Methodist Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 Based on review of the facility’s policies, medical records, and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with hospital’s policies and procedures, drug manufacturers guidance and warnings; and State law when chemical restraints/emergency behavioral medications were administered for the management of behaviors for 1 of 1 patients reviewed (Patient #1) with medication restraints identified, resulting in patient rights violations. Specifically, the facility failed to ensure: A. medications used as a restraint to manage patient’s behavior(s) or restrict the patient’s freedom of movement were identified as a chemical restraint/emergency behavioral medication (EBM) administration and monitored for Patient #1. B. a process or procedures were followed for use of chemical restraints/EBM including assessments, reassessments, and ongoing monitoring for side effects, respiratory or cardiac distress, medication effectiveness, and safety after administration of medications used as restraint including anesthesia sedative medications per drug manufacturer guidance, and the facility’s policy and procedures for; Moderate Sedation and Restraint for Patient #1. As a result of these failures, Patient #1 was administered various EMB including medications used for Moderate Sedation to control aggressive behaviors without consent, assessments and appropriate monitoring resulting in hypotensive symptoms and respiratory distress; subsequently becoming non-responsive and required intubation (insertion of a tube into the airway to aid in breathing). These deficient practices identified were determined to pose risks to patient health and safety, placing patients at significant risk of harm, or potential death. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to A 0160 for evidence of specific findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 21863 Based on review of the facility’s policies, medical records, and interviews, the facility failed to ensure medications used as a restraint to manage patient’s behavior(s) or restrict the patient’s freedom of movement were identified as a chemical restraint/emergency behavioral medication (EBM) administration, and monitored in accordance with hospital’s policies and procedures, drug manufacturers guidance and warnings; and State law for 1 of 1 Patient (Patient #1) reviewed with a complaint regarding the use of restraints. Specifically, the facility failed to ensure a process or procedures were followed for use of chemical restraints/EBM including assessments, reassessments, and ongoing monitoring for side effects, respiratory or cardiac distress, medication effectiveness, and safety after administration of medications used as restraint including anesthesia sedative medications per drug manufacturer guidance, and the facility’s policy and procedures for; Moderate Sedation and Restraint for Patient #1. As a result of these failures, Patient #1 was administered various EMB including medications used for Moderate Sedation to control aggressive behaviors without consent, assessments and appropriate monitoring resulting in hypotensive symptoms and respiratory distress; subsequently becoming non-responsive and required intubation (insertion of a tube into the airway to aid in breathing). Failure to identify and monitor emergency medications used as restraints could result in the improper ordering and administration of medication by unauthorized staff, improper monitoring of the patient after the medication(s) were given, and improper oversight by the facility which posed significant risks to patient safety. Findings included: Review of Patient #1’s Emergency Department (ED) Patient Record, Emergency Provider Report, and Clinical Documentation dated 5/10/25, revealed the following timeline documentation, in part: Patient #1 is a 59-year-old male with severe intellectual disability and a history of epilepsy since infancy, recent bowel surgery for obstruction, kidney stones, and enlarged prostate, presenting on 5/10/25 at 09:55 AM with a change in mental status (altered mental status) and increased seizure activity. Note: All Times from record are in 24-hour format (Military time). 10:34: Physician-A ordered Haloperidol (Haldol, an antipsychotic) Lactate 5 milligrams (mg) Intramuscular (IM) stat. There was no indication by Physician-A for the reason Haldol administered IM was ordered or the justifiable need. There was no documentation of any de-escalation or interventions before a chemical restraint/EBM was ordered. 10:41: Haldol 5mg, administered left upper arm by RN-A. There was no documentation of vital signs, or a face-to-face assessment conducted after the administration of Haldol 5mg. 11:02: Assessments-Seizure documented by RN-A, Behavior: calm, Postictal, Listless, Agitated, Anxious; Alert and oriented: No 11:18: Physician-A ordered Haloperidol Lactate 5 mg IM stat. There was no indication by Physician-A for the reason Haldol administered IM was ordered or the justifiable need. There was no documentation of any de-escalation or interventions before a chemical restraint/EBM was ordered. 11:21: Haldol 5 mg, administered right upper arm by RN-A. There was no documentation of vital signs, or a face-to-face assessment conducted after the administration of Haldol 5mg. 12:02: Physician-A ordered Midazolam (Versed, a benzodiazepine used for anesthesia sedation, and severe agitation) HCI 5 mg IM stat. 12:05: Midazolam 5 mg, administered left ventrogluteal by RN-A 12:52: Vital Signs (VS), Blood Pressure (B/P) 78/51 (mean 61), Pulse (P) 83, (oxygen stats) SP02% 90, Respirations (RR) 18, weight 57.8 kilograms (kg). Glasgow Coma Scale (GCS): eye opening 4, verbal response NT (non-testable), motor response 5, Glasgow coma score: Non testable. Records revealed the VS at 12:52 PM were the first documented vital signs following administration of Haldol at 10:41 AM (2 hours and 11 minutes later), Haldol at 11:21 AM (1 hour and 31 minutes later), and Midazolam at 12:05 PM. Further review of Patient #1’s ED record documented, Physician- A conducted a “Re-Evaluation” (specific time unknown), that indicated the following: The patient initially would just not allow us to do anything if we placed a blood pressure cuff he immediately take it off if we placed a monitor leads he would immediately take them off. I gave two 2 doses of Haldol in attempt to get him to “settle down and then a small dose of Versed.” The patient is now sleeping, does respond to painful stimulus, is protecting his airway, but seems to have some degree of obstructive sleep apnea. I discussed this with Neurologist/Physician -C, who recommended admission to the ICU. She is coming down to see him. 15:05: Accepted for Hospital Admission (remained holding in ED). 15:40: Ketamine (a dissociative general anesthetic), 100 MG, IV- administered by RN -A. Left hand gave 100 mg. Patient #1’s record did not contain a documented written, verbal, or telephone order from a licensed practitioner at the time of this Ketamine IV administration. There was no documentation of vital signs, or monitoring assessments conducted after the administration of Ketamine by IV at 15:40. 15:41: Decision for Intensive Care Unit (ICU) - Held in ED pending transfer. 15:49: Provider-F Order for Precedex (dexmedetomidine HCL, used for sedation and analgesia) “400 MCG, Rate 3.006 MLS/HR IV Titrate. Ordered 0.2 MCG/KG/HR. Titrate 0.1MCG/KG/HR every 15 minutes. Goal: maintain RASS of -1 to 0.” 15:57: RN-A documented dexmedetomidine HCL, 400 MCG/4 ML Vial. Left Hand Gave: 104 MLS 16:12: RN-A documented, Precedex Drip increased to 0.3/MCG/KG/HR at this time. 16:27: RN-A documented, Precedex Drip increased to 0.4/MCG/KG/HR at this time. 17:03: Medication Summary, Physician-B Order for Ketamine HCL 500 mg/10ml vial, 100 mg IV one time. Enter 17:03 by Physician- B. Is patient intubated: N. Is physician present: Y. Given with overridden Med. Administered at 15:40, Left hand. Gave 100 mg. Note: Order placed at 17:03 by Physician - B, Medication administered at 15:40 (1 hour and 23 minutes after administration of medication). There was no indication as to the reason Ketamine was ordered, or the justified need. 17:45: Ketamine, 100 MG, IV- administered by RN -A. Patient #1’s record did not contain a documented written, verbal, or telephone order from a licensed practitioner at the time of this Ketamine IV administration. There was no documentation of vital signs, or monitoring assessments conducted after the administration of Ketamine by IV at 17:45. 18:31: Administration Record, Physician-B Order for Ketamine HCL 500 mg/10 ml vial 100 mg IV one time. Enter 18:31. Administered at 17:45 Left hand. Is patient intubated: Y. [Patient was not Intubated at this time.] Medication can only be administered to a non-intubated patient in the presence of a physician at the bedside, who is able to monitor: and assist in the rescue of patient, if necessary. Is physician present: blank. Note: Order placed at 18:31 by Physician -B, Medication administered at 17:45 (administered 46 minutes prior to the physician’s order). 18:45: Another Order placed for Ketamine Injection by Physician-B, 100 mg IV. Not Administered according to Interview with Administration staff on 8/11/25. 19:30: vital signs, B/P 107/66, (mean 81), HR 75, 94%, 14 RR. Records revealed these were the first vital signs documented following the administration of Ketamine at 15:40 (3 hours and 50 minutes later) and 17:45 (1 hour and 45 minutes later). 20:41: Patient #1 transferred from ED to ICU (5 hours after admission to ICU). 21:21: Respiratory Therapy (RT): Intubation performed by Physician. Intubation time: 2121 21:29: Disclosure and Consent to authorize “Intubation” to treat the condition of “Respiratory Failure” was dated 5/10/25 and timed at 9:29 PM by Patient #1’s family member/Medical Power of Attorney (MPOA), and Registered Nurse (RN) - B. 22:16: Initial Restraint order for soft bilateral upper extremities (BUE), Non-violent, Attempts to remove device. Restraint expires 5/11/25 at 22:16. Review of Patient #1’s History and Physical dated 5/10/25 at 15:56 indicated in part: “59-year-old Male with epilepsy, intellectual disability, kidney stones, Benign Prostatic Hyperplasia (BPH), and bowel obstruction in March who presents to ER due to seizures and behavior change. Patient is normally redirectable and able to communicate without, but now exhibiting behavior disturbance. Patient seen with Neurology and ICU at bedside. Restless and agitated in the ER, given Haldol and midazolam, given ketamine X 2 doses and plan for precedex. Antiepileptic Drugs (AED’s) to be managed by Neurology. Plan also discussed with staff and family.” 5/11/25 at 00:23 Neurology Progress note by Physician-C indicated in part; Patient was intubated overnight for airway protection. Patient’s MPOA at bedside. The nursing staff states he becomes “very agitated once the sedation is weaned so he is going to remain sedated to help keep him calm.” Patient brought to the ED with a history of increased seizure frequency associated with a prolonged post-ictal state in the setting of sleep deprivation. On arrival, he had a witnessed seizure and was treated with Ativan. He became “combative during the post-ictal state and was treated with Haldol.” “Agitation continued to be an issue so he was treated with Ketamine.” 