Medical City Denton

“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 an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if the patients had an emergency medical condition for three of twenty patients (Patient #1, #18, and #19). . Patient #1 exhibiting signs of psychosis with “tremors shaking erratic movement and behavior” did not receive additional observations or a psychological reassessment before discharge to determine if the patient had an emergency medical condition. . Patient #18 brought to the facility by police under an emergency detention order for “substantial risk of serious harm” to himself of others during a mental health crisis. Patient #18 did not receive a CT scan of the head to rule out the documented closed head injury differential diagnosis, lithium level, or additional observation, and psychological reassessment . . Patient #19 presented to the facility with auditory and visual hallucinations. Patient #19 did not receive lab work, CT scan of the head to rule out all documented differential diagnoses, or additional observation and psychological reassessment. . 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 two of twenty patients (Patient #6 and Patient #18). Both Patient #6 and Patient #18 were under emergency detainment orders, discharged to police officers, and transferred to Facility B. . 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 did not 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 Tags 2406 and 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 an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if the patients had an emergency medical condition for three of twenty patients (Patient #1, #18, and #19). . Patient #1 exhibiting signs of psychosis with “tremors shaking erratic movement and behavior” did not receive additional observations or a psychological reassessment before discharge to determine if the patient had an emergency medical condition. . Patient #18 brought to the facility by police under an emergency detention order for “substantial risk of serious harm” to himself of others during a mental health crisis. Patient #18 did not receive a CT scan of the head to rule out the documented closed head injury differential diagnosis, lithium level, or additional observation, and psychological reassessment . . Patient #19 presented to the facility with auditory and visual hallucinations. Patient #19 did not receive lab work, CT scan of the head to rule out all documented differential diagnoses, or additional observation and psychological reassessment. . Record Review: Patient #1 Facility A Medical Record : On 04/01/2025 at 4:45 P.M., Patient #1, a thirty-eight-year-old male, presented to Facility A’s emergency department with a chief complaint of hallucinations, substance abuse, and a history of schizophrenia without medication compliance. At 5:34 P.M., Physician’s Assistant, Staff L began a medical screening examination. Staff L documented, “Patient presents off the streets walks in for evaluation after smoking something make him hallucinate, very anxious tremoring. Patient has a history of schizoaffective disorder, off all his medications also history of rhabdomyelitis (rhabdomyolysis) in the past. Denies any nausea vomiting alert oriented answering questions. Very tremors shaking movements and behaviors.” Patient #1’s medical screening examination noted “agitation, delusional, stress.” Treatment consisted of lab work, a chest x-ray, an electrocardiogram, one liter of fluids, and ten milligrams of Olanzapine (Zyprexa). A behavioral health consult was not ordered or completed. Patient #1 was diagnosed with “acute psychosis” and discharged home at 6:44 P.M.. Patient #1 did not receive a psychological re-assessment prior to discharge to determine if the patient was continuing to experience hallucinations. . A review of the Notification of Emergency Detention for Patient #18, completed bya Police Officer on 08/04/202 revealed: “ ... I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to him/herself or others...” Additionally, the Emergency Detention noted that the patient has a history of bipolar disorder and “appears to be mentally in a fantasy world and out of touch with reality as he continues to talk about having to do his death march.” . Patient #18 Facility A Medical Record: On 08/04/2025 at 8:45 P.M., Patient #18 presented to Facility A’s emergency department under an emergency detainment order with a chief complaint of altered mental status. At 8:50 P.M., Registered Nurse, Staff F documented, “”Pt (patient) out of bed and walked to stand in front of off duty and loudly states ‘Attention. Theres an officer on deck.” Pt redirected by officer back to bed. Pt follows commands