Parkridge Medical Center

“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: 30553 Based on video and photograph review, medical record review and interviews, the facility failed to provide a medical screening exam for one (1) patient (#20) of 20 ED records reviewed. The findings include: Patient #20 was brought to Facility B’s Psychiatric facility on 8/7/2025 by local law enforcement. The patient had been evaluated at the VA clinic (Facility D) by a provider related to Suicidal Ideations (SI) with a plan and a certificate of need (CON) was written for the patient. Facility A and Facility B were located on the same campus with an adjoining hallway. The staff at Facility B spoke with the transporting officer. The facility did not have an open bed and there were discussions with the officer related to taking Patient #20 to Facility A’s ED for evaluation. The patient was taken to Facility’s C’s ED (2.7 miles from Facility A and B). The patient was not evaluated at Facility A. The patient was not listed on Facility A’s ED Central Logs and there was no medical record for the patient. At Facility C, the patient received a medical screening examination and was found to have an ongoing Emergency Medical Condition. The patient required transfer to a inpatient psychiatric facility (Facility E). Cross Refer to A-2406.”

“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: 30553 Based on review of facility policy, review of the Emergency Department (ED) Central Logs and interview, the facility failed to ensure an accurate and complete ED Central Log for one (1) patient (#20) of 20 ED records reviewed. The findings include: Review of Facility A’s policy “EMTALA [Emergency Medical Treatment and Labor Act] ...Central Log Policy” last revised 12/2024, showed “...the hospital will maintain a Central Log containing information on each individual who comes to the hospital campus requesting assistance or whose appearance or behavior would case a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination should be performed, whether he or she refused treatment, whether he or she was refused treatment, or...transferred, admitted, and treated, stabilized and transferred or discharged...” Patient #20 was brought to Facility B by local police on 8/7/2025 related to suicidal ideations (SI) under a Certificate of Need (CON). Facility A was on the same campus as Facility B and had a dedicated Emergency Department (DED). Review of the ED Central Logs for 8/7/2025 showed Patient #20 was not listed on the ED Central Logs. During an interview on 8/18/2025 at 4:00 PM, the Director of Quality Management for Facility A, confirmed Patient #20 was not listed on the facility’s ED Central Logs. During an interview on 8/19/2025 at 11:15 AM, with Facility A’s Nurse Manager, the manager confirmed Patient #20 was not listed on the ED Central Logs. Cross Refer to 2406.”

“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: 30553 Based on review of facility policy, review of video footage and photographs, medical record review and interviews, the facility failed to provide a medical screening examination for one (1) patient (#20) of 20 Emergency Department (ED) records reviewed. The findings include: Review of Facility A’s policy “EMTALA [Emergency Medical Treatment and Labor Act] ...Medical Screening Examination and Stabilization, last revised 12/2024 showed “...an EMTALA obligation is triggered when an individual comes to a DED and the individual or a representative acting on the individuals behalf request an examination or treatment for a medical condition...a prudent layperson observer would conclude from the individuals appearance or behavior that the individual needs an examination or treatment of a medical condition...(j) Off-Campus Provider Based Emergency Department: an off campus provider based emergency department is a department of the hospital, located no more than 35 miles from the main hospital, that meets all the provider based requirement, holds the same Medicare provider number as the main hospital and either is (1) licensed by the state as an Emergency Department (ii) is advertised as providing care for the emergency medical condition on an urgent basis without appointment or (iii) provides at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring previously scheduled appointments...” Review of video footage and photographs dated 8/7/2025 for Facility B showed the following: 4:04 PM (25 seconds): The police cruiser arrived at the parking lot of Facility B. 4:04 PM (59 seconds): The police officer assisted a patient out of the police cruiser. 