Memorial Hermann Hospital System

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 23032 Based on interview and record review, the facility failed to implement an effective policy and process related to patient rights / advance directives for 4 of 4 sampled patients [Patient # 2, 3, 4, 5] . The facility failed to comply with the requirements of the Texas Administrative Code (TAC) Chapter 505.42 (a) (1)(C)(i)-(ii) I. Findings included : Review of the Texas Administrative Code (TAC) Chapter 505.42 (a) (1)(C) (i)-(ii) I, showed : (a) Patient rights requirements for all hospitals. (1) A hospital shall adopt, implement, and enforce a policy to ensure patient rights. The written policy shall include: (C ) the right of the patient, in collaboration with his or her physician, to make decisions involving his or her health care; to include the following: (i) the right of the patient to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal, and (ii) the right of the patient to formulate advanced directives and to appoint a surrogate to make health care decisions on his or her behalf to the extent permitted by law. Advanced directives are written instructions recognized under state law relating to the provision of healthcare when individuals are unable to communicate their wishes regarding medical treatment. The advanced directive may be a written document authorizing an agent or surrogate to make decisions on an individual’s behalf ( a medical power of attorney for healthcare), a written or verbal l statement (a living will) or some other form of instruction recognized under state law specifically addressing the provision of health care; (I) a hospital shall have in place a mechanism to ascertain the existence of, and, as appropriate, assist in the development of advanced directives at the time of a patient’s admission;... ~~~~~~~~~~ On 5/28/2026, surveyor reviewed the electronic medical records (emr) of four (4) current patients [Patient # 2 , 3, 4, 5 ] with Staff-K, RN. The purpose of the review was to verify the hospital’s process regarding patient rights related to advance directives. Review of the current emr section titled “Healthcare Directives “ showed the following questions / headings in the subsequent order: Advance Directives (For Healthcare}: -“ Have you reviewed your Advance Directive and is it valid for this stay? “ - Answer choices were : YES / NO / NOT APPLICABLE -“Advance Directives:” 6 “check boxes” were available for nursing to choose / complete : * “Patient has advance directive, copy in chart * Patient has advance directive, copy not in chart * Patient does not have an advance directive * Patient would like information * Patient would not like information * Not applicable” 3. “Information Provided on Healthcare Directives” : Answer choices were : YES / NO / OTHER (comment) ~~~~~~~~~~~~~~ During an interview at the time of emr review with Staff-K, RN , she said it was the responsibility of the admitting RN to complete the sections on Healthcare Directives and Healthcare Agents. Review of the current patient records showed: QUESTION: Have you reviewed your advance directive and is it valid for this stay ? - Patient # 2, 4, 5 : “ NO” was documented - Patient # 3: “N/A” was documented Staff K was unable to verify if “NO” meant the patient did not have an advance directive or if they just didn’t review it. Also, unclear if “N/A “ meant the patient did not have an advance directive. SECTION: Advance Directives - with “[6 “check boxes” available for nursing to choose / complete ]: * Patient has advance directive, copy in chart * Patient has advance directive, copy not in chart * Patient does not have an advance directive * Patient would like information * Patient would not like information * Not applicable” -Patients # 3, 4, 5 : all 6 boxes were left blank; no selections were made; -Patient # 2: “N/A” was documented. Staff K was unable to provide an example of when “N/A “ would be selected as a choice. ~~~~~~~~~~~~~~~~ .SECTION : “Information Provided on Healthcare Directives” : Answer choices were : YES / NO / OTHER (comment -Patient # 4- this section was left blank -Patient # 2: “Other” was selected - but no comment was documented . Staff-K, RN said any time “OTHER “ was a choice and had the word “comment” by it, a comment was required. The above information was reviewed and discussed with Staff-C, Quality Director in the afternoon of 5/28/2026. ~~~~~~~~~~~~~~~ During an interview on 5/28/2026 at 1:30 PM with Staff-N, Patient Access Representative, he said the patient registration process did not include any questions about advance directives; medical power of attorney; or out- of- hospital “Do Not Resuscitate (DNR)”.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 23032 Based on observation, interview, and record review, the facility failed to ensure that nursing staff accurately documented nursing care plan interventions based on patient needs. ( citing Patient # 7). Nursing staff documented for 3 days that Patient # 7 had sequential compression devices (SCDs) in place on both legs. The SCDs had not yet been applied at time of survey. Finding included : Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing; CHAPTER 217 ; RULE §217.11 “Standards of Nursing Practice” showed: (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (D) Accurately and completely report and document: (ii) nursing care rendered; ~~~~~~~~~~~ Observation on 5/28/2026 at 10 AM showed current Patient # 7 lying in bed. She was in a semi-private room; surveyor interviewed both patients. Patient # 7 questioned surveyor why she wasn’t wearing SCDs (sequential compression device) , as her roommate was. Patient # 7 said she had worn them in 2 recent admissions. Review of Patient # 7’s electronic medical record with Staff -K, RN, showed a physician order , dated 5/26/2026 (time 6:15 PM) : “Sequential Compression Device.” Continued record review of showed documentation by nursing the SCD’s were present on the patient the following dates / times : - 5/26/2026: 6:15 PM and 8:02 PM - 5/27/2026: 8:50 AM; 1147 AM; 3:31 PM; 8:00 PM - 5/28/2026: midnight; 4:00 am; 9:00 am On 5/28/2026 at 10: 15 AM, Staff-K accompanied surveyor to Patient #7’s room and verified the patient did not have SCDs on her legs or in her room.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to ensure that the Emergency Department (ED) effectively utilized case management/social work, which was an available ancillary service in the facility, in 1 out of 11 emergency room patient records selected for review (ID# 3). Findings included: Record review of facility policy titled “Discharge Planning Policy,” dated 05/16/2023 showed the following: POLICY PURPOSE: The Memorial Hermann Health System (MHHS) Discharge Planning-Case Management policy outlines the stages of the discharge planning process. The purpose is to ensure the patient’s needs are efficiently identified and coordinated resulting in a safe, smooth and sustainable discharge. POLICY STATEMENT: MHHS discharge planning involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a safe discharge from the hospital to the patient’s discharge destination. MHHS recognizes that collaboration, coordination and facilitation of a discharge is the responsibility of all members of the healthcare team including the patient/patient representative. To optimize compliance with a patient ’ s post-hospital plan of care, an assessment of the patient ’ s actual and potential discharge planning needs shall be initiated upon admission. A multidisciplinary team that may include the physician, registered nurse (RN), care manager (CM), and social worker (SW), together with the other members of the health care team, shall perform the assessment. A plan to meet these needs shall be developed, and interventions to meet specific discharge planning goals shall be designed. The plan shall be monitored and revised as necessary throughout the patient ’ s hospital stay. Record review of facility policy titled “Discharge Planning Procedure,” dated 05/16/2023 showed the following: PROCEDURE PURPOSE: The Memorial Hermann Health System (MHHS) Discharge Planning procedure outlines the stages of the discharge planning process. The purpose is to ensure the patient’s needs are efficiently identified and coordinated resulting in a safe, smooth and sustainable discharge and to comply with MHHS Discharge Planning Policy. I. PROCEDURE: The five stages in the discharge planning process include screening, evaluation, development, implementation and reassessment. A. Screening 1. The admitting registered nurse (RN) will complete the discharge planning screening to identify patients at risk for adverse health consequences upon discharge without adequate discharge planning. If the patient is identified to be at high risk from the discharge planning screening. Care Management will be notified for further evaluation. a. Reassessment of a patient ’ s discharge needs, and associated risks will occur during multi-disciplinary rounds (MDDR) and/or the nurse ’ s daily patient assessment. b. A referral to Care Management may be requested by a member of the patient ’ s care team, family, or provider at any time during the course of their hospitalization. 2. The Case Manager (CM), Social Worker (SW) or Registered Nurse (RN) will assess inpatient and outpatient observation patients. The assessment and review of medical record helps to identify discharge needs. The discharge planning assessment (DPA) will be completed and documented in the medical record to allow sufficient time to develop and coordinate a safe, smooth and sustainable discharge plan and avoid delays. Documentation of the DPA in the medical record will facilitate multidisciplinary communication and assist in identifying key team members for discharge planning. The discharge planning assessment evaluation will include the following: a. The patient ’ s anticipated or actual care needs upon discharge, and whether those needs are expected to remain constant or lessen over time. b. Assessment of patient home environment and whether the patient is capable of addressing self-care (activities of daily living). c. The patient/patient representative language barriers, cultural/religious preferences, motivation/desire to participate/learn; physical/cognitive limitations, sensory deficits, etc. d. Assessment of need for specialized medical equipment or permanent physical modifications to the home, and the feasibility of acquiring the equipment or the modifications. e. If the patient is not able to provide some or all the required self-care: i. an assessment of willingness, ability and availability of family/friends/care givers to provide the required care at the times it will be needed, and to receive training by the hospital to sufficiently provide the required care. ii. Community-based services will be identified that are available to meet the patient ’ s needs while allowing the patient to continue living at home (home health, attendant care, community-based services, hospice or palliative care; respiratory therapy, physical therapy, occupational therapy, speech, dialysis, pharmaceuticals and related supplies, nutritional consultation/supplemental diets, medical equipment and related supplies, etc.) ... 3. MHHS CM/SW will actively involve the patient or their representatives throughout the discharge planning process and incorporate the patient ’ s goals and preferences as much as possible. The CM/SW will discuss the results of the discharge planning assessment and ongoing re-assessments with the patient/patient representative and include agreement or disagreement with proposed plan. 4. The specific discharge planning evaluation requirement to assess a patient’s capability for post-discharge self-care requires MHHS, as needed, to actively solicit information not only from the patient or the patient ’ s representative, but also from family/friends/support persons with the patient consent. In general, the goal upon discharge is for a patient to be able to return to the setting in which they were living prior to admission... D. Implementation 2. The CM/SW/RN will arrange for the initial implementation of the discharge plan which may include: d. Written discharge instructions, medications, supplies... i. Referrals to pertinent community resources that may be able to assist with financial, transportation, meal preparation, or other post-discharge needs. Medical record for patient (ID# 3) showed the following: 12/17/25 - 0839 am Arrival to the emergency departments by EMS for chief complaint “seizures. Hx of epilepsy.” Triage note stated “patient ran out of Dilantin, wants refill, generalized weakness, had a seizure this morning.” Patient was admitted to observation for cardiac evaluation and neuro monitoring and was discharged home via ambulance transfer on12/19/25 at 12:50 pm. 12/20/25 1:17 pm. Arrival by EMS for chief complaint “Med refill, Ptn reports they called his medicine into pharmacy here, but they are closed so came here to get medicine.” Record further stated, “pharmacy closed on weekend and unable to pick up medicines.” 1:27 pm Triage VS T 36.4, BP 104/60, HR 94, RR 18. Medications administered included: 1:59 Midodrine 10 mg orally, Folic Acid 1 mg orally and Keppra 500 mg orally. He was discharged home via ambulance transfer on 12/20/25 at 2:07 pm. There was no evidence of social work consultation or healthcare team engagement to ensure patient would be able to receive prescriptions in a timely manner. 12/21/25 5:56 pm. Arrival by EMS for chief complaint “Seizures. Feels like he’s about to have a seizure.” 6:27 Triage VS T 36.5, HR 116, RR 18, BP 117/63. “Reports seizure earlier today and feels like may have another.” 7:58 pm BP 119/60, HR 75, RR 20, T 37.0, 0@ sat 99% RA. 7:59 pm medications administered included: Keppra 1500 mg po, Midodrine 10 mg orally. Brief social work notes stated “Social work confirmed he was given medication. Arranged for DC home with Acadian EMS transfer”. Social work Brief Assessment: 12/21/26 Social Worker received verbal referral requesting transportation for safe discharge. 12/21/2025 Social Worker noted patient visited hospital on 12/17/2025, 12/20/2025, and again today, 12/21/2025. Social Worker consulted with attending and nurse. Patient given medication at ER and is discharged. Intervention: Social Worker met with patient at bedside, introduced self, and provided purpose for the visit. Patient’s name and date of birth verified. Patient reports he was again feeling like he was having a seizure and called 911. Patient stated he much rather have a seizure at the hospital than having the episode at home when he is alone. Patient confirmed he was given medication. Patient also confirmed that his brother continues to pay his bills and sends food to his home. Resources/Information Provided: 1. Transportation for safe discharge. Plan: Patient is to maintain adherence to treatment and monitoring as determined by medical providers. Patient is to complete follow up appointment post discharge. Patient is to reach out to resource providers for assistance with financial stability post discharge. 9:59 pm Discharge via ambulance. 12/22/25 5:11 pm. Arrival by EMS for “Seizures - Had a seizure today.” Chart stated history of noncompliance and patient reports meds were discontinued by the Harris County Health Center after 35 years of use.” Triage VS: BP 84/62. BP repeated prior to DC was 106/71. Provider note stated “Instructed to pick up medicine from pharmacy and follow-up with primary care.” MSW note showed: Brief Assessment: Social Worker received verbal referral requesting transportation for safe discharge. Pt’s visits since from 12/07/2025: 12/07/2025-12/09/2025 Admission 12/9/2025 Returned 12/10/2025 Discharged and returned. 