Tristar Centennial Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 32777 Based on policy review, review of the State Operations Manual, and interview, the Governing Body failed to ensure the facility’s abuse policy was written to include all components listed in the State Operations Manual and failed to ensure the facility monitored Social Worker #1 after Patient #1 reported an allegation of sexual abuse by Social Worker #1 occurred in September, 2024 and Patient #2 reported an allegation of sexual abuse by Social Worker #1 in May, 2025. The findings inclued: 1. Review of the hospital policy titled “Alleged or Suspected Abuse (Child and/or Adult) dated 12/2024 revealed no components listed for an effective abuse protection plan. Review of the State Operations Manual (SOM) dated 04/19/2024 revealed, “ ...§482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment ...Interpretive Guidelines ... The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. The hospital must ensure that patients are free from all forms of abuse, neglect, or harassment. The hospital must have mechanisms/methods in place that ensure patients are free of all forms of abuse, neglect, or harassment ...The following components are suggested as necessary for effective abuse protection: Prevent. A critical part of this system is that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients ...Screen. Persons with a record of abuse or neglect should not be hired or retained as employees. Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Train. The hospital, during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection. Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment. Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. As a result of the implementation of this system, changes to the hospital’s policies and procedures should be made accordingly ...” During an interview on 05/28/2025 beginning at 10:41 AM, the Vice President (VP) of Quality was asked if there was a hospital abuse policy that listed all the components as written in the SOM. The VP of Quality stated these components were incorporated in other policies, training programs and the “Code of Conduct” but were not listed together in one policy. Further interview with VP of Quality revealed Social Worker #1 was not monitored after the allegation of sexual abuse was reported in September, 2024 and approximately 7 months later Patient #2 reported sexual abuse by Social Worker #1. The Governing Body failed to ensure that any incidents of abuse, neglect or harassment were reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred, in accordance with applicable local, State, or Federal law when Social Worker #1 allegedly went to Patient #1’s home and sexually assaulted her. Because of the failure to analyze and monitor Social Worker #1 with appropriate corrective action, Patient #2 was allegedly sexually abused 7 months later while she was a patient in the ED on 4/28/2025. Refer to A-0144, A-0263 and A-286”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 32777 Based on review of facility policy, review of a facility incident report, review of the Quality Assurance Process Improvement (QAPI) meeting minutes, review of facility video footage, medical record review, and interview, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee analyzed and monitored processes to ensure no future adverse events occurred as part of the facility wide QAPI program for 2 of 3 (female Patient #1 and female Patient #2) sample patients who were seen in the Emergency Department (ED). The findings included: 1. Review of a policy titled “Patient Grievance and Complaint Management Policy” dated 09/2013 revealed all patient grievances will be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance and tracking, trending and analysis of data will be ongoing actions, 2. Review of the medical record revealed Patient #1 was seen in the ED on 08/19/2024 at 2:20 PM. The visit diagnosis was Alcohol Abuse, Uncomplicated. Patient #1 was subsequently seen again in the ED on 09/24/2024 for abdominal pain. Patient #1 alleged male Social Worker #1 took her home in his personal vehicle (date unknown) and made an additional 2 visits to her apartment for welfare checks in 2024 (dates unknown). Patient #1 reported Social Worker #1 to the hospital via telephone on September 30, 2024. Patient #1 was unable to provide the dates Social Worker #1 came to her apartment. Patient #1 alleged Social Worker #1 fondled her and tried to climb on top of her while visiting her apartment. Social Worker #1 was placed on administrative leave pending the outcome of the investigation. The QAPI investigation was unable to substantiate the allegation however, Social Worker #1 was verbally counseled not to be in a room alone with a female patient and to leave the room doors open. Review of the facility incident report dated 10/01/2024 revealed, the allegation was not substantiated, and Social Worker #1 came back to work. There was no documented monitoring provided by the hospital for Social Worker #1. 3. Review of the medical record dated 04/28/2025 revealed Patient #2 was seen in the ED on 04/28/2025 at 10:46 AM for a potential overdose. Video footage of 4/28/2025 revealed Social Worker #1, a male, entered an ED room, alone where Patient #2, a female, was behind a closed door. The social worker entered the room without knocking at 2:39 PM. Fourteen minutes later both Social Worker #1 and Patient #2 exited the room; and Patient #2 was escorted to a chair to sit down. On 5/3/2025, Patient #2 called the facility and alleged Social Worker #1 went into Patient #2’s ED room on 04/28/2025, closed the door and was alone with Patient #2. Patient #2 reported Social Worker #1 had fondled her while in the ED room. 4. Review of the QAPI meeting minutes from October 2024 through April 2025 revealed no documentation of plans or monitoring of Social Worker #1. There was no documentation of any discussion of the sexual abuse allegation investigation in September and October 2024. The May 2025 QAPI meeting minutes had not been approved at the time of the survey and were unavailable for review. 5. Interview with the VP of Quality revealed Social Worker #1 was suspended pending the outcome of the investigation on 05/08/2025. The facility was unable to substantiate the allegations of sexual abuse but elected to terminate Social Worker #1 out of an abundance of caution. The facility did not adequately monitor Social Worker #1 after the first allegation of sexual abuse by Patient #1 in September 2024 and in May 2025, Patient #2 alleged sexual abuse by Social Worker #1. Refer to A-0286”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 32777 Based on policy review, review of the State Operations Manual and interview, the facility failed to ensure the patients’ rights were protected and the patients received care in a safe setting when Patient #1 reported alleged sexual abuse in September 2014 by Social Worker #1 and Patient #2 reported alleged sexual abuse in May, 2025. The facility failed to have an abuse policy that incorporated the 7 components listed in the State Operation Manual (SOM) that included any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. 1. Review of the hospital policy titled “Alleged or Suspected Abuse (Child and/or Adult) dated 12/2024 revealed no components listed for an effective abuse protection plan. Review of the State Operations Manual (SOM) dated 04/19/2024 revealed, “ ...§482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment ...Interpretive Guidelines ... The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. The hospital must ensure that patients are free from all forms of abuse, neglect, or harassment. The hospital must have mechanisms/methods in place that ensure patients are free of all forms of abuse, neglect, or harassment ...The following components are suggested as necessary for effective abuse protection: Prevent. A critical part of this system is that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients ...Screen. Persons with a record of abuse or neglect should not be hired or retained as employees. Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Train. The hospital, during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection. Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment. Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. As a result of the implementation of this system, changes to the hospital’s policies and procedures should be made accordingly ...” 2. Review of the medical record dated 08/19/2024 revealed Patient #1 was seen in the ED on 08/19/2024 at 2:20 PM. The reason for the visit diagnosis was Alcohol Abuse, Uncomplicated. 