Frye Regional Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 34065 Based on policy review, medical record review, physician and staff interview, the hospital’s governing body failed to provide an effective infection prevention and control program and have an organized nursing service to meet patient care and safety needs of a behavioral health patient in the emergency department. The findings included: 1. The hospital staff failed to provide a safe environment for patients by failing to place a COVID positive patient on isolation for 1 of 1 COVID positive patients with SI (suicidal ideations--thoughts of suicide). (Patient #13). Cross refer to 482.22 Infection Control: Tag A 0749. 2. Nursing staff failed to notify a medical doctor [MD] of a suicidal patient’s continued refusal of medications; complete nursing shift assessments and vital signs for 1 of 10 emergency department patients sampled (Patient #13); and failed to complete pain assessments in 1 of 10 emergency department patients sampled. (Patient #25). Cross refer to 482.23 Nursing Services: Tag A 0395.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 41946 Based on policy review, medical record review, physician and staff interview, the hospital’s nursing staff failed to have an effective nursing service providing oversight of day to day operations in the emergency department by failing to ensure systems were in place to supervise and provide safe delivery of care to patients. The findings included: Nursing staff failed to notify a medical doctor [MD] of a suicidal patient’s continued refusal of medications; complete nursing shift assessments and vital signs for 1 of 10 emergency department patients sampled (Patient #13); and failed to complete pain assessments in 1 of 10 emergency department patients sampled. (Patient #25). Cross refer to 482.23 Nursing Services: Tag A 0395.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 41946 Based on policy review, medical record review, physician and staff interview, the hospital’s nursing staff failed to provide oversight and have systems in place to ensure an effective infection control program, and to implement isolation orders to protect patients or staff to prevent the spread of COVID for 1 of 1 observations/records reviewed. The findings included: 1.The hospital staff failed to provide a safe environment for patients by failing to place a COVID positive patient on isolation for 1 of 1 COVID positive patients with SI (suicidal ideations--thoughts of suicide). (Patient #13). Cross refer to 482.22 Infection Control: Tag A0749.”

“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: 41946 Based on policy review, medical record review, physician and staff interview, nursing staff failed to notify a medical doctor [MD] of a suicidal patient’s continued refusal of medications; complete nursing shift assessments and vital signs for 1 of 10 emergency department patients sampled (Patient #13); and failed to complete pain assessments in 1 of 10 emergency department patients sampled. (Patient #25). The findings included: 1. Review of the policy titled, Assessment and Reassessment/Provision of Care, last approved 06/2024 revealed “ ...Definitions: Assessment includes the prioritization of patient problems or needs. ...Data includes ...objective ...clinical ...safety ...The data are [sic] analyzed to create information necessary to decide the approach to meet care of treatment needs. A nursing assessment is completed when nursing care will be provided regardless of setting. ..Nursing, ... The practice of nursing by a registered nurse [RN] consists ... E. Collaborating with other health care providers in determining the appropriate health care for a patient ...F. Implementing the treatment and pharmaceutical regimen prescribed by any person authorized by State law ...H. Reporting ...the plan of care, nursing care given and the patient’s response to that care ..Emergency Services: ..Patients presenting to the Emergency Department [ED] will be assessed and categorized using the ESI [emergency severity index] 5 Level Triage System defined as follows. ... Level 2 - Emergent: high risk situation, acute confusion, lethargy, severe pain and distress, or vital signs in the danger zone. Level 3 -Urgent: Danger zone vital signs or in need of multiple resources. A. Assessment ...1. Screening Assessment ...b. Screening assessment by the Registered Nurse [RN], as outlined in the documentation tool includes ... v. Pain assessment ...B. Reassessment ... 1. a. Exceptions: i. Psychiatric patients who have been medically cleared, awaiting psychiatric evaluation and/or placement will be reassessed, including vital signs once per shift or per provider order. 2. Reassessment of vital signs will be documented within one hour of admission, discharge, or transfer. ... b. Reassessment of pain will be documented per pain policy. ...” Open medical record review on 01/22/2026 revealed Patient #13, a 47-year-old male patient who arrived to the ED on 01/20/2026 at 1419 with a qualified professional from a facility with a complaint of not eating, weight loss, not taking medications, and altered behavior for one week. The triage began at 1434, and revealed Patient #13 reported suicidal ideation [SI], without a plan, and was given an emergency severity index score of 2-emergent by the ED RN #4. At 1439, Suicide Precautions were ordered with 4 times an hour rounding, by ED MD #5. At 1445, a Covid test was ordered by ED MD #5. At 1448, Patient #13 was roomed to ED ‘stay bed’ area, room 3. At 1511, ED MD #5 completed the medical screening exam, which included a chronic history of schizophrenia [a serious mental health condition that affects how a person thinks, feels, and behaves, often causing a loss of touch with reality]. Patient #13 had a positive Covid test, and was quarantined for 10 days in the ED, awaiting transfer to the inpatient psychiatric unit within the hospital system. On 01/20/2026 at 1846, telephone orders were received from ED MD #5 to Mental Health RN [MHRN] #7 for scheduled medications: atenolol [medication used to treat blood pressure, and lower heart rate] 25 milligrams [mg] 1 tab oral daily, atorvastatin, [medication used to lower cholesterol] 10 mg 1 tab oral at bedtime, Clozaril, [medication used to reduce the risk of suicidal behavior in people with schizophrenia] 25 mg 1 tab oral at bedtime for 2 days, first dose 01/20/2026 at 2000, ferrous sulfate [used as an iron supplement] 325mg, oral tablet, twice a day with meals, levothyroxine [medication used to treat thyroid disorder], 125 micrograms 1 tablet oral daily. Review of the Medication Administration Record [MAR] revealed atenolol 25mg, was charted as “patient refused” on 01/21/2026 at 0900, and 01/22/2026 at 0900, by ED Charge Nurse [CN] #6, atorvastatin 10mg, was charted as “patient refused” on 01/20/2026 at 2100 and 01/21/2026 at 2100 by ED RN #8, Clozaril 25mg was charted as “patient refused” on 01/20/2026 at 2100 and 01/21/2026 at 2100 by ED RN #8, ferrous sulfate 325 mg, was charted as “patient refused” on 01/21/2026 at 0730, by MHRN #7, and 1700 by ED CN #6 [Charted date and time for this administration was 1/22/2026 at 0730 [12 hours later], and 01/22/2026 at 0730 by ED CN #6, and Levothyroxine 125 mcg, was charted as “patient refused” 01/21/2026 at 0600 by MHRN #7, and 01/22/2026 at 0600 by ED CN #6. Review revealed 11 medication administrations documented as “patient refused” over 2 days. The review revealed no nursing documentation of reporting missed medications to a licensed provider. Review of Nursing Assessments for Patient #13 failed to reveal an assessment was performed on 01/20/2026 from 1900 through 01/21/2026 at 0700 by ED RN #8. Review of the Vital Sign Flow Sheet for Patient #13 failed to reveal vital signs were recorded on 01/20/2026 and 01/21/2026 from 1900 through 01/21/2026 at 0700 by ED RN #8. Patient #13 was a current ED patient on quarantine with known Covid, awaiting transfer to the inpatient psychiatric unit once medically cleared. In summary, Patient #13, refused 11 ordered medication administrations between 01/20/2026 and 1/22/2026 that included medication for SI. Patient #13 missed a nursing assessment on 01/20/2026 1900-0700 shift, and missed vital signs assessments on 01/20/2026 1900-0700, and 01/21/2026 1900-0700. The medical record revealed no notification to an ED Provider of missed medications, and no indication documented of missed assessment and vital signs by the RN. Interview on 01/23/2026 at 1135 with Chief Medical Officer, CMO #11, and Chief Executive Officer, CEO #12, revealed “ ... the expectation was for the RN to report to the MD missed ordered medications. The ED was not a typical setting for scheduled medication, but can occur with patients waiting to be transferred ...” Interview on 01/23/2026 at 1715 with Chief Nursing Officer, CNO #10 revealed “ ...the RN should complete a nursing assessment every 12-hour shift. A suicide screening/assessment would be appropriate for a behavioral health patient. ...RN communication to providers policy was developed today. A missed medication for whatever reason should be reported to the provider. ...” 2. Review on 01/20/2026 of the policy titled Pain Management, last approved 10/2024 revealed “...SCOPE: this policy applies to patient care areas of [Named Hospital]. PURPOSE: ...to define the responsibilities of the care providers for the assessment and reassessment of pain and interventions as appropriate ... RESPONSIBILITY: ...Each health care provider is responsible for the ongoing assessment of the patient’s pain and effectiveness of interventions aimed at reducing the level of pain. ...POLICY: ...3. Patients will be assessed for pain on admission ... PROCEDURE: ...1. Numerical Pain Scale: the organization utilized a ‘standard numerical pain scale’ with zero representing no pain and 10 representing worst pain. ... a. using a Pain Assessment Tool to Assess Pain ...3. Total scores as appropriate and document ...” Closed medical review on 01/21/2026 revealed Patient #25, a 23-year-old male patient who arrived to the emergency department [ED] on 12/07/2025 at 2146 by private vehicle with a parent for seizure. Record review revealed Patient #25 was “special needs” [physical or intellectual disability or behavioral difficulties], and parents were his health care power of attorneys. Review of the Triage Part I on 12/07/2025 at 2153 by ED Registered Nurse [RN] #18 revealed “pt. [patient] reports seizure at work tonight. Family reports seizure was about 3 minutes. Hx [history] of seizures on medications. Patient cut his lip and chipped his tooth. ..” Vital signs were recorded and an emergency index score of 2 -emergent was documented by ED RN #18. “ ...Pain present: no actual or suspected pain ...” Review failed to reveal a Pain Assessment Adult, or Numerical Pain Score was documented during the triage assessment. Review of the ED Documentation Note dated 12/08/2025 at 0243 by ED Medical Doctor [MD] #19 revealed “ ...History obtained from Patient’s mother who states he had a seizure at work today. ...He has not [sic] extensive history of seizures on multiple medications for it ....He complains of upper maxillary pain. ...Physical Exam: ...Face: tenderness over mid maxillary region. There is a chipped right front incisor. Left front incisors loosened. No intraoral [inside the mouth] laceration [cut in the skin caused by trauma]. ...” A Computed Tomography [Cat Scan] of the of the Head/Facial Bones was completed on 12/07/2025 at 0052 and revealed an acute fracture “ ...involving the anterior maxilla, with mild displacement and comminution [fragmented], with loosening of the first two maxillary teeth to the left of the midline ...” Discharge Disposition was set to discharge home at 0213 by ED MD #19. Vital Signs were recorded by the discharge ED RN #20 at 0243. Review failed to reveal a pain assessment tool/assessment was completed during 12/07/2025 ED visit. Patient #25 was discharged home on 12/08/2025 at 0247 with parent with a discharge diagnosis of “1. seizure, 2. fracture of tooth, 3. maxillary fracture. ...” In summary, Patient #25 after seizure, was diagnosed with a mouth injury with loosened teeth and maxillary fracture, without a numerical pain assessment completed/documented in triage or during ED visit on 12/07/2025. [4 hours, 50 minutes] Interview request for ED RN #18 revealed they were unavailable for interview. Interview on 01/21/2026 at 1330 with ED MD #19 revealed he remembered Patient #25. The interview revealed “ ...the jaw fracture did not require surgery. The loosened teeth needed to be secured by a dentist. The patient was speaking and told me he had a dentist. This was discussed with family. He made no complaints of pain to me. ...” The interview revealed the RN reported to the MD reports of patient pain. Interview on 01/21/2026 at 1603 with ED RN #20 revealed she remembered Patient #25. The interview revealed “ ...he talked very little, and answered with yes/no questions, parents were present. He said his face felt sore, had a laceration to the lip. I do not recall him complaining of pain. ..He would wake up and answer questions. At discharge there was no concerns about pain voiced. ..” The interview revealed pain assessments should be completed on admission, and reported to the MD, reassessments with any visible signs of pain, and before or after pain medication was administered. Closed medical review on 01/21/2026 revealed Patient #25, a 23-year-old patient who returned to the ED via emergency medical services on 12/08/2025 at 1214 for seizures. Record review revealed Patient #25 was “special needs” [physical or intellectual disability or behavioral difficulties], and parents were his health care power of attorneys. Review of Triage Part I by ED RN #21 revealed “BIBA [brought in by ambulance] from dentist, after having repeated seizures with 1-2 min [minute]. Does have hx of seziures, [sic] but has had under control. Sustained a head injury from fall yesterday but was seen here and d/c [discharge]. Head pain. Special Needs. 