Memorial Healthcare System, Inc.

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of personnel files and interview, the facility failed to ensure all required staff completed annual mandatory training related to behavioral health for 3 employees of 5 staff members reviewed. The findings include: Review of the facility policy, “Completion of Mandatory Education/In-Service Training,” dated 9/1/2023, revealed “...all employees are required to complete mandatory workplace violence and behavioral health training annually...” Review of 5 personnel files revealed Registered Nurse (RN) #1, RN #2, and Patient Care Technician #1 had not completed the required annual behavioral health training which was due 11/25/2025. During an interview on 2/18/2026 at 1:05 PM, the Director of Nursing (DON) stated a review of employee files was completed to ensure staff had completed deescalation and workplace violence required training. All staff were assigned annual competency training for abuse, workplace violence and deescalation training and must complete the required training as assigned. During an interview on 2/18/2026 at 5:55 PM, the Patient Safety Program Manager of Accreditation and Quality confirmed 3 employees (RN#1, RN #2, and Patient Care Technician #1) had not completed the facility’s required annual mandatory assessment, due by 11/25/2025, for behavioral health.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 49485 Based on review of facility policy, medical record review, facility documentation and interviews, the hospital’s Surgical Services failed to supervise the surgery staff in accordance with fire prevention policies and failed to ensure knowledge of and compliance with the hospital safety policies, which resulted in a fire and harm for 1 patient (Patient#1) of 4 surgical patients with temporal artery biopsies on 9/2/2025. §482.51 Condition of Participation: Surgical Services not met. The hospital failed to provide surgical services in accordance with acceptable standards of practice. Hospital oversight of the surgical services failed to ensure sufficient education and supervision in fire prevention. This failure resulted in the hospital placing a patient (#1) in an Immediate Jeopardy situation, when the patient received burns due to a flash fire during a surgical procedure. The hospital’s non-compliance placed all surgical patients in an Immediate Jeopardy situation which created the need for immediate action. The findings include: Medical record review revealed Patient #1 presented to the facility on 9/2/2025, for an outpatient procedure, a biopsy of her left temporal artery. Medical record review revealed a physician note for Patient #1 dated 9/2/2025, “Received call at 1119 [11:19 AM] from CRNA [certified registered nurse anesthetist] there was a small fire during the temporal artery biopsy. Interview with the Director of Quality Services, on 9/3/2025 at 1:25 PM, revealed the 80-year-old patient (Patient #1) on 9/2/2025, was in surgery to have a biopsy of her left temporal artery. The patient was covered by surgical drapes and the patient was receiving supplemental oxygen by a mask, not by a nasal cannula. The Quality Director shared when the surgeon operated the Bovie (a source of heat) to cauterize bleeding arteries or veins and cut through tissue to expose the surgical site, the Bovie created a flash fire on the left side of (Patient #1’s) neck which caused burns to her neck and left ear. The Director stated the fire was quickly extinguished. The physician/anesthesiologist who supervised the CRNA’s working at (name of hospital) was interviewed on the day after the incident. The physician sent out an email to all the anesthesiologist and the nurse anesthetist about a hospital policy, in place since January 1992, stating supplemental oxygen will be stopped for one minute before and during the use of a Bovie. He stated he was completely unfamiliar with this policy, and he had been working at (name of hospital) for the past five years and indicated no one in the anesthesia group was aware of this policy and a new policy would be forthcoming, “This was an old policy that nobody knew anything about in the anesthesia group.” The physician stated a speculation that the fire was caused by a buildup of supplemental oxygen under the surgical draping, being ignited by the heat source of the Bovie. Refer to A-942 and A-1002.”

“ANESTHESIA SERVICES CFR(s): 482.52 If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. This Condition is not met as evidenced by: 49485 Based on review of facility policy, medical record review, facility documentation and interviews, the hospital’s Anesthesia Services failed to supervise the anesthesia staff in accordance with fire prevention policies and failed to ensure knowledge of and compliance with the hospital safety policies, which resulted in a fire and harm for 1 patient (Patient#1) of 4 surgical patients with temporal artery biopsies on 9/2/2025. §482.52 Condition of Participation: Anesthesia Services not met. The hospital failed to provide anesthesia services in a well organized manner, in accordance with acceptable standards of practice, and under the direction of a qualified physician. Hospital oversight of the anesthesia services failed to ensure sufficient education and supervision in fire prevention. This failure resulted in the hospital placing a patient (#1) in an Immediate Jeopardy situation, when the patient received burns due to a flash fire during a surgical procedure. The hospital’s non-compliance placed all surgical patients in an Immediate Jeopardy situation which created the need for immediate action. The findings include: Medical record review revealed Patient #1 presented to the facility on 9/2/2025, for an outpatient procedure, a biopsy of her left temporal artery. Review revealed the supervising anesthesiologist physician note for Patient #1 dated 9/2/2025, “Received call at 1119 [11:19 AM] from CRNA [certified registered nurse anesthetist] there was a small fire during the temporal artery biopsy. Patient [#1] was on simple face mask and draped, there was an auditory ignition sound, and the field was flooded by the team. Supplemental 02 was immediately ceased. There was two spots, both approximately quarter sized on the left temple and left postauricular [behind the ear] area that had a burn. Patient [#1] had already been transported to phase II (post op) when I was notified. An interview with the Director of Quality Services, on 9/3/2025 at 1:25 PM, revealed the 80-year-old patient (Patient #1) on 9/2/2025, was in surgery to have a biopsy of her left temporal artery. The patient was covered by surgical drapes and the only spot exposed was the left temporal area of her head. The patient was receiving supplemental oxygen by a mask, not by a nasal cannula. Interview continued and the Quality Director shared when