05/11/25 at 02:13 PROGRESS NOTE, CLINICAL NOTE by Physician-E: “Called to assess patient for unresponsiveness.” Hospital course reviewed, consult from day Associate intensivist reviewed. On physical exam, pt unresponsive GCS 6, - gag reflex. Consent for intubation collected from family. Impression and plan: - Airway compromise, will intubate. - Seizures/Status epilepticus (SE) and AED per neurology, lorazepam for seizures more than 2 minutes. EEG Review of Patient #1’s complete record for “Informed Consents” revealed there was not a signed informed consent obtained for the use of Ketamine as a sedative, or for managing behaviors; thus resulting in the use of medications to manage and control behaviors. In addition, there was not any consents for the use of Haldol. Interview on 9/24/25 at 7:56 PM with Patient #1’s MPOA stated the following, in part; on 5/10/25 she took Patient #1 to the facility’s ED where they gave him three different doses of sedation, his blood pressure plummeted, and they had to take him to the ICU. He was not able to get up, they kept injecting him in the ER with something, I asked if it was for seizures and they said, “no, it was for behaviors.” It was “300 milligrams of something, he couldn’t breathe.” The ICU nurse reported to her, “they accidentally sedated him in the ER. He did come through after two days in a minor coma. They were giving him different meds. He ended up with full delirium.” They didn’t really want to deal with him, so they basically just sedated him. He is nonverbal, autistic with seizure disorder. The ICU case manager stated Patient #1 was “making all this up.” They were trying to get rid of him, called EMS to have him discharged but he couldn’t even stand up, he was so delirious; his blood pressure was too low. They ended up intubating him again. They were restraining him with all four limbs and at one point he had a “gait belt strapped across his chest with his arms crossed.” A nurse came in and saw the gait belt across his chest and said “we can’t be doing this.” It was RN-C who did it and put the gait belt across his chest. A Doctor came in and said, “what is wrong with y’all, he’s a human being. Even the PCT told them they are not supposed to be doing that; the way they had the restraints” on Patient #1. This happened during the time they had a camera on in the room monitoring him to keep him from getting up. Patient #1’s MPOA indicated she reported her complaints to the House Manager of ICU. Interview on 9/25/25 at 12:31 PM with RN-A indicated the following, in part; RN-A remembered Patient #1 that came into the ED on 5/10/25. He was “scared of health care staff” due to a recent hospitalization from a bowel obstruction. It was difficult to get his IV in, “he was trying to hit and yelling.” The “provider saw first-hand” and put an order in for Haldol, “to get stuff started, he kept ripping everything off.” Once Patient #1 was admitted to the ICU, the intensivist wanted a Foley catheter placed. Patient #1 was “fighting the sedation, bladder was distended.” Physician-B “put an order in for the Foley Catheter and sedation; was fighting hard” before he went to ICU. The Neurologist, Physician C wanted him “sedated for seizures.” Physician B and Physician C were down in the ED “accessing him.” RN-A stated Physician-B gave her a “verbal order in the room, override” to administer Ketamine, and then Physician (B) would place the order manually. RN-A stated that at 15:40, Patient #1 was administered Ketamine to place the IV and to complete Imaging and at 17:45, Patient #1 had the Foley catheter placed. RN-A stated that once Patient #1 was admitted to the ICU, she remained his assigned responsible nurse in the ED until report was given and he was transferred to the ICU. RN-A stated that Physician-B was present the “first time” when Patient #1 was administered Ketamine. She didn’t remember if Physician-B was there the 2nd time when Ketamine was administered. RN-A said she has received training for conscious sedation and that Patient #1 was monitored on the “CMI Monitor.” RN-A was asked what the parameters were for B/P monitoring and when the “mean” would be concerning. She responded anything below a 65, would notify the Physician, but confirmed she “did not always document.” RN-A said that when the CMI machine monitors vital signs, it does automatically “cross over” into the patient’s Electronic Health Record (EHR), however, you have to “manually cross over the vitals by pushing the button for them to carry over into the patient’s record” [EHR.] RN-A was asked what the monitoring requirements were for monitoring/assessing a patient that was administered Ketamine or a psychoactive medication used for behaviors and she responded, “every 15 minutes, at minimal” and if you cannot get a patient’s vital signs due to behaviors, you would at least count the respiration rate. RN-A reviewed Patient #1’s EHR from 5/10/25 and was asked if Patient #1 had any vital signs taken from 15:10 through 19:00 and she replied, “no, no vitals.” RN-A said that on 5/10/25 at 16:08, Patient #1 was “restless and agitated.” Physician- B was in the room and gave a verbal order for Ketamine. RN-A was asked what the level of sedation or RASS score was desired, and she responded, “that is unknown” and further confirmed the record did not contain this specific documentation. Interview with RN-C on 9/25/25 at 3:30 PM stated the following, in part; restraints are to be used as “least restrictive, last resort; with charting every 2 hours.” RN-C remembered Patient #1 from room #21 because “he was so profoundly off from his baseline.” RN-C stated he did remember an incident where a “tech” had used a gait belt across his chest area, stating, “this isn’t something we do; he was a tough one.” Patient #1, “would be screaming all day, wanting to get out of bed, we were keeping him in restraints.” They were trying to discharge him home, to a better environment, but couldn’t do it because EMS transportation would not transfer him, saying he wasn’t safe. Review of the facility’s policy titled, Moderate Sedation for Non-Intubated Patients, last revised 06/2025 indicated the following, in part; Scope includes ED. Policy B. Moderate sedation (“Conscious Sedation”) is provided by a Licensed Independent Practitioner (LIP) who is credentialed in the administration of moderate sedation. C. The Texas Board of Nursing position on the administration of certain medications states: “the administration of anesthetic agents (e.g. propofol, ketamine, or other anesthetic agents in non-intubated patients) are outside the scope of practice for RN’s ..... except in the following situations: 1.) When assisting in the physical presence of a CRNA or anesthesiologist (the CRNA or anesthesiologist may direct the RN to administer anesthetic agents in conjunction with the CRNA or anesthesiologist intubating or otherwise managing the patient’s airway) 2.) When administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist) 3.) When administering these medications to patients who are intubated and mechanically ventilated in critical care settings 4.) When assisting an individual with current competence in advanced airway management, including emergency intubation procedures Procedure: B. Overall Management and Monitoring 1. Monitoring includes an assessment of ventilation, circulation, level of consciousness, heart rate, heart rhythm, continuous ) saturation and end tidal Co2 (where available). 2. The physician credentialed to provide sedation analgesia must be present and available in the department before and during the administration of the sedative agent used for moderate sedation. 3. The RN monitoring the patient who receives moderate sedation will have no other responsibilities that prevent continuous patient monitoring. c. Pre-procedure/Pre-Moderate Sedation Assessment/Documentation 6. The pre-sedation nursing assessment will include, but not be limited to: a. Complete Patient Consent i. The patient, or legal representative must be informed, by the LIP, about the risks, benefits and alternatives to sedation and must consent to the proposed sedation plan. ii. The nurse will verify the consent with the patient or legal representative. iii. Documentation of informed consent for anesthesia/sedation to be included in the medical record prior to the administration of moderate sedation. D. Intra-Procedure Monitoring 5. Vital signs will be documented a minimum of every 5 minutes or more frequently if indicated, and will include, but are not limited to: a. Heart rate b. Blood pressure c. Respiratory rate d. Oxygen saturation e. Level of sedation after the administration of sedative f. Cardiac monitoring, as indicated g. EtCO2 h. Pain 9. Prior to and after the administration of any medication, the patient will be reassessed to determine any changes in condition since initial assessment. Review of the facility’s Restraint/Seclusion Policy last revised 04/2025 indicated the following, in part; “Policy: The facility will comply with state laws when initiating restraints to: B. Ensure the least restrictive methods of intervention are used, and C. Attempt alternatives whenever possible and only initiate restraint when those attempts are determined ineffective. 5. Order for Restraint a. An order for restraint must be obtained from a physician who is responsible for the care of the patient prior to the application of restraint. 1. An order for restraint may not be written as a standing order, protocol or as a PRN or “as needed” order. 5. Describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint or seclusion. e. Order for Restraint with Non-Violent or Non-Self Destructive Behavior 2. Duration of order for restraint must not exceed twenty-four (24) hours for the initial order. 3. To continue restraint use beyond the initial order duration, the physician must perform a face-to-face evaluation and clinical assessment and determine if continuation of restraint is necessary. 7. Monitoring the Patient in Restraints a. Patients are assessed by an RN immediately after restraints are initiated to assure safe application/initiation of the restraint. b. The assessment will include where appropriate: 1. Signs of injury associated with restraint, including circulation of affected extremities. 2. Respiratory, circulation, skin integrity and cardiac status 3. Psychological status including level of distress or agitation, mental status and cognitive functioning. c. More frequent monitoring and notification of the ordering physician occurs when: 1. Patient’s medical and emotional needs and health status change 2. The type and design of the device or intervention poses increased risk 9. Face-to-face assessment by a Physician or LIP: a. A face-to-face assessment by a physician or LIP, physician assistant or a RN who is trained with demonstrated competence in assessing medical and psychiatric stability, other than the nurse who initiated the use of violent restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of the restraint. 