University Health System

“. The purpose of this visit was to investigate complaint # TX00563809, with the allegation of a fire alarm system malfunction; specifically, impaired or faulted (red tag) fire alarm systems in 4 of 4 buildings of a hospital campus. Based on observations, interviews, and record reviews conducted during the investigation, it was determined that the allegation fire alarm system malfunction was substantiated but a deficient practice will not be cited. However, requested record review revealed a deficient practice which will be cited. There were no relevant trends or patterns identified in the off-site review prior to the on-site visit. The Surveyor entered the facility on July 16, 2026, at 12:40 PM. Summary of investigation: The Surveyor arrived unnuanced on 07/16/2026 at 12:40 PM. Upon arrival, the Surveyor requested to meet with the hospital administration staff. In an entrance interview at approximately 12:55 PM, The Surveyor met with the Director of Clinical Risk Manager, the Director of Regulatory Oversight, Director of Accreditation Services, Director of Risk Management, the Lead Fire Safety Tech, Clinical Risk Manager, Associate General Counsel, Senior Vice President Chief Quality & Health Informatics Officer, and the Senior Vice President Quality Outcomes. The meeting took place in the conference room. The Surveyor reviewed the complaint with the attendees and indicated he would like to be provided with the following documentation: 1. Latest Fire Alarm Inspection Reports 2. Latest Fire Sprinkler System Inspection Reports 3. Latest Fire Marshal Inspection Reports 4. Inspection Reports for Fire Rated Doors 5. Fire Watch Logs 6. Facilities/Occurrence Reports related to Fire Alarm, Fire Sprinkler Systems, and rated doors. 7. Work Order System related to correction of items cited in Fire Alarm and Fire Sprinkler Reports. The Surveyor then asked to visit the location where the alleged deficient practice had occurred (each of all four fire alarm control panels corresponding to each building within the hospital campus). The Surveyor was accompanied by the Lead Fire Safety Tech and the Director of Risk Management. Observations on 07/16/2026 at 1:14 PM revealed the fire alarm control panel for the Women-Children Tower had multiple Service Record (white) Tags indicating an Impaired or Faulted (red) tag had been corrected. Record of deficiencies corrected as noted on the Service Record (white) tags included: replacing a damaged strobe light in freezer in 07/23/2024; new batteries for fire alarm panel replaced on 04/23/2026. The newest Service Record (white) Tag had a date of 04/23/2026. Observations on 07/16/2026 at 1:25 PM revealed the fire alarm control panel for the Sky Tower had multiple Service Record (white) Tags indicating an Impaired or Faulted (red) tag had been corrected. Record of deficiencies corrected as noted on the Service Record (white) tags included: cleaned duct detector on 07/08/2024; battery replacement on 01/30/2025; faulty water flow switch in 11/13/2025; door releasing devices were corrected on 02/20/2026 The newest Service Record (white) Tag had a date of 07/15/2026. Observations on 07/16/2026 at 1:33 PM revealed the fire alarm control panel for the Rio Tower was a new system which had not yet been commissioned/inspected/approved by the Fire Marshal. Further observations revealed there was no New Installation (blue or white) tag on the brand-new system. In an interview at the time of the observation, the Lead Fire Safety Tech indicated that the system is for the most park working but has not been inspected/approved by the Fire Marshal. Observations on 07/16/2026 at 1:39 PM revealed the fire alarm control panel for the Rio Tower was a new system which had not yet been commissioned/inspected/approved by the Fire Marshal. Further observations revealed there was no New Installation (blue or white) tag on the brand-new system. In an interview at the time of the observation, the Lead Fire Safety Tech indicated that the system is for the most park working but has not been inspected/approved by the Fire Marshal. The surveyor returned to the conference room accompanied by the Lead Fire Safety Tech, and Director of Risk Management. The Executive Director of Facilities and the Director of Regulatory Oversight also joined the Surveyor in the conference room. In an interview on 07/16/2026 at approximately 1:45 PM the Director of Regulatory Oversight indicated that Rio Tower and Horizon Tower have been under “fire watch” because these two buildings do not have an approved Fire Alarm system. Additionally, the Executive Director of Facilities indicated that they are for the most part ready for the inspection of both new fire alarm systems and they are just trying to coordinate a date with the local Fire Marshal. He estimated that this could be accomplished within the next 30 days, if the local Fire Marshal can accommodate. Record review on 07/16/2026 revealed a Fire Watch has been in place for the duration of the Fire Alarm replacement project for each the Rio Tower and Horizon Tower. Further record review revealed the fire watch is conducted by a third party not associated with the hospital. Additional record review revealed the hospital is aware of all deficiencies noted in the Fire Alarm inspection report, the Fire Sprinkler inspection report, the Fire Door inspection report, and Fire Marshal inspection reports. The surveyor was able to review the hospital’s internal reporting system, internal work order system, and the completed work order system, which