the surgeon operated the Bovie (a source of heat) to cauterize bleeding arteries or veins and cut through tissue to expose the surgical site. The Bovie created a flash fire on the left side of (Patient #1’s) neck which caused burns to her neck and left ear. Further interview revealed the patient was not under general anesthesia, but was administered medications to create conscious sedation for the procedure by a CRNA (certified registered nurse anesthetist). An interview with RN B on 9/3/2025 at 1:45 PM, revealed the patient was lying on her back, with her head turned to the right, exposing the left temporal area of her head. RN B shared the patient was covered with surgical draping from head to toe, was under conscious sedation by a CRNA and closely monitored. The patient had a face mask on for receiving oxygen. He stated the CRNA is the person who determines the oxygen flow rate and the type of delivery method, such as a mask or nasal cannula. After the incision was made, the surgeon began to use the Bovie to control bleeding at the surgical site and a fire flash under the surgical drapes happened. RN B, the surgeon, and a medical student were the only 3 people who observed the fire flash. The patient was examined, and the burn site appeared to have a reddened area on her left side of neck and some burned hair under the draping. RN B stated the burned area was approximately 3 cm x 3 cm (centimeters) in diameter. Interview concluded with RN B offering a speculation that because of the way the surgical draping covered the patient’s head and the fact the patient was receiving supplemental oxygen via a mask at a higher flow rate, the oxygen could have pocketed under the surgical drapes. He stated the Bovie heat source could have ignited the oxygen build up under the surgical draping. RN B stated he had done this same exact procedure with the surgeon involved “hundreds of times over the past 15 years” and this was exactly how these procedures were done every time. The interview with CRNA D, on 9/3/2025 at 3:17 PM, revealed he was the nurse anesthetist who administered the anesthesia to Patient #1 on 9/2/2025. Interview revealed he provided Patient #1 with 6 liters of oxygen per minute via a simple mask during her left temporal arterial biopsy. Interview continued and CRNA D stated when the surgeon operated the Bovie, to cauterize some bleeding tissue, a flash fire happened underneath the surgical draping. The fire was not sustained on any material. CRNA D stated the surgical team evaluated the burn site on the left side of the patient’s neck and ear. The CRNA offered the speculation the fire was caused by a buildup of oxygen under the surgical draping and was ignited by the Bovie. An interview with the physician/anesthesiologist (Physician F) on 9/3/2025 at 1:30 PM, confirmed he supervised the CRNA’s working at (Hospital A). Interview revealed on the day after the incident, Physician F sent out an email to all the anesthesiologist and the nurse anesthetist about a hospital policy, in place since January 1992, stating supplemental oxygen will be stopped for one minute before and during the use of a Bovie. Physician F stated he was completely unfamiliar with this policy, and he had been working at (Hospital A) for the past five years. Physician F indicated no one in the anesthesia group was aware of this policy and a new policy would be forthcoming stating, “This was an old policy that nobody knew anything about in the anesthesia group.” Physician F stated a new policy is being developed for oxygen during the use of a Bovie, limiting the oxygen, indicating the percentage of oxygen can be reduced to 30% which is almost consistent with room air, to maintain oxygen saturation of the patient during surgery at appropriate levels. Physician F stated the simple face mask will no longer be used to provide supplemental oxygen, ventilator type masks will be used to prevent any supplemental oxygen from seeping out around a mask. The physician offered the speculation the fire was caused by a buildup of supplemental oxygen under the surgical draping being ignited by the heat source of the Bovie. Refer to A-940 and A-1002.”

“OPERATING ROOM SUPERVISION CFR(s): 482.51(a)(1) The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy. This Standard is not met as evidenced by: 49485 Based on review of facility policy, medical record review, facility documentation and interviews, the hospital failed to supervise the surgery staff in accordance with fire prevention policies and failed to ensure knowledge of and compliance with the hospital safety policies, which resulted in harm for 1 patient (Patient#1) of 4 surgical patients with temporal artery biopsies on 9/2/2025. The findings include: Review of the hospital policy titled, “Fire Prevention Response and Evacuation Plan Operating Room and Procedural Areas,” updated 8/2025, revealed “...Prevent N2O and O2 [nitrous oxide and oxygen]build up under drapes and in oropharynx in head and neck surgery...When possible, anesthesia personnel in conjunction with surgeon will stop supplemental oxygen for 1 minute before and during the use of ESU [electrical surgical unit]...” Medical record review revealed Patient #1 presented to the facility on 9/2/2025, for an outpatient procedure, a biopsy of her left temporal artery. Medical record review revealed a physician note for Patient #1 dated 9/2/2025, “Received call at 1119 [11:19 AM] from CRNA [certified registered nurse anesthetist] there was a small fire during the temporal artery biopsy. Patient [#1] was on simple face mask and draped, there was an auditory ignition sound, and the field was flooded by the team. Supplemental 02 was immediately ceased. There was two spots, both approximately quarter sized on the left temple and left postauricular [behind the ear] area that had a burn. Patient [#1] had already been transported to phase II when I was notified. I went directly to bedside to evaluate the patient, she was in NAO [post op], the burns had been dressed with [name of burn cream]. The patient was awake alert and oriented when I saw her and I indicated that she had two small burns. She had no pain or discomfort. I spoke with [name of surgeon]. He had already talked and notified the husband. I am going to notify our CQI [continuous quality improvement] nurse so she can follow up with the patient. I was told the circulator [surgery circulating nurse] already filed the URIS [name of the state incident reporting system] report.” Review of a facility document, provided by the biomedical department revealed the Bovie (electrical surgical unit), used during Patient #1’s surgery, was inspected by a biomedical technician and he indicated the machine was working properly. Interview with the Director of Quality Services, on 9/3/2025 at 1:25 PM, revealed the 80-year-old patient (Patient #1) on 9/2/2025, was in