HCA Houston Healthcare Northwest

“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: 46010 Based on observation, interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam for Patient IDs #4, 17, 21 and 22. The facility failed to provide appropriate stabilizing treatment until transfer or resolution of the emergency medical condition for Patient IDs# 17 and 22. Refer to tags A 2406 and A 2407 for additional information.”

“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: 37490 Based on record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) to determine whether an Emergent Medical Condition (EMC) existed in 4 of 26 patients . Patient IDs #4, 17, 21 and 22. Findings include: Record review of facility policy titled “EMTALA - Medical Screening Examination and Stabilization Policy” dated 7/2024 showed the following: Policy: An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (“DED”) and: 1. the individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition; or 2. a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition (“EMC”). Further, if a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE, within the capabilities of the hospital’s DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA. Stabilization treatment shall be applied in a non- discriminatory manner (e.g., no different level of care because of age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state or local law). Procedure: 1. When an MSE is Required A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when: a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition. ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person (“QMP”) must perform an appropriate MSE. The physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an EMC is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under EMTALA ceases. Medcial record review showed the following: Patient (ID#4) on 3/4/2026 arrived by ambulance/law enforcement for medical clearance for incarceration after reported erratic behavior and complaint of numbness throughout his body. The medical record failed to show QMP documentation of: history, physical examination, neurologic assessment, behavioral/psychiatric assessment, or medical decision-making addressing the reported erratic behavior and diffuse numbness. The patient was discharged to jail/court. Patient (ID#17) on 01/14/2026 arrived by ambulance with suicidal ideation and a reported intentional ingestion of approximately 6400 mg of ibuprofen. She stated she did not want to live and wanted to kill herself. The medical record failed to show a completed medical/toxicologic evaluation sufficient to determine whether an overdose-related Emergent Medical Condition (EMC) existed. Patient (ID#21) on 3/4/2026 arrived by EMS with auditory hallucinations/paranoia, concern that people were going to kill his family, history of schizophrenia, and reported medication noncompliance for approximately 3 weeks. He was tachycardic (abnormal elevated heart rate) and hypertensive (abnormal elevated blood pressure). The medical record failed to show clinically sufficient psychiatric risk assessment addressing whether symptoms were acute versus baseline, whether the patient posed danger to self or others, whether he had command hallucinations, whether he could maintain safety, or whether paranoid beliefs created risk of unsafe behavior. Patient (ID#21) on 3/5/2026 returned shortly after prior emergency department visit under HCSO (Harris County Sheriff’s Office) EDO (Emergency Detention Order) for paranoid/bizarre behavior. He reported that someone was after him, had punched a police vehicle window, was hiding in the patrol car, admitted drug use, and had tachycardia. The provider documented denial of suicidal/homicidal ideation and hallucinations and the patient was discharged. The medical record failed to show a clinically sufficient assessment of the EDO basis, acute psychosis risk, capacity/refusal, substance intoxication, or persistent abnormal vital signs. Patient (ID#22) on 3/5/2026 presented with suicidal ideation and a reported recent intentional ingestion of a handful of unknown pills. The MUSE identified a psychiatric ENC, with telepsychiatry documenting high suicide risk and recommending involuntary inpatient psychiatric hospitalization. The record does not support that the patient had capacity to refuse necessary treatment. Telepsychiatry documented impaired insight/judgment, impulsivity, high suicide risk, and need for involuntary inpatient psychiatric hospitalization. Interview with Emergency Room provider (ID# 61) on 4/1/2026 at 9:45 AM stated that no matter how the patient arrives at the facility (i.e. ambulance, walk-in, police), the providers still have the job of assessing the patient for a medical emergency. The provider would receive report, perform an evaluation and treat the patient as necessary for an emergency medical condition. She stated that the evaluation would consist of obtaining the patient’s medical history, review of systems, comorbidities, physical exam, labs and/or imaging as appropriate.”

“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: 46010 Based on interview and record review, the facility failed to provide stabilizing treatment, when they allowed 2 of 5 patients with psychiatric emergency medical conditions, to elope and/or leave against medical advice (AMA), while experiencing a psychiatric emergency medical condition (Patient IDs #17 and 22). Findings included: Record review of facility policy titled “Patient Rights and Responsibilities”, last approved 12/2025, stated “ 3. Patients have the right to ...Treatment and access to medically indicated care ... The hospital must provide evaluation, services and/or referral as indicated by the urgency of the case ...” Record review of facility policy titled “Suicide Risk Assessment Non-BH Settings”, last approved 02/2026, stated “Purpose: To provide guidance to assist with the identification of patients in non-Behavioral Health (BH) settings who are at risk for suicide, ensuring a safe environment for the provision of care.” The policy further stated “Definitions: Columbia Suicide Severity Rating Scale (C-SSRS) is the initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. One to one observation (1:1) may be implemented as virtual/line of sight (LOS) or physical in person based on the patient overall risk level. This is initiated by nursing based on the C-SSRS score and facility protocol. The level of observation may be adjusted by the provider after the patient has been assessed and ORL has been determined.” The policy stated “Patient who are at increased risk of suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well being. The scope of the plan begins at triage,..and continues until the patient is discharged.” The policy stated “Patients in noon-psychiatric areas (ER), aged 12 years and older, who are being evaluated or treated for BH conditions as their primary reason for care should be screened using the C-SSRS.” The policy further stated “10. The nurse will determine the appropriate interventions based on initial C-SSRS. Once the subsequent detailed risk assessment is completed and overall risk level assigned, the overall risk level will be used as the source of truth to determine the appropriate interventions: Physical patient safety attendant (PSA) in place 1:1 for high risk ...Maintain suicide safe environment precautions. Document environmental precautions in EHR every shift and as needed with a change in condition. Suicide interventions implemented... Complete Suicide Environmental Checklist once per shift. PSA observation log will be used to document Q 15 minutes ...” The policy further stated “12. 1:1 PSA Process: a. All patients identified as high risk for suicide in an outpatient or inpatient non-BH setting are required to have a process in place to provide 1:1 PSA observation. B. Provider/practitioner order is not required; this is a policy driven process. Primary nurse to initiate internal PSA request process. C. Documentation of observation q 15 minutes for all High Risk 1:1 patients utilizing the observation log.” Record review of facility policy titled “EMTALA- Medical Screening Examination and Stabilization Policy”, last approved 07/2024 stated “The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists, or (ii) with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA.” Medical Record Review of Patient ID #17 arrived to the facility on 1/14/26 at 5:16 pm via ambulance with chief complaint “Pt coming from home c/o SI (Suicidal Ideation) states she doesn’t want to live anymore and wants to kill herself. Took 6400 mg of ibuprofen at 16:30...”