3. Review of the medical record dated 09/24/2024 revealed Patient #1 was seen in the Emergency Department (ED) for Generalized Abdominal Pain. Review of a Free text HPI (History of Present Illness) Notes dated 09/24/2024 revealed Patient #1 stated she was a heavy drinker and drank regularly. Review of a facility investigation dated 10/01/2024 revealed Patient #1 called the facility on 09/30/2024 to report Social Worker #1 drove her home from one of her multiple ED visits (date unknown) and sexually abused her. During an interview on 05/28/2025 beginning at 10:41 AM, the Vice President (VP) of Quality was asked if Social Worker #1 was monitored after the allegation of sexual abuse in September, 2024. The VP of Quality stated did not monitor Social Worker #1 at the bedside. The VP of Quality was asked if the facility had an abuse policy that listed the components described in the SOM abuse regulation. The VP of Quality stated these components were incorporated in other policies, training programs and the “Code of Conduct” but were not listed together in one policy. 4. Review of the medical record dated 04/28/2025 revealed Patient #2 was seen in the ED on 04/28/2025 at 10:46 AM for a potential overdose. Patient #2 was found outside during a rainstorm and was brought to the ED via ambulance. Review of video footage dated 04/28/2025, revealed Social Worker #1 had some clothing rolled up in his left hand and without knocking, went into Patient #2’s ED room at 2:39 PM and closed the door. He was in the room for approximately 14 minutes. Further review of video footage at 2:53 PM, revealed Social Worker #1 walked out of the ED room with Patient #2. No one else exited the room with them. Social Worker #1 walked Patient #2 to the ED lobby where she sat down in a chair with her phone and some clothing rolled up under her left arm. Social Worker #1 also had some clothing rolled up in his left hand. The facility failed to ensure patient safety when the first alleged incident of sexual abuse was reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred, in accordance with applicable local, State, or Federal law when Social Worker #1 allegedly went to Patient #1’s home and sexually assaulted her and 7 months later, Patient #2 was allegedly sexually abused by Social Worker #1 while she was a patient in the ED on 4/28/2025.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 32777 Based on review of facility policy, review of a facility incident report, review of the Quality Assurance Process Improvement (QAPI) meeting minutes, review of facility video footage, medical record review, and interview, the facility failed to ensure the QAPI committee identified and implemented appropriate monitoring to ensure patients were safe from sexual abuse for 2 of 3 (female Patient #1 and female Patient #2) sampled patients seen in the hospital’s emergency department (ED). Patient #1 reported an allegation of sexual abuse to the hospital on 9/30/2024. Patient #1 had been admitted to the hospital’s ED multiple times, and following discharge, Social Worker #1 made three welfare visits to Patient #1’s apartment. Patient #1 alleged Social Worker #1 sexually abused her while in her apartment. A second allegation of sexual abuse was reported to the facility on 05/03/2025 when Social Worker #1 went into Patient #2’s ED room, closed the door and was alone with Patient #2 for approximately 14 minutes on 04/28/2025. Patient #2 alleged she was sexually abused by Social Worker #1 while he was alone in the room with her. Patient #1 reported the sexual abuse to the facility on 9/30/2024, via telephone to the patient advocate. Patient #2 reported the allegation of sexual abuse that occurred on 04/28/2025 to this facility on 05/03/2025. The findings included: 1. Review of a policy titled “Patient Grievance and Complaint Management Policy” dated 09/2013 revealed, “...Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient ...regarding ...abuse ...issues related to compliance with the CMS [Centers for Medicare and Medicaid] Conditions of Participation (CoP) ...PROCEDURE ...Grievance Resolution Process ...Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department director/manager to review, investigate and resolve with the patient ... Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance ...A grievance is considered resolved when the patient... is satisfied with the actions taken on their behalf...Tracking, Trending, and Analysis of Data... Status and success of any ongoing actions or other activities intended to reduce the number, frequency and/or seriousness of complaints and grievances...” Review of a policy titled, “2024 Plan for Improvement of Organizational Performance and Patient Safety” dated 03/2024 revealed, “...The objectives of this plan are to preserve/improve the quality of patient care, enhance appropriate utilization of resources, and to reduce or eliminate unnecessary risks and hazards within the facility by promoting ...The employment of qualified, competent, and effectively supervised personnel for patient care, using clear channels of supervision, responsibility, and accountability ...A system in which the findings of patient care monitoring and evaluation are utilized by the hospital in concrete ways to fulfill the objectives of the Performance Improvement/Patient Safety program ...” The facility was not able to provide an abuse policy that addressed a process for investigating or reporting allegations of abuse or neglect, or the monitoring of any alleged instances of abuse or neglect to ensure patients were safe from further instances when staff were accused of abuse and/or neglect. 2. Review of the medical record dated 08/19/2024 revealed Patient #1 was seen in the ED on 08/19/2024 at 2:20 PM. The reason for the visit diagnosis was Alcohol Abuse, Uncomplicated. Review of a Free Text History of Present Illness (HPI) Notes dated 08/19/2024 revealed, Patient #1 presented with alcohol use requesting for detoxification (detox)/assistance with rehabilitation (rehab). Patient #1 reports she has a history of alcohol abuse. Review of a Re-Evaluation/Progress #1 dated 8/19/2024 revealed, “...Patient seen by case management ...Plan for discharge home ...” Review of a Discharge Planning note dated 8/19/2024 at 4:25 PM by Social Worker #1 revealed, “...Pt (Patient) said she has been to 5 different ERs [Emergency Rooms]and nobody has helped her because she is uninsured ...” The medical record dated 08/19/2024 revealed Patient #1 was discharged at 5:15 PM and left the ED walking. On 9/30/2025, Patient #1 reported to the hospital that she had been sexually abused by Social Worker #1. Review of a portion of the facility investigation dated 10/1/2024, the Vice President of Quality, the Manager of Social Work, and Clinical Risk Manager interviewed Social Worker #1. The investigation findings revealed, “...At the conclusion of this interview, the social worker was advised that he was being placed on administrative leave while the investigation was continuing ...10/15/2024: at this time, after a thorough and credible investigation, we have been unable to substantiate with evidence the concern shared by this former patient [Patient #1] ...” Review of the QAPI meeting minutes from October 2024 through April 2025 did not reveal any evidence of a plan to monitor Social Worker #1 to ensure the safety of future female patients. During a telephone interview on 06/05/2025 beginning at 2:35 PM, Patient #1 stated after one of her visits to the ED, Social Worker #1 gave her a ride home from the hospital “because he was concerned about me taking an [Named share ride company] and so he asked me to meet him ...around the corner and that’s when I got in his car and he drove me home and walked me up to my apartment ...” Patient #1 confirmed Social Worker #1 came to her apartment and checked on her a second time and she let him into her apartment. Patient #1 stated, “...all I had was a bed studio apartment ...so I was just alone dealing with addiction and he was just lending an ear ...I just talked about things ...I’d also just lost my dad a couple months prior to that who I was really close to so it’s kind of a perfect storm in my life ...the first time coming back from the hospital he [Social Worker #1] ...tucked me into bed ...he’s a lot older than I am so it seemed kind of fatherly when I just lost my dad like 2 months prior ...the second time he came over nothing happened ... and then the third time ...he came over, I was drinking ...I had just done my nails and I couldn’t ...open it [alcohol] ...so he was opening it for me ...I was going through it really bad, I was kind of slamming them ...he told me that I shouldn’t stop drinking because I’ll have withdrawals so ...he was kind of encouraging the alcohol and then that’s when I realized something was kind of up ...He kept insisting on giving me a massage ...then he kept putting his hands under my clothes and up my bra and I was saying please just keep your hands outside of my clothes and then he would stop ...a couple seconds later he was doing it again ...then he abruptly started to pull me over to get on top of me and that’s when I started to scream really loud to get away from me, get off of me ...screaming as loud as possible ... then he ran out ...” Patient #1 was asked if she called the police. Patient #1 confirmed she called