4:05 PM (17-34 seconds): Patient (#20) and officer walked into Facility B’s waiting room. The officer went to the entrance desk and the patient was sitting in a chair in the waiting room. The officer was speaking with the receptionist and had an envelope in his hand. 4:08 PM (26 seconds): An employee at Facility B was talking to the police officer. 4:22 PM (11 seconds): Facility B’s staff member was talking to the police officer. 4:22 PM (38 seconds): The patient and officer walked out of the entrance doors of Facility B. 4:23 PM (2 seconds): The officer assisted the patient into the police cruiser. 4:23 PM (32 seconds): The police cruiser pulled away from the entrance of Facility B. Medical record review of a Certificate of Need (CON) dated 8/7/2025 at 2:15 PM, showed a certificate of need (CON) was signed by a provider at Facility D for Patient #20, diagnosed with Major Depressive Disorder with an active plan to shoot himself and Post Traumatic Stress Disorder (PTSD). Medical record review showed there was no ED record for patient #20 at Facility A. Medical record review showed Patient #20 was admitted to Facility C’s ED on 8/7/2025 at 4:46 PM. The patient was brought into the ED by local police related to Suicidal Ideations (SI) with a plan. The patient scored a ‘high risk’ on the Columbia Suicide Risk Rating Scale. Patient #20 had been evaluated at Facility D and placed under a CON related to a plan to shoot himself. On 8/7/2025, at 5:57 PM, the patient was medically cleared for psychiatric inpatient admission. The patient received Seroquel (antipsychotic) 100 milligrams (mg) orally, Zofran (medication used for nausea) 4 mg sublingual and Ambien (medication used for sleep) 10 mg orally while in the ED. Medical record review of an ED Provider Note from Facility C dated 8/8/2025 at 3:08 AM, showed “...Patient at acute risk of harm to himself if he is not treated with inpatient psychiatric care. Patient has a plan to shoot himself with a gun and needs inpatient psychiatric care for this. He has a history of ptsd (post-traumatic stress disorder) and depression...” Patient 20’s diagnosis included Depression with SI. Multiple referrals for inpatient psychiatric placement were made. Continued review showed the patient was accepted at Facility E on 8/8/2025 at 7:51 AM, and was transported by Emergency Medical Services (EMS). During an interview on 8/18/2025 at 4:00 PM, the Director of Quality Management for Facility A confirmed Facility A and Facility B were on the same campus. Patient #20 had been evaluated at Facility D where he presented with SI and a plan. A CON had been written for the patient and Facility D asked for the patient to be taken to Facility A’s ED for evaluation. Local police brought the patient to Facility B. Facility B staff spoke with the officer and told them they did not have an open bed and asked the officer to take the patient to Facility A’s ED for evaluation. The officer took the patient to Facility C and bypassed Facility A. The Director of Quality Management confirmed the patient did not receive a medical screening examination and the patient was on Facility A’s property. During an interview on 8/19/2025 at 11:15 AM, the ED Manager at Facility A, the manager confirmed the patient was not evaluated at Facility A and there was no medical record for Patient #20. During an interview on 8/19/2025 at 11:52 AM, the Director of Inpatient and Respond at Facility B, stated Patient #20 arrived with local police transporting. The patient had been evaluated at Facility D and placed under a CON. She had spoken with the officer and reviewed the paperwork. There were questions about if the patient should be taken to Facility A. She had spoken with the Chief Nursing Officer (CNO) and the Administrator on Call about the patient. They (Facility B) had evaluated the bed status and found they did not have an open bed for the patient. She spoke with the officer and told the officer to take the patient to (Facility A’s) ED for evaluation, stabilization, and disposition. The officer was in agreement. She was not aware of any communication between the facilities about the patient. She confirmed the patient was on the campus of Facility A and Facility B and the patient did not receive a medical screening examination.”