surgery to have a biopsy of her left temporal artery. The patient was covered by surgical drapes and the only spot exposed was the left temporal area of her head. The patient was receiving supplemental oxygen by a mask, not by a nasal cannula. Interview continued and the Quality Director shared when the surgeon operated the Bovie (a source of heat) to cauterize bleeding arteries or veins and cut through tissue to expose the surgical site, the Bovie created a flash fire on the left side of (Patient #1’s) neck which caused burns to her neck and left ear. The Director stated the fire was quickly extinguished and new surgical draping was applied to maintain a sterile field and the procedure continued. Further interview revealed the patient was not under general anesthesia, but was administered medications to create conscious sedation for the procedure by a CRNA (certified registered nurse anesthetist). After the procedure, the surgeon explained to the family what had happened during the surgery and ordered (name of a burn ointment) to be applied to the burn site and repeated daily. Interview with RN B on 9/3/2025 at 1:45 PM, revealed he had been working as a surgical first assistant at the hospital for the past 15 years and had worked with the surgeon involved in the incident for the same 15 years. Interview revealed (Patent #1) was lying on her back, with her head turned to the right, exposing the left temporal area of her head. RN B shared the patient was covered with surgical draping from head to toe, was under conscious sedation by a CRNA and closely monitored. The patient had a face mask on for receiving oxygen. RN B could not recall the oxygen flow rate, but indicated typically when a mask was used 6 to 10 liters of oxygen per minute was administered. He stated the CRNA is the person who determines the oxygen flow rate and the type of delivery method, such as a mask or nasal cannula. He clearly remembered using (name of a surgical prep) to the surgical site and waiting for 3 minutes after the application to ensure the prep was dry before proceeding with surgery. Interview continued and RN B revealed approximately 12 to 15 minutes after he had prepped the surgical site of (Patient #1’s) left temporal area, (name of surgeon) made the surgical incision and began to operate the Bovie to control bleeding. The Bovie has a very hot tip when operated and was used to control bleeding at the surgical site. RN B revealed before operating, the Bovie must be touching the skin of the patient to ground the device and if the Bovie was operated without touching the skin of the patient, any metal objects in the area can cause an electric arc. After the incision was made, the surgeon began to use the Bovie to control bleeding at the surgical site and a fire flash under the surgical drapes happened. RN B, the surgeon, and a medical student were the only 3 people who observed the fire flash. RN B stated he immediately began padding the area to put the fire out and a surgical technician provided him with surgical wash to rinse the area. The patient was examined, and the burn site appeared to have a reddened area on her left side of neck and some burned hair under the draping. RN B stated the burned area was approximately 3 cm x 3 cm (centimeters) in diameter. Interview concluded with RN B offering the speculation that because of the way the surgical draping covered the patient’s head and the fact the patient was receiving supplemental oxygen via a mask at a higher flow rate, the oxygen could have pocketed under the surgical drapes. He stated the Bovie heat source could have ignited the oxygen build up under the surgical draping. RN B stated he had done this same exact procedure with the surgeon involved “hundreds of times over the past 15 years” and this was exactly how these procedures were done every time. Interview with RN C, Vascular Surgery Manager, on 9/3/2025 at 2:15 PM, revealed he spoke with Patient #1 and the family after the procedure and examined the patient’s burn site on the left side of her neck and ear. RN C stated the burn site was reddened and at that time it was not blistering, but the following day, blisters began to form according to the patient’s spouse. Patient #1 did not recall the incident or the surgical procedure. RN C stated (name of a burn ointment) was applied to the burn site and Patient #1 was provided with the ointment to be used daily. Patient #1, at the time of his speaking with her, did not complain of pain at the burn site. Interview with CRNA D, on 9/3/2025 at 3:17 PM, revealed he was the nurse anesthetist who administered the anesthesia to Patient #1 on 9/2/2025. Interview revealed he provided Patient #1 with 6 liters of oxygen per minute via a simple mask during her left temporal arterial biopsy. Interview continued and CRNA D stated when the surgeon operated the Bovie, to cauterize some bleeding tissue, a flash fire happened underneath the surgical draping. The fire was not sustained on any material and the flash lasted about one second. CRNA D stated the surgical team evaluated the burn site on the left side of the patient’s neck and ear. The surgical team applied irrigation solution to the surgical draping, re-draped the patient to maintain a sterile field and the surgery continued successfully. The CRNA offered the speculation the fire was caused by a buildup of oxygen under the surgical draping and was ignited by the Bovie. Interview with the physician/anesthesiologist (Physician F) on 9/3/2025 at 1:30 PM, confirmed he supervised the CRNA’s working at Hospital A. Interview revealed on the day after the incident, Physician F sent out an email to all the anesthesiologist and the nurse anesthetist about a hospital policy, in place since January 1992, stating supplemental oxygen will be stopped for one minute before and during the use of a Bovie. Interview continued and Physician F stated he was completely unfamiliar with this policy, and he had been working at hospital A for the past five years. Physician F indicated no one in the anesthesia group was aware of this policy and a new policy would be forthcoming staking, “This was an old policy that nobody knew anything about in the anesthesia group.” Physician F stated a new policy is being developed for oxygen during the use of a Bovie, limiting the oxygen, indicating the percentage of oxygen can be reduced to 30% which is almost consistent with room air, to maintain oxygen saturation of the patient during surgery at appropriate levels. Physician F stated the simple face mask will no longer be used to provide supplemental oxygen, ventilator type masks will be used to prevent any supplemental oxygen from seeping out around a mask. The physician stated a speculation that the fire was caused by a buildup of supplemental oxygen under the surgical draping being ignited by the heat source of the Bovie.”