the police. Patient #1 stated, “ ...they [hospital investigation team] listened to me ...he [Social Worker #1] didn’t penetrate me so there was no need for like a rape kit but they encouraged me to go to the hospital. I went to the hospital. I reported the whole thing, but nothing was really done and I just I don’t want this to happen to another girl like this, because it’s clear that this is a predator ...I’m an addict so ...I’m not credible and he is. I was ...perfect for him and I know that there’s a lot of people like me out there and we’re just trying to get better ... and I put my faith in the wrong person ...” Patient #1 was asked if anyone from [Named Hospital] contacted her after she reported it to the facility. Patient #1 stated, “ ...yes ...they were asking me questions, they didn’t really ask what happened, they asked me what car he was in and if I could get the video footage from my apartment. I couldn’t ...I’ve even called the company that they have their surveillance footage through ... I can’t get it...I didn’t know the make of his car but I said it was like a maybe a 2015 black or green sedan like a [Make of Named Car] ...I don’t know, that’s all that’s all I could tell them, and they just started to completely brush me off and act like that was a problem ...I was forthcoming with what happened so they didn’t really ask too many questions ...I let them know what happened and the history and they were just asking for proof, really that’s the only thing they cared about and I unfortunately couldn’t really provide them proof ...” 3. Review of the medical record dated 04/28/2025 revealed Patient #2 was seen in the ED on 04/28/2025 at 10:46 AM for a potential overdose. Patient #2 was found outside during a rainstorm and was brought to the ED via ambulance. Further review of the medical record revealed Patient #2 had a history of polysubstance (use of multiple substances, including drugs and alcohol) abuse and homelessness. Patient #2 was not interviewed. She was unable to be reached at the time of this survey. Review of video footage dated 04/28/2025, revealed Social Worker #1 had some clothing rolled up in his left hand and without knocking, went into Patient #2’s ED room at 2:39 PM and closed the door. He was in the room for approximately 14 minutes. Further review of video footage at 2:53 PM, revealed Social Worker #1 walked out of the ED room with Patient #2. No one else exited the room with them. Social Worker #1 walked Patient #2 to the ED lobby where she sat down in a chair with her phone and some clothing rolled up under her left arm. Social Worker #1 also had some clothing rolled up in his left hand. During an interview on 5/27/2025 beginning at 10:45 AM, the Vice President (VP) of Quality was asked about the incident with Patient #2 and Social Worker #1 that took place on 04/28/2025. The VP of Quality confirmed the facility was first notified of the incident on 05/03/2025 (5 days after the incident occurred). She stated Patient #2 called the facility through the switchboard operator on 05/03/2025, and the complaint was elevated to her via text on that same day. The VP of Quality stated she had trouble getting in touch with Patient #2 and she first talked to Patient #2 on Wednesday 05/08/2025 via telephone. The VP of Quality was asked about the conversation with Patient #2. The VP of Quality stated, “...She [Patient #2] said he [Social Worker #1] had brought her some clothes from the clothes closet and while she was changing her clothes that he had put his hand between her legs, put his fingers up inside her he also had touched her on her breast had put his mouth on her breast and just stroked her on her back ...I asked her if she told anybody ...I said ...I’m sure there was a nurse and people in and out of the room, did you tell anybody while you were there and she said no that she did not tell anybody about it while she was there, that she had called back and talked to somebody at the hospital ...” Social Worker #1 was not interviewed. The VP of Quality stated they did not have a personal phone # for him on file. The facility was unable to provide Social Worker #1’s employment application. The VP of Quality confirmed she entered the allegations in the facility incident reporting system and reported it to the state. The VP of Quality also confirmed that she and the Supervisor of Case Management interviewed Social Worker #1 together via telephone. The VP of Quality stated she asked Social Worker #1 what he remembered about Patient #2. She stated, “ ...he [Social Worker #1] remembered her, he remembered she came in by EMS [Emergency Medical Service], that she had overdosed and he remembered going and getting her some clothes out of the closet ... her clothes were wet ...it was raining outside that day ...” The VP of Quality was asked about the facility’s investigation. The VP of Quality stated, she finished the investigation, and it was a “he said she said”. She stated they did a thorough investigation, there were no witnesses. The VP of Quality confirmed she was unable to substantiate the allegation. The Director of Case Management was asked about Social Worker #1’s demeanor during the interview with him. The Director of Case Management stated, “...he was calm ...he’s pretty stoic, he has a military background...” The VP of Quality and The Director of Case Management were asked if Social Worker #1 had ever had any other allegations of sexually inappropriate behavior. The VP of Quality stated, “ ...In October last year I had the chance to talk to [Named Social Worker #1] about another incident ...it was young lady who had come into our emergency department who also did not immediately let us know that she had a concern ...that he had come to her apartment. She had given him her address, they had exchanged phone numbers and she was alleging that ...he had touched her inappropriately in her apartment ...” The VP of Quality stated that happened off this campus he took her home from the hospital. She stated Patient 1 had filed a police report. The VP of Quality stated, “ ...we even tried to get video footage from her apartment complex to show whether or not his car was pulled up there and we never could get that ...she never alleged anything happened at the hospital, this was at her apartment ...of course he said it never happened, he never went there...” The VP of Quality was asked what the process was for the investigation in October, 2024. The VP of Quality confirmed Social Worker 1 was suspended pending the outcome of the investigation but was brought back to work because it was not substantiated. The VP of Quality was asked if any education and monitoring were done after the allegations were made in October of last year. The VP of Quality stated, “...I told him if it is a female patient, I’m recommending you have an escort when you’re in the room and never close the room door, you can have a private conversation with somebody where nobody else can hear what you’re saying ...” The VP of Quality was asked if there was documentation of the education and recommendations to Social Worker #1. The VP of Quality stated there was nothing in writing. The VP of Quality was asked when the second allegation came in regarding Social Worker #1, what was the conversation with Social Worker #1. The VP of Quality stated, “...the first thing I asked him on May 5th [2025], was do you remember those things we talked about ...he did remember, he forgot to do it though...he told me for [Named Patient #2], the door was not closed ...” The VP of Quality confirmed Social Worker #1 was suspended on 5/8/2025 pending the outcome of the investigation and was ultimately terminated out of an “abundance of caution”. During an interview on 5/28/2025 beginning at 11:20 AM, the Director of Case Management was asked to describe Patient #2’s demeanor during the interviews because there were allegations from both Patient #1 and Patient #2. The Director of Case Management stated, “...initially he was pretty nervous, and he said ... ‘I just need to quit trying to help people if this is what’s happening ...’ This person [Patient #1] came through the ER in October [2024] and it was a substance issue with her ...she may have been a person that had come through the ER couple of times and he connected with her a couple of times ...he came to her house afterwards and it wasn’t ever substantiated, I think they tried to pull video and the apartment complex didn’t have it, he denied it of course ...there was no other issues between then and now with any patient ...” The Director of Case Management was asked what was Social Worker #1’s main job duty and what type of patients did he routinely see. The Director of Case Management confirmed Social Worker #1 was the designated ED Social Worker ...so he has to do the initial discharge plan and evaluations and get all of that before the patients can get on the floor ...or make some decisions from that first review that may even circumvent an inpatient stay. That’s his role primarily ...””