“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: 51701 Based on review of facility policy and staff interviews, Facility A failed to provide an appropriate Medical Screening Examination (MSE) for one patient (#1) in transfer from Facility B. Patient #1 was diverted from Facility A’s ambulance bay, without being seen with an Elevated Blood Pressure, Headache and Brain Fog to Facility C’s emergency department (ED). This affected one out of 19 ED patient records reviewed. The findings include: Review of the facility policy, “EMTALA-Tennessee Medical Screening Examination and Stabilization,” last reviewed 12/2024, revealed “...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)...Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition...The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual’s behalf for examination or treatment...The individual arrives on the hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance of behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment...” Patient #1 was a 16-year-old male inpatient at Facility B on 7/22/2025, who developed High Blood Pressure, Headache, and Brain Fog. It was determined Patient #1 needed to be sent to Facility A’s Emergency Department (ED) for further evaluation. Patient #1 was transported by EMS to Facility A’s ED ambulance bay. Patient #1 was never transferred from the ambulance into Facility A’s ED. Facility A’s ED Physician called Facility B’s House Supervisor and told the House Supervisor to send Patient #1 to Facility C’s Children’s ED. Patient #1 did not have a Medical Screening Examination performed at Facility A’s ED. There is no medical record for Patient #1 at Facility A’s ED on 7/22/2025, since after arriving at Facility A’s ED, Patient #1 was never brought into the ED. Cross Refer to A-2406.”

“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: 51701 Based on review of facility policy, review of facility video and pictures, medical record review and staff interviews, the facility failed to keep an accurate Emergency Department Log for 1 patient, Patient #1 who was diverted from Facility A’s Ambulance Bay without being seen to Facility C’s Emergency Department (ED) of 19 ED medical records reviewed. The findings include: Review of the facility policy, “EMTALA-Tennessee Central Log Policy, “ last reviewed 12/2024, revealed “The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (“MSE”) could be performed, whether he or she refused treatment, whether he or she was refuse treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged.” Review of Facility A’s video tape and Security still pictures from the video were reviewed onsite. Facility A was unable to submit the Security video tapes, but provided the still picture for the investigation. The video and pictures revealed the EMS ambulance, which contained Patient #1 was parked in Facility A’s ED ambulance bay. The review of the video and pictures revealed Patient #1 was never removed from the ambulance and taken into Facility A’s ED. Medical record review from Facility B revealed Patient #1 was a 16-year-old male in-patient at Facility B on 7/22/2025. Patient #1 developed High Blood Pressure, Headache and Brain Fog. It was determined Patient #1 needed to be sent to Facility A’s ED for further evaluation. Facility A’s ED and Facility B are located on the same property. There is no medical record for Patient #1 at Facility A’s ED on 7/22/2025 due to Patient #1 was not brought into Facility A’s ED. There is no listing of Patient #1 on Facility A’s Central Emergency Department Log. Patient #1 was directed by Facility A’s ED Physician to be transferred to Facility C’s ED. During a telephone interview on 7/30/2025 at 3:11 PM, RN #2 stated on 7/22/2025 a medic (EMT) came in the front door of the ED. RN #2 stated “did not see” Patient #1 and “did not receive” any report. RN #2 stated Patient #1’s name was not on Facility A’s ED log because Patient #1 never came inside the facility. RN #2 stated the ED Physician told EMS to take the patient to Facility C. During an interview on 7/31/2025 at 10:20 AM, with the Vice-President of Quality, Safety, and Regulatory stated Patient #1’s name was not on the emergency department log and there was no medical record of this patient in the PNED.”