. The record included that ED provider staff ID #69 placed order at 5:23 pm for “suicide precautions STAT”. At 5:25 pm, suicide precautions and patient observations ordered by ED provider staff ID #69. 6:01 pm, Patient ID #17 had telepsych advanced practice provider staff ID # 70 whose recommendations stated “Recommendations: Inpatient Psychiatric Hospitalization to manage mood symptoms.... Monitor patient safety and behavior symptoms. Please ensure EDO has been initiated as patient is not safe to discharge due to current emotional state, with pending transfer to inptn psychiatric hospital.” Medical record reflected at 6:39 pm, ED RN Staff ID # 71 documented “Ptn refusing all tx @this time. States did not mention being suicidal to anyone was wants to go home...Provider notified.” At 6:59 pm, “Versed 5 mg IV x 1 chemical restraints ordered.” Entry at 7:31 pm, Patient 17 eloped and was removed from the computer. Interview with medical record review on 4/1/2026 at 11:20 am with ED Nurse Director Staff ID #54 for Patient ID #17. She confirmed she could not see evidence that the patient had continuous visual monitoring implemented, or an equivalent supervised safety environment, which had been ordered at 5:25 PM. She confirmed the medical record for Patient ID # 17 stated that the patient left the facility, unaccompanied at 7:31 PM, despite having identification of high suicide risk factors and documented need for involuntary inpatient psychiatric hospitalization. Medical record review of patient ID #22 arrived to the facility ED on 3/5/26 at 08:55 am as a walk-in “chief complaint: per mother. pt took a handful of pills, the other day and pt stated he no longer wanted to be here. Pt. states he is SI (suicidal ideation) but denies HI (homicidal ideation), pt did not know what med he took....”. At 09.41 am, Telepsych provider staff ID # 76 documents “Patient comes in depressed and suicidal. He is guarded and has no insight into his current situation; he is preoccupied to the point he needs significant oversight and I am having to get information from his mom. He is minimizing and uncooperative with my evaluation. He is impulsive and cannot be safely discharged. He will need supervision and med management to stabilize his mood to the point he is no longer a danger to himself.” 10:08 am. Patient Safety Attendant Monitoring was ordered. 10:43 am Behavioral Health Clinician staff ID # 65 documents “After ptn spoke to telepsych provider, he decided to go home with his mother and go directly to HCPC/Ben Taub...left before signing AMA form.” 10:48 am ED Physician staff ID #73 documents “Ptn was seen by psych then abruptly left without being seen by me. Was voluntarily here, no EDO. I did not have opportunity to evaluate patient.” Interview on 4/2/26 at 10:05 am with ED Nurse Director Staff ID #54. She confirmed she could not locate documentation or evidence that Patient ID #22 had continuous visual monitoring or an equivalent supervised safety environment implemented, that had been ordered at 3/5/26 at 10:07 am. She confirmed patient ID #22 left the facility at 10:43 am “against medical advice” after telepsychiatry consultation revealed the patient needed to be detained involuntarily due to high suicidal risks and need for involuntary inpatient psychiatric hospitalization. Interview with ED Medical Director Staff ID # 59 on 4/2/26 at 11:00 am. She stated that behavioral health safety assessments such as room sweeps and continuous visual monitoring/sitters, that are ordered “stat” should be initiated “immediately.” She stated that when these orders are placed by ED providers, they include verbal discussion between the patient’s assigned nurse or charge nurse, to ensure the care team is on the same page so they can be implemented immediately.”

“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: 23032 Based on interview and record review, the hospital failed to comply with the EMTALA (Emergency Medical Treatment and Labor Act) requirements at 42 CFR §489.24(d)(1). Based on record review , the facility failed to provide medical interventions to ensure with reasonable medical probability, Patient # 1’s emergency medical condition would not deteriorate and cause serious, potentially life-threatening complications. Refer to Tag A-2407”

“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: 23032 Based on record review , the facility failed to provide medical interventions to ensure reasonable medical probability, Patient # 1’s emergency medical condition would not deteriorate and cause serious, potentially life-threatening complications. Findings included: Review of facility policy titled “EMTALA-Medical Screening and Stabilization Policy,” last approved 07/2024, read: 7. Stabilizing Treatment within Hospital Capability: a) Stable: The physician or Qualified Medical professional (QMP) providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the emergency medical condition (EMC) that caused the individual to seek care in the Emergency Department (ED)has been revolved, although an underlying medical cognition may persist. ~~~~~~~~~~~~~ Hospital A - ED : Review of Patient # 1’s medical record showed she was a 12-year-old female who presented to the ED on 12/11/2025 with fever, right-sided facial swelling, neck pain, and pain with swallowing. She had been seen in the same ED [Hospital A] the day before, 12/10/2025, with symptoms of fever, sore throat, nausea and vomiting and was diagnosed with viral illness and dehydration. Patient # 1 was discharged home. On 12/11/2025, the ED medical screening exam showed : - physical exam showed fever; swelling to right side of face, extending to upper cheek, concerning facial cellulite. -exam of the middle section of the throat redness and swelling present on the right side of mouth compared to the left, concerning for extension of the infection. The following lab results were suggestive of a systemic inflammatory response and severe infection: - white blood count (wbc) findings showed predominance of neutrophils with elevated bands. - complete blood count (cbc) showed thrombocytopenia: 107 (reference range 130-408) - Erythrocyte Sedimentation Rate was elevated above reference range - C-Reactive Protein (CRP) -was elevated. [*see Glossary for more details provided on lab testing listed above] CT scan showed sinusitis involving the right sinuses; and swelling of soft tissues: concerning periorbital cellulitis. Review of ED MD Progress note, dated 12/11/2025 at 3:46 PM read: “ED Course; Patient has no leukocytosis on labs and no significant anemia, however she does have a neutrophil predominance and 6 % bands ...” Patient # 1 was found to have an Emergency Medical Condition of acute bacterial pan-sinusitis with systemic inflammatory response and right facial cellulitis/ preorbital cellulitis. On 12/11/2025, Patient # 1 was given one dose of intravenous (IV) ceftriaxone and was discharged home on oral cephalexin (antibiotic) for infection, which does not provide adequate coverage for sinusitis and facial cellulitis. The clinical findings showed a severe bacterial infection and inflammatory response . There was significant risk for rapid progression. Patient # 1 required inpatient admission and intravenous (IV) antibiotic coverage for Methiicillin -resistant Staphylococcus aureus [MRSA], given sinusitis as the suspected source of infection. Hospital B -ED: On 12/13/2025, Patient # 1 was brought to a different hospital ED by her mother with concerns for 3 days of progressive facial swelling. Seen twice at outside ER. Presented this day with worsening facial pain and swelling. Hospital B transferred Patient # 1 to a higher level of care to Hospital C , where she presented with persistent facial swelling and neck pain and was found to have complicated sinusitis with multiple associated thrombi. She was admitted as an inpatient.”

