Texas Health Harris Methodist Fort Worth

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45521 Based on record review and interview the facility failed to follow the Emergency Department facility policy requiring patient acknowledgment along with a nurse and witness to document patient leaving Against Medical Advice (AMA) in 1 of 20 medical records. The findings were: A review of the document titled “Patient Roster” revealed the following: Three of the twenty patients left Against Medical Advice. One of the three who left against Medical Advice did not have a nurse or witness signature documented for Patient #1’s AMA discharge. The facility documented the patient as leaving against medical advice. However, the facility did not ensure their policy was followed to obtain a patient acknowledgment on the AMA form. A review of the document titled “ED Leaving Against Medical Advice / Left Without Being Seen Policy” page 2, subsection 4.1.3 reveals the following: “If the patient refuses to sign the AMA form, the nurse should document on the form the patient’s refusal to sign and have a second witness who was present in the room sign the form. Any patient who leaves prior to being triaged, after triage but prior to seeing the physician, or who elopes after placed in a room and prior to being seen by a physician, will be considered “Left Without Being Seen” (LWBS). If possible, the nurse should secure the patient’s signature on the AMA form stating refusal of a Medical Screening Exam.” An interview with Staff #2, Emergency Room RN, on 10/15/2025 revealed the following: “Yes, I remeber the patient. She had hallucinations; she said she was seeing colors. Behavior Health evaluated her; she was low-risk, and no sitter was ordered. Behavioral Health’s recommendation was for the patient to be placed in an in-patient setting. She had to wait quite a bit for a transfer because she had requested a specific place. She got tired of waiting and wanted to leave. She waited for her family to pick her up. I canâ Euro (Trademark)t remember if she signed leaving against medical advice (AMA) papers.”

“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: 45847 . Based on record review and interview the facility failed to abide by the provider’s agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the facility’s emergency department (ED) three times. The first ED visit was on 11/11/2023 at 11:55 AM with complaints of a fall at home with right leg weakness following a recent Lumbar 4-Lumbar 5 transforaminal lumbar interbody fusion (a spinal fusion surgery that treats lower back pain and other conditions by joining two or more vertebrae in the spine) on 10/25/2023. The second ED visit was on 11/30/2023 at 11:00 AM with complaints of pain that did not respond to his prescribed pain medications. The medications included hydrocodone, methocarbamol, and gabapentin. Patient #1 also reported drainage from his surgical site. The third ED visit was on 12/02/2023 at 3:26 PM with complaints of increasing back pain, hip pain, abdominal pain, and pelvic pain and having had surgery recently. None of these three ED visits contained an appropriate MSE that was sufficient to rule out emergency medical conditions (EMCs) for Patient #1. . Cross Reference to: Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination. .”

“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: 45847 . Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the facility’s emergency department (ED) three times. The first ED visit was on 11/11/2023 at 11:55 AM with complaints of a fall at home with right leg weakness following a recent Lumbar 4-Lumbar 5 transforaminal lumbar interbody fusion (a spinal fusion surgery that treats lower back pain and other conditions by joining two or more vertebrae in the spine) on 10/25/2023. The second ED visit was on 11/30/2023 at 11:00 AM with complaints of pain that did not respond to his prescribed pain medications. The medications included hydrocodone, methocarbamol, and gabapentin. Patient #1 also reported drainage from his surgical site. The third ED visit was on 12/02/2023 at 3:26 PM with complaints of increasing back pain, hip pain, abdominal pain, and pelvic pain and having had surgery recently. None of these three ED visits contained an appropriate MSE that was sufficient to rule out emergency medical conditions (EMCs) for Patient #1. . Findings include: Medical Record Review for 11/11/2023 Emergency Department (ED) Visit #1: Patient #1, a 53-year-old male, presented to the emergency department (ED) on 11/11/2023 at 11:55 AM after a fall the night before (11/10/2023). His pertinent history included a recent Lumbar 4-Lumbar 5 transforaminal lumbar interbody fusion on 10/25/2023. The documented chief complaints were a fall at home with right leg weakness since yesterday (11/10/2023) and back pain that would not resolve while being two weeks post-operative. Staff #5 documented that Patient #1 had a “full range of motion to bilateral lower extremities” at the time of this ED visit. . Vital signs were documented on 11/11/2023 at 11:00 AM, 12:04 PM, 12:21 PM, 12:30 PM, 1:30 PM, 2:00 PM, and 4:00 PM. . On 11/11/2023 at 12:08 PM, Staff #5, the treating ED physician noted that after a fall last night at home, Patient #1 reported that, “He felt a loss of sensation of his RLE (right lower extremity)” and that “he has pain radiating down his R (right) side and foot numbness. He (Patient #1) is afraid he re-injured his back.” It was further documented