and sat back in bed.” At 9:07 P.M., ED Physician, Staff E began a medical screening examination. Staff E documented, “male with history of bipolar disorder, hypertension presenting to the emergency department with concern for “altered mental status” found wandering in the street. Police reports that the patient was found outside marching and pacing in the street. The patient reports that he is doing “a death march” because he saw someone die a few days ago. He denies any SI (suicidal ideations), HI (homicidal ideations), AVH (audio/visual hallucinations). Pleases (police) reports that the patient is been off his medications for “a while.” At 9:29 P.M. Staff F documented, “”Pt started singing loudly was redirected, started singing quieter.” “Pt continuously stand out of bed and yells, ‘eyes front, eyes front’ pt redirected to sit down, pt complied after refusing request to sit.” Treatment consisted of lab work, excluding a lithium level, one milligram of Haldol, three hundred milligrams of Quetiapine (Seroquel), and an ordered but not completed CT (computed tomography) scan to rule out the documented closed head injury differential diagnosis. At 10:13 P.M. Staff E documented, “”patient elected to leave against medical advice. He did not have any SI HI or AVH at the time of my evaluation. We explained to the patient that leaving against medical advice could lead to worsening debility including death however patient still requests to leave. Patient walked out of the ER (emergency room).” At 10:47 P.M., Patient #18 was diagnosed with “psychosis” and discharged against medical advice to police officers, who transferred Patient #18 to Facility B. Facility A failed to determine if the patient was experiencing a mental health crisis or was an imminent risk to himself or others. Additionally, the facility failed to test the patient’s lithium level, or rule out a head injury as a differential diagnosis. . Observation: Review of Police Bodycam Footage recorded on 08/04/2025 7:09 P.M.: Patient #18 can be visualized with police officers, walking in his pajamas, holding his shoes in his hand as he sings loudly. Patient #18 was walking in the road and stopping in front of traffic, preventing vehicles from moving. 7:11 P.M. An officer approaches Patient #18. Patient #18’s feet appear red and swollen as he walks barefoot on the cement. Patient #18’s face is red , and his shirt is wet. Patient #18 interrupts the conversation to stand at attention and yell. All responses to the officer are in military fashion, and then the patient switches to slowly walking/marching away while counting his steps aloud. Patient #18 has a flight of ideas. Patient #18 gets on his hands and knees in the grass and begins counting again. 8:48 P.M.: Patient #18 sits on a hallway bed, gives his birthday to the nurse, and allows her to place an ID (identity) bracelet and blood pressure cuff on him as he continues his behaviors. The nurse asked, “Do you know where you are?” and Patient #18 responded, “Nope.” Patient #18 was asked who the president is, and he responded correctly with, “Trump.” The nurse asked Patient #18, “Do you know why you are here?” and Patient #18 responded, “Because I don’t like him.” Patient #18 sings again, “I did not shoot his ear, and I promise he will never be shot again.” 9:31 P.M.: The ED physician states that if the patient becomes violent and wants to leave, they will not be able to keep him. The officer explains that hospitals typically keep the patient and give patients medication to subside that and then get them back on their meds. He continues to explain that due to underlying medical conditions and concerns for his physical health, including Patient #18’s feet, the officers brought Patient #18 to the ED as mental health facilities require patients to be seen before admission. The ED physician then asks, “If we medically clear him, will you then take him to (Facility B)?” The officer states, “If you medically clear him, then yeah.” 9:58 P.M.: The nurse stated, “ We are happy to see him. We are concerned that he is acting this way, and you took him out of handcuffs.” “Our concern is we cannot enforce the EDO, which we already established, we can’t force him to stay ...” The officer stated, “The hospital could actually. The EDO is from us. So all the hospital has to say is we are holding him because there is an EDO on him. Unless the doctor releases him from the EDO.” The physician and nurse repeat that they cannot enforce an EDO due to hospital policy. 