Northwest Texas Hospital

“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: 30250 Based on review of documents and interviews, the facility failed to ensure that patients have the right to receive care in a safe setting. The facility failed to ensure respect, dignity, and comfort, as components of an emotionally safe environment (for both patients and visitors), by failing to release a voluntary minor in a timely manner, at the repeated request by the minor’s parents. Finding included: Facility policy “BH RR 001 - Patient Rights and Responsibilities” stated in part, “POLICY: The Behavioral Health System respects all patients without regard to race, religious creed, color, ancestry, national origin, sex, disability, marital status, familial status, or sexual orientation. The Behavioral Health Unit shall support and protect the fundamental human, civil, constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times. Rights are restricted only in accordance with applicable law and regulation... List of Rights 1. Without limitation patients shall be entitled to: a. Considerate, respectful, humane care and treatment... c. Be treated with human dignity and in an environment that contributes to a positive self- image... Patient Responsibilities... C. Child/Adolescent Patients 1. The parent or legal guardian is identified as being responsible for care. 2. The appropriate individual will approve admission, medication initiation and changes, and will participate in special programming for Dual Diagnosis and/or Trauma as appropriate. Approval will be documented on the Consent for Treatment Form or double witnessed via telephone and included in the progress note.” Facility based policy entitled, “BH EC 003 - Patient Safety Intake and Assessment” stated in part, “16. If physician recommends admission and patient refuses to be admitted and is voluntary, Intake and Assessment staff: a. Contact provider on call to determine if patient should be placed on Emergency Detention Order b. If provider believes an Emergency Detention Order (EDO) is needed, Intake and Assessment staff contact Amarillo Police Department to determine if an EDO can be placed. i. If the EDO is not granted, the intake and assessment staff will 1. Complete Refusal to Treat form with patient signature 2. Complete crisis and safety referral form with patient signature 3. Contact a provider on site or by telehealth secure video to perform the medical screening exam. If staff are unable to reach a provider in a timely manner, the intake staff will call the emergency room charge nurse of the need for medical screening before escorting over the emergency department. c. If physician completes physician certification IMMEDIATELY send completed court paperwork to: i. NWTHS Court Liaison d. Per Texas Health and Safety Code, continue with admission process as EDO paperwork will be filed on the next business day with the court.” Facility based policy entitled, “BH 013 - Against Medical Advice Discharges” stated in part, “PURPOSE: A voluntary patient has the right to request to discharge from the Intake and Assessment department or inpatient behavioral health unit contrary to his/her physician’s opinion that continued stay is medically indicated for safety of the patient. Generally, except by court order, the hospital may not detain a patient against his/her will. However, because the hospital is charged with the responsibility of patient safety, staff must seek direction from a psychiatrist when a patient requests to leave from the intake and assessment department or inpatient setting prior to the proposed discharge date... POLICY: Intake and Assessment 1. If a patient is requesting to leave the facility while in the Intake and Assessment Department, staff: a. Call the telehealth physician to provide information regarding the patient’s request to leave i. If the physician believes the patient can safely return home, staff will: 1. Complete Refusal to Treat form and obtain patient signature 2. Complete Safety Plan with patient and provide referrals 3. Document changes in the patient’s behavior and mood that warrants the patient to return home 4. Complete Midas report for refusal of treatment ii. If the physician believes the patient requires inpatient treatment, the physician initiates the commitment process by completing the physician’s certification... Inpatient... 8. Minors: In the event, parents request to discharge their child/adolescent AMA, and the physician feels this may place the child/adolescent’s health in jeopardy, nursing or clinical staff will contact Child Protective Services (CPS). Staff may not detain the child/adolescent unless the psychiatrist feels it is a life-threatening situation. In this event, hospital security and the Amarillo Police Department can be contacted for assistance in detaining the child/adolescent until CPS is involved. The director of nursing and house supervisor are immediately notified of any AMA situation involving CPS.” Facility based policies, “BH EC 003 - Patient Safety Intake and Assessment” and “BH 013 - Against Medical Advice Discharges” are contradictory. “BH EC 003 - Patient Safety Intake and Assessment” indicates that “if provider believes an Emergency Detention Order (EDO) is needed, Intake and Assessment staff contact Amarillo Police Department [APD] to determine if an EDO can be placed.” While “BH 013 - Against Medical Advice Discharges” indicated, “1. If a patient is requesting to leave the facility while in the Intake and Assessment Department, staff:..a. Call the telehealth physician to provide information regarding the patient’s request to leave...ii. If the physician believes the patient requires inpatient treatment, the physician initiates the commitment process by completing the physician’s certification...” One policy (BH EC 003) indicates to call APD to obtain an emergency detention if a patient refuses to be admitted and is voluntary. While the other policy (BH 013) indicates the physician is to initiate the commitment process by completing the physician’s certification...” Review of the medical record for Patient #1 revealed the following: Arrived to the Behavioral Health Unit at 03/31/26 at 2013 and departed 2359 with disposition listed as “Referred”. BH Intake Assessment Note on 04/01/26 at 0107 stated in part, “Pt is vol, 16 yr old, Hispanic, 10th grade, female, student from Lubbock. Pt arrived by [another facility] EMS transfer. Pt presents as timid, alert, oriented, cooperative, with flat affect Pt’s [sic] support are mother and father. Parents at arrival refuse to cooperate and demand to be released with their daughter. Mother states pt was seeking inpatient but now is not comfortable with the environment and does not want inpatient services and rather get involved with outpatient services. [Another facility] medical records read: Pt has a history of depression, anxiety, PTSD, and ADHD who presented to the ER via [outside provider] for evaluation of suicidal ideation. Per pt’s mother pt has experienced multiple stressors with her grandfather passing away recently as well as her friend completing suicide about three weeks ago. Pt endorses anxiety and suicidal ideation with vocalizing to her mother yesterday morning that she ‘didn’t want to end up like her friend’. Pt denies self-harm... The parents continue to demand we let them out and holding them against their will. The father said he is calling APD. APD agreed to come out. The parents are refusing any assessment or answer any questions state they will not leave pt behind. Officer [Name] APD arrived to speak with the family. The parents agreed for the child to be interviewed in private with assessor present Pt states she has had suicidal ideation with no plan. Pt denies HI, AVH. Pt states she had suicidal in the past about three years ago. Pt denies self-harming behaviors. Pt states she is grieving the loss of her grandfather and friend who completed suicide. Pt states she has a psychiatrist and saw him two weeks ago and he treats her for depression and anxiety. Pt states she has a therapist that she sees weekly. Pt states she created a crisis/safety plan with her therapist and she has no access to anything that could be considered a weapon at home and her medications are secured . Pt states she has good relationships with her parents and they are her immediate support if she ever has SI. Officer [Name] of APD states he does not have enough to complete an EDO. I spoke with [Nurse Practitioner] and she spoke with Officer [Name] on the phone and he confirmed he would not be putting pt on an EDO. [Name], NP recommends admission and requests to see the pt via telehealth. [Name], NP was able to evaluate the pt by IPAD, Zoom for decision on referring out or AMA. [Name], NP evaluated the pt and recommeds [sic] admission. [Name], NP spoke with the parents and parents refuse to sign in patient on a voluntary basis. Parents agree to sign AMA form. Parents refuse the referrals. Parents are provided a copy of the AMA form and refuse the referral sheet. Mother explained pt is established with Relational Health Center and pt will meet with her psychiatrist and therapist tomorrow. Mother states pt has an appointment to begin Outpatient services with RHC at 9 am tomorrow. Pt and parents are released... BH Documented Risk at Intake: Suicide BH Clinical Reviewed with Physician: [Nurse Practitioner] BH Clinical Reviewed with Physician Dt/Tm: 3/31/2026 23:26 CDT Notification Action: admit AMA MD/MLP Notify Note: parents refuse to sign