“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: 38015 Based on record review and interview, the facility failed to ensure nursing staff; A) completed accurate and consistent skin assessments for Patient #2, which was likely a contributory factor leading to a hospital acquired pressure injury, and; B) were able to accurately show that patient repositioning to prevent pressure injuries was performed. Findings included: Review of facility policy #19165823 titled “Pressure Injury Policy” originating 3/2023, showed that all patients will have a full physical skin assessment once per shift. The skin assessments and any presence of skin alterations or wounds will be documented in the Electronic Health Records (EHR) for all patients. The documentation includes location, type, and staging for pressure injuries. The policy also stated that patients with a Braden II scale of 18 or less are considered to be at risk for pressure injuries. In addition, the policy did not specifically list repositioning of patients as a pressure injury intervention. Record review of Patient #2’s clinical chart showed the following: 77-year-old male admitted 11/9/25 due to respiratory failure secondary to congestive heart failure. His had past medical history diagnoses included chronic kidney disease, atrial fibrillation, diabetes mellitus, hypertension. Initial history & physical exam on 11/9/25 showed his skin was intact without significant lesions. The patient had a Braden II scale of 14, putting him at risk for pressure injury. Initial musculoskeletal assessment revealed there were no deformities noted around the thoracic and lumbar spine regions. He was primarily bed bound, with morbid obesity and functional quadriplegia. Skin assessments from 11/9/25 through 12/28/25 while the patient was residing on the facility’s third floor North Tower, a telemetry and intermediate care unit (IMU), showed there were no pressure injuries documented for the sacrum and/or left buttocks, and the skin assessments for these areas were normal. On 12/29/25, the patient was transferred to the facility’s medical intensive care unit (South MICU) for worsening acute respiratory failure and altered mental status secondary to toxic metabolic encephalon. Skin assessments were still normal; there were no indications or signs of pending pressure injuries over the sacrum or left buttocks noted in his EHR. On 12/30/25, skin assessments were all still normal. Then, skin assessment on 12/31/25 at 8:00 am showed: Posterior Sacrum Pressure Injury, present on admission, unstageable (Unstageable=the depth is unknown because slough or eschar obscured the extent of tissue damage), beefy red, dusky red tissue surrounding injury, and, Left Buttock Pressure Injury, present on admission, unstageable. Wound Care notes dated 12/31/25 at 10:25 am from Wound Care Nurse Staff #G showed patient was assessed for unstageable pressure injury on buttocks/sacrum Notes also showed treatment was initiated, consisting of cleansing wound with Vashe and using Mepilex to protect wound. Pictures taken 12/31/25 of the patient’s buttocks/sacrum were reviewed during survey; they showed severe tissue injury consistent with nursing assessment findings (Wound cultures were later taken on 1/1/26 with final results showing infection caused by the bacteria Morganella Morganii, a gram-negative rod bacillus). Then, skin assessment on 12/31/25 at 12:00 pm showed “Integumentary-All normal” and nothing regarding the sacral and buttock pressure injuries. Skin assessment on 1/1/26 at 8:00 am showed “Integumentary-All normal, but also showed “Posterior Sacrum pressure injury-unstageable” and “Left Buttocks Pressure Injury-unstageable”. However, the description entries on the EHR were left blank. These entries included: Pressure injury staging, skin alteration details, wound surround tissue appearance, wound surrounding tissue temperature, wound drainage description, wound drainage amount, wound drainage odor, wound cleansing, dressing status, dressing intervention, dressing type, alteration photographed, wound dressing change date, and, document advanced wound measurements. Skin assessment on 1/2/26 showed “Integumentary-All normal”. There was nothing noted about pressure injuries for the entire day. Skin assessment on 1/3/26 showed “Integumentary-All normal”. There was nothing noted about pressure injuries for the entire day. Skin assessments on 1/4/26 at 7:33 am showed “Integumentary-All normal” with nothing noted about the pressure injuries. Then an assessment at 1:26 pm showed: Posterior Sacrum-pressure injury, present on admission, Stage 2 (nothing noted for the left buttock, and no description entries). Then an assessment at 8:00 pm showed: “Integumentary-All normal”, again, with nothing noted about the pressure injuries. Skin assessments on 1/5/26 were not documented. Review of History & Physical/discharge summary from Dr. Staff #J showed that on 1/5/26, the patient expired. Assessment portion of the summary included: AMS (altered mental status) 2/2 (secondary to) toxic metabolic encephalopathy, Distributive shock 2/2 GNR bacteremia (Gram-Negative Rod bacteremia) + likely cardiogenic shock, Morganella Morganii bacteremia secondary to unstageable sacral ulcer and possible osteomyelitis (bone infection). Assessment also included Atrial Fibrillation, heart failure, respiratory failure, hyperammonemia (ammonia in bloodstream) likely secondary to liver failure, acute renal failure. In an interview on 1/29/25 at 4:00 pm, Wound Care Nurse Staff #G was questioned how a normal skin assessment can go from normal into an unstageable pressure injury the following day. She stated that staff may not have been able to turn the patient and that nursing staff on the floor could have consulted her earlier. In an interview on 1/29/25 at 4:30 pm, CNO Staff #B stated that it was unlikely an unstageable pressure injury would develop overnight. B) In an interview on 1/29/26 at 11:00 am, RN Staff #F, nurse manager on the 3 North Tower IMU unit, stated that patients at risk for skin breakdown and pressure injuries were turned and repositioned every two hours. In an interview with RN Staff #I during record review of Patient #2’s medical chart, she stated the patient was at risk for skin breakdown and pressure injuries due to being bed bound, morbid obesity, nutritional status, and numerous other complicities, and this was reflected on his Braden II score. Further review of Patient #2’s clinical records determined it could not be verified that the patient had been turned and repositioned every two hours; The records failed to document the times, if any, that the patient was turned and repositioned, the description of the position the patient was in, and how frequent the patient was turned, if at all. The records simply had documentation twice per day, at inconsistent and varying intervals, a one or two-word description such as “Chair”, “Dangle”, “Bedrest”, “Chair, Turned”, and “Other”. This was listed in the nursing assessment portion titled “Routine Daily Care” + under “Activity”. In another interview on 1/30/26 at 5:40 pm, Wound Care Nurse Staff #G stated that the patient’s pressure injury was classified as a Hospital Acquired Pressure Injury. She also stated that there were no specific times documented by nursing in the electronic health records to show exactly what time and in what position the patient was turned to when they were repositioned to prevent pressure injuries. In an interview on 2/2/26 at 11:30 am, QD Staff #D was asked how nursing documented repositioning of the patient and confirmed that the only documentation of this was the one or two-word description listed under “Routine Daily Care” + and “Activity”. Staff #D confirmed there was nothing else noting the exact times or positions in which the patient was placed. When asked how patient repositioning was supposed to be performed as well as documented per policy, Staff #D stated that the policy which addressed repositioning patients at risk for pressure injury was the “Pressure Injury Policy”. However, re-review of this policy failed to show any specific processes for doing so, including how and when repositioning would be performed and documented.