Medical City Lewisville

“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: 51738 Based on interviews and a review of medical records, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on interviews and a review of medical records, Facility A failed to initiate an appropriate transfer to a facility capable of providing services not offered at Facility A for 1 of 27 patients (Patient #1). Patient #1 was discharged AMA (Against Medical Advice) and transferred from Facility A with a police officer (PO) to Facility B. Facility A failed to initiate an appropriate transfer when the physician’s certification was not signed, acknowledging the risks and benefits of the transfer. Facility A did not ensure Facility B had available space and qualified personnel for the treatment of the individual, nor had Facility B agreed to accept transfer of the individual and to provide appropriate medical treatment. Facility A failed to send Facility B all medical records, informed consents, and certification for transfer. Facility A failed to transfer through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. Cross-Refer Tag 2409”

“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: 51738 Based on interviews and a review of medical records, Facility A failed to initiate an appropriate transfer to a facility capable of providing services not offered at Facility A for 1 of 27 patients (Patient #1). Patient #1 was discharged AMA (Against Medical Advice) and transferred from Facility A with a police officer (PO) to Facility B. Facility A failed to initiate an appropriate transfer when the physician’s certification was not signed, acknowledging the risks and benefits of the transfer. Facility A did not ensure Facility B had available space and qualified personnel for the treatment of the individual, nor had Facility B agreed to accept transfer of the individual and to provide appropriate medical treatment. Facility A failed to send Facility B all medical records, informed consents, and certification for transfer. Facility A failed to transfer through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. Findings were: Interviews: In interviews on 12/29/2025 and 12/30/25, Staff #2, ED Director reported that staff at Facility A cannot detain patients without their consent but do educate patients about the risks of leaving AMA and then contact onsite off-duty POs. These off-duty POs detain patients and contact the police department (PD). When the on-duty police officer (PO) arrives on-scene, they evaluate the patient and write an Emergency Detention Order (EDO) if warranted, then transfer the patient to a behavioral health facility. Sometimes they inform the ED staff where they are taking the patient. Sometimes they do not. If ED staff know where the PO is taking the patient, they will give a “courtesy call” to that facility. In an interview on the morning of 12/30/2025, Staff #1, VPQ (Vice President Quality) reported that if any patient wants to leave AMA and staff thinks that they are a danger to themselves, they will call the PD to get an EDO. Staff #1 also reported that there have been ongoing conversations with the staff at Facility B regarding why Facility A does not complete an MOT (Memorandum of Transfer) or send any documentation with the PO. In these talks, Facility A informed Facility B that sending medical records would violate HIPAA if a patient discharged AMA since it is not a formal transfer. Staff #1, VPQ reported that there was a meeting on 11/13/2025 with Facility A’s corporate attorney, the Chief Nursing Officer (CNO), Staff #2 - Chief Executive Officer (CEO), herself (Staff #1, VPQ), and Staff #2, ED director, and they are currently “in talks” with the PD about placing EDOs. Staff #1, VPQ reported that how the PD handles the EDO and timeline for transporting patients to behavioral health facilities is outside of their control. A Review of the Medical Record for patient #1 reveals in part: 9/16/2025: 10:06 PM - patient #1 presents to Facility A with “Stated Complaint: 17 WEEKS PREG. SUICIDAL THOUGHTS” 10:12 PM - Staff #14 - “Subjective Assessment - PT [patient #1] REPORTS HAVING SI [SUICIDAL IDEATION] THOUGHTS FOR 1 HOUR, PT STATES SHE TRIED TO HANG HERSELF BUT COULD NOT GO THROUGH WITH IT, PT ABOUT 17 WEEKS GESTATION, SHE STATES SHE THOUGHT ABOUT HER BABY AND THATS [sic] WHAT CAUSED HER TO STOP, PT REPORTS ATTEMPTING SUICIDE AT AGE 15 AND AGE 17, PT ALSO REPORTS PUNCHING HERSELF PTA [prior to arrival], PT HAS SEEN PSYCHOLOGY BUT HAS NEVER TAKEN MEDICATIONS FOR DEPRESSION” 10:21 PM - Staff #8, PA - Emergency Provider Report HPI [History of Present Illness] - Psychiatric Illness: “29-year-old female, approximately 17 weeks gestation, not receiving prenatal care, who presented to the ER with concerns over suicidal attempt and ideation. She endorses that she has been unemployed for the last 3 months, has been having a difficult time with finding a job, consequently which is causing her to have a lot of financial struggles and stress. She states that this evening she received a letter from her bank, that stated that they were closing her account, and she tried to express her concerns to her significant other, and she felt like he was not listening or was understanding her feelings on the subject. She states that because of that, she started feeling suicidal, and had a suicide attempt in which she attempted to hang herself however her feet were touching the ground the whole time, and she was unable to follow through with it because she was also thinking about her unborn baby. She also endorses that she was punching herself on the right side of her face. Reports history of previous attempt at age 15. She reports a history of anxiety and depression and has seen a psychologist in the past, but is not currently on any medication, has never needed inpatient psychiatric help.” Risk-Psychiatric Illness: Staff #8, PA documents that there was a positive nurse suicide risk screen, and that the “Overall level suicide risk risk” was high. Review of Systems ...Psychiatric - “Reports: Depression, Stress, Suicidal Ideation.” Focused Physical Exam - Staff #8, PA documents all systems within defined limits (WDL) except “Psychiatric - Abnormal Mood /Affect - Depressed, Hopeless. Abnormal thinking/Perception - Suicidal, with plan.” Re-Evaluation & MDM [Medical Decision-Making] - Staff #8, PA “Behavioral health assessment pending. Care transferred over to attending provider [Staff #7]” 10:33 PM - Staff #5, RN documents: Suicide Screening - “High risk” notified Staff #8, PA of patient’s suicide risk. 9/17/2025: 3:08 AM -Staff #13, Licensed Mental Health Counselor (LMHC) - Behavioral Health (BH) Assessment - Telehealth Consult. Staff #13, LMHC documents that patient #1 reported anxiety and depression all day related to not having a job and had tried to tell her boyfriend how she was feeling but he became upset with her. Patient #1 then went to her room, punched herself in the head, and tried to hang herself with a belt in her closet. Patient #1 told her boyfriend she needed to go to the hospital. When the car slowed down on the way to the hospital, patient #1 jumped out of the moving vehicle. Staff #13, LMHC documents patient #1 had a history of anxiety, depression, suicide attempts and a prior inpatient psychiatric hospitalization - date unknown. Patient #1 denied access to weapons, alcohol and substance use, and current psychiatric treatment including medications. Staff #13, LMHC further documented that patient #1 met the criteria (“recent suicide attempt, suicidal ideations, increased anxiety and depression, medication management, and stabilization”) for inpatient psychiatric treatment but that patient #1 refused inpatient treatment and wanted to be discharged home. According to Staff #13, LMHC, staff #7 “agrees with recommendation and reported that the patient #1 will be involuntary at this time as she is not willing to receive treatment voluntarily and is high risk.” 4:01 AM - Staff #12, ED RN calls MHMR [Mental Health Services] who recommends calling PD (police department) to assess patient for suicide risk and to initiate an EDO. Staff #12, RN notifies PD. 4:06 AM - PD Officer completes “Notification of Emergency Detention” [EDO - Emergency Detention Order]. 