Nacogdoches Medical Center

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interviews, the hospital staff failed to ensure that 2 (Patient # 3 and Patient # 4) of 3 patients presenting to the hospital with suicidal ideation received appropriate observation to ensure the patients received care in a safe setting. Additionally, the hospital staff failed to follow the hospital’s “Suicide Risk Assessment” policy. Findings include: Patient # 3 During a tour of the hospital’s Emergency Department on 01/20/2026 at 10:40 AM, the surveyor observed Patient # 3 lying on a stretcher in Room # 4. Room # 4 was the designated room for suicidal patients. The surveyor questioned Staff # 7 (Emergency Room Director) regarding the patient’s status because there was no constant observer present, and the patient was completely alone and unsupervised. A review of Patient # 3’s medical record revealed that the patient arrived at the Emergency Room via private vehicle on 01/20/2026 at 9:15 AM. A review of Staff # 13’s (Triage Registered Nurse) “Columbia Suicide Severity Rating Scale” revealed Patient # 3 presented with self-harm intent, which required further assessment with the following questions: 1. “Have you wished you were dead or wished you could go to sleep and not wake up?” Patient # 3 reported, “Lifetime, yes”. 2. “In the past month, have you actually had thoughts about killing yourself?” Patient # 3 reported, “Yes”. 3. “In the past month, have you been thinking about how you might kill yourself?” Patient # 3 reported, “Yes”. 4. “In the past month, have you had these thoughts and some intention on acting on them?” Patient # 3 reported, “Yes”. 5. “In the past month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?” Patient # 3 reported, “Yes”. 6. “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Patient # 3 reported, “Yes”. 7. “In the past 3 months, have you done anything, started to do anything, or prepared to do anything to end your life?” Patient # 3 reported, “Yes”. An instructional prompt in the electronic medical record system read, “When ‘yes’ is selected for questions 3, 4, 5, or 7; document ‘self-harm observation’ in the interventions field below. This will automatically place the ‘BH Constant Observation Self Harm’ order”. A review of the “interventions” field revealed that Staff # 13 (Registered Nurse) did not select “self-harm observation” and therefore no order was placed for “BH Constant Observation Self Harm”. A review of Staff # 14’s (ER Physician) notes on 01/20/2026 at 10:05 AM revealed, “The patient comes in after taking a handful of Xanax overnight last night. The stepdaughter is with the patient, who said that the husband of the patient called, stating that he needed help with her. She said that her husband said that things are getting out of control with medication. The patient says that she took approximately 30 Xanax in an effort to kill herself. When asked if she still feels suicidal, she says no because it did not work. I did ask her that if she were to have the opportunity, would she try to kill herself again. She did not give a clear answer. She does also still appears somewhat lethargic from the medications ....The patient was seen by psychiatry, and the plan is to admit the patient to an inpatient facility for her suicidal ideations.” A review of the “Constant Observer Flowsheet” for Patient # 3 on 01/20/2026 revealed that there was no constant observer documentation from the patient’s time of arrival at 9:15 AM until 10:40 AM. The surveyor observed the patient alone in the high-risk designated room. Patient # 3 arrived at the hospital’s Emergency Department seeking care for an intentional drug overdose. Patient # 3 was screened as a high risk for suicide, and there were no orders placed for a 1:1 constant observer. A constant observer was not implemented to ensure Patient # 3 was continuously watched as required by the hospital’s “Suicide Risk Assessment” policy. Patient # 4 A review of Patient # 4’s medical record on 01/20/2026 at 1:00 PM with Staff # 10 revealed, Patient # 4 arrived at the hospital’s Emergency Department on 12/20/2025 at 10:05 PM with complaints of an intentional drug overdose. A review of the “Columbia Suicide Severity Rating Scale” for Patient # 4 revealed, 1. “Have you wished you were dead or wished you could go to sleep and not wake up?” Patient # 3 reported, “Lifetime, yes”. 2. “In the past month, have you actually had thoughts about killing yourself?” Patient # 3 reported, “Yes”. 3. “In the past month, have you been thinking about how you might kill yourself?” Patient # 3 reported, “Yes”. 4. “In the past month, have you had these thoughts and some intention on acting on them?” Patient # 3 reported, “Yes”. 5. “In the past month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?” Patient # 3 reported, “Yes”. 6. “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Patient # 3 reported, “Yes”. 7. “In the past 3 months, have you done anything, started to do anything, or prepared to do anything to end your life?” Patient # 3 reported, “Yes”. An instructional prompt in the electronic medical record system read, “When ‘yes’ is selected for questions 3, 4, 5, or 7; document ‘self-harm observation’ in the interventions field below. This will automatically place the ‘BH Constant Observation Self Harm’ order”. A review of the “interventions” field revealed that “self-harm observation” was not selected, and therefore no order was placed for “BH Constant Observation Self Harm”. A review of Staff # 15’s (ER Physician) note on 12/20/2025 at 10:26 PM revealed, “Patient, a 65-year-old female, presents to the Emergency Department after taking an overdose of trazodone pills. The patient took 10 pills of 50 mg each (total 500 mg) of trazodone sometime between 7-8 PM tonight, after dark. When asked if she was trying to hurt herself, the patient responded, ‘maybe’. She states she took the excessive amount because she was depressed about her mother’s situation. The patient normally takes trazodone to help her sleep. She reports feeling a little nauseated currently but denies shortness of breath or pain. The patient received activated charcoal in the ambulance. She denies taking any other substances tonight, including Tylenol. The patient has no prior history of self-harm attempts. She is currently receiving treatment for depression at Burke Center and has an appointment scheduled for Monday ...Disposition: Transfer to psychiatric facility once placement has been obtained by the Burke patient, awaiting placement at shift change ...patient has been accepted at Oceans facility and is being transferred to Oceans facility at this time”. The surveyor requested to see the “Constant Observer Flowsheet” for Patient # 4. Staff # 10 confirmed that there was no Constant Observer documentation in the medical record. Staff # 4 arrived at the patient’s hospital after an intentional drug overdose. Patient # 4 was screened as a high risk for suicide. There was no order placed for a constant observer, and there was no constant observer documentation in the patient’s medical record. A review of the hospital’s “Suicide Risk Assessment” policy dated 02/2024 revealed the following: “Scope: This policy applies to all Emergency Departments, inpatient units, Behavioral Health Units, out-patient behavior health programs, and observation units at Nacogdoches Medical Center. Purpose: Nacogdoches Medical Center will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ....Policy: The Nacogdoches Medical Center will use a multidisciplinary approach for the care of the Suicidal Patient. Nacogdoches Medical Center will provide, at a minimum, an initial suicide screening for all patients aged 12 years and older who are being evaluated or treated for behavioral health conditions to determine further care and treatment. Procedure: A. Nacogdoches Medical Center conducts an annual self-harm environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide, and Nacogdoches Medical Center will take the necessary action to minimize the risk(s). This applies to all inpatient psychiatric units and outpatient psychiatric programs. B. For non-psychiatric units: Nacogdoches Medical Center will mitigate the environmental risks of suicide patients at high risk for suicide. The Registered Nurse and/or designee will: 1. Assess for and remove objects from the patient’s room that pose a risk for self-harm if they can be removed, and if they can be removed without adversely affecting the patient’s medical care. 2. Assess objects brought into a room by visitors. C. A registered nurse will pre-screen all patients, greater than 12 years of age, upon admission. D. A registered nurse will pre-screen children less than 12 years of age who exhibit signs or symptoms of self-harm or suicidal thoughts, actions, using the children’s CSSR assessment. E. If a registered nurse cannot assess the patient upon arrival due to the patient’s medical status, they will perform the pre-screening as soon as the patient’s condition permits. F. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. G. If the patient screens positive using C-SSRS, which is defined as providing a ‘yes’ response to questions 3, 4, 5, or 7, the nursing staff will complete the following: 1. Send an order request for one-to-one observation to the attending physician. 2. Send a referral for consult to case management, social services, and a BHP. 3. Immediately place the patient on a one-to-one observation by a CHP and obtain a physician’s order as soon as possible. 4. Implement at a minimum the following precautions: a. Place the patient in a safe hospital attire, preferably green safety scrubs. B. Provide safe patient food trays. C. Complete environmental checklist. D. When practical, place the patient in a preferred room or closest to the main nurse’s station. H. The nursing staff will use the constant observation flowsheet to document observation following the hospital protocol for a patient at risk of suicide ...N. Any decrease in observation status requires a physician’s order ....” An interview was conducted with Staff # 13 (Emergency Room Nurse Manager) on 01/20/2026 at 1:15 PM in the administrative conference room. Staff # 13 confirmed there was an educational gap in the suicide screening documentation process. Staff # 13 stated, “I did not know that staff had to manually select the constant observer intervention for the order to populate in the patient’s medical record. I thought if the staff selected ‘yes’ to any of the screening questions, it automatically placed the order for a constant observer”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital staff failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in 1 (Emergency Room) of 1 department of the hospital. Findings include: During a tour of the hospital’s Emergency Department on 01/20/2026 at 10:40 AM with Staff # 3 and Staff # 7, the following infection control issues were identified, Emergency Room # 6 The room was designated as clean and ready for a patient. There was an IV (intravenous) pump on a metal pole. The IV pump was dirty and had an unknown sticky residue on the outside and inside of the pump. The IV pole was dirty and had areas where the paint was chipping off, and rust was present. The suction canister and associated tubing were unwrapped and stored on the wall. The canister had a layer of dust on the lid. The associated tubing was unwrapped, and it was unknown if the tubing and canister had been previously used on another patient. Clean Supply Room There was a ceiling tile located directly above the door that had a large water stain present. There were sterile and clean patient supplies in the supply room. There was no temperature and humidity monitoring in the supply room as required for sterile supply storage. The sterile supplies included Foley catheter insertion kits, suture kits, and suture removal kits. Trauma Bay # 1 The room was designated as clean and ready for a patient. The overhead trauma lights had a thick layer of dust on the top of the lights. There was also rust noted on the lights. There was damage to the linoleum flooring, and there was a hole present that could allow for insects and pests to enter the patient care area. The sink had areas of rust present. There was a thick build-up of dust present on the return air duct located in the ceiling above the door. There was a metal table on wheels that was covered with a plastic bag. The bottom of the table was covered with rust and other unknown debris. The nurses’ station across from trauma bay # 1 had areas on the corners of the cabinets where raw wood was exposed and could not be adequately cleaned and disinfected. An interview was conducted with Staff # 3 and # 7 on 01/20/2026 at 10:50 AM, which confirmed the infection control findings. Staff # 3 and # 7 were present for the entire tour.”

