Dallas Regional Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45521 Based on record review and interviews, Facility A failed to provide stabilizing treatment in 1 of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to Facility A on 03/21/2026 at 10:08 PM with a complaint of a fall at home. The facility failed to order labs to verify that Patient #1’s potassium level was within the normal range and to order an EKG and cardiac monitoring during and after potassium administration. The patient presented at Facility B on 03/22/2026 at 9:51 AM and was diagnosed with hypokalemia and acute on chronic diastolic heart failure and was placed on observation status for telemetry monitoring for moderate-to-severe electrolyte imbalance due to a diagnosis of hypokalemia. Refer to A2407”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45521 Based on record review and interviews, Facility A failed to provide stabilizing treatment in 1 of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to Facility A on 03/21/2026 at 10:08 PM with a complaint of a fall at home. The facility failed to order labs to verify that Patient #1’s potassium level was within the normal range and to order an EKG and cardiac monitoring during and after potassium administration. The patient presented at Facility B on 03/22/2026 at 9:51 AM and was diagnosed with hypokalemia and acute on chronic diastolic heart failure and was placed on observation status for telemetry monitoring for moderate-to-severe electrolyte imbalance due to a diagnosis of hypokalemia. Findings included: Record Review A review of the document titled “ED Provider Note” by Staff # 1, FNP, on 03/21/2026, revealed the following: “The patient, a 60-year-old female, stated she fell twice today. Once this morning and again before arrival. She was unable to get up and reported she may have hit her head, and her husband called 911. Patient # 1 arrived via ambulance. Patient # 1 requested a CT scan. Patient #1 denied headache and had no signs of head injury. The patient has no cervical or thoracic tenderness. The mobility of her head and neck was within a normal range of motion. Patient #1 also requested labs, saying that over the past week she has felt weak and is concerned that she could have a problem with her blood. Patient is specifically requesting Toradol IV for discomfort and states that she is a recovered former addict.” Past Medical History: Atrial fibrillation, Bipolar 2 disorder, Congestive Heart Failure, Diabetes mellitus, History of cardiac catheterization, Hypertension, Malingerer, Obesity, and Renal disorder. Vital signs were BP 102/66, Pulse 77, Temp 98.4 °F (36.9 °C) (Oral), Resp 22, Ht 5’ 9” (1.753 m) | Wt 153 kg (337 lb), SpO2 91%, BMI 49.77 kg/m². The physical exam was normal except for multiple scabbed areas on her forearms. The patient was noted as anxious. Patient #1 was alert and oriented x3. Lab results revealed a potassium level of 2.1 (3.5-5.3 LL). Potassium chloride IV piggyback 20 mEq was ordered but delayed because the patient reported an allergy to potassium. The physician spoke with Patient #1 and explained that potassium is part of her metabolic function and that, without it, she would die. The patient stated she needed Benadryl or she would get a rash. Benadryl 50 mg oral was ordered and provided. The patient refused IV potassium. Patient #1 then accepted potassium chloride tablet 40 mEq tablet. The differential diagnosis included: Manipulative behavior, anxiety, reported falls at home, and reported weakness. The patient was unable to tolerate the first three attempts at a CT of her head and cervical spine. Hydroxyzine 100 mg tablet was ordered, and the patient agreed as she takes this for anxiety. The fourth attempt was successful. The CT of the head revealed no acute findings. CT of the C-spine showed degenerative changes but no acute findings. Prior to discharge, Patient # 1 received a potassium chloride tablet 40 mEq. Patient # 1 was discharged home. An RN was noted as present during the discharge instructions provided to Patient # 1. The facility failed to order labs four to six hours after the administration of potassium to verify that Patient #1’s potassium level was within the normal range. Additionally, Facility A failed to order an EKG and cardiac monitoring during and after potassium administration to monitor for cardiac symptoms. Patient # 1 later presented to Facility B. Patient # 1, Facility B: Patient # 1 arrived at Facility B on 03/22/2026 at 8:05 AM. A review of the” Emergency Department Physician Documentation” by Staff 7, Jason Deepak Vadhan, DO, Emergency Medicine, on 03/22/2026 at 9:51 AM revealed the following: Patient # 1 arrived with complaints of not taking her potassium supplement and having a fall yesterday. The patient went to another facility, was diagnosed with hypokalemia, and was discharged. She is here because she has concerns about her low potassium. Physical exam was within normal limits. EKG results completed on 03/22/2026 at 11:05 AM were within normal limits. Patient #1’s potassium level was taken on 03/22/2026 at 10:35 AM and the result was 2.4, which is low. The normal range is 3.5-5. , Potassium chloride 40 mEq oral was provided on 03/22/2026 at 6:17 PM. Potassium chloride 20 mEq oral was provided on 03/22/2026 at 8:36 PM. Potassium chloride 60 mEq oral was provided on 03/22/2026 at 11:21 PM, Potassium chloride in SW 20 mEq/100 mL IV, was started on 03/23/2026 at 12:00 AM and was completed on 03/23/2026 at 1:16 AM. Potassium chloride 40 mEq oral was provided on 03/23/2026 at 8:51 AM. A repeat potassium level was done on 03/23/2026 at 4:56 AM, the result was 3.4- low (3.5-5). EKG results completed on 03/22/2026 at 11:05 PM were within normal limits. Diagnoses were hypokalemia and acute on chronic diastolic heart failure. The patient was placed on Observation Status on 03/22/2026 at 11:41 PM for telemetry monitoring for moderate-to-severe electrolyte imbalance for a diagnosis of hypokalemia. Patient #1 was discharged on 03/23/2026 at 1:32 PM. Facility B ordered labs for potassium levels on admission on 03/22/2026 at 10:35 AM. A repeat potassium level was done on 03/23/2026 at 4:56 AM, the result was 3.4- low (3.5-5) to monitor for hypokalemia. Policy A review of the “Rules and Regulations” Article V, Emergency Medical Screening, Treatment, Transfer and On-Call Roster Policy, part 5.1(b) Stabilization, page 19, revealed the following: “(1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, excepting conditions set forth below. (2) A patient is stable for discharge when, within reasonable clinical confidence, it is determined by the treating qualified medical personnel that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions, or when the patient requires no further treatment and the treating qualified medical personnel has provided written documentation of his/her findings.” The facility failed to follow its Rules and Regulations by failing to order labs to verify that Patient #1’s potassium level was within the normal range and to order an EKG and cardiac monitoring during and after potassium administration. Interviews: 1. An interview with Staff # 4, RN, Chief Nursing Officer at 1:50 PM revealed the following: If I were monitoring a patient receiving potassium, I would have the patient on a cardiac monitor and monitor the vital signs. Based on her weight, I would monitor for 30 minutes. 2. An interview with Staff # 6, MD, Emergency Medicine, on 05/12/2026 at 3:32 PM revealed the following: When I order potassium, I may admit the patient to monitor the potassium level. I do not run another lab right away because potassium levels do not change quickly. It takes hours for the blood level to change. 3. An interview with Staff # 1, NP-C, Emergency Medicine on 05/211/2026 at 4:05 PM revealed the following: Patient # 1 came in via EMS; it was a busy night. She went to room 22, which is a fast-track room. She reported 2 falls: one in the morning and one before she arrived. There was no acute injury. I ordered a CT of the head and neck. She had secondary concerns about muscle weakness. She said she was unable to walk, but she was observed walking to the restroom. I reviewed her chart, saw she was treated for hypokalemia, and I ordered labs, which came back with low potassium; her medication included potassium, but she said she ran out. I ordered IV potassium. She said she was allergic to it because it burned during infusion. I then ordered 20 mEq oral potassium. Before she was discharged, I ordered another 40 mEq oral dose of potassium. I wanted to repeat the potassium level, but the patient refused as she didn’t want to be stuck again. She was a chronically ill patient. I saw the 2.1 (a low level) potassium level, but she didn’t look sick. Her blood pressure was good and had no signs of hypokalemia. I encouraged her to follow up with her primary care physician. When she was seen previously at the ED, her potassium level was in the 2’s; it is a chronic condition. I saw she was treated and discharged for that visit, so I wasn’t as worried. I also discussed this with the attending. He said she can go home.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33589 BASED ON video review, record review, and interview, the hospital failed to meet the Conditions of Participation of Patient Rights to protect and promote patient’s right to treatment, care, and services within the hospital’s capability and mission when laboring obstetrical patients who presented to the Emergency Department were not 1) received in a safe setting that provided a timely Qualified Medical Professional (QMP) examination. Nursing failed to ensure at least 1 of 21 laboring patients (Patient #1 on 11/11/2025) “in distress” were recognized as having an immediate/emergent condition that required a QMP examination to determine active labor to meet the needs of the patients according to the hospital policy. The current nursing practices delayed laboring obstetrical QMP examination and placed patients at risk of maternal and fetal/infant mortality and morbidity. Cross Refer to Tag A-0144 Care in a Safe Setting 2) free from all forms of abuse. Patient #1 presented to the emergency department in labor on 11/11/2025 and was not afforded compassionate, quality care during the lobby and triage encounters with Staff #1, #5, and #23 who did not intervene on behalf of the patient’s care needs. The current nursing practices exposed patients to unnecessary medical/psychological distress, trauma, and harm. Cross Refer to Tag A-0145 Free from Abuse/Harassment”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 33589 BASED ON video review, record review, and interview, the hospital failed to meet the Conditions of Participation for Nursing Services when obstetrical (OB) Qualified Medical Professional (QMP) examinations were delayed greater than 10 minutes for patients who presented at the Emergency Department (ED) in labor. ~ 13 of 21 laboring patients were incorrectly triaged by the Triage nurse according to the hospital’s Nursing Triage policy that governed the use of the Emergency Severity Index (ESI), resulting in a possible delay (Patient #1, #3, #4, #5, #6, #7, #8, #10, #11, #13, #14, #15, and #16); AND ~ 9 of 21 laboring patients were delayed longer than 10 minutes prior to arriving in L&D for a labor examination (Patient #1, #3, #4, #5, #6, #8, #9, #13, and #14). Nursing Services staff (the registrar/Staff #23; the charge nurse/Staff #5; and the triage nurse/Staff #1) failed to recognize labor as an immediate/emergent medical condition that required a Qualified Medical Professional (QMP) examination to determine active labor according to the hospital policy. Cross Refer Tag: A-0386 Organization of Nursing Services ~ The registered nurse (RN) failed to supervise and evaluate the nursing care of each patient to include repeated/ongoing monitoring according to the hospital policy and patient specific needs. At least 2 of 2 discharged ED patients did not receive repeated/ongoing monitoring of their vital signs in the emergency department including in the lobby area according to the hospital policy. (Patient #11 on 10/03/2025 and Patient #12 on 11/11/2025). Cross Refer to Tag: A-0395 RN Supervision ~ The hospital failed to ensure the nursing staff develops, and keeps current, a nursing care plan for each patient that reflected the patient’s goals and the nursing care to be provided to meet the patient’s needs. Patient #1 presented to the emergency department in labor on 11/11/2025 and was not recognized as having an immediate/emergent condition that required a Qualified Medical Professional (QMP) examination to determine active labor to meet the needs of the patient. Patient #1 was not afforded compassionate, quality care during the lobby and triage encounters with Staff #1, #5, and #23 who did not intervene on behalf of the patient’s care needs. Cross Refer to Tag: A-0396 Nursing Care Plan The current nursing practices delayed laboring obstetrical QMP examination and placed patients at risk of maternal and fetal/infant mortality and morbidity.”

“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: 33589 BASED ON video review, record review, and interview, the hospital failed to ensure the patient’s right to a safe setting when laboring obstetrical patients who presented to the Emergency Department were not received in a safe setting that provided a timely Qualified Medical Professional (QMP) examination. Nursing failed to ensure at least 1 of 21 laboring patients (Patient #1 on 11/11/2025) “in distress” was recognized as having an immediate/emergent condition that required a QMP examination to determine active labor to meet the needs of the patient according to the hospital policy. The current nursing practices delayed laboring obstetrical QMP examination and placed patients at risk of maternal and fetal/infant mortality and morbidity. FINDINGS The hospital’s 10/23/2019 “Obstetric Patient Presenting at the Front Lobby/Concierge Desk” policy required, “provide safe transfer of an obstetric patient to the Labor and Delivery area (L&D). 1. Obstetric patients who present to the Emergency Room (ED) will be transferred to the Labor and Delivery area via wheelchair by the ER staff if the patient is above 20 weeks gestation. 2. Patient will be seen and assessed in the Triage area unless patient status dictates that she be admitted directly to an LDR (Room)...register the patient...unless the patient appears to be in distress.” The hospital’s 1/25/2023 “Medical Screening in the Obstetrical Department” policy required, “To provide a consistent system for the evaluation of presenting women with pregnancy related issues in compliance with federal EMTALA requirements (Emergency Medical Treatment and Active Labor Act)...It is the policy of this hospital to provide a medical screening examination to all patients presenting for unscheduled obstetrical evaluation, testing or services within the capabilities of the obstetrical unit and the ancillary services routinely available to the obstetrical department, including the use of on call physicians. Patients 20 weeks gestation or greater, with obstetrical or gynecological presentations, (other than scheduled procedures) will receive a medical examination in the obstetrics department consistent with this policy...Medical screening examination is the process determining. with reasonable clinical confidence, whether or not an emergency medical condition exists or a woman is in labor. This is documented in the patient’s medical record...The medical screening consists of an assessment and any ancillary tests based on the patient’s chief complaint necessary to determine the presence or absence of an emergency medical condition. This may be a brief history and physical examination or may require complex ancillary studies and procedures such as, but not limited to lab tests, fetal monitoring or radiology procedures. Qualified providers to perform a medical screen in the obstetrical department...” The hospital’s “Triage in the Emergency Department” policy, last reviewed and implemented on 3/28/2023, stated on page 1 of 6: “ ...The Emergency Severity Index (ESI) is a five-level triage system that is simple to use and divides patients by acuity and resource needs. The ESI triage algorithm is based on four key decision points. The experienced ED RN will be able to rapidly and accurately triage patients using this system. ...Triage screening in the Emergency Department to establish a basis for appropriate care based on degree of illness or severity of traumatic injury. Code Stroke, Code Stemi, Code 44 and Code 88 are called at time of immediate identification of symptoms or injury by trained hospital personnel as deemed appropriate....” And on page 2 of 6: (Resuscitative) Level - 1 patients are critically ill, UNSTABLE and require immediate lifesaving physician evaluation and interventions. (Emergency) Level - 2 patients are very ill, high risk and require rapid initiation of care which in the emergency nurse can initiate care through protocols without a physician at the bedside. These patients should be taken to a room and treatments begun in less than 10 minutes... (Urgent) Level - 3 patients are predicted to require two or more resources... 1. The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either (Level 1) resuscitative, (Level 2) Emergency, (Level 3) urgent, (Level 2) semi-urgent, or (Level 5) routine categories. 2. Triage can take place in either the triage room or at the bedside. The goal is DIRECT BED and complete intake at the bedside whenever space and/or staff allow...” . And pages 3 - 4 of 6: “ ...Examples of Emergency Severity Index: Resuscitative Level 1...unstable, immediate care, life threatening conditions: ...acute chest pain...airway and breathing difficulty...anaphylaxis...Cardiac arrest... Emergency Level 2 - major injury or illness but STABLE; treatment and assessment should occur within 5 to 15 minutes...active labor...Acute Asthma...CVA/TIA (stroke/mini stroke)...Major burn...Pregnant patient with active bleeding... Urgent Level 3 treatment and assessment should occur in 15-45 minutes...abdominal pain...intoxication...closed fracture...drug ingestion...” The hospital’s March 2025 “Patient Rights & Responsibilities” policy required, “The hospital mission calls us to render personalized and compassionate care to patients in ways that respect the dignity of each person...The patient has the right to receive care in a safe setting...All patients have the right to be free of physical and mental abuse...Quality of care You have the right to: - respectful treatment, which recognizes and maintains your dignity and personal values without discrimination due to race, religion, age, sex or other personal values...” The hospital’s 4/23/2025 “EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act” policy required, “appropriate Medical Screening Exam (MSE)...Any woman in active labor is considered UNSTABLE...” According to facility policy, Patient #1 should have been assigned an ESI level 2 for active labor and taken up to L&D room within 10 minutes for the labor assessment. However, Patient #1 was assigned ESI Level 3 and was not taken to L&D for 26 minutes, resulting in a delay of the QMP examination and care. TikTok C Video was reviewed on 11/17/2025. Pre-Survey Observation Summary: https://www.threads.com/@wecookintahday_nataliekays/post/DRAoERaibVZ?xmt=AQF0pcQ8Zw68vYaLGDzAboo8xxM9WifpyyR8u5rZcTkW5AvGHIcNujXZhS9uKwAd-zuORDE&slof=1 The Patient was observed in the triage area while hospital Staff (Staff #1) typed at a computer with her back to the camera. The Patient seated in a wheelchair was observed having contractions, writhing in pain, screaming, and repeatedly adjusting her position. A blood pressure cuff was on the Patient’s left arm. The nurse looked at the patient and then turned to look at the computer. The Staff asked, “how many times have you been pregnant (without turning or looking at the patient)?” The Patient stated, “3.” The Staff asked, “this is your third pregnancy (without turning or looking at the patient)?” The Patient stated, “yes.” The Staff asked, “you have 2 babies at home (without turning or looking at the patient)?” The Patient stated, “it is in my aXX.” Staff did not turn to assess the patient for a change of condition. The Staff asked again, “you have 2 babies at home (without turning or looking at the patient)?” Audible panting was heard from the patient. Staff did not turn to assess the patient despite the patient’s audible sounds of panting. The Staff asked, “who is your doctor (without turning or looking at the patient)?” The Patient continued to writhe, audibly pant and was observed to be visibly exhausted. The Staff asked, “who is your doctor (without turning or looking at the patient)?” The video recorder (Grandma) finally answered, “ [Staff #7, primary OBGYN named] is her doctor.” The Patient began audibly grunting (28 seconds into the video) and was observed to brace her arm on the wheelchair and then placed her foot on the floor while panting. The video recorder stated, “(40 seconds into the video) y’all treat all your patients like this or just the black ones.” The Staff was heard speaking to someone on the phone reporting the situation, patient names, etc. The video recorder stated, “I bet y’all listen next time (1 minute 15 seconds into the video).” The Patient began to audibly sob. The video recorder stated, “when you found out you were delivering at this hospital (1 minutes 19 seconds into the video).” The Patient audibly cried out and stood up. The video recorder continued, “your aXX should have changed doctors.” The Patient stood up, turned around to bend over the wheelchair and audibly cried out in pain. TikTok A Video was reviewed on 11/17/2025. Pre-Survey Observation Summary: TikTok A.mp4 The Patient was observed in a triage area while Staff (Staff #1) typed at a computer. The Staff’s back was to the camera. A blood pressure cuff was on the Patient’s arm. The Patient was turned backward over a wheelchair with both knees in the wheelchair. The Patient dropped her right leg and placed her right foot on the floor. The Patient audibly screamed. The Patient then stopped screaming and stated, “ma’am.” Staff stated, “yes (without turning or looking at the patient).” The Patient stated, “are you able to call the anesthesiologist?” Staff stated, “someone is coming to take you to Labor and Delivery (again without turning or looking at the patient).” Patient stated, “that is not what I asked.” Staff then turned toward the patient with a flat affect and stated, “I cannot help.” Video review revealed the nurse did not look at or react to the patient for assessment/reassessment purposes despite crying and writhing in pain. Patient #1’s printed medical record was reviewed on 11/18/2025 from 11:00 AM and revealed: A 29-year-old black, female presented to the Emergency Department on 11/11/2025 at 12:05 AM (per surveillance video) with an “arrival complaint of labor.” She was registered and changed from an induction patient to an ED patient in the computer at 12:21 AM (16 minutes after arrival) after a registration issue was resolved. At 12:25 AM (20 minutes after arrival), the hospital documented on the “ED Care Timeline” the “Chief Complaint of Contractions, EDD (Estimated due date) 11/10/2025, G3P2 (3 pregnancies, 2 previous births), and begun triage of the patient including travel/infection screening, Glascow Coma Scale, and Allergies.” At 12:26 AM (21 minutes after arrival), the “Emergency Severity Index (ESI) Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy and included, “Arrived requiring immediate life-saving intervention?: No Arrived in high risk situation? or confused/lethargic/disoriented? or severe pain/distress?: No Danger zone vitals?: No How many different resources are needed?: Many” and vital signs were documented. Patient #1 was taken to L&D at 12:28 AM (23 minutes after arrival) by a technician and 2 nurses (per surveillance video). At 12:31 AM (26 minutes after arrival), Patient #1 was received in L&D by the QMP who noted, “Membrane: status Spontaneous...Color: Meconium...lightly...odor: none...Dilation: 10 Complete...Effacement: 100%...Fetal Station: 3...presenting part crowning.” Patient #1 delivered at 12:35 AM. During the hospital’s surveillance video review for the date of 11/11/2025 in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed arriving at the main ED patient drive (canopy; porte-cochere - roofed structure that vehicles drive under) around midnight. 