“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: 19001 Based on hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking medical treatment were provided an appropriate medical screening examination (MSE) for 1 of 21 (Patient #1) sampled patients, failed to ensure stabilizing treatment was provided to 1 of 21 (Patient #1) sampled patients presenting to the Emergency Department (ED) seeking medical care for pain. The hospital failed to ensure the risks and benefits of examination and treatment were explained to and documented for all patients presenting to the ED seeking medical care and leaving against medical advice (AMA) for 1 of 21 (Patient #13) sampled patients. The findings included: 1. Medical record revealed Patient #1, a 73-year-old male, presented to the Hospital’s ED on 10/29/2024 at 1:53 PM via Emergency Medical Services (EMS) with complaint of chest pain and all over pain. Patient #1 did not receive laboratory testing for troponin (troponin is a protein found in heart muscle cells that is released into the blood when the heart is damaged; a troponin test measures the amount of troponin in the blood to help diagnose heart attacks and assess the extent of heart damage) to rule out a heart event prior to discharge. Patient #1 reported his pain as moderate/5 on a scale from 0-10. Patient #1 was not administered any medications for his pain prior to discharge. Cross Refer to 2406 and 2407. 2. Medical record revealed Patient #13, an 87-year-old female, presented to the ED on 12/1/2024 at 10:59 AM via private vehicle with complaints of dizziness for 2 days and generalized weakness. Patient #13 had an abnormal electrocardiogram, and elevated troponin levels. Patient #13 decided to leave the ED against medical advice, while awaiting a hospital bed for admission. The ED Physician failed to document the discussion of the risks versus benefits for remaining at the hospital for further evaluation. Cross Refer to 2407.”

“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: 19001 Based on hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED), seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE) within the capabilities of the hospital for 1 of 21 (Patient #1) sampled patients. The findings included: 1. Review of the hospital policy “EMTALA [Emergency Medical Treatment and Active Labor Act] Tennessee Medical Screening Examination and Stabilization” revised 12/2023 revealed, “The policy reflects guidance under EMTALA and associated state laws only. 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...POLICY: An EMTALA obligation is triggered when an individual comes to the dedicated emergency department (DED) and 1. The individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition; or 2. A prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition...PROCEDURE 1. When an MSE is required. A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department including ancillary services routinely available to the DED, to determine whether or not and EMC exists to any individual...who requests such an examination...An MSE shall be provided to determine whether or not the individual is experiencing a EMC...An MSE is required when: a. The individual comes to the DED of a hospital and a request is made by the individual or on the individual’s behalf for examination and treatment of a medical condition including where i. the individual requests medication to resolve or provide stabilizing treatment for a medical condition....3. Extent of the MSE...b. definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital...e. Extent of MSE varies by presenting symptoms...i. Depending on the individual’s presenting symptoms, an MSE can involve a wide spectrum of actions, ranging from simple process involving only a brief history and physical...to a complex process that also involves ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures...” 2. Review of the Emergency Medical Services (EMS) trip report dated 10/29/2024 revealed Patient #1, a 73-year-old male called for EMS for complaints of chest pain. The EMS narrative revealed, “...responded to [Bus Company] station for Chest Pain. Arrived to find male sitting upright on bench, patient advised he had generalized body pains for the last 3 months, was seen [named another hospital] yesterday for chest pain and discharged to [homeless shelter]. Patient took 324 mg [milligrams] ASA [aspirin] prior to our arrival, advised he has nitro [nitroglycerin - medication used to treat and prevent chest pain] but has not taken any today. Pt [patient]...advised he is aching all over and feeling worn out...Vitals recorded. 12 lead [electrocardiogram test that shows electrical activity of the heart] shows a sinus tach [tachycardia - the heart is beating faster than 100 times per minute]. Pt [patient] refused Nitro at this time. Transported to [named Hospital #1] no incidents.” The EMS report revealed the unit arrived at Hospital #1 at 1:50 PM and care was transitioned to Hospital #1’s ED staff. 3. Patient #1’s ED record at Hospital #1 revealed a 73-year-old male who presented to the Hospital’s ED on 10/29/2024 at 1:53 PM via EMS with complaint of “pain all over”. Triage was initiated at 2:07 PM with the stated complaint “PAIN ALL OVER”, and chief complaint “Chest Pain”. The subjective assessment by Nurse #2 revealed, “EMS stated that patient was picked up from [Bus Company] bus station. Pts initial call was for chest pain but stated he hurt all over when EMS arrived.” Patient #1 reported his pain as moderate and rated it 5 on a scale of 0-10 with 0 being no pain and 10 being the worst pain. The MSE was initiated at 1:54 PM by ED Physician #1 with the chief complaint recorded as “generalized pain”. ED Physician #1’s History and Present Illness note revealed, “This is a 73-year-old patient with reported history of hypertension, DVT [deep vein thrombosis] and anticoagulated on Xarelto [medication to prevent blood clotting], also reports a history of chronic pain and used to be on pain management, visiting from [named state], brought in from [Bus Company] bus station reportedly for stated complaint of not feeling well, occurring over the past several days...Patient reports he hurts from head to toe, denies shortness of breath, vision disturbances, any facial/extremity tingling/numbness or weakness.” There were no troponin laboratory orders for Patient #1. (Troponin is a protein found in heart muscle cells that is released into the blood when the heart is damaged. A troponin test measures the amount of troponin in the blood to help diagnose heart attacks and assess the extent of heart damage). Patient #1 was discharged from Hospital #1 by ED Physician #3 on 10/29/2024 at 4:49 PM. 4. During an interview on 12/17/2024 at 12:35 PM, Nurse #2 verified she provided care to Patient #1 in the ED on 10/29/2024. Nurse #2 stated she did recall Patient #1, that he initially refused to have an IV started, but later agreed. Nurse #2 stated she drew labs for BMP, CMP and Troponin after getting Patient #1’s intravenous (IV) access started, however the physician made the determination about what orders and lab testing would be completed for each patient in the ED. During an interview on 12/17/2024 at 12:46 PM, the Director of Quality verified there were no orders for troponin for Patient #1. During an interview on 12/17/2024 at 3:01 PM, Nurse #3, a Clinical Coordinator in the ED, stated a troponin was typically drawn for all patients who reported chest pain. Nurse #3 stated there were no nurse driven protocols in the ED. Nurse #3 stated the nurses draw labs and wait for the providers to put orders in. Nurse #3 stated the ED Physician determine what labs to order. During a telephone interview on 12/17/2024 at 2:31 PM, ED Physician #2 stated Patient #1 complained of generalized pain all over and not chest pain. When asked if she would order an EKG on a patient who reported generalized weakness, she stated, “on an elderly patient who reported feeling weak, they often get an EKG.” When asked why no Troponin was ordered, ED Physician #2 stated that would be a better question for ED Physician #1 because he initiated the MSE for Patient #1. During a telephone interview on 12/17/2024 at 3:18 PM, ED Physician #1 stated he did not recall Patient #1. When asked what protocols he follows for a patient who presented to the ED with reports of chest pain, ED Physician #1 stated, “EKG, Chest X-ray and cardiac markers.” ED Physician #1 stated he did have access to the electronic medical record for Patient #1 and he did not see any orders for troponin for Patient #1 on 10/29/2024. ED Physician #1 stated Patient #1 reported generalized pain all over as his chief complaint during the MSE, not chest pain.”