“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: 48749 Based on record review and interview, the hospital’s emergency department staff failed to appropriately monitor Patient #1’s condition before transferring to another hospital admission to the Intensive Care Unit (ICU). Refer to 2406 Based on record review and interviews, the facility staff failed to meet the following requirements of an appropriate transfer for Patient #1 with an emergency medical condition by not explaining the risks and benefits to the patient before transfer. Refer to 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: 48749 Based on record review and interview, the hospital’s emergency department staff failed to appropriately monitor Patient #1’s condition before transferring to another hospital admission to the Intensive Care Unit (ICU). This deficient practice had the likelihood to cause harm to all patients presenting to the ED with emergent medical conditions. Hospital #1 located at 4920 NE Staling Dr. Nacogdoches, TX. 75965 A review of the electronic health record (EHR) revealed that Patient #1 arrived at the Emergency Department (ED) on 01/17/2025 at 3:16 PM via Emergency Medical Services (EMS). The Paramedic documented that instructions were received to place Patient #1 in the lobby until the patient could be evaluated by the triage nurse. A review of the hospital’s “Check-in, Registration, Triage & Treatment” policy dated 04/2024 revealed the following; “Individuals presenting by EMS I. Ideally, the pre-hospital provider will communicate their inbound information and estimated time of arrival prior to arrival at the Emergency Department. 2. The individual should be immediately greeted by an ED RN and placed in a bed in the main ED treatment area. 3. The triage/initial assessment shall be performed at the earliest opportunity by an ED RN. 4. The ED RN should initiate the computer registration process when time and patient condition permits. 5. The ED RN and the Patient Access Registration Staff will coordinate together the time and location to further complete the registration process following the MSE guidelines listed above. 6. The individual shall have an ID armband placed at the earliest opportunity.” A review of Staff #16 (triage nurse)’s notes revealed the patient was triaged at 3:52 PM on 01/17/2025. Staff #16 documented that the patient was alert and oriented with a chief complaint was rapid heart rate, vomiting, and tremors while in dialysis. The vital signs documented at the time of triage were: “A blood pressure of 76/41, 124 Heart Rate, 20 Respirations, 99% oxygen saturation on room air, a temperature of 103, and a pain scale of 10/10.” The patient was given an Emergency Severity Index of a Level 2. (The Emergency Severity Index (ESI) has five levels, with Level 1 representing the most urgent cases requiring immediate life-saving intervention, and Level 5 being the least urgent, needing only a basic history and physical exam; essentially ranking patients based on their acuity and the resources needed for their care.) There was no documentation found to support that Staff #16 reported Patient #1’s abnormal vital signs or the ESI level 2 designation to the ED Physician or ED Charge nurse. The surveyor was unable to determine when Patient #1 was moved from the triage area and placed in an exam room in the main ED for further evaluation. A review of Staff #8 (ED Physician)’s note revealed that Patient #1 received a Medical Screening Exam (MSE) at 4:36 PM on 01/17/2025. Further review of the Staff #8’s note revealed the following; “CHIEF COMPLAINT: rapid heart rate, vomiting, tremor, while in dialysis HISTORY OF PRESENT ILLNESS: The patient presents with an infected catheter in her chest, which she reports is causing severe pain. The catheter was placed on December 31st at CHI. The patient states that the dialysis clinic performed some tests that indicated an infection. She reports experiencing fever at home, though the specific temperature is not provided. The patient denies nausea, vomiting, and abdominal pain. She also denies any urine output and cough. The patient receives dialysis on a Monday, Wednesday, and Friday schedule. She reports having completed a full dialysis run today, as well as on Wednesday and Monday. The patient has a dialysis graft in her right arm, which is currently functional and was used for today’s dialysis session. The chest catheter (left chest port-a-cath) was initially placed when the graft was not working, but it is now redundant as the graft is operational. MEDICAL DECISION MAKING: Hx obtained from: Patient All decisions regarding above workups were done in consultation with the patient in a SHARED DECISION MAKING manner. IMPRESSION/PLAN: 1. Severe sepsis with septic shock R65.21 2. ESRD (end-stage renal disease) N18.6” Patient #1 received the following treatment and medications while in the ED; “Blood Cultures, Complete Blood Count With Auto Differential, Comprehensive Metabolic Panel Decision to Transfer, ED EKG-CernerCV, Lactic Acid Level, Magnesium Level, Manual Diff, Troponin I, and an XR Chest 1 View.” The following medications were administered; “Maxipime, IV Piggyback administered at 5:18 PM morphine, 2 mg, IV Push administered at 5:18 PM Sodium Chloride 0.9% bolus, 1845 ml, IV administered at 5:17 PM Zofran, 4 mg, IV Push administered at 5:18 PM” There was no documentation found in the medical chart to support that Patient #1 received any other treatment while in the ED at Hospital #1. A review of Patient #1’s vital signs in the ED at Hospital #1 revealed multiple episodes of Tachypnea (fast breathing) and Tachycardia (fast heart rate). The following respirations and heart rates were documented; 3:52 PM- 124 heart rate (HR), 22 respirations 5:00 PM- 115 HR, 33 respirations 5:30 PM- 115 HR, 40 respirations 6:00 PM- 114 HR, 40 respirations 6:30 PM- 111 HR, 34 respirations 7:15 PM- 148 HR, 35 respirations 7:45 PM- 131 HR, 54 respirations 8:15 PM- 109 HR, 37 respirations There was no documentation found to support that the abnormal vital signs were reported to the ED Physician. Also, there was no documentation found to support that Patient #1’s abnormal vital signs were addressed by the hospital staff.Further review of the vital signs for Patient #1 revealed that there were no vital signs taken between 8:15 PM and 9:30 PM. A review of Staff #17 (ED Registered Nurse)’s notes revealed the following; 4:52 PM “Pt resting at this time. Endorses generalized pain. NAD noted.” 