“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: 51701 Based on review of facility policy, review of facility video and pictures, medical record review and staff interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 1 patient (#1) who was diverted from the facility’s ambulance bay without being seen to another facility’s emergency department (ED) of 19 ED patient records reviewed. The findings include: Review of the facility policy,”EMTALA-Tennessee Medical Screening Examination and Stabilization,” last reviewed 12/2024, revealed “...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED)...Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition...The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual’s behalf for examination or treatment...The individual arrives on the hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance of behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment...” Review of Facility A’s video tape and Security still pictures from the video were reviewed onsite. Facility A was unable to submit the Security video tapes, but provided the still picture for the investigation. The video and pictures revealed the EMS ambulance, which contained Patient #1, was parked in Facility A’s ED ambulance bay. The review of the video and pictures revealed Patient #1 was never removed from the ambulance and taken into Facility A’s ED. Medical record review from Facility B revealed Patient #1 was a 16-year-old male in-patient at Facility B. Patient #1 developed a High Blood Pressure, Headache and Brain Fog. It was determined Patient #1 needed to be sent to the Facility A’s ED for further evaluation. Facility A’s ED and Facility B are located on the same property. There is no medical record for Patient #1 at Facility A’s ED on 7/22/2025 due to Patient #1 was not brought into Facility A’s ED. Patient #1 was directed by Facility A’s ED Physician to be transferred to Facility C’s ED. Patient #1 did not receive a MSE. During a telephone interview on 7/29/2025 at 7:30 PM, RN #1 stated an Emergency Medical Services (EMS) personal, an Emergency Medical Technician (EMT) went through Facility A’s ED on 7/22/2025 on the way to the restroom. Interview revealed the EMT spoke to the ED nurses and shared Facility B was sending a 16-year-old hypertensive patient with slurred speech. RN #1 stated the ED Physician overheard the conversation and started asking questions. RN #1 stated she telephoned Facility B so the ED Physician could speak directly with the House Supervisor about Patient #1. RN #1 stated the ED Physician told the House Supervisor she was not refusing the patient, but if the patient was having a stroke, the patient would be better off at Facility C’s ED. The ED Physician told the House Supervisor at Facility B if Patient #1 was bought to Facility A’s ED, she was going to turn around and transfer the patient to Facility C’s ED. RN #1 stated Facility A’s ED did not get a called nursing report from Facility B like they normally do when Facility B sends them patients. RN #1 stated she did not know Patient #1 was in Facility A’s ED ambulance bay at that time the EMT came into the ED to use the restroom and shared information. During a telephone interview on 7/30/2025 at 3:11 PM, RN #2 stated on 7/22/2025 a medic (EMT) came in the front door of the ED. RN #2 stated “did not see” Patient #1 and “did not receive” any report. RN #2 stated Patient #1’s name was not on Facility A’s ED log because Patient #1 never came inside the facility. RN #2 stated the ED Physician told EMS to take the patient to Facility C. During a telephone interview on 7/30/2025 at 6:08 PM, with Paramedic #1, Vice-President and Director of the EMS, stated the EMS truck that picked up Patient #1 from Facility B was a Basic Life Support (BLS) truck. He stated after the ambulance pulled in Facility A’s ED Bay, the EMT driver went inside to use the bathroom and told the ED nursing staff they were getting a patient from Facility B. Paramedic #1 stated due to Facility A’s ED close location from Facility B, the Advanced EMT in the back of the ambulance was busy and still taking the second set of vital signs on Patient #1. Paramedic #1 stated after the EMT driver used the bathroom she stopped at Facility A’s ED nursing station and the staff told her the ED physician had decided to send Patient #1 to Facility C. During a telephone interview on 7/30/2025 at 7:54 PM, with RN #3 she stated Patient #1 never came inside the [name of hospital] ED. She stated there was a phone call to Facility B. The ED Physician took over the phone and started talking to Facility B’s House Supervisor. During a telephone interview on 7/31/2025 at 10:10 AM, with the ED Physician, she stated one of the ED RNs said Facility B was sending Patient #1 to the ED. The ED Physician stated she thought Patient #1 needed to go to Facility C’s ED due to the stroke like symptoms. The ED Physician stated she told Facility B’s House Supervisor to call 911 if there was a problem with the patient. The ED Physician stated she never saw the patient. The ED physician stated she didn’t know Patient #1 was in the EMS ambulance in Facility A’s ED ambulance bay. The ED Physician stated she never received a report on the patient. She stated nurses were on the phone to Facility B and there was a lot of confusion in the communication. The ED physician stated she did not refuse to see Patient #1, but she did tell them to send Patient #1 to Facility C’s ED. During a telephone interview on 7/31/2025 at 10:38 AM, RN #4, who was Facility B’s House Supervisor, stated on 7/22/2025, Patient #1 was transported to Facility C’s ED. She stated she had just started her shift when Patient #1’s elevated blood pressure was reported to her. Facility B’s House Supervisor stated she intended to send Patient #1 next door to Facility A’s ED to be seen as they normally do. However, Facility A’s ED Physician called her and asked her why she was sending a pediatric patient to Facility A’s ED. RN #4 stated she called the Administrator on Call for approval to send Patient #1 out to Facility C’s ED since they normally don’t transfer patients out of the health system. During an interview on 7/31/2025 at 11:45 AM, Facility A’s ED Manager stated there were no bells or alarms to alert nursing staff when an ambulance pulls into the ED ambulance bay. The ED Manager stated the EMT driver stopped at the nursing station but did not tell them the patient was in the back of the ambulance in the ambulance bay. The ED Nurse Manager did state the EMT driver told the nursing staff they were getting Patient #1 from Facility C. In summary, Patient #1, a 16 year-old from a Behavioral facility (Facility B), was transferred to Facility A’s ED with sudden onset of Hypertension, Headache and Brain Fog and did not receive a medical screening. During interview, Facility A’s ED physician acknowledged the patient was not seen and she directed Patient #1 to be sent to Facility C.”