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 49485 Based on review of facility policy, medical record review, facility documentation and interviews, the hospital’s Anesthesia Services failed to supervise the anesthesia staff in accordance with fire prevention policies and failed to ensure knowledge of and compliance with the hospital safety policies, which resulted in a fire and harm for 1 patient (Patient#1) of 4 surgical patients with temporal artery biopsies on 9/2/2025. The findings include: Review of the hospital policy titled, “Fire Prevention Response and Evacuation Plan Operating Room and Procedural Areas,” updated 8/2025, revealed “...Prevent N2O and O2 [nitrous oxide and oxygen]build up under drapes and in oropharynx in head and neck surgery...When possible, anesthesia personnel in conjunction with surgeon will stop supplemental oxygen for 1 minute before and during the use of ESU [electrical surgical unit]...” Medical record review revealed Patient #1 presented to the facility on 9/2/2025, for an outpatient procedure, a biopsy of her left temporal artery. Medical record review revealed the supervising anesthesia physician note for Patient #1 dated 9/2/2025, “Received call at 1119 [11:19 AM] from CRNA [certified register nurse anesthetist] there was a small fire during the temporal artery biopsy. Patient [#1] was on simple face mask and draped, there was an auditory ignition sound, and the field was flooded by the team. Supplemental 02 was immediately ceased. There was two spots, both approximately quarter sized on the left temple and left postauricular [behind the ear] area that had a burn. Patient [#1] had already been transported to phase II (post op) when I was notified. I went directly to bedside to evaluate the patient, she was in NAO [post op], the burns had been dressed with [name of burn cream]. The patient was awake alert and oriented when I saw her and I indicated that she had two small burns. She had no pain or discomfort. I spoke with [name of surgeon]. He had already talked and notified the husband. I am going to notify our CQI [continuous quality improvement] nurse so she can follow up with the patient. I was told the circulator [surgery circulating nurse] already filed the URIS [name of the state incident reporting system] report.” Interview with the Director of Quality Services, on 9/3/2025 at 1:25 PM, revealed the 80-year-old patient (Patient #1) on 9/2/2025, was in surgery to have a biopsy of her left temporal artery. The patient was covered by surgical drapes and the only spot exposed was the left temporal area of her head. The patient was receiving supplemental oxygen by a mask, not by a nasal cannula. Interview continued and the Quality Director shared when the surgeon operated the Bovie, a source of heat, to cauterize bleeding arteries or veins and cut through tissue to expose the surgical site. The Bovie created a flash fire on the left side of (Patient #1’s) neck which caused burns to her neck and left ear. Further interview revealed the patient was not under general anesthesia, but was administered medications to create conscious sedation for the procedure by a CRNA (certified registered nurse anesthetist). Interview with RN B on 9/3/2025 at 1:45 PM, revealed he had been working as a surgical first assistant at the hospital for the past 15 years and had worked with the surgeon involved in the incident for the same 15 years. Interview revealed (Patent #1) was lying on her back, with her head turned to the right, exposing the left temporal area of her head. RN B shared the patient was covered with surgical draping from head to toe, was under conscious sedation by a CRNA and closely monitored. The patient had a face mask on for receiving oxygen. RN B could not recall the oxygen flow rate, but indicated typically when a mask was used 6 to 10 liters of oxygen per minute was administered. He stated the CRNA is the person who determines the oxygen flow rate and the type of delivery method, such as a mask or nasal cannula. The RN stated when the use of the Bovie began, a fire flash under the surgical drapes happened and RN B, the surgeon, and a medical student were the only 3 people who observed the fire flash. RN B stated he immediately began padding the area to put the fire out and a surgical technician provided him with surgical wash to rinse the area. The patient was examined, and the burn site appeared to have a reddened area on her left side of neck and some burned hair under the draping. RN B stated the burned area was approximately 3 cm x 3 cm (centimeters) in diameter. Interview concluded with RN B speculating that because of the way the surgical draping covered the patient’s head and the fact the patient was receiving supplemental oxygen via a mask at a higher flow rate, the oxygen could have pocketed under the surgical drapes. He stated the Bovie heat source could have ignited the oxygen build up under the surgical draping. RN B stated he had done this same exact procedure with the surgeon involved “hundreds of times over the past 15 years” and this was exactly how these procedures were done every time. Interview with RN C, Vascular Surgery Manager, on 9/3/2025 at 2:15 PM, revealed he spoke with the Patient #1 and the family after the procedure and examined the patient’s burn site on the left side of her neck and ear. RN C stated the burn site was reddened and at that time it was not blistering, but the following day, blisters began to form according to the patient’s spouse. Interview with CRNA D, on 9/3/2025 at 3:17 PM, revealed he was the nurse anesthetist who administered the anesthesia to Patient #1 on 9/2/2025. Interview revealed he provided Patient #1 with 6 liters of oxygen per minute via a simple mask during her left temporal arterial biopsy. Interview continued and CRNA D stated when the surgeon operated the Bovie, to cauterize some bleeding tissue, a flash fire happened underneath the surgical draping. The fire was not sustained on any material and the flash lasted about one second. CRNA D stated the surgical team evaluated the burn site on the left side of the patient’s neck and ear. The CRNA offered the speculation the fire was caused by a buildup of oxygen under the surgical draping and was ignited by the Bovie. Interview with the physician/anesthesiologist (Physician F) on 9/3/2025 at 1:30 PM, confirmed he supervised the CRNA’s working at Hospital A. Interview revealed on the day after the incident, Physician F sent out an email to all the anesthesiologist and the nurse anesthetist about a hospital policy, in place since January 1992, stating supplemental oxygen will be stopped for one minute before and during the use of a Bovie. Physician F stated he was completely unfamiliar with this policy, and he had been working at hospital A for the past five years. Physician F indicated no one in the anesthesia group was aware of this policy and a new policy would be forthcoming stating, “This was an old policy that nobody knew anything about in the anesthesia group.” Physician F stated a new policy is being developed for oxygen during the use of a Bovie, limiting the oxygen, indicating the percentage of oxygen can be reduced to 30% which is almost consistent with room air, to maintain oxygen saturation of the patient during surgery at appropriate levels. Physician F stated the simple face mask will no longer be used to provide supplemental oxygen, ventilator type masks will be used to prevent any supplemental oxygen from seeping out around a mask. The physician offered speculation the fire was caused by a buildup of supplemental oxygen under the surgical draping being ignited by the heat source of the Bovie.”

“Construction Type: II (222) Stories: 7 Constructed: 1952 Building Drawings Available: Yes Sprinklered: Yes Licensed Beds: 423 A Life Safety Code Complaint Investigation #TN00076798 was conducted by the State of Tennessee Health Facilities Commission on 09/04/2025. During this life safety survey, Memorial Healthcare Systems Inc. was found not to be in substantial compliance with the requirements for participation in Medicare/Medicaid with Title 42 CFR Subpart 482, Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Life Safety Code Complaint Investigation #TN00076798 conducted on 09/04/2025, no deficiencies were cited under Title 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101, 2012 Edition.”