“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: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure stabilizing treatment was provided to 1 of 21 ( Patient #1) sampled patients presenting to the Emergency Department (ED) seeking medical care for pain and failed to ensure the risks and benefits of examination and treatment was explained and documented to all patients presenting to the ED seeking medical care and leaving against medical advice (AMA) for 1 of 21 (Patient #13) sampled patients. The findings included: 1. Review of the hospital policy “EMTALA [Emergency Medical Treatment and Active Labor Act] Tennessee Medical Screening Examination and Stabilization” last revised 12/2023 revealed,” The policy reflects guidance under EMTALA and associated state laws only. 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...POLICY: ...6. Refusal to Consent to Treatment a. Written Refusal- Partial Refusal of Care or Against Medical Advice. If a physician or QMP [Qualified Medical Person] has begun the MSE or any other stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits and the hospital’s obligations under EMTALA, reasonable attempts should be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individual’s refusal to sign the Patient Refusal of Care or the Against Medical Advice form...7. Stabilizing Treatment Within Hospital Capability The determination of whether an individual is stable is not based on the clinical outcome of the individual’s medical condition. An individual has been provided a sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely ...a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist ...” Review of the hospital policy “Pain Assessment and Reassessment, Management and Documentation” revised 3/2023 revealed, “PURPOSE: To establish an approach to pain management consistent with patient needs, preferences and rights and within organizational ICARE/ PROMISE values. POLICY : [named Hospital #1] respects patient’s right to pain management ...[named Hospital #1] assesses. reassesses and manages its patient’s pain consistent with scope of care treatment, services and the patient’s condition ...[named Hospital #1] treats the patients pain or refers the patient to treatment if necessary ...” Review of the hospital policy “Discharge of Patient Against Medical Advice (AMA)” last revised 01/2012 revealed, “PURPOSE: To insure [ensure] that the patient and/or guardian have been informed and acknowledge understanding of risks involved in refusal to accept offered medical treatment/services. POLICY: The patient and/or guardian will be advised of the risks and benefits involved in leaving the medical center against medical advice relative to his or her medical condition. PROCEDURE: 1. If a patient or guardian wishes to sign out of the medical center against medical advice, the administrative supervisor of nursing and the patient’s physician are to be notified immediately. 2. If the physician (or nurse in the absence of the physician) has explained all the risks involved in the patient’s refusal of medical treatment, as well as all the benefits involved in his/her remaining a Release of Responsibility for Discharge form is to be signed by the patient...and witnessed by two nurses or a nurse and physician...” 2. Medical record review for Patient #1 revealed a 73-year-old male who presented to the hospital’s ED via Emergency Medical Services on 10/29/2024 at 1:53 PM with complaints of chest pain and generalized all over pain. Triage was initiated at 2:07 PM with the stated complaint “PAIN ALL OVER”, and chief complaint “Chest Pain”. The subjective assessment at 3:12 PM, by Nurse #2, revealed “EMS [Emergency Medical Services] stated that patient was picked up from [Bus Company] bus station. Pts [Patient’s] initial call was for chest pain but stated he hurt all over when EMS arrived.” At 3:14 PM, Patient #1 reported his pain as moderate and rated it 5 on a scale of 0-10 with 0 being no pain and 10 being the worst pain. There was no documentation that Patient #1’s pain was assessed from his arrival at 1:53 PM to the pain assessment conducted at 3:14 PM (1 hour 21 minutes). The MSE was initiated at 1:54 PM by ED Physician #1 with the chief complaint recorded as “generalized pain”. ED Physician #1’s History and Present Illness note revealed, “This is a 73-year-old patient with reported history of hypertension, DVT [deep vein thrombosis] and anticoagulated [use of medication to prevent blood clotting] on Xarelto [medication to prevent blood clotting], also reports a history of chronic pain and used to be on pain management, visiting from [named state], brought in from [Bus Company] bus station reportedly for stated complaint of not feeling well, occurring over the past several days ...Patient reports he hurts from head to toe...” Review of ED Physician #1’s Medical Decision-Making Notes revealed, “The patient presents with vague and stated complaint of generalized pain.” There was no treatment provided to Patient #1 to address his pain reported as 5 on a scale of 0-10. Patient #1 was discharged from Hospital #1 by ED Physician #2 on 10/29/2024 at 4:49 PM. There was no documentation Patient #1’s pain was reassessed after the time of the initial pain assessment documented at 3:14 PM to the time of his discharge at 4:49 PM (1 hour 35 minutes). During an interview on 12/17/2024 at 12:35 PM, Nurse #2 verified the patient was not administered any pain medication in the ED. During an interview on 12/17/2024 at 12:46 PM, the Director of Quality verified there were no orders for pain medication to address Patient #1’s pain. During a telephone interview on 12/17/2024 at 2:31 PM, ED Physician #2 stated Patient #1 complained of generalized pain all over and not chest pain. ED Physician #2 verified Patient #1 was not administered any pain medications in the ED on 10/29/2024. During a telephone interview on 12/17/2024 at 3:18 PM, ED Physician #1 stated he did not recall Patient #1. When asked if Patient #1’s pain was addressed, ED Physician #1 stated he signed out and transitioned the care for Patient #1 to ED Physician #2. 2. Medical record review for Patient #13 revealed a 87-year-old female who presented to the ED on 12/1/2024 at 10:59 AM via private vehicle with complaints of dizziness for 2 days and generalized weakness. Triage was initiated at 11:05 AM. The MSE was initiated at 11:10 AM. ED Physician #3 documented the patient presented for dizziness and weakness occurring for several days. Troponin (Troponin is a protein found in heart and skeletal muscles that helps regulate calcium and muscle contraction. In medical terminology, troponin levels in the blood can indicate heart damage or injury. Troponin levels are within normal limits are 0-54) labs revealed slightly elevated levels at 11:21 AM-55 and at 12:34 PM-59. An electrocardiogram (EKG- a test that measures electrical activity of the heart) report resulted at 11:58 AM revealed a sinus rhythm with a 1st degree AV block (is a minor arrhythmia that occurs when electrical signals from the atria (top chambers of the heart) to the ventricles (bottom chambers of the heart)are delayed), a non-specific intraventricular block (is a conduction disorder that causes a widened QRS complex on an electrocardiogram), T wave abnormality (refers to an unusual appearance of the T wave, which represents ventricular repolarization, indicating potential issues like myocardial ischemia). Review of ED Physician #3’s Clinical Impression note revealed, “Patient presents for generalized weakness, she does not report any chest pain or shortness of breath, denies any significant past cardiac history, her EKG is abnormal but does not appear significantly changed from prior and does not appear to meet STEMI (medical term for heart attack) criteria, her troponin is very mildly elevated and slightly up trending, will admit to the hospitalist for further work up, trend troponins, cardiology consult.” A nurse note dated 12/1/2024 at 3:11 PM revealed, “Pt [patient] opted to go home against medical advice despite explaining the risks. [named ED Physician #3] explained possible life-threatening incident if Pt will go AMA Patient Still signed AMA form.” Review of the Informed Refusal for Partial Refusal of Care and AMA form revealed ED Physician #3 did not document the risks and benefits explained to Patient #13, in the AMA section of the form. Review of ED Physician #3’s provider note did not document discussion with Patient #13 regarding the risks and potential outcomes of leaving the ED AMA . During a interview on 12/17/2024 at 11:50 AM, Nurse #1 verified she cared for Patient #13 in the ED on 12/1/2024. Nurse #1 verified she had signed page 1 of the AMA form for Patient #13, along with ED Physician #3. When asked who was required to complete page 2 of the AMA form specifically the risks and benefits section, Nurse #1 stated she did not know what to write there, and the ED Physician completed that section. The Assistant ED Medical Director called the surveyor on 12/18/204 at 8:27 AM and reported ED Physician #3 was not available for interview because he was sleeping. The Assistant ED Medical Director stated he was familiar with the case and felt comfortable answering questions about Patient #13. The Assistant ED Medical Director verified the risks and benefits section was not completed on the AMA form for Patient #13 but stated ED Physician #3 had documented the discussion in his notes. The surveyor explained there was no documentation in ED Physician #3’s notes. The Assistant ED Medical Director asked for time to review the notes a requested to telephone the surveyor back, as he was driving. During a subsequent telephone interview on 12/18/2024 at 8:59 AM, the Assistant ED Medical Director stated he was unable to find any documentation about a discussion regarding risks and benefits with Patient #13 by ED Physician #3. The Assistant ED Medical Director stated, “The nurse documented it but he [ED Physician #3] did not.” The Assistant ED Medical Director stated that was an area for improvement and he did expect physicians to document discussions with patients before they leave the ED AMA.”