12/11/2025 12/12/2025 12/14/2025 12/17/2025 12/20/2025 12/21/2025 Today’s visit: 12/22/2025 Social Worker consulted with attending and nurse. Patient continues to report “possible seizure” and requested food. Intervention: Patient reports he was again feeling like he was having a seizure and called 911. Social Worker received new consult by nurse who reports patient is medically cleared and has been discharged. Social Worker scheduled Acadian transport with ETA at 20:13 Nurses updated. Resources/Information Provided: 1. Transportation for safe discharge. Patient discharged home 7:49 pm via ambulance transfer. 12/23/25 12:37 pm Arrival by EMS for “chief complaint: Seizure. Patient does not feel good and has no access to primary care, and that he thinks he may be about to have a seizure.” Triage vital signs: BP 80/53, HR 84, RR 16, 02 sat 99% on RA. Provider note states: He has approximately 35 ER visits this year, and one of his most common chief complaints is “feel like about to have a seizure”. He is alert and oriented x 4. He actively answers questions and displays no signs or symptoms of acute psychosis, disorientation or confusion. He is not clinically intoxicated, although he endorses drinking alcohol on a regular basis. He is noted to have low blood pressure 84 systolic in triage, but is otherwise normal mental status, is mentating normally, with normal perfusion. Looking back through his records he often has low blood pressure and is supposed to be taking midodrine which he does not take. He is asking questions about getting food and indicating that he would like to be admitted to the hospital for various reasons. He has multiple admissions, and countless social work and care management interventions to help him acquire primary care regarding his chronic medical problems and need for medication. He states that the hospital or social workers never helped him, and that he is never able to follow-up with a primary care doctor or specialist. He says he has trouble with transportation, however given that he is able to drink alcohol on a regular basis, it is clear that he does have the ability to move around the city as his needs present. The note reflected the patient was medically screened and referred. Discharged home via ambulance at 1:51 pm. 12/24/25 2:17 pm. Arrival by EMS for patient here for weakness, was here yesterday, complaint of “out of seizure medications.” Triage VS: BP 93/62, HR 77, RR 16, o2 at 99% on RA. Provider note: is a very nice 72 y.o. Male, who has a past medical history of Cigarette nicotine dependence (03/30/2025), Dementia (CMS/HCC), and Seizures., now presenting to the ER by Ambulance for evaluation of[not feeling well, and has been unable / unwilling to try and follow up to a primary care doctor or specialist. He has been to the ER approx 30-40 times this year, and has been admitted multiple times, has had multiple and frequent interventions with social work and case management to help guide him to PCP and re-direct him from the ER when he is seeking routine medical care. He continuously states that although he has not tried to go to any primary care doctor, he is sure that they cannot help him, and that he prefers to call 911 when he wants to get healthcare. Despite his diagnosis of ‘dementia’ during all of our discussions, he is very alert, oriented and does not display any type of confusion, or word finding difficulty. He is able to understand all of my high-level questions and gives appropriate answers, he does not appear to have any type of advanced cognitive deficit. The patient was medically screened and referred out. 6:30 pm Discharged via ambulance transfer back home. 12/25/25 10:15 am. Arrival by EMS for chief complaint: Seizures. Provider Note: 73-year-old male patient with history of epilepsy, he is on Keppra, reports he took Keppra today, but ran out of the medication, and he feels a seizure coming, explained to him that we cannot treat prediction of seizure, provided him with 1 dose of Keppra in the ER, provided him with Keppra prescription for 1 month, at the time of evaluation there is no medical emergency that could be appreciated, the patient is awake alert and oriented, cooperative, and he mentioned that he will be calling 911 to come back to the ER anytime he feels a seizure is coming or he is feeling unwell. Explained to him that we are happy to help him whenever he comes to the ER. Advised him to follow-up with his primary care, and return precautions discussed in detail. Triage VS: 128/75, HR 99, RR 18, T 36.8, 02 sat 100%. He was provided one dose of oral Keppra 1000 mg orally and was give prescription for Keppra. MSW note showed: Brief Assessment: Social Worker consulted with attending and nurse. Patient continues to report “possible seizure” and requested food. Intervention: Patient reports he was again feeling like he was having a seizure and called 911. Social Worker received new consult by nurse who reports patient is medically cleared and has been discharged. Social Worker scheduled City Ambulance, (888) 227-8527 transport with ETA at 13:00. Nurses updated. Resources/Information Provided: 1. Transportation for safe discharge. Plan: Patient is to maintain adherence to treatment and monitoring as determined by medical providers. Patient is to complete follow up appointment post discharge. Patient is to reach out to resource providers for assistance with financial stability post discharge. He was Medically screened and referred at this visit. 12/26/25 2:25 pm. Arrival by EMS for chief complaint: Weakness. Patient feels weak and nauseous stated he has not had Keppra since yesterday, pt feels like he may have a seizure, here yesterday and prescribed Keppra but states he cannot take it to get it filled. c/o body aches. RN note: Patient states he came to ED to get medication for seizures instead of taking his prescription to the pharmacy; patient has prescription for Keppra Triage VS: BP 97/59, HR 81, T 36.8, o2 sat 100% on RA EKG performed and revealed 1st degree AV block. Notes reflected “midodrine and Keppra sent to MH outpatient pharmacy (onsite). Provider note: Pt feels weak and nauseous and states he hasn’t had Keppra since yesterday; pt feels like he may have a seizure but has not had one; pt was here yesterday and prescribed Keppra; but pt states he cannot take it to get filled; complains of body aches came to ED to get med for seizures instead of taking his prescription to pharmacy, patient has prescription for Keppra. EMR reviewed he was prescribed midodrine and Keppra earlier this month prescription was sent to Memorial Hermann Southwest pharmacy. Pharmacy is onsite, he should not have transportation issues. This month social work has spoken to him multiple times about help getting his medications. No suspicions that he had a seizure recently, unremarkable physical exam. Discussed outpatient follow-up and picking up medication from pharmacy. Discharged home at 3:15 pm. 12/27/25 9:34 pm. Arrival by EMS for chief complaint: Back pain. Generalized weakness, s/p seizure at 2 pm today. Triage VS: BP 128/78, HR 98, Pain 6/10. Provider note: Patient is a 72-year-old male with a history of seizures, presenting to the ED with multiple seizures over the past week and a new onset of weakness today. He reports an increase in seizure frequency, stating, “I’ve had a lot more lately than I’ve ever had for some reason.” He has been taking Keppra for 35 years and typically experiences one seizure every six months when compliant with his medication. However, he ran out of Keppra yesterday and has not been able to refill his prescription. He has a scheduled appointment with a new neurologist on Monday. Today, he woke up feeling weak, with no energy, and “drained, like I just had a seizure.” This weakness has persisted throughout the day. He also reports limited movement in his arm, stating, “I can’t, that’s as much as I can move it because I must have fell on it. From here on down, I can’t move it.” He believes he injured his arm during a seizure between 1200 and 1400 today, describing it as “banged up pretty good.” He has been to the ED four or five times in the past week due to seizures, noting, “I’ve never had this many in a row... Patient a well-known patient is presenting again with concern of possible seizures and request to have Keppra. On chart review, he has been evaluated every day this week in the ED for the same concern, and a total of 20-21 times for the month of December. This also includes a discharge summary. Though pt states he has no Keppra, his prescription review suggests otherwise with sufficient tablets to last him until March. Pt was medically screened. Stable, and well appearing Discharged at 10:10 pm via wheelchair. 12/28/25 12:27 pm. Arrival by EMS for chief complaint: Seizures (Hx of seizures, possible seizure overnight, pt feels fatigued, weak, + incontinence episode). Triage VS: BP 72/52, HR 81, RR 20, T 36.8, o2 sat 98% on RA. 12:53 pm EKG reveals 1 degree AV block. 2:05 pm Repeat BP 85/60. 2:09 Medication administration: Keppra 1000 mg and Midodrine 10 mg po given. 2:42 Generalized pain assessment reveals pain 6/10. 4:31 pm Repeat VS BP 94/65, HR 63, RR 18, o2 sat 100% on RA, pain 6/10. 4:41 pm Discharged home via ambulance. 12/29/25 4:22 pm. Arrival by EMS with chief complaint: seizures. “Felt like going to have a seizure.” Triage Vital signs: BP 89/61. T 35.7, RR 16, 02 sat 100%. Triage note stated “thinks had a seizure at 2pm. He was tired after seizure, so he went to sleep and when he woke up called 911. Provider Note:72-year-old male who has been evaluated multiple times in the past for seizure-like activity who is here because he has felt like he is going to have a seizure. He denies any trauma. He has been evaluated multiple times this month. Patient had lab tests done yesterday. No hyponatremia yesterday. Repeat labs are not indicated. Patient has underlying chronic illness such as: Seizure Repeat vitals have improved. Repeat temperature has improved. Admission is considered but not indicated. CT brain is considered but not indicated. 5:09 Medication administration of Keppra 1000 mg and Midodrine 10 mg orally given. 5:11pm Pain 8/10 Acute lower back pain. No further assessment or intervention of this. 5:15 pm T 36.2, BP 85/65, HR 60, RR 18, 02 sat 100% on RA. 8:11 pm Repeat Vital signs: T 36.4, BP 110/56, HR 66, RR 18, o2 sat 99%. 9:15 pm Discharged home via stretcher and ambulance. Social work assessment/ interventions do not consistently address barriers to access to primary healthcare and medication/ prescriptions, transportation, physical limitations and access to food. Interview 3/19/26 at 10:30 am with ED Charge RN (ID# 58) she stated that social workers are available in the emergency department, but she was not certain of the hours of availability. She stated they primarily are helping with patients presenting with psychiatric emergencies. Interview with staff (ID# 51) on 3/19/26 at 1:15 pm stated that there are no separate and/or additional policies related to social work/ case management/ discharge planning specific to emergency department patients.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 46010 Based on interview and record, the facility failed to uphold patients rights by failing to ensure compliance with the State of Texas Mental Health code Title 7. Chapter 573 Subchapter C Emergency Detention, by failing to ensure patients with mental health complaints, were not detained beyond 48 hour time period allowed by federal and state statutes, without written orders for protective custody in 4 of 33 patients reviewed (Patient ID # 7, 8, 13, 22). Findings Included: Record review of facility’s system policy titled “Patient Rights and Responsibilities”, last reviewed 06/10/2022, stated “POLICY PURPOSE: To ensure that a patient is informed of his or her rights and responsibilities upon receiving care treatment and service. To ensure that staff, physicians, volunteers, and other health care providers are informed of these rights and responsibilities.” It further stated “POLICY STATEMENT: It is the policy of Memorial Hermann to incorporate patient ’ s rights and responsibilities into the overall patient experience. This policy delineates many of these rights and responsibilities. This policy should not be construed as a complete notation of patient rights and responsibilities. There may be additional rights and responsibilities pertaining to identified patient populations that are not contained in this policy. Our facilities care for all patients and prohibit discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. Our facilities treat the patient in a dignified and respectful manner that supports his or her dignity.” The policy stated “PATIENT RIGHTS Patients have the right to:...Make informed decisions regarding care.... Be asked by the patient’s physician to give voluntary and informed consent before any medical procedure. The legally authorized representative may be asked as needed...Have care and treatment provided in a setting that is safe, which affords privacy, and which is free of all forms of abuse, harassment, retaliation or barriers to service.” Record review of facility system policy titled “Psych Response Team: Disposition Planning”, last reviewed 05/22/2023, stated “8. If the patient is to be Transferred Involuntarily, The Psych Response Team will assist in completing all commitment paperwork and: a) File Commitment Applications with the respective county in which the patient is currently hospitalized b) Monitor the issuance of a mental health warrant and keep the treatment team informed of the transport date and time c) In cases where the patient must be transported in an ambulance, with a Mental Health Deputy escort, The Psych Response Team will assist in these arrangements.” Record review of Record review of State of Texas Health and Safety Code Title 7. Mental Health and Intellectual Disability Subtitle C. Texas Mental Health Code Chapter 573. Subchapter C. Emergency Detention, release and Rights states “(b)A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the time the person is presented to the facility unless a written order for protective custody is obtained. The 48-hour period allowed by this section includes any time the patient spends waiting in the facility for medical care before the person receives the preliminary examination. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4 p.m. on the first succeeding business day, the person may be detained until 4 p.m. on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4 p.m. on the day the 48-hour period ends ...” Record review of closed electronic medical records for patients ID # 7, 8, 13, 22 reflected the patients had been brought to the emergency department with notification of emergency detention orders (EDOs) by law enforcement, they were held in involuntary status for psychiatric and medical evaluations and then exceeded the 48 hour timeframe for emergency evaluation, without evidence of completion of the order of protective custody process authorizing extended involuntary stay in the emergency department and involuntary transfer. There was no evidence of executed, signed or processed order of protective custody paperwork located in the closed medical record. Record Review of the Facility Court Liaison Coordinator Task Description document provided by staff ID #70 on 2/12/2025 stated “Harris County OPC Process: Review Secure Report to identify what hospitals are reported to have an OPC that need to be filed; completed and send to onsite clinicians according to farthest to closest hospital to HCPC Probate Court 3. This would be CY, KT, NE, SE, MC, SW, GH, TMC *Assure that all OPC’s have an onsite clinician that will be handling the OPC; if not let Coordinator know to coordinate getting a clinician there. (NP’s DO NOT DO OPC’s) *Make sure that all those reported to filed as OPC’s are still OPC’s. There is a 48 hour rule. The deadline for filing an OPC expires at 4pm on the day that the 48 hours passes “even if this results in the 48 hour deadline being less or more than 48 hours”. If the patient comes in Sunday-Wednesday you have 48 hours from the day of the EDO ....Make sure there is reasonable time to get in the OPC, if the OPC is due prior to 10:00 we will likely need to do EDW, please write paperwork or dispatch this to a clinician to do so.” Interview with Psych response team member staff ID #69 on 2/9/2025 at 09:30 am. She stated that the psych response team has a “court liaison” who she identified as staff ID #70 that assists with the coordination for obtaining legal court paperwork. She stated the liaison directs the on-site psych response team members at each campus to assist with completion of paperwork, obtaining appropriate physician signature and assistance with coordinating the courier service to pick up the paperwork for Harris County courts to sign off. Interview with Psych response team court liaison member staff ID #70 on 2/10/2025 at 12:15 pm. She stated that the system does “not have inpatient psychiatric capability” and they have been “instructed by their legal counsel not to file OPC (Orders of Protective Custody) to themselves.” She confirmed the process is to wait for terminal inpatient psychiatric bed placement, prior to completing the Order of Protective Custody paperwork. She stated the only “exception to this process is when working with Montgomery County patients because there is a limited number of facilities there who take behavioral health patients and so the wait time may be longer for placements.” She confirmed the facility did not have a policy and/or procedure which covered handling patients who needed orders of protective custody filed. She stated they have a department-based document, housed on an internal reference computer drive, which helped guide the process. She explained the process is very complex, as each county has different requirements for presentation of the completed forms to their respective county courts.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to ensure patients who were transferred from the facility, recieved informed consent for the transfer and failed to ensure the memorandum of transfer (MOT) form had been completely filled out (Patient ID #9). Findings Included: Record review of electronic medical records for patient ID # 9. There is a scanned memorandum of transfer form which is incomplete. There is no physician signature or date and no patient signature and date. This finding was confirmed with ED Nurse manager staff ID #61. Record review of facility policy titled “Patient Transfer Policy (EMTALA and Texas Transfer Act Compliance) “, last reviewed 3/29/2023 stated “a. The Hospital will provide a memorandum of transfer, as prescribed by the Texas Department of State Health Services, to be completed for every patient who is transferred unless such transfer is pursuant to a transfer agreement that does not require a memorandum of transfer be completed. b. The memorandum of transfer will be signed by the transferring physician or, if not present, a hospital staff member acting under the physician’s order if a delay in transfer has been determined to be detrimental to the patient. c. The memorandum of transfer must be signed by a representative of hospital administration. d. If a delay in transfer has occurred due to a delay in response time from the receiving hospital, the reason for the delay must be documented on the memorandum of transfer. Any agreed extension of response time must also be documented. e. A copy of the memorandum of transfer must accompany the patient being transferred as well as a copy of the medical record information mentioned above. f. The receipt of the memorandum of transfer shall be acknowledged in writing by the receiving hospital administration and the receiving physician. g. A copy of the memorandum of transfer will be retained for five years and filed separately from the medical record and in a manner which will facilitate its inspection.” Interview with ED Nurse Manager staff ID # 61 on 2/9/2025 at 11:30 am. He confirmed that he would expect the memorandum of transfer form to be fully completed, signed and dated.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 46010 Based on the observation, interview and record review, the facility failed to enforce medical staff bylaws, rules and regulations, by failing: a.) to have an identified process for ensuring patients evaluated and treated in the Emergency Department have documented medication histories, updated medication reconciliations and accurate discharge instructions which include medications to start, stop or hold (Patients ID # 10, 11, 17, 19, 22, 24, 27, 28, 30 and 31). b.) to ensure consultations were completed and documented (Patient ID# 27). Findings Included: Record review of facility document titled “Bylaws of the Medical Staff of Memorial Hermann Southeast Hospital”, last revised 5/1/2025 stated “3.7 Basic Responsibilities. Each Medical Staff Member agrees: 3.7.1 To provide continuous care and supervision to the Member’s patients in the Hospital. 3.7.2 To read the current Medical Staff Bylaws and associated manuals, policies, Rules and Regulations, and to abide by these documents.” Record review of facility document titled “Medical Staff Rules and Regulations of Memorial Hermann Southeast/Pearland Hospital”, version February 2025 stated “ 2.4 ED physicians will retain direct supervising responsibility for patients who are still within the ED regardless of the status of the patient’s admission until an attending physician has personally appeared and assumed care. The ED staff will continue to provide stabilizing treatment within the capability of the ED physician and the Hospital, including periodic reassessments and interventions as appropriate, as long as a patient is physically in the ED.” It further stated “3. PATIENT MEDICAL RECORD - RECORD OF CARE, TREATMENT, AND SERVICES 3.1 Documentation - General Content. A. The practitioner in attendance and any consultants are responsible for the preparation of a timely, complete and legible medical record for each patient. The medical record shall contain sufficient information to identify the patient, support the diagnosis and treatment and document the results. B. Each medical record contains the following clinical information: 1. The reason(s) for admission for care, treatment, and services; 2. The patient’s initial diagnosis, diagnostic impression(s), or condition(s); 3. Any findings of assessments and reassessments; 4. Any allergies to food; 5. Any allergies to medications; The rules and regulations further stated “3.11 Emergency Department Documentation Patients who receive urgent or immediate care, treatment or services shall have the following information documented in the medical record: A. The time and means of arrival; B. Documentation that the patient left against medical advice, when applicable; C. The patient’s final disposition, condition, and instructions given for follow-up care, treatment, and services 6. Any conclusions or impressions drawn from the patient’s medical history and physical examination; 7. Any diagnosis or conditions established during the patient’s course of care, treatment, and services; 8. Any consultation reports; 9. Any observations relevant to care, treatment, and services; 10. The patient’s response to care, treatment, and services; 11. Any emergency care, treatment, and services provided to the patient before his or her arrival; 12. Any progress notes; 13. Any medications ordered or prescribed; 14. Any medications administered, including the strength, dose and route; 15. Any access site for medication, administration devices used, and rate of administration; 16. Any adverse drug reactions; 17. Treatment goals, plan of care, and revisions to the plan of care; 18. Orders for diagnostic and therapeutic tests and procedures and their results; 19. Any medications dispensed or prescribed at discharge; 20. Any advanced directives; 21. Any informed consent, when required by hospital policy; 22. Any records of communication with the patient; 23. Any patient-generated information; C. All medical record entries are dated, timed and signed.” Record review of Woodlands campus facility policy titled “Home Medication Reconciliation Procedure”, last reviewed 11/16/2020, stated “MEDICATION RECONCILIATION FOR THE EMERGENCY CENTER: The Joint Commission’s National Patient Safety Goal 03.06.01 addresses the importance of obtaining a patient’s medication list across the continuum of care. AAEM, ACEP, and ENA recommend the emergency department participate in medication reconciliation in accordance with National Patient Safety Goal 03.06.01 according to the following strategy, based upon varying intensity, and consistent with medical necessity. · Screening Reconciliation: Routinely for all Emergency Center (EC) patients; this level of reconciliation consists of compiling an accurate list of medications, as stated by the patient. In most instances, the registered nurse (RN) accomplishes this level of reconciliation. · Focused Reconciliation: As needed based on medical relevance; this level of reconciliation may entail calling the patient’s pharmacy, Primary Care Physician (PCP), or family members to ensure an accurate medication list is compiled which includes drugs, dosages/routes and frequency of medications. In most instances, obtaining this level of information is directed by the EC physician/provider. · Full Reconciliation: For admitted patients to be completed by observation or inpatient unit and pharmacist. PROCEDURE: Page 5 of 6 NOTE: Printed copies of this document are uncontrolled. In the case of a conflict between printed and electronic versions of this document, the controlled version published on the Policy, Procedure, and Guideline Management System prevails. 1. The registered nurse or EC physician/provider (mid level practitioner) will obtain a patient’s home medication list which should include over the counter medicines, herbal and natural remedies, and vitamins. 2. The registered nurse is responsible for documenting the accurate home medication list in the medical record (screening reconciliation). 3. The EC physician/provider is responsible for reviewing the patient’s medication list when they anticipate ordering or prescribing any medications while the patient is in the EC, or upon discharge or transfer. Treatment will not be withheld if a complete list is not available. 4. At the discretion of the EC physician/provider and according to medical relevance, the registered nurse will acquire a complete and accurate medication list to include name, dose, strength, route, and date/time last taken (focused reconciliation). Because the patient’s time in the EC is limited, a complete list may not be possible during the time the patient spends in the EC. The RN should document any reason for an incomplete focused medication reconciliation list. 5. Upon admission to the hospital, the EC home medication list (screening reconciliation) should be sent as a part of the patient’s medical record for the full reconciliation by the patient’s nurse, primary care physician/provider, referral physician/provider, or hospital pharmacy to be completed according to hospital policy. If the patient brings their medication bottles, or a copy of their medication list, the EC RN responsible for the patient should instruct the patient or caregiver to bring these to the receiving unit where the full reconciliation will take place. 6. If a focused reconciliation is ordered by the EC physician/provider for the purpose of ordering a patient’s home medications upon admission to the hospital, the RN will document the patient’s home medications on the approved system “Home Medication Reconciliation” form, as used by the inpatient units. 7. Upon discharge from the EC, a patient should be given written instructions for both newly prescribed and recommended over the counter medications, as well as those medications to be discontinued, and instruct the patient to deliver this information to his/her ongoing care physician/provider or pharmacy. If the EC physician/provider feels the patient’s home medication regimen requires adjustment, the patient will receive clear, written instructions on any changes necessary. Changes in any of the patient’s current or long term medications will be provided to the patient’s known primary care physician/provider or original referring physician/provider or known next physician/provider of service.” Record review of facility policy for Southeast campus titled “Medication Reconciliation in the Emergency Center”, last reviewed on 07/11/2022 stated “PROCEDURE PURPOSE: To provide a consistent process in which to obtain a patient’s medication list for the purpose of ordering, prescribing, and treating the patient in the Emergency Center setting and along the continuum of care. DEFINITION(S): The Joint Commission’s National Patient Safety Goal 3.06.01 addresses the importance of obtaining and maintaining patient’s medication list across the continuum of care. AAEM, ACEP, and ENA recommend the emergency department participate in medication reconciliation in accordance with National Patient Safety Goal (as stated above) using the following strategy, based upon varying intensity, and consistent with medical necessity. (See attachment A and B for supporting documentation.) “ Screening Reconciliation: routinely for all EC patients; this level of reconciliation consists of compiling a list of medications, as stated by the patient. In most instances, the registered nurse accomplishes this level of reconciliation. “ “ Focused reconciliation: as needed based on medical relevance; this level of reconciliation may entail calling the patient’s pharmacy, Primary Care Physician (PCP), or family members to ensure an accurate medication list is compiled which includes drugs, dosages/routes of medications. In most instances, obtaining this level of information is directed by the emergency provider. “ “ Full Reconciliation: for admitted patients to be completed by inpatient unit attending physician and pharmacist.” Record review of Southwest facility policy titled “Medication Reconciliation in the Emergency Center Procedure”, last reviewed 4/24/2024, stated “RN Action: 1) To obtain the patient’s complete home medication list .... 2) Document all identified home medications in the electronic medical record. Documentation should include medication name, dose, strength, route, date and time last taken ... Documentation paperwork should include list of newly prescribed and recommended over the counter medications, as well as those medications to be discontinued. Instruction to the patient to deliver this information to his/her ongoing care provider or pharmacy. The EC provider shall: 1) review the patient’s medication list as documented in the EMR. 2) Clearly communicate to the RN and/or family when additional details on home medications are needed. 