UT Health East Texas Jacksonville Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital’s staff failed to ensure a patient presenting to the hospital’s emergency room with facial trauma after a physical assault received an appropriate medical screening exam (MSE) prior to discharge in 1 (Patient #1) of 20 patient medical records reviewed. Additionally, the hospital staff failed to follow the hospital’s “EMTALA-Medical Screening Examination and Stabilization” policy. (Cross Refer to Tag: A02406)”

“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: 48653 Based on record review and staff interviews, the hospital’s staff failed to ensure a patient presenting to the hospital’s emergency room with facial trauma after a physical assault received an appropriate medical screening exam (MSE) prior to discharge in 1 (Patient #1) of 20 patient medical records reviewed. Additionally, the hospital staff failed to follow the hospital’s “EMTALA-Medical Screening Examination and Stabilization” policy. Findings include: A review of Patient #1’s medical record was conducted with Staff # 5 and Staff # 10 on 12/03/2025 at 11:35 AM in the hospital’s administrative conference room. Patient # 1 presented to the hospital on 11/24/2025 for outpatient radiology studies. The patient was accompanied by staff from the patient’s residence (Hospital #2). A review of the hospital’s security footage was conducted on 12/03/2025 with the hospital’s leadership in the Security office. The date of 11/24/2025 was reviewed, and the following was observed on the hospital’s security footage, After the patient completed the radiology studies at 3:00 PM, the patient was escorted out of the hospital by a Hospital # 1 security officer (Staff # 7). Upon exiting the hospital, Patient # 1 attempted to go into the hospital’s emergency room waiting area instead of leaving the building to go outside, where transportation was waiting for the patient. Staff # 7 forcefully redirected the patient outside and pinned the patient up against the wall. The patient responded to this force by resisting, punching Staff # 7 to resist the force. Staff # 7 then punched the patient in return and threw the patient to the ground, resulting in the patient sustaining facial trauma. The patient fell directly on his face, hitting the concrete. The patient could be seen with a copious amount of blood on his face, and his shirt was covered with blood. Patient # 1 sustained facial injury as a result of the physical altercation with Staff # 7 and required emergency medical care at the hospital’s emergency room. Patient # 1 was escorted to the hospital’s emergency room on 11/24/2025 at 3:44 PM. A review of Staff # 14’s (Emergency Room Physician) Provider Note dated 11/24/2025 at 4:48 PM revealed the following, “77-year-old male coming from (Hospital #2) for 2 open wounds on his forehead. Patient has a history of a carcinoma, had biopsies done 10 days ago in Tyler from his dermatologist. Today he was coming to Jacksonville hospital for imaging when he got into the altercation with a security officer who then subsequently threw him down to the ground. Sutures from the 2 wounds broke and with subsequent bleeding. He was then brought into the emergency department for evaluation. He is not on anticoagulation. Denies headache. No loss of consciousness. Review of systems: Skin: Positive for wound. All other systems reviewed and are negative ...PMH: no past medical history on file ...” A review of the Triage Note by Staff # 4 on 11/24/2025 at 1:45 PM (incorrect time documented on medical record) revealed, “Patient presents to ER via wheelchair with facial injury. Allowed this nurse to clean blood off the face, refused vital signs. Noted no distress.” . Staff # 14 (ER Physician) failed to assess Patient # 1 for facial bone and cervical spine tenderness during physical exam. Additionally, there was no imaging ordered to rule out emergency medical conditions of facial bone fracture or cervical spine fracture. There were no labs, imaging, medication, or other diagnostic tests ordered for the patient on 11/24/2025. The patient was discharged from the hospital on 11/24/2025 at 5:39 PM without an appropriate Medical Screening Examination to rule out potential Emergency Medical Conditions. A review of the hospital’s “EMTALA-Medical Screening Examination and Stabilization” with a date of 04/19/2023 revealed, “PURPOSE: To ensure that all individuals who come to the Emergency Department receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder. POLICY: 1. Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual is determined to have an Emergency Medical Condition, within UT Health East Texas’s Capability and Capacity. 2. UT Health East Texas will not delay the Medical Screening Examination in order to inquire about an individual’s method of payment of insurance status. UT Health East Texas is discouraged from asking any questions about payment or insurance status until after the Medical Screening Examination is completed and appropriate, any Stabilizing treatment is initiated. 3. Some states have separate emergency services laws that may apply additional legal requirements to the Medical Screening Examination or Stabilizing treatment ....Procedure: 1. Please refer to policy ‘Hospital Compliance with EMTALA-CD-MKT’ for a complete list of definitions pertaining to this policy. 2. Performance of the Medical Screening Examination. The Dedicated Emergency Department must provide for an appropriate Medical Screening Examination within the Capability of the Dedicated Emergency Department, including ancillary services routinely available to the Dedicated Emergency Department, to determine whether or not an individual has an Emergency Medical Condition, or with respect to a pregnant woman having contractions, whether the woman is in Labor, where the individual Comes to the Emergency Department. As set forth in #7 of Definitions in the policy Hospital Compliance with EMTALA-CDMKT, an individual is deemed to have come to the Emergency Department in the following circumstances: a) Dedicated Emergency Department. The individual has presented at UT Health East Texas’s Dedicated Emergency Department and requests or has a request made on his/her behalf for examination or treatment for a medical condition, or a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs examination or treatment for a medical condition; b) Hospital Property. The individual has presented on UT Health East Texas Property other than a Dedicated Emergency Department, and requests or has a request made on his/her behalf for examination or treatment for what may be an Emergency Medical Condition, or a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs emergency examination or treatment; c) Hospital-Owned Ambulance. The individual is in a ground or air ambulance owned and operated by UT Health East Texas for the purposes of examination or treatment for a medical condition at UT Health East Texas’s Dedicated Emergency Department, unless the ambulance is operated i) under community-wide EMS protocols that direct the ambulance to transport the individual to another facility (e.g., the closest available facility), in which case the individual is considered to have come to the Emergency Department of the Hospital to which the individual is actually transported; or ii) at the direction of a Physician that is not employed or affiliated with UT Health East Texas; or d) Non-Hospital Owned Ambulance. The individual is in a non-Hospital owned ground or air ambulance that is on UT Health East Texas Property for presentation for examination or treatment for a medical condition at UT Health East Texas’s Dedicated Emergency Department. An individual in a non-Hospital owned ambulance off of UT Health East Texas Property is not considered to have come to the Emergency Department if the ambulance personnel contact UT Health East Texas by telephone or telemetry communications and inform UT Health East Texas that they want to transport the individual to UT Health East Texas for examination and treatment. UT Health East Texas may direct the ambulance to another facility if it is in “diversionary” status, that is, it does not have the staff or facilities to accept any additional emergency patients at that time. However, if the ambulance disregards UT Health East Texas’s instructions and brings the individual onto UT Health East Texas Property, the individual has come to the Emergency Department, and UT Health East Texas must provide the individual a Medical Screening Examination. 