pt in for inpatient mother signed AMA BH Physician’s Recommended Disposition: Patient does not meets inpatient criteria...” Initial Evaluation Note completed by [Nurse Practitioner] on 04/01/26 at 0008 stated in part, “Chief Complaint/Reason for Consultation SI thoughts increased depression recent loss of a friend via SI History of Present Illness Per intake: Patient was initially evaluated and inpatient psychiatric hospitalization was recommended, with agreement for transfer to NW Amarillo for inpatient stabilization. Upon arrival to NW Amarillo Intake, patient is now requesting to leave AMA. APD was contacted; however, Officer [Name] declined to initiate an EDO, stating it should have been completed at the transferring facility. No involuntary hold was placed. A face-to-face assessment was completed via Doxy. During evaluation, patient endorsed recent suicidal ideation prior to arrival, reporting a friend died by suicide approximately 3 weeks ago. Patient declined to provide further details. Patient initially expressed preference for inpatient treatment, stating it would be more beneficial than outpatient care; however, decision changed after speaking with parents, and patient now declines admission. Parents report they are able to maintain safety and implement a safety plan, and indicate close supervision at home... On exam, patient presents with flat affect and minimization of depressive and anxiety symptoms. Engagement is adequate. Sleep is variable; concentration and appetite are intact but limited. Patient denies current SI, plan, or intent, as well as HI and AVH. Patient and family were educated multiple times on risks, benefits, and recommendation for inpatient stabilization, and strongly encouraged to remain for admission. Despite this, patient and family refuse admission and report a scheduled outpatient appointment at 0900 tomorrow. Disposition: Patient electing to leave AMA despite clinical recommendation for inpatient psychiatric hospitalization... Assessment: Patient evaluated via face-to-face assessment Doxy. Inpatient psychiatric hospitalization was recommended by both intake assessor and provider prior to transfer for stabilization due to reported suicidal ideation and recent psychosocial stressor peer suicide. At time of reassessment, patient demonstrates decision making capacity, including ability to communicate a choice, understand risks/ benefits, appreciate consequences, and rationalize decision. Patient is refusing recommended inpatient admission and electing to leave AMA accompanied by both parents. Patient currently denies suicidal ideation, homicidal ideation, and auditory/ visual hallucinations... APD involvement: Officer [Name] present and declined to initiate EDO, stating no criteria met for involuntary hold at time of evaluation. Therefore, no legal mechanism available to detain patient involuntarily. Risk assessment completed. While patient denies current SI/HI, overall risk remains mod given recent SI, conflicting history, minimization of symptoms, and abrupt change in disposition following parental involvement. Protective factors include active parental supervision, stated follow-up, and access to care. Patient and parents verbalize understanding of: Recommendation for inpatient level of care Risks of refusing admission including potential for decompensation, self-harm, or worsening symptoms Available alternatives and emergency resources Plan/Disposition: Inpatient psychiatric hospitalization recommended; patient refused APD declined EDO no involuntary hold in place Patient left AMA with parents after risks, benefits, and alternatives were thoroughly explained Outpatient follow-up confirmed: 04/01/2026 at 0900 with [another facility] Strongly advised immediate return to ED if symptoms worsen or safety concerns arise Encouraged strict adherence to outpatient care and medication regimen... Discharge Planning: Pt left AMA...” Patient #1’s parent signed a Refusal of Treatment form on 03/31/26 at 2345. In interview with staff member #15 on 06/02/26, regarding the intake of Patient #1 stated, “They [Patient #’1 parents] were constantly complaining about not wanting to be here and not wanting an assessment. I explained how is set up with the state and we needed to provide an assessment. They didn’t want to hear it...” When asked about the reasons why Patient #1’s family wanted to leave, Staff member #15 said, “I asked them why, after viewing the environment, they didn’t feel safe about leaving her here. I told Dad I would see them next; he was loud. I must have told the provider they wanted to leave. APD complained about its ‘not their job to clear our patients.’” In several interviews from 06/03/26 to 06/04/26, facility staff members indicated the APD is contact to try to obtain Emergency Detention patients to maintain safety. The facility was unable to clearly answer why the release of patient #1 (a minor) was delayed, despite multiple notes and interviews that upon arrival they were requesting release. It also appears that Patient #1’s family feared for the safety of their child and themselves, stating they were “not comfortable with the environment” and stating the facility was “holding them against their will”. It is also unclear why, after the APD Officer declined to file and Emergency Detention on the patient, the nurse practitioner felt it necessary to complete a virtual assessment via I-Pad with no Emergency Detention Order in place and Patient #1 had not agreed to admission to the facility. Based on documenation, Patient #1 was denying suicidal ideation. Per policy, APD should have filed an Emergency Detention Order for this patient, which the declined to do. Or a physician should have been contacted to initiate the commitment process by completing the physician’s certification. Based on these findings, the facility did not ensure the right to receive care in a safe setting, by not ensuring respect, dignity, and comfort, as components of an emotionally safe environment (for both patients and visitors), by failing to release a voluntary minor in a timely manner, at the repeated request of release by the minor’s parents.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 30250 Based on tour of the facility and interview, the facility failed to to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. Findings included: Facility based policy entitled, “Title: RRI 012 - Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)” stated in part, “DEFINITIONS: ... V. Signage refers to the hospital requirement to post signs conspicuously in a DED or in a place or places likely to be noticed by all individuals entering the DED as well as those individuals waiting for examination and treatment in areas other than the DED located on hospital property, (e.g., outpatient departments, labor and delivery, waiting room, admitting area, entrance and treatment areas), informing individuals of their rights under Federal law with respect to examination and treatment for medical conditions, EMCs and women in labor ... O. SIGNAGE POLICY 1. Signage Requirements. Hospital will post signage that, at a minimum, (1) is conspicuously posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area); (2) is readable from anywhere in the area or a distance of at least twenty (20) feet; and (3) in language understandable by the population served by the Hospital.” Tour and observation of the Behavioral Health [BH] building of the facility was conducted by the surveyors on 06/01/26 at 4:25 PM. It was observed the intake/admission entrance did not have EMTALA signage posted outside or in the sallyport area when you enter the building. In an interview on 06/01/26 at 4:25 PM, with staff member #8, they stated there should be signage at those areas; the intake area had moved to its current location at the end of February; this staff member was unsure why the signage was not posted. EMTALA signage was placed in the sallyport area of intake/admission entrance the Behavioral Health building of the facility, on 06/02/26, after the issue was identified by the surveyors during the tour the previous day (06/01/26).