Methodist Richardson Medical Center

“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: 51905 Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to perform a medical screening examination (MSE) on Patient #14, who presented for sexual assault in the emergency department (ED). Facility A failed to determine if 1 of 20 patients (Patient #14) had an emergency medical condition (EMC ). . Based on observation, record review, and interviews, Facility A failed to provide stabilizing treatment for 1 of 20 patients (Patient #4) experiencing an emergency medical condition. Patient #4 presented to Facility A after a suicide attempt. Patient #4 was recommended for transfer to a facility with psychiatric capabilities. Patient #4 refused the transfer. Facility A failed to provide stabilizing treatment when an emergency detainment order was not initiated and the patient was not transferred with an emergency medical condition of suicidal ideation. . Based on observation, record review, and interviews, Facility A failed to initiate an appropriate transfer to a facility capable of providing services not offered at Facility A for 1 of 20 patients (Patient #4). Patient #4 was experiencing suicidal ideation; their evaluation recommended transfer to an inpatient psychiatric facility. Patient #4 refused the transfer. Facility A allowed Patient #4 to self-transfer to Facility B despite needing stabilizing treatment. . Facility A failed to initiate an appropriate transfer when the physician’s certification was not signed, acknowledging the risks and benefits of the transfer. . Facility A failed to ensure Facility B had available space and qualified personnel for the treatment of the individual, nor had Facility B agreed to accept transfer of the individual and to provide appropriate medical treatment. . Facility A failed to send Facility B all medical records, informed consents, and certification for transfer. . Facility A failed to transfer through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. . See Tag 2406, 2407, 2409”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to perform a medical screening examination (MSE) on Patient #14, who presented for sexual assault in the emergency department (ED). Facility A failed to determine if 1 of 20 patients (Patient #14) had an emergency medical condition (EMC ). . Record Review Review of Facility A’s Medical Record for Patient #14: On 02/14/2026 at 3:39 P.M., Patient #14 presented to Facility A’s emergency department (ED) for sexual assault (ED Notes, Page 9). At 3:45 P.M. ED Physician, Staff I documented a “History of Present Illness” (ED Provider Note, Page 5). Both sections, “Review of Systems” and “Physical Exam,” were left blank (Review of Systems and Physical Exam, Page 6). At 5:40 P.M, Patient #14 was evaluated by a sexual assault nurse examiner (SANE) nurse (ED Notes, Page 9). There is no documentation of the results of the exam. The section, “Medical Decision Making,” was left blank (Medical Decision Making, Page 6). Patient #14 was treated with prophylactics and underwent a CT (computed tomography) scan of the cervical spine. At 9:13 P.M., Patient #14 was discharged home with prescriptions and instructions to follow up with their primary care physician. Patient #14 did not have an appropriate medical screening exam to assess for an emergency medical condition related to the sexual assault. There was no documentation in the chart regarding whether or not the patient had pain, loss of consciousness, head injury, abdominal injury, extremity injury, or neurologic symptoms. . Review of Emergency Medical Treatment and Labor Evaluation Policy, Effective: 02/25/2025: “Policy: 1. Any individual (including a minor child and/or infant) who presents to any facility requesting assistance for a potential Emergency Medical Condition (EMC) or is in labor will receive a Medical Screening Examination (MSE) by a Qualified Medical Provider to determine whether an EMC exists” (Policy, Page 3). . Interviews: 02/24/2026 at 3:15 P.M., Trauma Program Coordinator, Staff C, stated during the chart review of Patient #4, that there was no MSE [Medical Screening Exam] documented in the chart. . 02/25/2026 at 11:06 A.M., ED Physician, Staff I, stated that normally, there would be a physical exam done. Staff I stated that for every visit, the provider is to complete a physical exam, and they were unsure why one was not documented for Patient #14. Staff I stated that “EMTALA means that every patient who comes to the hospital needs to be examined and worked up as necessary to make sure that they don’t have an emergency medical condition.” . 02/25/2026 at ED Nurse Practitioner, Staff N, stated that he cared for Patient #14. When asked about the patient’s physical assessment, Staff N stated that they had only listened to Patient #14’s heart and lungs. Staff N stated that they do not perform any treatment on sexual assault victims unless the patient has life-threatening injuries; otherwise, treatment is recommended by a third-party SANE nurse. Staff N stated that EMTALA means that “every patient that comes in receives a medical screening exam.” Staff N verified that each visit to the ED requires an MSE, even if the patient comes in multiple times on the same day. .”