UT Health East Texas Pittsburg Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 36827 Based on review of records, policies, and interview, the facility failed to ensure the Emergency Department (ED) medical staff maintained the certifications and specialized training in emergency care to meet the written emergency procedures and patient needs anticipated by the facility for 5 out of 5 (Staff #15, #16, #17, #18, and #19) medical staff credentialing files reviewed. Findings include: On 2-18-2026 at 11:30 am, credential files for Staff #15, #16, #17, #18, and #19 were reviewed with Staff #3. During the review, it was noted that none of the medical staff members being reviewed had current Restraint and Seclusion training in their file. Review of Policy Number 40039.5, Title: Restraint Policy-NS-MKT; Effective Date: 02/09/2024; Next Review Date: 02/09/2026 was as follows: Page 3 of 18 “Risk of Restraint Use: The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death. The hospital takes these risks factors into account when assessing the need for, selecting they type of and determining the patient care needs relative to restraint.” Page 14 of 18 “2) Physicians who order restraints and providers who assess patients who are in restraints must have a working knowledge of the hospital policy. Training occurs during the on-boarding process. a) Training content will include relevant content from the hospital policy. Retraining will occur annually. An attestation that the provider understands the training will be secured. Retraining may include discussion or didactic methods. Evidence of training will be placed in the medical staff files.” Review of Staff #17’s credential file showed that he was a Family Practice physician and was not certified by the American Board of Emergency Medicine. As such, he was required to maintain certification in Advanced Cardiac Life Support (ACLS), Pediatric Advance Life Support (PALS), and Advanced Trauma Life Support (ATLS). These certifications were not found in his file. Staff #3 confirmed there was no current records since 2024. Staff #3 stated “He has been notified multiple times.” Staff #3 confirmed that the physicians are part of a contract service company for emergency contracted medical staff. “I notified them (the contract company) on Monday, prior to the survey, and again last night” about the physician not having current certification. Review of Policy: 42154.3; Title: CPR (Cardiopulmonary Resuscitation), ACLS, PALS and NRP (Neonatal Resuscitation) Training Requirements-MS-MKT; Effective Date: 08/22/2024; Next Review Date: 08/22/2027 was as follows: Page 1 of 2: “3) For Facilities with Emergency Departments: Physicians providing care in an Emergency Department who are not board certified in Emergency Medicine will be required to maintain ATLS, ACLS, and PALS. a) However, facility specific bylaws and medical staff rules and regulations will dictate and may require specific certifications.” Medical Staff Bylaws with a signature page dated 10/27/2017 were reviewed as follows: Page 13 “5.5 EMERGENCY CONTRACT SERVICE MEDICAL STAFF 5.5.1 Qualifications (a) Each Emergency Contract Service Physician must meet the general qualifications required for Medical Staff Membership and must also furnish proof of current ACLS and ATLS certification.””