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 30250 Based on review of video surveillance and interviews, it appears the facility did not maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. Findings included: Facility based policy entitled, “Title: RRI 012 - Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)” stated in part, “P. CENTRAL LOG POLICY 1. Central Log Procedure. a. Hospital will maintain the Central Log in an electronic form in Midas. b. All ancillary logs maintained by all Hospital Departments, including the DED are incorporated by reference and become part of Hospital ’ s EMTALA Central Log. c. The Central Log must contain at a minimum, the name of the individual the date, time and means of the individual’s arrival, the individual’s age, the individual’s sex, the individual’s record number, the nature of the individual’s complaint, the individual’s disposition, the individual’s time of departure, and whether the individual: · refused treatment, · was refused treatment, · was transferred, · was admitted and treated, · was stabilized and transferred, · was stabilized and discharged; or expired. d. A log entry for all individuals protected under EMTALA should be made by the appropriate individual. Further, in non-DED departments of the hospital where an individual may present with an EMC, the department will provide the necessary information from the point of contact to the DED for logging purposes. e. The Central Log of individuals protected by EMTALA will be available within a reasonable amount of time for surveyor review and must be retained for a minimum of five years or as delineated by State regulation from the date of disposition of the individual.” An EMTALA complaint filed regarding this facility alleged, that on 05/02/26 around 2100, a 14-year-old male presented to the Emergency Room to be seen for suicidal ideation and “whoever was at the desk to check him in, told us to go across the street. They did not do a screening exam.” Review of Video Surveillance for the Acute Emergency Department Video Surveillance for 05/02/26 revealed the following: 2100: A small gray/silver SUV pulls up, lets an individual in a black shirt out of the car. 2100: The individual that exited small gray/silver SUV with shoulder length hair, in the black shirt, white pants, walks in by themselves up to the ER desk (possibly an adolescent female or male). This individual appeared to possibly be crying, frowning, upset, holding face - walked over to corner at 21:01:49, then walks to corner takes a cell phone call; then walks up to counter at 21:03:00 and speaks with the 2 females working the registration [identified as Staff members #16 and 17 (ED Nurses), identification was made by the ED Director]. A woman in an arm sling walks in and joins this individual at the registration desk. The individual with shoulder length hair and woman with the arm sling in place are observed briefly talking to 2 females working the registration desk. In the audio of the video, it appears the individual with shoulder length hair says something about the “Pavillion”. The individual with the shoulder length hair exchanges words with the 2 females working the registration desk. 21:04:54: One of the female registration desk workers hands something to the individual in the black shirt. The individual in the black shirt writes something on the paper and gives it back to the registration desk worker. The registration desk worker in an American flag t-shirt appears to gesture with their hand to the right towards the entry doors of the Emergency Department. 21:05:16: The individual with shoulder length hair and woman with the arm sling walk out of the Emergency Department. 21:06-21:07: The gray/silver SUV is observed leaving the Acute ED parking lot. 21:08 The small gray/silver SUV is observed exiting the Acute ED parking lot, turning out towards Coulter Street, away from the behavioral health building. *Of note, this facility is certified as an acute care hospital; the physical campus layout includes an Emergency Department for the Acute Hospital portion with a Behavioral Health Unit (often referred to as the Pavilion) located across the street (both operating under the same CCN/license number). Review of both the Acute Emergency Department and Behavioral Health EMTALA Logs for 05/02/26 to 05/03/26, revealed no registration of a 14 year old male with suicidal ideation between the hours of 1930-2200. In interview on 06/02/26 at 1637, staff member #16 (ER Nurse) was asked if individuals ever present to the Acute ED asked for mental health services. Staff member #16 replied, “It happens all the time.” Staff member #16 was asked what they would do if an adolescent with a parent presented at registration for mental health services? Staff member #16 replied, “We would get information to sign them in get vitals, a chief complaint, usually a NP [Nurse Practitioner] will come talk to them, triage and talk to them, find out what room they need to go into. For mental health things like either an overdose or suicidal ideation, we would get a sitter, or call APD [Amarillo Police Department], to file out a report, follow our process to get them to the Pavillion.”Staff member #16 was also asked if the facility kept a log of individuals that walk in and leave before providing information beyond an initial complaint. Staff member #16 replied, “I’m not aware of a log like that.” Based on the above findings, it appears that a 14-year-old male possibly presented to the facility Emergency Room on 05/02/26 around 2100, to be seen for suicidal ideation, however, this individual was not entered in the facility central log.”

“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: 30250 Based on review of video surveillance and interviews, it appears the facility did not ensure that 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. Findings included: Facility based policy entitled, “Title: RRI 012 - Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)” stated in part, “”DEFINITIONS: ... N. Medical Screening Examination (“MSE”) is the process (which begins with the initial collection of an individual’s vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or a woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening ... PROCEDURE: ... C. Extent of Medical Screening Examination 1. An MSE is the process (which begins with the initial collection of an individual’s vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists or a woman is in labor. 2. The MSE may vary depending on the individual’s signs and symptoms, from a simple process involving a brief history and physical examination to a complex process that also involves performing ancillary services and procedures. 3. The MSE is to be conducted to the extent necessary, by physicians and/or other QMP to determine whether an EMC exists. 4. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric/behavioral health screening. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others ... “ An EMTALA complaint filed regarding this facility, alleged that on 05/02/26 around 2100, a 14-year-old male presented to the Emergency Room to be seen for suicidal ideation and “whoever was at the desk to check him in, told us to go across the street. They did not do a screening exam.” Review of Video Surveillance for the Acute Emergency Department Video Surveillance for 05/02/26 revealed the following: 2100: A small gray/silver SUV pulls up, lets an individual in a black shirt out of the car. 2100: The individual that exited small gray/silver SUV with shoulder length hair, in the black shirt, white pants, walks in by themselves up to the ER desk (possibly an adolescent female or male). This individual appeared to possibly be crying, frowning, upset, holding face - walked over to corner at 21:01:49, then walks to corner takes a cell phone call; then walks up to counter at 21:03:00 and speaks with the 2 females working the registration [identified as Staff members #16 and 17 (ED Nurses), identification was made by the ED Director]. A woman in an arm sling walks in and joins this individual at the registration desk. The individual with shoulder length hair and woman with the arm sling in place are observed briefly talking to 2 females working the registration desk. In the audio of the video, it appears the individual with shoulder length hair says something about the “Pavillion”. The individual with the shoulder length hair exchanges words with the 2 females working the registration desk. 21:04:54: One of the female registration desk workers hands something to the individual in the black shirt. The individual in the black shirt writes something on the paper and gives it back to the registration desk worker. The registration desk worker in an American flag T-shirt appears to gesture with their hand to the right towards the entry doors of the Emergency Department. 21:05:16: The individual with shoulder length hair and woman with the arm sling walks out of the Emergency Department. 21:06-21:07: The gray/silver SUV is observed leaving the Acute ED parking lot. 21:08 The small gray/silver SUV is observed exiting the Acute ED parking lot, turning out towards Coulter Street, away from the behavioral health building. *Of note, this facility is certified as an acute care hospital; the physical campus layout includes an Emergency Department for the Acute Hospital portion with a Behavioral Health Unit (often referred to as the Pavilion) located across the street (both operating under the same CCN/license number). Review of both the Acute Emergency Department and Behavioral Health EMTALA Logs for 05/02/26 to 05/03/26, revealed no registration of a 14 year old male with suicidal ideation between the hours of 1930-2200. There was also no documented Medical Screening Exam for the individual described above that presented to the Acute BED on 05/02/26 at approximately 2100. In interview on 06/02/26 at 1637, staff member #16 (ER Nurse) was asked if individuals ever present to the Acute ED asked for mental health services. Staff member #16 replied, “It happens all the time.” Staff member #16 was asked what they would do if an adolescent with a parent presented at registration for mental health services? Staff member #16 replied, “We would get information to sign them in get vitals, a chief complaint, usually a NP [Nurse Practitioner] will come talk to them, triage and talk to them, find out what room they need to go into. For mental health things like either an overdose or suicidal ideation, we would get a sitter, or call APD [Amarillo Police Department], to file out a report, follow our process to get them to the Pavillion.” Based on the above findings, it appears that a 14-year-old male possibly presented to the facility Emergency Room on 05/02/26 around 2100, to be seen for suicidal ideation, however, this individual was not medically screened for psychiatric symptoms, per facility policy.”