includes time, date, and location in which work orders are completed for deficient items. The hospital was able to demonstrate recent items cited in the above mentioned inspection reports are being corrected. Evidence provided in the hospital internal reporting systems was supported by the Service Record (white) Tags on the fire alarm control panels, which indicated repairs had been complete. Additionally, the hospital was also able to demonstrate a continuous fire watch have been in place in the Rio Tower and Horizon Tower where currently there is no approved fire alarm system. A fire watch is a standard practice in the absence of a functioning fire alarm system and is deemed acceptable by the National Fire Protection Association and local jurisdictions. Record review on 07/16/2026 revealed Rio Tower had its last Fire Marshal inspection on 10/15/2024 and Horizon Tower had its last Fire Marshal inspection on 10/15/2024 which does not meet the requirement for annual inspections per local Authority Having Jurisdiction (AHJ) and Texas Health and Human Services licensing requirements. There were no outstanding fire alarm system items pending repair at the time of the end of the site visit. Phone interview on 07/17/2026 at 10:35 AM with a representative of the company conducting the fire alarm inspections, the Surveyor asked the representative if they have a record or database of each red tag. The representative was able to confirm red tags are in their system by providing red tag information from 03/26/2026. The Surveyor then asked the representative if and how does the Fire Alarm inspection company notify the fire marshal about the red tag. The representative stated that she and another co-worker are the ones in charge of notifying the fire marshal’s office. The representative stated that the way this notification is achieved is through the City of San Antonio’s portal, where red tag information is uploaded and then is automatically channeled to the Fire Marshal’s office. Additionally, the representative confirmed that an email also goes out to the hospital’s point of contact, which in this case is the Lead Life Safety Tech listed in the Fire Alarm Inspection Reports. Phone interview on 07/17/2026 at 11:55 AM with the Fire Alarm Monitoring Company representative confirmed they are currently monitoring all buildings from the hospital and monitoring company receive all alarms and notifications. An exit phone interview was conducted on 07/20/2026 at 2:40 PM with the Director of Risk Management. The surveyor informed the Director of Risk Management of the findings and gave an opportunity to ask questions. The Phone interview ended at 2:46 PM on 07/20/2026. .”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 35939 . Based on record review and interview, the facility failed to ensure a required annual fire marshal inspection was conducted within the last year for 2 of 4 towers. A fire marshal report is a requirement by the local authority having jurisdiction and the licensing requirements of Texas Health and Human Services. Two of four hospital towers have not had an annual fire marshal inspection since October 2024. This deficient practice could expose patients, visitors and staff to fire related injuries in the event of a fire due to undiscovered life safety code violations. Findings included: Record review on 07/16/2026 of the annual fire marshal inspection reports revealed the Rio Tower and Horizon Tower had their last annual fire marshal inspection conducted on 10/15/2024. In an interview at the time of record review, the Executive Director of Facilities and the Director of Regulatory Oversight confirmed that both Rio and Horizon Towers have not had an annual Fire Marshal inspection since 10/15/2024. Reference(s): NFPA 101, 2012 edition Chapter 19 Existing Health Care Occupancies 19.1 General Requirements 19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply. Chapter 4 General 4.1 Goals 4.2 Objectives 4.3 Assumptions 4.4 Life Safety Compliance Options 4.5 Fundamental Requirements 4.6 General Requirements 4.6.1 Authority Having Jurisdiction 4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction. .”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 26151 Based on a record reviews and interviews, Facility A failed to follow its policy to ensure that a medical record contained written documentation of all reasonable steps taken to secure the individual’s written form of refusal, that indicated the person had been informed of the risks and benefits for refusal of necessary diagnostic tests, for one of 19 patients (Patient #6) whose medical record was reviewed in that: Patient #6 left after medical screening examination (LAMSE). There was no documented evidence in the medical record that the “Informed Consent to Refuse” form was provided and signed by the patient. The findings included: A review of Patient #6 Medical Record from Facility A’s ED Visit dated: 11/13/2025 Patient presented to the ED on 11/13/2025 at 3:42 PM via ambulance with a chief complaint altered mental status (AMS) and numbness. Patient #6 reports sliding out of bed. Per EMS, patient was initially unresponsive, even to painful stimuli until fire lifted patient and patient began screaming of pain. Patient # 5 is now A&O x’s 4 (alert and oriented times four). GCS-15, Patient #5 denies hitting head, LOC or any trauma. ground level fall and shoulder pain. 3:42 PM: Time Patient #6 was triaged. Triage Nurse Notes: as documented by Triage RN Staff E, “Patient #6 was pulled to triage after EMS arrival...Patient #6 states he is having intermittent episodes of altered mental status (AMS) where he feels like he is awake but unconscious, also feels like his face is “pulling to the left” and numb. Describes as spasms. Has been happening since yesterday. Patient #6 states he has been having extreme sleep deprivation for 3-5 weeks. Denies SI/HI.” Vital Signs: BP (!) 