The Corpus Christi Medical Center

“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: 33326 Based on observations, interviews, and record reviews the facility failed to provide an emergency psychiatric screening exam when Patient #4, a 48-year-old male patient brought in to the emergency room under an emergency detention warrant (EDW) due to bizarre, violent behavior was allowed to elope from the emergency department, prior to receiving the psychiatric evaluation, placing the patient and others at risk of harm and injury. Findings include: Review of Patient #4’s medical record dated 12/22/25 reflected an admission into the facility’s emergency department, the Physician’s note reflected, “48-year-old man presented with bizarre behavior, violent behavior ...EDW due to threatening behavior, refusing any labs, very hostile with the staff, and eloped twice, patient does not have any injuries, and has been seen here for similar situations and left AGAINST MEDICAL ADVICE last week from ICU after he became violent and extubation. The patient eloped AGAINST MEDICAL ADVICE for the third time now, patient refuse blood work, refused urine work, and was very agitated and threating the staff, police was called back to take the patient to jail due to violent behavior, but the patient left again for the their time before the police arrive.” Further review of the physician’s medical exam reflected the physical exam did not identify Patient#4’s homicidal and delusional thought content. Observations made during the review of the facility provided video recording dated 12/22/2026 revealed the following: 2:30 pm revealed a male patient, 5’10”, 198 lbs. BMI of 25, wearing blue paper scrubs and yellow socks, exiting an unmarked hallway door, a nurse attending to a patient in a hallway bed is seen alerting someone the patient had left. 2:31 pm revealed a young slightly built male security staff member and an older police officer are seen following the patient out the hallway door. 2:32 pm revealed a new camera view shows the patient exiting the emergency’s ambulance entrance doors. The male patient appears to be middle aged, very muscular and larger than the two security personnel. The security guard and police officer walk closely behind him. 2:32 pm, the three stop and a conversation is being held. The patient is seen swinging his arms in the air and appears to be in a conversation with the officer. 2:33 pm, the patient continues to walk down the driveway toward the street; the two security personnel continue to follow the patient, once again stopping and having a conversation. The patient is seen exiting the property, nearly stepping out in front of a passing vehicle, the two security personnel continue to follow him to the street. 2:35 pm, the patient and the off-duty police disappear around a corner, out of the camera view. The nurse in charge, Staff #4, does not appear in the video during this time. During an interview on 01/21 /26 at 11:00 am in a facility conference room via a telephone conference call, Staff #13, Medical Director when asked about the Psychiatric Patient Evaluation and Hold Procedures stated, “Physicians initially perform a medical screening evaluation to address the medical portion of the visit. If an involuntary hold (EDW) is in place, the physician has the authority to release it if they determine no emergent psychiatric condition exists. If it is, then we hold them and admit them over to our psychiatric facility. Standard protocol involves a telepsychiatry evaluation before a patient is released from a hold. If psychiatry deems the patient safe, they will usually be discharged with outpatient follow-up. If an emergent condition is present, the patient is held and admitted to a psychiatric facility. In cases where telepsychiatry is unavailable, patients are typically held for the full 72-hour period.” “Let’s just say I was in the emergency room, and a patient came in and they had a seventy-two hour hold and I felt that they were suicidal, and I felt that they needed stabilization, or let’s say they were homicidal for that matter, and they needed stabilization. Even if we hit the end of the 72 hours, we may need to get involved and get a judge involved to issue an extended order to hold the patient until that psychiatric evaluation was done.” During an interview, on 01/21/26 at 2:00 pm in a facility conference room, Staff #9, ED Director when asked about patient #4’s ED discharge stated, “There is no documentation in the provider’s note that the hold was lifted. The patient eloped against medical advice three times. He refused blood work, and was very agitated, threatening the staff. Police were called to take the patient to jail due to violent behavior, but the patient left before police arrived. The physician ordered a behavior; that’s our behavior health assessment. We have telehealth and are able to have a psychiatrist conduct the evaluation. Generally, when the patient is medically cleared, it usually correlates at about the same time. An evaluation can take a couple of hours before it is conducted, but he was refusing treatment and laboratory tests, so that could have delayed it. He was here for a total of an hour and twenty minutes.” During an interview on 01/21/26 at 3:30 pm, in a facility conference room, Staff #10, facility’s security guard, when asked about detaining Patient #4 stated, “I was in the ED when a code BERT was called, it meant a patient was eloping; an off-duty police officer, and I tried to bring the patient back into the ED. He had already been brought back two times. He was swinging his arms and was agitated. The charge nurse, Staff #8 told us he had been released, so we did not detain him (Patient #4)”. 