that Patient #1 “is postoperative from back surgery done 10/25/2023.” . Morphine 10mg (intramuscularly) IM was administered for pain on 11/11/2023 at 1:00 PM. . On 11/11/2023 at 12:19 PM, Staff #5 documented that he consulted with Staff #6, Neurosurgery, about Patient #1’s case. It was recommended to Staff #5 that if a CT of the lumbar spine was reassuring and the hardware is intact, the patient could call on Monday to the Neurosurgery office for further follow-up. . The last documented pain level for Patient #1 was at level 8 of 10 at 1:01 PM on 11/11/2023. . A CT of the lumbar spine was completed at 1:43 PM showing “no concerning focal lesions.” . On 11/11/2023 at 3:53 PM, Staff #5 documented a plan for follow-up with Neurosurgery as an outpatient and that the referrals had been made with the understanding he should return to the ED for any new or worsening symptoms. . The treating physician, Staff #5, did not document an appropriate history to include Patient #1’s surgery on 10/25/2024. Staff #5 did not document in the medical record a “review of systems” nor did he document an appropriate physical exam. . There were no laboratory studies obtained by Staff #5 (such as a full white count, C-reactive protein (CRP), or a procalcitonin level) noted within the patient record that was provided. It is unknown if an infection had started at this time. The physician, Staff #5, did not ask whether Patient #1 had infectious symptoms such as fever or chills. . Medical Record Review for 11/30/2023 Emergency Department (ED) Visit #2: On 11/30/2023 at 11:00 AM, Patient #1 presented to the ED with complaints of pain that did not respond to his prescribed pain medications. The medications included hydrocodone, methocarbamol, and gabapentin. Patient #1 also reported drainage from his surgical site. . There was a “Sepsis Predictive” score obtained on 11/30/2023 at 11:20 AM documenting a score of 8. A “Sepsis Predictive” score is considered high risk if the score is 2 or higher. A “Sepsis Predictive” score uses a combination of clinical parameters like heartrate, respiratory rate, blood pressure, white blood cell count, lactate level, and mental status assessments. . On 11/30/2023 at 11:18 AM, the treating ED physician, Staff #13, documented that Patient #1 had uncontrollable lumbar back pain and was post-surgery on Monday (11/27/2023) and had been discharged on 11/29/2023. Staff #13 noted that Patient #1 had pain that radiated down his legs and was synchronous with his heartbeat and was worsening and was associated with profuse sweating. Staff #13 did not assess for cord compression, spinal epidural abscess, osteomyelitis, or discitis. . At 11:28 AM, the triage nurse, Staff #14 documented that the skin around the surgical incision was warm when touched and noted a small amount of drainage on the dressing. The initial vital signs at 11:28 AM demonstrated tachycardia (a heartrate above 100 beats per minute) and relative hypotension (a blood pressure less than 90/60 in an adult) when compared to blood pressures and heartrate on previous visits. Patient #1 had a heart rate of 112 and a blood pressure (BP) of 96/70. Patient #1 was afebrile and not hypoxic. . There was a “Sepsis Predictive” score obtained on 11/30/2023 at 11:35 AM of 60.1. . There was a “Sepsis Predictive” score obtained on 11/30/2023 at 11:50 AM of 46.7. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 12:01 PM of 46.7. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 12:16 PM of 26. . Staff #13 ordered a CBC (complete blood count) and a BMP (basic metabolic panel) on 11/30/2023 and the results were posted at 12:25 PM. Patient #1 was found to have a leukocytosis (a condition where a person has a high white blood cell count (WBC), typically more than 11,000 white blood cells per microliter (mcl) of blood in adults) with a WBC of 11.72 WBC/mcl and a slightly elevated anion gap. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 12:31 PM of 5.3. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 12:46 PM of 4.1. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 1:01 PM of 4.1. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 1:17 PM of 2.3. . There was a “Sepsis Predictive” score obtained on 11/31/2023 at 1:31 PM of 2.3. . No documented lab results for lactic acid to screen for sepsis were obtained. There were no documented lab results for an ESR (eosinophil sedimentation rate) or CRP (c-reactive protein) which could have assessed for a spinal infection. There was no EKG (electrocardiogram) ordered for Patient #1’s documented tachycardia and report of profuse sweating to rule out an arrhythmia. The MSEs (medical screening examinations) were inappropriate as it did not adequately rule out other EMCs (emergency medical conditions). . Medical Record Review for 12/02/2023 Emergency Department (ED) Visit #3: On 12/02/2023 at 3:26 PM, Patient #1 presented to the ED with complaints of increasing back pain, hip pain, abdominal pain, and pelvic pain and having had surgery recently. Patient #1 was seen in the same ED 2 days before this visit for severe back pain and at that time had a mild leukocytosis. . Vital signs were obtained on 12/02/2023 at 3:36 PM noting tachycardia and a pulse rate of 110. No EKG to rule out other emergency medical conditions (EMCs) such as acute coronary syndrome could be located within the provided patient record. . The treating ED physician, Staff #5, documented on 12/02/2023 at 3:39 PM that Patient #1’s family reported a bump near the incision