5 milligrams of Versed [used to treat acute prolonged seizures] given en route ... Pain Present: yes actual or suspected pain. Preferred Pain Tool: Numeric rating scale. ...Pain Assessment Adult: Pain location: Head, Numeric Pain Scale: 9 ... 12/08/2025 at 1216 by ED RN #21.” Patient #25 was given an ESI of 3-Urgent. Review of the ED Note Physician by the ED MD #22 on 12/08/2025 at 1232 revealed “ ...developed multiple episodes of seizure activity today ...Medical Decision Making ... Mental status has improved. He remains sleepy but would wake up and have conversation. CT did not show any acute emergent findings ...Assessment/Plan 1. Recurrent seizures ...” At 1242 there was an order for Cardiac Monitoring placed. At 1245, Blood pressure documented 152/113. At 1340 Blood pressure was documented as 179/119. At 1415 Blood pressure documented 163/110. Review failed to reveal physician notification of blood pressures, or pain reassessment was completed. Review of Physician Orders revealed seizure medication - Vimpat 200 mg [medication prescribed to treat tonic clonic seizures] intravenous was ordered at 1442 by ED MD #22 and was given at 1528 by ED RN #21. At 1503, Discharge disposition was set to discharge home by ED MD #22 after neurology consult was completed. On 12/08/2025 at 1637 a new Disposition was set to admit to observation by Hospitalist Admitting Nurse Practioner, NP #23. Review of the ED Physician Note on 12/08/2025 at 1754 by the ED Medical Director revealed he planned to admit Patient #25 to observation until patient had reached “neurological baseline.” Review of the History and Physical completed 12/08/2025 at 1752 by Hospitalist Admitting Nurse Practitioner, NP #23 revealed, History of Present Illness ... Pt. complains of some neck pain and tenderness. ...Assessment/Plan, ... 2. Neck Pain, on exam, Pt. is tender to the anterior and posterior neck to palpation and complains of neck pain. ...PRN [as needed] pain medication added. ...Medications Inpatient, ...Hydralazine, 10 mg [medication used to treat moderate to severe high blood pressure] = 0.5milliliter [ml], IV push every 4 hrs. ...” for blood pressure greater than 160 systolic. Patient #25 received Hydrocodone/Tylenol 5mg/325mg at 1805 by ED RN #21. Review failed to reveal a pain assessment was documented. At 1810, on 12/08/2025, Patient #25 was transferred to the neuro-progressive unit for observation admission. In summary, Patient #25 arrived with a numerical pain assessment of 9/10. Review failed to reveal pain reassessments or intervention for pain occurred for 5 hours and 51 minutes. Documented high blood pressures were not found to be reported to the ED MD by the ED RN in the record. The Hospitalist Admitting NP #23 on arrival ordered pain medication for Patient #25 who received it 5 minutes before transfer to the floor, and without a pain assessment completed by the RN. Interview on 01/21/2026 at 1346 with the ED Medical Director revealed, he was present in the ED on 12/08/2025. The interview revealed the original disposition was set to discharge home by the day ED Physician, ED MD #21. When the RN notified him the family had concerns about discharging home, he went to talk with them. The ED Medical Director stated, “ ... he had no problem admitting to observation at the families request, because the patient had received Versed 5mg and was not at his neurological baseline at discharge. ..” The interview revealed atypical high blood pressures can be a result of having pain, and pain assessment findings should be reported to the ED Physician by the RN. Interview on 01/21/2026 at approximately 1430 with ED RN #21 revealed they remembered Patient #25. The interview revealed “ ...he was able to communicate with me. ...I recall doing pain assessments, they didn’t make it to the chart. I remember his pain decreased but I don’t recall values. If I have abnormal vital signs I report them and ask what parameter was ok. That’s how I handle that. ..” The interview revealed the RN should document pain reassessments and provider notifications in the medical record. Telephone interview on 01/21/2026 at 1520 with ED MD #22 revealed “ ...his repeat scans and labs were good. We called the neurologist and was recommended to adjust seizure medication and discharge. ..This patient was verbal toward the end, he was sleepy, but he did answer me. ..nobody asked me for anything for pain. ...I don’t recall his blood pressure being high, but I don’t typically treat blood pressure in this acute setting, it leads to more troubles ...” The interview revealed ED MD #22 did not recall high blood pressures for Patient #25 was reported by the RN. Interview on 01/23/2026 at 1715 with Chief Nursing Officer, CNO #10 revealed “...RN communication to providers policy was developed today...” The interview revealed the expectation was for the RN to report any atypical vital signs, or reports of pain to the MD.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 41946 Draft: Based on policy review, medical record review, and staff interview, the facility failed to maintain an accurate record for a patient presenting with suicidal ideation to the emergency department (ED) in 1 of 10 medical records reviewed. [Patient #13]. The findings included: Review on 01/23/2026 of the policy titled, Legal Health Record and Designated Record Set, last approved 01/2026 revealed “ ...The legal health record contains sufficient information to ...justify the treatment and services, document the course and results of care, and promote the continuity of care among health providers..” Open medical record review on 01/22/2026 revealed Patient #13, a 47-year-old male patient who arrived to the ED on 01/20/2026 at 1419 with a qualified professional from a facility with a complaint of not eating, weight loss, not taking medications, and altered behavior for one week. The triage began at 1434, and revealed Patient #13 reported suicidal ideation [SI], without a plan, and was given an emergency severity index score of 2-emergent by the ED RN #4. At 1439, Suicide Precautions were ordered with 4 times an hour rounding, by ED MD #5. At 1445, a Covid test was ordered by ED MD #5. At 1448, Patient #13 was roomed to ED ‘stay bed’ area, room 3. At 1511, ED MD #5 completed the medical screening exam, which included a chronic history of schizophrenia [a serious mental health condition that