01/21/26 at 3:30 pm in a facility conference room, Staff #8, ED Charge Nurse, when asked about the release of patient #4 stated, “I keep all the EDW patient records, so no one gets lost. I would have asked the physician if he was able to be released. I can’t recall releasing the patient. Normally, I would write a note if someone has eloped prior to discharge. I was not the primary nurse.” Review of the facility provided policy, Elopement Precautions effective (6/2025) reflected, PURPOSE To ensure a safe and secure environment for patients at risk for elopement and to prevent the elopement of patients who are not able to safely care for themselves. NOTE: This policy does not cover patients who are competent to sign against medical advice (AMA) forms and depart the facility on their own cognizance or for patients who have been forced to leave the facility against their will. For patients at Bayview Behavioral Hospital, refer to facility specific policies. DEFINITIONS Elopement: An intentional unauthorized departure of a patient from a health-care setting (including the ED) Elopement Risk: A patient who does not have the mental capacity or legal authority to leave the hospital against medical advice (AMA), or a patient who may pose a safety risk to his/herself or others. POLICY A. All patients will be assessed for elopement risk and competency to care for his/herself. B. The following patients will be considered an elopement risk: 1. Behavioral Health patients. 2. Patients on an emergency detention warrant.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 26870 Based on record review and interviews the facility failed to ensure restraints were only imposed to ensure the immediate physical safety of the patient. Specifically, the facility failed to use the least restrictive intervention to promote patient safety for one of one (Patient #1) patient who was restained in an adult two person hold for trying to elope from their unit. Findings included: Record review of the patient 1’s (P#1) medical record revealed the P#1 was 12 years old. P#1 was admitted on 10/13/2025 for Suicidal Ideations. For safety, P#1 was on every 15 minute checks. Record review of the facility form, titled, Hospital Facility Incident Report Reported to HHSC 10/27/2025 Date of Incident 10/25/2025 10:05 AM, states, “Pt stated that on 10/25/25 during a restraint that occurred at 10:05 am, she felt pain in her right wrist. Patient was in a physical hold from 10:05 AM to 10:19 am and was in quiet room approximately 15 mins from 10-05 to 10:25 AM. Physician notified & medical consult ordered. X-ray completed and patient was found to have an acute non-displaced buckle fracture of distal radius.” Record review of the facility policy, titled Elopement and Elopement Policy, last reviewed 07/2017, stated in part... Attempted Elopement 1. In the event a patient attempts to elope, the staff shall intervene verbally to encourage the patient to return. If verbal intervention is unsuccessful, physical intervention may not occur unless the patient is at imminent risk for danger to self/others. Record review of the training manual NCI With Advanced Physical Skills Training 3rd edition, participant workbook by Crisis Prevention Institute (CPI) states in part...page 75, Risk of Restraints, “Risk of Restraints....Restraints is not risk free, and as such, staff have a legal duty for the Care, Welfare, Safety, and Security to anyone they retrain. Staff must fully understand the risks (the likelihood of harm occurring and the severity of harm that may result if it does occur) so they can identify concerns and quickly take corrective action ton maximize safety and minimize any harm.” “Figure 1: Factors that increase the likelihood of harm occurring during restraint...to include Children and Young People under the age of 20”. Page 94 revealed there was directions for Children’s Standing:Medium-Level Restriction, which was confirmed not to have been used. Further record review revealed that staff used the Standing :Medium-Level Restriction two person hold which is used for adults. This hold was further confirmed by staff that this was the restraint hold used. Interview on 10/29/25 at 12:17PM with facility S#1 states he was employed at the faclity for 3 years and have participated in many restraints. S#1 states he was trained in CPI and does get his annual CPI training every year. S#1 