and that Patient #1 felt a bulge in his stomach with pain that awakened him from sleep. Staff #5 documented that Patient #1 was in acute distress but did not document whether there was warmth, fluctuance, or induration to the site. Patient #1 was taking gabapentin, Robaxin, and hydrocodone without relief. Staff #5 did not document asking Patient #1 about fevers, chills, or night sweats. . On 12/02/2023 at 6:20 PM, a CT of the abdomen and pelvis with contrast noted “intervertebral body spacer is projecting dorsally from the disc space 10 mm into the right lateral recess, which may impinge upon the traversing right Lumbar 5 nerve root and a new fluid collection in the laminectomy bed”. . On 12/02/2023 at 7:28 PM, Staff #5 consulted Neurosurgery. Staff #5 documented that Neurosurgery recommended pain control with no surgical intervention needed. . Neurosurgery notes or any notes regarding a Neurosurgery call-back to Staff #5 could not be located within the patient record provided. No labs were ordered with which to follow up on the previous leukocytosis. . There were no documented labs found for a lactic acid level, which could be used to screen for sepsis in Patient #1, who had been seen two days prior with mild leukocytosis. There were no documented ESR (eosinophil sedimentation rate) or CRP (c-reactive protein) labs to assess for a spinal infection. There was no EKG (electrocardiogram) ordered for Patient #1’s documented tachycardia and report of profuse sweating to rule out an arrhythmia. The MSEs (medical screening examinations) was inappropriate as it did not adequately rule out other EMCs (emergency medical conditions). . There is no assessment for a mass or tenderness during an abdominal exam. There was no evaluation of the pelvic region, scrotum, or perineum relating to Patient #1’s complaints of pelvic pain. . Patient #1 was discharged on 12/03/2023 at 1:15 AM with outpatient follow-up with Neurosurgery. The follow-up was scheduled for 12/12/2023. . Patient #1 did not have an appropriate MSE. Patient #1 did not have a complete history obtained by Staff #5. The physical exam by Staff #5 was not sufficient to assess for potential EMCs related to Patient #1’s back pain, hip pain, abdominal pain, and pelvic pain. . From 11/27/2023 through 11/29/2023, Patient #1 had an inpatient admission at the same facility to remove the hardware placed during the initial surgery on 10/25/2023 and redo the Lumbar 4 and Lumbar 5 transforaminal interbody fusion. Policy Review: The facility’s policy titled, “ Medical Screening Examinations and Patient Transfers”, last reviewed and effective on 10/07/2022, stated on page 3 of 25: “ ...Any person who comes to Hospital Emergency Department (ED) and requests an examination or treatment for a medical condition shall receive an appropriate Medical Screening Examination by a physician or other Qualified Medical Person as defined in Section 5.0, within the Capability of the ED, including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition ...” . And page 10 of 25: “ ... 5) If based upon the screening physician’s evaluation, the physician determines that additional specialist services are needed to further assess the patient and these specialists are routinely available to the ED, these services must be utilized. The screening physician shall call the specialist physician on call for the particular medical condition and shall ask him/her to see the patient. Hospital medical staff rules and regulations require the specialist physician to respond ...” . Interviews: An interview with the Emergency Department’s (EDs) Risk Manager, Staff #9, was conducted on 04/08/2023 at 12:35 PM. Staff #9 indicated that Patient #1 had placed multiple complaints against the facility and felt that the facility had done an excellent job providing care to Patient #1. Staff #9 was asked if she and the facility had determined that anything was missed upon chart reviews completed by the facility and involved staff. Staff #9 was aware that Patient #1 had developed an infection and felt that the infection was caught in its early stages on 12/21/2023 (when Patient #1 was admitted treating the infection in his spine.) . Staff #9 was asked if she could explain what the indicators of infection were. Staff #9 replied, An infection could also cause changes in his/her labs. Such as an elevated white blood cell (WBC) count, elevated number of neutrophils, an elevated CRP (C-reactive Protein), or sometimes an elevated sedimentary rate (a test that measures how quickly red blood cells settle at the bottom of a test tube and can indicate inflammation in the body), you know, things like that. The patient could also have a surgical site that was oozing abnormal drainage, like pus draining from the incision and the incision site could be warm to the touch.” . An interview with a nurse practitioner for Neurosurgery, Staff #15, was conducted on 11/06/2023 at 9:08 AM in response to a grievance filed against the facility. Staff #15 indicated that Patient #1 was taking his pain medication incorrectly. Patient #1 was advised by Staff #15 that the Neurosurgery offices would not write a prescription for Norco or anything stronger and advised Patient #1 to seek help from a pain management doctor (whom Patient #1 had previously worked with) for something stronger if he felt it was needed. Staff #15 and Patient #1 agreed to try Tylenol #4 and alternative therapies such as ice and heat. Staff #15 could not be reached for further interviews. .”