“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: 33326 Based on record review, observations, and interview, the facility failed to protect a patient’s right to be free from all forms of abuse when the facility failed to report a credible allegation of a sexual assault for one out of three patients reviewed for allegations of a sexual assault, according to the State law. (Patient #1) Findings include: Review of the facility provided policy “Title: RRI 025 Abuse, Neglect, Abandonment of Patients” (last revised dated 6/2024) reflected, “Upon evidence of reasonable cause to believe that a child, or an elderly or disabled person is in a state of abuse, exploitation or neglect, staff are obliged to report the circumstances to the appropriate state agencies ...” Review of the facility provided, Risk Management Policy (revised 12/2023) reflected, “it is also important the Risk Manager report credible allegation of abuse or neglect of patient to the appropriate State agency, UHS Management Department, the patient’s guardians, insurance company, when appropriate, and local authorities.” Review of Patient #1’s Therapist note dated, 11/5/24 reflected, “ ...it happened on the unit with another patient during movie time at night shift at the back rectangle table ...she was sexually assaulted by a pt on unit 3 different times, 1 time listed in prior sentence, 2 time in the lunchroom, 3 time in the big group room sitting at the table.” Review of Patient #1’s facility provided behavioral health progress note dated 11/7/2024 reflected, “Therapist called pt (patient’s) parent and informed her of the allegations that Patient #1 had stated to me about being touched several times inappropriately by another pt who was male. Mother was sad and upset and did say she wanted to press charges ...” Review of Patient #1’s “Investigation Tool Checklist: Abuse/Neglect Response Plan” (dated 11/6/24) reflected, “Alleged incident Type: Sexual Assault, Date Reported: 11-5.” The report was completed by Staff #11, RN and signed by Staff #4, Risk Manager. An observation made on the morning of 7/1/25, in a facility conference room revealed a video recording of patient #1 and Patient #2 interacting in the adolescent units day room. Patient #1 and Patient #2 are not seen making physical contact during the recording. Further video review revealed Patient #2 touching Patient #17 between her legs, over her pants. The facility was unable to provide the video recordings for the movie night and the lunchroom videos. During a tour of the facility’s adolescent’s lunchroom on the afternoon of 6/30/25 revealed one lunchroom table that is blocked from the camera view by a large support wall that is approximately 3 feet wide. When asked if Patient #2 had been interviewed as part of the sexual assault investigation, Staff #4 stated, he (Patient #2) had already been discharged. Review of Patient #2’s medical record dated 11/7/2025 reflected the therapist contacted adolescent’s father and reported allegation of sexual assault and suggested intense counseling with someone who specialized in addiction and or sexually acting out. During an interview, on the morning of 7/1/25, in the facility conference room, Staff #4, Risk Manager stated in part, the facility had conducted an investigation. When asked if the facility had reported the incident to Health and Human Services, Staff #4 stated in part, “No, it was not substantiated. We investigate all allegations, three staff (administrative staffs) participated in reviewing the video; we didn’t see anything.” However, the facility failed to consider the camera’s blind spots in the lunch room and patient #2’s inappropriate touching of patient #17. Staff #4, Risk Manager confirmed the facility had not considered the incident of patient #2 being video recorded touching another female patient in the same manner, making patient #1’s reported incident more credible.”