10:09 P.M.: Officers and Patient #18 leave the facility without paperwork for Facility B. 10:34 P.M.: Patient #18 arrives at Facility B and sits quietly in the lobby as police officers register him. . Review of a Police Report documented on 08/04/2025 at 11:55 P.M.: Police Officers documented that the hospital staff at Facility A informed officers that they do not honor emergency detention orders. Facility A stated that they have no legal right to keep Patient #18, and they would allow Patient #18 to go against medical advice. Officers noted that they decided to ask for medical clearance from Facility A and instead go to Facility B for mental health treatment. . Patient #18’s Facility B Medical Record: On 08/04/2025 at 10:50 P.M., Patient #18 presented to Facility B with police officers while under an emergency detainment order. An admission intake assessment was completed by a licensed clinical social worker. The assessment could not be completed by the provider, as they listed the patient as alert and oriented times one, knowing only himself, and being unable to answer questions appropriately. Facility B’s physician recommended inpatient treatment for Patient #18. . Patient #19 Facility A Medical Record: On 08/06/2025 at 1:59 P.M., Patient #19, a forty-eight-year-old female, presented to the emergency department by emergency medical services, with a chief complaint of auditory and visual hallucinations.. At 2:07 P.M., Physician’s Assistant, Staff Q, began a medical screening examination. Staff Q documented, “pt (patient) was kicked out of her hotel, a restaurant and removed from care now today by police. Has current delusions of delivering a baby in two weeks and simultaneously having delivered 2 weeks ago. Pt states positive ETOH (alcohol) as of the AM (morning).” Patient states, “I’m tired of hospitals, at this point is a federal and Trump is even involved.” Patient is requesting, “a 1, he has my soul mate and I do not want you to take my blood until he is here”. Denies having SI (suicidal ideations) or HI (homicidal ideations), HPI (history of present illness) limited secondary to patient’s manic state.” Patient #19 refused lab work and testing. Staff Q noted, “Patient keeps trying to stand up and walk around, looking around for “moment”. Appears executed.” “Patient is standing up in rubbing her abdomen stating “cannot to see how pregnant I am, the babies are about to come out.” Patient #19 did not receive a complete medical screening examination, as no psychological evaluation was completed. Patient #19 was diagnosed with “auditory and visual hallucinations.” At 2:20 P.M., Patient #19 was discharged against medical advice, . On 08/09/2025 at 9:16 A.M., ED Physician Staff R signed off on Patient #19’s medical record and documented, “Patient eloped from the emergency department after PA evaluation but before I could see the patient. Reason for elopement is unknown however patient denied suicidal ideations or homicidal ideations so I do not feel we need to get police involved to check this patient down.” Facility A failed to perform a complete medical screening examination, as Patient #19 did not receive lab work or a CT scan of the head to rule out all documented differential diagnoses, or additional observation and psychological reassessment. . Review of Texas EMTALA (emergency medical treatment and labor act) - Medical Screening Examination and Stabilization Policy, revised 11/2024: “Procedure 3. Extent of the MSE e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual’s signs and symptoms: ii. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others.” . “4. Who May Perform the MSE b. Qualified Medical Personnel. QMPs may perform an MSE if licensed and certified, approved by the hospital’s governing board through the hospital’s by-laws, and only if the scope of the EMC is within the individual’s scope of practice. ii. Psychiatric QMP. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination, and providing necessary stabilizing treatment.” . Review of AMA (Against Medical Advice Discharge), Revised 09/2021: “Policy: The responsibility of the Primary Care and/or Charge Nurse for a patient attempting to leave AMA will be as follows: 7. Retained patients must have a court order preventing AMA. 8. Initiate the chain of command for AMA patient safety concerns.” . Review of Medical Staff Rules and Regulations, Approved 03/19/2025: “Section 1.2 - Admission and Discharge of Patients 1. The hospital will accept for medical screening examination, stabilization and treatment, persons who present on hospital property requesting such services regardless of race, religion, national origin, age, sex, disability, physical/mental handicap, economic status, or ability to pay. a. Medical screening, b. Medical Screening Examinations (MSE) i. Definition: A medical screening examination is the ongoing patient evaluation process required to determine, with