12:05 AM: She entered the main ED lobby/reception in the wheelchair accompanied by 2 staff members. 12:24 AM: (19 minutes after arrival): She entered the front triage door. 12:28 AM: (23 minutes after arrival): She exited the back triage door being pushed in a wheelchair by 1 staff member heading to L&D. Time in Triage was 4 minutes. Actual video times were observed later the same day. Interviews During the ED tour on 11/18/2025 at 10:00 AM, an interview was conducted with the ED Nursing Director, Staff #12 regarding the process for a patient who presents in labor. Staff #12 indicated that the patient signs in, then goes through triage, then is seen by a physician or mid-level (provider.) If the patient is emergent, like a gunshot or chest pain they should come straight back, and the triage information is obtained at the bedside. Staff #12 was asked how it was determined that a patient was emergent. Staff #12 indicated that the triage nurse assesses the patient and assigns a triage level. Staff #12 was then asked about patients with signs of precipitous deliveries. Staff #12 indicated that the triage nurse gets fetal heart tones but does not obtain a cervical examination since they are not placed in a bed. Staff #12 was asked if the ED staff monitored a pregnant patient’s contractions. Staff #12 stated that, “We don’t have tocos (labor contraction monitoring device) here, so we can’t monitor contractions.” During an interview while observing the hospital’s surveillance video in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed in the lobby near the triage door. Staff #10, Chief Nursing Officer (CNO) stated, “She (Triage nurse) should have bypassed them (registration Staff/issue) but the patient was registered under previous account. Triage did not have access to that account. She (Triage nurse/Staff #1) should have opened the door and pulled her in.” During an interview in the conference room on 11/19/2025 ending at 2:00 PM, Staff #18 was in the room. Staff #10, Chief Nursing Officer and Staff #11, Director of Quality discussed the (Staff #1) nurse’s action or lack of action observed during the TikTok videos gave the perception of lack of empathy. Staff #10 discussed, “we provide compassionate care, and we train for that.” Staff #10 was asked about the mission statement stating compassionate, quality care. Staff #10 stated, “we fell short of that in the video.” They were asked if they had a policy against patients and visitors videoing. Staff #11 stated, “we do, but it has not been enforceable.” During a telephone interview on 11/20/2025 at 8:17 AM, Staff #5, ED Charge nurse on duty at the time of Patient #1’s arrival. Staff #5 was asked if a delivery appeared to be imminent, if there was a hospital process or a designated code that would be called overhead such as for a stroke patient to get the delivery team to the patient rapidly. Staff #5 stated, “We do not. Do I feel it would be beneficial? Absolutely. Had she [Patient #1] come in by ambulance, we would have been able to get her in faster. They are registered as an ambulance patient and the way she came in created the delay.” Staff #5 was asked so if Patient #1 had been brought back in through the ambulance bay, would she have been seen sooner. Staff #5 stated, “Yes, she would have been handled as if she were a code coming in. At that point they were trying to follow the typical method for registration. The more active labor wasn’t seen until she was in the lobby. I didn’t witness it myself.” During record review and interview on 11/20/2025 at 8:51 AM, Staff #1, ED Triage nurse on duty at the time of Patient #1’s arrival, was asked how she found out Patient #1 was in the ED. Staff #1 stated, “They [clarified to be Registration Staff, Staff #23] brought the bracelet and told me I needed to take her [Patient #1] to L&D.” Staff #1 was asked what she could tell about Patient #1’s presentation when she first saw her. Staff #1 stated, “When I first laid eyes [on her], I could see her in the window sitting in a wheelchair filling out paperwork, calmly sitting there. She [Patient #1] didn’t show signs of being in active labor at that first glance. Then her mom [Grandma] walked up and started yelling at her, telling her she shouldn’t be filling out paperwork, she should be going to L&D. When I was able to bring her [Patient #1] into the triage room, I saw her standing in front of the wheelchair having a contraction. That was when I knew [clarified with Staff #1 to mean that she knew Patient #1 was in active labor].” Staff #1 was asked what clinical practice guidelines she referred to for guidance on treating pregnant women. Staff #1 stated, “I just know what I have been taught, and what policy says to do, which is to register them and get them to L&D as quickly as possible if they are in labor.” Staff #1 was asked if she had followed hospital policy. Staff #1 stated, “Yes ma’am.” Staff #1 was asked if a delivery appeared to be imminent rather than a precipitous delivery, if the hospital had a protocol or designated code that is called overhead (such as for a gunshot victim or someone in cardiac arrest). Staff #1 stated, “No ma’am.” Staff #1 was asked if the hospital and its policy considered an imminent/precipitous delivery and emergent situation. Staff #1 stated, “I, yes, but there is no way I can tell if she about to deliver without a physical exam and that is out of my scope of practice.” Staff #1 was asked if she personally would be able to determine if a patient was about to deliver. Staff #1 stated, “Honestly, I wouldn’t be able to tell on a laboring patient.” Staff #1 was asked if there was anything else she would like to say regarding this case. Staff #1 stated, “Honestly, I just wanted to call and get her out of my triage and up to L&D as fast as I could. I was being yelled at with some not so nice things. When I realized what she was saying, I didn’t realize she was recording, I was trying not to interact, I was just trying to do my job.” The hospital’s March 2025 “Leadership Plan for the Provision of Care” policy required, “the Provision of Care is appropriate to the scope and level of care required by the patients served...The goal of the Emergency Department is to provide quality urgent, emergent and crisis care to the members of the community who present to the department...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 33589 BASED ON video review, record review, and interview, the hospital failed to ensure each patient was free from all forms of abuse and was treated with compassionate, quality care. Patient #1 presented to the emergency department in labor on 11/11/2025 and was not afforded compassionate, quality care during the lobby and triage encounters with Staff #1, #5, and #23 who did not intervene on behalf of the patient’s care needs, when they failed to provide immediate medical care to a patient “in distress” and prioritized facility registration processes above patient’s dignity and medical care needs. The current nursing practices exposed patients to unnecessary medical/psychological distress, trauma, and harm. FINDINGS The hospital’s March 2023 “Abuse and Neglect” policy required, “III. A. Abused - “The willful infliction of injury, unreasonable conferment [sic], intimidation or cruel punishment with resulting physical harm, pain or mental anguish,” or “Willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness”...C. Neglect - “The failure to provide for one’s self the goods or services which are necessary to avoid physical harm, mental anguish, or mental illness.” or “The failure of a caretaker to provide such goods and services.” The hospital’s March 2025 “Patient Rights & Responsibilities” policy required, “The hospital mission calls us to render personalized and compassionate care to patients in ways that respect the dignity of each person...The patient has the right to receive care in a safe setting...All patients have the right to be free of physical and mental abuse...Quality of care You have the right to: - respectful treatment, which recognizes and maintains your dignity and personal values without discrimination due to race, religion, age, sex or other personal values...” TikTok C Video was reviewed on 11/17/2025. Pre-Survey Observation Summary: https://www.threads.com/@wecookintahday_nataliekays/post/DRAoERaibVZ?xmt=AQF0pcQ8Zw68vYaLGDzAboo8xxM9WifpyyR8u5rZcTkW5AvGHIcNujXZhS9uKwAd-zuORDE&slof=1 The Patient was observed in the triage area while hospital Staff (Staff #1) typed at a computer with her back to the camera. The Patient seated in a wheelchair was observed having contractions, writhing in pain, screaming, and repeatedly adjusting her position. A blood pressure cuff was on the Patient’s left arm. The nurse looked at the patient and then turned to look at the computer. The Staff asked, “how many times have you been pregnant (without turning or looking at the patient)?” The Patient stated, “3.” The Staff asked, “this is your third pregnancy (without turning or looking at the patient)?” The Patient stated, “yes.” The Staff asked, “you have 2 babies at home (without turning or looking at the patient)?” The Patient stated, “it is in my aXX.” Staff did not turn to assess the patient for a change of condition. The Staff asked again, “you have 2 babies at home (without turning or looking at the patient)?” Audible panting was heard from the patient. Staff did not turn to assess the patient despite the patient’s audible sounds of panting. The Staff asked, “who is your doctor (without turning or looking at the patient)?” The Patient continued to writhe, audibly pant and was observed to be visibly exhausted. The Staff asked, “who is your doctor (without turning or looking at the patient)?” The video recorder (Grandma) finally answered, “ [Staff #7, primary OBGYN named] is her doctor.” The Patient began audibly grunting (28 seconds into the video) and was observed to brace her arm on the wheelchair and then placed her foot on the floor while panting. The video recorder stated, “(40 seconds into the video) y’all treat all your patients like this or just the black ones.” The Staff was heard speaking to someone on the phone reporting the situation, patient names, etc. The video recorder stated, “I bet y’all listen next time (1 minute 15 seconds into the video).” The Patient began to audibly sob. The video recorder stated, “when you found out you were delivering at this hospital (1 minutes 19 seconds into the video).” The Patient audibly cried out and stood up. The video recorder continued, “your aXX should have changed doctors.” The Patient stood up, turned around to bend over the wheelchair and audibly cried out in pain. TikTok A Video was reviewed on 11/17/2025. Pre-Survey Observation Summary: TikTok A.mp4 The Patient was observed in a triage area while Staff (Staff #1) typed at a computer. The Staff’s back was to the camera. A blood pressure cuff was on the Patient’s arm. The Patient was turned backward over a wheelchair with both knees in the wheelchair. The Patient dropped her right leg and placed her right foot on the floor. The Patient audibly screamed. The Patient then stopped screaming and stated, “ma’am.” Staff stated, “yes (without turning or looking at the patient).” The Patient stated, “are you able to call the anesthesiologist?” Staff stated, “someone is coming to take you to Labor and Delivery (again without turning or looking at the patient).” Patient stated, “that is not what I asked.” Staff then turned toward the patient with a flat affect and stated, “I cannot help.” Video review revealed the nurse did not look at or react to the patient for assessment/reassessment purposes despite crying and writhing in pain. Patient #1’s printed medical record was reviewed on 11/18/2025 from 11:00 AM and revealed: A 29-year-old black, female presented to the Emergency Department on 11/11/2025 at 12:05 AM (per surveillance video) with an “arrival complaint of labor.” She was registered and changed from an induction patient to an ED patient in the computer at 12:21 AM (16 minutes after arrival) after a registration issue was resolved, resulting in a delay of care. At 12:25 AM (20 minutes after arrival), the hospital documented on the “ED Care Timeline” the “Chief Complaint of Contractions, EDD (Estimated due date) 11/10/2025, G3P2 (3 pregnancies, 2 previous births), and begun triage of the patient including travel/infection screening, Glascow Coma Scale, and Allergies.” At 12:26 AM (21 minutes after arrival), the “Emergency Severity Index (ESI) Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy and included “Arrived requiring immediate life-saving intervention?: No Arrived in high risk situation? or confused/lethargic/disoriented? or severe pain/distress?: No Danger zone vitals?: No How many different resources are needed?: Many” and vital signs were documented. Patient #1 was taken to L&D at 12:28 AM (23 minutes after arrival) by a technician and 2 nurses (per surveillance video). At 12:31 AM (26 minutes after arrival), Patient #1 was received in L&D by the QMP who noted, “Membrane: status Spontaneous...Color: Meconium...lightly...odor: none...Dilation: 10 Complete...Effacement: 100%...Fetal Station: 3...presenting part crowning.” Patient #1 delivered at 12:35 AM. During the hospital’s surveillance video review for the date of 11/11/2025 in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed arriving at the main ED patient drive (canopy; porte-cochere - roofed structure that vehicles drive under) around midnight. 12:05 AM: She entered the main ED lobby/reception in the wheelchair accompanied by 2 staff members. 12:24 AM: (19 minutes after arrival): She entered the front triage door. 12:28 AM: (23 minutes after arrival): She exited the back triage door being pushed in a wheelchair by 1 staff member heading to L&D. Time in Triage was 4 minutes. Actual video times were observed later the same day. Interviews During the ED tour on 11/18/2025 at 10:00 AM, an interview was conducted with the ED Nursing Director, Staff #12 regarding the process for a laboring patient. Staff #12 indicated that the patient signs in, then goes through triage, then is seen by a physician or mid-level (provider.) If the patient is emergent, like a gunshot or chest pain they should come straight back, and the triage information is obtained at the bedside. Staff #12 was asked how it was determined that a patient was emergent. Staff #12 indicated that the triage nurse assesses the patient and assigns a triage level. Staff #12 was then asked about patients with signs of precipitous deliveries. Staff #12 indicated that the triage nurse gets fetal heart tones but does not obtain a cervical examination since they are not placed in a bed. Staff #12 was asked if the ED staff monitored a pregnant patient’s contractions. Staff #12 stated that, “We don’t have tocos (labor contraction monitoring device) here, so we can’t monitor contractions.” During an interview while observing the hospital’s surveillance video in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed in the lobby near the triage door. Staff #10, Chief Nursing Officer (CNO) stated, “She (Triage nurse) should have bypassed them (registration personnel/issue) but the patient was registered under previous account. Triage did not have access to that account. She (Triage nurse/Staff #1) should have bypassed them (registration personnel/issue) but the patient was registered under previous account. Triage did not have access to that account. She (Triage nurse) should have opened the door and pulled her in.” During an interview in the conference room on 11/19/2025 at 8:25 AM, Staff #10, CNO was asked what the Triage nurse (Staff #1) said about caring for Patient #1. Staff #10 stated, “I asked her (Triage/Staff #1) about the patient. Triage stated the patient did not come up for them (in the computer) because the patient was not registered as an ED patient. Triage asked registration (Staff #23) to register her as an ED patient. There were words. The House Supervisor (Clarified to be Staff #5, Charge Nurse) got involved. Another staff completed the second registration. When she (Patient #1) came up (in the computer) for triage, triage went to get the patient. She (Patient #1) was in a contraction. Triage waited for that contraction before moving her. Triage brought her into triage and got her vitals as soon as they could. Triage called L&D, and someone came to get the patient. Once she (Patient #1) was in triage it was very short time. I asked Triage what she was thinking by bringing her (Patient #1) into ED (triage area) versus going to L&D. Triage stated sometimes they are screaming like that, and they are at a 1. Also, if they are at a 10.” During an interview in the conference room on 11/19/2025 ending at 2:00 PM, Staff #18 was in the room. Staff #10, CNO and Staff #11, Director of Quality discussed the (Staff #1) nurse’s action or lack of action observed during the TikTok videos gave the perception of lack of empathy. Staff #10 discussed, “we provide compassionate care, and we train for that.” Staff #10 was asked about the mission statement stating compassionate, quality care. Staff #10 stated, “we fell short of that in the video.” They were asked if they had a policy against patients and visitors videoing. Staff #11 stated, “we do, but it has not been enforceable.” During an interview on 11/19/2025 at 5:34 PM, the Second Registration Staff, Staff #9 was asked if she remembered Patient #1, or if she had a chance to review her medical records before this interview. Staff #9 stated, “Yes, I remember the circumstances.” Staff #9 was asked to describe the situation in her own words. Staff #9 stated, “She [Patient #1] came in and my former colleague was at the front desk doing registration that night. I was doing EMS registration at the time. Her [Patient #1’s] mom asked for a wheelchair, and she [Staff #23] gave her one. Her [Patient #1’s] mother asked if she could help her get Patient #1 inside. My former colleague said no because she wasn’t a medical person. That is when Security [Staff #4] came to help. My former colleague got her [Patient #1’s] information, my former colleague found an induction from the day before and put her [Patient #1] in as an induction patient instead of ED patient. The triage nurse [Staff #1] came out and told my former colleague she needed to change the registration to show her [Patient #1] as an ED patient and not an induction patient because she was in labor. The triage nurse [Staff #1] and my former colleague went back and forth about it. The triage nurse [Staff #1] then went to get the charge nurse [Staff #5]. The triage nurse [Staff #1] told the charge nurse [Staff #5] that she [Patient #1] wasn’t an induction patient and needed to be put in as an ED patient. Because they [Staff #1 and Staff #23] were going back and forth, the charge nurse [Staff #5] asked me to put her [Patient #1) in since my former colleague wouldn’t do it. I don’t know what happened after that because I went back to doing EMS registrations.” [Staff #9] was asked if she knew if [Staff #1] she refused to do the triage until [Patient #1] was correctly registered. Staff #9 stated, “I didn’t hear that, no ma’am.” Staff #9 was asked what is your hospital’s registration/triage/intake process for a woman in active labor. Staff #9 stated, “Me personally, I just get their ID and get them in for triage. I ask family for the ID if they have family with them. If they don’t, I go up to L&D with them and get their ID at the bedside.” Staff #9 was asked you don’t usually have to have them into the system before their triage. Staff #9 stated, “I don’t know how other staff do it. That is just me.” During a telephone interview on 11/20/2025 at 8:17 AM, Staff #5, ED Charge nurse on duty at the time of Patient #1’s arrival. Staff #5 was asked about the circumstances of Patient #1’s admission. Staff #5 stated, “they brought her into the front instead of back into the ambulance bay.” Staff #5 was asked what the hospital’s registration/triage intake process for a woman in active labor was. Staff #5 stated, “Typically, they [actively laboring patients] come in and get registered and taken into triage immediately. The bracelet prints. Then we can call L&D, and they can take that patient. If they don’t take them, we put them into a bed. Our goal is to get them to L&D ASAP.” Staff #5 was asked about the delay at registration and if it delayed the medical care the hospital staff were able to provide [Patient #1] at the time of her presentation. Staff #5 stated, “When she [Patient #1] came in, the registration clerk [later learned to be Staff #23] put her in under the previously scheduled induction that had been canceled. She [Patient #1] came in in labor. When that happens, it [the computer system] doesn’t show me that I have a patient waiting for me. We needed her [Patient #1’s] registration fixed so we could chart on her and get her upstairs.” Staff #5 was asked if a delivery appeared to be imminent, if there was a hospital process or a designated code that would be called overhead such as for a stroke patient to get the delivery team to the patient rapidly. Staff #5 stated, “We do not. Do I feel it would be beneficial? Absolutely. Had she [Patient #1] come in by ambulance, we would have been able to get her in faster. They are registered as an ambulance patient and the way she came in created the delay.” Staff #5 was asked so if Patient #1 had been brought back in through the ambulance bay, would she have been seen sooner. Staff #5 stated, “Yes, she would have been handled as if she were a code coming in. At that point they were trying to follow the typical method for registration. The more active labor wasn’t seen until she was in the lobby. I didn’t witness it myself.” During record review and interview on 11/20/2025 at 8:51 AM, Staff #1, ED Triage nurse on duty at the time of Patient #1’s arrival, was asked how she found out Patient #1 was in the ED. Staff #1 stated, “They [clarified to be Registration Staff, Staff #23] brought the bracelet and told me I needed to take her [Patient #1] to L&D.” Staff #1 was asked what she could tell about Patient #1’s presentation when she first saw her. Staff #1 stated, “When I first laid eyes [on her], I could see her in the window sitting in a wheelchair filling out paperwork, calmly sitting there. She [Patient #1] didn’t show signs of being in active labor at that first glance. Then her mom [Grandma] walked up and started yelling at her, telling her she shouldn’t be filling out paperwork, she should be going to L&D. When I was able to bring her [Patient #1] into the triage room, I saw her standing in front of the wheelchair having a contraction. That was when I knew [clarified with Staff #1 to mean that she knew Patient #1 was in active labor].” Staff #1 was asked what clinical practice guidelines she referred to for guidance on treating pregnant women. Staff #1 stated, “I just know what I have been taught, and what policy says to do, which is to register them and get them to L&D as quickly as possible if they are in labor.” Staff #1 was asked if she had followed hospital policy. Staff #1 stated, “Yes ma’am.” Staff #1 was asked if a delivery appeared to be imminent rather than a precipitous delivery, if the hospital had a protocol or designated code that is called overhead (such as for a gunshot victim or someone in cardiac arrest). Staff #1 stated, “No ma’am.” Staff #1 was asked if the hospital and its policy considered an imminent/precipitous delivery and emergent situation. Staff #1 stated, “I, yes, but there is no way I can tell if she about to deliver without a physical exam and that is out of my scope of practice.” Staff #1 was asked if she personally would be able to determine if a patient was about to deliver. Staff #1 stated, “Honestly, I wouldn’t be able to tell on a laboring patient.” Staff #1 was asked if there was anything else she would like to say regarding this case. Staff #1 stated, “Honestly, I just wanted to call and get her out of my triage and up to L&D as fast as I could. I was being yelled at with some not so nice things. When I realized what she was saying, I didn’t realize she was recording, I was trying not to interact, I was just trying to do my job.” The hospital’s 10/23/2019 “Obstetric Patient Presenting at the Front Lobby/Concierge Desk” policy required, “provide safe transfer of an obstetric patient to the Labor and Delivery area. 1. Obstetric patients who present to the Emergency Room (ED) will be transferred to the Labor and Delivery area via wheelchair by the ER staff if the patient is above 20 weeks gestation. 2. Patient will be seen and assessed in the Triage area unless patient status dictates that she be admitted directly to an LDR (Room)...register the patient...unless the patient appears to be in distress.” The hospital’s March 2025 “Leadership Plan for the Provision of Care” policy required, “the Provision of Care is appropriate to the scope and level of care required by the patients served...Mission is to deliver compassionate care to patients and better healthcare to communities...deliver patient-centered healthcare with compassion, dignity and respect for every patient and their family...committed to always providing exceptional care and performance...we believe that patients have a fundamental right to considerate care that safeguards their personal dignity and respects their cultural. Psychosocial and spiritual values...each patient’s care is determined and individualized through detailed interdisciplinary assessment and reassessment...House Supervisors or designee is accountable for providing staff guidance on a continuous basis in the planning, coordination, monitoring and organizing the provision of patient care. Staff is accountable to conduct its practice within the limits of license, certification or training, utilizing a self-managed team concept in providing patient services...Evolution of patient’s plan of care is determined by intervention effectiveness, responses, and revised as needed...Patient services are planned, coordinated, provided, delegated and supervised by profession-al healthcare providers who recognize the unique physical, emotional and spiritual needs of each patient. Patient care encompasses the recognition of disease and health, patient teaching, patient advocacy, spirituality and research...A RN performs triage assessment upon arrival of every patient who presents to the Emergency Department to determine the treatment urgency. A qualified medical provider will evaluate the patient and orders diagnostic testing and treatment required based on patient needs. Patients are reassessed for response to treatment and are admitted to the hospital, transferred to an appropriate facility or discharged with follow-up instructions as appropriate...The goal of the Emergency Department is to provide quality urgent, emergent and crisis care to the members of the community who present to the department...””

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 33589 BASED ON video review, record review, and interview, the hospital failed to ensure Nursing Services when obstetrical (OB) Qualified Medical Professional (QMP) examinations were delayed greater than 10 minutes for patients who presented at the Emergency Department (ED) in labor. 13 of 21 laboring patients were incorrectly triaged by the Triage nurse (Staff #1) according to the hospital’s Nursing Triage policy that governed the use of the Emergency Severity Index (ESI), resulting in a possible delay (Patient #1, #3, #4, #5, #6, #7, #8, #10, #11, #13, #14, #15, and #16); AND 9 of 21 laboring patients were delayed longer than 10 minutes prior to arriving in L&D (Labor & Delivery) for a labor examination (Patient #1, #3, #4, #5, #6, #8, #9, #13, and #14). Nursing Services staff (the registrar/Staff #23; the charge nurse/Staff #5; and the triage nurse/Staff #1) failed to recognize labor as an immediate/emergent medical condition that required a Qualified Medical Professional (QMP) examination to determine active labor according to the hospital policy. The current nursing practices delayed laboring obstetrical QMP examination and placed patients at risk of maternal and fetal/infant mortality and morbidity. FINDINGS The hospital’s 1/25/2023 “Medical Screening in the Obstetrical Department” policy required, “To provide a consistent system for the evaluation of presenting women with pregnancy related issues in compliance with federal EMTALA (Emergency Medical Treatment and Active Labor Act) requirements...It is the policy of this hospital to provide a medical screening examination to all patients presenting for unscheduled obstetrical evaluation, testing or services within the capabilities of the obstetrical unit and the ancillary services routinely available to the obstetrical department, including the use of on call physicians. Patients 20 weeks gestation or greater, with obstetrical or gynecological presentations, (other than scheduled procedures) will receive a medical examination in the obstetrics department consistent with this policy...Medical screening examination is the process determining. with reasonable clinical confidence, whether or not an emergency medical condition exists or a woman is in labor...to determine the presence or absence of an emergency medical condition....fetal monitoring...Qualified providers to perform a medical screen in the obstetrical department...” The hospital’s “Triage in the Emergency Department” policy, last reviewed and implemented on 3/28/2023, stated on page 1 of 6: “ ...The Emergency Severity Index (ESI) is a five-level triage system that is simple to use and divides patients by acuity and resource needs. The ESI triage algorithm is based on four key decision points. The experienced ED RN will be able to rapidly and accurately triage patients using this system. ...Triage screening in the Emergency Department to establish a basis for appropriate care based on degree of illness or severity of traumatic injury. Code Stroke, Code Stemi, Code 44 and Code 88 are called at time of immediate identification of symptoms or injury by trained hospital personnel as deemed appropriate....” And on page 2 of 6: (Resuscitative) Level - 1 patients are critically ill, UNSTABLE and require immediate lifesaving physician evaluation and interventions. (Emergency) Level - 2 patients are very ill, high risk and require rapid initiation of care which in the emergency nurse can initiate care through protocols without a physician at the bedside. These patients should be taken to a room and treatments begun in less than 10 minutes... (Urgent) Level - 3 patients are predicted to require two or more resources... 1. The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either (Level 1) resuscitative, (Level 2) Emergency, (Level 3) urgent, (Level 2) semi-urgent, or (Level 5) routine categories. 2. Triage can take place in either the triage room or at the bedside. The goal is DIRECT BED and complete intake at the bedside whenever space and/or staff allow...” . And pages 3 - 4 of 6: “ ...Examples of Emergency Severity Index: Resuscitative Level 1...unstable, immediate care, life threatening conditions: ...acute chest pain...airway and breathing difficulty...anaphylaxis...Cardiac arrest... Emergency Level 2 - major injury or illness but STABLE; treatment and assessment should occur within 5 to 15 minutes...active labor...Acute Asthma...CVA/TIA (stroke/mini-stroke)...Major burn...Pregnant patient with active bleeding... Urgent Level 3 treatment and assessment should occur in 15-45 minutes...abdominal pain...intoxication...closed fracture...drug ingestion...” The hospital’s 4/23/2025 “EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act” policy required, “appropriate Medical Screening Exam (MSE)...Any woman in active labor is considered UNSTABLE...” Nurses triaged obstetric patients in labor as an ESI Level 3, but the hospital policy required a triage at ESI Level 2(Patient #1, #3, #4, #5, #6, #7, #8, #10, #11, #13, #14, #15, and #16.) According to hospital policy, nursing services failed to take patients to Labor & Delivery (L&D) for a labor examination within 10 minutes. Patient #1, #3, #4, #5, #6, #8, #9, #13, and #14 were delayed longer than 10 minutes prior to arrival in L&D for a labor examination. During the hospital’s surveillance video review for the date of 11/11/2025 in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed arriving at the main ED patient drive (canopy; porte-cochere - roofed structure that vehicles drive under) around midnight. 12:05 AM: She entered the main ED lobby/reception in the wheelchair accompanied by 2 staff members. 12:24 AM: (19 minutes after arrival): She entered the front triage door. 12:28 AM: (23 minutes after arrival): She exited the back triage door being pushed in a wheelchair by 1 staff member heading to L&D. Time in Triage was 4 minutes. Actual video times were observed later the same day. Patient #1’s medical record review revealed: Patient #1 was delayed in the lobby and triage for 26 minutes after ED arrival. Patient #1 was incorrectly triaged as ESI Level 3. On 11/11/2025, a 29-year-old female presented to the ED in labor at 12:05 AM (per surveillance video). At 12:26 AM (21 minutes after arrival), the “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 12:31 AM (26 minutes after arrival), Patient #1 was received in L&D by the QMP who noted, “Membrane: status Spontaneous...Color: Meconium...lightly...odor: none...Dilation: 10 Complete...Effacement: 100%...Fetal Station: 3...presenting part crowning.” Patient #1 delivered at 12:35 AM. Patient #3’s medical record review revealed: Patient #3 was delayed in the lobby and triage areas for 16 minutes after ED arrival. Patient #3 was incorrectly triaged as ESI Level 3. On 11/01/2025, a 20-year-old female presented to the ED in labor at 11:26 AM. At 11:38 AM (12 minutes after arrival), the “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 11:42 AM (16 minutes after arrival), the physician noted, “first provider evaluation.” At 11:46 AM (20 minutes after arrival), the patient arrived in L&D and labored until the physician determined labor arrested. Patient #3 delivered via cesarean on 11/02/2025 at 10:11 AM. Patient #4’s medical record review revealed: Patient #4 was delayed in the lobby and triage for 15 minutes after ED arrival. Patient #4 was not assigned an ESI level. On 11/01/2025, a 21-year-old female presented to the ED in labor at 11:28 PM. At 11:35 PM (7 minutes after arrival) the triage process began. The triage nurse failed to assign an ESI level. The “ED Care Timeline” did not note an ESI level being assigned per the “Triage in the Emergency Department” policy. At 11:43 PM (15 minutes after arrival), Patient Acuity 3 was assigned and patient was admitted to L&D. At 11:58 PM (30 minutes after arrival), the QMP noted, “Dilation 2 Effacement 50% Fetal station -2 (page 416/720).” The patient labored until the physician determined labor arrested. Patient #4 delivered via c-section on 11/02/2025 at 12:25 PM. Patient #5’s medical record review revealed: Patient #5 was delayed in the lobby and triage for 17 minutes after arrival. Patient #5 was not assigned an ESI Level. On 10/11/2025, a 27-year-old female presented to the ED in labor at 1:19 PM. At 1:27 PM (8 minutes after arrival), the triage process began. The triage nurse failed to assign an ESI level. The “ED Care Timeline” did not note an ESI level being assigned per the “Triage in the Emergency Department” policy. At 1:36 PM (17 minutes after arrival), Patient #5 arrived in L&D. At 1:47 PM (28 minutes after arrival), the QMP noted, “Membrane: spontaneous...Dilation 2 cm Effacement 80% Station -3...(Page 123/354)...1:50 PM...good fetal movement.” Patient #5 delivered at 5:39 PM. Patient #6’s medical record review revealed: Patient #6 was delayed in the lobby and triage for 18 minutes after arrival. Patient #6 was incorrectly triaged as Level 3. On 10/15/2025, a 34-year-old female presented to the ED in labor at 5:11 AM. At 5:20 AM (9 minutes after arrival) the triage process began. The “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 5:29 AM (18 minutes after arrival) Patient #6 arrived in L&D. At 6:09 AM (58 minutes after arrival), the QMP noted, “Membrane: spontaneous...Meconium...Dilation 2 cm Effacement 30% Station Ballotable.” Patient #6 delivered via cesarean for fetal intolerance at 9:38 AM. Patient #7’s medical record review revealed: Patient #7 was not assigned an ESI Level. On 10/27/2025, a 27-year-old female presented to the ED in labor at 36 weeks at 3:25 AM. At 3:29 AM, the triage process began. The triage nurse failed to assign an ESI level. The “ED Care Timeline” did not note an ESI level being assigned per the “Triage in the Emergency Department” policy. Patient Acuity 3 was assigned. At 3:30 AM, Patient 7 arrived in L&D. At 4:00 AM, the QMP noted, “Dilation 2 cm Effacement 50% Station -3.” Patient #7 was discharged at 9:24 AM. Patient #8’s medical record review revealed: Patient #8 was delayed in the lobby and triage for 17 minutes after arrival. Patient #8 was incorrectly triaged as Level 3. On 10/06/2025, a 30-year-old female presented to the ED in labor at 11:52 AM. At 11:59 AM (7 minutes after arrival), the triage process began. The “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 12:09 PM (17 minutes after arrival), Patient # 8 arrived in the L&D. At 12:23 PM (36 minutes after arrival), the QMP noted, “Dilation 6 cm Effacement 70% Station -2.” Patient #8 delivered at 3:44 PM. Patient #9’s medical record review revealed: Patient #9 was delayed in the lobby and triage for 23 minutes after arrival. On 9/29/2025, a 16-year-old female presented to the ED in labor at 2:22 PM. At 2:41 PM (19 minutes after arrival), the triage process began. The “ED Care Timeline” noted the “ESI Level 2” was assigned, however, the patient was still delayed greater than 10 minutes. At 2:45 PM (23 minutes after arrival), Patient #9 arrived in the L&D. At 3:00 PM (43 minutes after arrival), the QMP noted, “reports good fetal movement...3:07 PM sluggish and lethargic...focal seizure suspected...3:35 PM physician at bedside...” Patient #9 delivered via emergency cesarean at 4:11 PM. Patient #10’s medical record review revealed: Patient #10 was incorrectly triaged as Level 3. On, 9/21/2025, a 31-year-old female presented to the ED in labor at 1:15 AM At 1:22 AM, the “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 1:25 AM, Patient #10 arrived in L&D. At 2:00 AM, the QMP noted, “fetal movement is audible on monitor via US (ultrasound / Page 28/439) Patient #10 delivered at 5:03 PM. Patient #11’s medical record review revealed: Patient #11 was incorrectly triaged as Level 3. On, 9/26/20025, a 32-year-old female presented to the ED in labor at 3:21 AM At 3:23 AM, the “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 3:24 AM, Patient #11 arrived in L&D. At 3:56 AM, the QMP noted, “8 cm.” Patient #11 delivered at 11:46 AM (page 176/378). Patient #13’s medical record review revealed: Patient #13 was delayed in the lobby and triage for 19 minutes after arrival. Patient #13 was not assigned an ESI Level. On 11/11/2025, a 25-year-old female presented to the ED in labor at 10:55 PM. At 11:05 PM (10 minutes after arrival), the triage process began. The triage nurse failed to assign an ESI level. The “ED Care Timeline” did not note an ESI level being assigned per the “Triage in the Emergency Department” policy. Patient acuity 3 assigned. At 11:14 PM (19 minutes after the arrival), Patient # 13 arrived in the L&D. At 11:25 PM (30 minutes after arrival), the QMP noted, “Dilation 5 Effacement 50% Station -2 (page 75/269).” Patient #13 delivered on 11/12/2025 at 4:35 PM. Patient #14’s medical record review revealed: Patient #14 was delayed in the lobby and triage for 32 minutes after arrival. Patient #14 was incorrectly triaged as Level 3. On 11/11/2025, a 29-year-old female presented to the ED in labor at 12:34 AM (00:34). At 12:48 AM (14 minutes after arrival), the triage process began. The “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 1:06 AM (32 minutes after the arrival), Patient #14 arrived in the L&D. At 1:32 AM (58 minutes after arrival), the QMP