“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: 35089 Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination within the capability of the hospital’s emergency department to determine whether an emergency medical condition existed for 1 of 21 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1 presented to the ED with psychosis, aggressive behavior, paranoid delusions, hallucinations, and what appeared to be self-inflicted wrist wounds. Patient #1 was allowed to leave against medical advice (AMA) even though the patient was a danger to themselves and others. The findings were: The facility document titled, “Medical Screening Examination and Patient Transfers,” [Last Reviewed Date: 10/7/22] states, “2.1 Performing medical screening exams of persons who seek examination or treatment for a medical condition ... 3.1 Hospital will provide, without discrimination, care for emergency medical conditions regardless of whether or not the patient is eligible for financial assistance. Hospital will not engage in any actions that would discourage individuals from seeking emergency medical care ... 4.1.1. Any person who comes to Hospital Emergency Department (ED) and requests an examination or treatment for a medical condition shall receive an appropriate Medical Screening Examination by a physician or other Qualified Medical Person as defined in Section 5.0, within the Capability of the ED, including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition.” The facility document titled, “Behavior Health Crisis Clinician Provision of Services Plan,” [Last Reviewed Date: 7/30/21] states, “4.3.2 ...BHCC [Behavioral Health Crisis Clinician] will assess the patient and communicate the findings and Recommendation to the physician and nurse as appropriate.” Patient #1 was brought to the ED by emergency medical services (EMS) after being found on the side of the highway with wounds to both wrists and paranoia. The ED physician performed a limited psychiatric exam with no comment on the patient’s thought content, judgment, insight or delusions/hallucinations. The clinical staff noted several times that patient is psychotic and aggressive and notified the ED physician but no documentation could be found regarding ED physician reassessments. Patient #1 required inpatient psychiatric treatment due to an emergency medical condition (auditory hallucinations and high suicide risk), the facility staff with police officers escorted the patient off the emergency department (ED) area due to the patient’s verbal aggressiveness towards ED staff and attempted physical assault of ED staff. The ED staff documented that the patient “eloped.” No physician order for physical holding or chemical sedation to facilitate safety for patient’s psychotic, uncooperative behavior could be found. While the patient was outside by the ED ambulance bay area, the local police officers arrested the patient and returned the patient into the ED department. The ED staff then discharged the patient “against medical advice” without discussing the risk and complications of not following the medical treatment or transfer to an inpatient psychiatric treatment facility with the patient or the fact that the patient was a danger to themselves and others. The ED physician did not request an emergency detention order even though the patient had an emergent psychiatric condition (high suicide risk). The local police officers then transported the patient to an inpatient psychiatric facility. The complete medical record of Patient #1’s ED visit on 11/20/23 was reviewed. It was noted: - ED registered nurse (RN) [Staff #5] note at 7:11PM states, “EMS report completed. EMS report states, ‘4 inch laceration to each wrist’ 4 inch laceration to bilateral wrists present upon arrival and assessment. This RN able to see cuts on wrists and unable to complete full assessment due to pt behavior at this time. Pt states, ‘stop asking me questions, I just want to sleep’ Treatment offered to patient and patient refused at this time. Unable to complete full triage due to patient refusing questions. CPI [Crisis Prevention Institute, a de-escalation technique] verbal intervention used.” - ED physician’s initial assessment at 7:35PM states, “[Patient #1] is a 42 y.o. female BIB [brought in by] EMS [emergency medical services] with paranoia. She was reportedly found on the side of the road. Pt [patient] denies SI [suicidal ideation] or HI [homicidal ideation]. Pt reports she has not done anything to hurt herself. Pt denies any significant PMHX [past medical history]. Pt denies alcohol use or drug use. However, EMS report states pt has been having hallucinations with suicidal ideations and has been cutting herself, which pt denies. HPI [history of present illness] limited d/t [due to] poor pt cooperation ... Physical Exam: Psychiatric: Pt is agitated and uncooperative with exam ... Differential Diagnosis: suicidal ideation, paranoia, hallucinations, psychosis, intoxication ...” - Behavioral Health (BH) assessment at 8:41PM showed that the patient was a “High Suicide Risk” and scored a “24” on the Columbia Suicide Severity Rating Scale [which is consider as Very Severe - 34x times the risk of suicide]. The Licensed Professional Counselor (LPC) [Staff #6] that completed the BH assessment recommended that the patient receive inpatient BH treatment and the ED physician’s notes agreed with this recommendation. The LPC notified the transfer center of transfer request. - ED physician’s note at 9:26 PM states, “Consult with [Staff #6], crisis clinician, about pt’s case. She recommends inpatient treatment. Will initiate process.” - RN note [Staff #5] at 9:30PM states, “This RN at bedside and reassessing pt and asked if we could obtain blood work, complete EKG, get an UA, and retake vitals. Pt refusing at this time. Patient states, ‘don’t you fucking dare touch me.’ Patient throwing herself from side to side in stretcher. Unsafe for staff to treat patient at this time. MD notified and aware. Charge nurse notified and aware. Multiple RN’s at bedside. Patient states, ‘you have to treat me I am mentally unstable.’ Explained to patient we have orders from MD to treat her in order to complete transfer to another facility. Pt states, ‘you are not a real nurse. All I want to do is sleep for a few hours.’ ‘do you know how hard it is to come by sleep these days’ ‘leave me the fuck alone’ CPI verbal intervention used. ED security called. - Charge RN note [Staff #3] at 9:40 PM states, “Responded to pt being verbally aggressive towards staff regarding medical clearance to begin psychiatric transfer process. Several RNs attempted to explain why pt must be medically cleared. Pt continued to be verbally aggressive with staff. This RN responded to pt in an attempt to explain process and necessity for lab/urine. Pt was verbally aggressive stating ‘Y’all can’t clear me, I aint Sane,’ then stated, ‘I should just punch you in the face.’ At this time security alert was activated. Continued to attempt to assist in managing situation, pt jumped out of bed, lunged at this RN and made an attempt to punch this RN in the face. Security interfered and staff assisted in demobilizing the patient until additional security. Pt escorted off the property with security, belongings provided. MD made aware. - RN note [Staff #5] at 9:40PM states, “AMA form completed without patient signing. [name], RN second witness. Patient escorted out by ED officers.” The surveyor reviewed the security body camera film footage from 11/20/23 that starts outside ED in the parking lot. The police officer asks the patient, “Do you want to hurt yourself?” The patient replies, “I want to kill you ... I want to kill myself, I want to kill you and I want to kill [difficult to understand] ...” The patient is informed that they are going to return to the ED for treatment for her homicidal and suicidal statements. The patient states, “No, I’m going to jail ... No, not here. I’m homicidal ... I just threatened a nurse in there and you’re going to put me back in there with her?” The patient is escorted back by police officers back inside the ED. Someone asks, “Is she already charted out?” And someone replies, “I’m doing it right now.” The film does not show any ED staff member discussing the AMA form with the patient. The patient is escorted out of the ED by wheelchair by police and security. The film also shows that the security officer retrieves a blank copy of the Notice of Emergency Detention (NED) form and provides it to the police officer with the patient. The police officer appears to be filling out the form but the film ends and it is unknown if the NED was shown to the ED staff. The surveyor interviewed the Licensed Professional Counselor (Staff #6) that performed Behavioral Health Assessment on Patient#1 on 11/20/23 via email. Below is Staff #6’s response on 1/8/24: Surveyor: What do you remember about this particular patient? Staff #6: “I remember the patient due to the fact that she was brought in from walking on a freeway and had lacerations on her wrists. She was very guarded in her responses to the assessment and had to be encouraged to participate. She was not willing to give me any details of her suicide attempt or why she was walking there, except to say she was ‘trying to get away from a dangerous situation.’ She stated a few times that she did not want to talk about her situation. She did participate as far as answering the suicide screening questions and endorsed a past attempt about a month previous by overdosing. She endorsed current demeaning auditory hallucinations. Pt refused to share any details about her mental health treatment. Substance use was denied and the labs were pending when I spoke to her. She was angry, labile, yelled yes or no when asked to repeat or clarify, but did agree with the recommendation for Inpatient psych treatment.” Surveyor: Did this patient have an emergency psychiatric condition? Staff #6: “The patient had an emergency psychiatric condition, and my recommendation was admission to inpatient Psych treatment. She endorsed SI [suicidal ideation] and had 4 inch wrist lacerations, active hallucinations and was brought in by EMS from a situation where she was a danger to self and others.” The surveyors interviewed the ED physician (Staff #4) that took care of Patient #1 on 11/20/23 via email. Below is Staff #4’s response on 1/9/24: Surveyor: What do you remember about this particular patient? Staff #4: “This was a female patient brought in by EMS after being found walking down the side of the road. EMS reported to the nursing staff who took report, a call was made for suicidal ideation. When I assessed the patient, EMS had already left, the patient had already been changed out of her street clothes and she was lying in a hallway stretcher. She was lying with her eyes closed and did not want engage with much of the assessment, giving only brief answers. When asked directly about suicidal ideation and the report from EMS, she denied this stating ‘No, i was just walking down the road to get away from some people.’ She also denied any homicidal ideation, but would not answer questions regarding hallucinations or substance abuse. She instead rolled over with her eyes closed stating she did not want to be bothered and did not want to be here. Her physical exam was limited by the blanket she would not remove, but I did not some superficial cuts to her arms, which she said, ‘happened trying to get away from those people.’ I ordered basic psych labs and an assessment by our crisis clinician. A quick review of her medical records noted a history of amphetamine abuse. I was later called by the crisis clinician after the patient had been assessed who reported the patient had not provided any additional information beyond what I had garnered, and confirmed the patient had denies suicidal or homicidal ideation to her, but since we could not get collateral information the recommendation was to transfer her to a psychiatric facility for further assessment and treatment. I assessment base on the limited information was the patient likely had a mood disorder exacerbated by substance abuse. After some time, I was then called by a member of the nursing staff who stated the patient had become aggressive and eloped, with her location being unknown.” Surveyor: Did this patient have an emergency psychiatric condition? Staff #4: “Yes. I believe she had a decompensated mood disorder, likely with self-harm given the cuts on her arms, which were likely self-inflicted. She however eloped from the ED prior to transfer. A warrant detention was not requested after my assessment or the crisis clinicians assessment, because she did not appear to be a flight risk at that time and denied suicidal/homicidal ideation.” Surveyor: Did you initiate a hospital-to-hospital transfer of this patient? If no, why not? Staff #4: “Yes. A transfer was initiated within the Texas Health system, but the status was pending at the time the patient left the ED. The transfer was initiated to have the patient assessed and treated for a mood disorder exacerbated by substance abuse.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 35089 Based on review of documentation and interviews with the facility staff, the facility failed to perform an appropriate transfer of Patient #1 to an inpatient psychiatric treatment facility after the patient’s medical screening examination and behavioral assessment determined Patient #1 required inpatient psychiatric treatment due to an emergency medical condition (auditory hallucinations and high suicide risk). The findings were: The facility document titled, “Medical Screening Examination and Patient Transfers,” [Last Reviewed Date: 10/7/22] states: “4.2.3 Transferring a patient with an Emergency Medical Condition that has not been stabilized when the transferring physician recommends the transfer: b. If the patient has an Emergency Medical Condition which has not been stabilized, no transfer can take place unless: 2) the physician informs the patient that the medical benefits reasonably expected from the provision of medical treatment at another hospital outweigh the increased risks to the patient (and in the case of labor, to the unborn child) and, therefore, transfer is recommended. The physician’s certification is documented on the Memorandum of Transfer form... 4.2.4 Physicians’ responsibilities b. The transferring physician shall: 4) Prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient’s medical treatment and hospital care. The transfer should minimize the risk to the patient. 4.2.5 Hospital responsibilities a. Arranging for transportation b. Providing medical records to the receiving hospital c. Form to be completed 1) Memorandum of Transfer 2) Patient’s Request/Refusal/Consent to Transfer” The facility document titled, “Behavior Health Crisis Clinician Provision of Services Plan,” [Last Reviewed Date: 7/30/21] states: “4.3.2 ...BHCC [Behavioral Health Crisis Clinician] will assess the patient and communicate the findings and Recommendation to the physician and nurse as appropriate. 4.3.4 Patients who are medically cleared at the conclusion of the Assessment and for whom inpatient behavioral health or substance use disorder treatment is recommended, BHCC will enter a Transfer Center Notification order to initiate the transfer process.” Patient #1 was brought to the ED by emergency medical services (EMS) after being found on the side of the highway with wounds to both wrists and paranoia. The ED physician performed a limited psychiatric exam with no comment on the patient’s thought content, judgment, insight or delusions/hallucinations. The clinical staff noted several times that patient is psychotic and aggressive and notified the ED physician but no documentation could be found regarding ED physician reassessments. Patient #1 required inpatient psychiatric treatment due to an emergency medical condition (auditory hallucinations and high suicide risk), the facility staff with police officers escorted the patient off the emergency department (ED) area due to the patient’s verbal aggressiveness towards ED staff and attempted physical assault of ED