reasonable clinical confidence, whether a medical emergency exists. o Who may perform MSE: Psychiatric medical screening in this facility may be performed by a qualified mental health liaison in collaboration with Emergency Department Physicians.” . “Section 1.4 - General Conduct of Care 14. The good conduct of medical practice includes the proper and timely use of consultation. Judgment as to the serious nature of the illness, and the question of doubt as to the diagnosis and treatment, rests with the practitioner responsible for the care of the patient. It is the duty of the organized medical staff through its departmental chairman in conjunction with the Medical Executive Committee to see that those with clinical privileges do not fail in the matter of calling consultants as needed. Except in an emergency, consultation is required in the following situations: a. When the patient is not a good risk for operation or treatment b. Where the diagnosis is obscure after ordinary diagnostic procedures have been completed c. Where there is doubt as to the choice of therapeutic measures to be utilized; d. In unusually complicated situations where specific skills of other practitioners may be needed e. When requested by the patient or his/her family f. Any known or suspected suicidal patient g. In case of suspected child abuse h. In case of suspected rape i. In instances in which the patient exhibits severe psychiatric symptoms (e.g. attempted suicide, chemical overdose, etc.) and j. In case of chemical dependency” . Review of 2024 Plan for the Provision of Care Treatment and Services, Revised 12/2023: “B. SCREENING AND RISK ASSESSMENT Patient screening and risk assessment addresses each domain of the CCC framework: health behavior (safety), functional, physiological, and psychological components. 6. Suicide risk screening is performed for patients admitted to inpatient locations and emergency department patients with behavioral indicators. Patients with positive screens are provided with appropriate monitoring and referrals for psychiatric evaluation.” . Review of Guideline Involuntary Legal Holds, Updated 06/28/2023: “CLINICAL GUIDANCE The responsibilities of Emergency Departments & non-behavioral health hospitals related to the care of involuntary legal holds centers on screening, application of safe environment interventions, and prevention of elopement. Clinical staff are intended to prevent legal hold patients from leaving the facility during the timeframe defined by state-specific involuntary detainment laws. Staff should never place themselves or colleagues in the way of harm/risk of injury to prevent a patient from elopement; if a legal hold patient is demonstrating escalating or violent behaviors that might lead to harm to staff or self, local security or the local authorities (police) should be notified. -Violence aggression screening (Broset scale) may help to identify when a patient is escalating. If a legal hold patient is successful in elopement attempts, the local authorities should be notified immediately.” . Interviews: On 09/26/2025 at 2:30 P.M., Emergency Department Physician, Staff E was asked if mental health patients receive a behavioral health assessment before being discharged. Staff E stated that “Typically, yes. Typically, our policy has been that if we are seeing them, we will do a physical exam, MSE (medical screening exam), and we will tack on a behavioral health consultStaff E was asked if patients who are not suicidal or homicidal, but are still experiencing a mental health crisis, can they be a harm to themselves after discharge. Staff E indicated that “Absolutely.” “If patients are “not fully aware of (their) capabilities,” they “might hurt” themselves. Staff E was asked if they find their psychiatric assessment to be part of the MSE, or do they consult behavioral health to complete that portion of the MSE. Staff E stated, “A little bit of both, I use my clinical judgement as best I can with these things. But with psychosis, it’s very tricky. Oftentimes, a behavioral health specialist is more useful.” .” Staff E indicated that they use telepsych for consults. .”