“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: 30553 Based on review of facility policy, medical record review, review of a police report and interviews, the facility failed to provide stabilizing treatment for 1 patient (#20) who presented to the Emergency Department (ED) for Suicidal Ideations (SI) and aggressive behaviors, of 20 patients reviewed. The findings include: Patient #20 was admitted to Facility A’s ED on 5/17/2025 at 12:35 AM, with SI and aggressive behaviors. While in the ED the patient continued with aggressive and threatening behaviors towards the ED staff and police officers. The patient was placed under a Certificate of Need for Emergency Involuntary Admission (CON). The patient refused to have blood work drawn. A telepsychiatry evaluation was performed and the patient’s diagnoses included Psychosis and SI. Psychiatry recommended the following: involuntary commitment for inpatient psychiatric services, the use of antipsychotic and sedative medications, and a reconsult for psychiatry services within 24-48 hours as needed. The patient refused the medications and continued with aggressive and threatening behaviors. There was discussion between the ED staff, the ED physician and law enforcement related to the patient’s behaviors and the patient’s refusal of the medications. There was a discussion with the patient including if he refused the medications, he would be taken to jail. The patient refused the medications. The patient was discharged and sent with law enforcement out of the ED for the jail. The CON was not rescinded upon discharge. The patient continued to have aggressive and threatening behaviors. The patient was taken by law enforcement to Facility B where the patient required the use antipsychotic and sedative medications related to his aggressive behaviors. A medical screening examination and psychiatric evaluation was performed. Patient #20 remained under an involuntary hold, in the ED until 5/20/2025, when the patient was transferred to an inpatient behavioral health facility. Cross Refer to A-2407.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 30553 Based on review of facility policy, medical record review, review of a police report and interviews, the facility failed to provide ongoing treatment and stabilization for 1 patient (#20) who presented to the Emergency Department (ED) for Suicidal Ideations (SI) and aggressive behaviors of 20 patients reviewed. The findings include: Review of facility policy “EMTALA-Medical Screening Examination and Stabilization,” revised 12/20/2024, showed “...Purpose: to establish guidelines for providing appropriate medical screening examinations [MSE] and any necessary stabilizing treatment or an appropriate transfer for the individual as required by EMTALA...[7] Stabilizing Treatment Within Hospital Capability: the determination of whether an individual is stable is not based on clinical outcome of the individual’s medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED [Dedicated Emergency Department] has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during a transfer or the individual from a facility...or in the case of an individual with a psychiatric or behavior condition, that the individual is protected and prevented from injuring himself/herself or others...[a] Stable. The physician or QMP [qualified medical provider] providing the medical screening examination and treating the emergency has determined within reasonable clinical confidence, that the EMC [Emergency Medical Condition] that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist...” Patient #20 was admitted to Facility A’s ED on 5/17/2025 at 12:35 AM, for a mental health evaluation related to Suicidal Ideation (SI), aggressive and threatening behaviors. Medical record review revealed Patient #20 was placed under a Certificate of Need for Emergency Involuntary Admission (CON) on 5/17/2025 at 12:44 AM. Review revealed the patient had a history of depression with current SI with a suicide plan and needed inpatient psychiatric treatment. Continued review revealed the CON was not rescinded upon the patient’s discharge. Medical record review of an ED Nursing Triage dated 5/17/2025 at 12:51 AM, revealed the patient was admitted for a mental health evaluation and SI. His suicide risk assessment showed the patient was a high risk. Continued review revealed Patient #20 was placed in a safe room with a 1:1 sitter in attendance. Medical record review of an ED Provider Record dated 5/17/2025 at 12:51 AM, revealed the patient presented with SI, “very manic” with rapid speech. Patient #20 stated he did not have an actual plan, but he would “shoot his brains down.” The physical examination showed the patient was alert, euphoric, with flight of ideas and pressured speech. Medical record review of an ED Nursing Note dated 5/17/2025 at 2:33 AM, revealed “...pt. [Patient #20] is continually escalating. While this RN [Registered Nurse] and charge RN were attempting to draw blood, pt. looked at this RN and stated ‘I will hammer fist the [expletive] out of your face’ and then raised his arm and flexed his bicep stating ‘you see how big my arm is and I don’t get no smaller. You better stop trying to take my [expletive] blood.’ Charge RN and this RN left the room at that time to try to allow the patient to deescalate. Pt. began pacing and muttering under his breath. Notified [named Police Department] officer...staff attempted to decrease external stimuli by closing door to room 17 and notified pt. we were just closing the door but it was not locked. Pt. got up and became verbally aggressive towards...officer stating things such as ‘I’m not suicidal, I could bust your head easy, see how big I am’ and also arguing with officer about who the officer’s father was and what year he was born. Notified hospital security and provider. Officer was able to verbally deescalate, and pt. went back and sat on the bed. Security standing by in the ER [Emergency Room] with [named police department] officer at this time...” Medical record review of a Psychiatric Assessment dated 5/17/2025 at 3:19 AM, revealed Patient #20 presented with SI, psychosis and mania. He had rapid speech stating he will “shoot his brains out.” He was belligerent, pressured speech, screaming non-stop, threatening staff and the provider. He exhibited paranoid delusions and hallucinations. The patient continued to escalate during the interview. During the telepsychiatry interview, the patient hit the teledoc (video monitor) machine across the room. It was unknown if the patient was taking his psychiatric medications. He was diagnosed with Psychosis. He was high risk for suicide. Patient #20 was deemed a likely danger to himself and others related to the patient’s mental impairment and poor coping strategies, Recommendations included involuntary hospitalization to prevent harm to self and others, to have an inpatient psychiatric admission once medically cleared, the patient should not be allowed to sign-out AMA (Against Medical Advice) and consult psychiatry in 24-48 hours for reevaluation if needed. Recommended medications included Zyprexa (antipsychotic medication) 5 milligrams (mg) BID (twice a day). Comfort medications included Trazodone (antidepressant medication) 50 mg at nighttime, Vistaril (sedative medication) 50 mg TID (three times a day) and Zyprexa 5 mg every 6 hours as needed (PRN) for mild to moderate agitation. For severe aggression, recommendations included Haldol (antipsychotic medication) 5 mg IM (intramuscular), Ativan (medication used for anxiety) 2 mg IM, and Benadryl (antihistamine medications used to treat insomnia) 50 mg IM. Continued review revealed there was a discussion with the ED Provider. Medical record review of an ED Provider Progress Note dated 5/17/2025 at 3:24 AM, revealed “...throughout his course here in the ED patient became agitated and aggressive. Upon reevaluation patient was offered medications to help manage his agitation. Medications were recommended by psychiatrist. Due to patient’s continued aggressive behavior refuse of medications...police deemed necessary for the safety of the patient and others around him. The patient was given the choice between accept a medical intervention or taken into police custody. Patient offer [elected] police custody over received a medication...” Patient #20’s diagnosis was Agitation and he was discharged into the custody of the police. He was given discharge instructions related to Psychosis and the police officer signed the discharge instructions. Medical record review of an ED Nurses Note dated 5/17/2025 at 4:11 AM, revealed “...pt. became agitated during tele-psych assessment and became aggressive towards the monitor. Provider offered IM medications for safety of pt. and staff. When this RN informed pt. that the doctor had ordered him some meds to be given in a shot form pt. replied ‘you can’t pierce my skin, I have been hit with 29 nuclear bombs and now my skin glows green. You aren’t giving me a shot, you can try to but I’ll bust your head wide open. You all can’t hold me down, you can try but I have killed hundred of people.’ Charge RN approached this RN and asked if this RN agreed it would be safer for pt. and staff if patient would be taken into [named Police Department] custody due to pt. level of agitation and aggression and the multiple verbal threats towards staff. This RN agreed that would be the safest route for all parties involved due to multiple staff members attempting to deescalate pt. without success. Pt. had made multiple threats towards nursing staff and [named police officer]. Charge RN spoke with [named police officer] and two other [named local police department officers] who arrived during the agitated outburst about possibly taking the pt. into custody for safety of staff. [Named police department] officers informed pt. that if he would not calm down and refrain from threatening staff then they would have to take him into custody. The pt. responded, ‘fine with me to jail, they are my family there.’ At that point pt. turned around and was placed into handcuffs without further incident. Pt. continued to threaten the arresting officers and staff on his way out the ambulance bay doors...” The patient left the ED in police custody. Review of a local Police Department report dated 5/17/2025 at 3:12 AM, revealed Patient #20 was brought to the ED earlier for a mental health evaluation. The patient was agitated, argumentative, and maintained an aggressive stance. The patient made statements related to his “veins were so big that could not be penetrated by a butcher knife, he was 750 pounds, he could not be sedated and his father would shoot anyone who attempts to medicate him.” The patient was delusional, stated he was the anti-Christ and he had killed Bin Laden. The ED staff had informed the patient he needed to take the medications or go to jail. Continued review of the police report revealed Patient #20 was taken into police custody and discharged per the facility’s request. The police officer spoke with patient who expressed he wanted to be transported to [Facility B] for a mental health evaluation. The patient was transported to Facility B’s ED. Further review of the police report revealed on arrival at Facility B the patient made similar remarks he had made at Facility A. He was aggressive with the staff at Facility B including the security and ED staff. The patient was placed on his stomach and administered medications. The patient did not resist and he was cooperative with the staff. Medical record review revealed Patient #20 arrived at Facility B’s ED, transported by local police on 5/17/2025 at 4:05 AM. The patient had been evaluated at Facility A for a voluntary evaluation, however while at Facility A the patient became agitated and refused all treatment. The patient was discharged from Facility A into the custody of local law enforcement to be transported to the jail. The patient was transported by law enforcement to Facility B with complaints of agitation and for a psych (psychiatric) evaluation. Continued review revealed the patient was placed in seclusion with a 1:1 sitter, given Ketamine (medication for sedation) 300 mg IM and Zyprexa 10 mg IM. He was placed under a CON by the ED Provider. Diagnostic testing included blood work for a Complete Blood Count, Basic Metabolic Panel, alcohol levels, Urine Drug Screen and COVID 19 testing, ordered and completed. Medical record review of an ED Provider Note from Facility B dated 5/17/2025 at 4:13 AM, revealed Patient #20 arrived via local police for Psychosis. The staff at Facility A reported to police that they offered medications, but the patient refused. The documentation from Facility A “...suggested the patient presented with mania with psychotic features. He was evaluated by tele-psychiatry there and recommended involuntary inpatient psychiatric treatment. The patient was recommended antipsychotic regimen of medications and PRN agitation medications. ED documentation suggested the staff there was concerned about their safety due to patient’s agitation and threatening behavior. Police report there was no crime committed and patient could not be taken to jail...Upon discharge from [Facility A] the police brought patient to [Facility B] for further evaluation due to symptoms of acute psychosis...” Continued review revealed in the ED at Facility B, the patient was hyperactive, aggressive, threatening staff, paranoid, with pressured speech, he endorsed religious delusions and appeared internally stimulated. The plan of care included placing the patient in seclusion, medication treatment including IM Ketamine and additional antipsychotics. Review revealed Patient #20 was placed under a CON with a plan for inpatient psychiatric treatment. Medical record review of a Psychiatric Evaluation dated 5/17/2025 at 11:02 AM, revealed the patient was previously at Facility A and involuntary hospitalization was recommended. It was unclear why Patient #20 was discharged but medical record review revealed either staff felt he was too acute/threatening or were hoping he would be discharged to police custody. The police brought the patient to Facility B for ongoing psychosis and agitation. The patient had previous history of Bipolar Disorder and Polysubstance Use Disorder. The plan of care included inpatient psychiatric involuntary admission, Risperdal (antipsychotic medication) 1 mg BID and Haldol (antipsychotic medication) 5 mg PO/IM every 6 hours as needed (PRN). Medical record review revealed Patient #20 remained in Facility B’s ED from 5/17/2025-5/20/2025. The patient was followed by the ED Physician daily and reassessed. Multiple referrals were made for the patient. On 5/20/2025 at 5:50 PM, the patient was accepted and transferred to an inpatient psychiatric facility. During a telephone interview on 5/28/2025 at 9:55 AM, RN #1 (employed at Facility A) stated the patient (Patient #20) was brought into the ED by local police related to a violent episode at a rehab facility. The patient was psychotic with internal stimulation. The patient was alert to himself, aggressive and uncooperative with the staff and the police. Interview continued and RN #1 stated he and another nurse had gone into the room to draw blood and the patient was threatening to the staff with expletive statements related to he would fight and harm the staff. The patient was given oral Valium for his agitation, but the medication did not appear to decrease the behaviors. The patient remained aggressive and threatening. During the psychiatric assessment, the patient become violent and knocked the teledoc machine across the room. There were IM medications ordered for the patient. When he and another nurse went in to give the medications, the patient stated he would not take the medication, he would fight them, and they could not hold him down. RN #1 stated he, the charge nurse, the physician and the police felt the patient was violent and felt their safety was in jeopardy while administering the medications. They felt the patient would be better served with the local police in the jail. The patient was offered the medications or to be discharged with local police to the jail. The patient stated “take me to jail.” The ED physician discharged the patient. RN #1 confirmed the patient was discharged to the local police with the agreement the patient would be taken to jail. During a telephone interview on 5/28/2025 at 10:05 AM, RN #2, (employed at Facility A) stated the patient (Patient #20) was brought into the ED by local police with Psychosis and SI. The patient presented violent and psychotic. The patient was place under a CON. When she and another nurse attempted to obtain blood from the patient, he stated he would ‘hammer our heads’ if we attempted to draw blood and was very threatening. Interview continued and RN #2 stated the patient remained very aggressive with the staff and remained manic. There were IM antipsychotic medications ordered for the patient per psychiatry and the ED provider. She and the other nurse went into the room to give the medications. The patient refused the medications. He stated he would fight and no one could hold him down. There were discussions between the nursing staff, the ED Provider, law enforcement and with the patient regarding the patient could take the medications or go to jail. The patient stated he would go to jail. The ED Provider stated the patient was medically cleared and he could go to jail in police custody. The patient left the ED in police custody to go to the jail. During a telephone interview on 5/28/2025 at 10:40 AM, Officer #1 stated the patient (Patient #20) was transported to the ED by local police with disruptive and aggressive behaviors. The patient was threatening the ED staff and law enforcement. The patient refused to take medications or to have his blood drawn. There were discussions with the patient by the ED staff regarding the patient taking the medications or going to jail. Officer #1 stated “...I asked the patient if he wanted to take the medications or go to jail, and the patient stated take me to jail. The local police officers placed the patient in handcuffs...” The patient left the ED with the local police officers to go to the jail. During a telephone interview on 5/28/2025 at 12:35 PM, the ED Physician #1 (employed at Facility A) stated the patient (Patient #20) presented to the ED with SI and acute behaviors. She had evaluated the patient and ordered diagnostic testing. The patient refused to have blood work drawn. Psychiatry was consulted and evaluated the patient by tele-psychiatry. The psychiatric assessment showed the patient met involuntary inpatient behavioral health criteria. Interview continued and ED Physician #1 stated she had placed the patient under an involuntary hold (CON). The patient’s aggressive behaviors continued. The patient refused the IM injections and threatened the staff. She stated the staffing was limited in the ED, she was the only provider in the ED and the staff did not feel safe. She had discharged the patient and he was taken out of the ED by local police with the intent to take the patient to jail.”