Medina Memorial Hospital

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 42611 Based on document review, observation and interview, the facility is not in compliance with applicable federal laws. Specifically, for 23 of 23 medical records reviewed the “Patients’ Bill of Rights” provided to patients and the “Patients’ Bill of Rights” posted in the Emergency Department (ED) were not the current version. Findings include: Observation on 02/04/25 at 11:00 AM in the Emergency Department revealed the posted “Patients’ Bill of Rights” for individuals receiving care was dated February 2016. This was not the current version of February 2019. Review on 02/04/25 of the policy titled “Patient’s Rights”, dated March 2024, revealed the facility’s commitment to protecting and promoting each patient/resident rights. This will be done in all its levels of care (inpatient, emergency services, and outpatient settings). These rights are outlined in both 405.7 NYS [New York State] Minimum Standards and 482.13 HCFA [Health Care Financing Administration] Condition of Participation. A copy of the 405.7 NYS Patient Rights will be provided to all patients/residents and will be posted throughout the system. A copy of the Patient’s Bill of Rights will be given to the patient or representative on admission by the patient registration staff. This is in the Patient Information Booklet. The signature acknowledging the receipt of this document will be obtained by the patient registration and placed on the medical record. Copies of the Patient’s Bill of Rights (Attachment A) will be provided to each Emergency Department patient, or person coming for outpatient services. Review of Attachment (A): “Patients’ Bill of Rights in a Hospital” is dated February 2019. Review on 02/05/25 of the facility document titled “Your Rights as a Hospital Patient In New York State [NYS]”, last revised December 2016, included the February 2016 “Patients’ Bill of Rights”, from Public Health Law (PHL) Section 2803(1)(g) Patient Rights, 10NYCRR. 405.7 (a)(1), 405.7 (c). This document is presented to patients receiving care. Review on 02/05/25 of 23 out of 23 medical records revealed the “Patients’ Bill of Rights” provided to patients in the admissions packet were dated February 2016. This was not the current version of February 2019. Interview on 02/04/25 at 04:25 PM with Staff (A), Risk revealed verified the findings.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48608 Based on policy review, document review, and interview, the hospital failed to follow manufacturer’s instructions for use for patient care supplies. Specifically, a single use disposable piece of equipment was sterilized and reused and a detergent used for the decontamination process of soiled surgical instruments was not measured to ensure the proper amount of detergent was adequate for amount of water used. Findings include: Findings #1: Review on 02/06/25 of the “Sterilization Policy for Sterile Processing Department,” last reviewed November 2024, revealed for cleaning and decontamination; all instruments must be manually or mechanically cleaned with approved detergents and by use of enzymatic cleaners (detergents to break down proteins) to remove organic debris. Review on 02/06/25 of the “EmPower Technical Bulletin” (enzymatic detergent instructions for use) revealed the recommended application for instrument reprocessing, presoak, manual cleaning, ultrasonic cleaner, dental evacuation system cleaner and automatic washers is one ounce of detergent per one gallon of water. Observation and interview on 02/05/25 at 01:00 PM Staff (KK), Sterile Processing Technician poured an unmeasured amount of EmPower enzymatic detergent into an unmarked sink basin located next to a sink basin with a labeled fill-line, with an unmeasured amount of water for the decontamination process of soiled surgical instruments. Staff (KK) stated they were unaware of the detergent to water ratio necessary for the decontamination process of soiled instruments. Finding #2: Review on 02/06/25 of the “Welch Allyn Kleenspec” disposable otoscope speculum covers, product #52134, instructions for use indicated the product is to be used once and discarded. Observation and interview on 02/05/25 at 04:15 PM revealed three Welch Allyn Kleenspec disposable otoscope speculum covers floating in a prepared basin of EmPower enzymatic detergent solution located in a procedure room where ear, nose and throat procedures were performed. There were several reprocessed and packaged specula covers located in the office with Staff (JJ), Nurse Practitioner’s name written on the product packages. Staff (JJ) stated the covers are sent to the sterile processing area for reprocessing and was unaware the item was a single use product that should be discarded after use. Interview on 02/06/25 at 09:30 AM with Staff (C), Chief Nursing Officer, verified these findings.