affects how a person thinks, feels, and behaves, often causing a loss of touch with reality]. Review of the Emergency Documentation Note by ED MD #5 dated for 01/20/2026 at 1511 revealed “ ...History of Present Illness ... Patient presents to the ER with concerns for psychiatric evaluation. Upon arrival, vital signs reassuring, patient well-appearing. He was calm and cooperative in the ER. Medically cleared and evaluated by psychiatric team, accepted for inpatient management. He does have COVID [communicable respiratory illness], and we will require a 10-day quarantine in the ER prior to transport to [named] campus per mental health liaison. He is voluntary. Medications ordered by the admitting team. ..” On 01/20/2026 at 1846, telephone orders were received from ED MD #5 to Mental Health RN [MHRN] #7 for scheduled medications: atenolol [medication used to treat blood pressure, and lower heart rate] 25 milligrams [mg] 1 tab oral daily, atorvastatin, [medication used to lower cholesterol] 10 mg 1 tab oral at bedtime, Clozaril, [medication used to reduce the risk of suicidal behavior in people with schizophrenia] 25 mg 1 tab oral at bedtime for 2 days, first dose 01/20/2026 at 2000, ferrous sulfate [used as an iron supplement] 325mg, oral tablet, twice a day with meals, levothyroxine [medication used to treat thyroid disorder], 125 micrograms 1 tablet oral daily. Review failed to reveal a psychiatric consult order was placed on 01/20/2026. Next morning, 01/21/2026 at 0655, ED MD #11 “..consult to psychiatry ...consult reason: SI ...Diagnoses Covid-19 (U07.1).” Review of the medical record failed to reveal an ED MD Progress Note for Patient #13 occurred on 01/21/2026 [24 hours]. The next day, a second psychiatric consult was requested on 01/22/2026 at 1446 by RN #13. Review revealed a Consult Note, dated for 01/22/2026 at 1553 by Psychiatric MD #12 “...Assessment/Plan: 1. Acute exacerbation of chronic schizophrenia, 2. suicidal ideation, 3. COVID-19. .. The patient is actively psychotic at this time. He has been responding to internal stimuli. He has been experiencing thought blocking. He is unable to take care of himself at this time. I would recommend inpatient psychiatric treatment after medical stabilization. ..” Patient #13 was a current ED patient on quarantine with known Covid, awaiting transfer to the inpatient psychiatric campus once medically stable. In summary, ED MD #5’s initial ED Documentation Note dated 01/20/2026 at 1511 indicated Patient #13, had been evaluated by the Psychiatric team, had been accepted for inpatient management and medications would be ordered by the admitting team. Record review revealed, the Psychiatric consult did not occur until 01/22/2026 at 1553 [43 hours later] due to the consult order being placed on 01/21/2026 and was delayed to the next day. The record indicated the medication orders were also delayed until 01/20/2026 at 1846. The review revealed Patient #13, was not documented on by an ED Provider for the entire 24 hours of 01/21/2026. The ED Documentation Note on 01/20/2026 was inaccurate and closed by ED MD #5 on 01/20/2026 at 1925. Interview on 01/23/2026 at 1510 with the Director of Health Information Management revealed ’ ...when a provider starts a note, they can go to save status. It will stay preliminary, and they can leave it open for their entire shift, until they are ready to sign it. Physicians use a ‘power mike’, to dictate directly to [named] electronic medical record system. It’s the provider’s responsibility to check what they are dictating. That’s the patient’s medical record. The patient has a right to a copy and can file an amendment request if they feel something is inaccurate. Medical records are reviewed daily for key components, and emails are sent daily to providers if corrections are indicated. ...I review all of this in orientation with providers. ...” The interview revealed it’s the provider’s responsibility to ensure a complete and accurate record before they sign a dictated note. Interview on 01/23/2026 at 1150 with the CEO and CMO after review of the ED Documentation Note dated 01/20/2026 revealed “ ...[CEO] Often a psychiatric consult can be completed once the patient arrives to the psychiatric campus [named]. Our ED Director does do periodic chart reviews with any complaints or concerns. ..” [CMO] revealed “ I do chart review, and peer reviews, and forward any concerns to the ED Medical Director for review ...” The interview revealed it’s the provider responsibility to ensure the note was accurate before signing off.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 41946 Based on observation, policy review, medical record review, hospital document review, and staff interviews, the hospital failed to maintain infection control practices to prevent and control transmission of a communicable respiratory illness in the emergency department in 1 of 1 COVID positive medical records reviewed. (Patient #13). The findings included: Observation on 01/22/2026 at 1005 during tour of the emergency department [ED] revealed an badge access closed area, referred to as “stay bed” with 3 patient rooms, and an enclosed staff observation room with hallway access via partial glassed double doors facing the nurse’s desk, and a side door access into the staff observation room from the adjacent hallway [two access points]. When I approached the double door, the Interim ED Manager, ED RN #1 instructed me not to enter “due to a patient with Covid.” Observation revealed a female staff with a surgical mask donned on the inside hallway with 3 opened doors, and two closed doors. It was described as 3 doors on the right, two patient rooms [open], and a bathroom door [closed]. The adjacent side had two rooms, a patient room[open], and an observation office door [closed]. The observation failed to reveal any isolation signage on the outside of the area, nor the inside of the area from that view. The observation revealed the same masked ED Staff #2 exiting the side door from the observation room, into the hallway, to hand a portable telephone to an ED Staff #3 member in the hallway, stationed outside of a patient room with an adolescent male patient .. “the family would like an update.” The observation revealed ED Staff #2 had a yellow surgical mask covering her mouth and not covering her nose. The observation continued as we entered the closed staff observation area, where there was a camera monitor screen divided into separate screens of patient rooms. The camera monitor showed one male patient [Patient #13] in room #3 who was laying on a bed, with a mask on, on his left side facing an open door to the hallway. ED Staff #2 was present, with a clipboard, exhibiting 4 checks an hour for Patient #13. The observation failed to reveal an isolation cart, inside the patient area, and failed to reveal any protective eyewear, isolation gowns, PPE, or N-95 masks available. The observation failed to reveal any isolation signage inside or outside the patient care areas from the staff observation room. The observation failed to reveal proper PPE available or being utilized by staff. Review of the policy titled, Isolation Precautions (Standard Precautions and Transmission-Based Precautions), lasted approved 04/2024 revealed “ ...Purpose: ...2. To prevent exposure of patients, visitors, and healthcare workers to communicable or infectious diseases. Responsibilities: 1. The physician, Infection Control Preventionist [ICP] or designee, charge nurse [CN] or registered nurse [RN] caring for the patient is responsible for promptly identifying the correct category of isolation precaution according to policy, and for informing the patient. 