3) Ensure discharge documents include a comprehensive medication list and stop/start instructions. Record review with ED Nursing Director Staff ID # 82 on 2/10/2026 at 11:05 am of patient ID # 17 encounter 01/01/2026. He confirmed that the patient’s medication reconciliation had been last completed on 2/4/2025 at 22:28 by an RN at a previous encounter. He confirmed that list included the following medications: acetaminophen (Tylenol) 325 MG tablet, atorvastatin (Lipitor) 20 MG tablet, calcium carbonate (Tums) 500 MG chewable tablet, diclofenac sodium 1 % gel, enoxaparin (Lovenox) 40 mg/0.4mL injection, ergocalciferol 1.25 MG (50000 UT) capsule, famotidine (Pepcid) 20 MG tablet, gabapentin (Neurontin) 300 MG capsule , hydroCHLOROthiazide (HYDRODiuril) 25 MG tablet, HYDROcodone-acetaminophen (Norco) 5-325 MG tablet., ibuprofen 600 MG tablet, insulin glargine (Lantus) 100 UNIT/ML pen, Instructions: Inject 15 Units under the skin at bedtime. insulin regular (HumuLIN R,NovoLIN R) 100 units/mL injection, insulin regular (HumuLIN R,NovoLIN R) 100 units/mL injection, melatonin 3 MG tablet, metFORMIN (Glucophage) 1000 MG tablet, ondansetron (Zofran) 4 MG/2ML injection, polyethylene glycol, PEG, 3350 (Miralax) 17 g packet, QUEtiapine (SEROquel) 100 MG tablet. ED Staff ID #82 confirmed there was no evidence the ED provider had performed a medication reconciliation and confirmed there was no maintenance monitoring for the patient’s chronic conditions which included insulin dependent diabetes mellitus during the patient’s 26 hour ED stay until transfer to an inpatient psychiatry facility. Record review of Patient ID #10 with date of service 4/8/2025. The ED record stated “Medication List - Prior To Admission. Last reviewed 12/10/24 01:27 am. Discharge Medication List - Robaxin 500 mg tablets (with instructions). Last reviewed 12/10/2024 01:27 am.” There was no evidence the medication list had been reviewed. The facility discharge after visit summary stated “Your medication list: Ask your doctor about these medications. methocarbamol (robaxin) 500 mg tablet.” Interview with record review of ED Nurse Manager staff ID # 61 on 2/9/2025 at 11:35 am. He confirmed that the medication reconciliation was not updated during th patient’s emergency department enounter. He confrimed the after-visit summary did not include discharge isntructions which reflected current medication recommendations. Record review of Patient ID # 11 with date of service 4/15/2025. The ED record stated “Medication List - Prior To Admission. None. Discharge Medication List - None. Stopped in visit. None.” The visit record indicates the patient received ketorolac 15 mg IV, lidocaine-racepinephrine-tetracaine (LET), and potassium chloride ER tablet 20 mEq orally. Interview with record review of ED Nurse Manager staff ID # 61 on 2/9/2025 at 11:40 am. There was no evidence the medication list had been reviewed as the record did not have a date and time stamp indicating that medications had been reviewed. Record review of Patient ID # 19 with date of service 1/2/2026. She presented suicidal with intentional drug ingestion. The ED record stated “Medication List - Prior To Admission. Baclofen tablet 5 mg. Discharge Medication List. Baclofen tablet 5 mg Reconciled 5/5/24 at 6:47 pm. Stopped in Visit None. “ The medical racord reflected the patient received LORazepam (Ativan) tablet 0.5 mg on 01/03/26 2016 and repeated on 01/04/26 2025. She received LORazepam (Ativan) tablet 1 mg on 01/04/26 1354. ED Nursing Director Staff ID # 82 on 2/10/2026 at 11:00 am confirmed that the medication reconciliation had not been updated during the course of the patient’s ED encoutner for 1/2/2026and prior to administration of medications in the ED. Record review of Patient ID#22 with date of service 10/24/2025 showed “Medication List - Prior To Admission: amLODIPine (Norvasc) 10 MG tablet, cloNIDine (Catapres-TTS) 0.3 MG/24HR, hydrALAZINE (Apresoline) 50 MG tablet, aspirin 81 MG chewable tablet, clopidogrel (Plavix) 75 MG tablet, atorvastatin (Lipitor) 80 MG tablet, OLANZapine (ZyPREXA) 15 MG tablet. Date and time stamp indicating that medications had been reviewed showed 10/8/25, a previous visit. Record review of Patient ID#24 with date of service 10/24/2025 showed “Medication List - Prior To Admission: ibuprofen 800 MG tablet reconciled by User, System Default on 5/4/2024 0713 Record review of Patient ID#27 with date of service 1/5/2026 showed “Medication List - Prior To Admission:None. Discharge Medication List - None. Stopped in visit. None. There was no evidence the medication list had been reviewed as the record did not have a date and time stamp indicating that medications had been reviewed. This visit record showed the patient received: sodium chloride (NS) 0.9 % flush 10 mL,droperidol (Inapsine) injection 1.25 mg on 1/5/26 and 1/6/26, diphenhydrAMINE (BENADryl) injection 25 mg, QUEtiapine (SEROquel) tablet 100 mg, QUEtiapine (SEROquel) tablet 25 mg, QUEtiapine (SEROquel) tablet 50 mg, sertraline (Zoloft) tablet 50 mg, Record review of Patient ID#28 with date of service 1/1/2026 showed “Medication List - Prior To Admission: None. Discharge Medication List - None. Stopped in visit. None. There was no evidence the medication list had been reviewed as the record did not have a date and time stamp indicating that medications had been reviewed. This visit record showed the patietn recevied: sodium chloride (NS) 0.9 % flush 10 mL, Tdap (Adacel) 5-2-15.5 LF-MCG/0.5 vaccine 0.5 mL, Lido-racEpinephrine-Tetracaine (L.E.T) gel 1.5 mL., dextrose 50 % solution 12.5 g, glucagon injection 1 mg, guaiFENesin-dextromethorphan (Robitussin DM) 100-10 MG/5ML syrup 10 mL. Record review of Patient ID#30 with date of service 1/7/2026 showed “Medication List - Prior To Admission:abacavir-dolutegravir-lamiVUDine (Triumeq) 600-50-300 MG tablet,QUEtiapine (SEROquel) 25 MG tablet, folic acid (Folvite) 1 MG tablet, pantoprazole (Protonix) 40 MG EC tablet. Discharge medication list: abacavir-dolutegravir-lamiVUDine (Triumeq) 600-50-300 MG tablet,QUEtiapine (SEROquel) 25 MG tablet, folic acid (Folvite) 1 MG tablet, pantoprazole (Protonix) 40 MG EC tablet. Stopped this visit: None. Reconciled by User, System Default on 5/7/2024. Record review of Patient ID#31 with date of service 1/10/2026 showed “Medication List - Prior To Admission:None. Discharge Medication List - None. Stopped in visit- None. There was no evidence the medication list had been reviewed as the record did not have a date and time stamp indicating that medications had been reviewed. Interview with ED Nursing Director Staff ID # 82 on 2/10/2026 at 11:00 am, he stated that the facility policy is that medication reconciliation is a part of the process for patients upon admission into the facility. He confirmed there is no ER policy and procedure which mandates the process in the ED and no “hard stops” requiring it prior to disposition from the ED. Record review of Patient ID#27 with date of service 1/5/2026 showed Chief complaint as: “Psychiatric Evaluation (Pt c/o mental health crisis reports in “life saving mode” wants to hurt herself states out of meds for 7 days).” IP Consult to Psych Response Team was placed at 16:12. There were multiple entries from nursing staff and physicians referring to the Psych Response Team Recommendations, the medical record showed no evidence or documentaion of Psych Resonse Team engagement or evaluation/recommendations for patient. Interview with ED Medical Director Staff ID # 81 on 2/12/2026 at 10:35 am. He stated that he believed the medication reconciliation task was a part of the nursing charting in the ED. He confirmed there was no facility procedure or process which mandated ED physicians or providers complete medication reconciliations in the electronic medical record prior to discharge. He confirmed that ED providers would be responsible for determining which chronic conditions required ongoing treatment and monitoring in the emergency department when the patient presented with other symptomology or complaints. He went on to say that the Psych Response Team will document the patient assessment in a consult note. Some of the information maybe relayed via secure chat but the same information is in the note in the medical record.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 46010 Based on observation, interview and record review, the facility failed to ensure that the medical record for patients were complete and accurate based on medical record policies and state statutes (Patient ID # 7, 8, 9, 10, 14, 15, 16, 18, 19, 22, 24, 25, 27, 30, 31, 32 and 33), by failing to ensure the following were in the medical record: 1) Copies of the Emergency Detention Orders for holding patients in involuntary status for 48 hours (Patient ID # 8, 9, 10, 14, 15, 16, 18, 19, 22, 24, 25, 30, 31, 32 and 33). 2) Completed Memorandum of Transfer Forms (Patient ID # 14, 15, 16, 18 19, 22, 24, 25, 27 and 33) 3) Patients Rights and Responsibilities, Consent for Treatment and Financial Disclosure Forms. (Patient ID # 7, 8, 13, 14, 15, 16, 18, 19, 22 and 30). FIndings Included: 1) No Evidence of Emergency Detention Orders Record review of closed electronic medical records for patients ID # 8, 9, 10, 14, 15, 16, 18, 19, 22, 24, 25, 30, 31, 32 and 33 reflected the patients had been brought to the emergency department with notification of emergency detention orders (EDOs) by law enforcement, however there was no evidence of the completed emergency detention form located in the medical record. Record review of State of Texas Health and Safety Code Title 7. Mental Health and Intellectual Disability Subtitle C. Texas Mental Health Code Chapter 573. Emergency Detention. Sec.A573.001. Apprehension by a peace officer without a warrant states “(c)The facility where the person is detained shall include in the detained person ‘s clinical file the notification of emergency detention described by this section.” Record review of State of Texas Health and Safety Code Title 7. Mental Health and Intellectual Disability Subtitle C. Texas Mental Health Code Chapter 573. Emergency Detention. Sec. A 573.002. Peace Officers Notification of Emergency Detention states “(a) A peace officer shall immediately file with a facility a notification of detention after transporting a person to that facility in accordance with Section 573.001. Emergency medical services personnel of an emergency medical services provider who transport a person to a facility at the request of a peace officer made in accordance with a memorandum of understanding executed under Section 573.005 shall immediately file with the facility the notification of detention completed by the peace officer who made the request. (b) The notification of detention must contain: (1) a statement that the officer has reason to believe and does believe that the person evidences mental illness; (2) a statement that the officer has reason to believe and does believe that the person evidences a substantial risk of serious harm to the person or others; (3) a specific description of the risk of harm; (4) a statement that the officer has reason to believe and does believe that the risk of harm is imminent unless the person is immediately restrained; (5) a statement that the officer’s beliefs are derived from specific recent behavior, overt acts, attempts, or threats that were observed by or reliably reported to the officer; (6) a detailed description of the specific behavior, acts, attempts, or threats; and (7) the name and relationship to the apprehended person of any person who reported or observed the behavior, acts, attempts, or threats. (c) The facility where the person is detained shall include in the detained person’s clinical file the notification of detention described by this section. Record Review of facility system policy titled “Designated Record Set”, last reviewed 2/12/2024 stated “Legal Health Record (LHR) 1. The collection of information concerning a patient and their health care that is created and maintained in the regular course of business, made by a person who has knowledge of the acts, events, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. This information is created, received or maintained by an organization that is the organization’s business record of activities and operations. The LHR is generated for healthcare operations, and may be released upon request and valid authorization or as required by law. a. These records may include records maintained in an electronic medical record system, e.g., an electronic system framework that integrates data from multiple sources, captures data at the point of care; and supports caregiver decision making. b. The LHR excludes health records that are not official business records, such as personal health records managed by the patient. c. The LHR is generated at or for Memorial Hermann Health System as its business record and is the record that will be disclosed upon receipt of valid patient authorization or as required by law. d. Generally, the custodian of the LHR is the Release of Information (ROI) director. Some exceptions may apply. e. The LHR contains individually identifiable data, is stored on any medium, and is collected and directly used in documenting healthcare or health status. f. The LHR must meet accepted standards as defined by applicable Centers for Medicare and Medicaid Services Conditions of Participation, Federal regulations, State laws, and standards of accrediting agencies, Joint Commission on Accreditation of Healthcare Organizations, as well as the policies of Memorial Hermann Health System. g. The LHR is a subset of the DRS that meets the requirements for a business record used for legal purposes. h. The LHR may only be accessed by and/or modified by individuals authorized to do so by Memorial Hermann Health System. 2. The Designated Record Set, in conjunction with the Legal Health Record, comprise a patient’s medical record. Record Review of the Facility Court Liaison Coordinator Task Description document provided by staff ID #70 on 2/12/2025 stated “EDO Binder: Hospital’s are all located in the binder and are in alphabetical order; please insert EDO’s as such. Place the newest EDO (received) for that location on the top. Once a patient is no longer on the report please remove and place the EDO in the shred bin. “ Interview with Psych response team member staff ID #70 on 2/10/2025 at 11:45 am. She stated that Notification of Emergency Detention Forms, that are brought in with patients and completed by law enforcement, are kept in the physical chart in the nurses station, while the patient is in the Emergency Department. Then they are moved to a binder in the workstation. She confirmed the facility did not have a policy and/or procedure which covered handling patients who presented to the facility with notification of emergency detention forms. Interview with ER Nurse Manager staff ID # 82 on 2/10/2025 at 1:45 pm during medical record review. He confirmed he was unable to locate a copy or scanned document in the electronic medical record of the notification of emergency detention form in any of the reviewed medical records. 