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 37322 Based on observation, and interview the facility failed to ensure the physical environment was clean and secure. Eleven (11) supply carts out of 18 were inspected (C1, C3, C5, C7, C9, C10, B6, A1, A3, A9, B9, B6) were inspected and found to be unlocked in the individual patient rooms in the emergency department; leaving the access of sterile supplies and needles to both patients and others. Findings: Based on observation, and interview the facility failed to ensure the physical environment was clean and secure. Eleven (11) supply carts out of 18 (C1, C3, C5, C7, C9, C10, B6, A1, A3, A9, B9, B6) were inspected and found to be unlocked in the individual patient rooms in the emergency department. Each cart had intravenous needles and other sterile supplies accessible to patients and visitors. Interview with 10/03/2024 at 1030, staff (ID#8) and others who were present during the tour “stated the carts should be locked” and proceeded to lock the carts during the tour. Based on observation and interview on 10/03/2024 at 1130, the blue equipment room was noted to be a clean utility room, but had dirty equipment in the room, i.e. a cart with visible brown stain fluid was noted, the Steris light had blood splatter on the light and broken equipment, ie intravenous pump, and a used bear hugger were also noted in the room. Interview with 10/03/2024 at 1130, staff (ID#8) who stated the room is a clean utility and the items should not be in the room.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38387 Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted. Specifically, the facility failed to ensure: 1.) patients were able to exercise their rights to request discharge and be informed of their commitement process. Refer to A0129 - A, B 2.) patients consented to their medical care. Refer to A0131 3.) they promoted patient safety and use the least restrictive intervention. Refer to A0154 4.) emergency behavioral medication orders included justification for the order by the provider and patients who received emergency behavioral medications were assessed and monitored per the facility policy Refer to A0160 The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38387 Based on a review of the clinical record and confirmed in interview, the hospital failed to inform the patient of his/her patient rights for three (Patient #1, 6, 11) of eleven patients reviewed. Findings included: Random record review of patient charts revealed three (Patient #1, 6, 11) of eleven patients had no documentation of them receiving their Patient Bill of Rights. An interview with Staff #C on 01/23/2024 in the administration conference room confirmed the above findings. She stated that the administration is responsible for getting the consents and providing the paperwork. She stated that for the above patients, the administration was ‘medically unable’ to get consents and acknowledged that there is no process to verify if consents are verified prior to treatment.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 38387 Based on review of the facility policy, patient clinical record, and confirmed in interview, the facility failed to follow its grievance policy for one of eleven (Patient #1) patients reviewed. Findings included: Review of the facility policy Patient Grievance and Complaint Management (Policy Stat ID 13184599, effective 03/2023) under Procedure it stated: “Notification of Rights Regarding Complaint/Grievance Resolution Each patient and/or patient representative is informed of the rights and responsibilities afforded patients upon entry into the facility, and the process by which they may lodge a complaint. Each patient receives information on how to lodge a grievance with the Texas Department of State Health Services upon entry to the facility. The Texas Department of State Health Services, phone number, and address are provided in the event that the patient decides not to use the internal grievance process. The patient may also contact the Quality Improvement Organization (QIO) if they have a complaint regarding the quality of care, disagree with a coverage decision, or wish to appeal a premature discharge. B. Complaint Resolution Process 1. The staff routinely rounds in the facility to greet patients, ask questions about the patient’s stay and determine whether their needs and expectations are being met during their stay. When a patient voices a complaint, the patient will be encouraged to discuss the complaint with their physician or unit nursing staff. The unit nurse director or nursing supervisor may be involved as needed. If the complaint is related to a particular department, a representative from that department may be invited to discuss the issue with the patient. A representative of the administrative staff may be involved as needed to assist with a prompt resolution. 2. Every effort will be made to resolve the complaint at the lowest level possible. Each staff member is empowered to respond and resolve promptly any complaint voiced by a patient and/or their representative. The staff member receiving the complaint will notify his/her supervisor when the issue cannot be immediately resolved. At each level of this process, the staff member will listen with concern to the patient’s complaint, consider the circumstances and context of the complaint, and assure the patient that their complaint will be investigated and resolved as soon as possible. 3. At any point in the process, the complaint may become a grievance based on the aforementioned criteria. C. Grievance Resolution Process 1. Grievances may be received written, verbally, via electronic mail or facsimile, or by telephone to any department. Complaints received via the Corporate Ethics Line are forwarded by the Corporate Ethics and Compliance Department to the facility ECo for coordination of the investigation and response to the complainant if identified. Response to an anonymous complaint will be forwarded from the facility ECO to the Corporate Ethics and Compliance Department for posting on the Ethics Line. Other patient care complaints received at the Corporate Office may be forwarded to the CA Quality Standards Department. These complaints are directed to the attention of the facility CEO who is responsible for the completion of the investigation and communication of resolution to the complainant. The HCA Quality Standards Department facilitates this process to assure resolution and compliance with regulatory standards. 