“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 two of twenty patients (Patient #6 and Patient #18). Both Patient #6 and Patient #18 were under emergency detainment orders, discharged to police officers, and transferred to Facility B. . 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 did not 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 Patient #6 Facility A Medical Record: On 05/02/2025 at 1:07 P.M., Patient #6, a forty-seven-year-old male, presented to Facility A’s emergency department under an emergency detainment order for a suicide attempt. Patient #6 “was in the car with the garage closed and car running.” Patient #6 “got scared,” went inside, and took half a bottle of Lisinopril and half a bottle of Tramadol. Treatment consisted of lab work, an electrocardiogram, and an order for a behavioral health consult. The behavioral health consult was not completed. At 6:33 P.M., a nursing note documented that Patient #6 was “very agitated” and the nurse “tried to explain the (Facility B) process,” but the patient continued “walking around the room, yelling, anxious.” Patient #6 was monitored for six hours as directed by poison control. At 6:40 P.M., a nurse’s note documented that the nurse “called and spoke with the intake RN (registered nurse). Notified that pt (patient) was coming with PD (police department). Medically cleared.” At 6:50 P.M., Patient #6 was diagnosed with a suicide attempt by intentional overdose and was discharged to the police. Facility A was aware of the patient’s transfer to Facility B. Facility A failed to initiate an appropriate transfer as there was no memorandum of transfer, the receiving facility did not accept the transfer, Facility A did not send any pertinent paperwork . Patient #6 Facility B Medical Record: On 05/02/2025 at 8:23 P.M., Patient #6 presented to Facility B under an emergency detainment order with police. A “High Risk Handoff” document details high-risk factors of suicide risk, aggression/homicide risk, elopement risk, and sexual aggression risk. The physician documented a history of physical illness that detailed Patient #6 was previously at Facility A for an overdose attempt. The physician noted that Patient #6 was depressed, anxious, irritable, and had suicidal ideations. Patient #6 was recommended to be admitted as an inpatient for treatment as they pose a “threat to self, others or property due to active manifestation of the psychiatric disorder”. . Patient #18 Facility A Medical Record: On 08/04/2025 at 8:45 P.M., Patient #18 presented to Facility A’s emergency department under an emergency detainment order with a chief complaint of altered mental status. At 8:50 P.M., Registered Nurse, Staff F documented, “”Pt (patient) out of bed and walked to stand in front of off duty and loudly states ‘Attention. Theres an officer on deck.” Pt redirected by officer back to bed. Pt follows commands and sat back in bed.” At 9:07 P.M., ED Physician, Staff E began a medical screening examination. Staff E documented, “male with history of bipolar disorder, hypertension presenting to the emergency department with concern for “altered mental status” found wandering in the street. Police reports that the patient was found outside marching and pacing in the street. The patient reports that he is doing “a death march” because he saw someone die a few days ago. He denies any SI (suicidal ideations), HI (homicidal ideations), AVH (audio/visual hallucinations). Pleases (police) reports that the patient is been off his medications for “a while.” At 9:29 P.M. Staff F documented, “”Pt started singing loudly was redirected, started singing quieter.” “Pt continuously stand out of bed and yells, ‘eyes front, eyes front’ pt redirected to sit down, pt complied after refusing request to sit.” Treatment consisted of lab work, excluding a lithium level, one milligram of Haldol, three hundred milligrams of Quetiapine (Seroquel), and an ordered but not completed CT (computed tomography) scan to rule out the documented closed head injury differential diagnosis. At 10:13 P.M. Staff E documented, “”patient elected to leave against medical advice. He did not have any SI HI or AVH at the time of my evaluation. We explained to the patient that leaving against medical advice could lead to worsening debility including death however patient still requests to leave. Patient walked out of the ER (emergency room).” At 10:47 P.M., Patient #18 was diagnosed with “psychosis” and discharged against medical advice to police officers, who transferred Patient #18 to Facility B. Nursing note stated, “”Pt[patient] walked “marched out” with [sic] police officers at this time. Pt was cooperative at the time of leaving out the ambulance bay.” Facility A failed to initiate an appropriate transfer as there was no memorandum of transfer, the receiving facility did not accept the transfer, Facility A did not send any pertinent paperwork. . Observation: Review of Police Bodycam Footage recorded on 08/04/2025 7:09 P.M.: Patient #18 can be visualized with police officers, walking in his pajamas, holding his shoes in his hand as he sings loudly. Patient #18 was walking in the road and stopping in front of traffic, preventing vehicles from moving. 