2) Completed Memorandum of Transfer Forms Record review of facility policy titled “Patient Transfer Policy (EMTALA and Texas Transfer Act Compliance) “, last reviewed 3/29/2023 stated “a. The Hospital will provide a memorandum of transfer, as prescribed by the Texas Department of State Health Services, to be completed for every patient who is transferred unless such transfer is pursuant to a transfer agreement that does not require a memorandum of transfer be completed. b. The memorandum of transfer will be signed by the transferring physician or, if not present, a hospital staff member acting under the physician’s order if a delay in transfer has been determined to be detrimental to the patient. c. The memorandum of transfer must be signed by a representative of hospital administration. d. If a delay in transfer has occurred due to a delay in response time from the receiving hospital, the reason for the delay must be documented on the memorandum of transfer. Any agreed extension of response time must also be documented. e. A copy of the memorandum of transfer must accompany the patient being transferred as well as a copy of the medical record information mentioned above. f. The receipt of the memorandum of transfer shall be acknowledged in writing by the receiving hospital administration and the receiving physician. g. A copy of the memorandum of transfer will be retained for five years and filed separately from the medical record and in a manner which will facilitate its inspection.” Record review of closed electronic medical records for patient Patient ID # 14, 15, 16, 18 19, 22, 24, 25, 27 and 33 for completed memorandum of transfer forms. There was no memorandum of transfer forms located in the medical record. Interview with ED Nurse Manager staff ID # 61 on 2/9/2025 at 11:30 am. He confirmed that he was unable to locate a memorandum of transfer form in Patient ID #13 medical record. Interview with ER Nurse Manager staff ID # 82 on 2/10/2025 at 1:45 pm during medical record review of patient ID #18 and 19. He confirmed he was unable to locate a copy or scanned document in the electronic medical record of a memorandum of transfer form. 3) No Patient Rights and Responsibilities Disclosures, Consent for Treatment or Financial Disclosures Record review of facility system policy titled “Patient Rights and Responsibilities”, last reviewed 06/10/2022, showed the following: “POLICY PURPOSE: To ensure that a patient is informed of his or her rights and responsibilities upon receiving care treatment and service. To ensure that staff, physicians, volunteers, and other health care providers are informed of these rights and responsibilities... INFORMING THE PATIENT: Patients are to be informed of their rights and responsibilities upon admission to an inpatient setting, or upon initial presentation to an outpatient setting. This will be accomplished by providing the patient with a written and/or posted statement of the rights and responsibilities.” Record Review of facility system policy titled “Designated Record Set”, last reviewed 2/12/2024 stated “Legal Health Record (LHR) 1. The collection of information concerning a patient and their health care that is created and maintained in the regular course of business, made by a person who has knowledge of the acts, events, opinions or diagnoses relating to the patient, and made at or around the time indicated in the documentation. This information is created, received or maintained by an organization that is the organization’s business record of activities and operations. The LHR is generated for healthcare operations, and may be released upon request and valid authorization or as required by law. a. These records may include records maintained in an electronic medical record system, e.g., an electronic system framework that integrates data from multiple sources, captures data at the point of care; and supports caregiver decision making. b. The LHR excludes health records that are not official business records, such as personal health records managed by the patient. c. The LHR is generated at or for Memorial Hermann Health System as its business record and is the record that will be disclosed upon receipt of valid patient authorization or as required by law. d. Generally, the custodian of the LHR is the Release of Information (ROI) director. Some exceptions may apply. e. The LHR contains individually identifiable data, is stored on any medium, and is collected and directly used in documenting healthcare or health status. f. The LHR must meet accepted standards as defined by applicable Centers for Medicare and Medicaid Services Conditions of Participation, Federal regulations, State laws, and standards of accrediting agencies, Joint Commission on Accreditation of Healthcare Organizations, as well as the policies of Memorial Hermann Health System. g. The LHR is a subset of the DRS that meets the requirements for a business record used for legal purposes. h. The LHR may only be accessed by and/or modified by individuals authorized to do so by Memorial Hermann Health System. 2. The Designated Record Set, in conjunction with the Legal Health Record, comprise a patient’s medical record. Record review of closed electronic medical records for patient Patient ID # 7, 8, 13, 14, 15, 16, 18, 19, 22 and 30. There was no evidence of patient rights and responsibilities/disclosures, consent for treatment or financial disclosures located in the closed medical record.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to ensure that social work assessments and discharge planning assessments were completed and documented on behavioral health patients with high risk indicators. (Patient ID # 6 and 10). Findings Included: Record review of facility system policy titled “Psych Response Team: Behavioral Health Services Access Policy”, last reviewed on 10/19/2024 stated “All patients determined to need a PRT consultation will be provided with a comprehensive assessment and linkage to inpatient and/or community-based mental health care and other support services.” It further stated “A referral to PRT can be made from any Memorial Hermann Health System entities/facilities covered under this policy. a. PRT can be accessed by completing the Psychiatric Response Team Form found in the applications section of One Source. All requests for consults will also require a physician’s order in Epic. Each request will detail Location, Registered Nurse (RN) or staff name, Medical Record Number and Call Back Phone number. In the event of problems with One Source, the team can also be accessed by calling 713-814-(redacted). b. PRT will use the BHS Comprehensive Assessment - Psych Response Team (Electronic Medical Record (EMR)-Epic) or PRT Comprehensive Assessment Downtime Form (Epic unavailable) to document assessment findings, management recommendations and a disposition/aftercare plan. c. PRT will provide staff education as necessary to floor staff and physician groups. Please contact the on-call manager at 713-814-(redacted).” Record Review of Patient ID # 6 electronic medical record with ED Nurse Manager Staff ID #61 on 2/9/2026 at 11:05 am. He confirmed that Patient ID #6 had presented to the facility ED for care on 1/5/2026. He confirmed that the triage nurse stated the patient had arrived with history of schizophrenia, on a bus from out of state and was requesting resources and assistance getting mental health medications. The chart reflected a “social work consult” had been ordered by physician staff ID # 73 on 1/5/2026 at 6:11 pm but there was no social work assessment completed. Staff ID # 61 stated he could only see Staff MSW brief notes entered on the “flowsheet” which reflected she had confirmed patient was going to take a Greyhound bus the next morning and that she had provided a Lyft pass to the bus station. He confirmed that all social determinant of health screenings entered by patient navigator stated “unable to answer.” He was unable to articulate based on the electronic medical record why the patient would be “unable to answer” if she was being discharged from the facility. Record Review of Patient ID #10 electronic medical record with ED Nurse Manager Staff ID # 61 on 2/9/2026 at 11:30 am. He confirmed that Patient ID # 10 on 4/7/2025 has telepsychiatry consultation notes dated 4/8/2025 where all data points carried over from prior encounters, at other medical systems in the region. He confirmed there was no evidence of social work consult, provider or nursing reassessment of those positive triggers. The note stated “Social Drivers of Health. Financial Resource Strain: At Risk (4/7/2025) Received from Harris Health System AAFP Finances. o How often does this describe you? I don’t have enough money to pay my bills: Always Food Insecurity: Food Insecurity Present (4/7/2025) Received from Harris Health System Hunger Vital Sign o Worried About Running Out of Food in the Last Year: Often true o Ran Out of Food in the Last Year: Often true Transportation Needs: Not At Risk (4/7/2025) Received from Harris Health System AAFP Transportation o Do you put off or neglect going to the doctor because of distance or transportation?: No Physical Activity: Inactive (11/13/2024) Received from Harris Health System Exercise Vital Sign o Days of Exercise per Week: 0 days o Minutes of Exercise per Session: 0 min Stress: No Stress Concern Present (11/13/2024) Received from Harris Health System Finnish Institute of Occupational Health - Occupational Stress Questionnaire o Feeling of Stress : Not at all Social Connections: Low Risk (1/12/2024) Received from Catholic Health Initiatives Family and Community Support o Help with Day to Day Activities: Not on file o Feeling Lonely or Isolated: Not on file Intimate Partner Violence: At Risk (4/7/2025) Received from Harris Health System Domestic Violence (HRSN) o How often does anyone, including family and friends, physically hurt you:1 o How often does anyone, including family and friends, insult or talk down to you?: 5 How often does anyone, including family and friends, threaten you with harm?: 1 Interview with Staff MSW ID # 72 on 2/9/2026 at 1:45 pm. She confirmed she was a social worker covering the ED and involved with Patient ID #6 on 1/5/2026. She stated that she was not aware a social worker consult had been ordered for the patient. She stated that she engaged with the patient and staff RN when the ED nurse called for assistance regarding transportation at discharge. She stated that she had not reviewed the medical record or patient history for this patient as part of the patient engagement. She denied knowledge that the patient had a schizophrenic mental health history or any details of the patients social history or presenting history including that she sought care asking for assistance obtaining psychiatric medications for her condition. Staff ID #72 stated that she confirmed that the patient’s grandmother was going to be providing a Greyhound bus ticket for tomorrow” for the patient to leave the area. She stated after confirming that the grandmother was in fact providing a bus ticket by telephone, she provided instructions to ED nursing staff on providing Lyft pass. She stated she did not provide any additional resources such as homeless shelters, locations to obtain psychiatric medications and followup (which was a part of the patient’s initial presenting complaint) or any other details. She confirmed that she did not complete a full social consult assessment or write a detailed note of her assessment or recommendations. Interview 2/9/2026 at 2:20 pm with Director of Case management Staff ID #74. She confirmed that a full social work consult had not been completed on Patient ID #6 or documented per EMR review. She stated that it is a “collaborative effort between the psych response team and social workers to complete this process.” She was unable to articulate what the components of the social work assessment which would be expected for a schizophrenic patient, who had presented from out of state, homeless, asking for assistance with mental health treatment and medications. She stated that the facility has a psych response team, but if the doctor determines the patient is safe to discharge, then they don’t do extensive social work involvement. She stated that pertinent risks and triggers which are components of discharge planning are typically found in psych response team notes for behavioral health patients that they engaged with.”

“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: 37322 Based on interview and record review, he hospital failed to enforce a policy to ensure patients’ rights to maintained the principles and practices for preventing transmission of infectious agents within the hospital ICU in 1 of 10 visitors observed in the 24-bed unit. Findings Include: Facility Policy “ Isolation Policy” last reviewed 09/25/2025 stated: Section !!: Transmission-Based Precautions. E. If visitors do not comply with transmission-based precautions, staff should escalate through their chain of command (for example a nurse may escalate to the charge nurse or nurse manager). Observation on 12/29/2025 at 1125 of this failed practice has the potential for the spread of infection to all patients and families within the facility by observing a patient (ID#6) son in the room without protective gear, i.e gown and gloves while visiting his mother. The patient (ID#6) had both MRSA and EBSL. MRSA stands for Methicillin-resistant Staphylococcus aureus bacteria. (Google, 2025) ESBL stands for Extended-Spectrum Beta-Lactamase, referring to enzymes produced by certain bacteria (like E. coli, Klebsiella) that make them resistant to many common antibiotics (penicillin’s, cephalosporins), leading to harder-to-treat infections, often in hospitals, requiring stronger drugs like carbapenems. (Goggle, 2025). Interview with staff (ID# H) who stated they had talked to the son several times and he refuses to put on protective gear during visiting hours, so they let him be.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 37322 Based on interview and record review, the facility failed to ensure nursing staff develop and keep current nursng plan of care which addresses the patients needs in 1 (ID#2) of 10 patient records review. Finding Include: Facility policy “Electronic Nursing Documentation and Intervention Documentation Frequency, last reviewed 11/07/2021. To Provide baseline framework for nursing assessment and nursing intervention documenation upon admission and throughout the patients hospitalization. 2. Develop and Initiate Interdisciplinary Plan of Care (IPOC). a. The plan of care will be reviewed and revisied as needed, minimally once in a 24 hour period. b. Nursing and Ancilliary departmeents are to contribute to the IPOC after assessing the patient. c. The problem list is ongoing and will be reviewed by each team member. Record review on 12/29/2025 at 10;00 am of patient (ID# 2) medical record indicated he was a diabetic and dialysis patient and didn’t take his pressure sock off and got a wound on his foot. No patient education related to his diabetes and foot care was noted on the plan of care. Interview with the staff nurse (ID#F) during the record review, vertified the findings in the record.