2. The physician, Infection Control Preventionist, designee, charge nurse, or registered nurse caring for the patient will place appropriate isolation order in the EMR [electronic medical record], if not auto generated by EMR system. ...4. The charge nurse is responsible for ensuring that isolation precautions are initiated and maintained according to policy. The charge nurse is also responsible for contacting infection control department personnel regarding any questions or problems concerning the isolation of a patient. ...Special Droplet-Contact Precautions Policy: ...use of a combination of Special Droplet & Contact Precautions (to include a NIOSH approved N-95 Mask (that has been fit tested to the wearer) ..., gown, gloves and Eye protection, for patients known or suspected to be infected with a highly communicable respiratory disease (i.e. SARS-CoV2). Procedure: 1. Place patient in a private room with door closed (if safe to do so). A special Airborne-Contact Isolation Precaution sign is to be placed on the door in clear view. ... 6. Wear designated personal protective equipment when entering patient room. 1. NIOSH approved N-95 mask ...2. Gown 3. Gloves 4. Eye Protection. ... 7. ...Above neck PPE (eye protection and respiratory protection) should be removed outside the room or immediately after exiting and discarded in trash ...” Open medical record review on 01/22/2026 revealed Patient #13, a 47-year-old male patient who arrived to the ED on 01/20/2026 at 1419 with a qualified professional from a facility with a complaint of not eating, weight loss, not taking medications, and altered behavior for one week. The triage began at 1434, and revealed Patient #13 reported suicidal ideation [SI], without a plan, and was given an emergency severity index score of 2-emergent by the ED RN #4. At 1439, Suicide Precautions were ordered with a sitter, by ED MD #5. At 1445, a Covid test was ordered by ED MD #5. Also at 1445, a system generated order populated for Isolation Precautions; with Special Droplet and Contact Precautions with eye protection. At 1448, Patient #13 was roomed to an ED ‘stay bed’ area, room 3. At 1511, ED MD #5 completed the medical screening exam. At 1619 on 01/20/2026 the Covid test resulted positive. Review of the ED Physician Note dated 1/20/2026 at 1511 through 1925 by ED MD #5 revealed “ ...History of Present Illness: ...He does have Covid and we will require a 10-day quarantine in the ER [emergency room] prior to transport to [named] campus per mental health liaison. ...” Patient #13 was a current ED patient on quarantine with known Covid, awaiting transfer to the inpatient psychiatric unit once medically cleared. In summary, special droplet isolation/contact precautions were ordered on 01/20/2026 at 1445. During tour of the ED on 01/22/2026 at 1005, [43 hours later] no isolation signage was observed for Patient #13. Further observation revealed proper PPE and eye protection was not being implemented to protect patients or staff to prevent the spread of Covid. Review on 01/22/2026 of the Hospital Document titled, [named] Emergency Department Staffing Form revealed that on 01/20/2026 0700-1900, the ED CN #6, and Mental Health Liaison RN, MHRN #7 were both assigned to Patient #13. On 01/20/2026 1900 to 0700, the ED RN #8, was assigned to Patient #13. On 01/21/2026 0700 - 1900, the ED CN #7, and MHRN #7 were both assigned to Patient #13. On 01/21/2026 1900-0700, the ED RN #8 was assigned to Patient #13. Interview requested on 01/23/2026 for ED RN #8 revealed they were unavailable for interview. Interview on 01/22/2026 at 1020 with ED CN #6, who was the current Charge Nurse and assigned to Patient #13 during tour and interview, revealed “ ...a patient with isolation, would have a sign on the door, and isolation cart nearby. There’s not one back there. The patient’s chart will display any isolation precautions. A Covid test was done prior to inpatient admission; it’s part of their workup. Isolation would be communicated during report for nurses, and sitters to relay the isolation precautions ordered ...This patient has been alone in a closed area. No other admission has been placed in that area. It’s a closed space. There’s been no other patients exposed. ...” The interview revealed the reason isolation signage had not been placed for Patient #13 as ordered on 01/20/2026, two days prior, was because he was in a closed space, with no other patients exposed to Covid. The interview revealed the isolation policy for special droplet/contact precautions had not been followed for Patient #13. Telephone interview on 01/22/2026 at 1036 with MHRN #7 revealed “... I am not assigned to a patient in the ED; I am not their nurse. ..being a primary nurse is not part of my job description ...Staff have been masking with this patient. ..” The interview revealed the MHRN #7 assisted with psychiatric patient needs, and medical needs would be taken care of by the primary assigned ED nurse. Interview on 01/22/2026 at 1030 with ED Manager, ED RN #1, who reviewed Patient #13’s medical record and isolation orders while on tour in the ED revealed “Signage and isolation cart will be here in minutes ...as for the assignment, the charge nurse is responsible for psychiatric patients in the ED. The Liaison completes an assessment and communicated to the psych provider. Both RNs are involved in care. ...N-95 mask, and protective eyewear should be worn for this patient. ..” The interview revealed isolation signage, and ordered precautions would be completed immediately. Interview on 01/22/2026 at 1030 with ED Staff #2, revealed they had been employed for 9 years as a sitter/certified nursing assistant. The interview revealed “...I asked the patient to mask when I arrived to the unit. ...I don’t have eye protection; I think they are bringing me some. I have had several interactions with the patient so far today, he was walking in the hallway [outside his room] earlier today. I have not worn a gown, gloves