“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: 51389 Based on review of facility policy, interviews, and medical record review, the facility failed to include one (1) patient (Patient #1) on the Emergency Department (ED) Log, failed to provide an appropriate and ongoing medical screening examination for three (3) patients (Patients #1, #4, and #6), and failed to maintain a timely and complete medical record for 4 patients (Patients #6, #9, #14 and #16) of 21 Emergency Department (ED) patients reviewed. The findings include: Patient #1 entered the ED on 1/18/2025 at 8:32 PM, and walked to the registration desk stating, “I am going to die, and I need to talk to someone.” The staff attempted to get him to register but he would not give his information. He sat in the waiting room and a security officer told him he couldn’t sit there and to come register. The security officer and a Registered Nurse (RN) attempted to get him to register again, and he would not. The staff described him as acting “strange.” He walked out of the ED at 8:38 PM. At approximately 9:10 PM, Patient #1 was found by the police department, sitting on top of a large cross on the side of an office building adjacent to the hospital, hollering for help. Review of the police report indicated Patient #1 felt “no one would help him because he...didn’t want to give his personal information, so he left.” He stated he went to the top of the building so someone would notice him and listen to him. Patient #4 entered the ED on 12/25/2024 at 7:27 PM, via ambulance with complaints of SI (Suicidal Ideations) and loneliness. The Patient was seen earlier on 12/25/24 at 4:30 PM, by Mobile Crisis and involuntary inpatient admission was recommended. The MSE (Medical Screening Examination) was completed at 7:36 PM (9 minutes after arrival). A clinical impression at discharge was “Malingering.” Patient #6 entered the ED on 12/15/2024 at 6:24 AM, with psychosis. She was evaluated by the ED physician and TelePsych and involuntary inpatient admission was recommended. Patient #6 was transferred via ambulance 12/16/2024 at 8:11 AM. Patient #6’s medical record did not have an EMTALA Transfer form present. The CON (Certificate of Need for Involuntary Commitment) was not included in Pt #6’s medical record. Patient #9 arrived to the ED at 11/2/2024 at 8:17 PM with complaints of SI (Suicidal Ideations). Patient #9 had a recent history of his mother passing away and stated he didn’t want to live. Patient #9 was assessed by TelePsych and recommended the patient needed inpatient psychiatric admission. Patient #9 was transferred to a Mental Health facility 11/3/2024 at 8:59 AM via ambulance. The medical record did not have an EMTALA transfer form. Patient #14 arrived to the ED 10/19/2025 at 1:14 PM with Psychosis. The patient arrived with a CON completed by Mobile Crisis. Patient #14 was assessed by TelePsych and it was determined she need inpatient psychiatric admission. Patient #14 was transferred to a Mental Health facility 10/20/2024 at 10:29 AM via ambulance. The medical record did not have an EMTALA transfer form or the CON form. Patient #16 arrived to the ED 9/9/2024 at 8:38 AM with complaints of SI. Medical record review showed showed Patient #16 recently had quit drinking and stated he had been having a lot of anxiety and depressive thoughts and began to have thoughts of driving his car into a tree. Patient #16 was assessed by TelePsych and it was recommended he needed inpatient psychiatric admission. The Patient was transferred to a Mental health facility 9/9/2024 at 3:50 PM via ambulance. The medical record did not have an EMTALA transfer form. Cross Refer to A2403, A2405, and A2406.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 51389 Based on review of facility policy, medical record review, Emergency Department (ED) logs, and interviews, the facility failed to maintain complete medical records related to individuals transferred from the hospital, for a period of 5 years from the date of transfer for four (4) patients (Patients #6, #9, #14, and #16) of 21 Emergency Department records reviewed. The findings include: Review of the facility’s policy, “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines-Treatment and Transfer of Individuals in Need of Emergency Medical Services,” revised 6/2024 showed “...Record Keeping...the hospital, whether transferring or receiving individuals, must maintain for a minimum period of 5 years the following...Medical and other records related to individuals transferred to or from the hospital...” Review of the ED Central Logs showed Patient (Pt) #6 arrived at the ED via personal vehicle 12/15/2024 at 6:24 AM, with complaints of mental health problems. Medical record review of ED Provider Notes dated 12/15/2024 at 7:38 AM, showed Pt #6 had a history of depression and psychosis. Review revealed Pt #6 “thinks there are young boys shooting her with pellet guns and trying to kill her as well as her daughter.” Review revealed an assessment was performed “...the patient is alert and oriented to person, place, and time and has flight of ideas and tangential speech (tendency to speak about topics unrelated to the main topic of discussion).” Medical record review of the Telepsych Notes dated 12/15/2024 at 5:07 PM, showed an evaluation was completed for Pt #6. The recommendation was “...offer voluntary inpatient behavioral health admission but if refused, hospitalize involuntarily...” Medical record review of ED Care Timeline dated 12/15/2024 at 10:51 PM, showed a Behavioral Health facility accepted Pt #6 but “cannot transfer until after 7:00 AM 12/16/2024.” Medical record review of ED Provider Note dated 12/15/2024 at 11:29 PM, for Pt #6 showed “psychiatry recommends admission. CON (certificate of need) placed. “ Medical record review of ED Care Timeline dated 12/16/2024 at 8:11 AM, showed Pt #6 was transferred via ambulance. Review of Pt #6’s medical record showed there was not an EMTALA Transfer form present. Review of the ED Central Logs showed Pt #9 arrived at the ED on 11/2/2024 at 8:17 PM, with complaints of mental health problems. Review of Provider Notes dated 11/2/2024 at 9:20 PM, showed Pt #9 presented to the ED for evaluation of suicidal ideations. The patient’s mother passed away 6 months prior, and he was depressed since that event. Continued review revealed “...the patient does have a history of suicide attempt several years ago when he turned his gas stove on but could not find a lighter in order to blow himself up...he states this time he has been planning an overdose on all of his medications that he has at home.” Review showed Pt #9 was cleared medically for inpatient psychiatric facility. Telepsych was consulted. Review of Progress Notes by Telepsych dated 11/3/2024 at 1:47 AM, showed a CSSRS risk assessment was completed, and he was a moderate risk for suicide. A recommendation was made for inpatient psychiatric hospitalization for safety and management of depression. Review of ED Notes dated 11/3/2024 at 3:28 AM, showed Pt #9 was accepted for transfer to a Behavioral Health facility. Review of the ED Care Timeline dated 11/3/2024 at 9:00 AM, showed Pt #9 was transferred via ambulance. Medical record review of Pt #9’s medical record showed there was not an EMTALA Transfer form present. Review of the ED Central Logs showed Pt #14 arrived at the ED on 10/19/2024 at 1:14 PM, via police department for a psychiatric evaluation. Review of an ED Provider Note dated 10/29/2024 at 1:27 PM, showed Pt #14 arrived at the ED with a CON in place from (proper name) Mental Health Center. Continued review showed “... the patient reportedly made threats of sexual violence toward family members, including his mother...