6:47 PM “Pt resting in bed at this time. NAD noted. Denies any needs.” 8:51 PM “Pt resting, denies any needs. VSS. States that she texted her son for an update on her care. Per pt, okay to give information if he calls for updates.” 9:30 PM “Pt left with EMS on stretcher. NAD noted. CBG 90.” A review of the hospital’s “Physician Certificate Transfer” form reveals two sections. The top section is labeled “For Transfer of Stable Patient” and the bottom section is labeled “For Transfer of Unstable Patient.” The top section for “For Transfer of Stable Patient” states, “I have examined the above-named patient, and in my medical opinion, this patient is not in an emergency medical condition, and transfer or the delay caused thereby will not create a medical hazard to the patient.” Per the “Physician Certificate Transfer” form in Patient #1’s chart, the top section of “For Transfer of Stable Patient” was signed on 01/17/2025 at 7:37 PM. The surveyor was unable to determine which ED staff member signed the form that Patient #1 was stable for transfer. Also, they was no way to determine the credentials for the staff member. A review of the EMS run sheet revealed that the EMS crew was dispatched on 01/17/2025 at 8:27 PM and arrived at the patient’s bedside in Hospital #1 at 8:40 PM. Per the EMS run sheet, the Paramedic documented the following; “Pt is responsive to painful stimuli. Pt is pale, hands are extremely cold to touch, skin is very diaphoretic.” Patient #1 was in the ED at Hospital #1 from 3:16 PM until discharge with EMS at 9:32 PM. There was no documentation found in the chart to support when Patient #1 had a change in mental status (an individual’s current psychological and cognitive state) or that the ED Physician was notified of a change in Patient #1’s mental and physical condition status. Also, there was no documentation found in the chart to support that Patient #1 had any form of reassessment by the ED nurse or ED Physician prior to transferring to Hospital #2. Hospital #2 located at 1204 N Mound St. Nacogdoches, TX. 75961 A review of the EMS run sheet revealed that the EMS unit arrived at Hospital #2 at 9:40 PM with Patient #1. The patient was taken to Hospital #2’s ICU for admission. The ICU RN documented the following nurse’s note; “ADMISSION NOTE: PT ARRIVED TO ICU 604 FROM NMC ER W/ REPORT HAVING PREVIOUSLY BEEN GIVEN TO STAFF LVN. NMC STAFF STATED THAT THE PATIENT WAS A/OX4 WITH STABLE VITAL SIGNS. EMS ARRIVED AT 2200 WITH PATIENT UNRESPONSIVE TO ALL STIMULI WITH AGONAL RESPIRATIONS. DR.WAS NOTIFIED IMMEDIATELY AND CAME TO INTUBATE PATIENT. PT UPGRADED TO ICU STATUS AND THIS RN ASSUMED CARE OF THE PATIENT. EMS STATED THAT THE PATIENT HAD BEEN UNRESPONSIVE AT NMC ER WHEN THEY ARRIVED THERE, UNRESPONSIVE THE ENTIRE RIDE OVER AND HAD A BLOOD SUGAR OF 90. ON ARRIVAL PATIENT IS COLD AND CLAMMY WITH BLOOD SUGAR OF 34. WHILE ATTEMPTING TO GIVE D50 THE IV PLACED BY NMC WAS INFILTRATED AND ALL ATEMPTS TO PLACE A NEW PIV WERE FAILED. DR PLACED A CENTRAL LINE. THE PATIENT WENT INTO CARDIAC ARREST AND ACLS PROTOCOL WAS INITIATED. SEE RESUSCITATION REPORTS X5 FOR DETAILS. PATIENT’S SISTER, MS RICHARDSON ARRIVED AT BEDSIDE SOON AFTER THE FIRST CODE BEGAN AND STATED THAT NMC ER HAD CALLED HER TO GET CONSENT TO TRANSFER THE PATIENT HERE AND STATED THAT NMC STAFF REPORTED TO HER THAT THE PATIENT WAS “A LITTLE” DROWSY D/T HAVING RECEIVED MORPHINE. UPON REVIEWING THE PATIENT’S PAPERWORK THIS RN NOTED THAT THE PATIENT’S BP WAS 70s/40s AT NMC, 4 MG OF MORPHINE WAS GIVEN, AND ADDITIONALLY THE PATIENT’S EMS RUN REPORT STATED THAT THE PATIENT WAS ALERT TO PAINFUL STIMULI, BLOOD SUGAR WAS 90, AND THAT AT THE MOMENT THE PATIENT WAS MOVED FROM THEIR STRETCHER HER MENTAL STATUS CHANGED. PATIENT REMAINED UNRESPONSIVE TO ANY STIMULI FOR THE DURATION” Further review of Patient #1’s medical chart at Hospital #2 revealed the patient experienced 6 cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness) events after admission to the ICU. The cardiac events were documented at 10:28 PM, 10:58 PM, 11:14 PM, 1:53 AM, 2:04 AM, and 2:18 AM. The patient expired at 2:32 AM on 01/18/2025. An interview was conducted with Staff #12 ED Charge nurse on 02/18/25 at 9:40 AM. Staff #12 stated, “All transfers are coordinated through the organization’s transfer center, Tenet Transfer Center.” Staff #12 reported patients who are transferring to a higher level of care, we will ask the patient or family for preference first. If there is no preference, the ED Physician will contact the closest hospital first and then branch out to other hospitals. Staff #12 stated, “For critical patients, we will do one-on-one nursing care until the patient transfers.” An interview was conducted with Staff #7 MD Medical Director on 02/19/2025 at 10:00 AM. Staff #7 was asked how the ED nursing staff communicates to the ED Physicians regarding an emergent patient or how the ED Physicians would know a patient is urgent. Staff #7 reported that during Staff #7’s shifts in the ED, the nurses would verbally tell Staff #7 or that Staff #7 would monitor the tracking board at the nurse’s station. Staff #7 reported that walkie-talkies are utilized. An interview was conducted with Staff #13 (Nursing Supervisor) on 02/19/2025 at 10:30 AM. Staff #13 reported that if a patient was identified as a sepsis suspect, the sepsis protocol allows for the ED nursing staff to put in orders while waiting but they still must notify the Physician.”