noted, “Dilation 7 cm.” Patient #14 delivered at 5:59 AM. Patient #15’s medical record review revealed: Patient #15 was incorrectly triaged as Level 3. On 11/10/2025, a 26-year-old female presented to the ED in labor at 28 weeks at 6:12 PM via ambulance. At 6:13 PM, the triage process began. The “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 6:17 PM, Patient #15 arrived in L&D. The patient was monitored and found to be in false labor. At 6:30 PM, the QMP noted, “reports good fetal movement...will continue to monitor...7:15 PM occasional Braxton-hicks contraction every 15-30 minutes apart...11:46 PM discharge instructions.” Patient #15 was discharged on 11/11/2025 at 12:10 AM. Patient #16’s medical record review revealed: Patient #16 was incorrectly triaged as Level 3. On 11/07/2025, a 30-year-old female presented to the ED in labor at 4:39 PM via ambulance. At 4:41 PM, the triage process began. The “ED Care Timeline” noted the “ESI Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy. At 4:50 PM, Patient #16 arrived in L&D. At 5:15 PM, the QMP noted, “Membranes intact Dilation 5 cm Effacement 90% Station 0.” Patient #16 delivered at 8:54 PM. Interviews During the ED tour on 11/18/2025 at 10:00 AM, an interview was conducted with the ED Nursing Director, Staff #12 and the on-duty Registration Clerk, Staff #16 regarding the registration process. Staff #16 stated that all patients sign in on a form and indicated a clipboard with the quick registration form on it. Staff #16 further stated that the registration clerk then entered the information in the computer, then the triage nurse sees the patient. The quick registration form was noted to have a blank area requesting insurance information that would be entered prior to the patient being seen in triage or for a Medical Screening Examination (MSE). Staff #12 indicated that the patient signs in, then goes through triage, then is seen by a physician or mid-level (provider.) If the patient is emergent, like a gunshot or chest pain they should come straight back, and the triage information is obtained at the bedside. Staff #12 was asked how it was determined that a patient was emergent. Staff #12 indicated that the triage nurse assesses the patient and assigns a triage level. Staff #12 was asked about the registration process for patients who call ahead or are in active labor or have experienced a rupture of membranes in pregnancy. Staff #12 indicated that those patients still go through the same process. Staff #12 was then asked about patients with signs of precipitous deliveries. Staff #12 indicated that the triage nurse gets fetal heart tones but does not obtain a cervical examination since they are not placed in a bed. Staff #12 was asked if the ED staff monitored a pregnant patient’s contractions. Staff #12 stated that, “We don’t have tocos (labor contraction monitoring device) here, so we can’t monitor contractions.” During an interview while observing the hospital’s surveillance video in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed in the lobby near the triage door. Staff #10, Chief Nursing Officer (CNO) stated, “She (Triage nurse/Staff #1) should have bypassed them (registration personnel/issue) but the patient was registered under previous account. Triage did not have access to that account. She (Triage nurse) should have opened the door and pulled her in.” During a record review and interview on 11/18/2025 at approximately 5:30 PM, Staff #18, Patient Access Supervisor, was called to the conference room by Staff #10, the Chief Nursing Officer, following the security camera video reviews with Staff #21, the IT Marketing Director, at 5:25 PM. The video reviews noted time differences in the arrival of Patient #1 on the videos (12:05 AM) and the time stamps in the medical records and ED/Transfer Logs (12:21 AM). Staff #18 was asked to explain time differences that were noted. Staff #18 explained that Patient #1 had initially been incorrectly registered as a scheduled induction patient at 12:10 AM. This error had kept staff from moving Patient #1 forward as the computer system would not allow ED staff to document on Patient #1, which necessitated re-registering Patient #1 as an ED patient at 12:21 AM. Staff #18 was asked if a re-registration of a patient always changed the documented patient arrival time. Staff #18 indicated that it would always reflect the time the registration was entered and not the actual arrival time of the patient. Staff #18 was asked to confirm that Patient #1 or any patient arrival time would not be accurately reflected under these circumstances. Staff #18 said yes. During an interview in the conference room on 11/19/2025 at 8:25 AM, Staff #10, CNO was asked what the Triage nurse said about caring for Patient #1. Staff #10 stated, “I asked her (Triage/Staff #1) about the patient. Triage stated the patient did not come up for them (in the computer) because the patient was not registered as an ED patient. Triage asked registration (Staff #23) to register her as an ED patient. There were words. The House Supervisor (clarified to be Staff #5, Charge Nurse) got involved. Another staff completed the second registration. When she (Patient #1) came up (in the computer) for triage, triage went to get the patient. She (Patient #1) was in a contraction. Triage waited for that contraction before moving her. Triage brought her into triage and got her vitals as soon as they could. Triage called L&D, and someone came to get the patient. Once she (Patient #1) was in triage it was very short time. I asked Triage what she was thinking by bringing her (Patient #1) into ED (triage area) versus going to L&D. Triage stated sometimes they are screaming like that, and they are at a 1. Also, if they are at a 10.” During an interview in the conference room on 11/19/2025 ending at 2:00 PM, Staff #18 was in the room. Staff #10, Chief Nursing Officer and Staff #11, Director of Quality discussed the nurse’s action or lack of action observed during the TikTok video gave the perception of lack of empathy. Staff #10 discussed, “we provide compassionate care, and we train for that.” Staff #10 was asked about the mission statement stating compassionate, quality care. Staff #10 stated, “we fell short of that in the video.” They were asked if they had a policy against patients and visitors videoing. Staff #11 stated, “we do, but it has not been enforceable.” During an interview on 11/19/2025 at 5:34 PM, the Second Registration Staff, Staff #9 was asked if she remembered Patient #1, or if she had a chance to review her medical records before this interview. Staff #9 stated, “Yes, I remember the circumstances.” Staff #9 was asked what is your hospital’s registration/ triage/ intake process for a woman in active labor. Staff #9 stated, “Me personally, I just get their ID (identification) and get them in for triage. I ask family for the ID if they have family with them. If they don’t, I go up to L&D with them and get their ID at the bedside.” Staff #9 was asked you don’t usually have to have them into the system before their triage. Staff #9 stated, “I don’t know how other staff do it. That is just me.” During a telephone interview on 11/20/2025 at 8:17 AM, Staff #5, ED Charge nurse on duty at the time of Patient #1’s arrival. Staff #5 was asked about the circumstances of Patient #1’s admission. Staff #5 stated, “they brought her into the front instead of back into the ambulance bay.” Staff #5 was asked what the hospital’s registration/triage intake process for a woman in active labor was. Staff #5 stated, “Typically, they [actively laboring patients] come in and get registered and taken into triage immediately. The bracelet prints. Then we can call L&D, and they can take that patient. If they don’t take them, we put them into a bed. Our goal is to get them to L&D ASAP.” Staff #5 was asked if a delivery appeared to be imminent, if there was a hospital process or a designated code that would be called overhead such as for a stroke patient to get the delivery team to the patient rapidly. Staff #5 stated, “We do not. Do I feel it would be beneficial? Absolutely. Had she [Patient #1] come in by ambulance, we would have been able to get her in faster. They are registered as an ambulance patient and the way she came in created the delay.” Staff #5 was asked so if Patient #1 had been brought back in through the ambulance bay, would she have been seen sooner. Staff #5 stated, “Yes, she would have been handled as if she were a code coming in. At that point they were trying to follow the typical method for registration. The more active labor wasn’t seen until she was in the lobby. I didn’t witness it myself.” During record review and interview on 11/20/2025 at 8:51 AM, Staff #1, ED Triage nurse on duty at the time of Patient #1’s arrival, was asked how she found out Patient #1 was in the ED. Staff #1 stated, “They [clarified to be Registration Staff, Staff #23] brought the bracelet and told me I needed to take her [Patient #1] to L&D.” Staff #1 was asked what she could tell about Patient #1’s presentation when she first saw her. Staff #1 stated, “When I first laid eyes [on her], I could see her in the window sitting in a wheelchair filling out paperwork, calmly sitting there. She [Patient #1] didn’t show signs of being in active labor at that first glance. Then her mom [Grandma] walked up and started yelling at her, telling her she shouldn’t be filling out paperwork, she should be going to L&D. When I was able to bring her [Patient #1] into the triage room, I saw her standing in front of the wheelchair having a contraction. That was when I knew [clarified with Staff #1 to mean that she knew Patient #1 was in active labor].” . Staff #1 was asked what clinical practice guidelines she referred to for guidance on treating pregnant women. Staff #1 stated, “I just know what I have been taught, and what policy says to do, which is to register them and get them to L&D as quickly as possible if they are in labor.” Staff #1 was asked if she had followed hospital policy. Staff #1 stated, “Yes ma’am.” Staff #1 was asked if a delivery appeared to be imminent rather than a precipitous delivery, if the hospital had a protocol or designated code that is called overhead (such as for a gunshot victim or someone in cardiac arrest). Staff #1 stated, “No ma’am.” Staff #1 was asked if the hospital and its policy considered an imminent/precipitous delivery and emergent situation. Staff #1 stated, “I, yes, but there is no way I can tell if she about to deliver without a physical exam and that is out of my scope of practice.” Staff #1 was asked if she personally would be able to determine if a patient was about to deliver. Staff #1 stated, “Honestly, I wouldn’t be able to tell on a laboring patient.” Staff #1 was asked if there was anything else she would like to say regarding this case. Staff #1 stated, “Honestly, I just wanted to call and get her out of my triage and up to L&D as fast as I could. I was being yelled at with some not so nice things. When I realized what she was saying, I didn’t realize she was recording, I was trying not to interact, I was just trying to do my job.” Policy The hospital’s 10/23/2019 “Obstetric Patient Presenting at the Front Lobby/Concierge Desk” policy required, “provide safe transfer of an obstetric patient to the Labor and Delivery area. 1. Obstetric patients who present to the Emergency Room (ED) will be transferred to the Labor and Delivery area via wheelchair by the ER staff if the patient is above 20 weeks gestation. 2. Patient will be seen and assessed in the Triage area unless patient status dictates that she be admitted directly to an LDR (Room)...register the patient...unless the patient appears to be in distress.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 33589 BASED ON record review, and interview, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient to include repeated/ongoing monitoring according to the hospital policy and patient specific needs. At least 2 of 2 ED (Emergency Department) discharged patients did not receive repeated/ongoing monitoring of their vital signs in the emergency department according to the hospital policy. (Patient #11 on 10/03/2025 and Patient #12 on 11/11/2025). FINDINGS The hospital’s 3/28/2023 “Vital Signs in the Emergency Department” policy required, “Vital signs on all patients on initial assessment...Priority 3-----URGENT repeat vital signs minimum every 30 - 60 minutes or change in patient’s condition or diagnosis. Priority 2-----EMERGENT Continuous or related to patient’s condition or diagnosis a minimum of every 15 - 30 minutes...Discharge vital signs will be taken on all patients prior to discharge if abnormal in triage assessment or if patient has been in department greater than 1 ½ hours and will be documented on the patients chart...” According to hospital policy, nursing failed to complete repeated and discharge vital signs for each patient. Patient #11’s medical record review revealed: Patient #11 was a 32-year-old who had given birth on 9/26/2025. Patient #11 arrived on 10/03/2025 at 1:16 AM with a chief complaint of Postpartum Hypertension, and Leg swelling. There were no vital signs or documentation while the patient waited in the lobby from 1:16 AM to 2:04 AM. Patient #11 was triaged at 2:04 AM (48 minutes after the arrival.) The initial triage blood pressure was 160/90. Emergency Severity Index (ESI) level of 3 was assigned. The Nurse noted, “HTN (Hypertensive) Crisis / Edema X X Today postpartum 9/26...” Patient #11 was returned to the lobby. At 2:37 AM (81 minutes/1 hour & 21 minutes after arrival), Patient #11 was roomed in the ED. Patient #11 had a medical screening exam at 2:48 AM. Patient #11 did not have (repeated/ongoing) vital signs for 1 hour and 52 minutes. At 3:56 AM the blood pressure was 146/86, which was the last vital signs documented. Patient #11 was discharged at 5:42 AM. Patient #11 was in the ED for 4 hours & 26 minutes before being discharged. There were no discharge vital signs. Patient #12’s medical record review revealed: Patient #12 was a 21-year-old who arrived on 11/11/2025 at 9:35 PM with a chief complaint of Vomiting. There were no vital signs or documentation while the patient waited in the lobby from 9:35 PM to 10:36 PM. Patient #12 triage vital signs were at 10:43 PM (1 hour and 8 minutes from arrival.) ESI Level 3 was assigned. Patient #12 was returned to the lobby. Patient #12 was roomed in the ED at 11:36 PM (2 hours and 1 minute from arrival). Patient #12 had a medical screening exam at 11:47 PM. Patient #12 did not have (repeated/ongoing) vital signs. Patient #12 was discharged at 4:17 AM (6 hours and 32 minutes after arrival). There were no discharge vital signs. Interviews During the ED tour on 11/18/2025 at 10:00 AM, an interview was conducted with the ED Nursing Director, Staff #12 was asked about the process for a laboring patient. Staff #12 indicated that the patient signs in, then goes through triage, then is seen by a physician or mid-level. If the patient is emergent, like a gunshot or chest pain they should come straight back, and the triage information is obtained at the bedside. Staff #12 was asked how it was determined that a patient was emergent. Staff #12 indicated that the triage nurse assesses the patient and assigns a triage level. During record review and interview on 11/20/2025 at 8:51 AM, Staff #1, ED Triage nurse was asked what clinical practice guidelines she referred to for guidance on treating pregnant women. Staff #1 stated, “I just know what I have been taught, and what policy says to do, which is to register them and get them to L&D as quickly as possible if they are in labor.” Staff #1 was asked if she had followed hospital policy. Staff #1 stated, “Yes ma’am.” The hospital’s 3/28/2023 “Triage in the Emergency Department” policy required, “to establish a basis for appropriate care based on degree of severity of traumatic injury... Emergency Severity Index (ESI)... (Resuscitative) Level - 1 patients are critically ill, UNSTABLE and require immediate lifesaving physician evaluation and interventions. (Emergency) Level - 2 patients are very ill, high risk and require rapid initiation of care which in the emergency nurse can initiate care through protocols without a physician at the bedside. These patients should be taken to a room and treatments begun in less than 10 minutes...Triage can take place in either the triage room or at the bedside. The goal is DIRECT BED and complete intake at the bedside whenever space and/or staff allow... Examples of Emergency Severity Index: ... Resuscitative Level 1...immediate care, life threatening conditions: ...acute chest pain...airway and breathing difficulty...anaphylaxis...Cardiac arrest... Emergency Level 2 - major injury or illness but STABLE; treatment and assessment should occur within 5 to 15 minutes...ACTIVE LABOR...Acute Asthma...CVA/TIA (stroke/mini-stroke)...Major burn...Pregnant patient with active bleeding... Urgent Level 3 treatment and assessment should occur in 15-45 minutes...abdominal pain...intoxication...closed fracture...drug ingestion...” The hospital’s March 2025 “Assessment & Re-assessment-Patient” policy required, “the goal is to identify patient specific problems...adjust the plan of care accordingly to the needs of the patient...Patient’s perception of the effectiveness of...symptoms of nausea or pain...reassessment occurs at...significant changes in condition...All patients receiving emergency care will be assessed by a licensed physician, physician assistant or nurse practitioner...Emergency (Department) assessment Guidelines: Initial on arrival, based on severity...scope of assessment...where complaint driven ED nursing documentation...re-assessment based on severity...” The hospital’s March 2025 “Leadership Plan for the Provision of Care” policy required, “the Provision of Care is appropriate to the scope and level of care required by the patients served...each patient’s care is determined and individualized through detailed interdisciplinary assessment and reassessment...House Supervisors or designee is accountable for providing staff guidance on a continuous basis in the planning, coordination, monitoring and organizing the provision of patient care. Staff is accountable to conduct its practice within the limits of license, certification or training, utilizing a self-managed team concept in providing patient services...Evolution of patient’s plan of care is determined by intervention effectiveness, responses, and revised as needed...Patient services are planned, coordinated, provided, delegated and supervised by profession-al healthcare providers who recognize the unique physical, emotional and spiritual needs of each patient. Patient care encompasses the recognition of disease and health, patient teaching, patient advocacy, spirituality and research...A RN performs triage assessment upon arrival of every patient who presents to the Emergency Department to determine the treatment urgency. A qualified medical provider will evaluate the patient and orders diagnostic testing and treatment required based on patient needs. Patients are reassessed for response to treatment and are admitted to the hospital, transferred to an appropriate facility or discharged with follow-up instructions as appropriate...The goal of the Emergency Department is to provide quality urgent, emergent and crisis care to the members of the community who present to the department...””