staff. The ED staff documented that the patient “eloped.” No physician order for physical holding or chemical sedation to facilitate safety for patient’s psychotic, uncooperative behavior could be found. While the patient was outside by the ED ambulance bay area, the local police officers arrested the patient and returned the patient into the ED department. The ED staff then discharged the patient “against medical advice” without discussing the risk and complications of not following the medical treatment or transfer to an inpatient psychiatric treatment facility with the patient or the fact that the patient was a danger to themselves and others. The ED physician did not request an emergency detention order even though the patient had an emergent psychiatric condition (high suicide risk). The local police officers then transported the patient to an inpatient psychiatric facility. The complete medical record of Patient #1’s ED visit on 11/20/23 was reviewed. It was noted: - ED registered nurse (RN) [Staff #5] note at 7:11PM states, “EMS report completed. EMS report states, ‘4 inch laceration to each wrist’ 4 inch laceration to bilateral wrists present upon arrival and assessment. This RN able to see cuts on wrists and unable to complete full assessment due to pt behavior at this time. Pt states, ‘stop asking me questions, I just want to sleep’ Treatment offered to patient and patient refused at this time. Unable to complete full triage due to patient refusing questions. CPI [Crisis Prevention Institute, a de-escalation technique] verbal intervention used.” - ED physician’s initial assessment at 7:35PM states, “[Patient #1] is a 42 y.o. female BIB [brought in by] EMS [emergency medical services] with paranoia. She was reportedly found on the side of the road. Pt [patient] denies SI [suicidal ideation] or HI [homicidal ideation]. Pt reports she has not done anything to hurt herself. Pt denies any significant PMHX [past medical history]. Pt denies alcohol use or drug use. However, EMS report states pt has been having hallucinations with suicidal ideations and has been cutting herself, which pt denies. HPI [history of present illness] limited d/t [due to] poor pt cooperation ... Physical Exam: Psychiatric: Pt is agitated and uncooperative with exam ... Differential Diagnosis: suicidal ideation, paranoia, hallucinations, psychosis, intoxication ...” - Behavioral Health (BH) assessment at 8:41PM showed that the patient was a “High Suicide Risk” and scored a “24” on the Columbia Suicide Severity Rating Scale [which is consider as Very Severe - 34x times the risk of suicide]. The Licensed Professional Counselor (LPC) [Staff #6] that completed the BH assessment recommended that the patient receive inpatient BH treatment and the ED physician’s notes agreed with this recommendation. The LPC notified the transfer center of transfer request. - ED physician’s note at 9:26 PM states, “Consult with [Staff #6], crisis clinician, about pt’s case. She recommends inpatient treatment. Will initiate process.” - RN note [Staff #5] at 9:30PM states, “This RN at bedside and reassessing pt and asked if we could obtain blood work, complete EKG, get an UA, and retake vitals. Pt refusing at this time. Patient states, ‘don’t you fucking dare touch me.’ Patient throwing herself from side to side in stretcher. Unsafe for staff to treat patient at this time. MD notified and aware. Charge nurse notified and aware. Multiple RN’s at bedside. Patient states, ‘you have to treat me I am mentally unstable.’ Explained to patient we have orders from MD to treat her in order to complete transfer to another facility. Pt states, ‘you are not a real nurse. All I want to do is sleep for a few hours.’ ‘do you know how hard it is to come by sleep these days’ ‘leave me the fuck alone’ CPI verbal intervention used. ED security called. - Charge RN note [Staff #3] at 9:40 PM states, “Responded to pt being verbally aggressive towards staff regarding medical clearance to begin psychiatric transfer process. Several RNs attempted to explain why pt must be medically cleared. Pt continued to be verbally aggressive with staff. This RN responded to pt in an attempt to explain process and necessity for lab/urine. Pt was verbally aggressive stating ‘Y’all can’t clear me, I aint Sane,’ then stated, ‘I should just punch you in the face.’ At this time security alert was activated. Continued to attempt to assist in managing situation, pt jumped out of bed, lunged at this RN and made an attempt to punch this RN in the face. Security interfered and staff assisted in demobilizing the patient until additional security. Pt escorted off the property with security, belongings provided. MD made aware. - RN note [Staff #5] at 9:40PM states, “AMA form completed without patient signing. [name], RN second witness. Patient escorted out by ED officers.” The surveyor reviewed the security body camera film footage from 11/20/23 that starts outside ED in the parking lot. The police officer asks the patient, “Do you want to hurt yourself?” The patient replies, “I want to kill you ... I want to kill myself, I want to kill you and I want to kill [difficult to understand] ...” The patient is informed that they are going to return to the ED for treatment for her homicidal and suicidal statements. The patient states, “No, I’m going to jail ... No, not here. I’m homicidal ... I just threatened a nurse in