“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: 30468 Based on record review and interview, the facility failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department to determine whether an emergency medical condition (EMC) existed for 1 of 1 patient (Patient #1) reviewed that presented to the emergency department (ED) December 27, 2024 with aggressive behavior issues. Patient #1, a 29 female with IDD (Intellectual and Developmental Disability) (IQ 60) presented to Facility A with representatives from her group home on 12/27/24. It was reported the patient was having aggressive behavior and outbursts at the group home. Based on record review and staff interviews, the hospital staff failed to provide patient #1 an appropriate medical screening exam prior to referring patient to another facility. Refer to A-2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30468 Based on record review and staff interviews, the hospital Facility A staff failed to provide patient #1 an appropriate medical screening exam and stabilization prior to referring patient to another facility. Referral was made due to patient not meeting admission criteria of IQ 70. Findings include: Patient #1 was brought to the Facility A on 12/27/24 by several staff members of the group home, where she resides. Group Home representatives expressed concerns for changes in the usual behavior. The patient had become verbally aggressive with angry outbursts. The three Medical records provided by Facility A include: 1. Medical Record indicates 15 minutes checks at 16:00 Activity 2(Lying or sitting), Location A (Access) initials “M” 16:15 Activity 2(Lying or sitting), Location A (Access) initials “M” 16.30 Activity 2(Lying or sitting), Location A (Access) initials “M” 16:45 Activity 2(Lying or sitting), Location A (Access) initials “M” 17:00 Activity 2(Lying or sitting), Location A (Access) initials “M” 17:15 Activity 2(Lying or sitting), Location A (Access) initials “M” 2. Final Report by Therapist BH Progress Note - Staff #6,Therapist, LPC Associate 12/27/24 18:29 *Final Report* 12/27/24 1800 - Pt presented with RN, (Group Home) “House Parent” and SW. Pt was hyperverbal and delusional but denies HI, SI, HALL, SIB ...Pt was sexually provocative in speech. It was confirmed pt has IDD with an IQ of 60, which is less than the minimum of 70 for admission. Case was staffed by Nurse Practitioner, Staff#13, who advised it would be best to refer out as pt could not even consent to a assessment and she did not have a guardian, pt was her own guardian. Staff from group home, board president asked “what if we just leave her, what will you do the?” Therapist responded ...it would result in an APS report. Group home responded “In all honest, I think you are abandoning her.” Therapist gave group home staff and pt referrals to Facility C as well as Facility B as that is where they said they were taking her. 3. Copy of Referral Recommendations and Crisis Safety Plan given to patient and group home staff dated 12/27/24 no time noted No record of a Medical Screening or Stabilization performed by Facility A since patient did not meet IQ criteria for admission. Patient and Group Home representatives were referred to another facility., Facility B. Interviews: Staff #2, DON, Facility A on 3/24/25 related “This patient was exclusionary due to being an adult with a guardian and the Amarillo Police Department (APD) officer would not place on an emergency detention order, as she did not meet criteria for the emergency hold. Per the Health and Safety code within the Texas Administrative Code an adult with a guardian cannot be admitted voluntarily to a locked psychiatric facility with the consent of the guardian therefore requiring an emergency detention or mental health warrant to be admitted involuntarily. Since the APD officer would not place on an emergency detention our hands were tied from admitting this patient. Due to guardianship status and APD not willing to place on emergency detention papers, and the patient not having the ability to consent, we were not able to complete a full assessment. Therefore, we were not able to admit without the emergency detention order since she did not meet criteria to the officer present. During the attempted assessment, the patient was calm, she simple would not allow the staff to access her in any way. She verbally refused vital signs and would not answer any questions, the patient’s house parents did not have guardianship not did they provide any guardianship information. They shared they wanted her admitted because she was acting out at the group home. The patient did not exhibit any suicidal ideations and was not aggressive or abusive during the time at the facility.” When asked why a referral was made instead of handling patient in ED, she stated “This patient was not transferred anywhere, nor did she need medical attention. This is why we did not send to our emergency department. The group home staff said they would take her to Facility B which is why it was on the referral list.” Staff #6, LPC associate, Facility A, was interviewed 2/11/25 via phone as she completed the initial intake on patient #1 dated 12/27/25. She has been employed at the facility since May 2024 and she shared the following ... “The patient arrived with two group home staff and an APD (Amarillo Police Department) officer as they had called ahead to have them meet here. During the officer’s assessment of the patient to be placed on an EDO, he stated the patient did not meet criteria. We attempted to get the patient assessed and have consents for voluntary admit signed, but the patient refused everything, and there was no information provided regarding patient #1 having a legal guardians. The house parents shared the patient had not been herself for the last few days, having verbal aggressive behavior and outbursts at the group home. The patient would not provide any information and refused all care during the intake assessment process. Staff #13, NP was contacted and provided recommendations for a referral of care with the crisis safety plan and explained to the patient’s house parents what they could do as the patient did not meet criteria for admit to the Behavioral Health at this time. My supervisor, Staff #5, the House Supervisor, and the administrative staff on call were updated of the situation.” When asked how the referral form is completed in reference to recommended locations, she said, “The referral request is given to the patient as a guide of various locations that may be able to get assistance , there was no direct referral provided to go to Facility B, it was only an option provided as they said they were going to take the patient there. They appeared frustrated and left with comments that they ‘knew what they would do,’ I received no further communication with the patient or the house parents Every attempt to have the patient sign consents for voluntary admit was tried but she refused everything. The patient appeared very relaxed with the house parents and the facility staff and showed no aggressive behavior during the time at the facility, no safety concerns were identified.” Note time in final report 18:29 Facility B: Note patient #1 arrived 42 minutes after leaving Facility A on 12/27/25 via personal car with group home house parents. Medical records indicate patient arrived at 12/27/24 at 7:12 PM. Triage notes 12/27/24 7:28 Patient lives in a group home in Amarillo for the past 2 year. Behavior that is not her baseline onset around 12/24 however changes in sleep pattern from the week before. Per case worker that is with patient a triage, she has made statements of killing others, killing herself, and has become physically aggressive to herself and staff. Unsure of when the patient actually last slept. Restless with clenched fist and random outburst of speech. “They stole all the blood in my body.” Patient was taken to the Facility A in Amarillo and was told she could not be admitted. She was not medically cleared at a local ER and was told by staff to come here to Facility B. Referral Recommendation and Crisis Safety Plan paperwork filled out with Facility B listed as an referral agency. Patient presents to the ED with abnormal behavior, hallucinations, suicidal and homicidal threats. The symptoms started lightly about 4 days ago and gotten progressively worse. The patient’s history is significant for intellectual delay and she lives in a group home. Her guardians brought her initially to the Pavilion for admission due to the symptoms but midline refused her and sent her to Facility B instead of across the street to the ER because she was too intellectually disabled to keep her there. Patient is not able to provide her own history due to hallucinations but states that there are demons everywhere that are harming her other friends and team as they are and she has to kill another girl named Jackie. Patient does seem distracted by other objects in the room that are not there. Majority of history is provided by her guardians. They have not noticed any other symptoms. Review of Systems Psychiatric/Behavioral: Positive for agitation, behavioral problems, hallucinations, sleep disturbance and suicidal ideas. All other systems reviewed and are negative. Comments: Patient actively has distraction to other objects in the room which are not there. Patient claims that she is going to stab herself as well as kill other people who are not sure of because of the demons torturing them. Patient has psychomotor agitation. Orders Placed Lab - Pregnancy, Serum, Qual; Drugs of Abuse, Screen, Urine; Urinalysis, Reflex Microscopic and/or Culture IV - Insert 1 peripheral IV 19:35 Final Diagnosis: COVID-19; Acute cystitis without hematuria; Acidosis, unspecified; Brief psychotic disorder (HCC). Patient #1 was discharged 12/28/25 back to group home. Medical Screen and Stabilization was provided at Facility B.