3) Triage. Triage is a sorting process to determine the order in which individuals will be provided a Medical Screening Examination by a Physician or Qualified Medical Person. Triage is not the equivalent of a Medical Screening Examination and does not determine the presence or absence of an Emergency Medical Condition. UT Health East Texas will establish policies and procedures for the performance and documentation of the Triage assessment. The Triage assessment must be maintained for a minimum of five years. 4) Personnel who May Perform the Medical Screening Examination. a) The Medical Screening Examination may be performed by a Physician or Qualified Medical Person who is qualified to conduct such examination. b) UT Health East Texas and its Medical Staff will determine the categories of Qualified Medical Persons who may perform the Medical Screening Examinations. The Medical Staff bylaws or rules and regulations, as approved by UT Health East Texas governing body, will designate the categories of Qualified Medical Persons in each Dedicated Emergency Department who are authorized to perform the Medical Screening Examination. c) A Qualified Medical Person who is authorized to perform a Medical Screening Examination must: i) Practice within the scope of his/her license issued by the State in which UT Health East Texas is located; ii) Demonstrate his/her current competence in the performance of Medical Screening Examinations within his/her health profession. The competencies for a Qualified Medical Person who performs the Medical Screening Examination should be documented and validated by a qualified Physician. There should also be an education plan for measuring and developing core competencies in Medical Screening Examinations; and iii) As applicable, perform the Medical Screening Examination in accordance with protocols, standardized procedures, or other policies as may be required by law or approved by UT Health East Texas governing body and the Medical Staff. 5) Scope of the Medical Screening Examination. a) A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition does or does not exist. b) The scope of the Medical Screening Examination must be tailored to the presenting complaint and the medical history of the individual. Depending on the individual’s presenting symptoms, the Medical Screening Examination may range from a simple examination (such as a brief history and physical) to a complex examination that may include the performance of ancillary studies and procedures, such as clinical laboratory tests, MRI or diagnostic imaging, lumbar punctures, and/or other diagnostic tests and procedures. c) The Medical Screening Examination must be the same Medical Screening Examination that UT Health East Texas would perform on any individual who comes to the Emergency Department with the same or similar signs and symptoms, regardless of the individual’s ability to pay for medical care or insurance status. The Medical Screening Examination must be performed in a non-discriminatory manner. d) UT Health East Texas is obligated to perform a Medical Screening Examination that is reasonably calculated to determine the presence or absence of an Emergency Medical Condition, consistent with UT Health East Texas’s Capability. It is not appropriate to merely “log in” an individual and not provide a Medical Screening Examination or fail to provide a Medical Screening Examination beyond Triage. e) A Medical Screening Examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the individual’s needs until it is determined whether or not the individual has an Emergency Medical Condition and, if he/she does, until he/she is Stabilized or appropriately transferred. There should be evidence of this ongoing monitoring documented in the medical record prior to discharge or Transfer. However, if the Medical Screening Examination determines that the individual does not have an Emergency Medical Condition, then UT Health East Texas’s EMTALA obligations have been satisfied. f) The treating Physician or a Qualified Medical Person may contact the individual’s Physician at any time to seek advice regarding the individual’s medical history and clinical needs that may be relevant to the Medical Screening Examination or Stabilizing treatment so long as the consultation does not inappropriately delay emergency services required for the individual. 6) The Location of the Medical Screening Examination. a) The Medical Screening Examination must be performed by a Physician or a Qualified Medical Person in the Dedicated Emergency Department or another Department of UT Health East Texas on UT Health East Texas Property. The Medical Screening Examination may not be performed in an Off-Campus Department of UT Health East Texas, in a private Physician’s office, or in a facility or clinic that is not part of UT Health East Texas and enrolled under UT Health East Texas’s provider number. b) If an individual comes to the Emergency Department, he/she may be directed to a Dedicated Emergency Department that is appropriate for his/her request or needs if it is safe to do so. For example, UT Health East Texas may adopt a policy that all women after a designated number of weeks of pregnancy may be directed to the Dedicated Emergency Department for individuals presenting with problems related to Labor and delivery. c) UT Health East Texas may adopt policies and procedures establishing guidelines for the movement of individuals from a Dedicated Emergency Department to other Departments of UT Health East Texas that are on UT Health East Texas Property for the performance or completion of the Medical Screening Examination or, as appropriate, the provision of any Stabilizing treatment. In order for an individual to be directed to another Department of UT Health East Texas on UT Health East Texas Property, the following conditions must be met: i) All persons with the same medical condition are moved to this location in such circumstances, regardless of their ability to pay for treatment; ii) There is a bona fide medical reason to move the individual; and iii) Qualified medical personnel accompany the individual. (Note that “qualified medical personnel” for this purpose should be distinguished from a Qualified Medical Person. The latter is a defined term in this Policy and specifically governs who may perform a Medical Screening Examination.) 7) Further Examination and Stabilizing Treatment. If the treating Physician or Qualified Medical Person determines that an individual has an Emergency Medical Condition, UT Health East Texas, within its Capability and Capacity, will provide further examination and Stabilizing treatment for the individual, or if the individual requires a specialty or level of care not available at UT Health East Texas for an Appropriate Transfer of the individual to another health facility (see policy EMTALA - Transfers-CDMKT). If a Physician or Qualified Medical Person has determined that the individual is not experiencing an Emergency Medical Condition, then UT Health East Texas EMTALA obligations are satisfied. Further examination and Stabilizing treatment will be provided without regard to the ability to pay or insurance status of the individual. 8) Inpatient Admission. If an individual receiving further examination and Stabilizing treatment is admitted by UT Health East Texas as an Inpatient, UT Health East Texas) has met its EMTALA obligations as to the individual, even if the individual remains in the Dedicated Emergency Department or other Department of UT Health East Texas pending the availability of a patient room. UT Health East Texas will have policies and procedures for ensuring that an Inpatient held (or “boarded”) in the Dedicated Emergency Department or other Department of UT Health East Texas will be assigned appropriate staff, monitored, and receive necessary treatment for his/her condition. 