[police] called due to the patient attempting to abscond from the scene...” Review of ED Consultation Note with TelePsych dated 10/29/2024 at 9:08 PM, showed Pt #14 was evaluated and “patient currently responding to internal stimuli with ongoing disorganized thought process and behaviors. Patient currently with severe psychiatric impairment and lacks medical decision-making capacity.” Review showed TelePsych recommended the patient be admitted to inpatient behavioral health on an involuntary basis. Review of ED Care Timeline dated 10/29/2024 at 9:56 PM, showed a Behavior Health accepted Pt #14 for transfer. Review of ED Care Timeline dated 10/30/2024 at 10:29 AM, showed Pt #14 was transferred via ambulance. Review of Pt #14’s medical record showed there was not an EMTALA Transfer form present. Review of the ED Central Logs showed Pt #16 arrived at the ED 9/9/2024 at 8:38 AM, with mental health problems. Medical record review of an ED Provider Note dated 9/9/2024 at 9:42 AM, showed Pt #16 had a previous history of Depression and Post-Traumatic Stress Syndrome (PTSD) from military service. Review showed “... he recently quit drinking and states he has been having a lot of anxiety and depressive thoughts...and began to have thoughts of driving his car into a tree.” Medical record review of an ED Consultation Note by Telepsych dated 9/9/2024 at 10:00 AM, showed Pt #16 had “...debilitating substance abuse and long-standing untreated PTSD...Long history of alcoholism...wife and daughters had an intervention recently that was impactful. He suddenly quit all drinking on 9/1/2024 but since then, his flashbacks, nightmares, and other PTSD related symptoms have been nearly constant...the patient stated he’s never wanted to kill himself, but he cannot manage the desire to be dead at this time without additional help. Given patient’s current presentation, a higher level of care is indicated for safety, further evaluation and medication management.” Medical record review of the ED Care Timeline dated 9/9/2024 at 11:42 AM, showed Pt #16’s transfer was accepted at a Behavioral Health facility. Medical record review of the ED Care Timeline dated 9/9/2024 at 3:50 PM, showed Pt #16 was transferred. Review of Pt #16’s medical record showed there was not an EMTALA Transfer form present. During an interview on 1/29/2025 at 1:15 PM, with the Director of ED, she stated it is the expectation that all forms such as EMS (Emergency Medical System) reports, transfer forms, CON (certificate of need) forms, and AMA (against medical advice) forms are scanned into the computer system and become part of the medical record. She reported obtaining EMS reports are sometimes difficult to get from the EMS providers and “this is a problem” they are currently working on with EMS. She revealed “it is sometimes difficult to get staff to remember this because they are piece of paper...they have to remember to have them scanned into the medical record.””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 51389 Based on review of facility policy, Central Logs, hospital video, police report, and interviews, the facility failed to maintain a central log on each person who comes to the Emergency Department (ED) for one (1) patient (Patient #1) out of 21 ED records reviewed. The findings include: Review of the facility’s policy revealed the Central Log as “...the log the hospital is required to maintain...containing information regarding each individual who comes to the emergency department...The Central Log must contain at minimum, the name of the individual seeking assistance whether the individual refused treatment, was refused treatment, was transferred, admitted, and treated, stabilized, and transferred, or discharged.” Review of ED Central Logs showed Patient (Pt) #1 was not registered in the ED. During an interview on 2/4/2025 at 9:30 PM, with RN (Registered Nurse) #1 revealed if a person comes up to the ED desk and states they are suicidal and then try to leave, he is unable to do anything “because that person is not held under a CON [Certificate of Need].” He said they cannot stop the person from leaving. He stated Pt #1 did come to the ED on 1/18/2025. He was the charge nurse that night and was told by RN #2 at the front desk Pt #1 was in the lobby and “wanted help but wouldn’t tell anyone why.” During an interview on 2/4/2025 at 9:50 PM, with SO (Security Officer) A, revealed he was on duty 1/18/2025 and when he came back to the ED desk, after making rounds, was told by RN #2 about a person sitting in the lobby who was asking for help but wouldn’t give his name. He stated Pt #1 said he just “came to the ED to talk to someone...His behavior was strange.” He revealed their policy is people cannot just sit in the ED waiting room unless they are waiting to be seen or a family member. He went over to Pt #1 and told him “You cannot stay here so come up to the desk and let’s get your registered...He got up and walked with me to the desk and he continued to refuse to put his social security number in the box...He kept saying he needed to talk to someone...Pt #1 left after this.” SO A stated before Pt #1 walked out the door, he said “what is the protocol here if I walk out and step in front of a car and get run over?” I told him we were not going to talk about that because you are here now. Review of video of the ED on 2/4/2025 for the date of 1/18/2025, showed Pt #1 entered the ED at 8:32 PM, and walked to the desk. He talked to RN #2. RN #2 did not get up. He started to walk away and stopped and talked further. At 8:36 SO A talks to Pt #1 and motions him to come to the desk. At 8:38 PM Pt #1 turned around and walked out the door. SO A and RN #2 watched Pt #1 walk out. Review of a police report dated 1/18/2025 at 10:59 PM showed Pt #1 would not give his real identity. He stated, “no one wanted to help him because he spoke with the hospital’s staff and did not want to give them his personal information, so he left...he went to the top of the building to get someone to notice him because he felt like no one was listening and he just wanted to speak to someone.” During an interview on 2/5/2025 at 12:30 PM with RN #2, he stated if a patient came to the ED desk saying they were suicidal, he would attempt to get the patient to stay. He would get security or call the police. He said he couldn’t physically hold them, but he would do what he could to prevent them from leaving and get them help. He revealed Pt #1 came in the ED and said “I am going to die, I need to talk to someone.”. He would not give his name or information. RN #2 stated Pt #1 was “acting strange...He was not acting right...He gave the vibe he was on drugs.” RN #2 reported the situation to RN #1, but Pt #1 left before RN #1 was able to come out. During an interview with Director of ED on 2/5/2025 at 1:15 PM, the Director revealed the expectation in the event there is a patient that doesn’t have a name or won’t give a name, and it is obvious they need help, they have a process to register the person as a “John Doe” to get them to the doctor for an MSE. This process allows “eyes on the patient” faster. The staff have been educated about this in the past and that is the expectation. “If a person was to come to the front desk and say they were suicidal, the staff cannot physically stop the person, but they should call security to help protect the patient. They have an escalation process for this. I would also expect the nurse to escalate to this to the charge nurse who then should escalate this to the house supervisor.””