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36827 Based on review of medical records, facility polices, state law, and interview, the facility failed to protect and promote patient’s rights. The facility failed to: A) protect 1 mental health patient’s (Patient #11) right to refuse treatment out of 20 mental health patient records reviewed. The facility staff forced a mental health patient to submit to collection of blood and urine for medical clearance for transfer to another hospital and to receive injections of mental health medications normally used for mood or behavior without the appropriate court order in the absence of an immediate life-threatening condition. The deficient practice has the potential to create physical and/or psychological harm to patients. Refer to TAG C2513 B) ensure restraints were not used as a means of coercion or staff convenience to compel compliance with non-emergent medical treatment for one patient (Patient #11) out of 20 patients’ medical records reviewed. This deficient practice resulted in staff administering psychotropic medication and applying physical restraint to force a patient to undergo laboratory testing against her expressed refusal. Refer to TAG C2340 C) ensure that staff were adequately trained and followed policies and procedures for the use of restraints and medications in emergency for 1 patient (Patient #11) of 20 patients reviewed. The facility failed to ensure that 5 out of 5 (Staff #15, #16, #17, #18, and #19) medical staff credentialing files reviewed contained the current training in the use of restraints. One (1) staff members (Staff #25) out of 4 staff involved in a physical hold of a patient did not have the appropriate training or demonstrate competency in the appropriate hold techniques to safely apply physical restraint holds to a patient. Refer to TAG C2560”

“QAPI CFR(s): (e) Standard: Program data collection and analysis. The program must incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program. This Standard is not met as evidenced by: 36827 Based on review of records and interview, the facility failed to accurately collect quality indicator data on use of restraints and seclusion, analyze data collected, and report analyzed and trended data in the quarterly quality reporting for 4 of 4 quarterly reporting periods in 2025. This deficient practice places patients at risk of receiving unnecessary restraints. By failing to identify and correct trends and patterns that may contribute to the use of restraint or seclusion, patients could be subject to an unnecessary intervention that is inherently dangerous. The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death. Findings include: On the morning of 2-18-2026, Staff #1 was asked to provide the Restraints and Seclusion Log (State required central file) for the past 3 months. Staff #1 indicated that the facility did not keep a separate Restraint and Seclusion log as required by the State of Texas. Staff #2 stated the facility ran the log as needed from the Electronic Medical Record (EMR), pulling the record from the physician orders for restraint. Staff #1 provided a list that contained 1 patient in January 2026 and 1 patient from December 2025. This list was found to be incomplete. The list did not contain information on Patient #7, #11, and #13 who had all received either Chemical Restraint/Emergency Behavioral Medication and/or physical restraints. The report did not contain the necessary information required on a restraint log for proper analysis of the use of restraints. The restraint log contained the following information: Episode Department Name Patient Name Medical Record Number Age Age Group (pediatric, adult, senior) Sex Race Ethnicity Encounter Number Admission Date/Time Discharge Date/Time Staff #1 was interviewed at that time about the lack of data and stated that the ED Director performed audits on psychiatric patient charts in the ED. The ED Director had recently left and the Interim ED Director did not have the chart audit tools that were used to review care for psychiatric patients in the ED. Staff #1 stated she did not have that data for the 4th quarter of 2025. Staff #1 was asked to provide the quality reporting data for the first three quarters of 2025 but was not able to provide it. Review of Policy Number 40039.5, Title: Restraint Policy-NS-MKT; Effective Date: 02/09/2024; Next Review Date: 02/09/2026 was as follows: Page 3 of 18 “Risk of Restraint Use: The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death. The hospital takes these risks factors into account when assessing the need for, selecting they type of and determining the patient care needs relative to restraint.” Page 15 of 18: Reducing the use of Restraint through Performance Improvement 1) The organization will make all reasonable efforts to reduce the use of restraints. To accomplish this, a performance improvement process occurs. 2) This process may include, but not necessarily be limited to: a) Collecting data b) Compiling data in the use of restraints in usable formats c) Analyze and compare the data over time to identify levels of Performace (sic) patterns, trends, and variations d) Use the result of its data analysis on the use of restraint to Identify (sic) opportunities to improve e) Take action on its improvement priorities and evaluate changes To (sic) confirm they resulted in improvements f) Collect Specific Data related to the use of restraints and address violent/behavioral and non-violent/medical usage i) The shift during which the episode begins ii) The setting/unit/location where the episode occurs iii) The staff who initiate restraint iv) The length of each episode v) The date and time each episode is initiated vi) The day of the week each episode is initiated vii) The type of restraint used viii) Any injuries sustained by the patient or staff ix) A patient identifier such as Medical Record Number or Account Number x) The patients age xi) The patients gender xii) Prolonged episodes of restraint Review of Policy Title: Emergency Behavioral Medications-NS-MKT; Policy Number 83537.1; Effective Date: 02/09/2024; Next Review Date: 02/09/2027 was as follows: Page 2 of 7 “4) Each instance of an Emergency Behavioral Medication will be documented on a central log in accordance with Texas Administrative Code Rule 415.271.” The Texas Administrative Code required hospitals to keep a central file (Restraint Log) of all restraint usage in order for quality review and evaluation of restraint usage in order to reduce the use of restraints.”