stated P#1 was on restrictions from trying to hurt herself with a coke can. The patients on the unit were going to leave the unit for Activity Time. P#1 stated she wanted to attend Activity Time. S#1 told P#1 she was restrictions and could not leave the unit. P#1 started to get upset, saying she wanted to go to Activity Time, S#1 stated he tried to de-escalate P#1. The unit door opened, as a student nurse was trying to enter the unit. P#1 took that opportunity to try to “bolt”. S#1 and another staff member restrained P#1, and was told to take her to seclusion. S#1 stated he first grabbed her by the wrist. S#1 stated her wrist hurt, so he moved up higher on her arm. P#1 was able to mover her wrist and did not complain of pain again while he was there. S#1 stated that P#1 never struggled nor did he feel that he held her wrist hard. Later he learned she had a fracture and felt so bad. Record review of a witness statement from the facility CPI trainer S#6, dated Dec 8, 2025, states in part... S#6 is the “Crisis Prevention Institute (CPI) Instructor at the facility and states the CPI two-person hold is an evidence-based, team-centered, trauma-informed physical intervention designed to minimize risk of harm to both the patient and the staff involved. Because the physical responsibilities are shared between two trained staff members, the intervention maintains greater stability, reduces the likelihood of excessive force, and allows for continuous assessment of the patient’s airway, breathing, circulation, and psychological safety. This structure decreases the risk of positional asphyxia, musculoskeletal injury, and unintended escalation. By contrast, a “child hold” is a one-person hold that places the full physical burden on a single staff member, increasing the risk of imbalance, uncontrolled movement, and inability to monitor the patient effectively. It introduces significant safety concerns for both the patient and the staff member, including the potential for airway compromise or accidental injury due to insufficient leverage or stability. CPI’s model emphasizes least restrictive intervention, injury prevention, team-based response, and structured physical techniques that are practiced, taught, and continuously monitored for safety....For these reasons, the CPI two-person supportive hold is the safer, standardized, and professionally endorsed intervention compared to the child hold. “ Interview on 10/29/25 at 2:15PM with facility staff #5 (S#5) stated, He is trained in CPI for almost 2 years and will be one of the instructors in CPI to the facility soon. S#5 stated the proper hold for the incident that occurred was the adult two person hold as the “little younger ones like to squirm”. S#5 later stated he did not know what the situations was and can not speak if the hold was appropriate or not. Interview on 11/13/25 at 2:00PM with a representative of CPI stated that he is not employed at the facility and not sure of what exactly happened at the facility, but did question why the facility used an adult restraint on a 12 year old who was trying to elope? And that a restraint should not have been used on on a patient trying to elope. Observation on 10/29/25 at 12:30PM of the video of the incident on 10/25/25, revealed the following: 10/25/25 09:59: P#1 at the nurses station. S#1 is with patient along with another staff member. 10:00 P#1 appeared agitated. S#1 there along with another staff. 10:04 P#1, S#1 and another staff at nurses station. 10:05 Door to unit opened, P#1 tried to run out, stopped by S#1 and another staff. P#1 was held in a two person medium level restraint. Walking P#1 to seclusion room, S#1 moves hand up the patient’s arm. 10:06 In seclusion room. 10:06 - 10:20 can not see patient or staff in the seclusion room. 10:20: Patient and staff leave the seclusion room.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 Based on observation of video surveillance, record reviews and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with the facility’s restraint policies and procedures during the implementation of restraints used for the management of behaviors for 5 of 7 patients (Patient’s #1, #2, #3, #4 and #7) reviewed with a patient rights violation complaint. Specifically, the facility failed to: 1.) Ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital’s restraint policy; and in accordance with State law during the implementation of restraints when used for the management of behavior for Patient’s #2, #3 and #4 when they were physically held in a restraint on the floor in a prone position which could result in positional asphyxia; 2.) Ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order a restraint in accordance with hospital policy and State law for Patient’s #1, #2, and #3 when they were physically held in restraint without a physician’s order; and 3.) Ensure a face-to-face assessment was conducted within 1-hour after the initiation of a restraint, seclusion or administration of medication used for the management of violent or self-destructive behaviors; and in accordance with the facility’s policies for Patient’s #1, #3, and #7. These deficient practices could compromise patient safety for all patients in the facility. The cumulative effect of these deficient practices resulted in the facility’s inability to meet the Condition of Participation for Patient Rights. Refer to tags A 0167, A 0168, and A 0178 for evidence of specific findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 21863 Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital’s restraint policy; and in accordance with State law during the implementation of restraints when used for the management of behavior for 3 of 7 patients (Patient’s #2, #3 and #4) reviewed for restraints. Specifically, Patient’s #2, #3 and #4 were physically held in a restraint on the floor in a prone position which could result in positional asphyxia, which occurs when a person’s body position prevents them from breathing normally. Findings included: Review of Complaint Intake TX00517608, received 9/24/2024, alleged patients are often restrained on the floor, and in prone position even though the facility does not train its staff on floor restraints. Further review of the complaint indicated that according to video that had been reviewed, the video footage showed that on 8/25/24 at 4:15 PM, Patient #2 was taken down into a physical restraint on the ground with a male staff member positioned on top of Patient #2, who was lying face down. Observation review on 10/17/24 at 1:00 PM of the 2 minute and 59 seconds video provided from the facility titled, 20240918 BVBH Camera 026, for Patient #3’s physical restraint on 9/18/24 at 8:17 PM revealed the following: At 34 seconds into the video, Patient #3 is taken down to the floor in a physical restraint by Mental Health Tech (MHT) - B in a prone position with MHT- B positioned on top of Patient #3. Other staff are seen walking by, and not assisting with the restraint. At the 1:21 minute mark of the video, Patient #3 attempts to get up and MHT- B continues to struggle to keep a physical hold of her. Another MHT- C comes to assist with the physical hold and then both MHT - B and C are seen holding down Patient #3 in a prone position. At the 2:37 minute mark, she is assisted up and then goes into her room. During an interview on 9/30/24 at 6:09 PM with Patient #2 who was asked about physical hold restraints and stated that she had one restraint by Mental Health Tech (MHT)- A (on 8/25/24 at 16:15) that made her feel uncomfortable. Patient #2 stated that MHT-A took me down to the ground by himself and laid on top of her, putting his leg “super high” in between her legs making her feel unsafe and triggered by her past trauma. Patient #2 stated she was face down (in prone position) during the restraint by MHT-A. During an interview on 9/30/24 at 6:25 PM with Patient #4 who was asked about physical hold restraints stated she had “only one bad one” (date unknown) when she was restrained “’face down, and they’re not supposed to be restraining me face down like that and pulling my arms upwards and I couldn’t breathe.” During an interview on 9/30/24 at 10:11 AM with Registered Nurse (RN)-A stated that personal hold restraints that are done on the floor are to be “side laying” on the floor. RN-A stated that staff get “very little” training regarding floor restraints. During an interview on 9/30/24 at 11:45 AM with the House Supervisor RN/CPI (Crisis Prevention Institute) trainer stated the following: There is very little physical restraint taught with CPI and nothing about taking a patient to the ground to restrain a patient. The restraint on the ground only happens if the patient is on the floor already or goes to the floor on their own, not staff taking them intentionally to the ground. Our facility teaches child hold with two-person restraint and escort techniques. During an interview with the Director of Nursing (DON) on 10/17/24 at 1:37 PM stated staff are not supposed to restrain patients in a prone position. Review of the facility’s Patient Restraint Policy, last revised 12/2023 stated the following, in part: Safe Application: Staff will be trained and able to demonstrate competency in the safe application of all types of restraint and seclusion used in this facility, including training to recognize and respond to signs of physical and psychological distress. Review of the CPI Nonviolent Crisis Intervention Training Participant Workbook, 2nd edition, 2020 indicated in part, on page 68, Positional Asphyxia and Restraint Position; that a relatively small number of restraint-related deaths reported are perceived to have occurred as a result of positional asphyxia. This had led to organizations advocating the unhelpful and largely unsupported view that prone restraint is the main risk and therefore should be abolished in favor of alternative positions which are perceived as less harmful. The principles of holding patients only included holding in a seated position, holding in a standing position, and holding in a standing position, “team control position.” The CPI training did not include training on floor restraints. Review of Texas Administrative Code, Title 25 Chapter 415.255 (b) A prone or supine hold shall not be used during a personal restraint. Should an individual become prone or supine during a restraint, then any staff member involved in administering the restraint shall immediately transition the individual to a side lying or other appropriate position.