“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: 33763 Based on hospital policy review, document review, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 23 (Patient #1) sampled patients reviewed. The findings included: 1. Review of the hospital policy titled, “EMTALA [Emergency Medical Treatment and Labor Act] - Definitions and General Requirements” last approved 8/2024 revealed, “...The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development, who “comes to the emergency department” an appropriate Medical Screening Examination (“MSE”) 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 (“EMC”) exists...” Review of the hospital policy titled, “EMTALA [named state] Medical Screening Examination and Stabilization” revised 12/2023 revealed, “...A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED [dedicated emergency department]...The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thought or gestures that indicates danger to self or others...Psychiatric QMP [Qualified Medical Personnel]. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies...” Review of the hospital policy titled, “Assessment/Reassessment/Plan of Care of Patients” revised 5/2023 revealed, “...Emergency Department...All patients (ESI [Emergency Severity Index] Level Triage 1-3) presenting to the Emergency Department will receive...Rapid Initial Assessment (Rapid Triage) with assigned acuity...Chief Complaint Assessment...Detailed Assessment...Suicide Risk Screening (on all patients > [greater than] 12 years old who are being evaluated for behavioral health conditions as their primary reason for care)...Disposition Assessment...Rapid Initial Assessment is the information-collecting and decision making process to sort ill patients into categories of acuity based on the urgency of medical and psychological needs...Triage Acuity Levels...Level 1 Resuscitation...Level 2 Emergent [patient is considered an emergency and should be seen by a physician promptly]...” Review of the hospital policy titled, “Suicide Risk Assessment (Non-Behavioral Health)” revised 4/2023 revealed, “Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. Suicide Detailed Risk Assessment (suicide DRA)...Any patient with a positive, “at-risk” C-SSRS screening...require a secondary level detailed suicide risk assessment (suicide DRA) to identify activating events, protective factors, and contributing clinical factors to risk of suicide. This would be completed by a licensed or credentialed physician/practitioner. The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgement to determine (estimate) the patient’s overall risk level (ORL)...The ORL is considered the standard of care for assigning suicide risk level as it is based on consideration of modifiable and protective risk factors...” 2. Review of the hospital document titled, “Medical Staff Rules and Regulations” revised 2/9/2023 revealed, “...Medical Screening Exam a. Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination (MSE) performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists. An appropriate MSE includes routinely available ancillary services...The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred...It is the policy of the hospital that the MSE is done by the emergency Physician, Quality Medical Personnel (QMP), attending physician or on-call Physician...In addition to Physicians, Physician Assistants, and Nurse Practitioners, QMP for Psychiatric Screening includes the Non-physician Community Assistance Program (CAPS) Staff meeting educational and experience qualifications are approved to perform the initial medical screening examination and consultation for patients with psychiatric care needs...” 3. Review of the hospital’s ED log revealed Patient #1, a 25 year old male, presented via walk in on 8/8/2024 at 5:26 PM with chief complaint of “Suicidal Thoughts.” Medical record review revealed Patient #1 was evaluated by Registered Nurse (RN) #1 at 5:26 PM. RN #1 documented Patient #1 reported having suicidal thoughts, was very anxious, agitated and verbally aggressive upon arrival. The nursing documentation further showed Patient #1’s blood pressure and heart rate were elevated, and the patient was very tearful and requested medications to help him calm down and to treat his pain. Patient #1 reported he had 5 previous suicide attempts and had just moved to the area from out of state. The C-SSRS assessment revealed Patient #1 was “high risk” for self-harming behaviors. Patient #1 was seen by ED Provider #1 initially on 8/8/2024 at 5:33 PM, and ED Provider #1 documented Patient #1 had a history of borderline personality disorder, denied suicidal and/or homicidal ideations and was anxious and agitated and stated he needed to relax. ED Provider #1 further documented the patient had no primary care provider. ED Provider #1 documented he spoke with Patient #1’s parents, and they didn’t think Patient #1 was suicidal. ED Provider #1 documented Patient #1 calmed down and was stable for discharge home. There were no physician orders for laboratory work, medications, and/or psychiatric or behavioral health consults. Patient #1 left the ED unaccompanied on 8/8/2024 at 6:25 PM with no follow-up appointment scheduled, no new prescriptions for medications to address his anxiety, and no documented safety plan. There was no documentation Patient #1 was assessed for physiologic causes of his psychiatric condition. There was no blood work or toxicology testing completed. There was no documentation a psychiatric evaluation was completed. There was no documentation Patient #1 received treatment for his acute anxiety while at the hospital’s ED. The hospital failed to ensure Patient #1 received an appropriate and on-going medical screening examination, monitoring and treatment to determine if an EMC existed. Refer to A2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33763 Based on hospital policy review, document review, medical record review, and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 23 (Patient #1) sampled patients reviewed. The findings included: 1. Review of the hospital policy titled, “EMTALA [Emergency Medical Treatment and Labor Act] - Definitions and General Requirements” last approved 8/2024 revealed, “...The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development, who “comes to the emergency department” an appropriate Medical Screening Examination (“MSE”) 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 (“EMC”) exists...” Review of the hospital policy titled, “EMTALA [named state hospital located] Medical Screening Examination and Stabilization” revised 12/2023 revealed, “...A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED [dedicated emergency department], including ancillary services routinely available to the DED, to determine whether or not an EMC exists: to...an individual who has such a request made on his or her behalf; or...an individual whom a prudent layperson observer would conclude from the individual’s appearance or behaviors needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC...An MSE is required when...The individual comes to a DED of a hospital and a request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition...Extent of the MSE...The hospital must perform an MSE to determine if an EMC exists...Triage entails the clinical assessment of the individual’s presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be screened by a physician or other QMP [qualified medical person]...An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not...The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital...The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer...The extent of the necessary examination to determine whether an EMC exists is generally within the judgement and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and governing board...Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thought or gestures that indicates danger to self or others...Psychiatric QMP. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies...” Review of the hospital policy titled, “Assessment/Reassessment/Plan of Care of Patients” revised 5/2023 revealed, “...Emergency Department...All patients (ESI [Emergency Severity Index] Level Triage 1-3) presenting to the Emergency Department will receive...Rapid Initial Assessment (Rapid Triage) with assigned acuity...Chief Complaint Assessment...Detailed Assessment...Suicide Risk Screening (on all patients > [greater than] 12 years old who are being evaluated for behavioral health conditions as their primary reason for care)...Disposition Assessment...Rapid Initial Assessment is the information-collecting and decision making process to sort ill patients into categories of acuity based on the urgency of medical and psychological needs...Triage Acuity Levels...Level 1 Resuscitation...Level 2 Emergent [patient is considered an emergency and should be seen by a physician promptly]...” Review of the hospital policy titled, “Suicide Risk Assessment (Non-Behavioral Health)” revised 4/2023 revealed, “Columbia Suicide Severity Rating Scale (C-SSRS): Initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. Suicide Detailed Risk Assessment (suicide DRA): Subsequent assessment completed by the Provider/practitioner. The Suicide DRA must be completed for any patient with a positive C-SSRS screen. Overall Risk Level (ORL): Determined by the provider/practitioner’s clinical judgement and suicide DRA. The provider/practitioner will assign a level of no risk, low, moderate, or high risk. This will take precedence over the C-SSRS, if the risk level differs...Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being...Patients in non-psychiatric areas (e.g. Emergency Room (ER) patients, and non-BH [behavioral health] inpatient units, age 12 years and older, who are being evaluated or treated for behavioral health...conditions as their primary reason for care should be screened using the C-SSRS...The Provider/Practitioner will be notified of positive screens (i.e. [such as], at risk patients)...The nursing assessment will include current, recent, and past thoughts of suicide, plans, means and/or intents, as well as recent or past history of suicide attempts within their lifetime for patients age twelve and above being admitted to emergency rooms...who are being evaluated for treatment for behavioral health (BH) conditions. The C-SSRS is the initial screening tool utilized by the nurse...it is intended to differentiate “at-risks” patients from patients without identified risk...Any patient with a positive, “at-risk” C-SSRS screening...require a secondary level detailed suicide risk assessment (suicide DRA) to identify activating events, protective factors, and contributing clinical factors to risk of suicide. This would be completed by a licensed or credentialed physician/practitioner. The Provider/Practitioner will use the information collected from the suicide DRA paired with clinical judgement to determine (estimate) the patient’s overall risk level (ORL)...The ORL is considered the standard of care for assigning suicide risk level as it is based on consideration of modifiable and protective risk factors...” 2. Review of the hospital document titled, “Medical Staff Rules and Regulations” revised 2/9/2023 revealed, “...Medical Screening Exam a. Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination (MSE) performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists. An appropriate MSE includes routinely available ancillary services...The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred...It is the policy of the hospital that the MSE is done by the emergency Physician, Quality Medical Personnel (QMP), attending physician or on-call Physician...QMP or Personnel...In addition to Physicians, Physician Assistants, and Nurse Practitioners, QMP for Psychiatric Screening includes the Non-physician Community Assistance Program (CAPS) Staff meeting educational and experience qualifications are approved to perform the initial medical screening examination and consultation for patients with psychiatric care needs...” 3. Review of the hospital’s ED log revealed Patient #1, a 25 year-old male, presented via walk in on 8/8/2024 at 5:26 PM with chief complaint of “Suicidal Thoughts.” Medical record review revealed a triage assessment was completed by Registered Nurse (RN) #1 on 8/8/2024 at 5:26 PM and revealed, “...Stated Complaint: Suicidal Thought...Pt [patient] reports having suicidal thoughts but does not want to be admitted. Pt [patient] state he just wants a ‘sedative and something for pain and to go home.’... Objective assessment...A&OX4 [alert and oriented to person, place, time, and situation], tearful and verbally aggressive/uncooperative...Hypertensive...” The patient’s presenting vital signs were Respiratory Rate (RR) 18, Pulse (P) 119, Blood Pressure (BP) 197/102, and oxygen saturation (O2 sat) of 99 percent (%) on room air. Patient #1 was assigned an ESI level 2, Emergent (patient is considered an emergency and should be seen by a physician promptly). The nursing documentation further revealed RN #1 completed the C-SSRS assessment and Patient #1 was found to be a High Risk for suicide. RN #1 documented, “Upon bringing pt back for triage, Pt was tearful but agitated/uncooperative/verbally aggressive and immediately stated ‘I am not being admitted to the hospital. I will sign out AMA [against medical advice].’ This RN told Pt about the psych [psychiatric] eval [evaluation] process and that we needed more information from him to be able to figure out best way to help him. Pt states he has had 5 SI [suicide] attempts in the past and that he just wanted a sedative and something for pain and to go home. Pt refused to answer if he recently attempted SI but stated ‘I know better than to answer that question with a camera pointed at me. I am not going to be trapped in a hospital.’ Pt stated that this RN...were ‘trying to trick him’.” Patient #1 was seen by ED Provider #1 at 5:33 PM. The Provider documented, “...The patient reportedly has a history of borderline personality disorder and bipolar disorder. The patient presents to the emergency department feeling anxious and feeling that he needed to relax. I spoke with the patient’s parents...who states that the patient just recently moved to this area...10 days ago. He states that the patient was going to depression/bipolar support [DBS] groups regularly...and went to a DBS group meeting locally 6 days ago. The patient’s dad states that he was tricked out of some money while at the mall her [here] today and this triggered him...Chief Complaint: Anxious...Reports Anxiety. Denies: Agitation, Anorexia, Delusions, Depression, Illicit drug use...Paranoia, Violence. Exacerbated by Recent stress Relieved by Nothing...Detailed Suicide Risk...Pos [positive] Nur [nursing] Sui [suicide] Risk Screen? No Overall level suicide risk: no risk Risk Stratification...Suicide - Adult Risk factors reviewed, Prior psych admission...Stated Complaint Suicidal Thoughts...” The Provider further documented that he reviewed the Nursing triage notes as well as the Patient’s home medication list. ED Provider #1 documented, “...Focused PE [Physical Exam]...Awake, alert, No acute distress...Oriented x 3, Speech NL [normal limits], No motor deficits...Psychiatric Not suicidal, Not homicidal...Agitated...Anxious...Both the patient’s parents who spoke with him while he was in emergency department state that they feel that the patient is state [safe]. They states [state] that they did not feel that the patient has any suicidal ideations.” At 6:21 PM, ED Provider #1 documented, “Re-Eval Status Improved, The patient appears very agitated and anxious initially, but is now very calm. The patient states he would just like some resources for local psychiatric services...Condition Stable, Improved...Primary Impression: Anxiety Secondary Impressions :Hx [history] of borderline personality disorder...Discharged to Home...Counseled Regarding Diagnosis, Need for follow-up, When to return to ED...Resource Referral: [named mental health facility]...Follow-Up: Call ASAP [as soon as possible] to arrange...” The Discharge Assessment completed by RN #1 at 6:25 PM revealed the Patient’s vital signs were P 99, RR 17, BP 170/86, and O2 sat 100%. The assessment further revealed, “...Behavioral Health Related--Patient condition assessment: No change...” Patient #1 left the ED unaccompanied on 8/8/2024 at 6:25 PM with no follow-up appointment scheduled, no new prescriptions for his anxiety, and no safety plan. There was no documentation Patient #1 was assessed for physiologic causes of his psychiatric condition. No blood work or toxicology testing was completed. There was no documentation a psychiatric evaluation was completed. There was no documentation Patient #1 received treatment for his acute anxiety while at the hospital’s ED. The hospital failed to ensure Patient #1 received an appropriate and on-going medical screening examination, monitoring and treatment to determine if an EMC existed. 