2. Upon receipt of a grievance, the appropriate department manager will be contacted. The grievance will need to be entered into the grievance log maintained by the Risk Management Department. Notification to the Risk Department and or Quality Director will be conducted by the person receiving the complaint. The person conducting the investigation will write or call the patient to let them know that we have received the letter and that they will be investigating the concerns of the letter. The director will review and investigate the grievance within seven days of receipt of the grievance, with the exception of complaints that endanger the patient (i.e., abuse or neglect). These grievances should be reviewed immediately given the seriousness of the allegation and the potential for harm to the patient. 1. A written response of the hospital’s investigation and subsequent actions will be sent as soon as possible, in most cases within seven days. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow up with a written response within 21 days. 2. The response will include the name of the contact person, steps taken to investigate, the results of the actions taken as applicable, and the date of completion. Either the appropriate Director or Administrator will provide this response. The written notice must be communicated appropriately to the patient or the patients representative in a language and manner the patient or the patient’s representative understands. 3. At the discretion of the person conducting the investigation, other mechanisms may be utilized to resolve a grievance. For example, conducting a meeting with the complainant may be very effective. 4. Patient Appeal Process if Not Satisfied with Resolution of Grievance: If a patient is not satisfied with the resolution of the grievance, the following shall occur in the event of a major complaint: the appropriate administrator shall review the complaint again, with the appropriate hospital personnel and confer with the CEO to review the resolution for possible modifications. A written response will be provided to the complainant within 10 days and the complainant will be invited to visit with the appropriate VP to obtain an oral explanation of the response to the appeal. A grievance is considered resolved when the patient and/or the patient’s representative is satisfied with the actions taken on their behalf. There may be situations where the organization has taken appropriate and reasonable actions on the patient’s behalf in order to respond to the patient’s grievance and the patient or patient’s representative remains unsatisfied with the actions taken by the organization. In these situations, the Grievance Committee may consider the grievance closed for the purpose of the requirements of the conditions of participation. o Grievance information is aggregated, tracked, trended, and communicated by the Risk Management Department to HCA Houston Healthcare Northwest management and leadership on an as-needed basis.” Review of Patient #1’s medical record revealed no documentation the facility provided the patient information regarding the grievance policy. Review of Patient #1’s medical record revealed nursing notes on 01/16/2024 at 11:24 AM where Staff #M noted “Mom at BS [bedside] after multi [multiple] calls this AM, now demanding to see MD so informed him, also demanding meds for her ‘UTI’ and wants her to take shower” Further review of Patient #1’s nursing notes on 01/16/2024, Staff #N noted “PT [patient] mother called, explained that I was advised in report that she could not have phone calls at this time. Explained to mother she could contact the director in the morning. Pt then came to the window and asked the same, when attempting to explain to pt she would not listen and talked over nurse stating ‘you don’t like your job? Why you mad?’ other nurse then addressed pt and explained that she could not have phone calls at this time.” Review of the grievance log from November 2023 to current revealed no documentation of the grievances/complaints from the Patient #1’s mother regarding the above grievances per the facility policy. An interview with Staff #C and Staff #D on 01/22/2024 at 12:00 PM in their office confirmed the above findings. They both stated that they had numerous conversations with Patient’s mother throughout the patient stay. However, they both acknowledged that their discussions were not documented nor logged onto the grievance log. No documentation was available for review to determine what was discussed and/or if grievances were noted and resolved.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 38387 A. Based on a review of facility policy, clinical record, and confirmed in interview, the facility failed to ensure the patients were able to exercise their rights as evidenced by failing to address requests appropriately and effectively for discharge for one of eleven (Patient #1) charts reviewed. Findings: Review of the facility policy Dismissal of Patient - AMA [against medical advice] stated in part, “- Every effort should be made to determine the factors precipitating the patient’s decision, and adequate correction of the problems should be attempted. - The patient ultimately retains the right to make this decision. - Physician is to be notified - Nurse Manager/Nursing Supervisor is to be notified at time of incident. - Document event in patient electronic medical record and per hospital standard. - Involve the patient’s family in this decision to leave, especially if the patient is not completely responsible for his decisions. - Notify the physician of the patient’s decision to leave. - Notify the Nursing Manager/ Nursing Supervisor of the incident. - Have patient or family sign the AMA form. - Discuss risks of leaving AMA including possible death and document that in a Nursing Note. - Witness the signature on the AMA form. - If the patient or family refused to sign the form, note that information on the AMA form and sign on the witness line with a second RN. - Document in patient electronic medical record and per hospital standard. Documentation should include whether the patient signed the AMA form, what attempts were made to dissuade the patient from leaving, including reviewing risks of leaving AMA with the patient and/or family including possible death. Additionally, document that the IV was removed if one is present and that the physician was notified.” Patient #1 was admitted to the ED (emergency department) on 01/14/2024 for an attempted suicide and swallowing pills. She was medically cleared on 01/15/2025 at 5:12 PM after 24 hours of no seizures and vitals along with consultation with Poison Control. Review of the nursing notes from 01/15/2024 at 7:57 PM of Patient #1’s medical record Staff #J noted the following: “Pt [patient] was in her room sitting on the bed in agitated mood. Pt was screaming stating ‘I want to leave...you all can’t keep me here. I am going to leave, and no one can stop me’” Staff #J also noted that Staff #E was informed and ordered 5 