) have so far denied pt, as well as inpatient facilities .... also advised a Peer to Peer was completed ... result of this is that pt will be strongly considered for placement. SW to follow for tele-Psychiatry assessment. ...” Review of the Tele-Psychiatry note dated 12/28/2024 at 1618 revealed “... Patient was initially seen by psychiatry on 12/11 and we are being re-consulted today given improvement in behaviors with medication compliance for the last 4 days ... Per collateral, patient continues to have low distress tolerance. Guardian reports improvement though not complete return to baseline. DSS unable to take patient back to their care until further improvement is noted.... It does appear patient’s status has improved with med compliance since last evaluation, however given severity of recent aggressive episodes, recommending continuing to pursue inpatient options... The patient DOES meet North Carolina involuntary commitment criteria at this time. ...” Review of the Tele-Psychiatry note dated 01/02/2024 at 1732 revealed “...We have been reconsulted again today given ongoing safe behaviors.... Although this patient presented for aggression and labile mood, they do NOT appear to be at imminent risk of dangerousness to self and dangerousness to others at this time .... the patient does not necessitate nor desire further acute inpatient psychiatric care at this time ... Unable to make formal recommendations for disposition due to inability to contact guardian and discuss aftercare planning. With respect to commitment criteria, it does not appear that the patient would currently meet this. ...” Review of the ED Provider note on 01/03/2024 at 1340 revealed “... Past 24 hour events: Currently resting there is been [sic] multiple discussion that this setting and [sic] certainly is not the most appropriate setting for this patient. ...” Review of a Case Management Note on 01/03/2024 at 1350 revealed “...pt has been placed for discharge from Emergency Department. SW made phone calls to both (DSS guardian #2 and DSS Supervisor) .... Left .... voicemail advising pt is discharged and if SW needs to arrange for transportation .... 1406 - SW received a call (from DSS Appointed Staff #5) .... advised he was forwarded a voicemail SW left worker (Guardian #2). SW confirmed pt is recommended for dc (discharge) and ready to be picked up .... (DSS Appointed #5) advised DSS stance has not changed .... they do not feel the DSS office is a safe place for the pt, so they will not be coming to pick the pt up. ...” Review of the ED Provider note on 01/04/2024 at 0812 revealed “... Past 24 hour events: ... Per chart review it does appear that patient will be discharged back to DSS by law enforcement ... Updated Plan: Working with case management for discharge back to DSS. ...” Review of the Tele-Psychiatry Consult note dated 01/04/2024 at 1341 revealed “ ... RELEVANT UPDATES TO HOSPITAL COURSE: Since the prior evaluation 2 days ago the patient has remained behaviorally stable .... She said that she was frustrated at still being in the hospital and that the DSS case worker had told her that she would not be going back with them but she did not know what the plan was. COLLATERAL INFORMATION: Participated in a video call with (SW #4) who is the social worker at the emergency department and a DSS supervisor. I explained that I had not made a formal recommendation for placement previously because I had not spoken with (Guardian #2) at that time. I wanted to know if the patient had communicated any other information such as suicidality, intention for aggression or other information regarding concerning psychiatric symptoms. The supervisor told me that he did not believe that the information the patient was conveying to (Guardian #2) was different from the information that I had had [sic]. I explained that given the sustained period of stable behavior I could not recommend that the patient be hospitalized acutely.” Review of the ED Provider note on 01/08/2024 at 1545 revealed “ ... After the last several evaluations she is felt no longer to require inpatient hospitalization. She is no longer involuntary [sic] committed. At this time she is safe for the outpatient community in the care of the DSS. ...” Review of the Case Management Note on 01/10/2024 at 0905 revealed “... 