7:11 P.M. An officer approaches Patient #18. Patient #18’s feet appear red and swollen as he walks barefoot on the cement. Patient #18’s face is red , and his shirt is wet. Patient #18 interrupts the conversation to stand at attention and yell. All responses to the officer are in military fashion, and then the patient switches to slowly walking/marching away while counting his steps aloud. Patient #18 has a flight of ideas. Patient #18 gets on his hands and knees in the grass and begins counting again. 8:48 P.M.: Patient #18 sits on a hallway bed, gives his birthday to the nurse, and allows her to place an ID (identity) bracelet and blood pressure cuff on him as he continues his behaviors. The nurse asked, “Do you know where you are?” and Patient #18 responded, “Nope.” Patient #18 was asked who the president is, and he responded correctly with, “Trump.” The nurse asked Patient #18, “Do you know why you are here?” and Patient #18 responded, “Because I don’t like him.” Patient #18 sings again, “I did not shoot his ear, and I promise he will never be shot again.” 9:31 P.M.: The ED physician states that if the patient becomes violent and wants to leave, they will not be able to keep him. The officer explains that hospitals typically keep the patient and give patients medication to subside that and then get them back on their meds. He continues to explain that due to underlying medical conditions and concerns for his physical health, including Patient #18’s feet, the officers brought Patient #18 to the ED as mental health facilities require patients to be seen before admission. The ED physician then asks, “If we medically clear him, will you then take him to (Facility B)?” The officer states, “If you medically clear him, then yeah.” 9:58 P.M.: The nurse stated, “ We are happy to see him. We are concerned that he is acting this way, and you took him out of handcuffs.” “Our concern is we cannot enforce the EDO, which we already established, we can’t force him to stay ...” The officer stated, “The hospital could actually. The EDO is from us. So all the hospital has to say is we are holding him because there is an EDO on him. Unless the doctor releases him from the EDO.” The physician and nurse repeat that they cannot enforce an EDO due to hospital policy. 10:09 P.M.: Officers and Patient #18 leave the facility without paperwork for Facility B. 10:34 P.M.: Patient #18 arrives at Facility B and sits quietly in the lobby as police officers register him. . Review of a Police Report documented on 08/04/2025 at 11:55 P.M.: Police Officers documented that the hospital staff at Facility A informed officers that they do not honor emergency detention orders. Facility A stated that they have no legal right to keep Patient #18, and they would allow Patient #18 to go against medical advice. Officers noted that they decided to ask for medical clearance from Facility A and instead go to Facility B for mental health treatment. . Patient #18’s Facility B Medical Record: On 08/04/2025 at 10:50 P.M., Patient #18 presented to Facility B with police officers while under an emergency detainment order. An admission intake assessment was completed by a licensed clinical social worker. The assessment could not be completed by the provider, as they listed the patient as alert and oriented times one, knowing only himself, and being unable to answer questions appropriately. Documented within the “presenting problems and significant history” portion of the chart, it is noted that Patient #18 was previously seen at Facility A and was medically cleared. Facility B’s physician recommended inpatient treatment for Patient #18. . Review of EMTALA (emergency medical treatment and labor act) - Definitions and General Requirements, Effective 07/01/2024: “A. General Requirements EMTALA requires the hospital to do the following: 2. If the hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer.” . “E. Transfer Obligations of Each Hospital 1. A hospital may transfer an individual with an EMC that has not been stabilized if the transfer is appropriate, and if: 2. A transfer to another medical facility will be appropriate in those cases in which the receiving hospital can provide medical treatment within its capacity that can minimize the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; and the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to provide such care. 3. The transferring hospital must send the medical records related to the EMC along with any history, preliminary diagnosis, results of diagnostic studies or telephone reports, and other medical records pertinent to the patient’s presenting EMC and the written informed consent or certification required for the transfer. Test results that become available after the individual is