“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: 48749 Based on record review and interviews, the facility staff failed to meet the following requirements of an appropriate transfer for Patient #1 with an emergency medical condition by not explaining the risks and benefits to the patient before transfer. This deficient practice had the likelihood to cause harm to all patients needing to be transferred. Findings include: A review of the hospital’s Memorandum of Transfer (MOT) form revealed that there was not a section for an explanation of risks and benefits or for a patient/designee to sign giving the facility consent to transfer. A review of the MOT for Patient #1 revealed that the initial contact with the receiving hospital was made on 01/17/2025 at 7:14 PM. The receiving hospital’s Physician accepted Patient #1 for transfer on 01/17/2025 at 7:55 PM and the receiving hospital accepted Patient #1 on 01/17/2025 at 8:00 PM. An interview with Staff #13 was conducted on 02/19/2025 at 10:30 AM. Staff #13 reported that the hospital utilizes a “Physician Certificate Transfer” form and a “Consent Transfer Authorization” form for patients needing transfer to another facility. Staff #13 stated, “ If a patient is unstable or unable to sign, then two physicians or 2 nurses would sign the consent to transfer if unable to locate immediate family.” A review of the hospital’s “Physician Certificate Transfer” form reveals two sections. The top section is labeled “For Transfer of Stable Patient” and the bottom section is labeled “For Transfer of Unstable Patient.” The top section for “For Transfer of Stable Patient” states, “I have examined the above-named patient, and in my medical opinion, this patient is not in an emergency medical condition, and transfer or the delay caused thereby will not create a medical hazard to the patient.” Per the “Physician Certificate Transfer” form in Patient #1’s chart, the top section of “For Transfer of Stable Patient” was signed on 01/17/2025 at 7:37 PM. The surveyor was unable to determine which Emergency Department (ED) staff member signed the form that Patient #1 was stable for transfer and the staff member’s credentials. A review of Patient #1’s “ Consent Transfer Authorization” revealed that the consent was not signed by Patient #1. The consent was completed as a phone consent with a family member. The surveyor was unable to determine the signatures or credentials of the hospital staff that signed the “ Consent Transfer Authorization.” Further review of the hospital staff roster revealed Staff #18 (Unit Secretary) as a staff member consulting with Patient #1’s family and as the signature of a witness. There was no documentation found that two Physicians or two Nurses signed the consent form. A review of Patient #1’s medical chart revealed that Staff # 8 (ED Physician) and Staff # 17 (ED Nurse) documented that Patient #1 was alert and oriented during the ED visit. There was no documentation found in Patient #1’s medical chart to support that Patient #1 was unstable or unable to sign the consent form or that the risks and benefits were explained to Patient #1 before the transfer. The surveyor requested a full copy of Patient #1’s medical chart. The Surveyor was unable to find the “Physician Certificate Transfer” form and the “Consent Transfer Authorization” in the medical chart provided by the transferring hospital. The Surveyor located the “Physician Certificate Transfer” form and the “Consent Transfer Authorization” in Patient #1’s medical chart provided by the receiving hospital.”