4:41 AM - Staff #7, DO - “Patient Discharge and Departure” Staff #7, DO documents that patient #1 left Against Medical Advice (AMA), with a diagnosis of suicidal ideation. In his “Discharge/Care Plan”, Staff #7, DO documents that patient #1 was “Counseled Regarding Diagnosis, Lab results, Imaging studies, Need for admission, Need for psych eval [evaluation]” 4:46 AM, LPD Officer escorted patient #1 out of Facility A and transported her under an EDO to Facility B. 4:53 AM, Staff #12 made a “courtesy call” to staff at Facility B to inform them that patient #1 was en route under an EDO to their facility. 5:38 AM, Facility B staff started the intake process for patient #1 5:56 AM Facility B “STANDARDIZED INTAKE ASSESSMENT - PT [patient #1] presented as transported via LPD on APOWW [Apprehension by a Police Officer Without a Warrant] with the chief complaint of suicide attempt. Pt reports that she is having thoughts of suicide that have been increasing since she became pregnant (pt is 17 weeks along) due to hormonal changes and feeling sick. Pt reports she is also currently unemployed and is worried about the future ...Additional Comments ...Pt reports it all became too much today and she hung herself, was found by her boyfriend who called 911. Pt was hanging for approximately 5 seconds per reports. Pt was taken to [Facility A] by PD PTA @ [Facility B]. Pt reports one previous attempt via OD [overdose] at age 15 ...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to perform an appropriate medical screening examination (MSE) in the emergency department (ED) for 3 of 22 patients (Patient #3, #5’s two visits, #13) to determine if the patients had an emergency medical condition . · Patient #3 did not receive additional observations, a psychological reassessment for anxiety and paranoia. During Patient #5’s first visit, Patient #5 did not receive additional observations or a psychological reassessment for formication [tactile hallucinations]. · During Patient #5’s second visit, Patient #5 did not receive additional observations or a psychological reassessment for formication · Patient #13 did not receive additional observations or a psychological reassessment for auditory hallucinations. . Based on observation, record review, and interviews, Facility A failed to initiate an appropriate transfer to a facility capable of providing services not offered at Facility A for 2 of 22 patients (Patient #2 and #6). Both Patient #2 and Patient #6 were discharged and transferred from Facility A with police officers to Facility B. . · Facility A failed to initiate an appropriate transfer when the physician’s certification was not signed, acknowledging the risks and benefits of the transfer. · Facility A did not ensure Facility B had available space and qualified personnel for the treatment of the individual, nor had Facility B agreed to accept transfer of the individual and to provide appropriate medical treatment. · Facility A failed to send Facility B all medical records, informed consents, and certification for transfer. · Facility A failed to transfer through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. . See Tags 2406 and 2409 .”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to perform an appropriate medical screening examination (MSE) in the emergency department (ED) for 3 of 22 patients (Patient #3, #5’s two visits, #13) to determine if the patients had an emergency medical condition . · Patient #3 did not receive additional observations, a psychological reassessment for anxiety and paranoia During Patient #5’s first visit, Patient #5 did not receive additional observations or a psychological reassessment for formication [tactile hallucinations]. · During Patient #5’s second visit, Patient #5 did not receive additional observations or a psychological reassessment for formication · Patient #13 did not receive additional observations or a psychological reassessment for auditory hallucinations. . Record Review Patient #3’s Medical Record Per Page 1, Section “Rapid Initial Assessment”., On 09/23/2025 at 8:01 P.M., Patient #3, a 59-year-old female, presented to Facility A’s emergency department. Patient #3 arrived with emergency medical services and law enforcement. Nursing notes indicate, “Prior to admission, Patient #3 jumped from the third floor of a building but was caught by a neighbor on the second floor (Page 4). Law enforcement stated that Patient #3 had a pill in her mouth, and several pills were found in her home. Emergency Department [ED] Registered Nurse [RN], Staff A, documented that Patient #3 was anxious, restless, diaphoretic, and alert and oriented. At 8:03 P.M., ED RN, Staff A, documented a negative suicide screening and a chief complaint of “Behavioral Health Related” (Suicide Screening, Page 2). At 8:14 P.M., Patient #3 had an elevated blood-alcohol level of 92 (Laboratory Tests, Page 4). At 8:14 P.M., ED Physician Assistant [PA], Staff B, documented that Patient #3 appeared paranoid. Staff B noted that Patient #3 would “receive labs for a psychiatric evaluation,” and a head CT [computed tomography] would be ordered to evaluate for any acute process (Free Text MDM [medical decision making] Notes, Page 5). At 8:43 P.M., ED RN Staff A documented that Patient #3’s family was notified of the patient’s request to pick them up. Family stated that law enforcement had placed Patient #3 on a 72-hour hold (Nursing Notes, Page 5). No emergency detainment order was in the medical record. At 8:48 P.M., ED PA, Staff B documented that Patient #3 refused the head CT. At 9:04 P.M., ED PA, Staff B documented that Patient #3 “chose to leave against medical advice” [AMA] and the patient was “refusing all labs and imaging” (Free Text MDM Notes, Page 7). Patient #3’s primary impression was listed as anxiety with a secondary impression of paranoia (Discharge & Departure, Page 8). ED RN, Staff A documented that Patient #3 left against medical advice with law enforcement to jail (Disposition, Page 4). Patient #3 did not receive a complete medical screening examination, as Patient #3 did not receive additional observation or a psychological reassessment. . Patient #3’s Ambulance Report On 09/23/2025 at 7:40 P.M., emergency medical services responded to Patient #3’s call. Page 1. Section “Clinical Impression”. Paramedic Staff C noted that barriers to care include Patient #3 being psychologically impaired, uncooperative, and in a state of emotional distress. Patient #3 had a documented history of schizophrenia. . Patient #5’s Medical Record for the First Visit On 06/10/2025, Patient #5 had two visits in one day. At 6:41 A.M., Patient #5, a 78-year-old female, presented to Facility A’s emergency department. Emergency Department [ED] Registered Nurse [RN], Staff D documented Patient #5 reported, “someone shoved fly eggs down her throat,” “her hypothyroid is due to things being in her body that don’t belong,” and she was “here for us [ED] to clean out the fly eggs.” ED RN Staff D noted that Patient #5 was alert and oriented times 4, knowing person, place, and time (Rapid Initial Assessment, Page 1). At 6:40 A.M., ED Physician, Staff E documented that Patient #5A was requesting “stronger magnets to pull [sic] infestation out.” Section “Focused Review