transferred should be telephoned to the receiving hospital, and then mailed or sent via electronic transmission consistent with HIPAA provisions on the transmission of electronic data. 5. The receiving facility must accept appropriate transfers of individuals with EMCs if the hospital has specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals.” . Review of Medical Staff Rules and Regulations, Approved 03/19/2025: “Section 1.2 - Admission and Discharge of Patients 1. The hospital will accept for medical screening examination, stabilization and treatment, persons who present on hospital property requesting such services regardless of race, religion, national origin, age, sex, disability, physical/mental handicap, economic status, or ability to pay. a. Medical screening, stabilization, treatment and/or transfers will be accomplished in accordance with Federal and State regulations. 14. For the protection of patients, the medical and nursing staff and the hospital, precautions will be taken in the care of the potentially suicidal patient. Suicidal and psychotic patients presenting themselves with these diagnoses will, when the physician treating the medical condition declares the patient stable, be transferred to another hospital, after transfer arrangements are completed. Stable, chemical dependent patients will be transferred to an appropriate setting after transfer arrangements are complete.” . Interviews : On 09/24/2025 at 2:22 P.M., Emergency Department Manager, Staff B, indicated that Patient #6 did not have an MOT (memorandum of transfer) as he was discharged to the police. Staff B verified that Patient #6 was discharged to the police, who then transported Patient #6 to Facility B. . On 09/25/2025 at 11:45 A.M., Emergency Department Registered Nurse, Staff F, indicated that all patient transfers require an MOT (memorandum of transfer), “no matter where they are going.” . On 09/25/2025 at 12:00 P.M., the Emergency Department Director, Staff C, was asked if the facility should initiate a memorandum of transfer (MOT) to known mental health facilities for patients who are discharged to the police. Staff C stated, “That’s definitely an opportunity.” . On 09/25/2025 at 12:45 P.M., Emergency Department Physician, Staff D confirmed that patients who transfer to another facility do require a memorandum of transfer (MOT). . On 09/25/2025 at 10:50 A.M., Staff K was asked if the facility is able to discharge patients to the police and have them take the patient to a mental health facility? Staff K stated, “I don’t think it’s called a transfer. We wouldn’t fill out an MOT; it’s not the same. We discharge them to police, and don’t do an MOT for that.” .”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 33589 BASED ON record review and interview, the facility registered nurse (RN) failed to supervise and evaluate the nursing care of each patient according to the patient specific needs. Patient #1 did not have a nurse assessment/re-assessment documented for 49 hours from 10/26/2024 to 10/28/2024 while receiving a Cardiac drip for an arrythmia as an Emergency Department (ED) hold patient awaiting a Heart and Vascular Unit (HVU) bed. FINDINGS Patient #1 came in with Atrial Fibrillation with Rapid Ventricular Rate (Afib with RVR) and was initiated on a Cardizem Drip in the Emergency Department (ED). Admission orders for the Heart/Vascular Stepdown Unit (HVU) were obtained, but the patient was held in ED awaiting a bed. During the ED hold from 10/26/2024 through 10/28/2024, there were no nurse assessment/re-assessments completed. The patient had bradycardia and Cardizem was stopped. Cardizem was restarted when the heart rate elevated again. Emergency Patient Record Triage Note noted, “Arrival 10/26/2024 18:01...Triage 18:04...Stated Complaint Afib with RVR...Chief Complaint: Cardiac related...Priority: 2...10/26/2024 22:43 Admit Patient...10/28/2024 12:01 Off Tracker...” There were 49 hours in between the “10/26/2024 18:35 (6:35 PM) Emergency Department nurse assessment” and the “10/28/2024 1930 (7:30 PM) Initial assessment/Health History” in HVU. There were 32 hours in between the “10/26/2024 22:43 (10:43 PM) Order Admit Heart/Vascular Stepdown (HVU)” and the “10/28/2024 1930 (7:30 PM) Initial Assessment/Health History” in HVU. Order: Diltiazem/Cardizem 10/26/2024 21:10 (9:10 PM) 100MG/100 ML Normal Saline (1 mg/mil -milligrams/milliter) Initial rate 5 mg/hour Titrate by 5 mg/hr (milligrams/hour) every 15 minutes ***Maximum rate 15 mg/hr for up to 24 hours Goal: Maintain hr 60 - 100; Hold for SBP (Systolic Blood Pressure) less than or equal to 100 mmHg. Cardizem Administration was recorded by Personnel #16 on 10/27/2024 at 3:19 AM for all the following “occurred” times: 10/26/2024 21:40 (9:40 PM) Cardizem started at 5 mg/hr with Heart Rate of 137; 2200 (10:00 PM) Heart Rate 101; 2215 (10:15 PM) Cardizem titrated up to 10mg/hr HR 112; 2230 (10:30 PM) Cardizem titrated up to 15 mg/hr HR 112; 10/27/2024 0345 (3:45 AM) Nurse Note: converted to sinus brady 50’s Cardizem stopped ... 