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33589 BASED ON video review, record review, and interview, the hospital failed to ensure the nursing staff developed, and kept current, a nursing care plan for each patient that reflected the patient’s goals and the nursing care to be provided to meet each patient’s needs. Nursing staff did not keep current and adjust the care plan for Patient #1 who presented to the emergency department (ED) in labor on 11/11/2025. Nursing staff did not recognized Patient #1 as having an immediate/emergent condition that required a Qualified Medical Professional (QMP) examination to determine active labor to meet the needs of the patient. Nursing staff (Staff #1, #5, and #23) did not intervene on behalf of the patient’s care needs. The current nursing practices delayed laboring obstetrical QMP examination and placed patients at risk of maternal and fetal/infant mortality and morbidity. FINDINGS TikTok C Video was reviewed on 11/17/2025. Pre-Survey Observation Summary: https://www.threads.com/@wecookintahday_nataliekays/post/DRAoERaibVZ?xmt=AQF0pcQ8Zw68vYaLGDzAboo8xxM9WifpyyR8u5rZcTkW5AvGHIcNujXZhS9uKwAd-zuORDE&slof=1 The Patient was observed in the triage area while hospital Staff (Staff #1) typed at a computer with her back to the camera. The Patient seated in a wheelchair was observed having contractions, writhing in pain, screaming, and repeatedly adjusting her position. A blood pressure cuff was on the Patient’s left arm. The nurse looked at the patient and then turned to look at the computer. The Staff asked, “how many times have you been pregnant (without turning or looking at the patient)?” The Patient stated, “3.” The Staff asked, “this is your third pregnancy (without turning or looking at the patient)?” The Patient stated, “yes.” The Staff asked, “you have 2 babies at home (without turning or looking at the patient)?” The Patient stated, “it is in my aXX.” Staff did not turn to assess the patient for a change of condition. The Staff asked again, “you have 2 babies at home (without turning or looking at the patient)?” Audible panting was heard from the patient. Staff did not turn to assess the patient despite the patient’s audible sounds of panting. The Staff asked, “who is your doctor (without turning or looking at the patient)?” The Patient continued to writhe, audibly pant and was observed to be visibly exhausted. The Staff asked, “who is your doctor (without turning or looking at the patient)?” The video recorder (Grandma) finally answered, “ [Staff #7, primary OBGYN named] is her doctor.” The Patient began audibly grunting (28 seconds into the video) and was observed to brace her arm on the wheelchair and then placed her foot on the floor while panting. The video recorder stated, “(40 seconds into the video) y’all treat all your patients like this or just the black ones.” The Staff was heard speaking to someone on the phone reporting the situation, patient names, etc. The video recorder stated, “I bet y’all listen next time (1 minute 15 seconds into the video).” The Patient began to audibly sob. The video recorder stated, “when you found out you were delivering at this hospital (1 minutes 19 seconds into the video).” The Patient audibly cried out and stood up. The video recorder continued, “your aXX should have changed doctors.” The Patient stood up, turned around to bend over the wheelchair and audibly cried out in pain. TikTok A Video was reviewed on 11/17/2025. Pre-Survey Observation Summary: TikTok A.mp4 The Patient was observed in a triage area while Staff (Staff #1) typed at a computer. The Staff’s back was to the camera. A blood pressure cuff was on the Patient’s arm. The Patient was turned backward over a wheelchair with both knees in the wheelchair. The Patient dropped her right leg and placed her right foot on the floor. The Patient audibly screamed. The Patient then stopped screaming and stated, “ma’am.” Staff stated, “yes (without turning or looking at the patient).” The Patient stated, “are you able to call the anesthesiologist?” Staff stated, “someone is coming to take you to Labor and Delivery (again without turning or looking at the patient).” Patient stated, “that is not what I asked.” Staff then turned toward the patient with a flat affect and stated, “I cannot help.” Video review revealed the nurse did not look at or react to the patient for assessment/reassessment purposes despite crying and writhing in pain. Patient #1’s printed medical record was reviewed on 11/18/2025 from 11:00 AM and revealed: A 29-year-old black, female presented to the Emergency Department on 11/11/2025 at 12:05 AM (per surveillance video) with an “arrival complaint of labor.” She was registered and changed from an induction patient to an ED patient in the computer at 12:21 AM (16 minutes after arrival) after a registration issue was resolved, resulting in a delay of care. At 12:25 AM (20 minutes after arrival), the hospital documented on the “ED Care Timeline” the “Chief Complaint of Contractions, EDD (Estimated due date) 11/10/2025, G3P2 (3 pregnancies, 2 previous births), and begun triage of the patient including travel/infection screening, Glascow Coma Scale, and Allergies.” At 12:26 AM (21 minutes after arrival), the “Emergency Severity Index (ESI) Level 3” was incorrectly assigned per the “Triage in the Emergency Department” policy and included “Arrived requiring immediate life-saving intervention?: No Arrived in high risk situation? or confused/lethargic/disoriented? or severe pain/distress?: No Danger zone vitals?: No How many different resources are needed?: Many” and vital signs were documented. Patient #1 was taken to L&D (Labor & Delivery) at 12:28 AM (23 minutes after arrival) by a technician and 2 nurses (per surveillance video). At 12:31 AM (26 minutes after arrival), Patient #1 was received in L&D by the QMP who noted, “Membrane: status Spontaneous...Color: Meconium...lightly...odor: none...Dilation: 10 Complete...Effacement: 100%...Fetal Station: 3...presenting part crowning.” Patient #1 delivered at 12:35 AM. ~ Nursing Care Plan (began on page 87/222) included problems with goals. Start 11/11/2025 Problem: Cognitive Goal: Expressions of a comfortable level of knowledge will increase ...Verbalization of understanding the information provided will improve ... Start 11/11/2025 Problem: Coping (page 91 of 222) Goal: Family member’s participation in the patient’s care will improve ...Ability to identify appropriate support needs will improve ...Participation in discharge planning will improve ...Ability to cope will improve ...Ability to identify and utilize available resources and services will improve ... Start 11/11/2025 Problem: Daily Care (page 91 of 222) Goal: Daily care needs are met ... Start 11/11/2025 Problem: Discharge Barriers (page 92 of 222) Goal: Patient discharge needs are met ... Start 11/11/2025 Problem: Health Behavior (page 93 of 222) Goal: Identification of resources available to assist in meeting health care needs will improve ... Start 11/11/2025 Problem: Language Barrier (page 93 of 222) Goal: Patient uses a form of communication to get needs met and to relate effectively with people and his/her environment ... Start 11/11/2025 Problem: Nutrition (page 95/222) Goal: Maintain optimal nutrition status ...Nutrient intake >75% of estimated needs Start 11/11/2025 Problem: Pain (page 96 of 222) Goal: Patient’s pain/discomfort is manageable ... Start 11/11/2025 Problem: Psychosocial needs (page 97 of 222) Goal: Demonstrates ability to cope with hospitalization/illness ...Collaborate with patient/family/caregiver to identify patient specific goals for this hospitalization ... Start 11/11/2025 Problem: Safety (page 98 of 222) Goal: Patient will be injury free during hospitalization ... During the hospital’s surveillance video review for the date of 11/11/2025 in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed arriving at the main ED patient drive (canopy; porte-cochere - roofed structure that vehicles drive under) around midnight. 12:05 AM: She entered the main ED lobby/reception in the wheelchair accompanied by 2 staff members. 12:24 AM: (19 minutes after arrival): She entered the front triage door. 12:28 AM: (23 minutes after arrival): She exited the back triage door being pushed in a wheelchair by 1 staff member heading to L&D. Time in Triage was 4 minutes. Actual video times were observed later the same day. Interviews During the ED tour on 11/18/2025 at 10:00 AM, an interview was conducted with the ED Nursing Director, Staff #12 was asked how it was determined that a patient was emergent. Staff #12 indicated that the triage nurse assesses the patient and assigns a triage level. Staff #12 was asked if the ED staff monitored a pregnant patient’s contractions. Staff #12 stated that, “We don’t have tocos (labor contraction monitoring device) here, so we can’t monitor contractions.” During the hospital’s surveillance video review in the conference room on 11/18/2025 at 11:39 AM, Patient #1 was observed in the lobby near the triage door. Staff #10, Chief Nursing Officer (CNO) stated, “She (Triage nurse) should have bypassed them (registration personnel/issue) but the patient was registered under previous account. Triage did not have access to that account. She (Triage nurse) should have opened the door and pulled her in.” During an interview in the conference room on 11/19/2025 at 8:25 AM, Staff #10, CNO was asked what the Triage nurse said about caring for Patient #1. Staff #10 stated, “I asked Triage what she was thinking by bringing her (Patient #1) into ED (triage area) versus going to L&D. Triage stated sometimes they are screaming like that, and they are at a 1. Also, if they are at a 10.” During an interview in the conference room on 11/19/2025 ending at 2:00 PM, Staff #18 was in the room. Staff #10, Chief Nursing Officer and Staff #11, Director of Quality discussed the (Staff #1) nurse’s action or lack of action observed during the TikTok video gave the perception of lack of empathy. Staff #10 discussed, “we provide compassionate care, and we train for that.” Staff #10 was asked about the mission statement stating compassionate, quality care. Staff #10 stated, “we fell short of that in the video.” They were asked if they had a policy against patients and visitors videoing. Staff #11 stated, “we do, but it has not been enforceable.” During an interview on 11/19/2025 at 5:34 PM, the Second Registration Staff, Staff #9, was asked if she remembered Patient #1, or if she had a chance to review her medical records before this interview. Staff #9 stated, “Yes, I remember the circumstances.” Staff #9 was asked to describe the situation in her own words. Staff #9 stated, “The triage nurse [Staff #1] came out and told my former colleague [Staff #23] she needed to change the registration to show her [Patient #1] as an ED patient and not an induction patient because she was in labor. The triage nurse [Staff #1] and my former colleague [Staff #23] went back and forth about it. The triage nurse [Staff #1] then went to get the ED Charge nurse [Staff #5]. The triage nurse [Staff #1] told the charge nurse [Staff #5] that she [Patient #1] wasn’t an induction patient and needed to be put in as an ED patient. Because they [Staff #1 and Staff #23] were going back and forth, the charge nurse [Staff #5] asked me to put her [Patient #1] in since my former colleague wouldn’t do it.” Staff #9 was asked what is your hospital’s registration/triage/intake process for a woman in active labor. Staff #9 stated, “Me personally, I just get their ID and get them in for triage. I ask family for the ID if they have family with them. If they don’t, I go up to L&D with them and get their ID at the bedside.” Staff #9 was asked you don’t usually have to have them into the system before their triage. Staff #9 stated, “I don’t know how other staff do it. That is just me.” During a telephone interview on 11/20/2025 at 8:17 AM, Staff #5, ED Charge nurse on duty at the time of Patient #1’s arrival. Staff #5 was asked about the circumstances of Patient #1’s admission. Staff #5 stated, “they brought her into the front instead of back into the ambulance bay.” Staff #5 was asked what the hospital’s registration/triage intake process for a woman in active labor was. Staff #5 stated, “Typically, they [actively laboring patients] come in and get registered and taken into triage immediately. The bracelet prints. Then we can call L&D, and they can take that patient. If they don’t take them, we put them into a bed. Our goal is to get them to L&D ASAP. Staff #5 was asked so if Patient #1 had been brought back in through the ambulance bay, would she have been seen sooner. Staff #5 stated, “Yes, she would have been handled as if she were a code coming in. At that point they were trying to follow the typical method for registration. The more active labor wasn’t seen until she was in the lobby. I didn’t witness it myself.” During record review and interview on 11/20/2025 at 8:51 AM, Staff #1, ED Triage nurse on duty at the time of Patient #1’s arrival, was asked how she found out Patient #1 was in the ED. Staff #1 stated, “They [clarified to be Registration Staff, Staff #23] brought the bracelet and told me I needed to take her [Patient #1] to L&D.” Staff #1 was asked what she could tell about Patient #1’s presentation when she first saw her. Staff #1 stated, “When I first laid eyes [on her], I could see her in the window sitting in a wheelchair filling out paperwork, calmly sitting there. She [Patient #1] didn’t show signs of being in active labor at that first glance. Then her mom [Grandma] walked up and started yelling at her, telling her she shouldn’t be filling out paperwork, she should be going to L&D. When I was able to bring her [Patient #1] into the triage room, I saw her standing in front of the wheelchair having a contraction. That was when I knew [clarified with Staff #1 to mean that she knew Patient #1 was in active labor].” Staff #1 was asked what clinical practice guidelines she referred to for guidance on treating pregnant women. Staff #1 stated, “I just know what I have been taught, and what policy says to do, which is to register them and get them to L&D as quickly as possible if they are in labor.” Staff #1 was asked if she had followed hospital policy. Staff #1 stated, “Yes ma’am.” Staff #1 was asked if a delivery appeared to be imminent rather than a precipitous delivery, if the hospital had a protocol or designated code that is called overhead (such as for a gunshot victim or someone in cardiac arrest). Staff #1 stated, “No ma’am.” Staff #1 was asked if the hospital and its policy considered an imminent/precipitous delivery and emergent situation. Staff #1 stated, “I, yes, but there is no way I can tell if she about to deliver without a physical exam and that is out of my scope of practice.” . Staff #1 was asked she personally would be able to determine if a patient was about to deliver. Staff #1 stated, “Honestly, I wouldn’t be able to tell on a laboring patient.” Staff #1 was asked if there was anything else she would like to say regarding this case. Staff #1 stated, “Honestly, I just wanted to call and get her out of my triage and up to L&D as fast as I could. I was being yelled at with some not so nice things. When I realized what she was saying, I didn’t realize she was recording, I was trying not to interact, I was just trying to do my job.” The hospital’s March 2025 “Patient Rights & Responsibilities” policy required, “The hospital mission calls us to render personalized and compassionate care to patients in ways that respect the dignity of each person...The patient has the right to receive care in a safe setting...All patients have the right to be free of physical and mental abuse...Quality of care You have the right to: - respectful treatment, which recognizes and maintains your dignity and personal values without discrimination due to race, religion, age, sex or other personal values...” The hospital’s March 2025 “Assessment & Re-assessment-Patient” policy required, “the goal is to identify patient specific problems...adjust the plan of care accordingly to the needs of the patient...Patient’s perception of the effectiveness of...symptoms of nausea or pain...reassessment occurs at...significant changes in condition...All patients receiving emergency care will be assessed by a licensed physician, physician assistant or nurse practitioner...Emergency (Department) assessment Guidelines: Initial on arrival, based on severity...scope of assessment...where complaint driven ED nursing documentation...re-assessment based on severity...” The hospital’s March 2025 “Leadership Plan for the Provision of Care” policy required, “the Provision of Care is appropriate to the scope and level of care required by the patients served...Mission is to deliver compassionate care to patients and better healthcare to communities...deliver patient-centered healthcare with compassion, dignity and respect for every patient and their family...committed to always providing exceptional care and performance...we believe that patients have a fundamental right to considerate care that safeguards their personal dignity and respects their cultural. Psychosocial and spiritual values...each patient’s care is determined and individualized through detailed interdisciplinary assessment and reassessment...House Supervisors or designee is accountable for providing staff guidance on a continuous basis in the planning, coordination, monitoring and organizing the provision of patient care. Staff is accountable to conduct its practice within the limits of license, certification or training, utilizing a self-managed team concept in providing patient services...Evolution of patient’s plan of care is determined by intervention effectiveness, responses, and revised as needed...Patient services are planned, coordinated, provided, delegated and supervised by profession-al healthcare providers who recognize the unique physical, emotional and spiritual needs of each patient. Patient care encompasses the recognition of disease and health, patient teaching, patient advocacy, spirituality and research...A RN performs triage assessment upon arrival of every patient who presents to the Emergency Department to determine the treatment urgency. A qualified medical provider will evaluate the patient and orders diagnostic testing and treatment required based on patient needs. Patients are reassessed for response to treatment and are admitted to the hospital, transferred to an appropriate facility or discharged with follow-up instructions as appropriate...The goal of the Emergency Department is to provide quality urgent, emergent and crisis care to the members of the community who present to the department...””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45847 . Based on record review, video surveillance review and interview, the hospital failed to ensure that emergency services were organized and coordinated with registration and emergency documentation to support timely emergency evaluation, continuity of care, and oversight of emergency department operations for 1 of 31 patients records reviewed (Patient #1). Registration process and emergency department logs were not integrated with timely emergency care, resulting in emergency services being dependent on registration completion and system documentation rather than ensuring immediate emergency evaluation. . Findings included: Patient #1: Security camera video confirmed Patient #1 physically presented to the emergency department on 11/11/2025 at 12:05 AM. Upon presentation, Patient #1 remained in the emergency department without initiation of triage or a medical screening examination while registration processes were completed. . Registration records showed Patient #1 was first registered at 12:10 AM under an incorrect encounter type as a scheduled “pre-admission for induction” rather than an emergency department visit. A second registration was entered at 12:21 AM to create an emergency department encounter. Emergency department clinical processes did not begin during this registration period. . Triage for Patient #1 was not initiated until 12:25 AM, approximately 20 minutes after physical presentation, and the medical screening examination was not initiated until 12:33 AM. Patient #1 delivered at 12:35 AM, shortly after initiation of the medical screening examination. Emergency department documentation, including the emergency department log and transfer log, reflected the 12:21 AM re-registration time as the patient’s arrival time rather than the actual presentation time of 12:05 AM, demonstrating that documentation systems were driven by registration workflows rather than coordinated with emergency department clinical operations. . The sequence of events demonstrated that emergency services were dependent on registration completion and system-generated documentation rather than organized to ensure immediate emergency evaluation upon presentation. . Policy Reviews: The hospital’s “EMTALA- Compliance with the Emergency Medical Treatment and Active Labor Act” policy, last reviewed and implemented on 04/23/2025stated on pages 2-3 of 6: “ ...2. Central Log: Each department of the hospital that provides medical screening examination shall maintain a central log recording the following: a. Patient’s name b. DOB c. Sex d. Chief complaint e. Arrival time f. Triage time g. Registration time h. MSE time i. Medical record/ Account number j. Mode of arrival k. Name of LIP who provided MSE l. If admitted Name of admitting LIP m. Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged ...” . The security camera video confirms that Patient #1 did not arrive at 12:21 AM but arrived at 12:05 AM. Registration documentation for Patient #1 confirms that Patient #1 was initially registered at 12:10 AM, and was re-registered at 12:21 AM, noting a time discrepancy created by the hospital’s registration process. The hospital’s Central Log did not reflect the correct arrival time for Patient #1. The Central Log reflected the time of the second registration time as the arrival time. The hospital failed to maintain a Central Log that was complete and accurate according to its policy. . Interviews: An ED triage RN, Staff #2, was interviewed on 11/18/2025 at 4:45 PM. Staff #2 was asked if she knew if a re-registered patient’s arrival time was changed upon the re-registration. Staff #2 replied, “Yes, it will reflect the time of the second registration, not the original time of registration.” . Staff #18, Patient Access Supervisor, was interviewed during medical record reviews on 11/18/2025 at approximately 5:30 PM. Staff #18 was asked if a re-registration of a patient always changed the documented patient arrival time. Staff #18 indicated that it would always reflect the time the registration was entered and not the actual arrival time of the patient. Staff #18 was asked to confirm that Patient #1 or any patient arrival time would not be accurately reflected under these circumstances. Staff #18 said, “Yes.” . A registration clerk, Staff #9, was interviewed on 11/19/2025 at 5:34 PM. Staff #9 was asked if she knew if a re-registered patient’s arrival time was changed upon the re-registration. Staff #9 replied, “Yes.” Staff #9 was asked if that was always the case. Staff #9 indicated that the computer system entered the new time and that they could not change the time. . The ED charge nurse on duty at the time of Patient #1’s arrival, Staff #5, was interviewed on 11/20/2025 at 8:17 AM. Staff #5 was asked if a re-registration of a patient always changed the documented patient arrival time. Staff #5 indicated that the registration time reflected the time the registration was entered. .”