of Symptoms” (Free Text HPI [history of present illness], Page 1). ED Physician Staff E documented a physical assessment with no abnormalities. ED Physician Staff E noted that Patient #5 was refusing all testing, both lab work and radiology. Patient #5 was offered admission to Facility A; however, she declined. Patient #5A was noted to have a normal mental status, was neurologically intact, and had no signs of altered mental status (Free Text MDM [medical decision making] Notes, Page 3). At 6:47 A.M., ED RN, Staff F documented Patient #5 as discharged home. Patient #5A was given referrals to outpatient infectious disease physicians (Disposition, Page 2). Patient #5’s primary impression was listed as formication [tactile hallucinations] (Clinical Impression, Page 4). Patient #5 did not receive a complete medical screening examination, as Patient #5 did not receive additional observation or a psychological reassessment. . Patient #5’s Medical Record for the Second Visit On 06/10/2025, Patient #5 had two visits in one day. At 9:59 P.M., Patient #5, a 78-year-old female, presented to Facility A’s emergency department. Patient #5B had been at Facility A earlier that day at 6:41 A.M [see Patient #5A]. At 10:41 P.M., Emergency Department [ED] Registered Nurse [RN], Staff G documented Patient #5’s complaint. “Pt [patient] states I have maggots running under my skin, you have to admit me and get me an MRI [magnetic resonance imaging] to get them out.” ED RN, Staff G, noted that Patient #5 was alert and oriented times 4, knowing person, place, time, and situation (Rapid Initial Assessment, Page 1). ED RN, Staff G, documented a negative suicidal screening and a negative wound evaluation (Non-Urgent General Focus, Page 2). At 10:46 P.M., ED Physician Assistant [PA], Staff H documented that Patient #5B denied any visual or audio hallucinations. Patient #5B refused “any imaging, including an X-ray or CT [computed tomography]” (Free Text HPI [history of present illness], Page 1). ED PA, Staff H, documented that Patient #5 reported visual hallucinations. Physical assessment was within normal limits, but ED PA, Staff H, noted, “abnormal thinking/perception and insight abnormal” (Focused Review of Symptoms, Page 2). At 11:52 P.M., ED PA, Staff H, documented that Patient #5B was concerned about the radiation from the CT and only wanted to be admitted and to have an MRI, also noting that Patient #5 had been seen twice for the same concern. ED PA, Staff H, indicated that Patient #5 had “no open wound, swelling, or abnormalities” on neck examination (Free Text MDM [medical decision making] Notes, Page 4). On 06/11/2025 at 1:05 A.M., ED RN, Staff I, documented Patient #5 was “observed in room responding to internal stimuli” (Notes, Page 3). At 1:19 A.M., ED RN, Staff I, documented that Patient #5B left against medical advice [AMA] without signing the AMA form (Disposition, Page 2). 1:26 A.M., ED PA, Staff H, documented that Patient #5 was seen eloping from the department by staff (Re-Evaluation/Progress #2, Page 8). Patient #5’s primary impression listed “Eloped from the emergency department” and secondary impression of formication [tactile hallucinations] (Clinical Impression, Page 9). Patient #5 did not receive a complete medical screening examination, as Patient #5 did not receive additional observation or a psychological reassessment. . Patient #13’s Medical Record On 09/07/2025 at 8:31 A.M., Patient #13, a 59-year-old female, presented to Facility A’s emergency department [ED] with auditory command hallucinations. At 8:31 A.M., ED Registered Nurse [RN], Staff M, documented Patient #13’s chief complaint. “Patient states she is hearing voices, she is unable to state what they are saying. She wants the pain and suffering to stop. She does not want to commit suicide, but she is tired” (Rapid Initial Assessment, Page 1). At 8:33 A.M., ED Physician, Staff N, documented Patient #13’s past medical history of a mood disorder and auditory hallucinations. Staff N noted that Patient #13 states the voices are getting louder and she has stopped taking her medications because the voices are telling her to do so (Free Text HPI [history of present illness], Page 1). ED Physician Staff N documented a negative suicide screen; however, they stated that it was “Difficult to assess the risk of SI [suicide ideation] and HI [homicidal ideation] because the patient has a history of auditory hallucinations”. Staff N noted that Patient #13 was denying both SI and HI (Risk-Psychiatric Illness, Page 1). Staff N assessed that Patient #13 was oriented times 3, knowing person, place, and time. At 8:55 A.M., Patient #13 was administered 2.5 milligrams of Haldol [antipsychotic]. At 9:13 A.M., a behavioral health consultation was ordered (Focused PE [physical examination], Page 3). ED Physician, Staff N, documented that Patient #13 stated her hallucinations had decreased. Patient #13 voiced that she did not want to stay at the hospital and wanted to sign out against medical advice. Staff N documented that Patient #13 had mental capacity (Text/DIC [dictation] Note, Page 6). At 10:43 A.M., Patient #13 was documented as being discharged with counsel regarding the need for a psychiatric evaluation. Patient #13 was given education on schizophrenia and referrals to psychiatrists. Primary impression, “left against medical advice” (Disposition Decision, Page 8). Patient #13 did not receive a complete medical screening examination, as Patient #13 did not receive additional observation or a psychological reassessment. . Review of Texas EMTALA (emergency medical treatment and labor act) - Medical Screening Examination and Stabilization Policy, revised 06/17/2024: Page 6. “Procedure 3. Extent of the MSE e. Extent of MSE varies by presenting symptoms. The MSE may vary depending on the individual’s signs and symptoms: ii. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others.” . Page 7. “4. Who May Perform the MSE b. Qualified Medical Personnel. QMPs may perform an MSE if licensed and certified, approved by the hospital’s governing board through the hospital’s by-laws, and only if the scope of the EMC is within the individual’s scope of practice. ii. Psychiatric QMP. The ED physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED with psychiatric or behavioral emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination, and providing necessary stabilizing treatment.” . Review of Medical Staff Rules and Regulations, Approved 6/11/2025: Page 5. “2.1 Admissions: (d) Acutely psychotic patients, patients at risk of harming themselves or others, or patients hospitalized for alcohol or substance abuse should be evaluated for transfer to specialized facilities.” . Page 25. “5.4. Mental Health Consultations: A mental health consultation and treatment will be requested for and offered to all patients who have engaged in self-destructive behavior (e.g., attempted suicide, chemical overdose) or who are determined to be a potential danger to others. If psychiatric care is recommended, evidence that such care has at least been offered and/or an appropriate referral made will be documented in the patient’s medical record.” . Interviews: 12/17/2025 at 6:30 P.M. with ED RN, Staff A. Staff A stated that Patient #3 presented at Facility A for a psychiatric evaluation. Staff A noted that Patient #3 did not receive a psychiatric evaluation. . 12/16/2025 at 3:00 P.M. with ED PA, Staff H. Staff H stated that any patient who comes in with a mental health condition, Staff H offers a behavioral health consultation, even if the patient is not suicidal or homicidal. Staff H stated that patients who come in for self-harm they try not to let the patient leave against medical advice. Staff H stated they get the police involved, and the facility doesn’t let the patient leave. . 