there and you’re going to put me back in there with her?” The patient is escorted back by police officers back inside the ED. Someone asks, “Is she already charted out?” And someone replies, “I’m doing it right now.” The film does not show any ED staff member discussing the AMA form with the patient. The patient is escorted out of the ED by wheelchair by police and security. The film also shows that the security officer retrieves a blank copy of the Notice of Emergency Detention (NED) form and provides it to the police officer with the patient. The police officer appears to be filling out the form but the film ends and it is unknown if the NED was shown to the ED staff. The surveyor interviewed the Licensed Professional Counselor (Staff #6) that performed Behavioral Health Assessment on Patient#1 on 11/20/23 via email. Below is Staff #6’s response on 1/8/24: Surveyor: What do you remember about this particular patient? Staff #6: “I remember the patient due to the fact that she was brought in from walking on a freeway and had lacerations on her wrists. She was very guarded in her responses to the assessment and had to be encouraged to participate. She was not willing to give me any details of her suicide attempt or why she was walking there, except to say she was ‘trying to get away from a dangerous situation.’ She stated a few times that she did not want to talk about her situation. She did participate as far as answering the suicide screening questions and endorsed a past attempt about a month previous by overdosing. She endorsed current demeaning auditory hallucinations. Pt refused to share any details about her mental health treatment. Substance use was denied and the labs were pending when I spoke to her. She was angry, labile, yelled yes or no when asked to repeat or clarify, but did agree with the recommendation for Inpatient psych treatment.” Surveyor: Did this patient have an emergency psychiatric condition? Staff #6: “The patient had an emergency psychiatric condition, and my recommendation was admission to inpatient Psych treatment. She endorsed SI [suicidal ideation] and had 4 inch wrist lacerations, active hallucinations and was brought in by EMS from a situation where she was a danger to self and others.” The surveyors interviewed the ED physician (Staff #4) that took care of Patient #1 on 11/20/23 via email. Below is Staff #4’s response on 1/9/24: Surveyor: What do you remember about this particular patient? Staff #4: “This was a female patient brought in by EMS after being found walking down the side of the road. EMS reported to the nursing staff who took report, a call was made for suicidal ideation. When I assessed the patient, EMS had already left, the patient had already been changed out of her street clothes and she was lying in a hallway stretcher. She was lying with her eyes closed and did not want engage with much of the assessment, giving only brief answers. When asked directly about suicidal ideation and the report from EMS, she denied this stating ‘No, i was just walking down the road to get away from some people.’ She also denied any homicidal ideation, but would not answer questions regarding hallucinations or substance abuse. She instead rolled over with her eyes closed stating she did not want to be bothered and did not want to be here. Her physical exam was limited by the blanket she would not remove, but I did not some superficial cuts to her arms, which she said, ‘happened trying to get away from those people.’ I ordered basic psych labs and an assessment by our crisis clinician. A quick review of her medical records noted a history of amphetamine abuse. I was later called by the crisis clinician after the patient had been assessed who reported the patient had not provided any additional information beyond what I had garnered, and confirmed the patient had denies suicidal or homicidal ideation to her, but since we could not get collateral information the recommendation was to transfer her to a psychiatric facility for further assessment and treatment. I assessment base on the limited information was the patient likely had a mood disorder exacerbated by substance abuse. After some time, I was then called by a member of the nursing staff who stated the patient had become aggressive and eloped, with her location being unknown.” Surveyor: Did this patient have an emergency psychiatric condition? Staff #4: “Yes. I believe she had a decompensated mood disorder, likely with self-harm given the cuts on her arms, which were likely self-inflicted. She however eloped from the ED prior to transfer. A warrant detention was not requested after my assessment or the crisis clinicians assessment, because she did not appear to be a flight risk at that time and denied suicidal/homicidal ideation.” Surveyor: Did you initiate a hospital-to-hospital transfer of this patient? If no, why not? Staff #4: “Yes. A transfer was initiated within the Texas Health system, but the status was pending at the time the patient left the ED. The transfer was initiated to have the patient assessed and treated for a mood disorder exacerbated by substance abuse.” No documentation could be found for the surveyor to review to indicate that the facility secured a transfer to an accepting hospital or physician; a nurse-to-nurse or physician-to-physician report was performed; or a memorandum of transfer (MOT) form was completed.”