MG Midazolam. This patient was admitted voluntarily on 01/14/2024 and an Emergency Detention Warrant (EDW) was simultaneously being processed the same day she requested discharge on 01/15/2024. It was faxed to the court on 01/15/2024 at 11:00PM and the warrant was executed on 01/16/2024 at 12:34 AM. Review of the Patient #1’s medical chart revealed no documentation of the AMA form per facility policy. No documentation was available for review that any staff discussed with the patient and/or family regarding her request for discharge. She was transferred involuntarily to a psych facility on 01/20/2024, five days after her initial request. An interview with Staff #C on 01/23/2024 at 10:00 AM in the conference room confirmed the above findings. B. Based on a review of facility policy, clinical record, and confirmed in interview, the facility failed to ensure the patients were able to exercise their rights as evidenced by failing to educate the patient and patient’s family regarding the warrant/commitment process for one of eleven (Patient #1) charts reviewed. Findings included: Review of the facility document Emergency Detention Warrant and Order of Protective Custody Commitment (PolicyStat ID 9852590, effective 07/2023) stated: “-patients have the right to request a re-evaluation by the physician to determine if they still meet commitment criteria. - Patients under the warrant/commitment process retain the same rights as voluntary patients, including the right to refuse medications and treatment, except that the physician must write orders for the patient’s privilege of leaving his/her assigned location with or without staff/family/associates. If possible, request a psychiatric consult if the patient requires an EDW or OPC to address psychiatric medications. The Mental Health Assessment Team may not prescribe. PATIENT/FAMILY EDUCATION 1. Explain the process to the family and request participation in taking information to the courts timely; and to attesting to the patient’s behavior. DOCUMENTATION A physician order is needed to initiate an EDW and/or OPC. If appropriate, the patient and/or family will be informed of the application processes in a language they can understand. In certain cases, where it is not in the best interest of the patient and/or the family to be informed of a pending emergency detention, education may be given after the issuance of the EDW by HHH-NW staff or the County Constables or can take place at the accepting psychiatric facility. For example, due to the emergent nature of the EDW, it may be best to delay patient and/or family education until the warrant has been issued, especially if behavioral escalation may be anticipated with the potential for harm to patients or others.” Review of Patient #1’s medical record revealed no documentation of any staff member providing education regarding the commitment process to the patient or the family. No doctor’s orders to initiate the EDW and/or OPC were available for review on the MAR (Medication Administration Record) per the facility policy; only the medical examination that attested for the need of involuntary hold and the paperwork submitted to the court were available for review. An interview with Staff #O on 01/22/2024 at 2:45 PM in the conference room, he stated that his team would evaluate the patient and they typically would inform the patient of their involuntary status. He was unaware if that is documented anywhere. He acknowledged that there is no policy or procedure that they followed. His team is also in charge of finding placement for inpatient psychiatric care. However, that is done offsite, and no records were available for review. Furthermore, he stated that they do not routinely provide information regarding patient information to their assigned lawyer and/or information of their probable cause hearing.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 38387 Based on records review and confirmed in interview, the facility failed to ensure that all patients consented to medical treatment prior to receiving treatment. There was no documented general consent to medical care in 3 (Patient #1, 6, 11) of 11 patient medical records reviewed. Findings include: Review of the facility document titled, “Conditions of Admission and Consent for Outpatient Care,” revealed that it is a document to be signed by the patient, indicating the patient was aware of and agreed to the following: - Consent to treatment - Communications about my healthcare - Patient self-determination Act - Acknowledgement of Notice of Patient Rights and Responsibilities Review of patient medical records #1, 6, and 11 revealed no “Conditions of Admission and Consent for Outpatient Care,” signed or unsigned. An interview with Staff #C on 01/23/2024 in the administration conference room confirmed the above findings. She stated that the administration is responsible for getting the consents and providing the paperwork. She stated that for the above patients, the administration was ‘medically unable’ to get consents and acknowledged that there is no process to verify if consents are verified prior to treatment.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 38387 Based on review of the facility policy, medical chart, video surveillance, and confirmed in interview, the facility failed to use the least restrictive intervention that promote patient safety for one of eleven (Patient #1) patients reviewed. Findings included: Review of the facility policy Patient Restraint/Seclusion (Policy Stat ID 9411529, Effective 05/2021) provided the following definitions: “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. When medications are used as restraints, it is important to note that the decision as to whether they constitute restraint is not specific to the treatment setting, but to the situation the restraint is being used to address. 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.” Further review of the policy provided the following procedure: “Assessment for Risk for Restraint a. The Registered Nurse (RN) performs an assessment for risk for restraint or seclusion when a patient exhibits behavior that may place the patient at risk for restraint or seclusion. This risk assessment includes: 1. Does the patient have a medical device? 2. Does the patient understand the need to not remove the device? 3. Is the patient required to be immobile? 4. Does the patient understand the need to remain immobile? 5. Is the patient exhibiting aggressive, combative or destructive behavior? 6. Does this behavior place the patient/staff/others in immediate danger? b. The assessment for the risk for restraint or seclusion also includes: 1. Patients who arrive in restraint. 2. Patients in restraint who have recovered from the effects of anesthesia and are awaiting transfer to a bed. Note: Patients in the NICU and nursery are excluded from the assessment for risk for restraint. 2. Alternatives to Restraint or Seclusion Patients that are determined to be at risk for restraint or seclusion will have alternatives initiated promptly. Appendix B contains a listing of alternatives to restraint or seclusion. 3. Determination That Alternatives to Restraint or Seclusion Have Failed The RN determines that alternatives to restraint or seclusion have failed and that the patient will be safer in restraints than continuing without restraint. 