9) Stable for Transfer or Discharge. If an individual is determined based on the Medical Screening Examination to have an Emergency Medical Condition, any subsequent determination as to whether the individual is Stable for Transfer or Stable for Discharge will be made by the treating Physician or, as applicable, by a Qualified Medical Person in consultation with a Physician, in accordance with number 9)a and number 9)b of this Procedure, see below. a) Stable for Discharge. i) Medical Condition. An individual with a medical condition is considered Stable for Discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an Outpatient or later as an Inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. The Emergency Medical Condition that caused the individual to present to the Dedicated Emergency Department must be resolved, though the underlying medical condition may persist. ii) Psychiatric Condition. An individual with a psychiatric condition is considered Stable for Discharge when the treating Physician has determined, within reasonable clinical confidence, that the individual is no longer considered to be a threat to himself/herself or to others. iii) Discharge Instructions. Each individual will be provided a copy of appropriate discharge instructions that will include, as applicable, special care and medication instructions and follow-up and referral information. b) Stable for Transfer. i) Medical Condition. An individual with a medical condition is considered Stable for Transfer from UT Health East Texas to another facility if the treating Physician determines, within reasonable clinical confidence, that the individual is expected to leave UT Health East Texas and arrive at the receiving facility with no material deterioration in his/her medical condition. The Emergency Medical Condition that caused the individual to seek care in the Dedicated Emergency Department must be resolved, though the underlying medical condition may persist. ii) Psychiatric Condition. An individual with a psychiatric condition is considered Stable for Transfer from UT Health East Texas to another facility if the treating Physician determines, within reasonable clinical confidence, that the individual is protected and prevented from injuring or harming himself/herself or others. The administration of chemical or physical restraints for purposes of transferring an individual from UT Health East Texas to another facility may Stabilize an individual with a psychiatric condition for a period of time and remove the immediate Emergency Medical Condition, but the underlying medical condition may persist and, if not treated for longevity, the individual may experience exacerbation of the Emergency Medical Condition. As such, care should be exercised when determining if a psychiatric condition is in fact stabilized after administering chemical or physical restraints. c) Transfer of an Individual who is Stable for Transfer. The Transfer of an individual who is determined by the treating Physician to be Stable for Transfer will be made in accordance with policy EMTALA - Transfers-CD-MKT. d) Disputes. If there is a disagreement between the treating Physician and an off-site Physician (which may include the receiving Physician, the individual’s primary care Physician, or a health plan Physician) as to the stability of the individual for a Transfer or discharge, the views of the treating Physician should be followed. Disputes that are not timely resolved should be reported to the department or person designated by UT Health East Texas. 10) Patient Registration. a) No Delay. There shall be no delay in providing a Medical Screening Examination, or further examination or Stabilizing treatment for a individual with an Emergency Medical Condition, in order to inquire about the individual’s method of payment or insurance status. b) Registration Process. UT Health East Texas may establish reasonable registration processes for individuals for whom examination or treatment is required under EMTALA. UT Health East Texas may inquire into insurance status so long as the inquiry does not delay the Medical Screening Examination or Stabilizing treatment or unduly discourage individuals from remaining for the Medical Screening Examination or further examination and/or Stabilizing treatment. However, UT Health East Texas is generally discouraged from any inquiry until after the Medical Screening Examination and initiation of any Stabilizing treatment, as applicable, is complete. c) Prior Authorization. For individuals who are enrolled in a managed care plan, UT Health East Texas may not seek, or direct an individual to seek, authorization from the individual’s insurance company or health plan for the Medical Screening Examination or Stabilizing treatment until UT Health East Texas has provided the Medical Screening Examination and initiated any further examination and treatment that may be required To Stabilize the Emergency Medical Condition. d) Financial Responsibility. The performance of the Medical Screening Examination, as well as further examination and/or Stabilizing treatment, will not be conditioned on the individual’s completion of a financial responsibility form or receipt of a co-payment. This does not preclude UT Health East Texas from ultimately requiring financial responsibility and, in fact, UT Health East Texas should establish procedures to ensure individuals are held responsible for co-payments and deductibles after its EMTALA obligations are satisfied. e) Inquiries on Financial Responsibility. Individuals who inquire about financial responsibility for emergency care will be encouraged to delay such discussion until after the completion of the Medical Screening Examination. These individuals will also be told that UT Health East Texas will provide a Medical Screening Examination and Stabilizing treatment, regardless of their ability to pay. f) Elopement. If an individual leaves UT Health East Texas without notifying UT Health East Texas personnel (i.e., elopement), this should be documented by Dedicated Emergency Department staff. The documentation should reflect that the individual had been at UT Health East Texas and the time the individual was discovered to have left the premises. g) Refusal of Medical Screening. If an individual advises Dedicated Emergency Department staff of his/her intent or decision to leave UT Health East Texas before receiving a Medical Screening Examination, staff will offer the individual the Medical Screening Examination and encourage the individual to remain for the Medical Screening Examination and any necessary Stabilizing treatment. Staff will also inform the individual of the risks of leaving before receiving a Medical Screening Examination and any necessary Stabilizing treatment. If the individual decides to leave UT Health East Texas, staff will document the circumstances and reasons (if known) for the individual’s departure and the time of departure. An individual leaving UT Health East Texas before receiving a Medical Screening Examination should not be requested to sign an AMA (Against Medical Advice). However, UT Health East Texas should request the individual or an authorized representative to sign an acknowledgement that he or she has left without being seen or has refused the Medical Screening Examination and any necessary Stabilizing treatment. If the individual refuses to sign such an acknowledgement, staff should document such refusal in the individual’s medical record. h) Refusal of Emergency Services. If an individual who has received a Medical Screening Examination refuses to consent to further examination or Stabilizing treatment, an appropriately trained individual from the Dedicated Emergency Department staff will: i) offer the individual further examination and treatment as may be required to identify and Stabilize an Emergency Medical Condition; ii) inform the individual of the benefits of the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment; and iii) ask the individual to sign a AMA form that he/she has refused further examination or treatment. If the individual refuses to sign the form, a description of risks discussed and of the examination and/or treatment that was refused shall be documented. 