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 31690 Based on observation, review of facility policy and staff interviews, the governing body failed to meet the Condition of Participation for Governing Body by failing to ensure its medical staff followed the Hospital Medical Staff Bylaws when Physician A did not follow facility policy and standards of care. Physician A continuously failed to participate in the “Time Out Process” even after the issue was brought up to administration, which could lead to adverse events up to and including death by not verifying the correct patient, correct procedure, allergies, lab results, and medications. Refer to A0049”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 31690 Based on observation, review of facility policy and staff interviews, the governing body failed to ensure its medical staff were accountable for the quality of care provided to patients. The governing Body by failed to ensure its medical staff followed the Hospital Medical Staff Bylaws even after the issue was brought to the attention of hospital administration. Physician A did not follow facility policy and standards of care. Physician A continuously failed to participate in the “Time Out Process” while performing surgical procedures in the Cardiac Cath Lab, which could lead to adverse events up to and including death by not verifying the correct patient, correct procedure, allergies, lab results, and medications. This deficient practice had the likelihood to cause harm to all patients (31 in the last month) undergoing procedures in the Cardiac Cath Lab performed by Physician A. Findings include: Review of the facility policy “NPSG - 006 - Universal Protocol (UHS)” reflected: “I. Scope: The Universal Protocol (UP) policy governs the performance of operative and invasive procedures for patients in both the inpatient and outpatient setting. UP consists of three distinct steps: Pre-procedure Verification, Site Marking and Time Out. Operative and invasive procedures are defined as puncture of the skin, instrument insertion, or inserting foreign material into the body ... II. Purpose: To establish a standardized policy for identifying the correct patient, procedure and anatomical site/side prior to all operative and invasive procedures that expose patient to more than minimal risk in order to prevent wrong person, wrong site, wrong procedure, and wrong physician events. III. Policy: Universal protocol is the process used to identify the correct patient, the correct procedure, the correct physician, and the correct site. Prior to the initiation of an operative or invasive procedure the UP must be followed and documented. The team members providing care for the patient are accountable for patient safety. Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process ... ... E. Time Out Process A time out is conducted immediately before the start of an operative or invasive procedure to provide a final verification of the patient, site, procedure, and physician ... The time out should be initiated by the person performing the procedure and should include all members of the surgical or procedural teams. All activities will be suspended for the time out unless a threat to patient safety exists. All members of the team will verbally engage in the time out. The time out will be halted if any of the team members are not actively engaged in the process ...” Review of “The 2021 Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement update on best practices in the cardiac catheterization laboratory updates the 2016 document with the latest scientific evidence and recommendations for the consistent delivery of high-quality care” found at https://scai.org/publications/clinical-documents/scai-expert-consensus-update-best-practices-cardiac-catheterization reflected: “Intra-Procedure Best Practices ...5.6 Universal protocol and ‘time out’ procedure All team members should understand the intended procedure and the sequence of that procedure. This should be confirmed during a dedicated ‘time out’ protocol, performed before vascular access or moderate sedation is initiated, when all members of the team are present... Universal infection precaution protocols should be followed by the staff.” Observation on the afternoon of 11/14/23 reflected Physician A entered the control room of the cardiac catheterization lab. The physician was introduced to this surveyor prior to entering the Cath lab. Upon entrance to the Cath lab, the physician requested a time out prior to the procedure. Further observation on the afternoon of 11/14/23 reflected the same physician entering the Cath lab without the knowledge that this surveyor was observing. Physician A entered the Cath lab and began putting on his gown and gloves. During this time, the Cath lab staff conducted the time out without Physician A’s participation. Following the procedure, Physician A was asked why he did not participate in the time out during the previous procedure and replied, “I did participate, I can do more than one thing at a time, and I was listening. I do not have to stop what I am doing and face the staff during the time out.” When asked about the facility policy and standards of care related to the time out, Physician A replied “I have been doing this for over 30 years and have never had a poor outcome, so I don’t need to change what I have been doing. If you are telling me that I have to do it differently, then tell me what to do and I will do it.” During an interview with the interim director of the Cath Lab, Staff # 7, on the afternoon of 11/14/23, Staff #7 reported that Physician A does not participate in the time out, but the staff complete a time out prior to each procedure. When asked if this has been addressed, Staff #7 reported that “it has been an issue for a long time and it has never been resolved.” Staff #7 continued that “there was a meeting several months ago with the Assistant Administrator, Former Director of the Cath Lab, CFO (Chief Financial Officer), HR (Human Resources) Director, Regional VP (Vice President), and me and there was no resolution at that time.” During a telephone interview with the former Director of the Cath Lab, Staff #8, on the morning of 11/15/2023, he reported that he reported Physician A’s refusal to participate in the time out multiple times to hospital administration. At one point he was told by the Regional VP (Staff #9) to just stop reporting. During an interview on the afternoon of 11/15/23 the Director of Human Resources (Staff#4) reported that he was in the meeting related to the Cath Lab and that the Regional VP (Staff #9) reported “We, meaning administration, would take care of the physicians.” During a telephone interview on the afternoon of 11/14/23, the Regional VP (Staff #9) denied remembering this meeting or conversation. Review of the facility document titled “Northwest Texas Healthcare System Staff Bylaws” last revised on 01/11/22 stated in part, “Article I, Purpose: The Medical Staff of Northwest Texas Healthcare System is established by the Board to assist the Hospital in meeting its mission and to carry out duties assigned to it by the Board in order to enhance the quality and safety of care, treatment, and services provided to patients. The Medical Staff is considered part of the Hospital’s Organized Health Care Arrangement. Article II, Medical Staff and Membership: 2.3 Responsibilities of Membership Each Member of the Medical Staff must continuously comply with the provisions of these Bylaws, the Ancillary Manuals and Medical Staff Rules, Regulations and Policies ... Furthermore, each Member of the Medial Staff by accepting Medical Staff appointment agrees: ...n....and compliance with Hospital efforts to meet standards such as those established by the Joint Commission, insurers, Centers for Medicare and Medicaid Services (CMS) and other governmental agencies (e.g. core measures) ... u. To abide by all local, state and federal laws and regulations, Joint Commission standards, and state licensure and professional review regulations and standards, as applicable to the Member’s professional practice ...””