12/16/2025 at 3:30 P.M. with ED Physician, Staff S. Staff F stated that patients who present without SI [suicidal ideation] or HI [homicidal ideation] providers tend to order behavioral health consultations; however, Staff S indicated that patients often leave before they are completed. Staff S stated their understanding is that if a patient presents to the facility under an emergency detainment order [EDO], the patient must stay and go through the whole process, whether they refuse or not. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to initiate an appropriate transfer to a facility capable of providing services not offered at Facility A for 2 of 22 patients (Patient #2 and #6). Both Patient #2 and Patient #6 were discharged and transferred from Facility A with police officers to Facility B. . · Facility A failed to initiate an appropriate transfer when the physician’s certification was not signed, acknowledging the risks and benefits of the transfer. · Facility A did not ensure Facility B had available space and qualified personnel for the treatment of the individual, nor had Facility B agreed to accept transfer of the individual and to provide appropriate medical treatment. · Facility A failed to send Facility B all medical records, informed consents, and certification for transfer. · Facility A failed to transfer through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. . Record Review Patient #2’s Facility A Medical Record On 09/20/2025 at 3:37 P.M., Patient #2, a 34-year-old female, presented to Facility A’s emergency department [ED], with a chief complaint of anxiety and panic attacks. At 4:07 P.M., ED Physician Assistant [PA], Staff O, documented a chief complaint of altered mentation and abnormal behavior. Patient #2 had recently started several medications, including Flexeril [muscle relaxer], Cymbalta [antidepressant], Norco [pain medication], Gabapentin [pain medication], and Adderall [stimulant to treat attention deficit disorder]. Patient #2 told the provider that she was tired of it all, had had enough, and was done. Patient #2’s spouse stated that the patient has made these statements for the past few weeks and that she had become more aggressive and appeared manic. The spouse also indicated that Patient #2 had taken all of her medication, including “benzo” [sedative] and Phenobarbital [sedative], and since she ran out, she started taking her dog’s seizure medication (Free Text HPI [history of present illness], Page 1). At 4:39 P.M., Patient #2’s urine drug screen was positive for benzodiazepines [sedatives], amphetamines [stimulants], and barbiturates [sedatives]. At 4:50 P.M., Patient #2’s CT [computed tomography scan] of the head and brain was negative (Laboratory Tests, Page 3). At 9:42 P.M., a behavioral health assessment was completed. At 10:00 P.M.: ED PA, Staff O noted that the behavioral health assessor believed Patient #2 was not safe to go home due to concerns for mania and aggression (ED [emergency department] BH [behavioral health] Level of Care Assessment, Page 4). Patient #2 was placed on an EDO [emergency detainment order], and the charge nurse and police department were to facilitate transfer to Facility B. Patient #2’s primary impression was listed as a manic episode. Facility A was aware of Patient #2’s transfer to Facility B. Facility A failed to initiate an appropriate transfer, as there was no memorandum of transfer, the receiving facility did not accept the transfer, and Facility A did not send any pertinent paperwork. . Patient #2’s Facility B Medical Record On 09/20/2025 at 11:47 P.M., Patient #2 presented to Facility B under an emergency detention order [EDO]. 09/21/2025 at 1:01 A.M., the attending psychiatrist noted that during the assessment, Patient #2 was crawling on the floor, pacing and checking doors, rambling, pulling her shirt up, and lowering her pants, exposing herself (HPI [history of present illness, Page 5). At 2:29 A.M., Patient #2 was admitted to Facility B as an inpatient. Handoff given to inpatient RN [registered nurse] (High Risk Handoff, Page 4). Diagnosis: “Bipolar disorder, current manic severe, without psychotic features” (A. Psychiatric Recommendation, Page 9). Facility B was unaware of Patient #2’s visit to Facility A’s emergency department prior to admission. . Patient #6’s Medical Record On 06/21/2025 at 4:58 A.M., Patient #6, an 18-year-old female, presented to Facility A’s emergency department [ED] with a chief complaint of depression and intentional drug overdose. At 4:58 A.M., ED Physician, Staff J, documented Patient #6’s past medical history of depression and home medication Geodon [antipsychotic]. Staff J noted that Patient #6 took a “handful” prior to presenting to the ED; the number of tablets and their dosage were unknown. Patient #6 was documented to be “tearful and depressed” and as having “multiple healed and previous excoriations or lacerations to her arms, legs, breasts” with no acute lacerations upon physical assessment (Free Text HPI [history of present illness] Notes, Page 1). A suicide risk screening indicated that Patient #6 was a high risk for suicide based on previous attempts and prior psychiatric admissions (Risk-Psychiatric Illness, Page 2). ED Physician, Staff J’s physical exam noted anxiety, depression, and suicidal ideation (Focused Review of Systems, Page 2ED Physician, Staff J, documented that Patient #6 was oriented times 3, knowing person, place, and time (Focused PE [physical examination], Page 5). At 5:21 A.M., Patient #6’s abnormal labs included an elevated potassium of 5.7 and a positive urine drug screen for marijuana (Laboratory Tests, Page 8). At 5:50 A.M., Patient #6 was administered 50 grams of Charcoal/Sorbitol and 1 liter of Normal Saline fluids (ED Course, Page 6). At 6:03 A.M., ED Registered Nurse, Staff K, documented that poison control was called, and ED Physician, Staff J, was notified of their recommendations for Patient #6 (Notes, Page 6). At 7:00 A.M., ED Physician, Staff L, documented, “Patient medically clear at this time. I discussed with the patient having ARC [mental health team] assessor from a psychiatric standpoint for psychiatric placement. Patient declines doing the psychiatric assessment in the ER and states she actually doesn’t want to go anywhere for treatment and will be signing out against medical advice. Patient is currently in police custody, and they will take her directly to [Facility B] for psychiatric treatment” (Re-Evaluation & MDM [medical decision making], Page 9). Page 7. Section “Clinical Impression”. Patient #6’s primary impression was listed as suicide attempt with a secondary impression of intentional drug overdose (Clinical Impression, Page 7). Section “Discharge/Care Plan”. “Counseled regarding: Diagnosis, Lab results, [sic] Need for psych [psychiatric] eval [evaluation]” Discharge/Care, Page 7). Patient #6 did not receive a complete medical screening examination, as Patient #6 did not receive additional observation or a psychological reassessment. . Patient #6 Facility B Medical Record On 06/21/2025 at 1:05 P.M., Patient #6 presented to Facility B under an emergency detainment order [EDO]. At 2:33 P.M., the attending Physician documented an evaluation that noted Patient #6 stated that “Edward” told her to take pills, “Michael” will not let her eat, and “Derek” tells her to hurt herself. The physician documented that Patient #6 was experiencing auditory and visual hallucinations. Documentation indicates that Patient #6 was experiencing “Severe mental/physical deterioration or incompetence”(Preadmission evaluation Medical Clearance Screening, Page 6). Documentation notes Patient #6 as cooperative, anxious, apathetic, with flat