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to ensure there were adequate numbers of staffing in a nursing unit, for 6/18 shifts reviewed for the 3A nursing unit. Findings Included: Record review of staffing grid provided by facility labeled “Cardiothoracic IMU 3A” with 3A unit charge nurse Staff ID #62 on 6/10/2025 at 11:00 am. She confirmed this was the staffing grid utilized by the 3A nursing unit for staffing the unit. Record review of staffing sheets from 3/20/2025 until 3/27/2025 with charge nurse staff ID #62. She confirmed the following findings: 3/21/25 7 pm, Census 34, Staffing sheet states Census 34 - 1 charge RN, 10 RNs and 3 PCAs; actual 1 charge RN, 9 RNs, 3 PCAs. 3/22/25 7 pm, Census 33, Staffing sheet states Census 33 - 1 charge RN, 10 RNs and 3 PCAs; actual 1 charge RN, 9 RNs, 2 PCAs. 3/24/25 7 am, Census 35, Staffing sheet states Census 35 - 1 charge RN, 10 RNs and 4 PCAs; actual 1 charge RN, 10 RNs, 3 PCAs. 3/24/25 7 pm, Census 34, Staffing sheet states Census 34 - 1 charge RN, 10 RNs and 4 PCAs; actual 1 charge RN, 9 RNs, 3 PCAs. 3/25/25 7 am, Census 34, Staffing sheet states Census 34 - 1 charge RN, 10 RNs and 4 PCAs; actual 1 charge RN, 10 RNs, 3 PCAs. 3/25/25 7 pm, Census 31, Staffing sheet states Census 31 - 1 charge RN, 9 RNs and 3 PCAs; actual 1 charge RN, 9 RNs, 2 PCAs. Record review of facility’s “Administration: Staffing Effectiveness”, last reviewed 12/19/2022, stated “MHSE will ensure that there is an adequate number of multidisciplinary clinical staff to fulfill its mission and meet the needs the needs of the populations served. There is a sufficient number of staff based on the hospital’s determination of the approrpiate level of staffing.” Interview 6/10/2025 at 11:00 with Charge RN Staff ID #62. She confrimed the above findings. She stated that the unit occasionally has to utilize PCA’s for 1:1 sitters in their unit and other units or occasionally due to staff unexpected call ins. She stated that the staffing office is responsible for allocating staff to the units.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38387 A. Based on review of facility policy, patient medical records, and confirmed in interviews, the facility failed to ensure patient rights were protected and promoted in accordance with the facility’s restraint policies and procedures for two of eight patients reviewed (Patient #A, B). Refer to A 0167, 0171, 0174, 0175 B. Based on review of facility policy, patient medical records, and confirmed in interviews, the facility failed to ensure patient rights were protected and promoted in accordance with the facility’s restraint policies and procedures, and in accordance with State law when chemical restraints/emergency behavioral medications were administered for the management of behaviors for four of four patients reviewed (Patient #A, B, E, G) with medication restraints identified. Refer to A0160 The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 38387 Based on review of the facility, medical records, and confirmed in interview, the facility failed to ensure chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) and or (IV) for behavioral emergencies were identified and monitored as a restraint for four of eight patient ’ s reviewed (Patient’s #A, #B, #E, #G). Failure to identify and monitor emergency medications used as restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication was given, and improper oversight by the facility which posed significant risks to patient safety. Findings included: Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated “Chemical Restraint: A drug or medication used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement. 1. It is not a standard treatment or dosage for the patient’s condition. 2. Drugs or medications that are used as part of a patient’s standard medical or psychiatric treatment and are administered within the standard dosage for the patient’s condition, are not considered to be chemical restraints. Criteria used to determine whether the use of a drug or medication, or combination of drugs or mediations is a standard treatment or dosage for the patient’s condition includes all of the following: a) The drug or medication issued within the pharmaceutical parameters approved by the Food and Drug Administration (FDA) and the manufacturer for the indications that it is manufactured and labeled to address, including listed dosage parameters. b) The use of the drug or medication follows national practice standards established or recognized by the medical community, or professional medical associations or organizations. c) The use of the drug or medication to treat a specific patient’s clinical condition is based on the patient’s symptoms, overall clinical situation, and on the physician’s knowledge of that patient’s expected and actual response to the medication.” Review of the available policies revealed no policy to ensure safe and appropriate administration and monitoring of an emergency psychoactive medication that shall: (1) identify the staff members authorized to administer an emergency psychoactive medication; (2) identify the psychoactive medications permitted and approved by the hospital for administration in a psychiatric emergency; (3) prescribe how and with what frequency and duration a staff member shall monitor a patient who has received an emergency psychoactive medication to ensure the health and safety of the patient, in addition to the in-person evaluation conducted as required by subsection (f) of this section; (4) identify the licensed practitioners authorized to examine the patient as required by subsection (f) of this section; and (5) ensure staff members follow all monitoring and evaluation requirements under this section and all hospital policies and procedures regarding administration of an emergency psychoactive medication each time a patient receives a separate dose of an emergency psychoactive medication. Review of four of eight medical charts (Patient #A, #B, #E, #G) revealed four patients who received drugs or medication to restrict the patient’s behavior and was not a standard treatment for the patient’s condition. Patient #A Review of Patient #A’s medical chart revealed she is a 12 year old female with a history of depression and anxiety and ADHD who presented to the ED for suicidal ideation on 05/12/2025. Review of her medical history from her previous psychiatric hospitalization revealed she did not routinely take Benadryl, Ativan, and/or Zyprexa for her mental health. Staff #16’s nursing notes on 05/14/2025 at 3:08 PM revealed “patient moved bed against wall and was hiding between the bed in the wall refusing to come out, security called to bedside. Explained to patient we need to be able to see her at all times, patient screaming and cussing and lunging at staff. Patient trying to pull bed against wall again and bed was removed from the room. At that time, patient punched the computer screen shattering it. Patient attempting to hit staff, bed brought back in room and patient placed on it, patient continues to attempt to hit and kick staff. Patient restrained at this time for self-destructive behavior.” Further review of Patient #A’s chart revealed chemical restraints/emegency behavioral medication were administered on 05/14/2025 at 2:30 PM (benadryl 25 mg IM); 2:45 PM (Zyprexa 5 mg IM); and 3:00 PM (Ativan 2 mg IM). The documentation reviewed did NOT include a face to face evaluation to determine the patient’s immediate situation, patient’s reaction to the medication nor patient’s medical and behavioral conditions after administering the above emergency behavioral medications. Patient #B Review of Patient #B medical record revealed she is an 18 year old female who was seen at the ED with complaints of SI with plan to harm herself with a piece of glass on 04/04/2025 via police EDO (emergency detention order). Further review of her chart revealed Haldol 5 mg IM; Ativan 2mg IM; Benadryl 50 mg, IM were administered on 04/05/2025 at 02:25 AM. The documentation reviewed did NOT include a face to face evaluation to determine the patient’s immediate situation, patient’s reaction to the medication nor patient’s medical and behavioral conditions after administering the above emergency behavioral medications. Patient #E Review of Patient #E’s chart revealed she is a “15-year-old female brought in by her mom and sisters and grandmother for the past few weeks she has been acting up possibly been smoking marijuana she is beginning to fight she tried to cut her wrists she tried to jump out of windows the family’s concern she may be a danger to herself and brought her in for evaluation. On exam patient is not cooperative very aggressive try to run out not provide any history for us.” She arrived in the ED via an EDO on 05/15/2025 at 2:24 PM. Review of the nursing notes (staff #28) on 05/15/2025 at 3:30 PM, it stated “Pt very agitated and uncooperative. Pt screaming that she wants to leave and states she does not know what she is here for. Will not comply with instruction and refuses to do anything anyone asks her to do but continues to scream very loudly and very high-pitched. Security, RN staff, sitters and MD all at bedside. Pt fighting and swatting at any staff that comes near her.” Review of the physician notes (staff #27) on 05/15/2025 at 7:26 PM it stated “Patient still pending evaluation but we had to sedate patient earlier due to her aggressive behavior.” Further review of Patient #E’s chart revealed emergency behavioral medications given on 05/15/2025 at 4:15 PM for Haldol 5 mg IM, Ativan 2 mg IM, Benadryl 25 mg IM. Review of records revealed no face to face assessment as required in the facility policy. The documentation reviewed did NOT include change in condition impacting need for restraint, pulse, respiratory status, vital signs, mental status, or readiness for discontinuation of restraints or justification for continued use. Patient #G Patient #G is a 47 year old female with history of schizophrenia and multiple sclerosis brought to the ED via EMS and police on 05/04/2025 for erratic behavior. Review of her medical record revealed she had five chemical restraints on 05/04/2025 at 3:40 AM; 05/05/2025 1:07 AM; 05/05/2025 at 05:31 AM; 05/05/2025 at 09:29 AM; 05/05/2025 at 11:12 AM with no face to face assessment as required in the facility policy. The documentation reviewed did NOT include change in condition impacting need for restraint, pulse, respiratory status, vital signs, mental status, or readiness for discontinuation of restraints or justification for continued use. Staff #21 notes on 05/04/2025 at 0324, “Given patient was threatening to grab the police’s gun and she has been a little bit aggressive with staff, will chemically sedate her for now.” 03:40 AM haloperidol lactate 5 mg IM; lorazepam 2mg IM; diphenhydramine 50 mg, IM Staff # 22 notes on 05/05/2025 1:07 AM Patient woke up and wanted to be discharged. Patient walked towards the door of the room. This nurse and the sitter attempted to redirect the patient back into bed. The staff was not able to redirect the patient. The patient became irritated and aggressive and pulled up her pants while advancing towards nurse and sitter. Security was called to assist with keeping the patient in the room while chemical restraints were prepared. Droperidol 5mg and Ativan 2mg were given IM. The patient is unwilling to cooperate and repeatedly stated that she did not want to go to an inpatient facility and wanted to go home. The patient is asleep in bed at this time. Will continue to monitor the patient. 01:00 AM Ativan 2 mg IM given 01:01 AM Droperidol (Inapsine) 5 mg IM given Staff #22 notes on 05/05/2025 at 05:31 AM “Patient woke up after given doperidol and lorazepam. The patient wasn’t redirectable back to her bed and wanted to leave. The patient was given another dose of doperidol and lorazepam to reduce her anxiety. Will continue to the patient. The patient is now asleep in bed. Rise and fall of chest 16 breaths/min. The patient is not showing any signs of distress.” 05:31 AM Ativan 2 mg IV given, Droperidol (Inapsine) 5 mg IV given Staff #23 notes on 05/05/2025 at 09:20 AM “Pt started to be aggressive and pulling computer lines and throwing things. Tried talking and reorienting the patient but wouldn’t listen. MD informed.” 09:29 AM Zyprexa 5 mg IM; Benadryl 50 mg IV; Ativan 1 mg IV given 11:12 AM Ativan 1 mg IV given”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38387 Based on observation of facility video surveillance, review of facility policy, record reviews, and interviews, the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital’s restraint policy, training program and in accordance with State law during the implementation of a physical restraint for one of eight patients reviewed (Patient #A). Findings included: Review of the facility Restraints and Seclusion Policy (Version 4, 02/13/2024), it stated under Policy Statements “restraints must have a physician’s order, appropriate clinical justification for the restraint, a start time and a time limit.” Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated under types of restraints “physical/therapeutic Hold: a manual method to restrict patient movement. a) a grasp on a patient that the patient cannot easily escape from, in order to escort the patient to another location. b) physically holding a patient for forced medications. This will require a physician order and the 1 hour face to face evaluation.” Video review of 05/14/2025 revealed the following observations from the body cam videos from Staff #7, #8, #9 from 2:51 PM to 3:03 PM, in part: Staff #9 looking into the room talking with Patient #A (patient is visibly agitated) Patient #A is observed punching a computer monitor Staff #9 walks up to Patient #A and physically holds her by her wrists/arms behind her back with face against the wall Medical bed is brought back in and Staff #7 and Staff #9 assist in holding patient onto the bed 2:52 PM The provider Staff #11 observed entering the room and assists by physically holding Patient #A’s forehead with a stiff arm onto the bed with his hand. Staff #9 is also seen holding the patient’s forehead with a stiff arm onto the bed as patient tries to bite staff. Several other clinical staff assist in placing the physical 4 point restraints. 2:54 PM The provider Staff #11 used 2 hands around sides of Patient #A’s face to prevent her from thrashing and spitting. 2:56 PM Staff #15 observed talking with patient (patient crying and thrashing) 2:58 PM The provider Staff #11 observed by the head of the bed and he is heard stating “the more you fight it, the longer you’ll be in it” Lights are turned off and music from the tv is turned on 3:00 PM Staff #14 and #15 are heard explaining the restraints and IM meds given at 3:03 PM. Review of the facility training for techniques for effective aggression management provided via email on 05/29/2025 did NOT include physical holds with both arms behind the patients back with face against the wall or a stiff arm technique to the forehead. It also did not include making threats of prolonging restraints if patient is uncooperative. In an email on 05/30/2025 from Staff #3, she stated “Staff members complete a total of 3 hours of TEAM training (Essentials is online module for 1 hour, Advanced is hand on in person 2 hour training). For our Security Officers, their commission license course spends 16 hours on holds and defensive tactics.