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 21863 Based on record review of documentation and interview, the facility failed to ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order a restraint in accordance with hospital policy and State law for 3 of 7 Patient’s (Patient’s #1, #2, and #3) reviewed for restraints. Specifically, Patient #2 was physically restrained on 8/25/24, released from the physical restraint and then re-restrained without obtaining a new physician order for restraint; Patient #1 was physically held on 8/22/24 for the administration of emergency medications without obtaining a physician order for restraint; and Patient #3 was physically held on 8/21/24 without obtaining a physician order for restraint. Findings included: 1.) Review of Compliant Intake TX00517608 dated 9/24/24 indicated that Patient #2 was physically restrained on 8/25/24, released from the physical restraint and then re-restrained without obtaining a new physician order for restraint. Review of Nursing Note on 8/25/24 at 5:45 PM by Registered Nurse (RN)-A documents Patient #2 kicking the wall, breaking the sheetrock, making a large hole in the wall. Patient #2 became physically aggressive with Mental Health Tech (MHT)- A as they attempted to redirect her away from the area and was restrained. “She was released but began to do the same behaviors and was restrained and then taken to seclusion.” Review of Patient #2’s physician orders for physical restraints on 8/25/24 revealed only one physical hold restraint order at 4:15 PM. During an interview on 10/17/24 at 3:19 PM with the Director of Nursing (DON) confirmed there was not a second and/or new physician order for Patient #2 when she was re-restrained after being released from the first restraint that was initiated at 4:15 PM. 2.) Review of nurses note dated 8/22/24 at 6:42 PM stated that Patient #1 went to her room and slammed the door. Patient #1 began kicking the door from the inside of the room. Patient #1 then began banging her head. Patient #1 then gritted her teeth and balled up her fists in a threatening manner. She was asked to walk to exclusion room but refused. The staff then escorted her to seclusion room where at the door she was placed on side lateral position for injections (Intramuscular) IM ordered by the doctor. The staff released her, and she remained in seclusion until she calmed down. Review of Patient #1’s physician orders for physical restraints on 8/22/24 revealed there was not a physical hold restraint order when Patient #1 was placed on side lateral position and administered IM emergency medications on 8/22/24 at 5:17 PM. During an interview on 10/18/24 at 10:35 AM, the Nurse Manager confirmed there was not a physician’s order in Patient #1’s record for the physical hold on 8/22/24 when Patient #1 was held and administered IM emergency medications. 3.) Review of Complaint Intake TX00517608 dated 9/24/24 indicated that according to video footage that was reviewed; on 8/21/24 at 10:58 AM, two staff members yank Patient #3 off the floor and drag her to the seclusion room, in what is not an approved restraint. Review of Patient #3’s physician orders for 8/21/24 revealed there was only a physician’s order for seclusion at 10:55 AM. There was not a physician’s order dated 8/21/24 for a physical restraint that was seen on the video footage at 10:58 AM. During an interview on 10/17/24 at 2:35 PM with the Nurse Manager confirmed there was not a physician’s order for a physical restraint for Patient #3 on 8/21/24. Review of the facility’s Patient Restraint Policy, last revised 12/2023 stated the following, in part: 5. Order for Restraint or Seclusion a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion. 2. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, new order is required. Review of Texas Administrative Code, Title 25 Chapter 415.260(b)(1)(C) (b) Physician’s order. Only a physician member of the facility’s medical staff may order restraint or seclusion. (1) The physician’s order for restraint or seclusion shall: (C) describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint or seclusion;”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 21863 Based on record review of the facility documentation and staff interviews, the facility failed to ensure a face-to-face assessment was conducted within 1-hour after the initiation of a restraint, seclusion or administration of medication used for the management of violent or self-destructive behaviors; and in accordance with the facility’s policies for 3 of 7 patients reviewed (Patient #1, #3, and #7) for restraints. Findings included: 1.) Patient #1 A