“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: 51389 Based on review of facility policy, medical record review, Emergency Department (ED) Central Logs, hospital video, police report, and interviews, the facility failed to provide an appropriate and ongoing medical screening examination for two (2) patients (Patients #1 and #4) of 21 Emergency Department (ED) patients reviewed. The findings include: Review of the facility’s policy, “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines-Treatment and Transfer of Individuals in Need of Emergency Medical Services,” last revised 6/2024 showed “...the hospital’s EMTALA obligations are triggered when there has been 1) request for examination and/or treatment of a medical condition by an individual...made within a dedicated emergency department (DED)...the hospital will provide to any individual...who comes to the Emergency Department an appropriate Medical Screening Examination (MSE) within the capability of the Hospitals DED, including ancillary services routinely available to the DED, to determine whether or not an EMC (Emergency Medical Condition) exists...If an EMC is determined to exist, the hospital will provide the individual either further medical examination and any necessary stabilizing treatment within its capabilities of the staff and the facilities available at the hospital or will affect an appropriate transfer to another medical facility in accordance with procedures set forth below...The hospital will use the EMTALA transfer form for transfers of inpatients unless otherwise notified...In no event shall the provision of emergency services and care be based upon or affected by an individuals race, ethnicity, religion, national origin, citizenship, age, sex, preexisting medical condition, physical or mental handicap, insurance status, sexual orientation, economic status or ability to pay for medical services, except to the extent that a circumstance such as age, sex, preexisting medical condition, or physical or mental handicap is significant to the provisions of appropriate medical care to the individual...F- ‘Comes to the Emergency Department’ means any of the following regarding an individual who presents to the DED or “comes to the hospital” when such an individual, who is not a patient meets one of the following definitions: 1. Presents to the Hospitals DED and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs examination and/or treatment for a medical condition...Emergency Medical Condition or EMC means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either: a. Placing the health of the individual...in serious jeopardy, or b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part...Medical Screening Examination or MSE means the process required to determine with reasonable clinical confidence whether an EMC does or does not exist...The extent of the necessary examination to determine whether an EMC exists is generally within the judgment and discretion of the physician or other QMP (qualified medical provider) performing the examination consist with algorithms or protocols established and approved by the medical staff and governing board. With respect to an individual manifesting behavioral or psychiatric symptom, the MSE consists of both a medical and behavioral/psychiatric health screening...” Review of facility’s Suicide Risk Assessment and Precautions (Adolescent, Adult, and Pediatric) reviewed 3/2024 showed “...Procedure: a. In any hospital department, if a patient verbalizes suicidal ideation; mentions harming self, states they would be ‘better off dead’ or have ‘nothing to live for’, implement suicide precautions. 1. Do not leave the patient alone. 2. Call department manager or house administrator (off hours)... d. 1. The initial screening of patients in the Emergency Department or inpatient will be completed as part of Triage or Admission Assessments, respectively. h. 1. Notify Tele Psych or Crisis Response Team (CRT) Services of need for evaluation and assistance with placement and transportation arrangements when the patient is medically stable and ready for transfer... i. 4. When a patient is not violent or self-destructive...staff should talk with the patient, inform them of risks of leaving, benefits of staying to receive help. If unsuccessful and the patient insists on leaving, notify the physician and Public Safety of patient leaving AMA. Public Safety will call law enforcement to notify them on the concern for patient safety. Public Safety will complete an occurrence report. Nursing will complete an IRIS [incident report].” Review of the ED Central Logs showed Patient #1 was not registered in the ED. During an interview on 2/4/2025 at 9:30 PM, RN (Registered Nurse) #1, in charge on the evening of 1/18/2025, stated if a person comes up to the registration ED desk and expresses suicidal ideation and then tries to leave, RN #1 is unable to do anything “because the person is not held under a CON [certificate of need].” He confirmed Patient #1 did come to the ED on 1/18/2025. RN #1 stated RN #2, staffing the registration desk, told him Patient #1 was in the lobby and “wanted help but wouldn’t tell anyone why.” He stated RN #2 told him the person looked like he was “tweaking.” RN #1 stated RN #2 told him “Security may need to come ask the person to leave the lobby.” When RN #1 arrived at the registration desk to talk to Patient #1, the patient was gone. RN #1 stated he was told Patient #1 “...walked out of the ED, went behind the hospital, and climbed a building to jump off. “ During an interview on 2/4/2025 at 9:50 PM, with SO (Security officer) A, he confirmed he was on duty 1/18/2025. He stated he came back to the ED desk, after making rounds, and was told by RN #2 about a person sitting in the lobby who was asking for help but wouldn’t give his name. He stated, “he just came to the ED to talk to someone...his behavior was strange...” He stated their policy is people cannot just sit in the ED waiting room unless they are waiting to be seen, or they are a family member. Interview continued and SO A stated he went over to Patient #1 and said, “You cannot stay here so come up to the desk and let’s get you registered...He got up and walked with me to the desk and he continued to refuse to put his social security number in the box. He kept saying he needed to talk to someone.” SO A stated Patient #1 left after this interaction but before he walked out the door he said, “What is the protocol here if I walk out and step in front of a car and get run over?” SO A said he I told him, “We were not going to talk about that because you are here now.” SO A stated “later” someone came into the ED stating someone was yelling for help outside and he went out to investigate, “At first, I didn’t hear anything and the [Police Department] pulled up and said they had a report of someone hollering for help.” SO A stated after this they heard someone hollering help, they went towards the sounds, looked up on the “East Building” and Patient #1 was sitting up on the cross attached to the side of the building. The SO A stated the police department was in charge “because that is not our building” and they were able to get Patient #1 off the building and took him to (another hospital). During an interview on 2/4/2025 at 10:15 PM, SO B stated he was the security supervisor on duty 1/18/2025. He stated SO A told him someone was on top of the cross and he witnessed Patient #1 on the building. He stated they did not do any kind of an incident report because this was “not their property.” Review on 2/4/2025 at 11:00 PM, of the ED video dated 1/18/2025, showed the following: 8:32 PM- Pt (patient) #1 entered the ED and walked to the desk. He talked to RN #2. RN #2 does not get up. He started to walk away and stopped and talked further. RN #2 picked up the phone. 