“EXERCISE OF RIGHTS CFR(s): The patient or their representative (as allowed under state law) has the right to make informed decisions regarding their care. The patient’s rights include being informed of their health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36827 Based on review of medical records, policies, state law, and interview, the facility failed to protect 1 mental health patient’s (Patient #11) right to refuse treatment out of 20 mental health patient records reviewed. The facility staff forced a mental health patient to submit to collection of blood and urine for medical clearance for transfer to another hospital and to receive injections of mental health medications normally used for mood or behavior without the appropriate court order in the absence of an immediate life-threatening condition. The deficient practice has the potential to create physical and/or psychological harm to patients. Findings include: On 12/3/2025, Patient #11 was brought to the Emergency Department (ED) by law enforcement on an Apprehension by a Peace Officer Without a Warrant (referred to as EDW [Emergency Detention Warrant] in Patient #11’s medical record) as described in Texas Health and Safety Code, Mental Health Code, Section 573.001. This section of the Mental Health Code allowed a peace officer to legally apprehend and transport a person to an ED for evaluation if that person is suspected of being substantial risk of serious harm to the person or to others; the person evidences severe emotional distress and deterioration in the person’s mental condition; or the person evidences an inability to recognize symptoms or appreciate the risks and benefits of treatment. The patient did not want to stay at the hospital for evaluation and kept trying to leave, so the facility applied for a Judge’s or Magistrate’s Order for Emergency Apprehension and Detention under the Texas Health and Safety Code, Mental Health Code, Section 573.011. This section of the Mental Health Code allows for the apprehension and detention of a person if the judge or magistrate finds: (1) the person evidences mental illness and because of that mental illness the person evidences: (A) a substantial risk of serious harm to himself or others; (B) severe emotional distress and deterioration in the person’s mental condition; or (C) an inability to recognize symptoms or appreciate the risks and benefits of treatment; (2) the person is likely without immediate detention to suffer serious risk of harm or to inflict serious harm on another person; (3) the risk of harm is imminent unless the person is immediately restrained; and (4) the necessary restraint cannot be accomplished without emergency detention. This order would allow the facility to detain the patient for the purpose of a preliminary examination and transfer to a mental health facility within 48 hours (or longer in the case of weekends, holiday, and inclement weather). The order was approved and signed by the judge and filed in court record on 12/04/2025 at 1:35 pm. These sections of the Mental Health Code did not provide for the removal of an individual’s right to consent to or refuse treatment/care (the hospital could not force the patient to take medications or provide specimens for laboratory testing), only for detention for the purpose of a preliminary examination to see if there was cause to involuntarily commit the patient to care. Review of Patient #11’s medical record was as follows: Initial care of patient was provided by physician Staff #18 on 12/3/2025. In the provider note, Staff #18 documented the following: Emergency Department (ED) Provider Note 12/3/2025 at 10:35 PM: “62-year-old female, unknown medical history, presents to the ED via sheriff’s department under an EDW (Emergency Detention Warrant). Patient was reportedly bothering patrons at a local dollar store in which per sheriff’s department, she was reportedly saying that she was running from witches. Patient alert to person, place, time and situation no does have multiple non sequitur statements and occasional flight of ideas during interview. Patient denies homicidal or suicidal ideation.” (sic) ... “Review of Systems Psychiatric/Behavioral: Negative for self-injury and suicidal ideas. The patient is nervous/anxious and is hyperactive” ... “Psychiatric: Attention and Perception: Attention and perception normal. Mood and Affect: Mood is anxious. Affect is labile. 