14. Documentation Requirements: The medical record contains documentation of: a. Assessment for risk for restraint b. Restraint or seclusion alternatives employed d. Second tier review of need for restraint j. Assessment of the patient in restraint k. Monitoring of the patient in restraint Appendix D: Definitions, C. Drugs as restraints: A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition is considered a restraint. A medication that is not being used as a standard treatment or in a dosage for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom would be a drug used as a restraint. e. “Chemical restraint” is defined as the use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not standard treatment for the individual’s medical or psychiatric conditions.” Further review of the policy and procedure of Patient Restraint/Seclusion revealed there was not any specific monitoring and evaluation requirements for the assessment, reassessment frequency and duration of a patient after the administration of an emergency psychoactive medication used as a restraint, which is in addition to the in-person evaluation requirement with one hour after administration. Review of the Rules and Regulations of the Medical Staff last revised 11/16/2023 indicated the following, in part for Minimal to Moderate Sedation (conscious sedation); 3.12.1 A pre-sedation evaluation must be performed and documented ....... At a minimum, the pre-sedation evaluation includes (in part): Patient’s condition ...... Appropriate physical examination, including vital signs and documented airway assessment; Formulation of sedation plan Review of the Medication Administration policy last revised 05/2022 indicated, B. Medication is administered only with the written, verbal, or telephone order from a licensed practitioner. Review of the “Prescribing of Medications” policy last revised 03/2025 indicated the following, in part; C. Verbal or telephone medication orders may be taken by a.... registered nurse. D. Verbal/Telephone orders should be reserved for urgent/emergency situations. Ordering Drugs R. Each medication ordered must have a documented diagnosis, condition, or indication for use in the patient’s medical record. According to, https://www.accessdata.fda.gov regarding: 1.) Ketamine HCL (Ketalar), Reference ID: 4089409, 04/17: For intravenous and intramuscular use SPECIAL NOTE EMERGENCE REACTIONS HAVE OCCURRED IN APPROXIMATELY 12 PERCENT OF PATIENTS. THE PSYCHOLOGICAL MANIFESTATIONS VARY IN SEVERITY BETWEEN PLEASANT DREAM-LIKE STATES, VIVID IMAGERY, HALLUCINATIONS, AND EMERGENCE DELIRIUM. WARNINGS Respiratory depression may occur with overdosage or too rapid a rate of administration of KETALAR, in which case supportive ventilation should be employed. Mechanical support of respiration is preferred to administration of analeptics. PRECAUTIONS KETALAR should be used by or under the direction of physicians experienced in administering general anesthetics and in maintenance of an airway and in the control of respiration. The onset of action of KETALAR is rapid; an intravenous dose of 2 mg/kg of body weight usually produces surgical anesthesia within 30 seconds after injection, with the anesthetic effect usually lasting five to ten minutes. 2.) Haldol, Reference ID: 4190883, 12/2017: WARNINGS A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs (see ADVERSE REACTIONS). Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status (including catatonic signs) and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmias). Additional signs may include elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis) and acute renal failure. Other HALDOL (haloperidol) should be administered cautiously to patients: receiving anticonvulsant medications, with a history of seizures, or with EEG abnormalities, because HALDOL may lower the convulsive threshold. If indicated, adequate anticonvulsant therapy should be concomitantly maintained. According to the Texas Board of Nursing (BON) 15.8 Role of the Nurse in Moderate Sedation at: https://www.bon.texas.gov/practice_bon_position_statements_content.asp.html#15.8 Therefore, it is the position of the Board that the administration of anesthetic agents (e.g. propofol, methohexital, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA advanced practice registered nurses except in the following situations: “ when assisting in the physical presence of a CRNA or anesthesiologist (the CRNA or anesthesiologist may direct the RN to administer anesthetic agents in conjunction with the CRNA or anesthesiologist intubating or otherwise managing the patient’s airway) “ when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist) “ when administering these medications to patients who are intubated and mechanically ventilated in critical care settings “ when assisting an individual with current competence in advanced airway management, including emergency intubation procedures “ when utilizing a US FDA approved computer-assisted personalized sedation system in accordance with the US FDA approval requirements, where appropriate safety requirements are met (such as immediate availability of anesthesia providers) after completing appropriate training In reference at: https://pmc.ncbi.nlm.nih.gov/ -Richmond Agitation Sedation Scale (RASS): is a 10-point scale/clinical tool used to assess a patient’s level of agitation and sedation ranging from -5 (unarousable sedation), to +4 (combative). -Glasgow Coma Scale (GCS): a tool in the neurological assessment of patients with impaired consciousness. Three parameters of responsiveness are evaluated; eye, verbal, and motor. Level of response are scored from 1 (no response) up to normal values of; 4 (eye-opening response), 5 (verbal response), and 6 (motor response). The total GCS score thus ranges from 3 to 15, with 3 being the lowest and 15 being the highest. A GCS total of 8 can reflect vegetative state, minimally conscious state, or posttraumatic confusional state. The American College of Surgeons Committee on Trauma Advanced Trauma Life Advanced Trauma Life Support (ATLS) course teaches that a Glasgow Coma Scale (GCS) score of 8 or lower mandates intubation for airway protection.”

“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: 45847 . Based on record reviews and interviews, Facility A failed to comply with §482.55(a)(3) 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. Facility A’s staff failed to have a nurse documenting or a physician adequately reviewing the patient’s vital signs according to its “Assessment/Reassessment Policy” and the addendum to that policy titled “Assessment/Reassessment Timeframes” for 1 of 20 patients (Patient #1) whose medical records were reviewed. . Medical Record: Patient #1 was a 37-year-old male, was admitted to Facility A’s emergency department (ED) on 06/10/2025 at 3:43 PM via emergency medical services (EMS) from his cardiologist’s office with chief complaints of weakness and pain in the testicles for 1 week. Patient #1 had a medical history of morbid obesity, heart failure with preserved ejection fraction, right ventricular heart failure, pulmonary hypertension, chronic hypoxic respiratory failure, obesity hypoventilation syndrome, obstructive sleep apnea, and hypertension. Patient #1 was sent to Facility A’s ED by his cardiologist’s clinic for scrotal pain and swelling (which could be related to his cardiac conditions). . The medical screening examination (MSE) on Patient #1 began at 3:46 PM by the ED Physician, Staff #4. His notes included: Patient #1, a 37-year-old male with a history of morbid obesity, HFpEF (heart failure with preserved ejection fraction), cor pulmonale (right ventricular heart failure), pulmonary hypertension, chronic hypoxic (absence of enough oxygen)/hypercapnic (carbon dioxide retention) respiratory failure, OHS (obesity hypoventilation syndrome), OSA (obstructive sleep apnea), hypertension sent over from cardiology clinic for scrotal pain and swelling ... Patient has had significant pain to the scrotal region he is also had some clear discharge from the area. His cardiologist (Staff #9) recently increased his Lasix dosing from 40 mg twice daily to 3 times daily he states that the swelling in his lower extremities significantly improved. Patient #1 sits for prolonged period secondary to his job and since then he has had sharp nonradiating pain that is worse with movement in the scrotal region. . The physical exam documented by the ED Physician, Staff #4, documented on the scrotal exam: “significant swelling, localized erythema on the scrotal region diffuse, there is ulcerations as well clear discharge is noted, no crepitus” and on the extremities: “minimal pitting edema in the lower extremities”. . Initial Vital signs documented by the ED RN, Staff #6, at 3:49 PM: Pulse ox 93% on room air, blood pressure 128/65, pulse 103, temperature 98.8 degrees Fahrenheit, and respirations 20. Patient #1’s height was documented as 6 foot 5 inches and weight was documented as 460 lbs./209.091 kg with a calculated BMI of 54.7. . Vital signs were documented by Staff #6 at 4:01 PM: Pulse ox 91% on room air (a drop in pulse ox of 2%), blood pressure 118/58, and pulse 103. . An EKG was ordered by Staff #4 at 4:11 PM “to be done immediately” and was completed at 4:28 PM. The EKG noted “Normal sinus rhythm, low voltage QRS, borderline ECG, ventricular rate 94, PR interval 148, QRS duration 82, QT/QTc 344/417, and P-R-T axes 50 - 85 - 40”. The EKG remains “unconfirmed”. An interpretation by Staff #4 or a cardiologist was not documented in the medical record. . Staff #4, the ED Physician, reviewed the following abnormal lab results at 4:37 PM: Carbon Dioxide 32 mmol/L (Normal is 20-31 mmol/L) (a key indicator of respiratory distress or metabolic issues requiring urgent medical attention) C-reactive Protein (CRP) 59.9 mg/L (Normal is 0-5.0 mg/L) (an elevation indicates the presence of inflammation in the body.) . Staff #4 reviewed a 1 view chest x-ray (CXR) at 4:43 PM. The CXR findings included: The heart is enlarged ... mild central vascular congestion ... left costophrenic (relationship between the ribs and the diaphragm) angle is not included ... left basilar atelectasis (collapsed portions of the lung). The impression included: 1. Stable cardiomegaly 2. Mild vascular congestion 3. Left basilar atelectasis. . A B-type natriuretic peptide (BNP) at 5:15 PM was 72. . Vital signs were documented by Staff #6 at 5:45 PM: Pulse ox 93% on room air. . Staff #4 reviewed a CT of the abdomen and pelvis (for scrotal edema) at 6:37 PM. The impression included: 1. Diffuse scrotal soft tissue swelling without evidence of soft tissue gas. Limited evaluation for abscess given significant streak artifact. Findings likely represent scrotal cellulitis. 2. Enlarged pelvic and inguinal lymph nodes are likely reactive. 3. Cholelithiasis. . Staff #4 documented the following in re-evaluations notes/medical decision making (MDM): ...Patient #1 ...multiple comorbidities ... presents to the ED with complaint of scrotal pain and swelling ongoing for the past 2 to 3 days ... . The documented differential diagnoses (DD) included: Edema could be secondary to underlying heart failure, low suspicion for necrotizing fasciitis, cellulitis, abscess, no clinical signs of torsion, doubt underlying sexually transmitted infection (STI). . Staff #4 documented in re-evaluation notes at 6:59 PM the following: ... Patient unable to provide a urine ... no clinical concerns for underlying urinary tract infection (UTI) no flank pain ... has pain controlled ... no concerns for any life-threatening etiology of patient’s symptoms... . Staff #4 documented the following at 6:59 PM: ...Primary Impression: Scrotal pain ... Secondary Impressions: Cellulitis of scrotum ... . A discharge note was documented b Staff #4 at 7:03 PM included: ...The vital signs have been stable. The patient’s condition is stable and appropriate for discharge from the emergency department. . Patient #1 was discharged home on 06/10/2025 at 7:22 PM. Patient #1 was found dead in his home the morning after his discharge on 06/11/2025. . Patient #1 had documented hypoxia as low as 91% on room air. Patient #1 did not have additional vital signs documented for the remainder of his 3.5-hour ED course except for an oxygenation of 93% more than 90 minutes prior to his discharge. . Facility A’s staff failed to have a nurse documenting or a physician adequately reviewing the patient’s vital signs according to its “Assessment/Reassessment Policy” and the addendum to that policy titled “Assessment/Reassessment Timeframes” for Patient #1 whose comorbidities made vital signs, including oxygenation and respiratory rate. . Certificate of Death Review: The Certificate of Death, issued on 06/30/2025, documented a date of death as 06/11/2025 but does not document a time of death. The cause of death was noted as congestive heart failure and morbid obesity. . Medical Examiner’s Report Review: The Medical Examiner’s report, completed on 07/10/2025, and initiated on 06/12/2025, at 10:00 AM noted Patient #1’s weight as 609 lbs. Patient’s weight documented in the medical records was 460 lbs. (a difference of 149 lbs.). The cause of death as “Congestive Heart failure due to morbid obesity”. The Medical Examiner’s report noted “Other significant Conditions” as “Systemic and pulmonary hypertension, obstructive sleep apnea”. . Policy Review: Facility A’s “Assessment/Reassessment” Policy, last revised and implemented on 03/2025, stated on page 5 of 31: “ ...A. Triage/Outpatient / Observation Area: 1. Patient’s diagnosis and reason for admission will be identified by the registered nurse prior to registration in Admitting. 