or N-95 mask. ...” The interview revealed Patient #13’s door had not been closed, and no isolation signage was inside the patient area. The interview revealed there was not a designated isolation cart for Patient #13. The interview revealed the isolation policy for special droplet/contact precautions had not been followed for Patient #13. Interview on 01/22/2026 at 1140 with the Infection Control Preventionist [ICP] #9 revealed she was made aware yesterday (January 21,2026) of the COVID positive patient in the ED area. Interview revealed no rounds were made today on Patient #13. Interview revealed a COVID positive patient should have available PPE, sign on the door indicating special airborne/contact isolation, and staff should receive information regarding isolation during hand off/shift change. Interview revealed masks should be worn covering the nose and the mouth. Interview on 01/23/2026 at 1715 with the Chief Nursing Officer, CNO #10 revealed “...the expectation was for nursing staff to follow isolation orders, and report any outliers to the infection control nurse, and/or ED Manager to be corrected. ..””

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 41946 Based on facility Bylaw and Regulation review, medical record review, physician schedule review, consult report review, physician and staff interview, the facility failed to coordinate a psychiatric consult for a suicidal patient within 24 hours of consult ordered and failed to provide medical services for a patient in the emergency department on 01/21/2026 for 1 of 10 medical records reviewed. [Patient #13] The findings included: Review of the Bylaws and Regulations, last approved 03/20/2025 revealed “ ...Article III - Medical Staff Membership ...3.4 History and Physical Examination ...Similarly, on call physicians have the responsibility of performing a consult (or having a partner perform a consult) within 24 hours. ...” Open medical record review on 01/22/2026 revealed Patient #13, a 47-year-old male patient who arrived to the ED on 01/20/2026 at 1419 with a qualified professional from a facility with a complaint of not eating, weight loss, not taking medications, and altered behavior for one week. The triage began at 1434, and revealed Patient #13 reported suicidal ideation [SI] , without a plan, and was given an emergency severity index score of 2-emergent by the ED RN #4. At 1439, Suicide Precautions were ordered with 4 times an hour rounding, by ED MD #5. At 1445, a Covid test was ordered by ED MD #5. At 1448, Patient #13 was roomed to an ED ‘stay bed’ area, room 3. At 1511, ED MD #5 completed the medical screening exam, which included a chronic history of schizophrenia [a serious mental health condition that affects how a person thinks, feels, and behaves, often causing a loss of touch with reality]. Review of the Emergency Documentation Note by ED MD #5 dated for 01/20/2026 at 1511 revealed “ ...History of Present Illness ... Patient presents to the ER with concerns for psychiatric evaluation. Upon arrival, vital signs reassuring, patient well-appearing. He was calm and cooperative in the ER. Medically cleared and evaluated by psychiatric team, accepted for inpatient management. He does have COVID [communicable respiratory illness], and we will require a 10-day quarantine in the ER prior to transport to [named] campus per mental health liaison. He is voluntary ....” On 01/20/2026 at 1846, telephone orders were received from ED MD #5 to Mental Health RN [MHRN] #7 for scheduled medications. Review failed to reveal a psychiatric consult ordered was placed on 01/20/2026. Next morning, 01/21/2026 at 0655, ED MD #11 “..consult to psychiatry ...consult reason: SI ...Diagnoses Covid-19 [communicable respiratory illness] ... .” Review of the medical record failed to reveal an ED MD Progress Note for Patient #13 occurred on 01/21/2026 [24 hours]. The next day, a second psychiatric consult was requested on 01/22/2026 at 1446 by RN #13. Review revealed a Consult Note, dated for 01/22/2026 at 1553 by Psychiatric MD #12 “ ...Assessment/Plan: 1. Acute exacerbation of chronic schizophrenia, 2. suicidal ideation, 3. COVID-19. .. The patient is actively psychotic at this time. He has been responding to internal stimuli. He has been experiencing thought blocking. He is unable to take care of himself at this time. I would recommend inpatient psychiatric treatment after medical stabilization. ..” Patient #13 was a current ED patient on quarantine with known Covid, awaiting transfer to the inpatient psychiatric campus once medically stable. In summary, Patient #13, had a psychiatric consult placed on 01/21/2026 at 0655. A second psychiatric consult was placed on 01/22/2026 at 1446. The Psychiatric Consult occurred on 01/22/2026 at 1553. [32 hours later]. Review of the record failed to reveal Patient #13, was assessed by a physician from 01/20/2026 at 1925 through 01/22/2026 at 1553 while in the ED. [43 hours]. Review of the Emergency Department Physician Schedule for January 2026 revealed on 01/21/2026 from 0700-1600 ED MD #14, 1400-2300 ED MD #15, and 2100-0700 ED MD #11. Review of the Physician Schedule for Psychiatric ER Call for [named] Campus for January 2026 revealed on 01/20/2026 0700 - 0700 [24 hrs.] was Psych MD #16, and 01/21/2026 0700 - 0700 [24 hrs.] was Psych MD #17. Review of the Psych Consults Report completed 01/21/2026 at 0645 [before consult was placed for Patient #13] failed to reveal Patient #13. Review of the Psych Consult Report completed on 01/22/2026 at 0645 revealed for time frame: 01/19/2026 at 1417 through 01/21/2026 at 0655 revealed 4 patients consulted to Psychiatry. On line 3 revealed “ ...[Named Patient #13], ...consult to psychiatry by [ED MD #11] on 01/21/2026 at 0655. Reason for Visit: PSYCH EVAL.” In summary, a daily report was run for psychiatric consults at 0645. Patient #13’s consult was placed 10 minutes after daily consult report was collected on 01/21/2026. Request to interview ED MD #14 revealed they were unavailable for interview. Interview on 01/22/2026 at 1440 with ED MD #5 revealed once the psychiatry consult was made “ ...the attending record becomes psychiatry at that point ...” The interview revealed the ED Provider does not normally round on patients boarding in the ED, if they have a consulting provider. Interview on 01/22/2026 at 1445 with the ED Medical Director revealed “ ...we are always happy to provide service. If a change in condition we are there. There were 2 PRN [as needed] providers scheduled that day. It may have been missed ...” The interview revealed the 0700-1600 shift and 1400-2300 shift on 01/21/2026 were part-time physicians who work once a month in the ED providing coverage. The interview revealed every boarding patient in the ED would see a physician once daily. Interview on 01/22/2026 with a Quality