“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: 45847 . 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 interview, the hospital failed to ensure 13 of 23 patients (Patient #1, Patient #3, Patient #4, Patient #6, Patient #8, Patient #9, Patient #12, Patient #13, Patient #14, and Patient #15, ) presenting for emergency obstetric care received a medical screening exam (MSE) and stabilizing treatment without delay. Registration processes which included insurance collection were required as part of the facilities policies and procedures prior to MSE or treatment resulting in delayed care for patients who presented to the Emergency Department (ED). . Refer to A2408 for additional information. .”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45847 . Based on record review, video surveillance review and interview, the hospital failed to maintain an accurate emergency department central log for 1 of 31 patients to reflect the correct time of patient to the emergency department (ED) (Patient #1). As a result, the hospital failed to ensure that the emergency department central log accurately recorded the time of patient arrival. . Observations: The Facility’s Emergency Department (ED). security camera videos were reviewed, and the timeline of Patient #1’s ED visit is as follows: A review of security video footage confirmed Patient #1’s arrival was to the ED patient drive (canopy; porte-cochere - roofed structure) where that vehicles drive under for patient drop off). Further review of the security footage revealed Patient #1 arrived at the ED at- 12:05 AM (the security camera time) - . Patient #1 was observed sitting beside the registration desk in the ED for 19 minutes. . Record Reviews: Patient #1 Registration Record Review: Record review show Patient #1 was initially registered 12:10 AM, under an incorrect encounter as scheduled “pre-admission for induction” record rather than an ED visit. A second registration was created at 12:21 AM or the ED visit for “labor” check in. As a result of the re-registration process, the arrival time documented in the medical record defaulted to 12:21 AM, rather than reflecting the patient’s actual time of presentation to the ED at 12:05 AM. . ED and Transfer Logs (Central Log) Reviews: Patient #1: Review of the emergency department log for Patient #1 revealed the following required elements were affected by the inaccurate arrival time: The arrival time reflected the time of registration was 12:21 AM, not the actual time of presentation at 12:05 AM, which was confirmed by hospital security footage. Both the ED Log and the ED Transfer Log inaccurately indicated Patient #1’s arrival time as 12:21 AM, rendering all other times documented inaccurate. . Policy Reviews: The hospital’s “EMTALA- Compliance with the Emergency Medical Treatment and Active Labor Act” policy, last reviewed and implemented on 04/23/2025stated on pages 2-3 of 6: “ ...2. Central Log: Each department of the hospital that provides medical screening examination shall maintain a central log recording the following: n. Patient’s name o. DOB p. Sex q. Chief complaint r. Arrival time s. Triage time t. Registration time u. MSE time v. Medical record/ Account number w. Mode of arrival x. Name of LIP who provided MSE y. If admitted Name of admitting LIP z. Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged ...” . The security surveillance video confirms Patient #1 did not arrive at 12:21 AM but arrived at 12:05 AM. Registration documentation for Patient #1 confirms Patient #1 was initially registered at 12:10 AM, and was re-registered at 12:21 AM, noting a time discrepancy created by the registration process. The hospital’s Central Log did not reflect the correct arrival time for Patient #1. The Central Log reflected the time of the second registration time as the arrival time. The hospital failed to maintain a Central Log that was complete and accurate according to its policy. . Interviews: An ED triage RN, Staff #2, was interviewed on 11/18/2025 at 4:45 PM. Staff #2 was asked if she knew if a re-registered patient’s arrival time was changed upon the re-registration. Staff #2 replied, “Yes, it will reflect the time of the second registration, not the original time of registration.” . Staff #18, Patient Access Supervisor, was interviewed during medical record reviews on 11/18/2025 at approximately 5:30 PM. Staff #18 was asked if a re-registration of a patient always changed the documented patient arrival time. Staff #18 indicated that it would always reflect the time the registration was entered and not the actual arrival time of the patient. Staff #18 was asked to confirm if Patient #1 or any other patient arrival times would be documented inaccurately under these circumstances. Staff #18 said, “Yes.” . A registration clerk, Staff #9, was interviewed on 11/19/2025 at 5:34 PM. Staff #9 was asked if she knew if a patient’s arrival time was changed upon re-registration. Staff #9 replied, “Yes.” Staff #9 was asked if that was always the case. Staff #9 indicated that the computer system entered the new time and that they could not change the time. . The ED charge nurse on duty at the time of Patient #1’s arrival, Staff #5, was interviewed on 11/20/2025 at 8:17 AM. Staff #5 was asked if a re-registration of a patient always changed the documented patient arrival time. Staff #5 indicated that the registration time reflected the time the registration was entered. .”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 45847 . Based on record review and interview, the hospital failed to ensure 13 of 23 patients (Patient #1, Patient #3, Patient #4, Patient #6, Patient #8, Patient #9, Patient #12, Patient #13, Patient #14, and Patient #15, ) presenting for emergency obstetric care received a medical screening exam (MSE) and stabilizing treatment without delay. Registration processes which included insurance collection were required as part of the facilities policies and procedures prior to MSE or treatment resulting in delayed care for patients who presented to the Emergency Department (ED). . Findings included: A review of the facility policy “Obstetric Patient Presenting At The Front Lobby/Concierge Desk,” last reviewed by the facility on 10/19 revealed, “Purpose: To Provide a safe transfer to an obstetric patient to the Labor and Delivery area. Procedure: 1. Obstetric patients who present to the Emergency Room will be transferred to the labor and delivery are via wheelchair by the ER staff if the patient is above 20 weeks gestations. 2. Patients will be seen and assessed in the Triage area unless patient status dictates that she be admitted directly to an LDR. ER Admission will collect demographic information, register the patient, and create Medical Record and account numbers before bringing the patient to L&D, unless the patient appears to be in distress.” . A review of the facility policy title “Medical Screening Exam,” last reviewed by the facility on 3/9/2023 revealed: “ PURPOSE: To provide treatment options to patients who have undergone a medical screeing [sic] examination and have been determined not to have an Emergency Medical Condition (EMC). POLICY: Patients presenting to Dallas Regional Medical Center under EMTALA will receive a medical screening exam (MSE) by a qualified medical professional (QMP) as defined by DRMC bylaws. All patients within the Emergency Department will be triaged with a chief complaint and ESI Triage level. The Physician/Qualified Medical Person on duty will complete a medical screening examination on all patients. Patients with ESI triage level 4 or 5 who are determined to have a non-emergent medical condition will be met by registration staff to collect any insurance information. Those without insurance will be counseled regarding options for treatment and payment ...” . The hospital’s “ER Registration” policy, last reviewed and implemented on 03/08/2023, stated on page 1 of 3: “ ...PROCEDURE During the Admission process through the Emergency Room Department the Patient signs in through the main entrance of the Emergency Department and is asked to sign in. The Patient is required to fill out minimum information known as Quick Registration. The Registrar will first confirm the reason why the patient is seeking medical attention. If the response is something that is extremely urgent such as (Chest Pain) the Registrar will notify the Nursing staff via Radio/Phone ...” . A review of the registration documentation for each patient revealed: Patient #1 - A review of the medical record for Patient #1, a 29-year-old female who was 39 weeks pregnant, shows Patient #1 physically presented to the hospital emergency department (ED) on 11/11/2025 at 12:05 AM, as verified by security camera footage. The patient’s chief complaint was “labor” (page 7/232). Despite presenting to the ED seeking evaluation for an emergency medical examination. Patient #1 was required to complete registration processes. The record revealed that Patient #1’s registration was completed at 12:26 AM (page 8/232). The registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” (page 118/232) forms were completed by Patient #1 and scanned in at 12:29 AM. During this period, Patient #1 remained without triage or medical screening examination for approximately 20 minutes. The record shows the registration process was completed prior to the triage assessment initiation at 12:25 AM and MSE at 12:33 AM. Patient #1 delivered the child at 12:35 AM, shortly after the initiation of the medical screening exam. . Patient #3 - A review of the medical record for Patient #3, a 20-year-old female, who was 39 weeks pregnant, shows Patient #3 arrived at the hospital ED on 11/01/2025 at 11:27 AM with an arrival complainant of, “water broke, laboring” (page 44/585). The record revealed Patient #3’s registration was completed at 11:29 AM (page 359/585). The registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in on 11/1/2025 at 11:30 AM (page 362-366/585). The record shows the registration process was completed prior to the triage assessment initiation at 11:38 AM (page 44/485). Patient #3 was assigned to an obstetrician and received a medical screening examination by a QMP at 11:42 AM. Patient #3 required a cesarean section on 11/2/2025 at 10:11 am. Patient #3 had complications including, “failure to progress in Fist Stage, Pregnancy-induced hypertension, Premature rupture of membranes, Prolonged rupture of membranes.” The medical screening examination was initiated at 11:42 AM. The record demonstrates that emergency evaluation was delayed while registration processes were completed prior to triage and the medical screening examination. . Patient #4 - A review of the medical record for Patient #4, a 21-year-old female, who was 39 weeks 5 days pregnant (page 345/720) shows Patient #4 arrived at the hospital ED on 11/1/2025 at 11:28 PM with a complainant of “possible in labor” (page 187/720). The record review revealed Patient #4’s registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in on 11/1/2025 at 11:00 PM (page 559/720). The record shows the registration process was completed prior to the triage assessment initiation at 11:42 PM (page 187/720) or a medical screening exam at 11:58 PM (page 416/720), resulting in a delay in emergency evaluation related to completion of registration processes. . Patient #6 - A review of the medical record for Patient #6, a 34-year-old female who was 37 weeks and 6 days pregnant (page 25/654) arrived at the hospital ED on 10/15/2025 at 5:11 AM with a complainant of “38 weeks pregnant; Contractions; Water Broke” (page 23/654). The record revealed Patient #6’s registration was completed at 5:20 AM (page 23/654). The registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned on 10/15/2025 at 5:25 AM (page 416/654). Patient #6 did not receive a medical screening examination until10/15/2025 at 6:09 AM (page 272/654). The patient delivered via C-section on 10/15 at 9:38 PM (page 181/654). The record demonstrates a delay in emergency evaluation while registration process were completed. . Patient #8 - A review of the record for Patient #8, a 30-year-old female who was 39 weeks pregnant arrived at the hospital ED on 10/06/2025 at 11:52 AM with a complaint of “lower abdominal pain” (page 19/269). The record revealed Patient #8’s registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in on 10/06/2025 at 11:50 AM (pages 136-137/269). The record shows the registration process was completed prior to the triage assessment initiation at 11:59 AM (page 17/269). Patient #8 did not receive a medical screening examination until 12:23 PM, demonstrating a delay in emergency evaluation. . Patient #9 - A review of the record for Patient #9, a 16-year-old female who was 39 weeks pregnant, arrived at the hospital ED on 09/29/2025 at 2:22 PM with an arrival complaint of labor 39 weeks (page 120/689). The record revealed that Patient #9’s registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed on 09/29/2025 at 2:23 PM (pages 373/689) and scanned in on 09/29/2025 at 3:47 PM (page 374/689). The record shows the registration process was completed prior to the triage assessment initiation at 2:41 PM (page 120/689). Patient #9 did not receive a medical screening examination until 3:05 PM (page 132/689), demonstrating a delay in emergency evaluation. . Patient #12 - A review of the record for Patient #12 a 21-year-old female who was 15 weeks 0 days pregnant (page 12/74) arrived at the hospital ED on 11/11/2025 at 9:35 PM with a complaint of “nausea/vomiting” (page 21/74). The record revealed Patient #12’s registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in at 9:51 PM (page 53/74). The record shows the registration process was completed prior to the triage assessment initiation at 10:23 PM (page 21/74). Patient #12 did not receive a medical screening examination until 11:46 AM (page 23/74), demonstrating a delay in emergency evaluation. . Patient #13 - A review of the record for Patient #13 a 25-year-old female who was 40 weeks pregnant arrived at the hospital ED on 11/11/2025 at 10:54 PM with a complaint of “40 weeks pregnant; contractions” (page 8/269). The record revealed Patient #13’s registration was completed at 11:07 PM (page 11/269). The registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in on 11/11/2025 at 11:12 PM (page 137/269). The record shows the registration process was completed after the triage at 11:05 PM (page 10/269). Patient #13 received a medical screening examination by a QMP at 11:25 PM (page 71/269), demonstrating a delay in emergency evaluation. . Patient #14 - A review of the record for Patient #14 a 29-year-old female who was 40 weeks pregnant arrived at the hospital ED on 11/11/2025 at 12:34 AM with a complaint of “labor” (page 7/309). The record revealed Patient #14’s registration was completed at 1:13 AM (page 9/309). The registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in on 1:35 AM (page 203/309). The record shows the registration process was completed prior to triage at 12:48 AM (page 9/309). Patient #14 did not receive a medical screening examination until 1:32 AM (page 102/309), demonstrating a delay in emergency evaluation. . Patient #15 - A review of the record for Patient #15 a 26-year-old female who was 40 weeks pregnant arrived at the hospital ED on 11/10/2025 at 6:12 PM with an arrival complaint of EMS/28 weeks/G2P1AB0/thinks she lost her mucous plug/and having pain (page 12/120). The record revealed Patient #15’s registration which included obtaining insurance information and the “Conditions of Admission and Financial Responsibility” forms were completed and scanned in on at 11/10/2025 6:43 PM (page 47/120). The record shows the registration process was completed after the triage at 6:13 PM (page 12/120). Patient #15 did not receive a medical screening examination until11/10/2025 at 7:15 PM (page 15/120), demonstrating a delay in emergency evaluation. . The record review shows a delay in emergency care or medical treatment due to the patients being required to complete insurance or payment information as part of the registration process. The hospital policies indicate all registration is required for each patient prior to receiving a medical screening exam to determine if they had an emergency medical condition. . Interviews: In an interview on 11/18/2025 at 4:45 PM with Staff #2, ED Triage RN, Staff #2 stated that the hospital triage and intake process includes ensuring that all paper registration is completed first, including if a patient is in active labor. . In an interview on 11/19/2025 at 8:25 AM, Staff #10, Chief Nursing Officer stated there was a delay in registering Patient #1 due to Staff #1, ED Nurse, and Staff #5, ED Charge Nurse, determining how the patient needed to be registered which resulted in Patient #1 being registered twice before Labor and Delivery was called to come pick up the patient. Staff #10 further indicated the patient was actively contracting while Staff #1 and Staff #5 were completing registration. . In an interview on 11/19/2025 at 5:34 PM with Staff #9, Registration Staff, Staff #9 stated they recalled Patient #1 coming into the ED. Staff #9 stated that there was a delay in registering Patient #1 due to back and forth with Staff #1, ED Nurse, member regarding how to register Patient #1, either an induction patient or an emergency department patient. . In an interview on 11/20/2025 at 8:51 AM, Staff #1, Triage Nurse, stated she follows the hospital policies for patients which include registering the patient prior to getting them to Labor and Delivery as quickly as possible if they are in labor. Staff #1 further stated there is not a designated code to call for precipitous delivery. Staff #1 stated there is no way to know if a patient is in labor without a physical examination, which is completed after the registration process. . Interviews conducted with Staff #16, Registration Clerk, Staff #15 Director of L&D, Staff #12 ED Nursing Director, Staff #2 ED triage RN, Staff #5, ED charge nurse, supported that the hospital’s registration process includes obtaining insurance information from patients prior to triage and/or medical screening regardless of the patient condition. .”