4. Second Tier of Review A member of nursing administration/management (e.g., nursing supervisor/manager, charge nurse, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application of restraint or seclusion. Renewals of restraint or seclusion orders do not require a second tier of review. The review includes: a. Alternatives attempted b. Reason for restraint or seclusion c. Least restrictive type of restraint d. Staff’s knowledge of the cause of patient behavior (physiological, psychological, environmental, medication) e. Appropriate restraint for vulnerable patient populations f. Staffing available for monitoring g. Affirmation of partnering to meet the patient needs with safety and compassion Note: In an emergency application of the restraint or seclusion, the above review will be done immediately after the application of restraint. 5. Order for Restraint or Seclusion a. An order for restraint or seclusion must be obtained from an physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion.3 A resident who is authorized by State law and the Documentation Requirements The medical record contains documentation of: a. Assessment for risk for restraint or seclusion b. Restraint or seclusion alternatives employed c. The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion d. Determination of effectiveness/ineffectiveness of restraint or seclusion alternatives e. Second tier review of need for restraint or seclusion f. Order for restraint or seclusion and any renewal orders for restraint or seclusion g. Restraint or seclusion application/initiation h. Family notification of restraint or seclusion use i. Patient and family education regarding restraint or seclusion use j. Assessment of the patient in restraint or seclusion k. Monitoring of the patient in restraint or seclusion l. Medical and behavioral evaluation for restraint or seclusion management of violent or self destructive behavior m. The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention n. Modifications of the plan of care o. Physician notification of changes in patient condition p. Restraint or seclusion removal/termination” Random review of patient records revealed one of eleven patients (Patient #1) with no documentation to justify the need of the emergency behavioral medication administered. Patient #1 Patient #1 a 20 year old female was seen in the emergency room on 01/14/2024 with increased depression, suicidal thoughts, and suicide attempt. EMS brought her in for medical clearance and psychiatric evaluation. Review of Patient #1’s medication administration records documented ED [emergency department] provider (staff #E) ordered on 01/15/2024 at 7:12 PM a onetime dose of Midazolam HCL 5 MG/mL IM (sedative) and on 1/15/2024 at 9:56 PM a onetime dose of Droperidol 5 mg/2 mL IM (antipsychotic medication). The physician orders did not include the rationale or justification for administering the medication. Both orders were signed off and administered by Staff #J at 7:41 PM and 10:01 PM respectively. Surveyor reviewed video surveillance from 1/15/2024 and it provided the following timeline of events for Patient #1: 7:30 PM, Patient #1 was seen on the phone in front of nursing station of ED Pod D. 7:34 PM, MAT (mobile behavioral assessment team) reviewer (Staff # P) seen having discussion with Patient #1 by the phone 7:37 PM, Patient #1 goes back to patient room 7:43 PM, Patient #1 goes back to phone 7:48 PM, Patient #1 handed phone receiver to security (Staff #Q). Staff #Q is having discussion on the phone 7:50 PM, Patient #1 goes back to room along with 3 security officers and 3 nursing personnel 7:52 PM, Patient #1 walks to restroom accompanied by security and nursing staff 7:54 PM, Patient #1 walks back to room 7:55 PM - 9:30 PM, Patient #1 in the room Review of the nursing notes from 01/15/2024 at 7:57 PM of Patient #1’s medical record Staff #J noted the following: “Pt [patient] was in her room sitting on the bed in agitated mood. Pt was screaming stating ‘I want to leave...you all can’t keep me here. I am going to leave, and no one can stop me’” Staff #J also noted that Staff #E was informed and ordered 5 MG Midazolam. Review of all available documentation revealed no documentation of any other de-escalation alternatives attempted prior to the emergency behavioral medication administered were available for review. Further review of the video illustrated the following timeline: 9:30 PM, Patient #1 approached the nursing station in the ED Pod D 9:33 PM, Patient #1 walks back to room 9:47 PM, security is by Patient #1 doorway 9:48 PM, security (Staff #Q) and 4 other nursing personnel are seen in and out of Patient #1’s room, with one nurse unraveling one soft restraint and entering the room (remaining bag of soft restraints on the floor outside of patient room) 9:50 PM, nurse handed bag of soft restraint to another nurse inside of patient room 10:06 PM, lights are turned off and all staff exit patient room Review of documentation available revealed no documentation of the incident at 10:00 PM that corresponded to the emergency behavioral medication administered. Review of documentation available revealed no documentation of any other de-escalation alternatives attempted prior to the emergency behavioral medication administered were available for review. In an interview with Staff #G on 01/23/2024 at 12:50 PM in his office and after his review of the video, he acknowledged that the incident we reviewed warranted at least a code Bert (behavioral incident). However, no documentation was provided. He stated he was unaware why no one called a code. An interview with the Staff #R on 01/23/2024 at 1:10 PM in Staff #G’s office confirmed the above findings. When inquired about the soft restraints viewed on the video, she stated that the nurse only unraveled one and their nursing staff would need all 4 to utilize. She was unaware why the nurse would bring into the room and not use them however. No documentation was available for review that the soft restraint were ordered or utilized. In an interview with both Staff #G and Staff #R on 01/23/2024 at 1:15 PM, they both acknowledged that Patient #1 did not seem combative, nor did she try to elope after review of the video surveillance from 7:30 PM to 10:30 PM of 1/15/2024. Review of the progress Behavioral Health Progress note signed by Staff #E stated “the patient was evaluated by the BHC [Behavioral Health Connections] mobile assessment team on 1/15/24 at 16:15 [4:15 PM] with involuntary inpatient psychiatric hospitalization and continues to require involuntary inpatient psychiatric hospitalization as evidenced by patient actively endorses suicide, threatened hospital personnel, and tried to elope. Patient has poor insight and judgement evidenced by refusing help and trying to elope.” Review of the facility incident log from January 2023 revealed no incident of patient #1 trying to elope. A phone interview with Staff #Q via telephone on 01/23/2024 at 1:00 PM, she stated that she was on shift that day and interacted with patient #1 most of the afternoon and evening. She stated that Patient #1 never tried to elope, she just threatened to elope.”