Director revealed “ ...the consult was entered after the previous days report was sent out. Reports only come out once every 24 hours at 0645 daily. The Liaison did not see the consult due to not being on the consult sheet. ...Documented counseling will occur with the Liaison to educate on documentation requirements. ...” Interview on 01/23/2026 at 1135 with the Chief Medical Officer, who has oversight of Psychiatric Medical Staff revealed “ ...The behavioral health intake gets a report for consults at 0645. The patient’s consult was placed at 0655 so the patient was not listed. ..On 01/21 the day provider was [named ED MD #14], there was a process breakdown. A Progress Note was required every 24 hours, [named ED MD #5] did not close her note until 1700, so a Progress Note should have been documented by the next day, same time. The ED physicians give verbal report for handoff. There’s a tracking board also, with all ED patients listed. This was not following the usual process. The day ED Provider should see all behavioral health patients daily pending consult. There was not a MD Note on 01/21/2026 confirmed. ...We can strengthen our report ...” NC00234471; NC00234358; NC00234331; NC00229781; NC00228204; NC226558; NC00224557; and NC00235507”

“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: 33790 Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings included: The hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital’s Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 2 of 26 sampled emergency department patients (Patients #3, #4). ~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - 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: 33790 Based on policy reviews, medical record reviews, police report, and interviews, the hospital failed to ensure an appropriate medical screening examination was provided within the capability of the hospital’s Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 2 of 26 sampled emergency department patients (Patients #3, #4). The findings included: Review of the policy titled “...EMTALA - Medical Screening and Treatment of Emergency Medical Conditions”, effective 01/2024, revealed “PURPOSE: To ensure that individuals coming to an affiliated hospital’s Dedicated Emergency Department seeking assessment and treatment for a medical condition, or coming to Hospital Property requesting....treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required.... Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor. Such screening must be done within the facility’s capability and available personnel, including on-call physicians. ...” 1. Review of “Emergency Documentation” by an ED Provider (NP#1), dated 05/31/2024 at 2029, revealed Patient #3 had “...History of Present Illness 63-year-old.... with past medical history of coronary disease (disease of the heart’s major blood vessels), pacemaker (implantable device to help regulate the heart’s rhythm), congestive heart failure (chronic condition where the heart does not pump blood like it should), hypertension (high blood pressure).... Patient was brought in by EMS (Emergency Medical Services) for intoxication complaint of chest pain. Had 12 lead EKG per EMS showed no signs of STEMI (ST segment elevation myocardial infarction- serious heart attack). Patient was placed in waiting room. I was standing in the hallway doing him (sic) SCDs and he walked back into the ED department and walked proximally 50 ft without any difficulty and then laid down on the floor yelling that he was having chest pain and he needed to be seen immediately. Patient was offered wheelchair he was asked repeatedly to get up into the wheelchair so I can take him to triage and check his EKG and start lab work on him he states he refused that he was not going back out to the waiting room. I tried informed (sic) that he was taking him to triage so he could be evaluated and get his EKG and get his workup started patient keeps screaming that he was having chest pain and he needed a room immediately. He repeatedly refused to get up off the floor and get into the wheelchair he refused to let us assist him into the wheelchair. When myself and where the nurses attempted to pick him up off the floor and put him in the wheelchair he started to get aggressive and threatened as in informed this (sic) to take his hands off of him. He was asked numerous times to get in the wheelchair and then we can get him treatment but want to lay on the floor could not treat him. He refused to get up off the floor laid on the floor. (City name) police department was called and patient was taken away in handcuffs by the police. Again he repeatedly refused to get up off the floor and get into the wheelchair so he could receive treatment he was in no apparent distress. ...” The provider note further revealed “...Assessment/ Plan 1. Left against medical advice.” Review of an ED Nursing Note, dated 05/31/2024 at 2037, revealed “...Patient continued to refuse assistance. Patient given AMA (against medical advice) paperwork; patient refused to sign. (City) PD notified that patient was uncooperative and refusing to participate in care. Patient escorted off of hospital property in custody of .... PD. An “Addendum” to the Emergency Documentation provider note was made 06/03/2024 at 0520 which noted “...Patient was able to tell me his name, where he was and why he was at hospital. He again repeatedly refused to get up of the floor and refused assistance into wheelchair or to let us do any assessment on him. He was told I would take him to stretcher in Triage but was told repeatedly that I did not have a room with stretcher available at the time and he needed to be triaged. He again repeatedly refused to get off hte (sic) floor or let us start any kind of assessment on him. he was told that by refusing to be assessed or let us move him off the floor that he was refusing treatment and ....PD would be called to get him off the floor. He told us to go ahead and call them.” Review of a security report, dated 05/31/2024 at 2049, revealed “...Called to triage... to watch patient (Pt #3) throw a temper tantrum on the floor. He would not comply with doctor’s orders. Charge nurse.... called police to have patient removed. Police arrived and took patient away. ...” Review of a police report, “INCIDENT/INVESTIGATION REPORT” dated 05/31/2024 revealed “Suspect Actions/ TRESPASS...” The Narrative noted “SUBJECT TRESPASSED” and “SUBJECT WAS ARRESTED WITHOUT INCIDENT.” Review of the Hospital B medical record, on 01/16/2025, revealed an ED Triage Assessment on 05/31/2024 at 2249 that documented a stated complaint of chest pain times 3 days. Review of the Emergency Department Provider Note at 2355 revealed “... presents with chest pain for 3 days. He was seen at (Hospital A) immediately prior to being seen