11) Hospital Policies and Procedures: UT Health East Texas will adopt policies and procedures in accordance with this Policy describing the conduct of the Medical Screening Examination and Stabilizing treatment in its Dedicated Emergency Department(s) and other Departments of UT Health East Texas The policies and procedures shall also address documentation of the Triage assessment and the Medical Screening Examination, in-service training for UT Health East Texas personnel and quality management assessment of Medical Screening Examinations.” An interview was conducted with Staff # 5 on 12/03/2025 at 1:00 PM in the hospital’s administrative conference room which confirmed the patient was discharged from the hospital on 11/24/2025 without an appropriate medical screening examination.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48653 Based on record review and staff interviews, the hospital staff failed to ensure that: A. two (Patient # 1 and 10) of 2 patients were informed of the patient’s rights, in advance of furnishing patient care. The hospital staff failed to follow the “Patient Rights and Responsibilities” policy. (Cross Refer to Tag A0117) B. one (Patient # 1) of 1 patient remained free from all forms of abuse, neglect, and/or harassment when Patient # 1 was physically assaulted by Staff # 7 (Hospital # 1 Security Officer) while receiving outpatient radiology services at the hospital. The hospital staff failed to follow the hospital’s “Use of Force, Patient Rights and Responsibilities, and Abuse Identification and Reporting” policies. (Cross Refer to Tag A0145)”

“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: 48653 Based on record review and staff interviews, the hospital staff failed to ensure that 2 (Patient # 1 and 10) of 2 patients were informed of the patient’s rights, in advance of furnishing patient care. The hospital staff failed to follow the “Patient Rights and Responsibilities” policy. Findings include: Patient # 1 A review of Patient # 1’s medical records revealed that Patient # 1 arrived at the hospital on 11/24/2025 at 3:00 PM for outpatient radiology testing. Patient # 1 was also treated in the hospital’s emergency room on 11/24/2025 at 3:44 PM after completion of outpatient radiology testing. A review of Staff # 14’s (Emergency Room Physician) Provider Note dated 11/24/2025 at 4:48 PM revealed the following, “77-year-old male coming from (Hospital #2) for 2 open wounds on his forehead. Patient has a history of a carcinoma, had biopsies done 10 days ago in Tyler from his dermatologist. Today he was coming to Jacksonville hospital for imaging when he got into an altercation with a security officer who then subsequently threw him down to the ground. Sutures from the 2 wounds broke and with subsequent bleeding. He was then brought into the emergency department for evaluation. He is not on anticoagulation. Denies headache. No loss of consciousness. Review of systems: Skin: Positive for wound. All other systems reviewed and are negative ...PMH: no past medical history on file ...” There was no documentation in the patient’s medical record to provide proof that Patient # 1 or the patient’s surrogate received a “Notice of Patient Rights and Responsibilities” before being provided care and treatment by hospital staff. Patient # 10 A review of Patient # 10’s medical records revealed that Patient # 10 arrived at the hospital’s emergency room on 11/23/2025 at 3:10 AM for lower extremity swelling. A review of the emergency room physician’s note documented on 11/23/2025 at 3:24 AM revealed, “Patient is a 65-year-old from the Russell County jail who supposedly had some seizure-like activity at the jail. He complains of bilateral leg swelling ...” There was no documentation in the patient’s medical record to provide proof that Patient # 10 or the patient’s surrogate received a “Notice of Patient Rights and Responsibilities” before being provided care and treatment by hospital staff. A review of the hospital’s “Patient Rights and Responsibilities” policy with a date of 12/18/2023 revealed, “Policy: A written copy of the hospital’s statement of patient rights and responsibilities should be given to inpatients and outpatients and made available to them throughout the hospital stay. The statement should be appropriate to the patient’s age, understanding, and language. It should be documented that the patient has received a copy of their rights and responsibilities. The patient’s understanding of his/her rights and responsibilities should be assessed and documented as well. When the patient’s assessment of understanding his/her rights and responsibilities indicates that written communication is not effective, the patient should be informed again of these rights after admission and in a manner that he/she can understand. Complaints and concerns regarding a patient’s rights or responsibilities expressed by the patient/family should be registered with the Quality Improvement Department, who will keep a log of all activity and periodically aggregate the data to look for patterns and trends. Purpose: To outline the responsibilities of the hospital staff to provide information to patients regarding their rights to health care and health care-related activities during hospitalization ...Procedure: 1. Provide information that outlines the patient rights during the admission process to the patient or someone acting on the patient’s behalf for all inpatients, outpatients, and ER patients. A. Patient Rights Information will be provided to the patient in the form of the Hospital’s Patient Handbook or other printed material. In addition, patient rights will be posted in English and Spanish in various areas of the hospital. 2. Instruct the patient or surrogate to sign the acknowledgement document, which will acknowledge their receipt of the patient’s rights. 3. The admitting or nursing staff may refer to the Interpreter List for patients with language barriers. 4. Obtain an interpreter if the patient cannot speak English or if the patient has a hearing impairment ...5. Provide the patient with access to the patient complaint procedure if requested by the patient. 6. Documentation: Treatment Authorization and Terms of Treatment Agreement. Procedure: Outpatient: 1. When the patient enters an outpatient area of the hospital: a. Patient rights are available in English and Spanish and are posted in a visible area of the outpatient area. B. Patient rights will be provided to the patient or surrogate in the form of a handout when the patient enters an outpatient area of the hospital and under any type of procedure ....” A review of the hospital’s statement titled, “Patient Rights and Responsibilities” (no date) revealed, “UTHET recognizes the rights of human beings for independence of expression, decision, and action and will protect these rights of all patients regardless of age, race, creed, sex, national origin, religion, or source of payment. In order to provide quality healthcare to patients and their families, UTHET maintains that our patients have the following rights to the extent permitted by law: Effective communication that is delivered in a manner which is understandable to each patient, including the use of language interpreters and resources for patients with communication impairments. Information provided in a manner tailored to the patient’s age, language, and ability to understand. Respect for cultural and personal values, beliefs, and preferences. Privacy and confidentiality of protected health information, within legal limits, including discrete handling of case discussion, consultation, examination, and treatment. Visitation, including, but not limited to, a spouse, a domestic partner, another family member, or a friend and the right to withdraw or deny such consent at any time. Know the name and professional status of the physicians and others involved in care. Access spiritual guidance and pastoral care support. Effective assessment and management of pain. Access, request amendment to, and obtain information on disclosures of health information, in