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 48506 Based on policy review, medical record review, and interview, the hospital failed to ensure in one of four records reviewed that nursing staff documented the monitoring of restraints. Findings include: Review on 02/06/25 of policy “Patient Restraints,” dated 04/01/19, revealed safety checks and circulation will be monitored and documented at minimum every 15 minutes. Vital Signs will be monitored and documented at minimum every 30 minutes. Review on 02/05/25 of the Emergency Department medical record for Patient #15, dated 08/16/24, revealed at 08:47 PM, Staff (OO), Physician Assistant ordered the application of four-point behavioral restraints. At 08:50 PM, Staff (NN), Registered Nurse, documented police with Patient #15 during triage process. Patient #15 was attempting to get out of bed and fight staff. Patient #15 placed in four-point restraints. At 09:07 PM, Staff (OO) documented Patient #15 was unconsolable, agitated violent behavior requiring restraints for their own safety as well as staff. Medications were administered to attempt to treat Patient #15. At 09:37 PM, Staff (NN), documented restraints removed from Patient #15. There was no documented evidence by nursing staff of safety checks/circulation checks on 8/16/24 at 09:05 PM and 09:20 PM. There was no documented evidence by nursing staff that vital signs were obtained at 09:29 PM. Interview on 02/05/25 at 02:10 PM with Staff (X), Corporate Educator, revealed the “Behavioral Restraint Flow and Monitoring Sheet” every 15-minute nursing documentation was not in the record of Patient #15.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the smoke resistive barriers and one-hour fire resistant barriers are maintained. Findings Include: Observations on 02/04/24 at 11:55 AM in the power room on the ground floor, above the door, revealed two approximately one inch holes with information technology and fire alarm wire penetrating the wall without a smoke resistant system in place to seal around the wires. Interview on 02/04/24 with Staff (Z), Director of Facilities, verified this finding as observed. Observations on 02/05/24 during a tour of the facility with Staff (AA), Maintenance Mechanic, and Staff (BB), Maintenance Helper revealed the following penetrations in the smoke and fire resistant barriers: -At 9:25 AM in the maintenance room, above the door to the boiler room, an approximately ½-inch pipe penetrating the wall without a smoke resistant system in place to seal around the pipe. -At 9:30 AM in the boiler room, above the condensate tank, two approximately 5-inch pipes penetrating the wall without a smoke resistant system in place to seal around the pipes. -At 9:32 AM in the boiler room, above the door to the corridor, an approximately 4-inch by 12-inch hole penetrating the ceiling without a smoke resistant system in place to seal the hole. -At 10:30 AM in the mechanical room on the first floor for air handler number two, above the door, an approximately 12-inch by 12-inch hole for copper pipes penetrating the wall without a smoke resistant system in place to seal around the pipes. -At 10:43 AM in the soiled utility room next to the medical rehab unit, a penetration in the drywalled ceiling which was previously patched with an approximately 24-inch by 36-inch piece of drywall that was sagging and falling away resulting in a penetration without a smoke resistant system in place. -At 11:30 AM in the mechanical room on the second floor, on the east wall, two approximately 2-inch pipes penetrating the wall without a smoke resistant system in place to seal around the pipes. -At 11:50 AM in the mechanical room on the third floor, on the south wall, two approximately 2½-inch steam pipes penetrating the wall without a one hour fire resistant system in place to seal around the pipes. -At 11:55 AM in the mechanical room on the third floor, on the north wall, an approximately 2-inch electrical conduit penetrating the wall without a one hour fire resistant system in place to seal around the conduit. Interview on 02/06/24 at 1:00 PM with Staff (Z), Director of Facilities, verified these findings.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 42572 Based on observation and staff interview, the facility does not ensure that the smoke barriers 1/2-hour fire resistance rating is maintained. Findings Include: Observations on 02/05/24 during a tour of the facility with Staff (AA), Maintenance Mechanic, and Staff (BB), Maintenance Helper revealed the following penetrations in the smoke barrier walls: -At 9:50 AM in the corridor on the back side of the cafeteria, over the door above the drop ceiling, an approximately 4-inch hole with a paper towel stuffed in it without a ½-hour fire resistant smoke barrier system in place. -At 11:00 AM in the corridor near board room B door, above the drop ceiling, an approximately 1-inch hole with an electrical conduit penetrating the wall without a ½-hour fire resistant smoke barrier system in place. -At 11:05 AM in board room B near the corridor door, above the drop ceiling, an approximately 4-inch by 18-inch hole in the wall without a ½-hour fire resistant smoke barrier system in place. Interview on 02/06/24 at 1:00 PM with Staff (Z), Director of Facilities, verified these findings.”