2. Upon patient’s arrival after registration, vital signs will be taken per particular disciplinary protocol. Patient’s physical assessment will be completed within the hour by the registered nurse and documented in Meditech. 3. Physician’s order will be transcribed and carried out accordingly. 4. An on-going appraisal will be conducted by the registered nurse and vital signs will be taken per particular disciplinary protocol if needed. 5. Upon patient’s discharge from this area, another set of vital signs will be taken...” . Facility A’s “Assessment/Reassessment” Timeframes, an attachment to the “Assessment/Reassessment” policy was reviewed and noted to have been taken from “Standards for frequency of measurement and documentation of vital signs and physical assessment written by Staul L. Schuman C. in 2010,” stated on page 1 of 5: “ ...Emergency Department Assessment o Triage assessment upon arrival o Focused exam relevant to chief complaint on arrival to treatment area Reassessment o Hourly pending MSE (medical screening exam) o After MSE: According to acuity or any significant change in patient status o As ordered by LIP o To evaluate a treatment intervention ...” . Interviews: The Director of Patient Safety/Interim Vice President of Quality, Staff #1 was informed of the lack in vital signs and asked for cardiac monitoring strips to be provided on 07/17/2025 at 1:45 PM. Staff #1 replied, “The ED does not have vital sign strips.” Staff #4 further stated, “After reviewing the chart, I see a full set is recorded upon arrival, followed by BP, HR, and pulse oximetry being documented about 10 minutes later. I’ll make sure to share this feedback with the ED leaders.” . Staff #1 was asked for a copy of the facility’s review of Patient #1’s death on 07/17/2025 during interviews and again on 08/04/2025 at 7:52 PM via email. As of 08/05/2025 at 3:51 PM, none has been received. .”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45847 . Based on record review and interviews, Northeast Methodist Hospital failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on record review and interviews , the hospital failed to provide an appropriate transfer for 5 of 23 patients whose records were reviewed (patient #1, patient #4, patient #16, patient #17 and patient #19) in that the hospital did not: 1. Ensure the MOT included appropriate information for patient #1, patient #4, patient #16, patient #17 and patient #19. The physician certifications indicated their emergency medical condition(s) had been stabilized, however, the emergency medical condition (EMC) persisted. 3. Document the name and address of the on-call physician (the on-call trauma surgeon) for (Patient #1) . Cross Reference: Tag A-2409 - §489.24 (e)(1) and (2) Appropriate Transfer. .”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 45847 Based on record reviews and interviews, the hospital failed to maintain a written policies and procedures in place to respond to situations in which a particular specialty was on-call but not available to the off campus dedicated emergency department (DED) or to situations in which the on-call physician could not respond to the off-campus DED because of circumstances beyond the physician’s control . As a result, 1 of 23 patients (Patient #1) who presented with an emergency medical condition at an off-campus DED operating under the hospital’s Medicare provider agreement required a transfer due to not having an on-call OB/GYN and physician available to the off-campus DED to provide stabilizing treatment. Findings: A review of the OB/GYN On-call Schedule at the main facility and holding the CMS Certification Number under which the off-campus DED operates under indicated OB/GYN coverage as follows: December 2024 - 31 of 31 days did have OB/GYN On-Call. January 2025 - 31 of 31 days did have OB/GYN On-Call. February 2025 - 28 of 28 days did have OB/GYN On-Call. March 2025 - 31 of 31 days did have OB/GYN On-Call. April 2025 - 30 of 30 days did have OB/GYN On-Call. June 2025 - 30 of 30 days did have OB/GYN On-Call. Patient #1 Medical Record Review: Patient #1, a 31-year-old female, arrived the hospital’s off-campus DED (dedicated emergency department) on 05/13/2025, at 8:07 AM and the ED (emergency department) physician, Staff #5, began his examination at 8:17 AM. Staff #5 ‘s documentation in the medical record included: “ ...Presentation Chief Complaint Decreased alertness ...” “ ...Past Medical History -Adult Stated Complaint UNRESPONSIVE ...” The HPI (history of present illness) documented by Staff #5 included: “31-year-old female presents emergency room for unresponsiveness. Boyfriend notes this morning brought him [sic] to the ER. States she started have some lower abdominal pain last night. She is about 3 weeks gestation[;] she had an ultrasound last week no IUP. Assessment requiring an independent historian Boyfriend MEDICAL DECISION MAKING Differential Diagnosis includes: Ruptured ectopic, seizure, syncope, ACS, PE, dehydration, AKI, electrolyte abnormality Conditions present include: Ruptured ectopic Considerations: Independently review imaging, reviewed prior records from prior ER Visits and hospitalizations, history obtained from patient chart review ...” The triage assessment by ED RN (Staff #9) initiated at 8:27 AM revealed: Patient #1 arrived as a walk-in patient. Patient #1 “rolled into ER unresponsive with agonal respirations sitting in wheelchair. Boyfriend reports onset of contractions and ‘weird breathing’ starting upon arrival to ER.” Objective assessment: “Sitting in chair, snoring respirations. Contracted/arching back and posturing upon arrival.” Patient #1 was assigned a priority level of ESI 1 (emergent, may require resuscitation). . A review of the electrocardiogram interpreted at 8:27 AM noted that the patient had tachycardia with a heart rate of 117. Vital signs documented by ED RN, Staff #11, included: 9:27 AM - Blood pressure 89/55. 9:30 AM - Blood pressure 89/55, pulse 97. An ultrasound - OB Pelvis resulted at 9:44 AM. The findings included: “TECHNIQUE: Ultrasound was performed to visualize the intrauterine contents using a transabdominal and transvaginal probe. FINDINGS: FETUS: No intrauterine pregnancy is seen Uterus: 7. 0 x 3.8 x 0.4 cm ... Free fluid: Mild complex fluid ... IMPRESSION: 1. No intrauterine pregnancy visualized. 2. No adnexal mass 3. Clinical follow up recommended with repeat imaging in 7-10 days if indicated ...” Vital signs documented by ED RN, Staff #10, were as follows: 9:52 AM - Blood pressure 101/55, pulse 100, oxygenation, 100%. Vital signs documented by Staff #11 were as follows: 10:00 AM - Blood pressure 96/56, pulse 104, oxygenation 100%. 10:04 AM - Blood pressure 91/52, pulse 103, oxygenation 100%. . The ED physician, Staff #5 consulted with Staff #6 the hospital’s off campus DED on-call surgeon at 10:18 AM. Additionally, Staff #5 consulted with Staff #7, the Gynecological Oncologist on-call at (Facility D, an affiliate hospital) at 10:18 AM. A review of the medical record revealed Patient #1 clinical condition remained critical and required an emergency blood transfusion at 2:01 PM while awaiting further action by the facility. The Hospital course, documented by Staff #5 included: 9:40 AM: Staff #5 the ED Physician consulted with an OB/GYN, Staff #40, at Facility C, the main affiliate hospital. Staff #40 recommended that Staff #5 send the patient to Facility B, where Staff #23 would provide services. Staff #40 informed Staff #5 that they would assist if they had difficulty securing an acceptance. 9:45 AM: A repeat blood pressure of 105/55 was obtained. 10:15 AM: Staff #23 the OB/GYN at Facility B recommended contacting Staff #7, the Gynecological Oncologist at Facility D and general surgery. Staff #5 spoke with Staff #6, Facility A’s on-call surgeon, who stated to transfer Patient #1. Staff #7 also stated to transfer Patient #1. 10:30 AM: Staff #5 spoke with the ED Physician, Staff #24, at Facility B, the receiving hospital. Staff #24 agreed with the transfer to Facility B. 10:58 AM: EMS arrived at Facility A and transported Patient #1 to Facility B. Although Staff #6 was the on-call surgeon at the hospital where the patient required emergency treatment, Staff #6 made the recommendation to transfer the patient to another hospital. Staff #5 documented the following: “ ...Blood pressure 93/51 blood pressure is being transfused. Evaluation patient seen for minimally responsive abdominal pain affecting her mental responsive was hypovolemia or hemorrhagic shock from a ruptured ectopic. Patient given fluids and also unit of crash blood unfortunately we do not have OB/GYN on-call here also spoke with (Staff #7) who recommended transfer and (Staff #6) General Surgery recommends transfer. [Staff #22, an OB/GYN at Facility B] has accepted transfer. We have maximized the capabilities of this hospital to stabilize this patient and proceeded to transfer for definitive care of emergent surgery at [Facility B] ...” The “Clinical Impression” documented by Staff #5 included: “ ...Clinical Impression Primary Impression: Ectopic pregnancy Disposition Decision Transfer Request Time 0940 ... Call Returned Time 1010 Spoke with: Attending physician [Staff #24] Receiving Hospital [Facility B] Transfer Accepted Yes Accepted by: [Staff #22] Acceptance Time 1031 Acceptance Date 05/13/25 Transfer Reason Higher level of care ...” Nursing noted that Patient #1 departed the ED at 11:01 AM. A review of the “Transfer Assessment” in the “Emergency Patient Record” completed on 05/13/2025 by Staff #11 ED RN at 8:34 AM for Patient #1 revealed, “Service not offered, Specialist not available; Services required for transfer: Obstetrics; ...” Website Review: Facility A’s off campus DED’s web page was found at: https://www.sahealth.com/locations/methodist-hospital-northeast?utm_campaign=corp_listings_mgmt&utm_source=google&utm_medium=business_listing on 06/05/2025 . Upon opening the hospital web page for Facility A, when selecting under “Specialties,” “Women’s care” was found. Within this subsection for the services page under “Women’s care” was a list of “Conditions we treat.” Those conditions included were: “Pre-Term Labor Pre-eclampsia Diabetes Rupture of membranes Hypertension Incompetent or weakened cervix Multiple births Low-risk and high-risk pregnancies.” Policy Review: Facility A’s “EMTALA - Provision of On-Call Coverage” policy, last reviewed and implemented on 02/2025, stated on pages 2 and 3 of 6: “ ...Maintain a List. Each hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC. The Medical Staff Bylaws or appropriate policy and procedures must define the responsibility of on-call physicians to respond, examine, and treat patients with an EMC. Factors to consider in developing the on-call list include: the level of trauma and emergency care afforded by the