here.... Medical Decision Making....The patient does appear to have acute coronary syndrome in the context of his positive troponin (lab test).... I am concerned he is having NSTEMI with this positive troponin and his chest pain.... he does not meet.... criteria for STEMI.... He does have critically low potassium and required both IV and oral potassium.... Patient admitted. ...” Review revealed Patient #3 was discharged home on 06/06/2024. Interview with a Nurse Practitioner (NP #1), on 01/07/2025 at 1700, revealed when Pt #3 arrived to the DED it was a “very busy night.” There were multiple patients in the department, including the waiting room. EMS had reported the EKG on Patient (Pt) #3 did not show a STEMI so the patient was placed in the waiting room and would have been the next back to be seen. All the treatment rooms were full, per interview, and the patient was to go to triage to assess vital signs and get another EKG. Interview revealed there was a locked door between the waiting room and the ED treatment area. Pt #3 followed someone through the doors, then laid down on the floor and refused to get up. NP #1 stated Pt #3 screamed that he needed to be seen immediately but would not get off the floor into the wheelchair to be evaluated. Interview revealed NP #1 talked with the patient, told him there were no rooms/stretchers available in the “back” and they would get care started in triage. Pt #3, per interview, had an extensive cardiac history and the workup needed to be started, which would have begun during triage but the patient would not let staff touch him and was extremely disruptive. They tried to help the patient off the floor but he screamed not to touch him and physically stopped them from helping him up or touching him. Interview revealed the police was called due to Pt #3’s behaviors, which included screaming, refusing to be touched or assisted up and threatening, disruptive behaviors. Interview with RN #4, on 01/09/2025 at 0840, revealed the RN was the triage nurse when Patient #3 arrived. RN #4 stated EMS put Pt #3 in a wheelchair in the waiting area near triage. RN #4 was in process of triaging another patient when Pt #3 arrived, the RN stated, and Pt #3 was told by EMS that triage would get to him in a minute. The patient, per interview, demanded a bed but there were no beds available at the time. RN #4 stated Pt #3 ran through the ED door from the lobby waiting area into the ED, yelling “I’m in pain...stuck me in waiting room....need help... .” Interview revealed Patient #3 laid in the floor, would not get up and started acting like a “lunatic”. Interview revealed it was a “massive scene.” RN #4 stated the patient would not get up and then started refusing care. RN #4 stated when staff tried to help lift him off the floor, the patient started swatting at people, refused to be touched or moved and began demanding another hospital. Interview revealed security was involved, then the local police were called and the patient “...was arrested, it became a police issue” and Patient #3 was handcuffed and taken away. In summary, Pt #3 arrived to the hospital complaining of chest pain. There were no beds available and the patient was placed in a wheelchair in the waiting room. Pt #3 got out of the wheelchair, entered the ED treatment area, laid down on the floor and refused to get up, screaming and demanding immediate bedding in the ED. Staff attempted to talk with the patient, but the patient continued to disrupt the department. Security and police were called. Per security and police documents, police was called to have the patient removed. No medical screening was performed. EMS was called later that night from the police department and the patient was transported to Hospital B and admitted. 50403 2. Medical record review on 01/08/2025 for Pt #4 revealed the 41-year-old presented to the DED on 05/05/2024 at 1218 with complaints of “feeling suicidal like jumping in front of car”. Review of the Past Medical History (PMH) revealed ...” Schizoaffective behavior (chronic mental health disorder), history of substance abuse, Hepatitis C (an infection caused by a virus that attacks the liver), Seizures ...” Suicidal precautions were initiated. Labs were ordered for medical screening, but the phlebotomist was unable to draw the labs due to “patient refusal”. Record review revealed Pt #4 became belligerent with medical staff and stated, “don’t want to go to (name of Hospital A Campus 2). Review revealed a drug screen, COVID, RSV, and Flu swabs were able to be completed, and the results were negative. Pt #4 was discharged home to follow up with behavioral health within 1 week or sooner. Medical record review failed to reveal the stability of the patient. Pt #4 was discharged at 1320 (62 minutes after arrival to the ED). Further review of the medical record failed to reveal evidence of a safety contract, any documentation of a Psychiatric Nurse Liaison note or a Psychiatrist consult completed for Pt #4. Interview on 01/09/2025 at 0838 with RN #2 revealed RN #2 did not recall Pt #4. The interview revealed the RN was doing triage the day Pt #4 came into the ED. Interview revealed RN #2 reviewed the record and based on the record a suicide screening was done and Pt #4 would have been “high risk” due to the thoughts and plan regarding suicide. RN #2 indicated the patient would then have changed into paper scrubs to ensure safety and security called to escort the patient back to a dedicated place in the ED for behavioral patients who are being held for disposition. The interview revealed RN #2 would have expected Pt #4 to be admitted based on the “high risk” screening result. Telephone interview on 01/09/2025 at 0910 with RN #3 (a Psychiatric Nurse Liaison) revealed RN #3 remembered Pt #4. Interview revealed RN#3 was on shift the day Pt #4 came in. “Pt#4 came in here a lot and had been admitted numerous times before”. The interview revealed the RN #3 saw Pt #4 on the day in question and discharged the patient. RN #3 indicated that if there was not a note then “that was on me- my fault that I didn’t remember to document a note”. The interview revealed that normally Psychiatrists would clear the patients. The interview revealed a referral was not made to the psychiatrist for this visit. Safety contracts were made on all patients not being admitted and they were supposed to be scanned into the medical record. The interview revealed a safety contract would have been done by this RN and the RN remembered one. RN #3 indicated a safety contract had been made but the nurse could not explain why it wasn’t in the medical record. Further interview revealed Pt #4 was a current patient at Campus B at the time of the interview. Request to interview the Emergency Department Physician who saw Pt #4 revealed the MD was unavailable for interview.”