0800 - SW received communication from hospital administration to arrange transportation to DSS office. SW attempted call to [DSS Appointed #5] at his desk and cell phone, SW left a message requesting a call back. SW completed the following email to DSS and LME representatives: ‘Good morning all, Per hospital administration, our mutual patient will be leaving the Emergency Department today. I am happy to coordinate transportation to the DSS office with [DSS Appointed #5 first name] and [Guardian #2 first name] if able. If not, I will coordinate transportation to the DSS office [DSS D] with law enforcement. If there are any questions or concerns, feel free to reach out to me! Thank you’ ... 1230 - Pt transported to [DSS D county office] via [ PS {public safety} #1].” Interview on 07/31/2024 at 1451 with SW #4 revealed DSS brought Patient #3 to the ED for a “psych eval”. Interview further revealed when Patient #3 was no longer recommended for inpatient admission, DSS quit answering calls and emails when the hospital tried to notify them Patient #3 was ready to be discharged. Follow-up interview on 08/01/2024 at 1305 revealed SW #4 was involved with all adolescent patients that are evaluated by tele-psych. SW #4 found inpatient placement for Patient #3 at (Facility E) however they rescinded the bed offer due to notes that showed aggressive history. Continued interview at 1646 with SW #4 revealed a WebEx meeting was held with DSS, [Hospital A]’s Administration, LME, and SW #3 where the decision was made to send Patient #3 back via LEO. DSS did not agree with the discharge and wanted Patient #3 to remain at the hospital until proper placement was found. SW #4 stated “can’t appeal discharge from the ED.” SW #4 felt it was a safe discharge since Patient #3 was being discharged back to her legal guardian and to where she was prior to admission. It is the understanding it is the practice of DSS to house children in their offices who do not meet inpatient criteria and they are trying to find placement. Interview revealed Patient #3 was discharged during business hours to assure someone was at the DSS office to receive the patient from LEO. DSS quit communicating with SW #4 and with our legal team who was already involved when they appointed [DSS Appointed #5] to be the primary contact between DSS and the hospital SW. [DSS Appointed #5] was involved in the WebEx and was notified by the Providers, that Patient #3 no longer needed to be in the hospital and notified it was not a safe environment for a patient to stay in the ED long term when not needed. Interview on 08/01/2024 at 1148 with Provider #8 revealed the provider remembered seeing Patient #3. Patient #3 was not communicative at all. She was being evaluated for aggression and had recently been hospitalized. Interview revealed Provider #8 saw Patient #3 on 12/11/2023 for her initial consult and inpatient admission was recommended. Patient #3 was not sleeping, she hit security, broke the sink off the wall, and tried to stab the EMS worker with a syringe. Interview revealed Patient #3 was re-evaluated on 12/28/2023 and again was recommended for inpatient admission. On 01/02/2024 Patient #3 was evaluated by one of Provider #8’s colleagues who determined Patient #3 did not meet IVC criteria anymore. Interview revealed on 01/04/2024 Patient #3 was again re-evaluated and inpatient admission to psychiatry was not recommended. Interview revealed telepsych providers usually do not make specific recommendations because each county has different resources available and telepsych would not know all the resources available. Interview on 08/02/2024 at 1117 with RN #7 revealed the RN remembered Patient #3. Interview revealed DSS did not want to come pick Patient #3 up when she was ready for discharge. RN #7 did not think Patient #3 met the criteria for inpatient admission. Interview revealed some days Patient #3 was out of control and would hit staff members and/or take off running if she did not get to use her IPAD. She would throw a tantrum. DSS kept telling Patient #3 daily they were trying to find her somewhere to go. Interview revealed RN #7 thought the “ED department is not the best for kids.” Patient #3 DED visit 01/10/2024 Review of the electronic log of emergency department encounters for Patient #3 revealed Patient #3 had a visit entered on 01/10/2024 at 1630 (3 hours and 6 minutes after discharge to DSS via LE). Review of a Case Management note, dated 01/10/2024 at 1649, revealed that at 1630 the Social Worker (#4) got a call from an ED RN that Patient #3 had just walked into the hospital. Review revealed SW #4 found the patient in the lobby