“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: 32143 Based on the chart review and interviews, the facility failed to ensure that an appropriate medical screening was performed. The medical screening examination was inappropriate as imaging of the brain and continuous monitoring with pediatric specialist consultation were not obtained in 1 of 1 (pt.#1) patient charts reviewed. FINDINGS: A review of the patient #1’s medical chart revealed she was a 4-day-old female who was born at this facility. The patient was brought into the Emergency Department (ED) by her mother and father on 9/21/24 at 0243. The triage nurse documented, “Mother states patient had a seizure, patient started ‘jerking her arms, dropped her head, and her mouth started moving. Mother also states isn’t eating much.” The triage nurse documented the patient was alert, awake, active, and playful. Smiles and coos appropriately.” Patient #1 was entered as a level 5 ESI. A review of the chart revealed that the ER Physician #4, MD, saw the patient at 0254. The physician’s notes dated 9/21/24 at 0301 stated, “CHIEF COMPLAINT: Mother states patient had a_ seizure. patient started “jerking her arms, dropped her head and her mouth started moving. Mother also states patient isn’t eating much. HISTORY OF PRESENT ILLNESS: The patient is a 4--day-old born full-term without complications. Mom had apparently just fed the baby a few hours ago and shortly after she was holding the baby and the baby started making some funny motions and mom took a video of. In looking at it looks like the child is very awake and alert but has an interesting repetitive head motion and also had a little bit of right-hand twitching. It lasted less than a minute. During that time the child did not seem to lose consciousness or change in color in any way and remained pink and alert. Mom states the child has been feeding although it takes the child a little while to get going. Child’s been wetting the diaper not having any vomiting or fevers or difficulty breathing. Vital signs Temperature Oral 36 5 degC (09121 02:43) Heart Rate 127 bpm (09121 02:43) Respiratory Rate 31 breaths/min (09/21 02:43) Sp02/Pulse Oximetry 100 % (09/21 02:43) Dosing BMI 15 (09/21 02:43) The child is alert and very active, moving all extremities, and appears to be in no distress. Pink both well-perfused and well-hydrated. Anterior fontanelle is open and flat, mucous membranes are moist, there is no nystagmus. Pupils are reactive and equal. The patient has an excellent suck Neck is supple without adenopathy Chest is clear to auscultation Heart regular rate without murmur Abdomen is benign soft and nontender in the umbilical stump is clean and dry GU is normal female Extremities are without edema Skin is warm and dry without rash Neuro: The child moves all extremities equally. Child has a positive Moro and a positive startle response. MEDICAL DECISION MAKING: The video that the mom showed me is a bit concerning as there was some repetitive hand motion is in a little bit of head motion that was repetitive as well. But the child never was altered in any way and did not turn dusky at all and then was completely fine after that So it is difficult to know what to make of this. Especially is an isolated incident and an otherwise well-appearing child with normal vital signs and a completely benign exam with no complications during the birth or pregnancy. 1 very much doubt without any altered mental status that the electrolytes are grossly abnormal and there is been no vomiting or diarrhea or fevers and so I do not think this child has meningitis or encephalitis or head bleed at this time Or any type of perinatal infection. Basic labs were done as a screen all of which were fine x for elevated K from hemolysis. Ca, Na and Glu and WBC all normal and reassuring. I don’t think the child needs imaging at this time . Mom was told to contact the pediatrician on Monday for follow-up or to return to the ED if the child continues to have repetitive activities like this as this was just 1 isolated event. Or if there is other new symptoms such as failure to feed at all or persistent vomiting or fevers. IMPRESSION/PLAN: Orders: Primary Assessment Screenings/History Peds Triage Pa rt 1 Triage Part 2 Seizure-like activity DISPOSITION: home FOLLOW UP: No qualifying data available PCP in 2 days” A review of the chart revealed the parents were given discharge paperwork on neonatal seizures and discharged on 9/21/24 at 0445. An interview was conducted with the complainant on 9/30/24 at 10:15 a.m. The complainant was patient #1’s grandmother. The Grandmother stated her daughter called her on 9/21/24 and stated the baby was twitching. The Grandmother stated she was a traveling RN and asked the mother to send her the video of the event. The Grandmother stated that she was afraid the baby may be having a seizure and advised her daughter to take the baby to the ER. The baby was seen at the Nacogdoches Medical Center ER and was discharged home with seizure paperwork. The Grandmother stated her daughter was told by the ER physician that it did not look like a seizure to him at this time. The daughter took the patient home. The grandmother stated the baby had another episode at home, and the daughter decided to take her to Longview Regional Medical Center (LRMC) ER. The Grandmother kept stating that Nacogdoches Medical Center would not send LRMC the patient’s chart and all the tests had to be reordered. The Grandmother stated the patient was transferred to Children’s Hospital in Dallas, Texas on 9/22/24. She stated the baby was in ICU and had just been extubated due to a stroke and brain bleed. She stated the physicians were unsure what happened first the bleed or the stroke. The complainant stated that she wanted to know why physician #4 did not take more precautions or scan the baby if he felt the baby was having seizures. The complainant stated she did not make a complaint to Nacogdoches Medical Center. A review of the medical record from Good Shepherd Medical Center in Longview, Texas (GSMC) revealed, “9/21/24 13:40 ED Triage Notes Pt presents to ED. Pt family states yesterday the pt started having small episodes of tightening up and flinching. Pt family states her mouth moves in a funny way during these episodes. Pt family states they last between 30s-1 min, provider shown a video of the episodes. Family states they were seen at Nacogdoches Medical Center around 2am this morning.” A review of the physician notes dated 9/21/2024 1336 stated, “ Patient is 4 days old mom is G3, P3 Ab0. Mom brought the child in because she noticed that yesterday and today while feeding she was having some episodes that she describes as a seizure. The