hospital; number of physicians on the medical staff who are holding the privileges of the specialty; other demands on the physicians; frequency with which the physician’s services are required; and the provisions the hospital has made for situations where the on-call physician is not available or not able to respond due to circumstances beyond his or her control. The hospital is expected to provide adequate specialty on-call coverage consistent with the services provided at the hospital and the resources the hospital has available. In addition, the on-call list requirement applies to any hospital with specialized capabilities that is participating in the Medicare program regardless of whether the hospital has a DED. Specialty Hospitals must have appropriate on-call specialists available for receiving those individuals transferred pursuant to EMTALA. Hospitals should verify that the privileges of each on-call physician are current as to the procedures that each on-call physician is able to perform and the services that each on-call physician may provide. The on-call list maintained for the main hospital Emergency Department shall be the on-call list for the hospital, including any Off-Campus Provider-based Emergency Departments ...” And on page 3 of 6: “ ...In addition, the on-call list requirement applies to any hospital with specialized capabilities that is participating in the Medicare program regardless of whether the hospital has a DED. Specialty Hospitals must have appropriate on-call specialists available for receiving those individuals transferred pursuant to EMTALA. Hospitals should verify that the privileges of each on-call physician are current as to the procedures that each on-call physician is able to perform and the services that each on-call physician may provide. The on-call list maintained for the main hospital Emergency Department shall be the on-call list for the hospital, including any Off-Campus Provider-based Emergency Departments. Physician’s Responsibility. The hospital has a process to ensure that when a physician is identified as being “on-call” to the DED for a given specialty, it shall be that physician’s duty and responsibility to assure the following: 1. Immediate availability, at least by telephone, to the ED physician for his or her scheduled “on-call” period, or to secure a qualified alternate who has privileges at the hospital if appropriate. 2. If a PLC is being utilized to contact the on-call physician, the on-call physician must respond to the PLC within a reasonable timeframe (generally, within 30 minutes). 3. Arrival or response to the DED within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The ED physician, in consultation with the on-call physician, shall determine whether the individual’s condition requires the on-call physician to see the individual immediately. The determination of the ED physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. 4. The on-call physician has a responsibility to provide specialty care services as needed to any individual who comes to the Emergency Department either as an initial presentation or upon transfer from another facility. 5. The on-call physician has a responsibility to notify the Medical Staff Offices of changes to the on-call schedule. Authority to Decline Transfers. The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility. Only the CEO, Administrator on-call (AOC), or a hospital leader who routinely takes administrative call has the authority to verify that the facility does not have the capability and capacity to accept a transfer ...” The on-call coverage policy did not address situations in which a particular specialty, such as obstetrical services are not available or when the on-call physician cannot respond because of circumstances beyond the physician’s control, or the physician is not physically at the main campus. Interviews: In an interview with the ED Unit Clerk (Staff #14) during a tour of the Obstetrical (OB) ED on 06/09/2025 at 11:00 AM, Staff #14 indicated that there were no on-call OB/GYNs for emergency cases. In an interview with the ED Provider in Triage, a Nurse Practitioner, (Staff #13) on 06/09/2025 at 11:02 AM, Staff #13 indicted that Facility A’s off campus DED does not have on-call OB/GYNs for emergency cases. Staff #13 indicated that Facility A’s off campus DED did receive patients requiring OB/GYN services, but “most can be treated and/or referred to their GYN or OB doctors.” In an interview with the Patient Care Technician (PCT), Staff #20, on 06/09/2025 at 11:17 AM in the triage receiving area front desk, Staff #20 indicated that Facility A’s off campus DED does get OB/GYN emergencies who are taken “straight back” to the nursing staff. In interviews with 2 of the on-duty ED Physicians (Staff #15, and Staff #16) on 06/09/2025 at 11:30 AM, Staff #15 and Staff #16 indicated that Facility A’s off campus DED did not have on-call OB/GYN providers. Staff #15 and Staff #16 indicated that all GYN emergencies would be transferred out. In an interview with the triage ED RN (Staff #11) for Patient #1 on 06/09/2025 at 11:47 AM, Staff #11 indicated that Facility A’s off campus DED did not have on-call OB/GYN providers and that all OB/GYN emergencies would be transferred. In an interview with an on-duty ED RN (Staff #9) by telephone on 06/09/2025 at 2:20 PM, Staff #9 indicated that Facility A’s off campus DED used to have OB/GYN on-call coverage and “now it was harder to get OB on-call coverage. We have no OB/GYN on-call at all.” In an interview with the Interim Director for Facility A’s off campus DED (Staff #12) on 06/09/2025 at 2:33 PM indicated that Facility A’s off campus DED did not have OB/GYN on-call services. Staff #9 indicated that Facility A’s off campus DED had the need for OB/GYN on call services at Facility A’s off campus DED. Staff #9 stated, “We (Facility A’s off campus DED) need OB GYN coverage, and we have been talking to administration to get OB in the ED. We (Facility A’s off campus DED) are very busy with 150,000 patients a year, so we need this service.” Staff #12 stated that not having OB/GYN on call puts patients in danger and he has been trying to get the service back to the facility. Staff #12 stated that the service was, “once available but somehow it was lost due to remunerations and scheduling.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 Based on record review and interviews, the hospital failed to provide an appropriate transfer for 5 of 23 patients whose records were reviewed (patient #1, patient #4, patient #16, patient #17 and patient #19) in that the hospital did not: 1. Ensure the MOT included appropriate information for patient #1, patient #4, patient #16, patient #17 and patient #19. The physician certifications indicated their emergency medical condition(s) had been stabilized, however, the emergency medical condition (EMC) persisted. 3. Document the name and address of the on-call physician (the on-call trauma surgeon) for (Patient #1) Findings: Medical Record Reviews: Patient #1: Patient #1, a 31-year-old female, arrived the hospital’s off-campus DED (dedicated emergency department) on 05/13/2025, at 8:07 AM and the ED (emergency department) physician, Staff #5, began his examination at 8:17 AM. Staff #5 ‘s documentation in the medical record included: “ ...Presentation Chief Complaint Decreased alertness ...” “ ...Past Medical History -Adult Stated Complaint UNRESPONSIVE ...” The HPI (history of present illness) documented by Staff #5 included: 31-year-old female presents emergency room for unresponsiveness. Boyfriend notes this morning brought him [sic] to the ER. States she started have some lower abdominal pain last night. She is about 3 weeks gestation[;] she had an ultrasound last week no IUP. Assessment requiring an independent historian Boyfriend MEDICAL DECISION MAKING Differential Diagnosis includes: Ruptured ectopic, seizure, syncope, ACS, PE, dehydration, AKI, electrolyte abnormality Conditions present include: Ruptured ectopic Considerations: Independently review imaging, reviewed prior records from prior ER Visits and hospitalizations, history obtained from patient chart review ...” The triage assessment by ED RN (Staff #9) initiated at 8:27 AM included: Patient #1 arrived as a walk-in patient. Patient #1 “rolled into ER unresponsive with agonal respirations sitting in wheelchair. Boyfriend reports onset of contractions and ‘weird breathing’ starting upon arrival to ER.” Objective assessment: “Sitting in chair, snoring respirations. Contracted/arching back and posturing upon arrival.” Patient #1 was assigned a priority level of ESI 1 (emergent, may require resuscitation). . A review of the electrocardiogram interpreted at 8:27 AM noted that the patient had tachycardia with a heart rate of 117. Vital signs documented by ED RN, Staff #11, included: 9:27 AM - Blood pressure 89/55. 9:30 AM - Blood pressure 89/55, pulse 97. An ultrasound - OB Pelvis was resulted at 9:44 AM. The findings included: “TECHNIQUE: Ultrasound was performed to visualize the intrauterine contents using a transabdominal and transvaginal probe. FINDINGS: FETUS: No intrauterine pregnancy is seen Uterus: 7. 0 x 3.8 x 0.4 cm ... Free fluid: Mild complex fluid ... IMPRESSION: 1. No intrauterine pregnancy visualized. 2. No adnexal mass 3. Clinical follow up recommended with repeat imaging in 7-10 days if indicated ...” Vital signs documented by ED RN, Staff #10, were as follows: 9:52 AM - Blood pressure 101/55, pulse 100, oxygenation, 100%. Vital signs documented by Staff #11 were as follows: 10:00 AM - Blood pressure 96/56, pulse 104, oxygenation 100%. 10:04 AM - Blood pressure 91/52, pulse 103, oxygenation 100%. The ED physician, Staff #5 consulted with Staff #6 the hospital’s off campus DED on-call surgeon at 10:18 AM. Additionally, Staff #5 consulted with Staff #7, the Gynecological Oncologist on-call at (Facility D, an affiliate hospital) at 10:18 AM. A review of the medical record revealed Patient #1 clinical condition remained critical and required an emergency blood transfusion at 2:01 PM while awaiting further action by the facility. . The Hospital course, documented by Staff #5 included: 9:40 AM: Staff #5 the ED Physician consulted with an OB/GYN, Staff #40, at Facility C, the main affiliate hospital. Staff #40 recommended that Staff #5 send the patient to Facility B, where Staff #23 would provide services. Staff #40 informed Staff #5 that they would assist if they had difficulty securing an acceptance. 9:45 AM: A repeat blood pressure of 105/55 was obtained. 10:15 AM: Staff #23 the OB/GYN at Facility B recommended contacting Staff #7, the Gynecological Oncologist at Facility D and general surgery. Staff #5 spoke with Staff #6, Facility A’s on-call surgeon, who stated to transfer Patient #1. Staff #7 also stated to transfer Patient #1. 