accordance with law and regulations. Have an individual support present for emotional support during your stay, unless the individual’s presence infringes on others’ rights, safety, or is medically or therapeutically contraindicated. An environment free from discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. Considerate and respectful care that recognizes individual psychosocial, cultural, and spiritual values, beliefs, and preferences. Participate in decisions about care, treatment, and services, including the right to have family and physician promptly notified of admission to the hospital. Involvement of a surrogate decision-maker in making these decisions when the patient is unable. Refuse treatment to the extent permitted by law, and to be informed of the medical consequences of such refusal. Family involvement in care, treatment, and services, decisions to the extent permitted by the patient or surrogate decision maker. Receive information about outcomes of care, treatment, and services, and any unanticipated outcomes. Participate in determining care by consenting to recommended treatments or procedures, formulating advance directives, deciding to withhold informed consent, including informed consent for production or use of recordings, films, or other images of the patient for purposes other than their care. Participate or not participate in a research, investigation, or clinical trial program. Create an advanced directive and have hospital staff and practitioners who provide care in the hospital comply with the directive. Be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse. File a complaint and have complaints reviewed by the hospital. Access to protective and advocacy services. Remain free from seclusion and restraint of any form that is not medically necessary. Optimal comfort and dignity during the terminal stage of an illness ....” An interview was conducted with Staff # 5 and # 6 on 12/03/2025 at 3:30 PM in the administrative conference room. Staff # 5 and # 6 confirmed that there was no documentation in Patient # 1 and Patient # 10’s medical records to prove the patients and/or surrogates were given a “Notice of Patient Rights and Responsibilities” before receiving care at the hospital.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interviews, the hospital staff failed to ensure that 1 (Patient # 1) of 1 patient remained free from all forms of abuse, neglect, and/or harassment when Patient # 1 was physically assaulted by Staff # 7 (Hospital # 1 Security Officer) while receiving outpatient radiology services at the hospital. The hospital staff failed to follow the hospital’s “Use of Force, Patient Rights and Responsibilities, and Abuse Identification and Reporting” policies. Findings include: A review of Patient #1’s medical record was conducted with Staff # 5 and # 10 on 12/03/2025 at 11:35 AM in the hospital’s administrative conference room. Patient # 1 presented to the hospital on 11/24/2025 for outpatient radiology studies. The patient was accompanied by staff from the patient’s residence (Hospital #2) as well as Staff # 7 (Hospital # 1 Security Officer). A review of the hospital’s security footage was conducted on 12/03/2025 with the hospital’s leadership in the Security Office. The date of 11/24/2025 was reviewed, and the following was observed on the hospital’s security footage, 3:00 PM: The patient was seen in the “ER Entrance Hallway” accompanied by Staff # 7 (Hospital # 1 Security Officer) and staff from Hospital # 2. The patient was escorted to a radiology appointment. There was no further footage of the patient until after the radiology appointment. 3:23 PM: The patient was seen walking through the “ER Entrance Hallway” when the automatic door to the emergency room waiting room opened. The patient attempted to go into the emergency room waiting room. Staff # 7 grabbed the back of the patient’s coat in an attempt to keep the patient from entering the emergency room waiting room. Staff # 7 then forcefully pushed the patient outside and pinned the patient to the wall outside of the “Main ER Entrance”. 3:24:02-:33 PM: The patient resisted Staff # 7’s physical force and swung his fist at Staff # 7’s face, contacting Staff # 7’s right lower face. 3:24:35 PM: Staff # 7 returned a punch to the patient, punching the patient in the face with his fist. 3:24:38 PM: Staff # 7 forcefully threw the patient to the concrete ground. The patient landed directly on his face. The patient laid on the concrete face down, until 3:24:45 PM when Staff # 7 turned the patient over onto his back. The patient continued to lie on the ground on his back until 3:25:10 PM, when Hospital # 2 staff members assisted the patient up to a sitting position. Blood was observed on the patient’s face, shirt, and on the ground where the patient landed. 3:26:35 PM: Staff # 7 can be seen pushing an orange wheelchair toward the patient. The patient was assisted into the wheelchair by Hospital # 2 staff. 3:28:49 PM: The patient was rolled into the hospital’s emergency room triage area for further evaluation and examination. There was no further footage of the patient until 5:24 PM, when the patient walked out of the emergency room lobby. The patient had a bandage on his forehead between his eyes. 5:25:23 PM: The patient got into the Hospital # 2 van. 5:28:17 PM: Hospital # 2 van left the hospital premises with the patient. Patient # 1 sustained facial injury as a result of the physical altercation with Staff # 7 and required emergency medical care at the hospital’s emergency room. Patient # 1 was escorted to the hospital’s emergency room on 11/24/2025 at 3:44 PM. A review of Staff # 14’s (Emergency Room Physician) Provider Note dated 11/24/2025 at 4:48 PM revealed the following, “77-year-old male coming from (Hospital #2) for 2 open wounds on his forehead. Patient has a history of a carcinoma, had biopsies done 10 days ago in Tyler from his dermatologist. Today he was coming to Jacksonville hospital for imaging when he got into an altercation with a security officer who then subsequently threw him down to the ground. Sutures from the 2 wounds broke and with subsequent bleeding. He was then brought into the emergency department for evaluation. He is not on anticoagulation. Denies headache. No loss of consciousness. Review of systems: Skin: Positive for wound. All other systems reviewed and are negative ...PMH: no past medical history on file ...” The patient was discharged from the hospital’s emergency room on 11/24/2025 at 5:39 PM. Staff # 7 (Security Officer) completed an “HRP (high-reliability platform) report” on 11/24/2025 for the incident involving himself and Patient # 1. Staff # 7 documented the following, “Security staff was assaulted in the process of removing a threatening person from the ER lobby. Suspect was ultimately removed from the location after law enforcement intervention.” The HRP was reviewed by Staff # 9 (Security Manager) and subsequently closed. There was no documentation made by Staff # 9, Quality Staff, or Risk Management Staff. There was no internal investigation into the event by hospital administration. The Emergency Room staff members did not report a possible incident of abuse and/or harassment in accordance with the hospital’s “Abuse Identification and Reporting” policy. A review of Staff # 7’s personnel file revealed the following education modules were completed by Staff # 7 on 8/03/2025: “2025 Annual Code of Business Conduct and Ethics Evaluation, Patient or Resident Safety Basics, Patient-Facing, Rights and Responsibilities Basics, Patient-Facing, Employee Safety Basics, Patient-Facing, Workplace Safety Basics” Staff # 7 completed the education module titled “Workplace Violence Recognize and Respond and Skills of De-escalation” on 02/24/2025. Staff # 7 did not receive any disciplinary action or formal education as a result of the event and was allowed to continue to work at the hospital with access to patients and visitors. A review of the hospital’s “Use of Force” policy (no date) revealed, “”Policy: To clearly define the circumstances under which the use of force by a Security Officer may be considered justifiable, the Security Department will