“A life safety code (LSC) survey was conducted onsite at the facility on 05/08/25 and 05/09/25. An entrance conference was held on 05/08/2025 with the Director of Plant Operations, Director of Quality and Performance Improvement, Maintenance Supervisor, and Chief Nursing Officer to discuss the purpose of the unannounced LSC onsite visit and the survey process was explained. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. An LSC exit conference was conducted on 05/09/25 at the hospital. In attendance were the facility’s the Director of Plant Operations, Director of Quality and Performance Improvement, and Chief Nursing Officer The preliminary findings of the survey and the next steps of the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure an exit sign was visible for 1 of 2 remote exit access paths (to the main egress corridor) on the ground floor, in accordance with NFPA 101, 19.2.10.1 and 7.10.1.8. This failure could delay evacuation in the event of a fire or emergency and affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/08/25 at 11:35 a.m., on the ground floor in the exit access corridor outside the emergency room staff exit, the path to the main egress corridor (north-south orientation and running the length of the hospital) had its exit sign visually obstructed by a bulkhead and additional informational signage. The director of plant operations confirmed the observations when the surveyor discussed the finding.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 31958 Based on observation, interview, and record review, the facility failed to conduct monthly quick check inspections for 2 of 2 fire suppression hood systems (in the dietary kitchen), in accordance with NFPA 17A, 7.2, as referenced by NFPA 96, 10.2.6(4) and NFPA 101, 19.3.2.5.1 and 9.2.3. This failure could affect the reliability of the fire suppression hood system and potentially adversely affect the safety of the building’s occupants in the event of a cooking related fire in the kitchen. Findings included: During observation, interview, and record review on 05/08/25 from 3:30 p.m. to 3:40 p.m., the inspection tag at the manual pull actuator for both range hood fire suppression systems in the kitchen did not contain any dates or initials of a person performing quick check inspections. The facility’s Life Safety and maintenance records did not include any other documentation that quick check inspections (owner performed) for the kitchen’s fire suppression hood system. The director of plant operations confirmed the observations when the surveyor discussed the finding.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure of 3 of 9 smoke barrier walls on the ground floor (separating smoke compartments 1C and 1D, 1C and 1E, 1H and 1I) and 1 of 2 smoke barrier walls on the 2nd floor (separating the Labor Delivery Recovery Post-Partum suite), were constructed to least a ½-hour fire resistance rating and all penetrations sealed, in accordance with NFPA 101, 19.3.7.3, 8.5, 8.5.6. This failure could allow fire/smoke to spread from one smoke compartment to another, and adversely affect the safety of the building’s occupants in the event of a fire or emergency. Findings included: During observations and interviews on 05/09/25 from 09:30 a.m. to 11:00 a.m., the following were noted during inspection of smoke barrier walls: At the ground floor smoke barrier wall separating smoke compartments 1C and 1D, above the ceiling over the pair of corridor smoke barrier doors there was a one-inch hole in the wall. At the ground floor smoke barrier wall separating smoke compartments 1C and 1E, above the ceiling in the wall between the corridor and maintenance department there was a five-inch by five-inch opening in the wall and an opening around a flexible electrical conduit penetration. At the ground floor smoke barrier wall separating smoke compartments 1H and 1I, above the ceiling over the pair of corridor smoke barrier doors there were openings around multiple rigid electrical conduit penetrations and openings around a bundle of low voltage wiring inside a sleeve penetration. At the 2nd floor smoke barrier wall separating the Labor Delivery Recovery Post-Partum suite, on the corridor side past the elevators, above the ceiling there was a 3-inch open ended conduit with wire penetrations. The maintenance supervisor confirmed the observations when the surveyor discussed the finding. He said a preventative maintenance program in place to inspect the hospital’s smoke barrier walls and it has been about a year since they were last checked and are due for inspection again.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure a junction box in 1 of 2 electrical rooms (Elec E107) in smoke compartment 1H was covered and protected, in accordance with NFPA 70, 314.17. This failure could allow damage to electrical wiring, result in an electrical fire, and adversely affect the safety of the building’s occupants. Findings included: During observations and interviews on 05/09/25 from 10:18 a.m., above the ceiling of the electrical room (Elec E107) there was an electrical junction box without a cover plate installed. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 31958 Based on observation and interview, the facility failed to ensure items powered from the essential electrical system were correctly located on the Life Safety branch and Critical branch, in accordance with NFPA 99, 6.4.2.2.3 and 6.4.2.2.4. This failure could affect the reliability of certain items on the essential electrical system in the event of power loss and adversely affect the health and safety of the building occupants. Findings included: During observations and interviews on 05/08/25 from 10:00 a.m. to 10:10 a.m., in electrical room E109, there was an emergency panel designated as LSLA and labeled as life safety indicated it was a life safety branch panel. Panel LSLA contained critical branch items for electrical receptacles on operating rooms 1, 2, and 3, and other receptacles in the surgical suite. These items are not permitted on the life safety branch. Circuit #24 was for additional panels fire alarm panels in room E111 and circuit #3 was for the generator light and receptacle (these two items permitted only on the life safety branch). It could not be determined if this panel was mislabeled and intended as a critical branch panel, or if it was the life safety branch that was currently powering items only allowed on the critical branch. The maintenance supervisor confirmed the observations when the surveyor discussed the finding.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility failed to maintain the food services department in a organized and sanitary environment when, - the dirty dustpan was hanging in a utility closet touching the light switch, staff had to touch the dustpan to turn the light on and off, - the microwave had dried, dark brown, crusty food debris on the inside vents, - the standing refrigerators outside temperature gauge was not working, it read less than -40 degrees Fahrenheit, - (9) Styrofoam containers, filled with Jello, were not dated, or labeled, - the steel shelving rails had rust, making them unable to be cleaned properly, -(5) large white rolling food storage bins had dried, crusty food debris on the handle and lips and (3) had large plastic scoops inside the bins, - An approximately 3 x 8-inch sticky insect trap was sitting on the floor next to the pot washing station, the trap had copious amounts of insects stuck to the mat, the mat had standing water in the mat; the insects were decomposing on the mat, - the dirty dishes and pots were being stored next to clean dishware and pans, in two locations in the kitchen, - the splash guards had dried food debris on (3) mats located around the kitchen and clean pans had food debris on them, - a ½ gallon of Sweet & Sour sauce had been opened on 3/17/25, the jar had ¼ gallon of content missing. The manufacturer label read “REFRIGERATE AFTER OPENING”; the opened container was sitting on the bottom shelf in the food preparation area, not in the refrigerator, - a 1-quart plastic container, unlabeled, filled with an unknown yellow substance, was located on the baker’s rack shelving; the contents smelt like discarded lard, - the facility’s food processor’s on and off buttons had dark, sticky food debris on the switches, - the facility’s food mixer had dried and flaking food debris on the undercarriage of the mixer, from previously mixed food products, - the walk-in refrigerator’s inner freezer door had food debris noted on the door, - thawing, pork, beef, and turkey products had been removed from the original packaging; the items were not dated as to when they were placed in the refrigerator, - the facility’s milk crates were sitting on the walk-in floor, the floor had signs of dried milk residue, and - (9) opened spices did not have a date when opened. This failure places all patients, receiving food from the facility’s kitchen, at risk of contracting a food born illness. Findings include: During the tour of the facility’s dietary department on the morning of 4/28/25, Staff #4, Director of Food and Nutrition Services confirmed the findings and stated, “We have been working on cleaning up the kitchen.” During an interview, on 4/29/25 in the conference room, when asked if rounding the kitchen was part of the infection control program, Staff #6, Infection Control Nurse stated she had started 6 weeks ago and had not gone into the kitchen yet. Review of the facility provided policy, “Food Labeling and Dating” (Revised 12/2019) reflected, All prepared foods and food stored out of the original container, are to be covered, labeled and dated ...9. Spices are labeled with an open date and expire 1 year after opening.” Review of the city of Mesquite food service Inspection dated March 21, 2025 reflected, the facility was out of compliance for Food contact surfaces and returnables; cleaned and Sanitized. Review of the Texas Food Establishment Regulation Code (2024) reflected, “228.101(i)Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. 228.113(3)Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 228.114(c)Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 33326 Based on observation, interview, and record review, the facility’s Environment of Care committee (EOC) failed to develop and maintain an effective Environmental Rounds Program to recognize and effectively investigate and correct potentially hazardous situations when, (1) The dishware washing hood vent had dark brown, dried drainage noted on the outside of the vent; the vent went up into the ceiling. (2) The facility’s food service department’s floor was found to have numerous areas of cracked and missing grout, creating an unsanitary environment. (3) The facility’s cafeteria smelt of sewage, and the doorway between the dry storage area and the kitchen smelt of sewage on this day and two days prior; this had been reported the previous month and been recorded as completed. Findings include: Review of the facility provided policy “Environmental Tours: (revised 4/2022) reflected, “Procedure: The Program shall serve the dual purpose of identifying potentially hazardous situations ...b. specific concerns of Infection Control ...work orders will be created to correct deficiencies found and will serve as a tracking tool ...” (1) An observation on the morning of 4/28/2025, in the facility’s dish room revealed the dishware washing hood vent had an unidentified dark brown, dried drainage noted on the outside of the vent running down to the front of the machine. During an interview on the morning of 4/30/2025, in the facility’s dish room, Staff #45, Regional Director of Plant Operations confirmed the dark residue and stated in part it could be condensation. (2) An observation of the facility’s food service department on the morning of 4/28/2025 revealed numerous areas of missing grout to the kitchen’s heavy traffic areas, there was black debris and dirt noted in the missing space. The interior wall to the walk-in refrigerator had a 3 x 2-inch piece of tile missing, the interior wall insulation was exposed and there was a yellow substance noted in the opening. The facility’s wall boards were detached at points and the tile and baseboard were missing, where the tile leads to the outside of the kitchen back door; there was dirt and debris in the missing spaces. (3) An observation of the facility’s food service department on 4/28/25 at 12:30 pm reflected as strong odor of sewage in the facility’s cafeteria. An observation on 4/30/25 at 11:00 am, of the facility’s cafeteria revealed a strong odor of sewage in the facility cafeteria. The connecting door led to a dry storage area containing paper products; there was no odor detected in the room. Through the next doorway, which led into small room, the sewage odor was emanating from a wall; there was no open drain in the room or obvious source of the smell. Review of the facility’s work order dated 3/17/25 reflected, location: Cafeteria, Short description: Odor, there is an odor coming from the wall in the storage room in the cafeteria. Resolution Detail: Check for smell. Result: Complete During an interview on the afternoon of 4/30/25, while trying to locate the source of the odor, Staff #45, Regional Director of Plant Operations, confirmed the odors. Staff #46, Plant Operations Supervisor stated, “I will get someone right on it.” During an interview, on the afternoon of 4/30/25, Staff #46, Plant operations supervisor stated in part, when the staff put in a work order, he will assign a person to make the repairs. The plant operations person making the repair can close out the repair order, they can also put in additional repair orders if needed. When asked if the Plant operations conducts rounding to ensure the upkeep of the facility, Staff #46 said yes, but did not provide evidence of the rounding. Staff #46 stated, “We try to be proactive.” Review of the Texas Food Establishment Regulation Code (2024) reflected, 228.173(a)Cleanability. Floor, wall ceiling constructed installed are smooth and easily cleanable 228.173(f)(1) Wall and ceiling covering materials shall be attached so that they are easily cleanable, 228.186(a)Repairing. The physical facilities shall be maintained in good repair,228.149(e)(2)A plumbing system shall be maintained in good repair.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 51738 Based on observations, review of facility documents, and staff interviews, the facility failed to prevent and control infection transmission as noted in policies and procedures. Findings were: During a surgery observed on the afternoon of 4/29/25 of patient #15: - staff #36, CRNA, did not wipe the tops of medication vials with 70% alcohol prior to drawing up the medication. Staff #36 then administered medications to the patient without cleaning the septum of the intravenous lines. - staff #35, circulating registered nurse (RN), entered and exited the surgical suite multiple times without performing hand hygiene. During tours of the radiology and laboratory departments on the morning of 4/28/25, the Operating Room and endoscopy suite on the afternoon of 4/29/25, and the labor and delivery unit on the morning of 4/30/25, dust was observed on both high and mid-level horizontal surfaces. These findings were verified by staff during each tour. During a tour of the labor and delivery surgical area on the morning of 4/30/25 with Staff #48, Director L&D, two handwashing sinks were operating for several minutes without the water becoming warm. Staff #48 felt the water and verified the water was not warming. Facility policy titled “Hand Hygiene (CDC [U.S. Center for Disease Control and Prevention] based)” last reviewed 03/2025 stated in part, “Purpose: Hand hygiene is the most important procedure for preventing infections and a top priority ... Procedure: 1. Alcohol Based Hand Rub 1.1 Decontaminate hands using alcohol based hand rub in the following circumstances: ...g. After contact with inanimate objects (including medical equipment) in the patient room. h. After removing gloves. 2. Hand Washing 2.1 Was hand with soap and water in under [sic] the following circumstances d. As an alternative to alcohol based hand rub in any of the situations describes [sic] in 1, above.” Facility policy titled “Cleaning of Operating Rooms” last revised 04/2025 stated in part, “1. Damp dust all flat surfaces and overhead lights every morning prior to the first surgical procedure ... 3. All flat surfaces shall be cleaned first with an approved detergent germicide dampened disposable wipe.” Facility policy titled “Patient Room Cleaning” last reviewed 10/2020 stated in part, “4. Clean and disinfect room ... countertops, light switches, furniture, arm/seat of patient chairs, window sills [sic], beside [sic] commode, medical equipment, other miscellaneous surfaces.” Facility policy titled “Lobby and Waiting Area” last reviewed 10/2020 stated in part, “1. Daily: 1.1 High dust - use high duster. TV, ceiling vents, horizontal surfaces, window and door frames. 1.2 Damp Wipe - use disinfectant wipe. Table tops, counters, window sills [sic], spot wash walls, check under loose cushions, arrange magazines neatly, public phones ...” In an interview on the afternoon of 4/29/25, staff #47, Director of Surgical Services, confirmed OR staff should be performing hand hygiene when entering and exiting the surgical suite and should be cleaning the tops of medication vials and IV ports prior to administering medications. CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings found at https://www.cdc.gov/infection-control/hcp/core-practices/index.html Standard Precautions stated, in part, “ ...Use aseptic technique when preparing and administering medications.” Open Resources for Nursing (Open RN); Chapter 4 Aseptic Technique. Available from: https://www.ncbi.nlm.nih.gov/books/NBK596727/ stated in part, “In addition to using standard precautions and transmission-based precautions, aseptic technique (also called medical asepsis) is the purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure ... When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during routine care or procedures. The word “aseptic” literally means an absence of disease-causing microbes and pathogens. In the clinical setting, aseptic technique refers to the purposeful prevention of microbe contamination from one person or object to another. These potentially infectious, microscopic organisms can be present in the environment, on an instrument, in liquids, on skin surfaces, or within a wound.””