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 51905 Based on observation, record review, and interviews, Facility A failed to provide stabilizing treatment for 1 of 20 patients (Patient #4) experiencing an emergency medical condition. Patient #4 presented to Facility A with suicidal and homicidal ideation. Patient #4 was recommended for transfer to a facility with psychiatric capabilities. Patient #4 refused the transfer. Facility A failed to provide stabilizing treatment when an emergency detainment order was not initiated and the patient was not transferred with an emergency medical condition of suicidal ideation. . Record Review Review of Facility A’s Medical Record for Patient #4: 11/11/2025 at 2:40 A.M., Patient #4 presented to Facility A’s emergency department [ED] with a chief complaint of suicidal and homicidal ideations. At 2:47 A.M., ED Physician Staff J completed a medical screening exam. Staff J documented that Patient #4 was having auditory and visual hallucinations. The command hallucinations were telling Patient #4 to “kill [himself] and police officers”, and that he was being chased by Federal Marshals. Patient #4 had a history of schizoaffective disorder and previous inpatient psychiatric admissions (ED Provider Note, Page 19). A review of systems revealed Patient #4 was positive for hallucinations and suicidal ideation (Review of Systems, Page 20). The physical exam revealed that Patient #4 was alert and oriented, presented with tremors, was actively hallucinating, and thought content included suicidal ideation. Staff J did note that Patient #4 was not homicidal (Physical Exam, Page 21). Patient #4’s urine drug screen was “presumptively positive” for cocaine. At 4:31 A.M., Patient #4 was medically cleared (ED Course, Page 25). At 5:06 A.M, Patient #4 was assessed by a licensed clinical social worker [LCSW]. It was documented that Patient #4 had fleeting thoughts of both suicidal and homicidal ideations with auditory hallucinations. The LCSW noted that Patient #4 has a history of suicide attempts and was non-compliant with medications. The LCSW recommended inpatient psychiatric care and noted that Patient #4 agreed to go and requested Facility B (Mental Health Preadmission Assessment, Page 26). At 9:15 A.M., the LCSW documented that Patient #4 was denied from Facility B due to his medical acuity (ED Notes, Page 28). At 9:38 A.M., Patient #4 was accepted to another psychiatric facility (ED Course, Page 25). A medical decision-making note was documented, “Patient medically cleared and evaluated by a psych assessor who managed to get the patient accepted to [Psychiatric facility] however patient declined, wishing to go to Facility B who had previously denied his admission. Patient stated that he would like to be discharged home” (ED Provider Note, Page 13). At 10:10 A.M., Patient #4 was discharged home (Discharge Information, Page 13). Patient #4 was diagnosed with Suicidal Ideation, an acute episode of schizophrenia (Visit Diagnoses, Page 14). Facility A failed to provide stabilizing treatment when an emergency detainment order was not initiated and the patient was not transferred with an emergency medical condition of suicidal ideation. . Review of Facility B’s Medical Record for Patient #4: 11/12/2025 at 3:30 P.M., Patient #4 voluntarily presented to Facility B with a chief complaint of a suicide attempt. A screening assessment was completed that listed the complaint as, “patient reports command hallucinations telling him to ‘kill himself and all police officers’. Patient reports trying to strangle himself with a sheet yesterday, which broke off, causing him to fail. Patient reports hx [history] of paranoid schizophrenia” (Screening Assessment, Page 40). Patient #4 screened as a high risk on the Columbia Suicide Severity Rating Scale (Screening Assessment, Page 42). Patient #4 was described as boisterous, loud, and hitting windows and doors during intake. The providers listed him as disheveled, irritable, resistant, paranoid, and with poor impulse control (Screening Assessment, Page 45). Per the inpatient comprehensive psychiatric evaluation, Patient #4 had schizoaffective disorder and was admitted voluntarily for command auditory hallucinations and a recent suicide attempt by strangulation. Patient #4 had a history of multiple inpatient psychiatric admissions, was described as having persecutory delusions of Federal Marshals chasing him, and he had been off all his psychiatric medications (Inpatient Comprehensive Psychiatric Evaluation, Page 14). The physician documented that Patient #4 would be admitted to inpatient due to the imminent risk of harm to himself, others, and impaired psychosocial functioning (Inpatient Comprehensive Psychiatric Evaluation, Page 17). Patient #4 was discharged home on 11/20/2025. . Review of Emergency Medical Treatment and Labor Evaluation Policy, Effective 02/25/2025: “PURPOSE: To provide guidelines for the provision of necessary assessment and/or stabilizing treatment of an individual with a possible emergency medical condition or who is in labor and to support adherence to the Emergency Medical Treatment and Active Labor Act (“EMTALA”) requirements.” . “Stabilize,” “Stabilized,” or “Stabilizing” means, with respect to treatment related to an Emergency Medical Condition, to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the Hospital or, in the case of a woman in Labor, that the woman has delivered the child and the placenta .” . Review of Article 24 - Emergency Services Policies, Approved 5/27/2008: “24.2.9 Definitions Emergency Medical Condition means: a) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: (i) Placing the health of the individual (or, with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy, (ii) Serious impairment to bodily functions, or (iii) Serious dysfunction of any bodily organ or part” (Page 113). . Review of Leaving Against Medical Advice (AMA) Policy, Effective 02/17/2025: “1. Patients requesting/attempting to leave AMA from medical units and the Emergency Dept F. If a patient is believed to be mentally incompetent due to illness or medications, and/or their departure could lead to harm to the patient or others, his/her departure should be delayed pending consultation with the social worker or Risk Management concerning obtaining court authorization to detain the patient. Refer to CM 007, Psychiatric Care/Referral.” . 2. Patients requesting/attempting to leave AMA from Behavioral Health Services C. The physician has 4 hours from the time of the discharge request to decide if the patient can be released or if the patient should be placed on a 24 hour hold to allow him/her the opportunity to perform a face to face evaluation for court commitment. . D. If the physician determines there is no need to perform the face to face evaluation to determine risk to self/others, the patient must be released within 4 hours of the time of the discharge request. . E. The physician can designate the discharge as a routine discharge or as an AMA discharge. . G. If the physician places the patient on a 24 hold, the “Certificate of Medical Examination” must be completed in order for the case manager or nursing supervisor to secure the Order of Protective Custody (OPC) to hold the patient.” . Interview: 02/25/2026 at 11:15 A.M., ED Physician, Staff J. Staff J explained that psychiatric patients can be stuck in the ED for days. Staff J stated that you have to do what you can for psychiatric patients, but there is only so much that can be done for them. Regarding Patient #4, Staff J stated that patients cannot pick and choose where they want to go. He stated that he was not concerned for Patient #4’s discharge, as they [the facility] were able to secure a facility to transfer Patient #4 to, and when he refused, there was an understanding and belief that Patient #4 would “self-present’ to Facility B. Staff J stated that “we [the facility] can’t keep them forever.” Staff J stated that Patient #4 did not go AMA. . 02/25/2026 at 11:40 A.M. ED Physician, Staff K stated if a patient was “lined up” for transfer and the patient refused the transfer, they would call the social worker back and ask them, “What’s the plan?” Staff K stated that the social workers guide the physicians with psychiatric patients. Staff K stated, “Medically, it is us, and psychiatrically, it is them”. Staff K stated that if a patient is not on an APOWW [Apprehension by a Police Officer Without a Warrant], the patient is voluntary and suicidal and homicidal, the patient needs to be evaluated and sent to a facility to get help. Staff K stated, “No one wants to send home a patient who is suicidal or homicidal”. Staff K stated that they didn’t know the thought process behind this particular discharge, but felt they would have needed another evaluation by the social worker before being discharged home. . 02/25/2026 at 12:07 P.M., ED Physician, Staff L, was given the scenario of a psychiatric patient with recommendations to transfer to inpatient psychiatric care who was then discharged home. Staff L stated that “that is not something that happens and that [they] would not discharge someone like that with those recommendations.” Staff L stated that even if they did discharge a patient like this, they would have “made a note reassessing the patient. Staff L stated, “We [physicians] will not make a decision without psych social workers. We don’t unilaterally say, “Oh, this person’s been here two days, let me just discharge them.” “The psych social worker will come to us and say I reassessed this patient, they’re not a danger to themselves, he’s alert oriented, and I feel this patient is safe to go home. Ultimately, the physicians make the final determination, but we [physicians] use that information a lot; we give it a lot of weight.” Dispositions are always done in conjunction with a social worker who either transfers, admits the patient to a facility, or discharges home with resources.” .”