10:30 AM: Staff #5 spoke with the ED Physician, Staff #24, at Facility B, the receiving hospital. Staff #24 agreed with the transfer to Facility B. 10:58 AM: EMS arrived at Facility A and transported Patient #1 to Facility B. Staff #5 documented the following: “ ...Blood pressure 93/51 blood pressure is being transfused. Evaluation patient seen for minimally responsive abdominal pain affecting her mental responsive was hypovolemia or hemorrhagic shock from a ruptured ectopic. Patient given fluids and also unit of crash blood unfortunately we do not have OB/GYN on-call here also spoke with (Staff #7) who recommended transfer and (Staff #6) General Surgery recommends transfer. [Staff #22, an OB/GYN at Facility B] has accepted transfer. We have maximized the capabilities of this hospital to stabilize this patient and proceeded to transfer for definitive care of emergent surgery at [Facility B] ...” The “Clinical Impression” documented by Staff #5 included: “ ...Clinical Impression Primary Impression: Ectopic pregnancy Disposition Decision Transfer Request Time 0940 ... Call Returned Time 1010 Spoke with: Attending physician [Staff #24] Receiving Hospital [Facility B] Transfer Accepted Yes Accepted by: [Staff #22] Acceptance Time 1031 Acceptance Date 05/13/25 Transfer Reason Higher level of care ...” Nursing noted that Patient #1 departed the ED at 11:01 AM. A review of the “Transfer Assessment” in the “Emergency Patient Record” completed on 05/13/2025 by Staff #11 ED RN at 8:34 AM for Patient #1 revealed, “Service not offered, Specialist not available; Services required for transfer: Obstetrics; ...” The memorandum of transfer (MOT) for Patient #1 was reviewed from both Facility A and Facility B. The MOT noted a diagnosis of “ectopic pregnancy,” stated the patient was “stable.” The checkbox to indicate if the transfer was emergent was blank. Patient #1 was transferred via ambulance requiring cardiac monitoring, pulse oximetry, and an IV pump for the emergency blood transfusion that was in progress. The physician certification indicated that the emergency medical condition(s) had been stabilized for transfer however, “death” was a reasonably expected risk on the transfer form and the emergency medical condition persisted. Furthermore, the name and address of the on-call physician were not documented on the MOT. Neither copy of the MOT contained information regarding the general/trauma surgeon’s failed to appear within a reasonable time to treat Patient #1. Facility B provided two copies of the memorandum of transfer for review. One copy contained a blank Physician’s Certification, risks or benefits of the transfer were not listed and did not contain a physician signature. The second copy of the transfer documents provided by Facility B reflected the physician’s certification area had been completed. Patient #1 Medical Record Review at Facility B, the receiving hospital: Triage was initiated and the first vital signs at Facility B were documented on 05/13/2025 at 11:27 AM included: temperature 37.0 degrees Celsius, heart rate 104, respiratory rate 22, blood pressure 111/54, and oxygenation 99%. The receiving OB/GYN and surgeon, Staff #22, began examining Patient #1 upon arrival to Facility B and documentation at 11:50 AM included: “ ...CHIEF COMPLAINT: ruptured ectopic HISTORY OF PRESENT ILLNESS: Note I received a phone call earlier this morning from [Staff #5, ED Physician], at [Facility A’s off campus DED] stating that patient presented with ruptured ectopic. When she arrived, she had syncopal episodes and had a hypotensive episode to 70s over 40s. Patient was diagnosed with a ruptured ectopic. ...” “ ...Plan for laparoscopic evacuation of hemoperitoneum, unilateral salpingectomy versus salpingostomy. Patient counseled on procedure including associated risk benefits alternatives side effects expectations. All questions were answered to patient satisfaction. Informed consent was obtained. PROCEDURE(S) PERFORMED: Lscopic evacuation of hemoperitoneum and R salpingectomy PROCEDURE DATE AND START TIME: 5/13/25@ 1216 PRIMARY SURGEON(S): [Staff #22] ...” Review of medical records for Patient #1 at the recipient hospital, Facility B, revealed that she arrived on 05/13/2025 at or about 11:27 AM and underwent emergent laparoscopic evacuation of hemoperitoneum and right salpingectomy surgical removal of blood from the abdominal cavity and surgical removal of the right fallopian tube for ruptured ectopic pregnancy at 12:16 PM. On 05/15/2025, Patient #1 was discharged home at 10:55 AM. Policy Review: Facility A’s “MHS Emergency Blood Release” policy, last reviewed and effective on 07/2024, stated on page 1 of 9: “ ... Principle The Blood Bank will have a process for situations when the urgent release of blood and/or components is necessary to prevent a fatal patient outcome ...” Interviews: Medical Record Review: Patient #4: Patient #4 was an 80-year-old male who presented to the hospital’s off-campus DED on 12/11/2024 at 11:17 PM via ambulance with chief complaints noted as being found unresponsive with oxygen saturations in the 80%’s. The EMS Run Report for the transport to Facility A’s off campus DED with attachments was reviewed. Noted were the following: “Transport mode: Emergency Response Type: Lights and Sirens Transport Priority: Priority 1 The HPI documented by the ED Physician, Staff #29, included: “Transport mode: Emergency Response Type: Lights and Sirens Transport Priority: Priority 1 The HPI documented by the ED Physician, Staff #29, included: “Family reports that they found patient on the floor and minimally responsive. They state that they he was last seen normal around 2100 but had not been checked on since then. He does have a history of COPD and is on hospice with a valid DNR. Patient appears to be very lethargic and is noted to have an increased work of breathing. Patient was tracking responders but was unable to follow commands or speak. Family reports that he was intubated approximately 4 weeks prior for COPD as well.” The triage assessment by ED RN, Staff #28, began on 12/12/2024 at 12:17 AM. A priority/ESI level 1 was assigned. which indicates resuscitation - immediate life-saving intervention required. The medical screening exam by the ED Provider, Staff #29, began at 11:27 PM. Notes included: “80-year-old male with history of COPD, diabetes, hypertension, hyperlipidemia, CKD, CHF, anemia, depression, GI bleed, on 4 L of oxygen at baseline presents to the ER for evaluation of episode of unresponsiveness at his nursing facility. Nursing went to check on the patient and were unable to arouse him. When EMS arrived, patient’s oxygen saturation was in the low 80s. Patient was not responding to them. Attempted CPAP and breathing treatments however due to patient’s mental status and lack of response to treatments, they elected to intubate the patient. Wife was present and requested intubation although patient is on hospice and family did not want CPR. Patient is otherwise reportedly in his normal state of health, no reported trauma or falls. Patient also has questionable history of seizures based on discharge paperwork from recent visit he the VA hospital. Patient received ketamine and rocuronium for intubation. EMS also notes that patient blood pressure did start to drop and so they gave 1 dose of push dose epi.” . “Patient intubated, on ventilator, no acute distress, vital signs stable Chest x-ray ordered to confirm placement. VBG shows mild respiratory acidosis. Repeat improved. Due to change in mental status, CT scan of the head obtained which reveals no acute abnormalities Labs reveal baseline anemia and CKD although no other acute abnormalities. EKG unremarkable troponin BNP negative. Chest x-ray shows sufficient placement of ET tube but did note NG tube in the left lung. NG tube was immediately removed. Patient does have a PEG tube in place however this was cut by EMS during transport. Patient’s blood pressure is fluctuating and dropped with Versed, so small amount of Levophed was given intermittently as needed to support blood pressure. 500 cc bolus fluids given. Patient and family requesting transfer to VA, so this process was initiated. There is reportedly an ICU bed available so doc to doc and transfer process pending at time of turnover [named physician at the VA hospital] at 0630.” “VA finally accepted patient at 2 PM. Gave a doc-to-doc.” The diagnosis at disposition: acute respiratory failure. . The patient was transferred to [a named VA hospital] on 12/13/2024 at 4:52 PM for a diagnosis of “acute respiratory failure.” A review of the “Transfer Assessment” in the “Emergency Patient Record” completed on 12/12/2024 by Staff #11 ED RN at 4:52 PM for Patient #4 revealed, “Service not offered, Specialist not available; Services required for transfer: Insurance request; ...” A nursing note was documented on 12/13/2024 at 4:58 PM included: “Ventilatory weaning impairment. Inability to tolerate decreased levels of ventilator support.” This would indicate that the patient was transferred to another facility while intubated. There was no record found to indicate that the patient had been extubated prior to transfer. The transfer documents were reviewed. The transfer documents noted a diagnosis of “acute respiratory failure.” The physician certification indicated that the emergency medical condition(s) had been stabilized for transfer. However, the memorandum of transfer included “death” and “worsening of condition” as risks of the transfer, indicating that the patient’s persistent emergency medical condition required further stabilizing treatment. It was also documented that he was transferred by ambulance and required cardiac monitoring, an IV pump, and pulse oximetry. Patient #4 remained intubated at the time of transfer. Patient #16: Patient #16, a 51-year-old female, presented to the hospital’s off-campus DED on 03/26/2025 at 8:35 PM via ambulance with chief complaints of “wanting to die so she can have an autopsy and find the parasites invading her body”. The medical screening exam by the ED Physician Assistant (PA), Staff #30, began at 8:42 PM. Staff #30’s notes included: “HPI (history of present illness) 51-year-old female with past medical history of hypertension, hyperlipidemia, schizophrenia, COPD, liver cirrhosis, methamphetamine use, and anxiety presents ED today brought in by EMS under emergency detention after patient reportedly had SI] with attempt via taking multiple medications to include not limited to Robaxin, ibuprofen, and gabapentin. There are conflicting stories with this, patient originally had told EMS that she had taken these meds, but on my assessment of patient she denies any medication use. Patient states she had told them she had “wanted to die so they can perform an autopsy to see the parasites that are invading her body. “Patient also admits to not being on any of her schizophrenia meds for about a month. Patient denies any fevers/chills, NVD, CP, SOB, abd pain, night sweats, urinary sx, bloody stools, HA, syncope, or any other systemic complaints. Patient denies any HI or auditory hallucinations. No other reported complaints this time.” The differential diagnosis included “DDx: SI versus HI versus visual/auditory hallucinations versus electrolyte derangement versus all other etiologies not mentioned.” The Medical Decision Making (MDM) revealed: “On exam, patient in no acute distress, nontoxic-appearing, ANOx3, speaks in complete sentences, responds appropriately. Bilateral TMs and EACs normal and clear. Oropharynx is without injection or exudates, bilateral tonsils without swelling or exudates, uvula midline, no trismus, no hot potato voice, no drooling. No cervical lymphadenopathy. Lungs clear bilaterally without any wheezing, crackles, rhonchi, decreased breath sounds, no respiratory distress, no accessory muscle use, no tripoding. Abdomen nontender, nondistended, no rebound/guarding, no rigidity ... EKG obtained at 2133 shows NSR with sinus arrhythmia, rate of 92 bpm, normal axis, normal intervals, no ST elevation or depression consistent with ischemia, no STEMI. CBC with 13.3k leukocytosis, normal hemoglobin, elevated platelets of 407. CMP with normal creatinine, normal electrolytes, normal LFTs. TSH is normal. UA negative for any blood or infection. UDS positive for methamphetamines. Tylenol and salicylate levels are negative. Alcohol level is negative. Patient has been medically cleared for tele psych. I spoke with psych intake regarding patient, their recommendation is for inpatient admission. Patient is under emergency detention. They state there was no room at [a named facility], however they will reach out to the nearest facility, state patient is insured and this will be a problem. Patient recommended to have meds for acute psychosis. She was given olanzapine. Otherwise, patient stable, pending doc to doc for transfer at this time. Patient will be handed off to oncoming morning provider [a named physician assistant] who will continue to monitor patient until she is transferred ...” . The triage assessment by ED RN, Staff #31, began at 8:47 PM. A priority/ESI level 2 indicating emergent and could be life threatening was assigned. All screenings were completed. “Calculated suicide risk level: High risk.” An addendum by ED physician, Staff #32, included: 0700: Assumed care patient, patient reassessed, resting comfortably in bed, no distress. Currently pending bed placement. 