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 38387 Based on review of facility policy, review of medical records and confirmed in interview, the facility failed to ensure each restraint used for the management of violent or self-destructive behavior was in accordance with the 2 hour time limit for adolescents in one of two patients with restraints reviewed (Patient #A). Findings included: Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated “Obtain and renew restraint orders with the following limits for up to 24-hours for continued need: a. Every four (4) hours for adults age 18 or older b. Every two (2) hours for children and adolescents ages 9 to 17 years C. Every one (1) hour for patients under age 9 years Obtain a new order for the restraint if the restraint use is discontinued prior to the expiration of the original order and re-initiation of restraint is deemed necessary. Prior to expiration of the order, the RN will contact the provider with the results of the most recent patient assessment and request that the provider renew the original order for another period of time not to exceed the time limits established above. A face-to-face assessment is left to the discretion of the provider. “ Review of Patient #A’s medical chart revealed she is a 12 year old female with a history of depression and anxiety and ADHD who presented to the ED for suicidal ideation on 05/12/2025. Further review of her chart revealed physical restraints were used on 05/14/2025. Staff #16’s nursing notes included: 3:08 PM “patient moved bed against wall and was hiding between the bed in the wall refusing to come out, security called to bedside. Explained to patient we need to be able to see her at all times, patient screaming and cussing and lunging at staff. Patient trying to pull bed against wall again and bed was removed from the room. At that time, patient punched the computer screen shattering it. Patient attempting to hit staff, bed brought back in room and patient placed on it, patient continues to attempt to hit and kick staff. Patient restrained at this time for self-destructive behavior.” 5:30 PM “All restraints discontinued, patient tearful but cooperative. Skin is clean, dry, and intact. Patient given crayons to color with per request.” Review of Patient #A’s medical chart revealed the following orders for restraints: 3:10 PM Restraints violent or self-destructive adolescent 5:08 PM Restraints discontinued (user system defaulted) 5:17 PM Restraints discontinued order acknowledged by RN (Staff #16) Restraints were kept on for over 2 hours (2 hours 20 minutes) with no documentation of a new order to continue. In an interview with Staff #1, she acknowledged that the restraints were kept on longer than the 2 hour limit for patient’s age.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 38387 Based on review of facility policy, patient medical records, and confirmed in interview, the facility failed to ensure restraints were discontinued at the earliest possible time according to the physician orders and facility policy for one of eight Patients (Patient #A) reviewed for restraints. Specifically, Patient #A remained in 4 point restraints while nursing documentation indicated she was sleeping, indicating she was no longer a threat to herself or others. Findings included: Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated “within 1 hour of the application of restraints, a face to face evaluation must be completed by physician or other provider. Telephonic or telemedicine methods of evaluation are not permitted. Should a patient’s violent or self-destructive behavior be resolved and the restraint intervention is discontinued before the practitioner arrives, a face-to-face evaluation must be completed within one (1) hour after the initiation of the intervention. The face-to-face evaluation should include: a. An evaluation of the patient’s immediate situation b. Factors that may have contributed to the violent or destructive behavior c. Whether the intervention was appropriate to address the violent of destructive behavior d. The patient’s reaction to the intervention e. The patient’s medical and behavioral condition f. The need to continue or terminate the restraint. g. The need for other interventions or treatments. The attending physician or provider responsible for the care of the patient must be consulted if the face-to-face evaluation is conducted by someone other than the attending physician or other provider responsible for the care of the patient. Obtain and renew restraint orders with the following limits for up to 24-hours for continued need: a. Every four (4) hours for adults age 18 or older b. Every two (2) hours for children and adolescents ages 9 to 17 years C. Every one (1) hour for patients under age 9 years Obtain a new order for the restraint if the restraint use is discontinued prior to the expiration of the original order and re-initiation of restraint is deemed necessary. Prior to expiration of the order, the RN will contact the provider with the results of the most recent patient assessment and request that the provider renew the original order for another period of time not to exceed the time limits established above. A face-to-face assessment is left to the discretion of the provider. The provider must conduct a face-to-face reevaluation before writing a new order for the continued use of restraint, if the patient remains in restraint 24-hours after the original order. Violent patients must be monitored for safe application at least every 30 minutes. Monitor the patient: a. Observe patients older than 9 at least every two (2) hours (patients under the age of 9 years must be assessed every (1) hour) for: i. change in condition impacting the need for restraint (such as level of distress or agitation) ii. circulation (pulse) distal to the restraint iii. skin integrity distal to the restraint (restraint may be removed to assess skin) iv. respiratory status v. vital signs - which include at a minimum the measurement of blood pressure, heart rate, respiratory rate, and 02 saturation vi. mental status vii. nutritional and hydration needs vili. elimination and toileting needs ix. range of motion and position change x. readiness for discontinuation of restraints xi. justification for continued use of restraints. Staff are expected to assess and monitor the patient’s condition on an ongoing basis to determine whether restraint can safely be discontinued as quickly as possible.” Review of Patient # A’s records revealed the following restraint orders: MD Notified: Yes Security Called: Yes Injuries During Intervention: No Incident Note Filed: Yes Assessment Alternatives to Restraints Tried/Judged to be Ineffective Prior to Application: Repositioning; Reorientation to surrounds; Increased frequency of nursing rounds; Verbal redirection; Decrease stimulation; Diversionary activities Risk Factors: History of physical abuse Justification Clinical Justification: Imminent risk of harm to self and others Restraint Type 4 Point Restraints (V): START Both Upper Extremities Wrist Restraints (V): START Both Lower Extremities Ankle Restraints (V): START Education Discontinuation Criteria: Contracts not to harm self; Absence of behavior that required restraint; Contracts not to harm others Criteria Explained: Yes Patient’s Response: Verbalized understanding Family Notification: Guardian ED Restraint Care Plan ED Restraint Care Plan: Assess for continued need for restraints/discontinuation of restraints; Release restraints every two hours for ten minutes; Exercise and maintain range of motion; Assess and assist with toileting needs; Administer medications as ordered for agitation/restlessness; Observe for urinary incontinence, constipation; Circulation checks; Monitor Vital Signs; Cover/protect IV lines and tubes” Patient #A remained in a 4-point restraint from 05/14/2025 at 3:00 PM until discontinued on 05/14/2025 at 5:30 PM (over 2 hours). Nursing documentation (Staff #16) indicated she was sleeping, but aggressive and uncooperative on the Violent Restraints Monitoring Every 30 minutes at 3:25 PM and 3:55 PM; but tearful and uncooperative at 4:25 PM. 3:25 PM Physical Comfort: Patient asleep Continuous Observation: Yes Psychological Status: Aggressive/Violent; Uncooperative 3:55 PM Physical Comfort: Patient asleep Continuous Observation: Yes Psychological Status: Aggressive/Violent; Uncooperative 4:25 PM Physical Comfort: Reposition; Pillows Continuous Observation: Yes Psychological Status: Tearful; Uncooperative Review of Patient #A’s medical chart revealed the following Q15 checks. Prior to and during restraints on 5/14/25, Staff #19 documented the Q15 minute checks: 2:30 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 2:45 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 3:00 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 3:15 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 3:30 PM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep Physical Comfort: Patient asleep 15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep Food/Meal: Patient asleep Elimination: Patient asleep During restraints on 5/14/25, Staff #18 continued the Q15 minute checks 3:45 PM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep Physical Comfort: Patient asleep 15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep Food/Meal: Patient asleep Elimination: Patient asleep 4:00 PM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep Physical Comfort: Patient asleep 15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep Food/Meal: Patient asleep Elimination: Patient asleep 4:15 PM Patient Location: In room Patient Activity: Awake 15 Minute Sitter Check Observation Complete: Yes Elimination: Offered 4:30 PM Patient Location: In room Patient Activity: Awake Visual Check: Tearful 15 Minute Sitter Check Observation Complete: Yes 4:45 PM Patient Location: In room Patient Activity: Awake Visual Check: Tearful (crying) 15 Minute Sitter Check Observation Complete: Yes 5:00 PM Patient Location: In room Patient Activity: Watching TV Visual Check: Tearful (crying wants nurse) 15 Minute Sitter Check Observation Complete: Yes 5:16 PM Patient Location: In room Visual Check: (crying) 15 Minute Sitter Check Observation Complete: Yes The behavior requiring restraint was absent while Patient #A was sleeping as documented by both Staff #16 and Staff #19 on 05/14/2025 at 3:30 PM. In an interview with Staff #6 on 5/27/25 at 1:20 PM in the small conference room, he stated that he believed that Staff #16 accidentally input ‘patient asleep’ in the chart. He stated that Patient #A couldn’t have been aggressive/violent, uncooperative if she was asleep. He acknowledged that restraints could be kept on as a precaution but that it should be reassessed for need.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 38387 Based on review of facility policy, patient chart review and confirmed in interview, the facility failed to ensure the condition of the patient who was restrained was monitored at intervals determined by hospital policy for two of eight charts reviewed (Patient #A, B). Findings included: Review of the facility Restraints and Seclusion Procedure (Version 4, 02/13/2024), it stated “within 1 hour of the application of restraints, a face to face evaluation must be completed by physician or other provider. Telephonic or telemedicine methods of evaluation are not permitted. Should a patient’s violent or self-destructive behavior be resolved and the restraint intervention is discontinued before the practitioner arrives, a face-to-face evaluation must be completed within one (1) hour after the initiation of the intervention. The face-to-face evaluation should include: a. An evaluation of the patient’s immediate situation b. Factors that may have contributed to the violent or destructive behavior c. Whether the intervention was appropriate to address the violent of destructive behavior d. The patient’s reaction to the intervention e. The patient’s medical and behavioral condition f. The need to continue or terminate the restraint. g. The need for other interventions or treatments. The attending physician or provider responsible for the care of the patient must be consulted if the face-to-face evaluation is conducted by someone other than the attending physician or other provider responsible for the care of the patientViolent patients must be monitored for safe application at least every 30 minutes. Monitor the patient: a. Observe patients older than 9 at least every two (2) hours (patients under the age of 9 years must be assessed every (1) hour) for: i. change in condition impacting the need for restraint (such as level of distress or agitation) ii. circulation (pulse) distal to the restraint iii. skin integrity distal to the restraint (restraint may be removed to assess skin) iv. respiratory status v. vital signs - which include at a minimum the measurement of blood pressure, heart rate, respiratory rate, and 02 saturation vi. mental status vii. nutritional and hydration needs vili. elimination and toileting needs ix. range of motion and position change x. readiness for discontinuation of restraints xi. justification for continued use of restraints. Staff are expected to assess and monitor the patient’s condition on an ongoing basis to determine whether restraint can safely be discontinued as quickly as possible.” Patient #A Review of Patient #A’s medical chart revealed she is a 12 year old female with a history of depression and anxiety and ADHD who presented to the ED for suicidal ideation on 05/12/2025. Staff #16’s nursing notes included: 3:08 PM “patient moved bed against wall and was hiding between the bed in the wall refusing to come out, security called to bedside. Explained to patient we need to be able to see her at all times, patient screaming and cussing and lunging at staff. Patient trying to pull bed against wall again and bed was removed from the room. At that time, patient punched the computer screen shattering it. Patient attempting to hit staff, bed brought back in room and patient placed on it, patient continues to attempt to hit and kick staff. Patient restrained at this time for self-destructive behavior.” Review of Patient #A’s medical chart revealed physical restraints were used on 05/14/2025 from 3:00 PM to 5:30 PM. Patient #A’s medical chart included the 30 min Violent Restraints monitoring performed by Staff #16 3:25 PM Physical Comfort: Patient asleep Continuous Observation: Yes Psychological Status: Aggressive/Violent; Uncooperative 3:55 PM Physical Comfort: Patient asleep Continuous Observation: Yes Psychological Status: Aggressive/Violent; Uncooperative 4:25 PM Physical Comfort: Reposition; Pillows Continuous Observation: Yes Psychological Status: Tearful; Uncooperative Review of Patient #A’s medical chart revealed the following Q15 checks. Prior to and during restraints on 5/14/25, Staff #19 documented the Q15 minute checks: 2:30 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 2:45 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 3:00 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 3:15 PM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless Physical Comfort: Reposition 15 Minute Sitter Check Observation Complete: Yes 3:30 PM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep Physical Comfort: Patient asleep 15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep Food/Meal: Patient asleep Elimination: Patient asleep During restraints on 5/14/25, Staff #18 continued the Q15 minute checks 3:45 PM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep Physical Comfort: Patient asleep 15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep Food/Meal: Patient asleep Elimination: Patient asleep 4:00 PM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep Physical Comfort: Patient asleep 15 Minute Sitter Check Observation Complete: Yes Fluids: Patient asleep Food/Meal: Patient asleep Elimination: Patient asleep 4:15 PM Patient Location: In room Patient Activity: Awake 15 Minute Sitter Check Observation Complete: Yes Elimination: Offered 4:30 PM Patient Location: In room Patient Activity: Awake Visual Check: Tearful 15 Minute Sitter Check Observation Complete: Yes 4:45 PM Patient Location: In room Patient Activity: Awake Visual Check: Tearful (crying) 15 Minute Sitter Check Observation Complete: Yes 5:00 PM Patient Location: In room Patient Activity: Watching TV Visual Check: Tearful (crying wants nurse) 15 Minute Sitter Check