142/94 Pulse 82 Temp 37 °C (98.6 °F) Resp 18 SpO2 97% 3:42 PM - History of Present Illness (HPI): A review of HPI as documented by the ED Attending Physician, stated that Patient #6 is a 43-year-old male presenting with headache and numbness. Patient #6 reported that for the past 24 hours, he has had a headache to the right side and right upper extremity (right arm) paresthesia that has been present for 3 weeks with associated right neck tension. Review of Systems: Smoking Status: Unknown General: Awake, alert, in no acute distress. Neuro: Speech clear and appropriate. Moving all extremities spontaneously. No obvious focal deficit. Right paraspinal (extensive set of muscles that run all the way along the back of spine) TTP (tender to palpation). Normal upper extremity strength. Respiratory: Breathing comfortably on room air. Speaking in full sentences. No increased work of breathing noted. Cardiac: Normal heart rate, well perfused, no cyanosis or pallor. Abdomen: Non-distended. No visible guarding. Patient moving/sitting comfortably. Skin: Warm, dry, no diaphoresis. Assessment/Plan: 43-year-old male presenting with right sided headache with RUE paresthesia. Plan for transfer to Fast Track for treatment as indicated. -Medications as ordered. - Prior to discharge needs strong neuro exam documented: Gait, extremity strength and sensation. Further review Patient #6’s medical record dated 11/13/2025 revealed a “Nurses Note” as documented by ED/RN Staff [RN Ashley Lee] which stated the following: “Patient (#6) cursing at this RN demanding to speak with a doctor within 15 minutes, RN advised that this cannot be guaranteed due to current census. Patient (#6) states that he is actively having a seizure and we [ED staff] are not giving him the “right equipment for testing.” Patient (#6) advised that there are only so many tests that can be done in the lobby [wait area]and if an EEG is warranted in his next care area [exam room], that can happen. Patient (#6) continues to curse at this RN and other staff. Patient (#6) states he is going to leave and is arranging a ride. Patient (#6) continues to curse at the staff and demand supervisor. Facility A’s Police Department called for assistance.” ED Disposition: Left After Medical Screening Exam (LAMSE) on 11/13/25 at 8:58 PM. There was no other documentation regarding whether the ED provider was informed that Patient #6 intended to leave and if Patient #6 was informed of the risks for leaving without further assessment. Patient #6’s second visit to Facility A’s emergency department on 11/14/2025 revealed the following: A review of Patient #6’s Medical Record from Facility A’s ED Visit dated: 11/14/2025 Patient presented to the ED on 11/14/2025 at 5:11 PM via private vehicle with a chief complaint of Muscle Pain Numbness (Pt c/o generalized paresthesia and muscle pain in back and in neck). 5:11 PM: History of Present Illness (HPI): A review of the HPI as documented by the ED Provider Family Nurse Practitioner (FNP), stated that, “Patient #6 is a 43-year-old male who presents to ED complaining of Muscle Pain and Numbness (Patient #6 c/o generalized paresthesia and muscle pain in back and neck). An initial screening was to initiate workup and expedite care. Patient #6 is complaining of spasm to his right neck that he has had since the birth of his son 7 months ago and now has a cold sensation to his mid thoracic back. Patient #6 states occasionally, he has paresthesia and feels numbness to his right side of his face and was seen at another facility and diagnosed with a paresthesia, states symptoms have not improved.” Review of Systems: Pertinent Exam: Nontoxic appearance, moves all extremities x 4 Brief Assessment: Abnormal paresthesia, otherwise, moves all extremities x 4 Plan: Obtain labs and Provide symptomatic treatment and Forward Flow to Post-CS Destination: Mid Track. Further review of Patient #6’s medical record for ED visit dated 11/14/2025 revealed a note as documented by ED/RN that stated: Patient #6 stated that he needed to leave and further that Patient # 6 was alert and oriented times four (medical assessment term indicating that a patient is fully awake, conscious and aware of four key cognitive domains: person (who they are) place (where they live) time (date/time) and situation (why they are there); was ambulatory and given return to ED instructions. Disposition was documented as Left After Medical Screening Examination (LAMSE) on 11/14/26 at 7:43 PM. There was no other documentation regarding whether the ED provider was informed that Patient #6 intended to leave and if Patient #6 was informed of the risks for leaving without further assessment. Facility A’s Policy: A review of Facility A’s policy No. 8.03 dated 10/22/18 titled, “Emergency Medical Treatment and Patient Transfer” read in part, “II. Medical Screening Examination A. General 1. Medical Screening c. Refusal of care in either ED...If a Medical Screening Exam has been started, and the individual insists on leaving, the “Informed Consent to Refuse” form ( form referenced as Attachment III) should be used.” Interviews: In an interview on 02/10/2026 at 12:00 PM, with Administrative staff, the Director of Clinical Risk Management