patient seemed to be jerking a little bit and mom took a couple of videos of it. Mom says that her pregnancy was unremarkable other than mom had some anemia and she said the delivery was okay except she had a nuchal cord but otherwise was normal she did not have to stay any extra days in the hospital and she had no respiratory problems. Neurological: Mental Status: She is alert. Motor: No abnormal muscle tone. Comments: No seizure-like activity was observed during the exam. 6:41 PM CDT: Patient presented to the ED with report of possible seizure-like activity we did a workup with blood work I did not witness any seizure-like activity in the ED at this time but the mom has videos that could be confirmatory. I had the on-call pediatrician come down and look at the video and we both agree that this does appear to be abnormal and I think the patient should be transferred to high-level care for further evaluation family agreed with the plan. The differential for the patient includes, but not limited to new onset seizure electrolyte abnormality hyperbilirubinemia jaundice I believe the patient should be transferred to Dallas Children’s for evaluation for possible seizure-like activity.” 18:35:37 Transfer Disposition Set up transport to CMC Dallas with Christus EMS. ETA for pick up is 2130 ____ (RN) on 09/21/24 1915. Noted pt was 89% on RA, RT placed pt on 1L NC. O2 is 95%. Transferred by ambulance on 09/21/2024 at 2046 to Dallas Children’s Hospital. Called report to Children Medical Center ER on 09/21/24 2057.” An interview was conducted with Staff #1, Director of Nurses at Nacogdoches Medical Center. Staff #1 stated that the facility would accept Neonates back to the NICU for up to 28 days if they were born at the facility. Staff #1 provided the Neonatal Program Plan. On page three, the plan stated, “ Infants/neonates up to 28 days after birth with noninfectious clinical conditions may also be admitted to the SCN with Neonatologist and Neonatal Program Manager approval.” Staff #1 was asked if this baby could have been admitted for observation to the neonatal unit. Staff #1 stated that if the neonatologist agreed to admit for observation, the designation plan would allow for that. Staff #1 was asked if the physician ER group was aware of this, and she stated she was not sure what type of orientation they received. Staff #3 RN stated that he talks with the physicians when they are new to the ER, but is not aware of any orientation done with the physicians within the facility. There was no orientation in Physician #4’s credential file to the hospital. A phone interview was conducted with Physician #4 on 10/1/24 at 8:32 am. Physician #4 stated he remembered the case and had been informed of the patient’s outcome. Physician #4 reported that he was a board-certified ER physician and pediatrician. He reported that when the patient came in, she was very responsive for a newborn, had a flat fontanel, flat no trauma was noted. He reported the baby was sucking and grasping fingers. Blood work was ordered. It all looked good except for a slightly elevated Bili. I watched the video, and there was some mild twitching but no noted postictal state afterwards. I had thought about scanning the baby, but I never saw any signs of seizures or abnormal activity. I talked with the parents and explained that if it happened again, they should come straight back. The patients were to follow up with a pediatrician on Monday for a more extensive workup. Physician #4 reported that he works for a contracted service for ER care at Nacogdoches Medical Center. Physician #4 was asked what type of orientation he had received at the facility. He stated that he had just started at the hospital on 9/17/24 as a locum. Physician #4 reported that the owner of the contracted service was out of the country, but he asked questions from other physicians and staff to orient himself to the facility. Physician #4 reported that he was not aware that the hospital NICU would accept patients back for observation.”

“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: 49344 Based on review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital’s emergency department. Given the patient’s state of confusion and agitation, poor memory, poor ability to focus, and irrational thinking, Patient #1 lacked capacity to refuse or be denied medical care. There was no discussion of risks of not receiving care. An appropriate medical screening examination was not completed to determine whether or not an emergency medical condition exists Refer to A2406.”

“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: 49344 Based on review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital’s emergency department. Given the patient’s state of confusion and agitation, poor memory, poor ability to focus, and irrational thinking, Patient #1 lacked capacity to refuse or be denied medical care. There was no discussion of risks of not receiving care. An appropriate medical screening examination was not completed to determine whether or not an emergency medical condition exists. Findings: Facility #1, Emergency Department (ED) sees an average of 1800 patients a month, they have 12 beds, 1 of which is a trauma bay. They are a designated Trauma IV. Central Log: The patient’s name appears on the Emergency Room log on 09/15/2023 at 10:14 AM for “Rib/trunk pain-swelling” with an ESI Level 3. Patient #1 was a 54-year-old, female with a history of COPD (chronic obstructive pulmonary diseases) (patient stated), Emphysema (patient stated), Hypertension (patient stated), Mycoplasma infection (Medical), PTSD (post-traumatic stress disorder) (patient stated). Patient arrived at Facility #1 via EMS on 9/15/2024 at 10:14 AM for complaints of “I broke 4 ribs”. EMS Care Record documented “Behavioral/psychiatric episode” with signs and symptoms “Strange and inexplicable behavior (Primary), injury to chest”. EMS unit 635 was dispatched to Patient #1’s address for a fall. “EMS responded to the scene with lights and sirens using due regard without incident. EMS arrived on scene to find a female patient sitting on the stairs outside. The patient had a fast, strong, regular radial pulse with pink, warm, and dry skin. The patient was A&Ox4 (alert and oriented to person, place, time and situation) and GCS (Glascow Coma Scale) of 15. The patient was making strange motions with her arms and hands. The patient was telling story’s that could not have happened. The patient stated she tripped in a hole in her kitchen floor and landed on the broom stick. EMS asked the patient if she landed on the pointed end of the broom stick and the patient stated she hit the corner of the table. EMS asked the patient which was