follow the guidelines established in the State of Texas Penal Code, Chapter 9. This policy is intended to be a guide to the use of force and the moral and ethical approach to the use of force. This policy is not intended as a strictly enforced set of rules, rather it must be interpreted in conjunction with the totality of circumstances and the Officer’s judgement. Protection of human life is the primary goal of the Hospital; therefore, Security Officers have a responsibility to use only the degree of force necessary to protect and preserve life and will exercise caution for the protection of innocent life. UTHealth East Texas places a greater value on human life and on the protection of property; therefore, the use of deadly force is not endorsed to protect property interests. Definitions: 1. Force means both non-deadly force and deadly force 2. non-deadly force means a level or degree of force that is not intended to cause, known to cause, reasonably capable of causing, or reasonably likely to cause death or serious bodily injury under the circumstances known to the user. 3. Deadly force means force that is intended or known by the actor to cause, or in the manner of its use or intended use is capable of causing death or serious bodily injury. 4. Hospital is the particular facility involved whether a hospital unit specifically or any other unit of the UTHEALTH East Texas. 5. Officer or Security Officer is a person employed by UTHEALTH East Texas as a part of its designated security unit. 6. Suspect means any person that a Security Officer may question or is a cause of an incident. PROCEDURE: 1. No officer may use any amount of force, degree of force, or level of force that is excessive, unnecessary, or unreasonable under the circumstances. The following is a non-exhaustive list of factors to be taken into account when determining the appropriate response: a. the nature and seriousness of the risk of injury to anyone; b. the nature and seriousness of the alleges offense; c. the physical and mental condition of the suspect; d. the behavior and actions of the suspect; e. any relevant actions by a third party; f. the feasibility and availability of alternative actions; and g. the opportunity and actual ability of the suspect to injure the Officer or another. 2. Application of Force: a. This policy applies to the Security Officers of UTHET. It does not apply to other employees who are not necessarily trained for or familiar with this area of responsibility. All other such employees within the System are instructed to refrain from any use of force on behalf of the Hospital, its property, patients and guests except in extreme circumstances when someone’s safety or life is endangered and no Security Officer is reasonably available. B. Before using the lowest level of force or escalating to a higher or more severe level of force, a Security Officer will, unless impractical under the circumstances, exhaust every reasonable means of obtaining compliance, including a non-physical display of authority and verbal commands, directions, or notifications. ac. If emergency circumstances make it immediately necessary, a Security Officer may reject any lesser level of force or may escalate to the highest and most severe level of force deemed necessary in the circumstances by the Security Officer so confronted. d. A Security Officer shall be able to justify the use of force at any level. 3. Use of Non-deadly force: An officer may use non-deadly force in the following situations and when and to the degree the officer reasonably believes the non-deadly force is immediately necessary to: a. make, or overcome resistance to an arrest that a Security Officer is authorized to make under the law; b. defend the Officer from the violence of another directed against said Officer; c. prevent escape from lawful custody; d. prevent the commission of a crime for which the Officer has enforcement jurisdiction; e. prevent a self-inflicted wound or suicide; and f. prevent or interrupt interference with the lawful possession of property. g. When the Officer reasonably believes that the force is lawful and in compliance with this policy. 4. Verbal Abuse: No Officer will use force solely in response to mere verbal provocation or to abusive language directed at the officer. 5. Justification for the Use of Deadly Force: Justification for the use of deadly force must be limited to the facts reasonably apparent to the officer at the time said officer decides to use the force. 6. Avoiding the Use of Deadly Force: At the point when an Officer should reasonably perceive that the potential exists that deadly force may be an outcome of any situation, the Officer must plan ahead and use reasonable alternatives if time and opportunity permits. In each case, a ‘reasonable alternative’ is defined as an action, which may be taken by the Officer that may allow the Officer to avoid the use of deadly force. The reasonable of the action is based upon the time available, the opportunity of performing the action, and the facts apparent to the Officer prior to and during the incident...” A review of the hospital’s “Patient Rights and Responsibilities” policy with a date of 12/18/2023 revealed, “ Policy: A written copy of the hospital’s statement of patient rights and responsibilities should be given to inpatients and outpatients and made available to them throughout the hospital stay. The statement should be appropriate to the patient’s age, understanding, and language. It should be documented that the patient has received a copy of their rights and responsibilities. The patient’s understanding of his/her rights and responsibilities should be assessed and documented as well. When the patient’s assessment of understanding his/her rights and responsibilities indicates that written communication is not effective, the patient should be informed again of these rights after admission and in a manner that he/she can understand. Complaints and concerns regarding a patient’s rights or responsibilities expressed by the patient/family should be registered with the Quality Improvement Department, who will keep a log of all activity and periodically aggregate the data to look for patterns and trends. Purpose: To outline the responsibilities of the hospital staff to provide information to patients regarding their rights to health care and health care-related activities during hospitalization ...Procedure: 1. Provide information that outlines the patient rights during the admission process to the patient or someone acting on the patient’s behalf for all inpatients, outpatients, and ER patients. A. Patient Rights Information will be provided to the patient in the form of the Hospital’s Patient Handbook or other printed material. In addition, patient rights will be posted in English and Spanish in various areas of the hospital. 2. Instruct the patient or surrogate to sign the acknowledgement document, which will acknowledge their receipt of the patient’s rights. 3. The admitting or nursing staff may refer to the Interpreter List for patients with language barriers. 4. Obtain an interpreter if the patient cannot speak English or if the patient has a hearing impairment ...5. Provide the patient with access to the patient complaint procedure if requested by the patient. 6. Documentation: Treatment Authorization and Terms of Treatment Agreement. Procedure: Outpatient: 1. When the patient enters an outpatient area of the hospital: a. Patient rights are available in English and Spanish and are posted in a visible area of the outpatient area. B. Patient rights will be provided to the patient or surrogate in the form of a handout when the patient enters an outpatient area of the hospital and under any type of procedure ....” A review of the hospital’s “Abuse Identification and Reporting” policy with a date of 05/06/2024 revealed, “Purpose: 1. To identify possible victims of abuse or neglect that present to an Inpatient or Outpatient location and/or setting using community established indictors (elder, adult, or child). 