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to initiate an appropriate transfer to a facility capable of providing services not offered at Facility A for 1 of 20 patients (Patient #4). Patient #4 was experiencing suicidal ideation; their evaluation recommended transfer to an inpatient psychiatric facility. Patient #4 refused the transfer. Facility A allowed Patient #4 to self-transfer to Facility B despite needing stabilizing treatment. Facility A failed to initiate an appropriate transfer when the physician’s certification was not signed, acknowledging the risks and benefits of the transfer. . Facility A failed to ensure Facility B had available space and qualified personnel for the treatment of the individual, nor had Facility B agreed to accept transfer of the individual and to provide appropriate medical treatment. . Facility A failed to send Facility B all medical records, informed consents, and certification for transfer. . Facility A failed to transfer through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. . Record Review Review of Facility A’s Medical Record for Patient #4: 11/11/2025 at 2:40 A.M., Patient #4 presented to Facility A’s emergency department [ED] with a chief complaint of suicidal and homicidal ideation. At 2:47 A.M., ED Physician Staff J completed a medical screening exam. Staff J documented that Patient #4 was having auditory and visual hallucinations. The command hallucinations were telling Patient #4 to kill himself and police officers, and that he was being chased by Federal Marshals. Patient #4 had a history of schizoaffective disorder and previous inpatient psychiatric admissions (ED Provider Note, Page 19). A review of systems revealed Patient #4 was positive for hallucinations and suicidal ideation (Review of Systems, Page 20). The physical exam revealed that Patient #4 was alert and oriented, presented with tremors, was actively hallucinating, and thought content included suicidal ideation. Staff J did note that Patient #4 was not homicidal (Physical Exam, Page 21). Patient #4’s urine drug screen was “presumptively positive” for cocaine. At 4:31 A.M., Patient #4 was medically cleared (ED Course, Page 25). At 5:06 A.M, Patient #4 was assessed by a licensed clinical social worker [LCSW]. It was documented that Patient #4 had fleeting thoughts of both suicidal and homicidal ideations with auditory hallucinations. The LCSW noted that Patient #4 has a history of suicide attempts and was non-compliant with medications. The LCSW recommended inpatient psychiatric care and noted that Patient #4 agreed to go and requested Facility B (Mental Health Preadmission Assessment, Page 26). At 9:15 A.M., the LCSW documented that Patient #4 was denied from Facility B due to his medical acuity (ED Notes, Page 28). At 9:38 A.M., Patient #4 was accepted to another psychiatric facility (ED Course, Page 25). A medical decision-making note was documented, “Patient medically cleared and evaluated by a psych assessor who managed to get the patient accepted to [Psychiatric facility]; however patient declined, wishing to go to Facility B, which had previously denied his admission. “Patient stated that he would like to be discharged home and will self-present to: [Facility B]” (ED Provider Note, Page 22). At 10:10 A.M., Patient #4 was discharged home (Discharge Information, Page 13). Patient #4 was diagnosed with Suicidal Ideation, an acute episode of schizophrenia (Visit Diagnoses, Page 14). Facility A knew that Patient #4 had been denied by Facility B for inpatient psychiatric care. Facility A discharged Patient #4 home to “self-present” to Facility B. It is not documented that Facility B agreed to the transfer or knew that Patient #4 would be presenting to their facility. Facility A failed to initiate an appropriate transfer with Facility B. . Review of Facility B’s Medical Record for Patient #4: 11/12/2025 at 3:30 P.M., Patient #4 voluntarily presented to Facility B with a chief complaint of a suicide attempt. A screening assessment was completed that listed the complaint as, “patient reports command hallucinations telling him to ‘kill himself and all police officers’. Patient reports trying to strangle himself with a sheet yesterday, which broke off, causing him to fail. Patient reports hx [history] of paranoid schizophrenia” (Screening Assessment, Page 40). Patient #4 screened as a high risk on the Columbia Suicide Severity Rating Scale (Screening Assessment, Page 42). Patient #4 was described as boisterous, loud, and hitting windows and doors during intake. The providers listed him as disheveled, irritable, resistant, paranoid, and with poor impulse control (Screening Assessment, Page 45). Per the inpatient comprehensive psychiatric evaluation, Patient #4 had schizoaffective disorder and was admitted voluntarily for command auditory hallucinations and a recent suicide attempt by strangulation. Patient #4 had a history of multiple inpatient psychiatric admissions, was described as having persecutory delusions of Federal Marshals chasing him, and he had been off all his psychiatric medications (Inpatient Comprehensive Psychiatric Evaluation, Page 14). The physician documented that Patient #4 would be admitted to inpatient due to the imminent risk of harm to himself, others, and impaired psychosocial functioning (Inpatient Comprehensive Psychiatric Evaluation, Page 17). Patient #4 was discharged home on 11/20/2025. . Review of Emergency Medical Treatment and Labor Evaluation Policy, Effective 02/25/2025: “B. Transfers 1) The hospital will provide for an appropriate transfer if the individual requests transfer or if the hospital does not have the capability or capacity to provide necessary treatment, pursuant to PC 055, Patient Transfers. . 