affect, having poor judgment, poor reliability, poor insight, with suicidal ideation and audio/visual hallucinations (Mental Status Exam, Page 6). Patient #6 is documented to have had anxiety, depression, major depressive disorder, mood disorder, post-traumatic stress disorder, and a psychotic disorder (Previous Psychiatric Conditions, Page 7). “Major depression recurrent severe, with psychotic features,” with a recommendation to be admitted for inpatient treatment (Preliminary Psychiatric Impression, Page 7). Facility B was unaware of Patient #6’s visit to Facility A’s emergency department prior to admission. . Review of Medical Staff Rules and Regulations, Approved 6/11/2025: Page 44. “11.4. Admissions and Transfers: (c) A transfer of a patient that occurs after the completion of the medical screening examination will be initiated in accordance with Medical Center Policy 911-500.003 entitled EMTALA - Texas Transfer Policy of Patients Between Hospitals With or Without Emergency Medical Conditions.” . Page 49. “13.1. Transfer: The process for providing appropriate care for a patient, during and after transfer from the Medical Center to another facility, includes: (a) assessing the reason(s) for transfer; (b) establishing the conditions under which transfer can occur; (c) evaluating the mode of transfer/transport to assure the patient’s safety; and (d) ensuring that the organization receiving the patient also receives necessary medical information” . Page 49. “13.2. Procedures: (a) Patients will be transferred to another hospital or facility based on the patient’s needs and the Medical Center’s capabilities. The responsible practitioner will take the following steps as appropriate under the circumstances: (1) identify the patient’s need for continuing care in order to meet the patient’s physical and psychosocial needs; (2) inform patients and their family members (as appropriate), in a timely manner, of the need to plan for a transfer to another organization; (3) involve the patient and all appropriate practitioners, Medical Center staff, and family members involved in the patient’s care, treatment, and services in the planning for transfer; and (4) provide the following information to the patient whenever the patient is transferred: (i) the reason for the transfer; (ii) the risks and benefits of the transfer; and (iii) available alternatives to the transfer. (b) When patients are transferred, the responsible practitioner will provide appropriate information to the accepting practitioner/facility, including: (1) reason for transfer; (2) significant findings; (3) a summary of the procedures performed and care, treatment and services provided; (4) condition at discharge; (5) information provided to the patient and family, as appropriate; and (6) working diagnosis.” . Review of EMTALA - Texas Transfer Policy of Patients Between Hospitals With and Without Emergency Medical Conditions policy, Revised 6/17/2024 Page 2. “1. Transfer of Individuals Who Have Not Been Stabilized b. A transfer will be an appropriate transfer if: 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 has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer as well as the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and iv. The transfer is affected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport.” . f. Physician Certification of Risks and Benefits. A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the unborn child, from being transferred. The certification should meet the following requirements: · The certification must state the reason for transfer. The narrative rationale need not be · a lengthy discussion of the individual’s medical condition as this can be found in the · medical record but should be specific to the condition of the patient upon transfer. · The certification must contain a complete picture of the benefits to be expected from · appropriate care at the receiving facility and the risks associated with the transfer, · including the time away from an acute care setting necessary to effect the transfer. · The date and time of the physician certification should closely match the date and time · of the transfer. · Certifications may not be backdated. . Page 4. “2. Additional Transfer-Related Situations b. Off-Campus hospital-based facilities to nonaffiliated hospital. A transfer from a hospital-based facility located off-campus to a nonaffiliated hospital must still comply with the requirements of an appropriate transfer as defined by EMTALA. A Memorandum of Transfer must be used in such situations.” . Page 8. “h. Send Memorandum of Transfer. A Memorandum of Transfer must be completed for every patient who is transferred to another separately licensed hospital. The Memorandum of Transfer and the patient’s medical record must be sent with the patient at the time of the transfer. A copy of the Memorandum of Transfer shall be retained by the transferring hospital and incorporated into the patient’s medical record. A copy of the MOT must be filed separately from the patient’s medical record and in a manner which will facilitate its inspection by the department. All MOT forms filed separately must be retained for five years.” . Interviews: 12/15/2025 at 1:30 P.M. with Director of Patient Safety, Staff R. “There is not one [memorandum of transfer for Patient #2].” . 12/17/2025 at 6:30 P.M. with ED RN, Staff A. “Police officers will sometimes let us know where they are going, but not all the time. If a patient is going to a facility, we do a normal transfer with the MOT [memorandum of transfer].” . 12/16/2025 at 3:00 P.M. with ED PA, Staff H. Staff H verified that police officers will notify the staff of where the patient is going. Staff H stated that staff are to document “where the patient is going, the officer’s name, the protocol, and transfer.” Staff H stated that they try to get as much information as they can to ensure a proper hand-off. The doctors facilitate the transfers, and providers are supposed to do the MOTs. . 12/16/2025 at 3:30 P.M. with ED Physician, Staff S. Staff S stated that patients under an emergency detainment order are kept at the facility, go through the behavioral health process, and then are properly transferred with an MOT [memorandum of transfer]. .”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51905 Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review and interviews, Facility A failed to perform and document a complete medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for three of twenty patients (Patient #1, #3, #7). Patients #1, #3, and #7 did not receive a behavioral health consult or assessment when presenting to the emergency department with a mental health crisis. . Facility A failed to initiate an appropriate transfer to a behavioral health facility for three of the twenty patients (Patient #3, #7, #10). Patients #3, #7, and #10 were all under an EDO (emergency detention order) and transferred to known behavioral health facilities. . See Tags 2406 and 2409”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 51905 Based on observation, record review, and staff interviews, Facility A failed to provide adequate physician on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists. Failure to staff on-call gastroenterologists at night subjects patients needing specific gastrointestinal emergent treatment to probable harm. . Findings: . 