Observation Complete: Yes 5:16 PM Patient Location: In room Visual Check: (crying) 15 Minute Sitter Check Observation Complete: Yes The documentation reviewed did NOT include pulse, skin integrity, respiratory status, vital signs, readiness for discontinuation of restraints or justification for continued use. Patient #B Review of Patient #B medical record revealed she is an 18 year old female who was seen at the ED with complaints of SI with plan to harm herself with a piece of glass on 04/04/2025 via police EDO. Review of Staff #20 nursing notes on 04/05/2025, it stated “this RN explained to the patient that we were going to try and redraw the labs. Patient screamed ‘no you are not going to take my blood’ and became verbally aggressive. Security was called to the room and MD ordered medication. Patient became physically aggressive towards staff and was medicated and restrained at 0230 to obtain IV access to get the labs.” Review of orders revealed the 4 point physical restraints were ordered on 04/05/2025 at 2:30 AM and discontinued at 3:30 AM. Review of Patient #B chart revealed the following restraint monitoring: 30 min Violent Restraints monitoring performed 3:00 AM Physical Comfort: Patient declined Continuous Observation:Yes Psychological Status: Uncooperative Q15 min 2:15 AM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless 15 Minute Sitter Check Observation Complete: Yes 2:30 AM Patient Location: In room Patient Activity: Awake Visual Check: Agitated/restless 15 Minute Sitter Check Observation Complete: Yes 2:45 AM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep 15 Minute Sitter Check Observation Complete: Yes 3:00 AM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep 15 Minute Sitter Check Observation Complete: Yes 3:15 AM Patient Location: In room Patient Activity: Sleeping Visual Check: Asleep 15 Minute Sitter Check Observation Complete: Yes Vital Signs were assessed at 03:55 AM: Temp 36.7 C Pulse 89 Resp 18 BP 106/65 No vitals assessed from 2:30 AM to 3:30 AM while patient was in restraints. The documentation reviewed did NOT include pulse, skin integrity, respiratory status, vital signs, readiness for discontinuation of restraints or justification for continued use. In an interview with Staff #1 on 05/27/2025 at 0940 AM in the small conference room, she acknowledged that staff did not monitor the patients per their protocol.”

“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: 38387 Based on facility policy, patient record review and confirmed in interviews, the facility failed to provide an appropriate and thorough medical screening examination (MSE), within the capability of the hospital’s emergency department, including a psychiatric evaluation available to the emergency department for two of twenty six patients who presented to the emergency department (ED). (Patient ID #A and #B). Findings included: Review of the facility policy Triage Procedure (Version 3, 04/12/2022) it stated “to provide a standardized system whereby patients presenting to the Emergency Center are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) five level triage system. Level 1: Critical Level 2: Emergent Level 3: Urgent Level 4: Non-urgent Level 5: Routine” Patient #A Review of the patient chart revealed Patient #A presented to the emergency department via walk in on 06/30/2024. “Patient complains of [suicide ideation]. Last drink last night, [history] of alcohol abuse. Reports chest pain x 1 year and anxious in triage.” Nurse (Staff #10 ) triaged the patient and assigned an acuity of 2 (Emergent). Staff #10 assessed Patient #A for suicide risk on 07/29/2024 at 3:29 PM that included the following screening prompts and corresponding answers from the patient. In the past two weeks, have you felt down, depressed or hopeless? patient #A responded “yes” In the past two weeks, have you had thoughts of killing yourself? patient #A responded “yes” In your lifetime, have you ever attempted to kill yourself? patient #A responded “yes” If yes, when did this happen? within 24 hours? patient #A responded “yes” Nurse Staff #13 reassessed Patient #A on 07/30/2024 at 3:59 PM that included the following Mental Status and Psych Assessment Affect: Anxious Thought Content: Appropriate Mood: depressed Attention and Concentration: Impaired Behavior: Anxious Hallucination: denied Delusions: denied In an interview with the ED Director (Staff #12) on 08/21/2024 at 10:05 AM, he stated “most patients with current, acute suicidal ideation or homicidal ideation will require a consult from the behavioral assessment team, and together with their recommendation will determine if patient psych needs will require further medical evaluation (inpatient treatment).” Review of the physician notes (Staff #11) revealed no request for consult from the behavioral assessment team; no documentation of prior suicide attempts, thoughts of suicide ideation in the past month, delusions, impaired thought processes, or hallucinations. No documentation of the evaluation of the patient’s behavior, speech, mood, thought process, perception, cognition, and insight. No follow up as to the questions and answers from the nursing staff of his mood and/or affect. Psychiatric evaluation is incomplete. Review of the patient record revealed no documentation of a plan for immediate safety or clear outpatient follow-up other than generic referrals. Review of the website from the NIH (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4724471), it stated “while all substances elevate the risk for suicidal behavior, alcohol and opioids are the most common substances identified in suicide decedents (22% and 20%, respectively), far above rates of marijuana (10.2%), cocaine (4.6%), and amphetamines (3.4%)....The 24-hour period following alcohol intoxication is associated with a seven-fold increase in the risk for suicidal behavior. Moreover, alcohol intoxication is related to greater lethality of attempt methods, making suicide fatalities more likely. Over a third of suicide decedents test positive for alcohol; 63.5% of whom have blood concentrations demonstrating intoxication, and more suicide decedents test positive for alcohol than other substances..Importantly, asking a patient about suicidal thoughts or plans does not incite or encourage suicidal behavior, and providers should ask specific questions about the nature and content of suicidal thoughts, as described below in greater detail. Information from appropriate “collateral” sources is particularly important for suicidal patients; relevant sources include prehospital or police personnel, the patient ’ s family or friends, or outpatient healthcare providers. Asking the patient for permission enhances rapport, but an ED provider can make these contacts without consent when necessary to protect the individual or the public from an imminent and serious safety threat.” Patient #B Review of the patient chart revealed Patient #B presented to the emergency department via police on 07/06/2024. “PD [police department] bringing patient in under emergency detention order for repeating the same phrases, yelling he is schizophrenic, with family and friends.” Nurse (Staff #15 ) triaged the patient and assigned an acuity of 2 (Emergent). Review of Patient #B History of Present Illness included “The patient presents with psychiatric problem. The onset was just prior to arrival. The course/duration of symptoms is unknown. Character of symptoms paranoid. The degree of symptoms is moderate. Patient brought to the ER by police for belligerent behavior. Patient is currently has a history of schizophrenia and was acting out at home. Patient’s wife was alert who called police. Patient was placed on EDO.” Nurse (Staff #15) assessed suicide risk from patient on 07/06/2024 at 04:29 AM and documented ‘patient unable to complete’ for the following prompts In the past two weeks, have you felt down, depressed or hopeless? In the past two weeks, have you had thoughts of killing yourself? In your lifetime, have you ever attempted to kill yourself? Review of the patient chart nursing notes available revealed no documentation of the Columbia Suicide Screening at triage or at any time at reassessments. While in the ED (emergency room), Patient #B required placement with a 1:1 sitter and immediate physical and chemical restraints. Per the provider’s notes (Staff #17), she stated “patient presents with clinical picture of acute psychosis, and severe agitation which is a threat to themselves and staff...multiple IM antipsychotic and sedative medications are used to control the patient’s dangerous behavior.” Review of patient chart revealed Patient #B also had physical restraints (2 full length/4 half siderails on ankles and wrists) on 07/06/2024 at 06:20 AM for cognitive impairment that interferes with medical care and safety. Review of patient chart revealed Patient #B received the follow antipsychotic medication: Ativan 2mg IM, Benadryl 25 mg IM and Haldol 5 mg IM on 07/06/2024 at 07:18 AM for patient’s combative and aggressive behavior. Further review of the physician notes (Staff #17) indicated “Reevaluation at bedside - patient alert, oriented, and cooperative. No longer agitated. Is able to answer questions appropriately. No suicidal ideation, homicidal ideation, signs or symptoms of acute psychosis. Not responding to internal stimuli, directable with questioning, and regretful for behavior earlier.” In an interview with the ED Director (Staff #12) on 08/21/2024 at 10:05 AM, he stated “most patients with current, acute suicidal ideation or homicidal ideation will require a consult from the behavioral assessment team, and together with their recommendation will determine if patient psych needs will require further medical evaluation (inpatient treatment).” Review of the physician notes (Staff #17) revealed no request for consult from the behavioral assessment team; no documentation of prior suicide attempts, thoughts of suicide ideation in the past month, delusions, impaired thought processes, or hallucinations. No documentation of the evaluation of the patient’s behavior, speech, mood, thought process, perception, cognition, and insight. Psychiatric evaluation is incomplete.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to fully investigate a grievance regarding discharge care coordination issues involving lack of access to pain medications. (Patient ID# 1). Findings included: HHSC Intake received 10/23/23 via hotline telephone. Complainant stated the facility negligently discharged patient from hospital to a personal care home and they were unable to provide the care he needed. She stated 13 hours after arrival she picked him up and he was brought to another acute care hospital where he was admitted. The intake stated “complainant filed a complaint with the patient advocate.” Telephone Interview with Complainant for HHSC Intake TX on 10/30/23 at 10:00 am. She re-stated that Patient ID#1 had been “very ill” and she felt the facility “rushed to discharge patient.” She stated the personal care home did not have medicines needed to manage patient’s pain. She stated when she arrived the following morning, she took him from the facility to another acute care hospital and he was admitted. Record review of electronic grievance and complaint log dated April 1, 2023 to 11/14/2023 revealed Patient ID#1 with grievance entered 10/23/2023 Patient Relations Manager Staff ID #63. The electronic log classified event type “Discharge - Service Coordination ...” Record review of electronic grievance and complaint entry related to Patient ID #1 revealed: 10/23/23 at 03:29 pm grievance received by Patient Relations Staff ID #63 via a telephone call from complainant for Patient ID#1. The grievance log record stated “ ....caller felt that the discharge was not a safe discharge because the hospital discharged patient knowing that he would not have access to any pain medication until Monday (3 days from discharge).” Grievance records show a letter dated 10/23/2023 by Staff ID # 63, Patient Relations Representative. The letter was a grievance acknowledgment letter mailed to patient via certified mail. The letter stated the hospital had “received your concerns” and “would conduct a review on his behalf.” It further stated they would communicate findings in writing within 30 calendar days. Grievance investigation records prepared by case management department on 10/23/23 stated “Description of complaint ... Caller felt that the discharge was not safe because the hospital discharged patient knowing he would not have access to any pain medication until Monday.” There were “results of chart review” and “Interviews conducted.” Grievance closure occurred 11/02/2023 by Patient Relations staff ID #63 and certified letter was mailed to patient. The grievance was categorized “closed, able to satisfy.” Record review of facility “Patient Rights and Responsibilities” policy, last reviewed 06/2022, stated “Patient Rights: Patients have the right to ... effective communication with all who are involved in the patients care ...” It further stated “Register complaints about your care or treatment, and receive a timely response to those complaints ....” Record Review of facility’s “Patient Complaints and Grievances Procedure”, last reviewed 6/3/2022, stated “Action: 5. Document grievances in the hospital approved electronic tracking tool.. and refer to appropriate personnel to review and investigate ... 7. Department leadership will investigate the grievance including, as appropriate, clinical reviews and staff interviews.” Interview 11/14/2023 1:35 pm, Case Management Director, Staff ID #55, confirmed the facility was aware that the patient was discharged on a Friday afternoon and that the initial hospice visit would not occur until Monday. She confirmed the patient had been on morphine 10 mg per PEG tube scheduled round the clock for pain. She stated that the morphine elixir had been sent to the pharmacy and would be “picked up by personal care home staff.” Interview 11/14/2023 1:45 pm with Case Management Medical Director, Staff ID #69, she stated that the medical record reflected the hospital medicine physician had continued all admission medications, including a muscle relaxant and nerve pain medicine, and sent a new prescription for morphine elixir to a local pharmacy. She stated that it would be patient and or family responsibility to provide prior home medications to the new facility to avoid duplicating medications and cost. She stated that the physician would have determined this prior to discharge. She stated the medical record stated the patient had full “capacity” and would have been decision-maker for care. She confirmed she could not locate documentation in the medical record that this had been coordinated. Telephone Interview 11/14/2023 2:15 pm with Personal Care Home owner, Staff ID #70, she stated that the morphine elixir had been sent late on 10/22/2023 (Friday) to a local pharmacy (Bemaj) that delivers to them. She stated that the medicine was delivered at 9am on 10/23/2023 (Saturday morning). She stated she had provided over the counter Tylenol for pain in the interim. She stated that after the patient was discharged from the hospital, the personal care home would use the discharge instructions to provide care for the patient until hospice assumed care. Interview 11/14/23 at 2:30 pm with Patient Relations Manager Staff ID #63, she confirmed that there had not been analysis or response related to the lack of pain medication availability/discharge care coordination of medications prior to grievance closure.”