0400 (4:00 AM) HR 54 There were no meals evidenced with the “10/27/2024 0158 Heart Healthy diet order.” During a telephone interview on 2/11/2025 at 3:59 PM, Personnel #2 and #3 were asked if the investigation had found there were no nurse assessments. Personnel #2 stated, “no. I did not.” They were informed there was no nurse assessment documented for > 48 hours and the date/times were given. Personnel #2 stated, “it was 49 hours. It (initial admit assessment) was done on the 6th Floor.” They were asked if assessments were required. Personnel #2 stated, “yes. Once they are admitted, they are to be monitored at the admit level. Med Surg is 12 hours and ICU is 8 hours.” Personnel #3 stated, “initial nursing assessments are to be completed within 12 hours of the ordered admit.” They were asked if the patient was in the ED the whole time until the 10/28/2024 Cath Lab transfer. Personnel #2 stated, “yes, it looks like they were. The patient went to the Cath Lab at noon and then the 6th floor at 1600 (4:00 PM).” They were asked if the 6th floor was HVU. Personnel #2 stated, “yes.” They were asked about nurse monitoring on a Cardiac drip. Personnel #3 stated, “we have a titration protocol, but I don’t think we have a specific monitoring policy.” They were asked what food and fluids the patient received on the Heart Healthy diet. Personnel #2 stated, “I see a 500-milliliter bag of Normal Saline and a Saline lock. I am not seeing meals.” They were given the opportunity to provide further evidence if they found it. No further evidence was provided. From: Personnel #3 Sent: Wednesday, February 12, 2025 8:16 AM “...I did clarify that we do not have a specific titration policy, the titration is order dependent and vital signs are dependent on titration timing and are reassessed depending on level of care. We also do not have a policy on boarding/holding in the Emergency Department...” The facility’s policy for the ED required every 15-minute vitals and every hour for 4 hours focused reassessments for Priority: Level 2 / Emergent patient care. The HVU required an initial assessment within 12 hours. Re-assessment every 4-hour vitals and every 4-hour re-assessments per the policy. The Facility’s 2024 Plan for the Provision of Care & Services / Assessment / Reassessment Policy required, “The initial assessment is initiated upon admission or initiation of service by a licensed professional. For inpatients, the initial assessment is completed within 12 hours ...Reassessment frequency is defined by each inpatient and outpatient care area based on the usual course of care for the patient population. Reassessment is also undertaken whenever a change in patient condition is identified and at key points in the treatment process including at change of shift, and/or at transition of caregiver or care unit...Frequency of vital signs monitoring; including Modified Early Warning Scoring System (MEWS) is defined by each care area. More frequent vital signs monitoring is required during and after procedures, in relation to specific medications or treatments, and whenever a change in condition is identified...Emergency Department Re-Assessment: - Prior to a medical screening exam (MSE), a registered nurse initiates evaluation of the patient, including assessing the patient’s vital signs, conducting a focused physical assessment including pain assessment, assessing general appearance, and collecting pertinent medical history information. Patients waiting for the initiation of the MSE should have a reassessment performed at a minimum of...Level 2 / Emergent: Every 15 minutes...Reassessments after initiation of the MSE are performed by RN’s according to acuity...Level 2 / Emergent: At least every hour based on clinical presentation for a minimum of 4 hours and more frequently if needed... HVU (Heart and Vascular Unit) Assessment: - Initiated upon arrival and at the beginning of each shift - Completed by RN within 8 hours - Plan of Care initiated within first 8 hours of admission - Routine vital signs every 4 hours including blood pressure, pulse, respiration rate, temperature, O2 saturation. - Daily weights on specific populations: heart failure, renal, dialysis and TPN - Input and output monitored on all patients and recorded at the end of each shift - Continuous cardiac monitoring Re-assessments: - At a minimum of every 4 hours, focused reassessment.””