1.Record Review . Review of the on-call physicians’ schedule at Facility A: a.October: twenty-two (22) of twenty-two (22) days there was no Gastroenterology provider on-call at night. b.November: thirty (30) of thirty (30) days there was no Gastroenterology provider on-call at night. c.December: thirty-one (31) of thirty-one (31) days there was no Gastroenterology provider on-call at night. d.January: thirty-one (31) of thirty-one (31) days there was no Gastroenterology provider on-call at night. e.February: twenty-eight (28) of twenty-eight (28) days there was no Gastroenterology provider on-call at night. f.March: thirty-one (31) of thirty-one (31) days there was no Gastroenterology provider on-call at night. . Review of Facility A’s EMTALA- Provision of On-Call Coverage Policy, 911.500.002 - Revised 07/2024: Page 2 of 5: “Procedure: Maintain a List: Each hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC.” “The hospital is expected to provide adequate specialty on-call coverage consistent with the services provided at the hospital and the resources the hospital has available.” . 2.Interview: a.04/17/2025 at 9:53 P.M. in an interview with Medical Staff Director Staff G, Staff G explained the colors of the schedule provided. Staff G stated, “ ...the orange is a change in schedule, blue is the original schedule, green means there’s a back-up provider, and red means there is no coverage.” Staff G was asked to verify that there was no coverage for gastroenterology. “Yes, that’s right. We do not have GI (gastroenterologists) at night.” . b.04/17/2025 at 10:00 A.M. in an interview with Director of Emergency Services Staff C, Staff C indicated that if a gastroenterologist was needed at night for a patient with a gastrointestinal emergent medical condition, the facility would stabilize the patient and transfer them to a higher level of care.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51905 Based on record review, facility policy, and interviews, Facility A failed to perform and document a complete medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for three of twenty patients (Patient #1, #3, #7). Patients #1, #3, and #7 did not receive a behavioral health consult or assessment when presenting to the emergency department with a mental health crisis. . Findings: 1.Medical Record: a.Review of Patient #1’s medical record from Facility A: On 03/09/2025 at 9:14 P.M., Patient #1 presented to Facility A’s emergency department. Patient #1 was under an EDO (emergency detention order) and accompanied by police. Patient #1’s chief complaint was suicidal ideation. Patient #1 had run away from home and threatened family he was going to kill himself by laying in the road and getting hit by a car. At 9:17 P.M., Patient #1 received a physical assessment and a detailed suicide risk screening that scored “low risk” from the physician though Patient #1 voiced suicidal ideation and plan. A suicide screening completed by the nurse screened positive. Per, Staff J, Patient #1 denied suicidal ideation at the time of assessment. . At 9:28 P.M. All labs resulted within normal limits aside from a urine drug screen being positive for THC (Tetrahydrocannabinol ). . A police report created 03/09/2025 at 9:29 A.M., scanned in the chart, states that the officer has “reason to believe and do believe that the above-named (Patient #1) evidences a substantial risk of serious harm to himself/herself or to others.” Additionally reported that the officer has “reason to believe and do believe that the above (Patient #1) risk of harm is imminent.” . At 10:20 A.M. Lamotrigine was administered to the patient. . Staff J noted, “Patient here with suicidal ideations. Says he was going to lay down in traffic. History of psychiatric illness in the past. PD (police department) involved, and a detention order placed and patient discharged to police custody.” . At 10:40 P.M. Staff I noted, PT (patient) A&Ox4 (alert and oriented times 4) NAD (no acute distress) PT (patient) VSS (vital signs stable) PT (patient) verbalized understanding of discharge.” “Patient Instructions: ED suicidal, 72-Hour hold.” . Patient #1 presented with suicidal ideation. Patient #1 was not provided a behavioral health consult to adequately rule out an emergency medical condition of suicidal ideation before Patient #1 was discharged. Facility A failed to provide an appropriate medical screening exam. . b.Review of Patient #1’s medical record from Facility B: On 03/09/2025 at 11:17 P.M., Patient #1 presented to Facility B’s emergency department. Patient #1 was under an EDO (emergency detention order) and accompanied by police. Patient #1’s chief complain was suicidal ideation. Patient #1 stated “he was going to lie in the road to kill himself.” Additional “reason for visit” included “aggressive behavior, autism disorder, and impulse control disorder.” . On 03/10/2025 at 1:16 A.M., behavioral health was consulted and assessed Patient #1. Per the assessment, “Pt (patient) denied SI (suicidal ideation) however per report pt threatened his family to kill himself by being hit by a car after a disagreement.” “Pt is not currently under the care of a therapist or psychiatrist.” “Pt is recommended for inpatient BH (behavioral health) Invol (involuntary) admit.” “Risk level: High Suicide Risk.” . At 5:06 P.M., Patient #1 was transferred to an inpatient behavioral health facility. . c.Review of Patient #3’s medical record from Facility A: On 03/12/2025 at 5:46 P.M., Patient #3 arrived at Facility A’s emergency department with the chief complaint of a fall and a suicide attempt. Patient’s physical assessment, labs, and imaging were all within normal limits aside from an alcohol level of 4. . At 6:30 P.M., an EKG and suicide assessment were documented. Patient #3 was “calculated suicide risk level: High Risk.” . At 6:44 P.M., Per the ED (emergency department) physician, Staff K, “Patient has no discernible injuries or complaints other than states he was suicidal and wanted to kill himself. He claims that he jumped off a third story building, but he has no injuries that would be consistent with the story. I do not believe he actually did that. Patient is being transported by police who has ...directly to psychiatric facility.” . Patient #3 presented with a suicidal attempt. Patient #3’s psychological screening was limited. Patient #3 was not provided a behavioral health consult or a physician risk assessment and conflicting exam findings were insufficient to determine if there was a psychological emergency medical condition before Patient #3 was discharged. Facility A failed to provide an appropriate medical screening exam. . d.Review of Patient #7’s medical record from Facility A: On 03/20/2025 at 11:53 P.M., Patient #7 arrived at Facility A’s emergency department. Patient #7 was under an EDO (emergency detention order) and accompanied by police. Patient #7’s chief complaint was “medical clearance for psychiatric admission.” . Fire Department report included in Patient #7’s medical record states, “The Pt (patient) tonight had threatened to barricade himself in the house when PD contacted him. At this point the Pt was writhing on the ground handcuffed and had hit his head on the baseboard causing a cut that prompted PD (police department) to call EMS (emergency medical services). EMS went upstairs where the Pt was found cuffed behind the back laying on his right-side thrashing from side to side. The Pt had an apparent open airway and was yelling incoherently. The Pt allowed EMS to apply diagnostic equipment and inspect the wound to the head. An approximate 1 cm length laceration was seen over the right eye that was not bleeding. EMS acquired all necessary signatures and began to leave the scene when the Pt reported pain to the chest. The need for EMS transport to a higher level of care to receive a full medical clearance was clearly identified and PD prepped the Pt for transport. At one point the Pt expressed that they did not want to go to Facility A and would prefer another hospital. EMS clearly stated that due to the Pt’s mental status and the fact he was in police