“COMPLIANCE WITH FED, ST, AND LOCAL LAWS CFR(s): The CAH and its staff are in compliance with applicable Federal, State and local laws and regulations. This Condition is not met as evidenced by: 48506 Based on policy review, medical record review, and interview in one of one medical record reviewed (Patient #1), the hospital failed to follow the guidance of their policies. Specifically, the hospital did not follow policy for obtaining a provider order for suicide risk level and did not include review of suicide precautions every 24 hours. Review on 08/06/24 of policy “Suicide Risk Assessment”, last reviewed March 2016 revealed, “If a patient is deemed by a registered nurse to be an immediate risk to act out on suicidal thoughts and feelings, threatening to kill or harm [themselves], or has made an overt suicide attempt, the registered nurse will initiate 1:1 observation until the physician orders for level of observation are received. In the emergency department, the emergency department physician will be notified of the results of the suicide risk assessment. Specific suicide precautions will be ordered by the physician at [their] discretion. Every 24 hours the physician will be accountable for reviewing suicide precautions. Types of suicide precautions include: “1:1 observation” which requires one staff member to one patient to continuously observe the patient within arm’s length at all times; or “line of sight” which requires the direct view of staff at all times (only in the emergency department and intensive care unit.)” Assessment findings are required to be documented on the observation log every 15 minutes for both types of suicide precautions. “Nursing care for the patient who is considered to have suicidal potential and has been placed on suicide precautions will include: explaining to the patient/family why the precaution is necessary; signage will be placed outside the patient’s room; the patient will be placed in a private room to assure safety; a room search will be performed to ensure a safe room; the patient’s clothing and belongings will be removed from [them]; the patient will be placed in a cloth gown with no drawstrings (snaps only); only paper or plastic dishes/utensils and no knives on the patient’s tray; if a patient who is on suicide precautions attempts to leave the treatment setting call a “doctor gray” to assist in detaining the patient while the attending physician is contacted; and patients on suicide precautions will not be allowed to leave against medical advice. An emergency department patient will be placed in room five, which is considered a “safe room” for suicidal patients. This room is in direct line of sight from the nurse’s station. If the patient requires 1:1 observation, the nursing supervisor or nurse manager will arrange for this. If room five is unavailable 1:1 observation is necessary.” Physician assessment and documentation are as follows: “The attending physician/designee assesses a suicidal patient at least every 24 hours and records in the progress note [their] findings. Suicide level remains in effect until changed or discontinued by the attending physician/designee providing clinical justification for decreasing the level of observation.” Review on 08/06/24 of policy “Sitter Guidelines”, last reviewed 03/26/24 revealed, “a sitter may be used to continuously monitor the patient to prevent the patient from harming [themselves] or others. Sitters must be within arm’s length from the patient. Sitters must be between the patient and the door/exit from the room. Sitters observe the patient and maintain a safe environment. Sitters sit in the patient’s room with an unobstructed view of the patient. If the patient is suicidal/homicidal, the sitter must document every 15 minutes. Review on 08/05/24 of Patient #1 emergency department medical record revealed on 06/08/24 at 04:42 PM, Patient #1 arrived ambulatory to the emergency department with the complaint of “mental issues”. At 04:47 PM, Staff (K), Registered Nurse documented a triage note indicating Patient #1 presented to the emergency department stating that “the spirits are following me and telling me to leave my body”. Patient #1 stated the voices are telling [them] to harm [themselves] or others. At 05:07 PM, Staff (K), Registered Nurse documented a suicide risk assessment as “moderate risk. The charge nurse was notified. Patient #1’s risk level was highly changeable.” At 04:29 PM, Staff (G), Nurse Practitioner documented Patient #1 had been declined by multiple facilities with inpatient psychiatric care. A repeat psychiatric evaluation was requested to reassess if Patient #1 had a drug-induced psychosis. Patient #1 received another dose of Olanzapine (antipsychotic medication that treats mental health conditions) due to hearing more voices with a verbal response to the voices. Staff (T), Local County Licensed Clinical Social Worker, re-evaluated Patient #1 and felt that Patient #1 would benefit from inpatient psychiatric care. (There was no documentation of the continued need for review of suicide precautions.) On 06/10/24 at 02:30 PM, Staff (J), Registered Nurse documented Patient #1 was discharged in police custody. All belongings were taken by Medina Police Department. Medina Police Department stated Patient #1 was transporting to [another hospital]. There was no evidence that a suicide precaution observation level was ordered by a provider. Further, there was no evidence that a physician/designee reviewed suicide precautions on 06/09/24. Interview on 08/06/24 at 03:35 PM with Staff (B), Physician revealed it is a protocol for patients that come in with suicidal ideations to have a sitter, and an order is not required for the placement of the sitter. The sitter sits in the doorway of the room and uses a table for their documentation. Interview on 08/06/24 at 04:09 PM with Staff (A), Risk Manager revealed the “Suicide Risk Assessment” policy is the current policy in use. Medina Memorial Hospital does not provide 1:1 observation, only line of sight observation (within arm’s length at all times) for suicide precautions. A patient care technician is three to four feet from the patient when they sit in the doorway of the room. Medina Memorial Hospital stopped providing 1:1 within arm ’ s length observation when the behavioral health unit closed eight years ago. Medina Memorial Hospital staff are only trained for line-of-sight observations based off of the “Sitter Guidelines Policy.” Interview on 08/06/24 at 04:18 PM with Staff (A), Risk Manager verified these findings.