1600: Patient placed under OPC, cued for bed at [a named facility]. 1900: Patient reassessed, again found to be resting calmly in bed, no distress. Discussed case with [a named nurse practitioner], remains pending bed placement.” A review of the “Psychiatric Consultation Note” completed by Staff #30 stated the following: “Assessment/ Diagnoses/ Plan: # Risk assessment: The patient appears to be at imminent risk for harm to self-based on a recent suicide attempt, depression, anxiety, stated suicidal intent, and psychosis with limited insight and judgment. -Recommend suicide precautions and inpatient psychiatric hospitalization # Schizophrenia, GAD --Recommend Seroquel 100 mg po xl for mood, anxiety, sleep and psychosis support. Pt has declined psychotropic medication at this time. # Methamphetamine use disorder -Supportive care # Dispo Recommend inpt psych hospitalization, level 2 appropriate.” The diagnosis at disposition: “Primary Impression: Suicidal ideation. Secondary Impressions: Schizophrenia.” The patient was transferred to [a named psychiatric facility] on 03/29/2025 at 1:57 AM. A review of the “Transfer Assessment” in the “Emergency Patient Record” completed on 03/29/2025 by Staff #31 ED RN at 4:36 AM for Patient #16 revealed, “Service not offered, Specialist not available; Services required for transfer: Service not offered. Psychiatric; ...” The transfer documents were reviewed. The transfer documents noted a diagnosis of “suicidal ideation.” The physician certification indicated that the emergency medical condition(s) had been stabilized. However, the memorandum of transfer included “death” as a reasonably expected risk on the transfer form, indicating the emergency medical condition required further stabilizing treatment. Patient #16 was transferred by ambulance with suicide precautions in place. Patient #17: Patient #17, a 13-year-old female, arrived at the hospital’s off-campus DED on 04/04/2025 at 10:18 AM when she was brought in by the Police under a detention warrant with chief complaints of telling parents she wanted to harm herself and has a plan. The triage assessment began by ED RN, Staff #33, at 11:04 AM. A priority/ESI level 2 indicating emergent, could be life threatening, was assigned. The “Calculated suicide risk level: High Risk.” The patient was placed on 1:1 observation. The medical screening exam by the ED Physician, Staff #34, began at 10:21 AM. The Notes included: HPI Notes “13-year-old female history of anxiety, depression, PTSD brought in under emergency detention after endorsing feelings of wanting to hurt herself earlier today. History obtained by family at bedside including mother and father. Patient has been increasingly agitated, somewhat defiant and left the home briefly yesterday for about an hour. Family was concerned that she may have ran away. Then this morning patient became distracted throughout the home throwing things and family called police. When police arrived she was questioned if she wanted to hurt herself and she stated yes. She would not answer any additional questions. ...She became combative this morning throwing things around the house. She also took a knife yesterday and slashed their door. She states that she has a plan but does not want to tell me her plan. No auditory visual hallucinations. Family reports patient has never been hospitalized for underlying psychiatric diagnosis Past medical history: Anxiety, depression.” The MDM notes by Staff #34 included: “ ...Differential Diagnoses considered, but not limited to: Acute psychosis, suicidal ideations, low suspicion for drug-induced etiology, doubt underlying electrolyte disorder infectious etiology. I have ordered the following labs +/- Imaging for evaluation of the above patient: At this time patient is already under emergency detention, she has agreed to talk to psychiatry. Will check basic labs including [a pregnancy test], [urine drug screen], and consult psychiatry family is agreeable to plan they would prefer if patient needs to be admitted to be admitted to clarity.” A Telehealth Psych Consult was ordered on 04/04/2025 at 10:54 AM and was documented at 5:12 PM. The psychiatry evaluation was document by Staff #34 and noted: “PT MEETS CRITERIA FOR INPATIENT PSYCH ADMISSION FOR MOOD STABILIZATION AND PSYCHIATRIC TREATMENT.; Describe current safety concerns: PT IS DIFFICULTY CONTROLLING TEMPER AND HAS EXPLOSIVE OUTBURSTS THAT D0 NOT MATCH WITH THE CURRENT PROBLEM. PT IS VERYHIGHLY IMPULSIVE.” Re-Evaluation/Progress #1 by Staff #34 included: “Patient is pending psych evaluation. Patient is medically cleared for admission Patient was seen and eval by psychiatry that recommended inpatient admission for patient Currently patient and family are waiting for a bed at clarity. Patient was signed out to oncoming provider pending disposition.” The diagnosis at disposition: “Primary Impression: Aggressive behavior”. The patient was transferred to (a named psychiatric facility) at on 04/07/2025 at 12:15 PM. A review of the “Transfer Assessment” in the “Emergency Patient Record” completed on 04/07/2025 by Staff #33, ED RN, at 12:30 PM for Patient #17 revealed, “Service not offered, Services required for transfer: Psychiatric; ...” The “Notice of Emergency Detention” (ED) was provided and reviewed. The ED noted concerns for self-harm and suicide attempt. The transfer documents were reviewed. The transfer documents noted a diagnosis of suicidal ideation. The physician certification indicated that their emergency medical condition(s) had been stabilized for transfer. However, the memorandum of transfer included “death” as a reasonably expected risk on the transfer form, indicating the emergency medical condition required further stabilizing treatment. The transfer was effected by ambulance and suicide precautions were in place. Patient #19: Patient #19, a 68-year-old male, arrived at the hospital’s off-campus DED on 04/23/2025 at 9:58 AM by ambulance with chief complaints of purulent drainage to right knee following a knee replacement on 10/31/2024. The medical screening exam by ED physician, Staff #34, began at 10:00 AM. The notes included: HPI Notes “68-year-old male past medical history of major depressive disorder, CAD status post stent, GERD, gastritis, hypertension, hyperlipidemia, BPH, tardive dyskinesias sent from [a named facility] with purulent drainage from his surgical site. He had a recent right TKA performed by [a named physician] back in January 31 since then he has been in rehab center. He was supposed to come home today nursing staff noticed some purulent drainage from his surgical wound and sent him to the emergency department. He denies any fevers, chills, he is endorsing pain to the area, also associated redness. He has been unable to ambulate secondary to postsurgical complications. He was admitted to the hospital in early March in the setting of hypokalemia and right lower extremity edema. He was getting wound care to the surgical site orthopedics saw this patient at that time no surgical intervention. Patient is currently not on any antibiotics.” The MDM Notes by Staff #34 included: “ ...Differential Diagnoses considered, but not limited to: Likely consistent with postsurgical infection, can consider septic joint, underlying abscess, cellulitis, osteomyelitis I have ordered the following labs +/- Imaging for evaluation of the above patient: At this time we will give empiric antibiotics, check basic labs, consult orthopedics will obtain a CT with IV contrast, likely admission.” Re-Evaluation/Progress #2 Text/Diet Note “Still awaiting callback from PPC transfer was initiated around 2 PM. I already spoke to [a named physician] who accepted patient but needs a medicine admission Patient received Vanco and ceftriaxone here in the emergency department. ...Patient is pending transfer.” A CT of the right lower extremity was obtained and entered at 12:01 PM noting the following: IMPRESSION: 1. Status post knee replacement. Moderate effusion. 2. Anterior pretibial wound with surrounding cellulitis but no CT evidence for osteomyelitis or localized abscess otherwise 3. Fatty atrophy of the medial head gastrocnemius.” The diagnosis at disposition: “Primary Impression: Post surgical complication. Secondary Impressions: Cellulitis”. The patient was transferred to (a named facility) on 04/23/2025 at 9:43 PM. A review of the “Transfer Assessment” in the “Emergency Patient Record” completed on 04/23/2025 by Staff #37, ED RN, at 9:50 PM for Patient #19 revealed, “Service not offered, Specialist not available; Services required for transfer: Surgical; ...” The transfer documents were reviewed. The transfer documents noted a diagnosis of “post-surgical complication.” The physician certification indicated that their emergency medical condition(s) had been stabilized for transfer. However, the memorandum of transfer included “death” as a reasonably expected risk on the transfer form, indicating the emergency medical condition required further stabilizing treatment. The transfer was affected by ambulance and required “pulse oximetry” to be in place. Policy Reviews: Facility A’s “Evaluation of an Obstetrical Patient in Non-Obstetric Areas” policy, last reviewed and effective on 03/2024, stated on page 1 of 2: “ ...GUIDELINES: 1. After identification of need for obstetrical assessment, the attending physician contacts the patient’s Primary OB or emergency room (ER) OB on call as applicable. L&D/Antepartum staff is notified of the need for an obstetrical assessment ...” Facility A’s “Pregnant and Obstetrical Patients in the Emergency Department” policy, last reviewed and effective on 09/2023, stated on page 2 of 3: “ ...Pregnant patients presenting with a non-labor related chief complaint: 1. The Emergency Department Physician performs the MSE (Medical Screening Exam). 2. If the ED physician determines the patient requires fetal monitoring, the RN notes the order from the ED physician to transport the patient to OB ED. Alternatively, a request for the Labor & Delivery staff to assess the patient in the ED can be determined by the ED physician. 3. Assessment and reassessment of the patient is determined by the triage acuity assignment and according to triage acuity guidelines. 4. For (an affiliate hospital name): Collaboration with the OB physician may determine that patients at 20 weeks or greater, and ? 6 weeks postpartum with obstetrical complaints need to be further evaluated in OB Triage. 