2. To establish the mechanism by which a possible victim will be automatically screened and assessed at the location or setting by an appropriate qualified nurse in that location or setting that will lead to an examination, treatment and referral for follow-up in order to meet their physical and psychological needs. 3. To ensure that notification to appropriate authorities is in accordance with Texas State Law. Definitions: 1) Neglect: A form of abuse, defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 2) Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. This includes staff neglect, indifference to infliction of injury, or intimidation of one patient by another. 3) Child: A person under 18 years of age. 4) Elder Abuse: “An act which results in harm or threatened harm, to the health or welfare of an elderly person” -according to the American Medical Association (AMA) These include: a) Physical abuse or neglect b) Psychological abuse or neglect c) Material abuse or exploitation d) Violation of personal rights or exploitation 5) Endangered Adult: An individual who is of legal age but is: a) Incapable by reason of insanity, mental illness, mental retardation, senility, habitual drunkenness, excessive use of drugs, old age, infirmity, or other incapacitating processes of managing either their property or caring for self. b) Harmed or threatened with harm as a result of neglect, battery or exploitation in the individual’s personal services or property. 6) Psychological Abuse/Neglect: a) Verbal assaults such as screaming or ridicule and threats that induce fear but do not make use of a weapon. b) The failure of the caretaker to satisfy emotional or psychological needs of a dependent or elder dependent (social isolations or lack of stimulation). 7) Material Abuse/Exploitation: Stealing or misusing money or property belonging to the elderly or endangered adult. 8) Violation of Personal Rights or Exploitation: Depriving an elderly adult of the right to freedom of choice, life or privacy ....Procedure: 1) The Health Care Provider will use established objective criteria for identifying possible victims of abuse. Physical and behavioral criteria for identifying possible victims of abuse are listed within the policy. 2) Once the possible victim has been identified, the health care provider will follow the established flow chart: “Managing the Abused/Neglected Patients”: see attached. 3) Appropriate authorities (CPS, APS, law enforcement) will be notified of ALL possible/actual victims of abuse/neglect. This referral will be documented in the medical record. 4) All possible/actual cases of abuse/neglect will be reported to Quality Improvement department via electronic Event Reporting system. a) Quality Improvement and Risk Management staff will be able to view the report in the electronic Event Reporting system. 5) Patients undergoing a sexual assault exam will be placed in a private room as medically indicated. 6) Visual and auditory privacy will be provided for any interviewing or examinations for all possible/actual abused or neglected patients. 7) An available list of private and public community agencies are attached as attachment C. 8) Physical and Behavioral Criteria for Identifying Possible Victims: a) Physical: These injuries cover a wide range and most commonly include burns, lacerations, contusions, fractures, head injuries and dislocations: i) Injuries that are not in keeping with the patient’s level of development or physical capabilities ii) Explanations for the injuries are implausible iii) Physical markings consistent with the use of objects iv) Skeletal injuries: untreated; in various states of healing; unexplainable v) Unexplained bruises, lacerations and welts: may be in various stage of resolution vi) Defensive injuries: hand and foreman injuries resulting from protecting oneself vii) Injuries consistent with “Shaken Infant Syndrome”: internal cranial bleeding, retinal hemorrhages viii)Poor hygiene, inadequate clothing ix) Apparent malnutrition, non-organic failure to thrive x) Unattended medical or physical needs (decayed teeth, broken glasses, overgrown nails) b) Behavioral: i) Irritability ii) Sleep disturbances (insomnia, nightmares) iii) Difficult concentrating iv) Exaggerated “startle” response v) Phobias, obsessions vi) Depression vii) Anxiety/apprehension/fearfulness/suicidal viii)Withdrawal ix) Reluctance to establish eye contact with the health care provider x) Extreme dependence on the partner and reluctance to make simple decisions without partner approval xi) Verbal statement or accusations xii) The abuser may also give clues by appearing dominant, answering questions for the partner, usurping his/her care to make their own medical decisions c) Pediatric Specific Indicators: Adopted from the manual for “Sexual Assault Nurse Examiner” Training-attachment B. d) Documentation Guidelines: All documentation will be specific to facts, observations and description. Any impressions/beliefs are not appropriate. An assessment will be conducted and documented upon entry into hospital and an ongoing basis. Documentation should include: i) Specifics regarding physical findings (i.e. 1-3 purple circular region on left inner wrist) ii) Behaviors observed iii) Any unsolicited verbal statements iv) Any contact with outside agencies. v) Any persons working with patient/family from outside systems will have their identity verified with their respective agency and documents (i.e. CPS, S.O. - badge number and verification with their office) vi) Referral for support; medical and psychosocial follow up plans ...” An interview was conducted with Staff # 1 and # 2 on 12/03/2025 at 4:30 PM. Staff # 1 and # 2 confirmed they watched the security footage of the event and confirmed that Staff # 7 failed to follow hospital policy and that the security manager (Staff # 9) failed to properly investigate and escalate the event to hospital administration for further investigation and action.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47892 Based on observation, document review, and interview, the hospital failed to ensure a sanitary environment in 3 (rooms 1, 2, and 6) of 3 rooms in the Emergency Department (ED). This violates Texas Administrative Code (TAC) Rule 505.41(g). This Rule states, “(g) Infection control. The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control, and surveillance of infections and communicable diseases. A. ED room 1. B. ED room 2. C. ED room 6. Findings A. ED room 1. A tour of the ED was conducted on 8/19/2025 after 12:30 PM with Staff #1. Staff #1 was asked if this room was clean and ready to receive patients. Staff #1 stated, “Yes, this room is clean and ready to receive a patient”. On the floor of room #1was a white plastic cap, along with material that appeared to be leaves, dirt, hair, dust, and other debris. The floor integrity had multiple cracks and chips. This has the potential to allow fluids to get under the floor covering and onto the subfloor. This cannot be cleaned or sanitized without removing the floor covering. Upon removing the mattress cover and lifting the mattress away from the stretcher, a large brown, dry substance was found on the back of the mattress and the top of the stretcher. Stuck to the sink was a used sticky tab that was placed on the patient for electrocardiograms (ECG). Inside the infusion pump (the pump used to push medication through tubing into a patient’s vein) drip chamber was a dried yellowish substance, dust, and debris. Staff #1 was asked if she believed this room was ready to receive a patient. Staff #1 stated, “No, it is not”. Staff #1 confirmed the room was dirty and not ready to receive patients. B. ED room 2. Staff #1 and #6 were asked if this room was clean and ready to receive patients. Staff #1 and #6 stated, “Yes, this room is clean and ready to receive a patient”. On the floor of room #2 was dirt, hair, dust, and other debris. The floor integrity had multiple cracks and chips. This has the potential to allow fluids to get under the floor covering and onto the subfloor. This cannot be cleaned or sanitized without removing the floor covering. After removing the mattress pad and lifting the mattress away from the stretcher, on the right railing and on the platform under the mattress pad were spots of a reddish-brown dried