“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: 31690 Based on observation, interview, and record review, the facility failed to ensure that patients received care in a safe setting by not addressing Physicians A failure to follow the facility Policy “NPSG 006 - Universal Protocol (UHS)” last revised 03/19/2021. Physician A continuously failed to participate in the “Time Out Process” even after the issue was brought to the attention to hospital administration, which could lead to adverse events up to and including death by not verifying the correct patient, correct procedure, allergies, lab results, and medications. This deficient practice had the likelihood to cause harm to all patients (31 in the last month) undergoing procedures in the Cardiac Cath Lab by Physician A. Findings include: Review of the facility policy “NPSG - 006 - Universal Protocol (UHS)” reflected: “I. Scope: The Universal Protocol (UP) policy governs the performance of operative and invasive procedures for patients in both the inpatient and outpatient setting. UP consists of three distinct steps: Pre-procedure Verification, Site Marking and Time Out. Operative and invasive procedures are defined as puncture of the skin, instrument insertion, or inserting foreign material into the body ... II. Purpose: To establish a standardized policy for identifying the correct patient, procedure and anatomical site/side prior to all operative and invasive procedures that expose patient to more than minimal risk in order to prevent wrong person, wrong site, wrong procedure, and wrong physician events. III. Policy: Universal protocol is the process used to identify the correct patient, the correct procedure, the correct physician, and the correct site. Prior to the initiation of an operative or invasive procedure the UP must be followed and documented. The team members providing care for the patient are accountable for patient safety. Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process ... ... E. Time Out Process A time out is conducted immediately before the start of an operative or invasive procedure to provide a final verification of the patient, site, procedure, and physician ... The time out should be initiated by the person performing the procedure and should include all members of the surgical or procedural teams. All activities will be suspended for the time out unless a threat to patient safety exists. All members of the team will verbally engage in the time out. The time out will be halted if any of the team members are not actively engaged in the process ...” Review of “The 2021 Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement update on best practices in the cardiac catheterization laboratory updates the 2016 document with the latest scientific evidence and recommendations for the consistent delivery of high-quality care” found at https://scai.org/publications/clinical-documents/scai-expert-consensus-update-best-practices-cardiac-catheterization reflected: “Intra-Procedure Best Practices ...5.6 Universal protocol and ‘time out’ procedure All team members should understand the intended procedure and the sequence of that procedure. This should be confirmed during a dedicated ‘time out’ protocol, performed before vascular access or moderate sedation is initiated, when all members of the team are present... Universal infection precaution protocols should be followed by the staff.” Observation on the afternoon of 11/14/23 reflected Physician A entered the control room of the cardiac catheterization lab. The physician was introduced to this surveyor prior to entering the Cath lab. Upon entrance to the Cath lab, the physician requested a time out prior to the procedure. Further observation on the afternoon of 11/14/23 reflected the same physician entered the Cath lab without the knowledge that this surveyor was observing. Physician A entered the Cath lab and began putting on his gown and gloves. During this time, the Cath lab staff conducted the time out without Physician A’s participation. Following the procedure, Physician A was asked why he did not participate in the time out during the previous procedure and replied, “I did participate, I can do more than one thing at a time, and I was listening. I do not have to stop what I am doing and face the staff during the time out.” When asked about the facility policy and standards of care related to the time out, Physician A replied, “I have been doing this for over 30 years and have never had a poor outcome, so I don’t need to change what I have been doing. If you are telling me that I have to do it differently, then tell me what to do and I will do it.” During an interview with the interim director of the Cath Lab, Staff # 7, on the afternoon of 11/14/23, Staff #7 reported that Physician A does not participate in the time out, but the staff complete a time out prior to each procedure. When asked if this has been addressed, Staff #7 reported that “it has been an issue for a long time and it has never been resolved.” Staff #7 continued that “there was a meeting several months ago with the Assistant Administrator, Former Director of the Cath Lab, CFO (Chief Financial Officer), HR (Human Resources) Director, Regional VP (Vice President), and me and there was no resolution at that time.” During a telephone interview with the former Director of the Cath Lab, Staff #8, on the morning of 11/15/2023, he reported that he reported Physician A’s refusal to participate in the time out multiple times to hospital administration. At one point he was told by the Regional VP (Staff #9) to just stop reporting. During an interview on the afternoon of 11/15/23 the Director of Human Resources (Staff#4) reported that he was in the meeting related to the Cath Lab and that the Regional VP (Staff #9) reported “We, meaning administration, would take care of the physicians.” During a telephone interview on the afternoon of 11/14/23 the Regional VP (Staff #9) denied remembering this meeting or conversation.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 31690 Based on observation, review of facility policy and staff interviews, the governing body failed to ensure its medical staff were accountable for the quality of care provided to patients. The governing Body by failed to ensure its medical staff followed the Hospital Medical Staff Bylaws even after the issue was brought to the attention of hospital administration. Physician A did not follow facility policy and standards of care. Physician A continuously failed to participate in the “Time Out Process” while performing surgical procedures in the Cardiac Cath Lab, which could lead to adverse events up to and including death by not verifying the correct patient, correct procedure, allergies, lab results, and medications. This deficient practice had the likelihood to cause harm to all patients (31 in the last month) undergoing procedures in the Cardiac Cath Lab performed by Physician A. Findings include: Review of the facility policy “NPSG - 006 - Universal Protocol (UHS)” reflected: “I. Scope: The Universal Protocol (UP) policy governs the performance of operative and invasive procedures for patients in both the inpatient and outpatient setting. UP consists of three distinct steps: Pre-procedure Verification, Site Marking and Time Out. Operative and invasive procedures are defined as puncture of the skin, instrument insertion, or inserting foreign material into the body ... II. Purpose: To establish a standardized policy for identifying the correct patient, procedure and anatomical site/side prior to all operative and invasive procedures that expose patient to more than minimal risk in order to prevent wrong person, wrong site, wrong procedure, and wrong physician events. III. Policy: Universal protocol is the process used to identify the correct patient, the correct procedure, the correct physician, and the correct site. Prior to the initiation of an operative or invasive procedure the UP must be followed and documented. The team members providing care for the patient are accountable for patient safety. Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process ... ... E. Time Out Process A time out is conducted immediately before the start of an operative or invasive procedure to provide a final verification of the patient, site, procedure, and physician ... The time out should be initiated by the person performing the procedure and should include all members of the surgical or procedural teams. All activities will be suspended for the time out unless a threat to patient safety exists. All members of the team will verbally engage in the time out. The time out will be halted if any of the team members are not actively engaged in the process ...” Review of “The 2021 Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement update on best practices in the cardiac catheterization laboratory updates the 2016 document with the latest scientific evidence and recommendations for the consistent delivery of high-quality care” found at https://scai.org/publications/clinical-documents/scai-expert-consensus-update-best-practices-cardiac-catheterization reflected: “Intra-Procedure Best Practices ...5.6 Universal protocol and ‘time out’ procedure All team members should understand the intended procedure and the sequence of that procedure. This should be confirmed during a dedicated ‘time out’ protocol, performed before vascular access or moderate sedation is initiated, when all members of the team are present... Universal infection precaution protocols should be followed by the staff.” Observation on the afternoon of 11/14/23 reflected Physician A entered the control room of the cardiac catheterization lab. The physician was introduced to this surveyor prior to entering the Cath lab. Upon entrance to the Cath lab, the physician requested a time out prior to the procedure. Further observation on the afternoon of 11/14/23 reflected the same physician entering the Cath lab without the knowledge that this surveyor was observing. Physician A entered the Cath lab and began putting on his gown and gloves. During this time, the Cath lab staff conducted the time out without Physician A’s participation. Following the procedure, Physician A was asked why he did not participate in the time out during the previous procedure and replied, “I did participate, I can do more than one thing at a time, and I was listening. I do not have to stop what I am doing and face the staff