8:33 PM- Pt #1 turned around and sat in a chair. He immediately put his hands up to his head and bent over. He started to rock back and forth. 8:34 PM- RN #1 came out and said something to RN #2 and they both walked to the back of the registration area. Pt #1 was still sitting with his head in his hands and rocking back and forth. 8:35 PM- Pt #1 was still sitting with is head in his hands and rocking back and forth. SO #1 came out to the desk and stood looking at Pt #1. RN #2 came back out and sat down at the desk. 8:36 PM- SO #1 walked behind the desk and put gloves on. He then walked towards Pt #1 who continued to rock back and forth. SO #1 talked to Pt #1 and motioned him to go to the desk. Pt #1 rubbed his head and walked to the desk. 8:37 PM- Pt #1 talked to SO #1 and RN #2. He put his face in both of his hands and rubbed his face. He started to walk off and turned back around to the desk still rubbing his face. He talked to RN #2 while moving his arms around. 8:38 PM- Pt #1 turned around and walked out the door. SO #1 and RN #2 watched Pt #1 walk out. RN #1 walked out again and talked to RN #2. During an interview on 2/5/2025 at 12:30 PM, RN #2 stated if a patient came to the ED desk saying they were suicidal, he would attempt to get the patient to stay...he would get security or call the police...he said he couldn’t physically hold them, but he would do what he could to prevent them from leaving and get them help. RN #2 stated Pt #1 came in the ED and said, “I am going to die, I need to talk to someone.” RN #2 stated he would not give his name or information, “I asked him several times.” RN #2 stated Pt #1 was “acting strange. He was not acting right...He gave the vibe he was on drugs.” He stated the patient never said he was suicidal. RN #2 stated he reported the situation to the Charge Nurse, RN #1, but Pt #1 left before RN #1 was able to come out. RN #2 stated they get a lot of patients in the ED that are homeless, and they don’t want to leave, “We notify security, and they will ask them to leave.” Review of a police report dated 1/18/2025 at 10:59 PM, showed a police officer responded due to information a person was on top of (proper name) Hospital. Review showed Pt #1 came down, but he would not give his real identity. He stated, “no one wanted to help him because he spoke with [hospital] staff and did not want to give them his personal information, so he left...he went to the top of the building to get someone to notice him because he felt like no one was listening and he just wanted to speak to someone.” Pt #1 was transported to another hospital for a psychiatric evaluation. Review of the ED Central Logs showed Pt #4 arrived at the ED via ambulance on 12/25/2024 at 7:27 PM, with complaints of SI (suicidal ideation). Medical record review of Pt. #4’s ED Patient Care Timeline dated 12/25/2024 at 7:29 PM, showed the provider first contact started and the MSE (medical screening exam) was complete at 7:36 PM. Medical record review of the ED Patient Care Timeline dated 12/25/2024 at 7:41 PM showed Pt #4’s vital signs were obtained and triage notes were started. ESI (Emergency Severity Level) assigned was 4 (not severe or life threatening). A CSSRS (Columbia-Suicide Severity Rating Scale) and psychological assessment were not completed. Medical record review of Pt #4’s history and physical, dated 12/25/2024 at 7:40 PM, showed, ...psychiatric/behavioral: positive for suicidal ideas...patient is well-known to our facility who presents to the emergency department via EMS for evaluation of suicidal ideation. The patient has been seen twice in the last 24 hours at different facilities for suicidal ideation. Patient has a known history of malingering and has already been checked out by telepsychiatry and has been cleared...She does not have a current plan although earlier she stated that she wanted to overdose.” Review showed the discharge diagnosis listed was malingering and inadequate social skills and disposition was set for discharge. Medical record review of scanned documents dated 12/25/2024 at 1:06 AM, showed Pt #4 was seen and evaluated by Mobile Crisis for suicidal ideations. Pt #4 reported SI, depression, and anxiety for approximately a week. She admitted she “...planned to use rubbing alcohol and a cloth to suffocate herself.” The Mobile Crisis recommendation for final disposition was involuntary inpatient admission. A CON for involuntary commitment was completed 12/25/2024 at 4:35 PM and it stated “patient has clinical s/s (signs and symptoms) of psychiatric disorder. She reports she is suicidal with plan to smother herself to death with rubbing alcohol. The patient is likely to deteriorate without intervention.” Review of the ambulance report, dated 12/25/2024, not included in Pt #4’s ED record, was obtained and reviewed on 2/6/2025. The report showed Pt #4 was brought to the ED with a Certificate of Need attached to the ambulance record. The report stated the patient was “...unable to sign for self-reason: under 6404 (involuntary commitment form).” A RN signed the Authorized Representative Signature box, and it stated the patient was unable to sign due to being “mentally impaired”. Report was given to the ED RN. During an interview on 2/5/2025 at 1:15 PM, with the Director of ED, she revealed the expectation during triage the nurse is responsible for completing the following: obtain history of chief complaint, focused assessment, sepsis screening, falls risk screening, Glasgow Coma Scale, vital signs, height and weight, and CSSRS on all patients. She stated in the event there is a patient that doesn’t have a name or won’t give a name and it is obvious they need help, they have a process to register the person as a “John Doe” in order to get them to the doctor for an MSE. This process allows “eyes on the patient” faster. The Director stated the staff have been educated about this in the past and that is the expectation, “...if a person was to come to the front desk and say they were suicidal, the staff cannot physically stop the person, but they should call security to help protect the patient. They have an escalation process for this. I would also expect the nurse to escalate to this to the charge nurse who then should escalate this to the house supervisor.””