Staff A, stated that Patient #6 returned to the ED the following day on 11/14/25 for muscle pain and generalized paresthesia in the neck and back...was seen by a different ED Provider, placed in mid track area and left after medical screening examination. (LAMSE). Surveyor requested policy/procedures for LAMSE. Staff A stated that procedures for LAMSE are in the EMTALA policy. ED/RN Staff D was asked via email on 02/13/2026 and stated the following: Can you tell me what happened in the care wait area when you conducted the care reassessment for Patient #6? Response: “I called Patient #6 to my desk for reassessment ...Vital signs were obtained and were stable, Patient #6 then began expressing frustration that he had been waiting for a couple of hours to be seen again by a provider and stated that he was only giving us 15 minutes to be seen by a provider ...He demanded to be seen immediately because he felt like he was actively having a seizure ...Patient #6 continued cursing at me, stating that we were doing nothing for him and that he was going to leave immediately and go to another hospital. While trying to deescalate the situation, I removed his IV so that he would not walk out with it still in his arm. Patient #6 then walked out of the lobby with a steady gait continuing to curse and yell at staff and stated that he would find a ride on his way out. I called Facility A’s Police Department for assistance at that time.” Did you inform the Provider that Patient #6 was leaving? Response: “Due to the situation with Patient #6 escalating so quickly, I was not able to let the provider know that he was wanting to leave beforehand.” Was Patient #6 asked to complete an AMA document? Response: “No, he was not. As I had stated previously, the situation with Patient #6 escalated very quickly. While I was trying to deescalate the situation, I removed his IV so that he would not walk out with it in his arm ...As soon as it was removed, he promptly walked out of the ED waiting room.” The Director of Clinical Risk Management Staff A, was asked via email on 02/26/2026 and stated the following: Was there a consent for treatment signed by Patient #6 for ED visit dates 11/13/2025 and 11/14/2025? Response: “There was not a consent for treatment for the ED visit dates of 11/13/25 and 11/14/25.” Date of Service: 11/13/25 “The patient completed the initial screening. After being directed to the waiting room, staff were unable to locate the patient. Two separate attempts were made to find the patient, and a follow-up call was attempted on 11/18; however, there was no answer. The discharge disposition reflects “Left Against Medical Advice.” We were unable to make contact with the patient during this visit.” Date of Service: 11/14/25 “The patient arrived at 17:11 [5:11 PM] and was discharged at 19:45 [7:45 PM] with a disposition of “Left Against Medical Advice.” Due to the relatively quick turnaround from arrival to discharge, our team was unable to locate the patient for Registration following the initial assessment.””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 21863 Based on observations, interviews and record reviews, the facility failed to ensure the emergency department’s environment was maintained to assure the safety and well-being of patients using the waiting area facilities. Specifically, the Emergency Department’s (ED) bathrooms in the waiting area of the emergency department did not have an emergency communication system for patient safety in the event of a medical need, medical event, and/or emergency. These bathrooms are utilized by admitted patient’s that are in overflow during high capacity times; pending a bed and/or further placement. This failure created the potential for serious injury, harm, and the possibility for delay in care in the event of a fall or medical deterioration event. Findings included: Review of the intake information for complaint TX00550193, dated 6/28/25, revealed the following, in part: Patient #1 alleged she was, “left alone in a hospital bathroom after being sedated with morphine and a nerve block, then forced to wobble back down the hallway to my stretcher without assistance.” Observations conducted on 9/4/25 at 12:10 PM with Staff #2, and Staff #4 present revealed the ED’s waiting room bathrooms; Male, Female, and a single use bathroom did not have an emergency communication system in the event of a medical need, and/or an emergency event of a patient. Further observations revealed these bathroom facilities were the closest bathrooms accessible to patients placed in overflow/waiting placement during high capacity times. Interview on 9/4/25 at 12:15 PM, with Staff #4 confirmed the bathrooms did not have an emergency call system, stating the bathroom facilities were “public use.” Further interview with Staff #4 confirmed admitted patients would be held in the emergency waiting area during high capacity times as an overflow area when patient treatment areas were full. The waiting area was also used by patients pending discharge during high capacity times. Interview on 9/4/25 at 12: 17 PM, with Staff #2 indicated the issue of no communication system in the bathrooms had been reviewed previously, and the facility would ensure it is addressed. Review of the facility’s Policy, No. 9.06 titled, Patient Rights and Responsibilities, effective 12/17/2021 indicated in part; In accordance with all applicable federal and state laws and regulations, [the facility] respects, protects and promotes the patient’s right to: B. Receive care that is in a safe setting.......”