during the time out.” When asked about the facility policy and standards of care related to the time out, Physician A replied “I have been doing this for over 30 years and have never had a poor outcome, so I don’t need to change what I have been doing. If you are telling me that I have to do it differently, then tell me what to do and I will do it.” During an interview with the interim director of the Cath Lab, Staff # 7, on the afternoon of 11/14/23, Staff #7 reported that Physician A does not participate in the time out, but the staff complete a time out prior to each procedure. When asked if this has been addressed, Staff #7 reported that “it has been an issue for a long time and it has never been resolved.” Staff #7 continued that “there was a meeting several months ago with the Assistant Administrator, Former Director of the Cath Lab, CFO (Chief Financial Officer), HR (Human Resources) Director, Regional VP (Vice President), and me and there was no resolution at that time.” During a telephone interview with the former Director of the Cath Lab, Staff #8, on the morning of 11/15/2023, he reported that he reported Physician A’s refusal to participate in the time out multiple times to hospital administration. At one point he was told by the Regional VP (Staff #9) to just stop reporting. During an interview on the afternoon of 11/15/23 the Director of Human Resources (Staff#4) reported that he was in the meeting related to the Cath Lab and that the Regional VP (Staff #9) reported “We, meaning administration, would take care of the physicians.” During a telephone interview on the afternoon of 11/14/23, the Regional VP (Staff #9) denied remembering this meeting or conversation. Review of the facility document titled “Northwest Texas Healthcare System Staff Bylaws” last revised on 01/11/22 stated in part, “Article I, Purpose: The Medical Staff of Northwest Texas Healthcare System is established by the Board to assist the Hospital in meeting its mission and to carry out duties assigned to it by the Board in order to enhance the quality and safety of care, treatment, and services provided to patients. The Medical Staff is considered part of the Hospital’s Organized Health Care Arrangement. Article II, Medical Staff and Membership: 2.3 Responsibilities of Membership Each Member of the Medical Staff must continuously comply with the provisions of these Bylaws, the Ancillary Manuals and Medical Staff Rules, Regulations and Policies ... Furthermore, each Member of the Medial Staff by accepting Medical Staff appointment agrees: ...n....and compliance with Hospital efforts to meet standards such as those established by the Joint Commission, insurers, Centers for Medicare and Medicaid Services (CMS) and other governmental agencies (e.g. core measures) ... u. To abide by all local, state and federal laws and regulations, Joint Commission standards, and state licensure and professional review regulations and standards, as applicable to the Member’s professional practice ...””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 31690 Based on observation, review of facility policy and staff interviews, the governing body failed to ensure its medical staff were accountable for the quality of care provided to patients. The governing Body by failed to ensure its medical staff followed the Hospital Medical Staff Bylaws even after the issue was brought to the attention of hospital administration. Physician A did not follow facility policy and standards of care. Physician A continuously failed to participate in the “Time Out Process” while performing surgical procedures in the Cardiac Cath Lab, which could lead to adverse events up to and including death by not verifying the correct patient, correct procedure, allergies, lab results, and medications. This deficient practice had the likelihood to cause harm to all patients (31 in the last month) undergoing procedures in the Cardiac Cath Lab performed by Physician A. Findings include: Review of the facility policy “NPSG - 006 - Universal Protocol (UHS)” reflected: “I. Scope: The Universal Protocol (UP) policy governs the performance of operative and invasive procedures for patients in both the inpatient and outpatient setting. UP consists of three distinct steps: Pre-procedure Verification, Site Marking and Time Out. Operative and invasive procedures are defined as puncture of the skin, instrument insertion, or inserting foreign material into the body ... II. Purpose: To establish a standardized policy for identifying the correct patient, procedure and anatomical site/side prior to all operative and invasive procedures that expose patient to more than minimal risk in order to prevent wrong person, wrong site, wrong procedure, and wrong physician events. III. Policy: Universal protocol is the process used to identify the correct patient, the correct procedure, the correct physician, and the correct site. Prior to the initiation of an operative or invasive procedure the UP must be followed and documented. The team members providing care for the patient are accountable for patient safety. Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process ... ... E. Time Out Process A time out is conducted immediately before the start of an operative or invasive procedure to provide a final verification of the patient, site, procedure, and physician ... The time out should be initiated by the person performing the procedure and should include all members of the surgical or procedural teams. All activities will be suspended for the time out unless a threat to patient safety exists. All members of the team will verbally engage in the time out. The time out will be halted if any of the team members are not actively engaged in the process ...” Review of “The 2021 Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement update on best practices in the cardiac catheterization laboratory updates the 2016 document with the latest scientific evidence and recommendations for the consistent delivery of high-quality care” found at https://scai.org/publications/clinical-documents/scai-expert-consensus-update-best-practices-cardiac-catheterization reflected: “Intra-Procedure Best Practices ...5.6 Universal protocol and ‘time out’ procedure All team members should understand the intended procedure and the sequence of that procedure. This should be confirmed during a dedicated ‘time out’ protocol, performed before vascular access or moderate sedation is initiated, when all members of the team are present... Universal infection precaution protocols should be followed by the staff.” Observation on the afternoon of 11/14/23 reflected Physician A entered the control room of the cardiac catheterization lab. The physician was introduced to this surveyor prior to entering the Cath lab. Upon entrance to the Cath lab, the physician requested a time out prior to the procedure. Further observation on the afternoon of 11/14/23 reflected the same physician entering the Cath lab without the knowledge that this surveyor was observing. Physician A entered the Cath lab and began putting on his gown and gloves. During this time, the Cath lab staff conducted the time out without Physician A’s participation. Following the procedure, Physician A was asked why he did not participate in the time out during the previous procedure and replied, “I did participate, I can do more than one thing at a time, and I was listening. I do not have to stop what I am doing and face the staff during the time out.” When asked about the facility policy and standards of care related to the time out, Physician A replied “I have been doing this for over 30 years and have never had a poor outcome, so I don’t need to change what I have been doing. If you are telling me that I have to do it differently, then tell me what to do and I will do it.” During an interview with the interim director of the Cath Lab, Staff # 7, on the afternoon of 11/14/23, Staff #7 reported that Physician A does not participate in the time out, but the staff complete a time out prior to each procedure. When asked if this has been addressed, Staff #7 reported that “it has been an issue for a long time and it has never been resolved.” Staff #7 continued that “there was a meeting several months ago with the Assistant Administrator, Former Director of the Cath Lab, CFO (Chief Financial Officer), HR (Human Resources) Director, Regional VP (Vice President), and me and there was no resolution at that time.” During a telephone interview with the former Director of the Cath Lab, Staff #8, on the morning of 11/15/2023, he reported that he reported Physician A’s refusal to participate in the time out multiple times to hospital administration. At one point he was told by the Regional VP (Staff #9) to just stop reporting. During an interview on the afternoon of 11/15/23 the Director of Human Resources (Staff#4) reported that he was in the meeting related to the Cath Lab and that the Regional VP (Staff #9) reported “We, meaning administration, would take care of the physicians.” During a telephone interview on the afternoon of 11/14/23, the Regional VP (Staff #9) denied remembering this meeting or conversation. Review of the facility document titled “Northwest Texas Healthcare System Staff Bylaws” last revised on 01/11/22 stated in part, “Article I, Purpose: The Medical Staff of Northwest Texas Healthcare System is established by the Board to assist the Hospital in meeting its mission and to carry out duties assigned to it by the Board in order to enhance the quality and safety of care, treatment, and services provided to patients. The Medical Staff is considered part of the Hospital’s Organized Health Care Arrangement. Article II, Medical Staff and Membership: 2.3 Responsibilities of Membership Each Member of the Medical Staff must continuously comply with the provisions of these Bylaws, the Ancillary Manuals and Medical Staff Rules, Regulations and Policies ... Furthermore, each Member of the Medial Staff by accepting Medical Staff appointment agrees: ...n....and compliance with Hospital efforts to meet standards such as those established by the Joint Commission, insurers, Centers for Medicare and Medicaid Services (CMS) and other governmental agencies (e.g. core measures) ... u. To abide by all local, state and federal laws and regulations, Joint Commission standards, and state licensure and professional review regulations and standards, as applicable to the Member’s professional practice ...””