5. For (an affiliate hospital name & (an affiliate hospital name: Collaboration with the OB physician may determine that patients at 16 weeks or greater, and less than 6 weeks postpartum with obstetrical complaints need to be further evaluated in the OB ED ...” Facility A’s “Patient Transfer Policy 9:1”, last reviewed and effective on 10/2024, stated on pages 2 and 3 of 8: “ ...B. PATIENT EVALUATION 1. The Hospital shall provide that each patient who arrives at the Hospital is evaluated by a physician who is present in the hospital at the time the patient presents or is presented or evaluated by a physician on-call who is: A patient must also be personally examined and evaluated by the physician before an attempt to transfer is made. However: a. after receiving a report on the patient’s condition from a hospital registered nurse, physician assistant, or other qualified medical personnel as established by the Hospital’s Board of Directors by telephone or radio, if the physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of a patient will unnecessarily delay the transfer to the detriment of the patient, the physician on call may order the transfer by telephone or radio; and b. physician orders for the transfer of a patient which are issued by telephone or radio shall be reduced to writing in the patient’s medical record, signed by the hospital registered nurse, physician assistant, or other qualified medical personnel as established by the Hospital’s Board of Directors receiving the order, and countersigned by the physician authorizing the transfer as soon as possible. The patient transfers resulting from physician orders issued by telephone or radio shall be subject to automatic review by the medical staff pursuant to 25 Texas Administrative Code § 133.44(c)(8), as may be amended, and Section D.8 of this policy ...” Facility A’s “Patient Placement” policy, last reviewed and effective on 05/2024, stated on page 2 of 4: “ ...2. EMTALA Transfers: o EMTALA transfer requests must be responded to within 30 minutes of receiving the initial request or the requesting facility will be notified of the delay and reason for delay. o If the transfer is an EMTALA transfer the PPC will determine capability and/or capacity to provide the patient the appropriate care. If capability, capacity and/or level of care is not available at the requested facility, the patient will be placed at another facility within Methodist Healthcare that meets the needs of the patient. o The PPC will contact the sending facility and provide them with administrative approval, accepting facility, accepting physician and a room assignment along with the phone number to call report to the nursing unit. The sending facility will be asked to fax patient demographics to the admitting department of the receiving Methodist facility. o If the on-call Methodist Healthcare Physician refuses to accept the admission, the escalation algorithm will be utilized, and the facility CEO will be contacted ...” Facility A’s “Patient Transfer Policy 9:1”, last reviewed and effective on 10/2024, stated on pages 2 and 3 of 8: “ ...B. PATIENT EVALUATION 2. The Hospital shall provide that each patient who arrives at the Hospital is evaluated by a physician who is present in the hospital at the time the patient presents or is presented or evaluated by a physician on-call who is: A patient must also be personally examined and evaluated by the physician before an attempt to transfer is made. However: a. after receiving a report on the patient’s condition from a hospital registered nurse, physician assistant, or other qualified medical personnel as established by the Hospital’s Board of Directors by telephone or radio, if the physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of a patient will unnecessarily delay the transfer to the detriment of the patient, the physician on call may order the transfer by telephone or radio; and b. physician orders for the transfer of a patient which are issued by telephone or radio shall be reduced to writing in the patient’s medical record, signed by the hospital registered nurse, physician assistant, or other qualified medical personnel as established by the Hospital’s Board of Directors receiving the order, and countersigned by the physician authorizing the transfer as soon as possible. The patient transfers resulting from physician orders issued by telephone or radio shall be subject to automatic review by the medical staff pursuant to 25 Texas Administrative Code § 133.44(c)(8), as may be amended, and Section D.8 of this policy ...” and on pages 3 and 4 of 8: “ ...D. SPECIAL REQUIREMENTS RELATED TO THE TRANSFER OF PATIENTS WHO HAVE EMERGENCY CONDITIONS 1. Except as provided in Sections C.5 and C.6, the transfer of a patient who has an emergency medical condition, as determined by a physician, shall be undertaken for medical reasons only. The hospital must provide medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child. For additional guidance concerning patient transfers to which EMTALA is applicable, see Texas EMTALA Transfer Policy, Policy Stat ID: 5689153. 2. When a patient has an emergency medical condition that has not been stabilized, or when stabilization of the patient’s vital signs is not possible because the Hospital or emergency department does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment shall be performed and patient transfer shall be carried out as quickly as possible. The hospital may not transfer a patient with an emergency medical condition which has not been stabilized unless: a. the patient or a legally responsible person acting on the patient’s behalf, after being informed of the Hospital’s obligations under this section and of the risks and benefits of transfer, requests transfer to another hospital in writing and indicates the reasons for the request, as well as that he or she is aware of the risks and benefits of the transfer; b. a physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer; ...” Interviews: In an interview with OB/GYN at Facility B, the receiving hospital, on 06/04/2025 at 2:02 PM, Staff #22 indicated that she was the surgeon that completed the operation on Patient #1. Staff #22 also stated, [Staff #6, a surgeon at Facility A’s off campus DED] refused to accept [Patient #1].’ Staff #22 further indicated that Staff #6 “should have been able to handle this. At a minimum, he could have started the procedure and gotten an intraoperative consult with one of [Facility A’s off campus DED’s] OB’s.” Staff #22 further stated, “[Patient #1] could have died without more immediate care.” In an interview with the General Surgeon/Trauma Surgeon on-call (Staff #6) at the time of the incident via telephone on 06/09/2025 2:13 PM, Staff #6 indicated that, “anything can be done with surgery, but my focus is to stop bleeding ...save the patient and that is it.” Staff #6 stated, “I have never been asked to participate in an ectopic pregnancy procedure.” Staff #6 indicated that he did not, “take responsibility for being the on-call for a GYN patient” and Facility A’s off campus DED had a transfer process. Key: 1. Hemoperitoneum: The presence of blood in the peritoneal cavity, the space between the abdominal wall and the abdominal organs. 2. Unilateral salpingectomy: A surgical procedure involving the removal of one fallopian tube). 3. Salpingostomy: A surgical procedure involving an incision into a fallopian tube). 4. COPD: chronic obstructive pulmonary disease 5. DNR: do not resuscitate order 6. CPR (cardiopulmonary resuscitation) 7. Veterans Administration (VA) 8. Epi: epinephrine, a drug used to dilate airways 9. CKD: chronic kidney disease 10. CHF: congestive heart failure 11. GI: gastrointestinal 12. EMS: emergency medical services 13. CPAP: continuous positive air pressure 14. VBG: venous blood gas 15. EKG: electrocardiogram 16. BNP: B-type natriuretic peptide 17. PEG: percutaneous endoscopic gastrostomy 18. HPI: history of present illness 19. SI: suicidal ideation 20. N/V/D: nausea, vomiting, diarrhea 21. HI: homicidal ideation 22. HA: headache 23. Sx: symptoms 24. Abd: abdomen 25. TMs: temporal mandibula’s 26. EACs: external auditory canals 27. LFT: liver function tests 28. CMP: comprehensive metabolic panel 29. CBC: complete blood count 30. NSR: normal sinus rhythm 31. OPC: order of protective custody 32. GAD: generalized anxiety disorder 33. PTSD: post-traumatic stress disorder 34. GERD: gastroesophageal reflux disease 35. NICU: neonatal intensive care unit .”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 35321 The Surveyor observed a loose electrical receptacle outlet (red color) in patient room 310AB. [The Standard] Electrical Systems – Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of . 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals . 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45847 . Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1). . On 02/25/2024, Patient #1 presented to the emergency department with complaints of left and right ankle pain after a fall. Medical records show that Patient #1 was provided with a partial MSE at 1156 AM, given an x-ray of the ankles that indicated a need for further evaluation at 1243 PM and noting a bimalleolar fracture of the right ankle, and was discharged from the ED at 1337 PM without further evaluation or an orthopedic consult. . Cross reference to Tag A2406 CFR §489.24(c). .”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45847 . Based on record review and interviews, the facility failed to perform and document an appropriate medical screening examination (MSE) in one of 20 patient records reviewed (Patient #1). . Findings: Facility A Chart Review: On 02/25/2024 at 1156 AM during the medical screening process by Staff #8 (ED physician), a physical exam was completed noting, “ ...no external signs of trauma...” and “ ...Right Ankle - Swelling present, tenderness present, tender medial ligaments, ROM (range of motion) reduced. Joint effusion (fluid in the joint spaces) present. Negative: Achilles deficit, Anterior drawer test pos (positive), Deformity present, open fracture present, Pulse post tib (tibial) absent, Pulse post tib decreased, Neuro deficit present ....Left Ankle - Tender lat (lateral) ligaments, Tender medial ligaments, Tender lateral malleolus ... Patient at this time unable to bear weight due to pain ...” . An x-ray of the right ankle resulted on 02/25/2024 at 1243 PM noted, “ ...Fractures of the posterior and medial malleoli ... bimalleolar fracture of the right ankle ... Recommend further evaluation with a right lower leg series to evaluate for a Maisonneuve fracture of the more proximal fibula ...” A bimalleolar fracture is unstable, and a Maisonneuve fracture requires non weight bearing, thus leaving Patient #1 at non-weight bearing bilaterally (on both sides). There is no evidence that the Facility tried to obtain an orthopedic consult. . A physician’s note on 02/25/2024 at 1203 PM noted, “ ...patient sustained a 2-part fracture of the medial malleolus. X-rays of the left ankle shows no bony abnormalities. Patient be diagnosed with sprain of left ankle. Ace wrap and walking boot were applied to (the) patients’ lower extremities. Advised patient to follow RICE protocols patient is weight bearing as tolerated on the left ankle. She is non-weightbearing on the right ankle ...” . The MSE did not complete further evaluations as recommended by the radiologist, which resulted in a failure to detect a second emergency medical condition (EMC) of a Maisonneuve fracture. Patient #1 was discharged home on 02/25/2024 at 1337 PM. . Facility B Chart Review: On 02/26/2024 at 1626 PM, Patient #1 went to Facility B and a triage assessment noted that the patient was complaining of “severe ankle pain.” A Medical screening examination was initiated on 02/26/2024 at 1655 PM. At 1738 PM Patient #1 was accepted for admission for orthopedic surgery. The Maisonneuve fracture was not detected at Facility A. It was however detected intra-operatively at Hospital B. . Interviews on the afternoon of 04/22/2024, Staff #10 (ED RN) and Staff #8 (ED Physician) confirmed the above findings and indicated that they were unaware that the MSE was incomplete for Patient #1. .”