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48506 Based on policy review, document review, medical record review, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). This failure potentially placed all patients at increased risk for adverse outcomes. Findings include: The emergency department physician did not provide an appropriate transfer for one of one patients (A-2409). Cross Reference: 489.24 (e) (1)-(2) Appropriate Transfer”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48506 Based on policy review, medical record review, and interview in one of one (Patient #1) medical records reviewed, it was determined the hospital did not notify the receiving hospital of Patient #1’s transport by the Police Department on a 9.41 (any police officer may take into custody any person who appears to be mentally ill and is conducting themselves in a manner which is likely to result in serious harm to themselves or others to a hospital capable of treating a psychiatric patient) transport and failed to advise law enforcement officers of the medical risks associated with the removal of Patient #1 from the emergency department with a emergency medical condition. Findings include: Review of policy “Patient Transfer and Emergency Medical Treatment & Active Labor Act (EMTALA) Compliance”, last reviewed November 2021, revealed “All patient transfers must be appropriate, as defined by the following requirements: the transferring hospital provides medical treatment within its capacity, the receiving facility has agreed to accept the patient, the transferring hospital sends to the receiving facility all medical records at the time of transfer, and the transfer is affected through qualified personnel and transportation equipment. Review on 08/05/24 of the emergency department medical record for Patient #1 revealed the following: -On 06/08/24 at 04:42 PM, Patient #1 arrived ambulatory to the emergency department with the complaint of “mental issues.” At 04:47 PM, Staff (K), Registered Nurse documented Patient #1 presented stating that “the spirits are following me and telling me to leave my body.” The voices are telling Patient #1 to harm themself or others. Patient has not been on medications for schizophrenia and only smoked marijuana for the symptoms. Patient #1 was cooperative and was seeking help. At 05:45 PM, Staff (F), Physician Assistant documented the voices are getting louder, more demanding, and Patient #1 wants to hurt themself. Patient #1 had no homicidal thoughts or suicidal plan. At 07:40 PM, Staff (S), Local County Mental Health Counselor performed a mental health examination and recommended further assessment with a possible admission to psychiatric care. At 08:14 PM, Staff (F), Physician Assistant documented Patient #1 was medically cleared and was being prepared for a transport to a psychiatric facility for evaluation. -On 06/09/24 at 03:00 PM Staff (T), Local County Licensed Clinical Social Worker performed a mental health evaluation and recommended further evaluation and possible admission for psychiatric care. -On 06/10/24 at 05:44 AM, Staff (J), Registered Nurse spoke with another hospital to transfer Patient #1 and faxed over the medical record. The hospital indicated they did have an open bed if Patient #1 met admission criteria. At 09:40 AM and 12:23 PM, Staff (J), Registered Nurse documented another hospital had not reviewed Patient #1’s medical record. At 01:59 PM, Staff (B), Physician documented Patient #1 became increasingly combative and aggressive, verbally yelling and threatening. Patient #1 exited their room and followed someone out of the emergency department exit door. The police were notified and brought Patient #1 back to the emergency department. A decision was made by the police officer to 9.41 Patient #1 and bring the patient to another hospital for psychiatric care. At 02:30 PM, Staff (J), Registered Nurse documented the police spoke with Staff (B), Physician and indicated Patient #1 was placed on a 9.41 and will be transported to a mental health hospital. Patient #1 was discharged in police custody and transported to a mental health hospital. (There was no documentation found which indicated the police had been advised of the medical risks associated with removing Patient#1 from the emergency department with an emergency medical condition). Interview on 08/05/24 at 10:50 AM with Staff (B), Physician revealed Patient #1 was in the emergency department for two days. Multiple attempts were made to transfer Patient #1 to another facility that had psychiatric care. After a discussion, the police department decided to 9.41 Patient #1 and take them to another hospital with psychiatric care. Staff (B) stated “I did not call the receiving hospital. The emergency department was stressful and busy on 06/10/24. It slipped my mind to call.” Interview on 08/06/2024 at 10:46 AM with Staff (J), Registered Nurse revealed a conversation with the receiving hospital’s emergency department registered nurse took place and report on Patient #1 was given. Staff (J) was unable to recall if they called [another hospital] or if [another hospital] called them. Interview on 08/06/24 at 04:18 PM with Staff (A), Risk Manager verified these findings.”