sampled record review of Patient #1’s restraints, seclusion and emergency medications used for the management of violent or self-destructive behaviors revealed the following: a.) On 8/25/24, Patient #1’s electronic Medication Administration Report (eMAR) documented; -Ativan 2 milligrams (mg) Injection (INJ) administered at 11:12 AM, -Haloperidol Lactate 5mg/1 milliliter (ml) INJ at 11:12 AM, -Diphenhydramine HCL 50mg/1ml INJ (25mg) administered at 11:12 AM, and -Diphenhydramine HCL 50mg/1mg INJ administered at 11:22 AM for emergency management of behaviors. Further review of Patient #1’s record revealed there was not a face-to-face assessment conducted within 1-hour after the administration of medication used on 8/25/24 at 11:12 AM and 11:22 AM for the management of behaviors. Review of the Restraint Documentation for Patient #1 on 8/25/24 revealed a physical restraint at 11:08 AM. Patient #1’s record revealed there was not a face-to-face assessment conducted on 8/25/24 within 1-hour after the initiation of a physical restraint implemented for the management of behaviors. Review of the Seclusion Documentation for Patient #1 on 8/25/24 revealed she was in seclusion from 11:08 AM to 12:45 PM. Patient #1’s record revealed there was not a face-to-face assessment conducted on 8/25/24 within 1-hour after the initiation of seclusion implemented for the management of behaviors. During an interview on 10/18/24 at 10:38 AM with the Nurse Manager confirmed there were not any face-to-face assessments completed for Patient #1 on 8/25/24 within 1 hour after the initiation of a restraint, seclusion and administration of medication used for the management of violent or self-destructive behaviors. The Nurse Manager further stated he did not understand why the electronic health record (EHR) did not have a hard stop built in that would require the documentation of the face-to-face assessments after a restraint, seclusion and/or emergency medications administered. b.) On 8/22/24, Patient #1’s eMAR documented at 5:24 PM for Thorazine INJ 50mg IM, Administered at 5:17 PM for emergency management of behaviors. Further review of Patient #1’s record revealed there was not a face-to-face assessment conducted within 1-hour after the administration of medication used on 8/22/24 at 5:17 PM for the management of behaviors. During an interview on 10/18/24 at 10:33 AM with the Nurse Manager confirmed there was not a face-to-face assessment completed for Patient #1 on 8/22/24 within 1 hour after the administration of medication used for the management of behaviors. Review of the Seclusion Documentation for Patient #1 on 8/22/24 revealed she was in seclusion from 5:15 PM to 7:05 PM. Review of Patient #1’s record documented a face-to-face assessment completed by Registered Nurse (RN) - B at 5:15 PM; the exact time of the implementation of seclusion and not after the initiation of the intervention to assess the patient’s reaction to the intervention. c.) On 7/21/24, Patient #1’s eMAR documented the following administered emergency medications to Patient #1 for the management of behaviors without evidence of a face-to-face assessment conducted within 1 hour of administration. -Benadryl 25mg (50mg) at 4:22 PM -Haldol 5mg at 4:22 PM -Ativan 1mg (2mg) at 4:22 PM -Thorazine 50mg INJ at 6:56 PM -Benadryl 50mg INJ at 6:56 PM During an interview on 10/18/24 at 10:20 AM with the Nurse Manager confirmed Patient #1’s was administered the above emergency medications without evidence that a face-to-face assessment was conducted within 1 hour of administration. 2.) Patient #3 Review of Complaint Intake TX00517608 indicated that according to video footage reviewed; on 8/21/24 at 10:58 AM, two staff members yank Patient #3 off the floor and drag her to the seclusion room, in what is not an approved restraint. Further review of Patient #3’s record revealed there was not a face-to-face assessment conducted within 1-hour after the physical hold restraint on 8/21/24 at 10:58 AM; used for the management of behaviors. Review of Patient #3’s Seclusion documentation revealed on 8/21/24 seclusion was initiated at 10:55 AM and discontinued at 11:40 AM. Review of Patient #1’s record documented a face-to-face assessment completed by Registered Nurse (RN) - B at 10:55 AM; the exact time of the implementation of seclusion and not after the initiation of the intervention to assess the patient’s reaction to the intervention. On 8/21/24, Patient #3’s eMAR documented at 11:13 AM Olanzapine (Zyprexa) 10mg/vial was administered IM for emergency management of behaviors. Further review of Patient #3’s record revealed there was not a face-to-face assessment conducted within 1-hour after the administration of medication used on 8/21/24 at 11:13 AM for the management of behaviors. During an interview on 10/17/24 at 2:40 PM with the Director of Nursing (DON) confirmed Patient #3 did not have a face-to-face assessment for the physical restraint and did not have a face-to-face assessment after the administration of emergency medications. 