custody, he did not have the decision-making capacity.” . At 12:04 A.M., Per Staff L, “objective assessment: word salad, non-cohesive words, rambling, hyper talking, VS (vital signs) stable No acute distress, dried blood around the mouth, no eye contact. Blood pressure 130/69. Heart rate 113. Respiratory rate 18. Temperature 37.1 Celsius. Oxygen Saturation 96%.” . At 12:07 A.M., Per Staff M, with hx (history) of bipolar and schizophrenia and mania, police were called to the home as the pt (patient) was “manic” according to family because he had not taken his psych meds for days, he threatened to barricade himself in his room and would not come out.” “Police brought him in as they have an EDO (emergency detention order), he was not cooperative and was placed in a wrap as the pt was not cooperating with leaving home. They state he may have hit his head on the headboard, did not struggle, and did not fall on the ground. Pt did not want to be here and wants to leave.” “Risk-Psychiatric Illness. Detailed Suicide Risk. Pos (positive) Nur (nurse) Sui (suicide) Risk Screen? No. Overall level suicide risk: unable to clinically assess.” “Physical assessment within normal limits. NP notes “behavior: restless, uncooperative.” “Psychiatric Abnormal Mood/Affect: Fearful, Flight of ideas. Abnormal Thinking/Perception: Delusions - grandeur. Negative: Suicidal, no plan, Homicidal, no plan.” “The pt was brought in wrapped because he was not cooperative and in a manic state, according to them. Pt refused care.” “Primary Impression: Medical Clearance for psychiatric admission. Discharge to home: Yes.” . At 12:11 A.M., Per Staff L, “Patient has been medically cleared and discharged to go psychiatric facility with PD (police department) via EDO (emergency detention order).” . Patient #7 presented with bizarre behavior with police and complaints of pain and laceration to the eye. There was no sufficient screening for suicide ideation, complaints of chest pain, laceration over the eye, examination of Patient #7’s head, blood in the mouth, or documented tachycardia to rule out an emergency medical condition. Patient #7’s signs and symptoms reflected that he lacked the capacity to refuse care. Patient #7 was discharged. Facility A failed to provide an appropriate medical screening exam. . e.Review of Facility A’s Texas EMTALA - Medical Screening Examination 911.500.001 - Revised 07/2024: Page 6 of 11 “Procedure: 3.Extent of the MSE ii. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The MSE includes assessment of suicidal or homicidal thoughts of gestures that indicated danger to self or others.” . 2.Interview: . a.04/16/2025 at 9:00 A.M. in an interview with VP Quality Staff B, Staff B explained that Facility A does not have a specific EDO policy. . b.04/17/2025 at 10:00 A.M. in an interview with ED Physician Staff J, Staff J explained that an MSE (medical screening exam) is “no different than any other patient. The patient first must stabilize and then [we] determine if they require further care (i.e. admission to a psych facility or admission for medical stabilization. Staff J stated that “an emergency detention order is a process that PD (police department) uses to get patients the appropriate treatment if PD believes a patient is a harm to themselves or others, and the patient is not willing to voluntary get the appropriate treatment.” Staff J stated that, it does not affect the patients care. The patient requires the same MSE and stabilization as any other patient.” When asked if a behavioral health consult would be considered part of the treatment plan for a mental health patient, Staff J said, “yes, in most cases.” . c.04/17/2025 at 9:35 A.M. in an interview with ED Nurse Practitioner Staff H, Staff H indicated that “behavioral health consults come after medical clearance when they don’t need ICU (intensive care unit) or to be admitted. Staff H states that when police take the patient, the police will tell them [staff] which facility [they go to]. The police don’t leave with the patient unless they know exactly where they are going.” . d.04/16/2025 at 1:30 P.M. in an interview with Director of Emergency Services Staff C, Staff C was asked if the facility knows where the patient goes once the patient is discharged to police. Staff C explains that “they [the police] might mention the name, but they do tell us, yes. We are not choosing the facility because we haven’t done the consult to see if they qualify.” . e.04/16/2025 at 2:15 P.M. in an interview with ED Manager Staff D, Staff D was asked if patients can transfer to behavioral health facilities without a behavioral health consult. Staff D indicated that “if no [psychological] evaluation has been done, there is no way to transfer” the patient. . f.06/04/2025 at 12:34 P.M. in an interview with the Director of Quality Resource Staff E, Staff E was asked who is responsible for conducting the behavioral health consults and if any policies state such. Staff E indicated that they “do not have a policy that states who conducts behavioral health exams. The provider completes a medical screening exam, and at that time, the provider may review whether an additional, more comprehensive behavioral health assessment is needed, based on the provider’s clinical judgement.” . g.06/04/2025 at 12:34 P.M. in an interview with the Director of Quality Resource Staff E, Staff E was asked what the process is to obtain a behavioral health consult. Staff E stated, “Behavioral health consults are ordered by the provider, after their assessment of the patient. It may be included as a component of the ED psych workup but would be determined on an individual patient basis, per their clinical judgement, and then will be completed by the consulted entity, if ordered. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 51905 Based on record review, facility policy, and interviews, Facility A failed to initiate an appropriate transfer to a behavioral health facility for three of the twenty patients (Patient #3, #7, #10). Patients #3, #7, and #10 were all under an EDO (emergency detention order) and transferred to known behavioral health facilities without appropriate transportation, medical records, or a memorandum of transfer. . Findings: 2.Medical Record: d.Review of Patient #3’s medical record from Facility A: On 03/12/2025 at 5:46 P.M., Patient #3 arrived at Facility A’s emergency department with the chief complaint of a fall and a suicide attempt. Patient’s physical assessment, labs, and imaging were all within normal limits aside from an alcohol level of 4. . At 6:08 P.M.: CT L-Spine (lumbar), T-Spine (thoracic), Chest, C-Spine (cervical), and Brain, all within normal limits. . At 6:30 P.M., an EKG and suicide assessment were documented. Patient #7 was “calculated suicide risk level: High Risk.” . At 6:44 P.M., Per the ED (emergency department) physician, Staff K, “Patient has no discernible injuries or complaints other than states he was suicidal and wanted to kill himself. He claims that he jumped off a third story building, but he has no injuries that would be consistent with the story. I do not believe he actually did that. Patient is being transported by police who has ...directly to psychiatric facility.” . Patient #3 presented with a suicide attempt. Patient #3 was experiencing an emergent medical condition. Patient #3 was documented as discharged home. Patient #3 was transported by police to a known behavioral health facility for a psychiatric assessment without medical records or a memorandum of transfer. Facility A failed to initiate an appropriate transfer. . e.Review of Patient #7’s medical record from Facility A: On 03/20/2025 at 11:53 P.M., Patient #7 arrived at Facility A’s emergency department. Patient #7 was