it, and the patient stated “yeah”. The patient would not tell EMS what she landed on. EMS did not see any deformities or wounds to any aspect of her body. The patient stated she was in severe pain in her right anterior chest. The patient stated, “I broke 4 ribs, 5/8th of an inch away from my heart”. The patient kept moving her arms around. When asked if the patient took something the patient stated she did not. The patient stated there was people in her yard dancing is the reason why she fell. The patient did not appear to be in any distress or pain. The patient got mad and started yelling because she said someone was laughing and making fun of her. EMS preformed a Cincinnati stroke screen on the patient to find no abnormalities. The patient stated she wants to go to ____(Facility #1). EMS assisted the patient to a standing position and onto the stretcher without incident. EMS raised both rails and secured all straps. EMS transported the patient to the ambulance via stretcher without incident. EMS loaded the patient into the back of the ambulance via stretcher with the stretcher locked into the locking mechanism. EMS obtained a set of vitals (BP 138/62, Pulse, 126 R, RR 20 R, SPO2 95 RA, BG 129, Temp 98.7 F, Pain 0/10). The patient stated, “I absolutely do not want any other treatments”. EMS explained the risks to the patient and the patient still refused. EMS told the patient if she changes her mind to let EMS know and the patient stated okay. EMS obtained a signed refusal by the patient EMS transported the patient to the ER via ambulance without incident. EMS notified the receiving facility via Pulsara. EMS monitored the patient throughout transport to find no patient changes. The patient was still moving her arms in all motions. The patient stated she was driving a stick shift car. The patient then was looking outside and making sure people was pulling over for a funeral progression (there was no funeral progression). The patient stated she was still having chest pain on her right side. EMS still did not see any wounds or deformities. The patient still did not appear to be in any distress or pain. EMS obtained another set of vitals (BP 100/63, Pulse 128 R, RR 20 R, SPO2 97 RA, Pain 0/10). EMS arrived at the ER and transported the patient inside via stretcher without incident. EMS moved the patient over from the stretcher to the ER bed via draw sheet method. EMS gave a patient report to RN and obtained all signatures. EMS turned over patient care to ER. EMS unit 635 returned back to service and available for call.” Facility #1 ED Triage on 9/15/2023 at 10:16 AM Systolic BP: 172 mmHg Diastolic BP: 68 mmHg Mean Arterial Pressure: 103 mmHg Heart Rate: 112 bpm Respiratory Rate: 20 breaths/min Sp02/Pulse oximetry: 95 % OXygen Delivery: Room air Dosing BSA-Mosteller: 1.87 m2 Height: 167 cm Dosing Weight: 75 kg Dosing BMI: 27 Mentation Perfusion Hydration Assessment: Alert, Awake, Pink, Warm ESI Level 1: No ESI Level 2: No ESI Level 3: Many Vital Signs ESI: No Recommended ESI Level: 3 Nursing Note 9/15/2023 at 10:30 AM by Staff #7, ER, RN “Nursing Note: Patient wandering halls and verbally yelling profane language at nurses. Asked to return to her room and patient proceeded to pull her shirt up exposing her breasts. Security called.” Nursing Note 9/15/2023 at 10:40 AM by Staff #7, ER, RN Nursing Note: “________(Staff #8, ED, MD) attempting to visit with patient but patient being verbally disruptive in hallway and again pulling her shirt up flashing everyone. _______(Staff #8, ED, MD) asked patient not to do so and that to be aware that there are very sick patients in here and she needed to return to her room. Patient proceeded to go up to patient in hallway 1 and put her breast in her face. At this point security went to call PD (police department) and patient was escorted out of ER doors.” ED Physician Note 9/15/2023 at 10:45 AM by Staff #8, ED physician CHIEF COMPLAINT: “C/O broken ribs close to her heart. Patient does not relate incident. States “broken, glasses, shield, flew, just put it together.” Exhibits flight of ideas.” MEDICAL DECISION MAKING: “Patient was repeatedly walking up into the nursing station, was not following instructions for back into her room. Would not cooperate with staff for the full set of vital signs, refused a temperature check. Security guard was called and was in the hallway, patient was shouting and cursing at the security guard as well as staff. I saw patient in the hallway, discussed with patient that she is disturbing other patients here, I asked that if she cannot go back to room and follow instructions, and stop exposing herself, that she cannot stay here. Patient has been lifting her shirt up and showing her breast to staff as well as to other patients who was in the hallway as well. I asked her again that if she cannot behave appropriately then she will have to leave. We will also call police for indecent exposure as well. Patient started mocking us when we discussed that this is disturbing other sick patients with her behavior. Patient states that she would rather leave. She chose not to behave, she continued to show her breasts as she was walking out, and to make sure that she wants her breast to be seen on camera. Patient had clear speech, no facial droop, she was ambulating unassisted without any difficulties moving all 4 extremities, she did not look in any distress. She was actually laughing at points and mocking the staff as well. She did not exhibit any signs of self-harm. Normal sats on room air at 95%, normal respiratory effort at 20. She was slightly tachycardic at 112 but she was also easily riled up. Blood pressure slightly elevated 172/68. She would not let us check it for temperature. No impressions/plan, pt choose to leave as she does not want to behave properly.” Facility #1 Incident Report with attached POLICE REPORT 9/15/2023: Staff #9, Security Officer: “A patient started acting up in the ER and had to be removed. We had her trespassed. However, she snuck back in the ER and we had to call the police on her again, and had her taken off the property. _______ (Patient #1) was coming at nurses and security in a threatening manner. She was also flashing the other patients and visitors.” 911 was called on 9/15/2023 at 10:52 AM by Staff #9 An interview with Staff #6, ED physician 6/04/2024 at 1:10 PM stated: “If a patient is not homicidal or suicidal and they are medically stable, we cannot legally hold someone because they are acting strange. At that point we must let them leave if that is what they choose to do. If they are homicidal or suicidal, we will call the judge for a temporary hold until we can get the patient the care they need and keep them safe.””