3.) Patient #7 Review of the Restraint Documentation for Patient #7 on 9/13/24 revealed a physical restraint at 8:10 AM. Review of Patient #7’s record documented a face-to-face assessment completed on 9/13/24 at 8:10 AM; the exact time of the implementation of the physical restraint, and not after the initiation of the intervention to assess the patient’s reaction to the intervention. During an interview on 10/17/24 at 2:48 PM with RN-B stated she was trained to conduct the face to face assessment “at the same time” of the intervention. Review of the facility’s Patient Restraint Policy, last revised 12/2023 stated the following, in part: 11. Face-to-face assessment by a Physician or Licensed Practitioner: A face-to-face assessment by a physician, licensed practitioner, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. The purpose of the one hour face-to-face evaluation is to complete a comprehensive review of the patient’s condition and determine if other factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient’s violent or self-destructive behavior. Review of the facility’s policy titled Emergency Administration of Psychoactive Medications in a Psychiatric Emergency without Patient Consent, last revised 12/2023 indicated the following, in part; 6. Within 1 hour post administration, a face to face assessment will be conducted and documented in medical record by a provider or an RN specifically trained on the following: a. Evaluation of the patient’s immediate situation, b. The patient’s reaction to the intervention, c. The patient’s medical and behavioral condition and the need to continue or terminate the restraint or seclusion.”

“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: 34726 Based on record review, staff interviews, and policy review, the hospital failed to meet the EMTALA requirements for 1 of 1 patients reviewed (Patient #1) who presented to the Emergency Department with signs and symptoms of a possible emergency medical condition (EMC), including frequent epistaxis (nosebleeds), gingival bleeding, recent transfusion history, lightheadedness, and abnormal vital signs. The facility did not conduct a comprehensive medical screening examination (MSE) capable of ruling out serious underlying causes such as a hematologic disorder. The facility prematurely discharged the patient home with instructions to follow up with ENT, despite continued symptoms and the availability of further diagnostic services (e.g., CBC, coagulation studies) within the hospital’s capabilities. The findings include: Record review of the P#1’s medical record revealed the patient received limited evaluation with physical exam (while lab work was obtained) however no documentation for PT/ PTT, Factor VIII was in the patient’s medical record.While the Patient received nose clamp and oxymetazoline nasal spray, the documentation does not reflect that adequate hemostasis was achieved. Patient was apparently offered nasal tampon, however refused. Patient was subsequently discharged to home with what appeared to be ongoing epistaxis and was instructed to follow up with ENT. It does appear patient independently sought care at another hospital at a later time, however it does not appear that any hospital staff directed the patient to seek care at another hospital.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 34726 Based on Record review and interview the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the Emergency Department (including ancillary services) to determine whether an emergency medical condition (EMC) existed for Patient # 1 who presented with recurrent epistaxis, gingival bleeding, dizziness, and a history of recent transfusions. Key evidence points: Specifically, the facility failed to ensure: o A coagulation profile was ordered despite ongoing bleeding. o Clinical documentation revealed differential diagnosis for possible hematologic disorder. The facility did not conduct a comprehensive medical screening examination (MSE) capable of ruling out serious underlying causes such as a hematologic disorder. The facility prematurely discharged the patient home with instructions to follow up with ENT, despite continued symptoms and the availability of further diagnostic services (e.g., CBC, coagulation studies) within the hospital’s capabilities. The findings include: Record review of the P#1’s medical record revealed the patient received limited evaluation with physical exam (while lab work was obtained) however no documentation for PT/ PTT, Factor VIII was in the patient’s medical record.While the Patient received nose clamp and oxymetazoline nasal spray, the documentation does not reflect that adequate hemostasis was achieved. Patient was apparently offered nasal tampon, however refused. Patient was subsequently discharged to home with what appeared to be ongoing epistaxis and was instructed to follow up with ENT. It does appear patient independently sought care at another hospital at a later time, however it does not appear that any hospital staff directed the patient to seek care at another hospital.”