substance. Staff #1 and #6 were asked if they believed this room was ready to receive a patient. Staff #1 and #6 stated, “No, it is not”. Staff #1 and #6 confirmed the room was dirty and not ready to receive patients. C. ED room 6, the trauma room. Staff #1 and #6 were asked if this room was clean and ready to receive patients. Staff #1 and #6 stated, “Yes, this room is clean and ready to receive a patient”. On the floor of room #6 was dirt, hair, dust, and other debris. The floor integrity had multiple cracks and chips. This has the potential to allow fluids to get under the floor covering and onto the subfloor. This cannot be cleaned or sanitized without removing the floor covering. The IV (intravenous) pole (pole used to hang fluids and medication to be infused into patients) had a dried yellowish substance on the stand part of the pole. Staff #1 and #6 were asked if they believed this room was ready to receive a patient. Staff #1 and #6 stated, “No, it is not”. Staff #1 and #6 confirmed the room was dirty and not ready to receive patients. An interview was conducted on 8/17/2025 at 11:45 AM with the complainant (a Rusk State Hospital primary care tech (PCT) who was sent with another PCT to monitor the patient because of self-harm risk). Patient #2 was at risk of self-harm. The complainant stated that when they arrived at the hospital ED, patient #2 was brought into the ED room 1 by wheelchair. The complainant stated upon entering the room that she noticed that the “floor was dirty, and the bed had not been made”. The complainant stated, “the room had white plastic caps from medical supplies on the floor, and that the floor just looked dirty”. The complainant said that patient #2 “climbed up in the bed, but then a lady (the complainant did not know who this lady was) showed up and removed the bed from the room”. The complainant stated that patient #2 “then sat in a chair that was in the room, and the same lady returned and removed the chair”. The complainant asked the lady, “Where was the patient supposed to sit?”. The lady replied that Patient #2 “could sit on the floor”. Upon hearing this, Patient #2 “lay down on the dirty floor”. A medical record review of Patient #2 was performed on 8/19/2025 after 12:30 PM. In the medical record it states that Patient #2 came to the hospital ED on 7/24/2025 at 3:58 PM. Patient #2 had been previously discharged form this hospital on 7/23/2025 at 8:39 AM. The ED Triage note on 7/24/2023 states “Pt to ER from Rusk state w/ c/o foreign object in left flank wound. Per pt, she was recently admitted in this hospital for wound washout. Pt states that she stuffs ‘things’ in her wound. Pt reports that she stuffed 11 items in her wound last Saturday before her discharge from hospital yesterday. Foil, soda can tabs, paper clip type wire, etc are all stuffed in wound per pt right after she got an xray last week.” The ED physician attempted to remove the items in the ED but was unsuccessful. Because this hospital did not have a surgeon on call, Patient #2 was transferred to another facility for surgical services. An interview was conducted with Staff #6 on 8/19/2025 after 12:30 PM. Staff #6 was asked which staff members are responsible for cleaning these rooms in the ED. Staff #6 stated, “The nurses are”. An interview was conducted with Staff #1 and #6 on 08/19/2025 after 12:30 PM. Staff #1 and #6 were asked how long the patient was without a place to sit in ED room #1. Staff #1 and 6 stated they were unsure of the exact time frame, but the bed was returned to the room. Staff #1 and #6 were asked di the patient lay down on the floor in ED room #1. Staff #1 and #6 were unable to confirm or deny that the patient lay on the floor of ED room #1.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 47892 Based on document review and interviews, the facility failed to ensure that surgical instruments were monitored for temperature and humidity during transportation, following sterilization at a sister facility. Additionally, the facility did not adhere to its policy titled “Transporting Soiled Instruments Outside of Surgery Department-SS-MKT,” Policy number 48490.1. Findings: An observation tour was conducted on 9/18/2024 at 10:00 AM with Staff #4, the Director of Surgical Services, and Chief Nursing Officer (CNO) Staff #3. An interview was conducted with the Sterile Processing Technicians, Staff #5, and Staff #6 on 9/18/2024 after 10:00 AM. Staff #5 and Staff #6 were asked if the temperature and humidity were monitored when sterile instruments were transported back to the facility from an outside facility. Staff #5 stated, “Yes, we do monitor temperature and humidity when we transport sterilized instruments”. Staff #5 and #6 were asked how the instruments were transported. Staff #6 stated, “We wash the instruments here after the procedure is complete and then place them in a transport cart and take them to the main hospital in a transport van. We process the instruments ourselves and bring them back, but we don’t do this all the time.” An interview was conducted on 9/18/2024 at 10:30 AM with Staff #4, Director of Surgical Services. Staff #4 was asked how the temperature and humidity were monitored when sterile instruments were transported from an outside facility. Staff #4 stated, “Instruments are cleaned and taken out of the operating room (OR) to the sterile processing department (SPD). The SPD staff then continued to clean the instruments to make sure there is no human tissue or blood on the instruments before placing them in the enclosed transportation cart and taking them to the van for transport. The SPD staff get a portable temperature and humidity device from plant operations before they leave the hospital with the instruments. Our SPD staff wash and process the instruments at the sister hospital and when they are complete, the instruments get covered and placed in a clean transport cart and brought back to our hospital. The temperature and humidity are monitored during the transport back to our hospital”. A review of the blank document titled, “Sterile Instrument Transportation Log for Temp/Humidity” revealed a place to document the date the instruments left the facility, the date the instruments returned to the facility, the name of the instruments that were transported, the temperature and humidity in the transport van when the instruments were loaded, the temperature humidity in the van when the instruments were unloaded, and the SPD personal signature. Staff #4 was asked how the surgical department would know which surgical procedures the transported instruments were used on. Staff # 4 confirmed there was no way to know which patient or surgical procedure the transported instruments were used on. After multiple requests for the temperature and humidity logs for the transported instruments, none were provided for review. An interview was conducted with the Infection Control Preventionist (ICP), Staff #11 on 9/18/2024 before noon via video call. Staff #11 was asked if she monitored surgical site infections (SSI). Staff #11 confirmed that all surgical site infections were monitored through her department. Staff #11 confirmed there was only one return to surgery from 8/21/2024 to 9/18/2024 and the surgical procedure was not related to an infection. During an interview with Staff #4 on 9/18/2024 after 10:30 AM, Staff #4 confirmed there was no return to surgery procedures for post-operative infections from 8/21/2024 to 9/18/2024. A review of the policy titled “Transporting Soiled Instruments Outside of Surgery Department-SS-MKT” Policy number 48490.1, approval date 09/27/2023, stated: “ ...Policy: Contaminated instruments will be transported to SPD for reprocessing. Procedure: 1 ... 8. Temperature and Humidity log will be kept for the transportation of sterile instruments. See Attachment A. If the temperature and/or humidity goes out of range, the instruments will need to be re-processed prior to use ...” In a final interview on 9/18/2024 after 11:30 AM, Staff #4 confirmed that the facility had failed to follow its policy by not documenting temperature and humidity during the transport of sterilized instruments, thus failing to ensure their sterility.”