2) If the patient’s EMC cannot be stabilized within the capability and capacity of the hospital, the patient may be transferred to other licensed healthcare facilities in compliance with state and federal law, and as addressed in PC 055, Patient Transfers. Any/all treatments that are within the capability and capacity of the hospital will be provided that may minimize the risk of transfer.” . “C. Leaving Against Medical Advice (AMA) or Without Being Seen (LWBS) 1) Patients who have completed the MSE but have not been stabilized or released for discharge or transfer by the attending physician and request to leave will be identified as requesting to leave the hospital AMA. In this event, staff will follow PC 042, Leaving Hospital Against Medical Advice. “ . Review of Patient Transfers Policy, Effective 11/29/2024” “5. Transfers To Other Hospitals A. Except under circumstances described in this policy, the physician who authorizes the transfer shall personally examine and evaluate the patient prior to the transfer to determine the patient’s medical needs and to assure that proper transfer procedures are used. The physician shall completed the form entitled Physician Assessment Prior to Transfer and sign the Memorandum of Transfer.” . “The transferring physician shall determine and other the utilization of appropriate personnel and equipment for the transfer and medically appropriate life support measures to stabilize the patient prior to transfer and sustain the patient during transfer. If a patient has an emergency medical condition which 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 an appropriate transfer shall be carried out as quickly as possible. The attending physician will provide any/all treatments within the capability and capacity of the facility to minimize the risk of transfer. However, before a patient with an emergency medical condition which has not been stabilized can be transferred one of the following requirements must be met: . 2.) the transferring physician signs 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 outweighs the increased risks to the patient.” . “C. Prior to transfer of a patient, the transferring physician will secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient’s medical treatment and hospital care.” . Interview: 02/25/2026 at 11:15 A.M., ED Physician, Staff J. Staff J explained that psychiatric patients can be stuck in the ED for days. Staff J stated that you have to do what you can for psychiatric patients, but there is only so much that can be done for them. Regarding Patient #4, Staff J stated that patients cannot pick and choose where they want to go. He stated that he was not concerned for Patient #4’s discharge, as they [the facility] were able to secure a facility to transfer Patient #4 to, and when he refused, there was an understanding and belief that Patient #4 would “self-present’ to Facility B. Staff J stated that “we [the facility] can’t keep them forever.” Staff J stated that Patient #4 did not go AMA. . 02/25/2026 at 11:40 A.M. ED Physician, Staff K stated if a patient was “lined up” for transfer and the patient refused the transfer, they would call the social worker back and ask them, “What’s the plan?” Staff K stated that the social workers guide the physicians with psychiatric patients. Staff K stated, “Medically, it is us, and psychiatrically, it is them”. Staff K stated that if a patient is not on an APOWW [Apprehension by a Police Officer Without a Warrant], the patient is voluntary and suicidal and homicidal, the patient needs to be evaluated and sent to a facility to get help. Staff K stated, “No one wants to send home a patient who is suicidal or homicidal”. Staff K stated that they didn’t know the thought process behind this particular discharge, but felt they would have needed another evaluation by the social worker before being discharged home. . 02/25/2026 at 12:07 P.M., ED Physician, Staff L, was given the scenario of a psychiatric patient with recommendations to transfer to inpatient psychiatric care who was then discharged home. Staff L stated that “that is not something that happens and that [they] would not discharge someone like that with those recommendations.” Staff L stated that even if they did discharge a patient like this, they would have made a note reassessing the patient. Staff L stated, “We [physicians] will not make a decision without psych social workers. We don’t unilaterally say, “Oh, this person’s been here two days, let me just discharge them.” “The psych social worker will come to us and say I reassessed this patient, they’re not a danger to themselves, he’s alert oriented, and I feel this patient is safe to go home. Ultimately, the physicians make the final determination, but we [physicians] use that information a lot; we give it a lot of weight.” Dispositions are always done in conjunction with a social worker who either transfers, admits the patient to a facility, or discharges home with resources.” . 02/26/2026, at 4:01 P.M., Chief Operating Officer, Staff P, at Facility B, stated that Patient #4 presented the next day, 11/12/25, to [Facility B] psychiatric facility. .”