4. During an interview on 9/17/2024 at 12:20 PM, the ED Medical Director (EDMD) was asked to describe the standard of care for patients presenting to the ED with psychiatric complaints. The EDMD stated the hospital had no “standing orders” for psychiatric patients. The EDMD continued and stated when patients presented to the ED with psychiatric complaints, they would first make sure the patient was “medically stable” and do “routine lab workup” to rule out any medical etiology.” The EDMD stated once the patient had been cleared medically, they would consult CAPS for a behavioral health evaluation, then review their recommendations on whether the patient required inpatient services, outpatient services, or if they were deemed stable for discharge home. The EDMD stated that if the behavioral health evaluation indicated the patient required inpatient hospitalization, a psychiatrist would be consulted for a second evaluation and then begin searching for an available bed. The EDMD was asked if there were times when CAPS would not be consulted to complete a behavioral health assessment. The EDMD stated, “Yes. Some patients are here frequently, and we know their history...” The EDMD continued and stated when dealing with pediatric patients, he would rely heavily on the patient’s parents to see if they wanted to have a psychiatric evaluation completed. The EDMD stated, “A lot of patients have counselors available and might reach out to their counselors for the first available appointment.” The EDMD was provided the opportunity to review Patient #1’s ED record and was asked if any lab work or psychiatric evaluation should have been completed. The EDMD stated, “Just reviewing the record it’s hard to tell without interacting with the patient myself. It’s hard to tell. It looks like he [ED Provider #1] did talk to his parents. I think these cases are so hard to determine. The interaction with the patient is vital to determine whether or not further work up is necessary. We rely a lot on outsider’s information.” The EDMD was asked if he recognized Patient #1’s name. The EDMD stated, “No, it says he just moved here.” During an interview on 9/17/2024 at 12:30 PM, the Director of Emergency Medicine (DEM) was asked to describe the standard of care for nursing when dealing with patients who presented with psychiatric complaints. The DEM stated nurses would assess the patient’s symptoms and complaints such as anxiety, suicidal ideations, or homicidal ideations. The DEM continued and stated if the nurse feels there is a safety issue with the patient, the patient’s belongings would be removed along with any items that would present a safety risk and the patient would be asked to remove their clothes and provided a paper gown. The DEM stated once the patient was safe, the ED Provider would complete the MSE. During an interview on 9/17/2024 at 2:24 PM, RN #1 was asked to describe the nursing role when caring for patients who presented to the ED with psychiatric complaints. The RN stated the patient would be taken to room 10 or 11 (ED rooms designated for psychiatric patients), and a triage assessment would be completed including a risk assessment. RN #1 stated they would follow the protocol based on the risk assessment, such as collecting the patient’s belongings. The RN stated a Crisis Prevention Intervention (CPI) trained person would remain with the patient until the Provider did the assessment. RN #1 continued and stated, the ED Provider would put in orders for a psychiatric consult via telehealth and then they would follow the recommendations accordingly. RN #1 confirmed she recalled Patient #1 and.stated, “He had just moved here from out of state I believe. He came in by himself. He was extremely agitated, belligerent and wouldn’t answer questions. I asked him ‘what brought you in?’ He said I was looking at him judgmentally. He said he wanted some medication and wanted to go home.” RN #1 was asked if she completed a suicide risk assessment or aggression risk assessment on the Patient. The RN stated, “He said he wasn’t suicidal at the time, but has had thoughts (suicidal); it was more along the lines of he was tired and wanted meds [medications].” RN #1 continued and stated the patient was informed of the hospital’s process and that the ED Provider would have to evaluate him to determine what his needs were and what needed to be done to help him. The RN stated Patient #1 “didn’t like that and said he wasn’t going to be hospitalized. RN #1 was asked if she was present when ED Provider #1 assessed the Patient. The RN stated, she met the ED Provider as he was entering and she was exiting the Patient’s room, but she did not stay in the room for the exam. RN #1 was asked if she told the Patient he couldn’t leave the ED against medical advice. The RN stated, “No, we said he would have to wait until the doctor sees him. He was very agitated and aggressive.” The RN was asked if any lab work was collected or any medications were given to Patient #1, or if a psychiatric consult was completed. RN #1 stated, “I didn’t see any. I don’t recall.” RN #1 continued and stated, the “ED Provider puts in the order for a psychiatric consult.” RN #1 was asked if psychiatric consults were usually ordered for patients who presented with psychiatric complaints. The RN stated, “Yes.” During an interview on 9/17/2024 at 2:36 PM, the Director of Quality (DOQ) stated there was an algorithm model in the electronic charting. The DOQ stated, “Not all psych patients are suicidal or homicidal. The may just be having a panic attack or something.” The DOQ continued and stated for all behavioral health patients, the nurse does a risk assessment and if the assessment is positive, the ED Provider is notified, and he does his own risk assessment. If the ED Provider determines the patient is at risk, the Provider will order a psychiatric or behavioral health evaluation.” During a telephone interview on 9/17/2024 at 2:45 PM, ED Provider #1 was asked to describe the standard of care for patients who presented to the ED with psychiatric complaints. The ED Provider stated, “It depends on the complaint.” The ED Provider continued and stated if there were complaints concerning for danger, the patient would be assessed and taken to a safe place and obtain a full history on what was going on. The ED Provider continued and stated, the patient would be “medically cleared and we would consult a mental health provider.” ED Provider #1 was asked if he could recall Patient #1. The Provider stated, “This person just had anxiety and he came to me for something for anxiety.” ED Provider #1 continued and stated Patient #1 was not suicidal, “I talked to him, and his parents confirmed he was not suicidal, just borderline personality.” When asked if he ordered any lab tests on Patient #1, the ED Provider stated, “Labs are for clearance, not for anxiety.” ED Provider #1 was asked if Patient #1 was given any medication for his anxiety. The ED Provider stated, “I think he was offered some medications, but he declined it prior to leaving.” During an interview on 9/17/2024 at 2:52 PM, the DEM verified there was no documentation in Patient #1’s medical record to indicate the Patient was offered medications to treat his anxiety. The DEM then confirmed there were no medications ordered or prescribed for Patient #1. During a telephone interview on 9/17/2024 at 3:29 PM, Patient #1 stated, he was “very much in distress” when he presented to the ED. The Patient continued and stated, “As soon as I stepped in the facility things went downhill from there. I’ve been admitted to a psych [psychiatric] floor twice, and the 3rd time, I signed out AMA. I made a promise to myself that I wasn’t going back. I made it clear to them as well. I had mentioned AMA after [Named ED Provider #1] said he was recommending something I will not like. I ended up feeling like I got brushed off by him.” Patient #1 was asked if anything was done to address his condition. The Patient verified he was not offered any medications; no lab work was collected and no psychiatric or behavioral health assessment and/or consults were completed. Patient #1 continued and stated, “I went in because I was wanting some relief...my hands were shaking, and I couldn’t breathe...” Patient #1 stated he had been on the phone with his parents while in the ED. The Patient continued and stated, “I put him [ED Provider #1] on the phone with my parents. He wasn’t very helpful at all. I couldn’t see his last name on his lab coat, so I call him Dr. [ED Provider #1’s first name]. He said, ‘we’re not friends, you can call me Dr. [ED Provider #1’s last name].’ I didn’t feel safe at all, and then I wasn’t allowed to leave.””