“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: 45521 Based on observation, medical record review, and interviews, the facility failed to comply with 42 CFR §489.24, Special responsibilities of Medicare Hospitals in emergency cases, when they did not complete a medical screening examination (MSE) for one of 20 (Patient #1) whose records were reviewed. Patient #1 was discharged from Facility A and called 911 while still on the facility property to report active suicidal ideation. [Police Department # 5] arrived at Facility A, where the patient was placed on an Apprehension by Police Officer Without Warrant (APPOW) for suicidal ideation. Patient # 1 was transferred from Facility A to Facility B. Patient #1 left Facility A via ambulance to seek treatment at Facility B, where he was admitted. At facility B, Patient # 1 was admitted inpatient for 1.5 days and place on suicidal precautions. 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: 45521 Based on observation, medical record review and interviews, the facility failed to complete a medical screening examination (MSE) for one of 20 (Patient #1) whose records were reviewed. Facility A did not complete a psychiatric assessment to determine if Patient #1 had an emergency medical condition and was not a danger to himself or others. Patient #1 was discharged from Facility A with “thought content that is paranoid and delusional.” Patient #1 called 911 after discharge while still on the facility property to report active suicidal ideation. [Police Department # 5] arrived at Facility A, where the patient was placed on an Apprehension by Police Officer Without Warrant (APPOW) for suicidal ideation. Patient # 1 was transferred from Facility A to Facility B. At facility B, Patient # 1 was admitted inpatient for 1.5 days and place on suicidal precautions. Findings included: Review Patient #1, Facility A - Visit 1 A review of the document titled “ED Provider Notes” completed by Staff # 4, the Physician Assistant in the Emergency Department on 03/30/2024 at approximately 9:02 AM revealed the following: “patient is a 41-year-old male with past medical history significant for bipolar, schizophrenia, polysubstance abuse presents to the emergency department via EMS for paranoia and chest pain. EMS reported that the patient was sitting at a gas station down the street when locals became concerned about the patient and called 911. EMS arrived and the patient complaining at that time of chest pain. He-had told the EMS personnel that he had been homeless for approximately 2 days with no other background information given at that time. The patient is with EMS and here in the emergency department is saying he has a “bug “ inside of him and that people are listening to him. During the-interview and exam the patient is visibly upset and anxious appearing. The patient is a poor historian due to his emotional state at this time.” ... ...Past Medical diagnoses: Bipolar 1 disorder, Psychiatric disorder and Schizophrenia. During the Physical Exam it is documented the patient is, “Disheveled appearing, smells unkempt.” ... “Speaking full sentences, no shortness of breath noted.” ... ...Neurological: “General: No focal deficit present. Mental Status: He is alert GCS: [Glasgow Coma Score measures consciousness] GCS eye subscore is 4. GCS verbal[ response to questions] subscore is 5. GCS motor subscore is 6[How the brain tells the body to move.]. Motor: Tremor (right hand shaking often) present. No weakness. Psychiatric: Attention and Perception: He is inattentive. He perceives auditory hallucinations. Mood and Affect: Mood is anxious. Affect is labile and tearful. Speech: Speech is rapid and pressured and tangential. Behavior: Behavior is hyperactive. Thought Content: Thought content is paranoid and delusional. Thought content does not include homicidal or suicidal ideation. Cognition and Memory: Cognition is impaired. Judgment: Judgment is impulsive and inappropriate.” Remaining physical exam was unremarkable.” A review of the medical record revealed Patient #1 was an ambulatory discharged at approximately 11:30 AM with a diagnosis of methamphetamine abuse and paranoia. There was no documentation in the medical record to determine if the patient had an emergency medical condition for his psychiatric symptoms. There is no psychiatric evaluation, Columbia Scale or assessment of orientation noted prior to dischage. Patient #1 called 911 while still on the facility premises and report suicidal ideation. Police Department #5 arrived to the Facility A Police Department # 5- Body Cam Timelines A review of the transcript of the body cam of Officer # 1, and Officer # 2, revealed the following: Video from Officer 1: (video time is represented in minutes) 00:00 - Video of ambulance bay, patient seen sitting on the ground, no staff around the patient, one officer (Officer 2) standing near him conversing, another officer (Officer 1) walking up with bodycam. Patient was heard talking but the words were undecipherable. 00:15 - Officer 2 asks, “What’s your name pal?” Patient 1 stated his name. 00:19 - Officer 2 repeated Patient 1’s name and asked him, “What were you seen for here originally?” Patient stated, “uh ...uh ...they picked me in front of ...uh ...uh” 00:22 - Officer 2, “They who?” Patient stated, “uh ...the paramedics, they picked me up in Garland, I can’t remember the name of ...” 00:26 - Officer 2, “Ok, but you came from Garland by ambulance?” Patient 1 stated, “yeah and uh ...” 00:28 - Officer 2 asks, “What for?” Patient stated, “I..I been up for a couple of days and ... uh ... I told them that ... and I was sweating real bad and uh, I was going through anxiety again and things in my head ...it’s doing it again, and like I said they don’t have no psych here so needed, like ...” 00:47 - Officer 2 stated, “They actually ...they do have psych here.” Patient 1 said, “He, they told me ...they brought me here but there like was no one I could talk to cause I was trying to explain that I need to get to a doctor so I can talk to him ... about the voices in my head, even when I been sober or not sober they are still there ....and I ...I need some help ... I need some help.” 1:12 - Officer 2, “Ok.” Patient speaking incoherently ... 1:13 - Officer 2, “You said ...What’s that?” 1:16 - A nurse, Nurse 1, comes out and asks Officer 1, “Is he coming back in?” 1:17 - Officer 2, “I assume so based on what he just told us.” 1:19 - Patient 1 said, “I was trying to get to [facility # 1] or..or ...or, uh [facility # 2] to talk to a psychiatrist, cuz I was told y’all didn’t have psych here.” 1:27 - Nurse stated, “We are not a psych facility, we are happy to see you but he just asked you if had any suicidal thoughts ... you said no.” 1:33 - Patient 1 said, “And, and I told him yeah and all I got was ...uh ...uh..and he sat in the chair and looked at me like I was stupid ...and ...and ...I ...and then ...I got discharge papers 15 minutes later. And I have no way to get to [facility # 1]or anything here cuz there’s no bus route.” - (Nurse was speaking to Officer 1 while Patient 1 is talking but it was undecipherable.) 1:47 - Nurse 1, “Ok.” 1:50 - Patient, “And I don’t know what, and I’m trying to go see a doctor, and ...” (Nurse 1 and Officer 1 talking in background.) 1:53 - Officer 2 said, “Sure. So, what the proper procedure is, since you are here, is to ...to be seen here and then they’ll transfer you to an actual psych facility after ...after they their assessment on you ...ok? They have help here. It is true they don’t have a full-blown psych unit here, that is true ...(Patient mumbling) I know, but that..that’s the reason you are in a hospital and they will facilitate getting you there, ok and ...you are here for emergency services and so that’s what they’ll provide you while trying to get you in a stable environment.” (Patient mumbling ...I don’t, I don’t ...etc. while Officer 1 is speaking.) 2:19 - Patient, “I don’t ...I don’t ...I don’t feel safe outside ...” 2:23 - Officer 2 said, “I understand.” Patient, “I don’t ...I don’t ...” 2:25 - Officer 2 asks, “What’s making you want to hurt other people?” Patient says, “I don’t wanna ...its myself ...it’s hurting me ...I don’t wanna hurt anybody ...” 2:32 - Officer 2 asks, “Yeah, I mean what’s making you ...is there, are you hearing voices that are telling you to hurt other people?” 2:36 - Patient says, “No, I don’t wanna hurt anybody, it’s to hurt myself ... it’s my ...I shoulda done it a long time ago ...I shoulda killed myself a long time ago ...” 2:44 - Officer 2 asks, “Why do you feel that way?” 2:46 - Patient says, “Because my life been shit ...(patient starts crying) 2:50 - Officer 2 asks, “When ...you ...you said you came in last night from Garland?” 2:55 - Patient says, “(stuttering and mumbling ...I called, I lived here, I tried to get a ride from somebody I know ...they can’t come get me I know ...I tried to call non-emergency and they was closed or whatever, and then I they ...I just called 911 and my mother, she was just like (undecipherable) ...well y’all go there..” 3:16 - Officer 2 says, “I understand.” 3:20 - Patient says, “I don’t have no way in ....” 3:20 - Officer 2 says, “Ok. (Nurse talking) We ...we’ll fill out an APPOW.” Nurse 1 said, “”That’s fine” 3:24 - Officer 2 says, “Alright (patient name), well here is what we are going to do, ok. We’re going to go back inside and were going to start getting them to help you, ok? And we will facilitate getting you some help, but the right process here is to start back in there and then we will get you to the right place.” 3:35 - Patient says, “I don’t want to stay ...I need to get to ...to a doctor ...” Video Surveillance from Officer 2 body cam: (video time is represented in minutes) 0:00 - Patient is seen standing in ambulance bay of the facility talking to the approaching Officer 2. He was talking about the facility not having a psych facility and trying to get help. Patient is scratching his head, patting his head, sounds nervous and trembling is noted in his voice. 0:14 - Patient said, “I ...I ...I need to get to see a doctor. I need to go to, and they don’t have a psych unit here, I need to get to [Facility # 1]or ...or [ facility # 2]or something I imagine ....(makes noise with his mouth)” 0:27 - Officer 2 say, “Ok. Um, do you mind setting your jacket down just so I can see ...make sure that you don’t have anything on you?” (Patient drops his jacket, places his hands over his head, and backs up toward Officer 2) 0:37 - Officer 2 places Patient’s hands on his head and ask”, “Are the shakes new, or is that something that ...? 0:37 - Patient say, “No, I (undecipherable words spoke”).” 0:41 - Officer 2 can be seen patting Patient down, then ask, “you’ve just got a phone, and just a normal wallet and what you got in here?” 0:54 - (undecipherable talk) 0:59 - Officer 2 said, “OK, you’re good. Um ...If you don’t mind just having a seat for just a minute ...Um ...What’s your name?” 1:07 - Patient gives his name and begins sitting down on the curb in the ambulance bay. Officer is seen with a note pad and begins writing notes and Patient mumbles while he sits. 1:17 - Officer 2 said, “Spell it for me.” Patient spells his name. There is clarifying talk back and forth between Officer 2 and Patient. 1:40 - Officer 2 asks Patient his DOB and writes it on the notepad. Patient is notably fidgety and anxious during the conversation. 1:54 - Patient says, “I just need... um, um to get a doctor so I can talk to him ..” 1:57 - Officer 2 says, “ok.” 2:08 - Patient says, “If there was a bus line I would be on it ...and I tried to call for a ride and I don’t have one ...I don’t (undecipherable) and I can’t get a ride ..” 2:15 - Officer 2 says, “Did you say that [Police Depart # 3]PD brought you here?” Patient says, “um the paramedics” Officer 2 says, “Ok.” Patient says, “um I don’t know they just ...I was in [facility # 1] over there by the freeway somewhere, I don’t know where the exact ...” 2:28 - Officer 2 says, “Where do you live?” Patient says, “Right now I’m a, I’m homeless, I’m not ...I have nowhere to go, I was looking to get back into rehab and I fucked that up and now I just, I’m just having a mental breakdown because ...there’s shit going on in my head and it’s just (undecipherable ...)” 2:48 - Officer 2 says, “When you say you’re having a mental breakdown, what do you mean?” 2:50 - Patient says, “It’s the voices in my head and I want to hurt myself and all that and like I said, they don’t have a psych unit here and all they could do is release me cuz all they don’t have ...like psych departments, and ...and, like I told that lady, I just don’t feel safe out here, I don’t, not at all.” 3:06 - Officer 2 says, “What are the voices saying?” 3:09 - Patient says, “They, ah, to hurt me, and I hurt myself and stuff..and I ...I ...I need to see a doctor ...I can’t be out here, I don’t I don’t feel safe. (undecipherable) I get anxious and my and when I start shaking like this and the anxiety, and I ...” 3:40 - 8:04 - Officer 2 is joined by Officer 1 and the conversations are the same as in video 1 throughout 8:04, when the officers go separate directions. Officer 2 follows Patient into the room with Patient and Officer 1 completes paperwork at the nurse’s station. 8:10 - Officer 2 says, “Hold on just one second, let him get to the bed dressed.” The video shows a technician making up a bed for Patient. 8:29 - Technician says to Patient, “Ok, right there for me, sir.” Technician points to the bed he just made. Technician says to Patient, “I am going to need all your things.” Patient hands Technician his hand-held belongings. Technician says to Patient, “Can you empty out your pockets now for me?” Patient places items from his pockets on a bedside table. 8:46 - Patient says, “I am just wobbly.” Patient is seen leaning onto bedside table. Technician says, “I understand, I understand.” 9:00 - Technician requests a belongings bag from another technician. 9:03 - Patient says, “I just wanna get some help.” Technician says, “Ok. Get right there on the bed for me.” 9:10 - A male nurse walks in and says, “so you are wanting to kill yourself again, huh? Is that right?” 9:15 - Patient says, “Is it again?” Male Nurse, “Yeah.” 9:17 - Patient says, “Well I tried to tell y’all that earlier and all y’all told me is that y’all didn’t have a psych unit and just gave me discharge papers.” 9:21 - Male Nurse, “Yeah, we don’t have it.” 9:23 - Patient says, “OK, then I was told y’all was trying to get a department of whatever and I don’t know who it was but he was saying that there was no way that y’all could do that. Yeah, we don’t do that, that’s what he told me. We don’t do that, that’s what he said.” Nurse 1 walks in with an armband. 9:33 - Male Nurse, “Yeah, we don’t transfer, yeah.” 9:34 - Nurse 1, “Can you tell me if this is your right name and date of birth?” Patient reads the band and nods, then Nurse 1 says, “Let me see your arm so I can put on your bracelet.” Patient holds out his arm and Nurse 1 places the armband on Patient. 9:40 - Patient says, “You know I just want to get to [facility # 1] ...” 9:43 - Male Nurse, “Why not stop doing drugs, that’ll help.” 9:47 - Patient says, “I explained that I was honest with everybody when I said that.” 9:50 - Male Nurse, “Ok.” 9:53 - Patient says, “I need (incoherent) when I am sober, too, and that’s what to do.” 9:56 - Male Nurse, “How do you want to kill yourself?” (There is a lot of traffic in and out of Patient room during this time with background conversations.) 9:57 - Patient says, “There’s been plenty of times when I thought about cutting my own throat. I haven’t done it, and when I was clean, I’ve been clean for one or two years ...” I’ve thought about jumping off a bridge when I was drunk.” (There is a lot of traffic in and out of Patient room during this time with background conversations making transcription difficult.) 10:12 - Male Nurse, “Ok. What are you thinking about this time? Do you have a method (alarms beeping in background)” 10:13 - Patient says, “There’s plenty of times I’d run out in traffic and same thing, jump off a bridge there’s plenty of times ...I just want to go see a doctor and ...” 10:27 - Male Nurse, “Do you want to die?” 10:29 - Patient says, “Did I want to die, yeah, yeah, I wanted to die (There is a lot of traffic in and out of Patient room during this time with background conversations making transcription difficult.)” 10:38 - Male Nurse, “So what made you get help instead of acting on it?” 10:44 - Male Nurse, “Have you gotten help in the past for this?” 10:47 - Patient says, “Um ...I got on my meds, my ... I got off all my meds and I started drinking ... on the meds ...off the meds ...drink again ...I got sober, and I worked ...couldn’t get off work to get back on my meds because my hiring supervisor was working me 12 hour days, so it was impossible ....” Patient continues speaking, but Officer 2 walks out of the room at 11:03 and conversation gets more difficult to understand. Officer 1 & Officer 2 meet up at 13:25 on this video and they exit. Patient #1, Facility A-Visit 2 The facility continued documentation on the initial medical record for Patient #1 despite being discharged. A review of the “ED Provider Notes” for Patient #1 completed on 3/30/24 at 1:07 pm by Staff #3 and emergency room medical doctor (MD) revealed, “ ... [History of Present Illness]HPI 41 M returning to ER, now voicing suicidal ideation. Patient struggles with methamphetamine use disorder. Also has history of BPD [Bipolar Disorder]. He was seen earlier in the day for chest pain, shortness of breath, paranoia. Seemed to acutely be under the influence of methamphetamines. His work-up was normal/reassuring. He was discharged but never left the hospital grounds. He is requesting inpatient psychiatric treatment. He is hearing voices. Past Medical History Diagnosis Bipolar 1 disorder (CMS/HCC) Psychiatric disorder Schizophrenia (CMS/HCC)” A review of the “ED Course” for Patient #1 completed on 3/30/2024 at 2:21 pm by Staff # 2 & Staff #11, emergency room medical doctors (MD). “Pt care signed out to me from previous ED Physician pending [Behavioral Health Evaluation] BHE for [suicidal ideation] SI, likely voluntary placement.” -Staff #11 “1547 Discussed with BHC [Behavioral Health Connections], pt has Apprehension by Peace Officer Without Warrant (APOWW) at this time, wants inpatient treatment, they will Pursue [Order of Protective Custody] OPC at this time’” - Staff #11 “2322 Taking over patient care from preceding ER provider. Patient was evaluated early this morning for chest pain and paranoia’ He was found to be methamphetamine positive was discharged. He never left the facility and called 911 stating that he was now suicidal. He was placed under an APOWW and brought back to the emergency department. He was medically cleared by Staff #12 and was evaluated by BHE [Behavioral Health Examiner . After his behavioral health evaluation, he is amenable to going to an inpatient psychiatric facility’ Staff # 2 signed OPC paperwork. I have added on Tylenol and salicylate levels as they are the only lab work not collected prior to his behavioral health evaluation. He remained stable we will continue to monitor throughout my shift’”.- Staff #11 “Sun Mar 31,2024 Discussed pt case with Transfer Center for Texas Health, they have bed ready for pt at [facility # 4]tomorrow’ doc to doc with Facility B, Staff # 1 done - pending OPC and transfer tomorrow.” - Staff #2 A review of the document tiled “Psychiatric Assessment” by Staff # 10, Licensed Master’s Social Worker on 03/30/2024 at 3:55 PM revealed the following: Patient # 1 reports suicidal thoughts and identifies his mother as a support person. Patient # 1 is homeless. Patient is alert an oriented to person, place, date and time, and circumstances. A level 1 care was recommended: “Inpatient level of care due to behavior that is imminently threating, destructive or disturbing to self or others.” Three places were recommended for transfer: [facilities #8, 9 and 10] Patient # 1 refused to sign the document. A review of the document titled “Medical Decision Making” completed on 3/31/2024 at 2:11 am by Staff #3 revealed, “41 M evaluated for symptoms of psychosis. Does have suicidal thoughts. Wants to get inpatient psychiatric treatment, voluntary. Medically cleared. I suspect psychotic symptoms may be attributed to methamphetamine use. Requested behavioral health evaluation. Anticipate attempting placement into inpatient psychiatric facility on a voluntary basis.” A review of the ED Notes by Staff # 13, RN-ED on 4/1/2024 at 12:41 PM revealed the following: “Patient inquiring about leaving. States he doesn’t want to go anywhere any longer. Informed patient he was here under order of protective custody and would have to stay for now.” A review of the document titled “ED Notes” by Staff # 9, RN-ED on 4/1/2024 at 8:00 PM revealed the following “Transport here to take patient to facility. Pt refusing transport to facility. Charge Nurse notified. House Sup at bedside to speak with patient about his options. Transport has left d/t [due to] patient refusal. Pt now agrees to transport. Charge RN called transport to come back. Transport will return after completing next call.” A review of the document titled “ED Notes” by Staff # 9, RN-ED on 4/2/2024 at 12:25 AM revealed the following: Patient #1 was transported via ambulance to Facility 4 for inpatient psychiatric treatment. Review Patient #1-Facility B Patient # 1 was a direct admit from [facility A]. Patient # 1 arrived on 04/02/2024 at 12:57 AM. Patient # 1 was placed on Suicide Precaution-Continuous with observation every 15-minute observation on 04/02/2024 at 0105. Patient # 1 was discharged from Facility B on 04/03/2024 at 7:46 AM. Condition was noted as stable. A review of the document titled “Psychiatric Initial Assessment and Evaluation” by Staff # 1, Facility B, MD on 04/02/2024 at 7:52 AM reveals the following: “I. Chief Complaint: “they said I was suicidal but I am not “ II. History of Present Illness: Patient is a 41-year-old Caucasian male has a history of depression and alcohol use. Patient states that “they said I was suicidal but I am not “. Patient states that “I was drunk”. Patient states that he does drink heavy amounts of alcohol daily. States he can easily drink a 12 pack of beer. Reported his last drink was more than 4 days ago. States that “I am done detoxing now “. Patient states that “I am looking to get into a rehab center and they said I have to wait 2 weeks. “ Patient this morning denies feelings of depression. Denies SI or HI.” A review of the document titled “Discharge Summary” by Staff # 2, LPC [licensed Professional Counselor] on 04/03/2024 at 10:45 AM revealed the following: “Therapist met with patient individually to discuss discharge. Pt agreeable and acknowledged discharge plan. Pt denied SI. and denied HI. Pt declined ROI. Therapist unable to contact collateral for safety concerns. Therapist informed Staff # 1, MD and provider reports pt cleared to discharge. Pt will d/c to [facility # 7]Pt will be transported via Bus. Reviewed and updated safety plan with pt, pt voices understanding and agreement and will follow up with the following providers: Discharge Plan for Patient # 1 Follow-up with your psychiatrist and substance abuse provider Please present for walk-in intake assessment Wednesday April 4, 2024, at 8:00 am” Policy Review A review of the policy titled “Suicidal Ideation Risk Assessment” revealed the facility did not follow their own policy: page 1, Procedure 1.1 and 1.2 “1.1 A suicide risk screen is completed on every patient who presents to the Emergency Department, who presents to Behavioral Health, or is admitted to any inpatient area.” 1.2 The Columbia-Suicide Severity Rating Scales (C-SSRS) will be used for screening and risk assessments; this includes school-age children and adolescents. Patient # 1 did not receive a Columbia-Suicide Severity Rating Scales (C-SSRS) assessment on his initial arrival. Interviews: An interview with Officer # 1 on 05/15/2024 at approximately 7:24 AM revealed the following: “We got a call from the patient telling us he was discharged from the facility and was in the back of the building and is suicidal. Dispatch called the hospital and informed them that officers were on their way for a suicidal individual and the location. I was hoping when we arrived the patient would be inside, but he was outside, near a camera. My partner and I wrote out an APOWW. I felt this would be the only way this individual would be taken care of. As I was filling out the paperwork, I could hear the nurse belittling him.” An interview with Staff # 2, MD-ED on 05/14/2024 at approximately 1:52 PM revealed the following: When asked the process for patient that arrive with suicidal ideation, Staff #6 stated, “The room would be cleared of anything that could allow self-harm. The patient is provided paper scrubs. The patient waits for medical clearance and will be transferred to different facility for placement. Additionally, when asked if he would discharge a delusional patient he stated, “If a patient had delusions and they were safe it might be ok. We would make sure the patient did not have command hallucinations to harm. The patient might have conditions that at baseline they would have delusions or hallucinations.””