“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: 38387 Based on review of the facility policy, medical chart, and confirmed in interview, the facility failed to ensure emergency behavioral medication orders included justification for the order by the provider and patients who received emergency behavioral medications were assessed and monitored per the facility policy for three of eleven patients (Patient #1, 5, 6) reviewed. Findings included: Review on 01/23/2024 of the facility’s current policy Emergency Administration of Psychoactive Medications in a Psychiatric Emergency Without Patient Consent (Policy ID # 14928813, Effective 12/2023, Last Revised 12/2023) stated “Purpose: To define protocol and safe guidelines for the administration of intramuscular psychoactive medications during a psychiatric emergency in compliance with CMS Conditions of Participation requirements for restraints. Definitions: Psychoactive Medications - medication that the primary intended therapeutic purpose is to treat or improve signs or symptoms of a mental disorder, or to modify mood, affect perception of behavior. Behavioral Emergency - a situation in which a patient is behaving in a violent or self-destructive manner and verbal intervention was not effective in de-escalating the patient, and it is immediately necessary to restrain, seclude, or administer psychoactive medication to prevent a patient from harm to self or others. Significant agitation requiring intervention in the emergency setting. Emergency Medication - a psychoactive medication administered during a psychiatric emergency with a physician’s order for a one-time, immediate dose of an intramuscular medication or a combination of medications used to assist a patient in regaining control of their behavior. PRN medications are not in scope for this policy. Examples of medications in scope for this policy are antipsychotic, benzodiazepines, and other sedating medications administered via intramuscular route. Procedure/Guidelines: 3. Documentation by the nurse shall include but is not limited to: a. Information communicated to the patient by the nurse. b. Precautions taken to assure patient safety during the administration of medication. c. All measures implemented to obtain patient cooperation in an attempt to avoid more restrictive measures. e. The condition of the patient following administration of the medication including the following assessments: a. vital signs (HR, RR, BP, SPO2) q 30 minutes x 2 hours, then q 1 hour x 2 hours for a total of 4 hours of monitoring (note if unable to obtain full set of vita signs due to threat to safety of staff or patients, minimum monitoring will include respiratory rate). b. psychological status and current behavior q 30 minutes x 2 hours. c. Response of the patient to the medication, including any adverse effects. 6. Within 1 hour post administration, a face to face assessment will be conducted and documented in medical record by a provider, or an RN specifically trained on the following: 1. Evaluation of the patient’s immediate situation. 2. The patient’s reaction to the intervention. 3. The patient’s medical and behavioral condition and the need to continue or terminate the restraint or seclusion. 7. If 1 hour post administration face to face assessment is performed by specially trained nurse, that nurse will consult a provider to discuss findings. This consultation should include, at a minimum, a discussion of the findings of the 1-hour face-to-face evaluation, and the need for other interventions or treatments.” Random review of patient charts revealed three of eleven patients (Patient #1, 5, 6) who were administered emergency behavioral medication with no documentation of the rationale for the emergency behavioral medication and the required assessment and reassessment after administering the medication per the facility policy. Patient #1 Patient #1 a 20 year old female was seen in the emergency room on 01/14/2024 with increased depression, suicidal thoughts, and suicide attempt. EMS brought her in for medical clearance and psychiatric evaluation. Review of Patient #1’s medication administration records documented ED provider (staff #E) ordered on 01/15/2024 at 7:12 PM a onetime dose of Midazolam HCL 5 MG/mL IM (sedative) and on 1/15/2024 at 9:56 PM a onetime dose of Droperidol 5 mg/2 mL IM (antipsychotic medication). The physician orders did not include the rationale or justification for administering the medication. Both orders were signed off and administered by Staff #J at 7:41 PM and 10:01 PM respectively. Review of patient #1’s medical records revealed no documentation of the required nursing assessment of the condition of the patient following administration of the emergency medication. No assessment or reassessment by the physician pre or post administration of the emergency behavioral medication was documented. No documentation was found for the reason the patient received the emergency medication. Patient #5 Patient #5 a 30-year-old male was seen in the emergency department on 01/20/2024 with suspected psychiatric illnesses including bipolar disorder, schizophrenia, and acute psychosis with medication noncompliance. EMS brought him in for from another hospital for medical clearance pending psychiatric evaluation. Review of Patient #5’s medication administration records documented emergency room provider, staff # H on 01/22/2024 at 12:43 PM ordered a onetime dose of Zyprexa 10 mg IM (antipsychotic medication). The physician order did not include the rationale or justification for administering the medication. The order was signed off and administered at 12:51 PM by staff # K a licensed vocational nurse. Review of patient #5’s medical records along with staff ID # L on 01/23/2024 at 1:30 PM failed to find documentation of the required nursing assessment of the condition of the patient following administration of the emergency medication. No assessment or reassessment by the physician pre or post administration of the antipsychotic emergency medication was documented. No documentation was found for the reason the patient received the emergency medication. Patient #6 Patient #6 a 17-year-old female was seen in the emergency department on 01/19/2024. Patient brought in by EMS and has a history of depression, presenting for violent behavior and agitation after taking a large amount of acid at home with suicidal ideation with suicide attempt. Review of patient #6’s medication administration records documented emergency room provider, staff ID # I on 01/21/2024 at 2024 PM ordered Droperidol 5 mg IM (antipsychotic). The physician order did not include the rationale or justification for administering the medication. The order was signed off and administered at 8:29 PM by staff # J a licensed vocational nurse. Review of patient #6’s medical records along with staff ID # L on 01/23/2024 at 1:30 PM failed to find documentation of the required nursing assessment of the condition of the patient following administration of the emergency medication. No assessment or reassessment by the physician pre or post administration of the antipsychotic emergency medication was documented. No documentation was found for the reason the patient received the emergency medication. Interview on 01/23/2024 at 14:30 PM with Emergency Room Manager, Staff ID # L confirmed the above findings.”