without a guardian, that the patient stated DSS took her belongings, including her computer, and she got upset and left. SW #4 made a call to DSS and “ ...all got on the call .... stating pt has been displaying ‘behavioral issues’ within the ‘first four minutes’ of pt being at their office. DSS representatives stated pt walking to ED also show impulsivity and they would like pt to be evaluated. ... (SW #4) advised this is not a reason to IVC or telepsych pt, and (SW #4) will reach out to Hospital administration on what to do from here. ...” Review revealed the social worker was advised they were to take Patient #3 back to DSS and Patient #3 left the hospital willingly with law enforcement. Record review did not reveal that Patient #3 was reevaluated as requested by the guardian. Telephone interview on 08/01/2024 at 1441 with Patient #3’s legal guardian revealed Patient #3 was driven to (Hospital B) when she returned on 01/10/2024 due to Patient #3’s escalating behaviors. Hospital B (Patient #3) visit 01/10/2024 Review on 08/05/2024 of the open medical record from Hospital B revealed Patient #3 arrived at the hospital on 01/10/2024. Review of the EVALUATION FOR ADMISSION /CONTINUAL STAY form revealed “ ... The above named [check box] minor ... was examined on 01/10/2024 at 2000 o’clock ... DESCRIPTION OF FINDINGS: ... Patient requests admission. Has continued to engage in disruptive, aggressive, and some self injuries (sic) behaviors saying to DSS staff she will escalate if not admitted ...” Review of the Provider note dated 01/10/2024 at 2041 revealed “... Reason for Admission:... a 16-year-old Caucasian female ... presented to the Admissions Office ... as a volunteer ... walk-in early on the evening of 01/10/2024. She was brought ... by staff from [DSS D] .... Because of behavioral problems (arguments, physical aggression, property destruction), the patient was taken to the emergency department at [Hospital A Campus A] on multiple occasions. However, after undergoing telepsychiatry evaluations, it appears that the decision was made not to admit her to the hospital because of a lack of suicidality or sufficient risk of harm to others .... After eloping from the [DSS D] offices and walking back to [Hospital A Campus A] earlier today, the patient was brought to [Hospital B] to seek admission ... PLAN: 1. The on-call attending psychiatrist... made the decision to admit the patient to [Hospital B] this evening. ...” Review of the “Psychiatric Assessment” at 2025 revealed “... 3. Present Illness ....16-year-old female with a long history of psychiatric illness with multiple placements and hospitalizations throughout the years. She is in the custody of DSS. She was admitted as a volunteer and volunteer by guardian for mood stabilization and behavioral stabilization ... Upon seeing her and interviewing her, she is calm, pleasant, cooperative. She tends to minimize her role in all of this, minimizing the degree of aggression and disruptive behaviors she has been engaging in. She tends to externalize things onto others ....In any case, she has definitely been aggressive, disruptive, and oppositional in these situations .... 34. Admission: Approved ...” In summary, Patient #3 was taken to the Emergency Department of Hospital A on 12/10/2023 where she initially displayed very aggressive behavior requiring involuntary commitment and inpatient care. The hospital attempted to get the patient admitted for inpatient psychiatric care but was not able to find placement. Over the next few weeks, behaviors improved and telepsychiatry determined an IVC was no longer needed. Other placement options had not been located. DSS indicated that they did not believe discharge to the DSS office was a safe discharge plan and refused to come pick the patient up. Patient #3 was discharged to DSS on 01/10/2024 by law enforcement (LE). Around three hours after discharge, Patient #3 walked back into the hospital, stating she had become upset with DSS and left the office on foot. The hospital reached out to the DSS guardian, a conversation was held and DSS requested the patient be reassessed for behaviors and impulsivity. The hospital did not reevaluate Patient #3 and sent her back to the DSS offices via LE without reassessment. That same day, DSS staff/guardian took Patient #3 to Hospital B where the patient was evaluated and voluntarily admitted. The hospital did not ensure a safe discharge plan and did not reevaluate Patient #3 upon return to the ED.”