under an EDO (emergency detention order) and accompanied by police. Patient #7’s chief complaint was “medical clearance for psychiatric admission.” . Fire Department report included in Patient #7’s medical record states, “The Pt (patient) tonight had threatened to barricade himself in the house when PD contacted him. At this point the Pt was writhing on the ground handcuffed and had hit his head on the baseboard causing a cut that prompted PD (police department) to call EMS (emergency medical services). EMS went upstairs where the Pt was found cuffed behind the back laying on his right-side thrashing from side to side. The Pt had an apparent open airway and was yelling incoherently. The Pt allowed EMS to apply diagnostic equipment and inspect the wound to the head. An approximate 1 cm length laceration was seen over the right eye that was not bleeding. EMS acquired all necessary signatures and began to leave the scene when the Pt reported pain to the chest. The need for EMS transport to a higher level of care to receive a full medical clearance was clearly identified and PD prepped the Pt for transport. At one point the Pt expressed that they did not want to go to Facility A and would prefer another hospital. EMS clearly stated that due to the Pt’s mental status and the fact he was in police custody, he did not have the decision-making capacity.” . At 12:04 A.M., Per Staff L, “objective assessment: word salad, non-cohesive words, rambling, hyper talking, VS (vital signs) stable No acute distress, dried blood around the mouth, no eye contact. Blood pressure 130/69. Heart rate 113. Respiratory rate 18. Temperature 37.1 Celsius. Oxygen Saturation 96%.” . At 12:07 A.M., Per Staff M, with hx (history) of bipolar and schizophrenia and mania, police were called to the home as the pt (patient) was “manic” according to family because he had not taken his psych meds for days, he threatened to barricade himself in his room and would not come out.” “Police brought him in as they have an EDO (emergency detention order), he was not cooperative and was placed in a wrap as the pt was not cooperating with leaving home. They state he may have hit his head on the headboard, did not struggle, and did not fall on the ground. Pt did not want to be here and wants to leave.” “Risk-Psychiatric Illness. Detailed Suicide Risk. Pos (positive) Nur (nurse) Sui (suicide) Risk Screen? No. Overall level suicide risk: unable to clinically assess.” “Physical assessment within normal limits. NP notes “behavior: restless, uncooperative.” “Psychiatric Abnormal Mood/Affect: Fearful, Flight of ideas. Abnormal Thinking/Perception: Delusions - grandeur. Negative: Suicidal, no plan, Homicidal, no plan.” “The pt was brought in wrapped because he was not cooperative and in a manic state, according to them. Pt refused care.” “Primary Impression: Medical Clearance for psychiatric admission. Discharge to home: Yes.” . At 12:11 A.M., Per Staff L, “Patient has been medically cleared and discharged to go psychiatric facility with PD (police department) via EDO (emergency detention order).” . Patient #7 presented with bizarre and erratic behavior, with complaints of pain and laceration of the eye. Patient #7 was experiencing an emergent medical condition. Patient #7 was documented as being discharged home. Patient #3 was transported by police to a known behavioral health facility for a psychiatric assessment without medical records or a memorandum of transfer. Facility A failed to initiate an appropriate transfer. . f.Review of Patient #10’s medical record from Facility A: On 02/03/2025 at 11:18 A.M., Patient #10 arrived at Facility A’s emergency department. Patient #10’s chief complaint of suicide attempt. . At 11:23 A.M., Per Staff N Patient #10 was “found in his car with a hose from his exhaust pipe into his car. He reports he was in the care for approximately 45 minutes prior to their arrival.” . At 12:30 P.M., Per Staff O, “Ongoing signs/symptoms: Suicidal Ideations” “PT medically cleared by Staff N. PT (patient) taken by PD (police department) for psych treatment. In PD (police department) custody.” . Patient #10 presented with a suicide attempt. Patient #10 was experiencing an emergent medical condition. Patient #10 was documented as discharged home. Patient #10 was transported by police to a known behavioral health facility for a psychiatric assessment without medical records or a memorandum of transfer. Facility A failed to initiate an appropriate transfer. . g.Review of Facility A’s Medical Staff Rules & Regulations - Approved 08/2024: “Emergency Services 11.4 Admissions and Transfers: (c) A transfer of a patient that occurs after the completion of the medical screening examination will be initiated in accordance with Medical Center Policy 911-500.003 entitled EMTALA - Texas Transfer Policy of Patients Between Hospitals With or Without Emergency Medical Conditions. . h.Review of Facility A’s EMTALA - Texas Transfer Policy of Patients Between Hospital with and Without Emergency Medical Conditions 911.500.0003 - Revised 06/2024: “1. Transfers of Individuals Who Have Not Been Stabilized b. A transfer will be an appropriate transfer if: 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 has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer as well as the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and iv. The transfer is affected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport.” . “Requirements Prior to Transfer i.Minimize the Risk j.Individual’s Request of Physician’s Order k.Request to Transfer Made to Receiving Facility l.Document Request m.Send Medical Records n.Physician Certification of Risks and Benefits o.QMP Certification p.Send Memorandum of Transfer” . 3.Interviews a.04/17/2025 at 10:00 A.M. in an interview with Director of Emergency Services Staff C, Staff C was asked if patients could transfer to a behavioral health facility before having a behavioral health consultation and assessment. Staff C explained that, “No, we can’t transfer them without us having the consult and recommendation for inpatient.” Staff C went on to say that “transporting patients by police gets them there (behavioral facility) quicker. It ensures the patient gets to where they need to be. They (behavior facility) don’t turn them (patients) away once they get to intake.” Whereas “the hospital has to go through a process to transfer patients to a behavioral health facility. They have to get approval from the AOC (administrator on call), the doctors have to agree, and of course they have to have a bed all prior to transfer.” . b.04/16/2025 at 1:30 P.M. in an interview with Director of Emergency Services Staff C, Staff C was asked if the facility knows where the patient goes once the patient is discharged to police. Staff C explains that “they [the police] might mention the name, but they do tell us, yes. We are not choosing the facility because we haven’t done the consult to see if they qualify.” Staff C also explained that “when the doctor deems them (the patients) medically clear, the police hear that and they say, ‘okay, we can take this patient now that they are medically cleared.’” . c.04/17/2025 at 7:31 P.M. in an interview with ED Registered Nurse Staff I, Staff I was asked if patients have previously been discharged without having a behavioral health consult. Staff I indicated yes. . d.04/17/2025 at 10:00 A.M. in an interview with ED Physician Staff J, Staff J was asked if any patients under an EDO have left before without a behavioral health consult. Staff J explained, “if a patient has declined the behavioral health consult, usually uncooperative and refuses to do a BH (behavioral health) consult then it [is] possible that patients have been taken “into custody” by PD.””