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. Judgment: Judgment is impulsive.” “Diagnostic considerations and differential diagnoses: 62-year-old female and a hypomanic episode with delusions. No evidence of hallucinations. Patient denies suicidal or homicidal ideation. Patient was alert to person, place, time and situation though does have delusions an episodes of hypomania. Per Texas law, see below, patient can not be chemically restrained in order to obtain blood or urine. Patient with normal vital signs. Patient has been placed under an emergency detention warrant by the sheriff’s department. Patient will continue to be observed in the emergency department with until she either consents to blood, urine and an EKG or her EDW expires and she leaves of her own accord.” ... 21220 Prohibited Restrictive Interventions The use of personal restraints is prohibited except in a behavioral health emergency. PAs are prohibited from using chemical restraints, mechanical restraints, or seclusion. Other forms of interventions that restrict participant movement, participant access to other persons, locations, or activities, restrict participant rights, or employ other aversive methods to modify behavior are not allowed. A behavioral emergency is a situation which involves a participant behaving in a violent or self-destructive manner where preventive, de-escalating, or verbal techniques have been determined ineffective, deeming it immediately necessary to restrain the participant to prevent: Imminent probable death or substantial bodily harm to the participant because the participant is attempting to commit suicide or inflict serious bodily harm; or Imminent physical harm to others because of acts the participant commits. Restrictive interventions shall not be used: As a means of discipline, retaliation, punishment, or coercion; For the convenience of staff members or other persons; As a substitute for effective treatment or habilitation; or Unless it is necessary to intervene to prevent imminent probable death or substantial bodily harm to the participant or imminent physical harm to another, and less restrictive methods have been tried and failed. PAs and RMEs shall not use more force than is necessary to prevent imminent harm and shall ensure the safety, well-being, and dignity of participants who are personally restrained, including attention for personal needs.” On the morning of 12/04/2025, physician Staff #17 assumed care of the patient. Staff #17 consulted with physician Staff #26 regarding the psychiatric evaluation and plan of care for the patient. The clinical note was found to contain the following recommendations: “Given her erratic behavior, statements about needing to set fires to ward away witches, hunting witches, need to defend herself against witches, calling/contacting White House/other government officials, and police detainment, patient presents an immediate threat to herself and others owning to her mental illness. Due to the severity of her mental state, she does not possess medical decision making capacity and meets criteria for involuntary psychiatric hospitalization. She is currently on EDW/POW and ED staff have begun a bed search but have been hampered with placement as patient has refused labs necessary for medical clearance. At this time, will recommend one time haloperidol, lorazepam, and diphenhydramine as patient has been exit seeking, disruptive/intrusive, and verbally aggressive in the ED and as witnessed by this note writer during her evaluation. This combination may be repeated q4h while she boards in the ED. Elopement, assault, and self-harm precautions added to orders/alerts in chart along with Legal Hold. Advised staff of need for brief personal hold for emergency medications and to draw necessary labs for medical clearance. Advise OPC to be filed with county judge and ongoing bed search for placement. The treatment plan was discussed with the patient who disagreed with the plan. She is currently on POW and meets criteria for involuntary psychiatric hospitalization. The psychiatric service will continue to follow patient as necessary. We appreciate this consult.” The medical record showed the patient received injections of the following medications, despite her objection. Benadryl, 50 milligrams injected into the right buttocks muscle on 12/04/2025 at 12:19 PM Haldol, 5 milligrams injected into the right buttocks muscle on 12/04/2025 at 12:18 PM Ativan, 2 milligrams injected into the right buttocks muscle on 12/04/2025 at 12:18 PM Benadryl, 25 milligrams injected into the left thigh muscle on 12/04/2025 at 6:50 PM Haldol, 5 milligrams injected into the left thigh muscle on 12/04/2025 at 6:50 PM Ativan, 2 milligrams injected into the left thigh muscle on 12/04/2025 at 6:50 PM Hospital Staff #17 followed the recommendations of Staff #26 without regard to Texas Health and Safety Code, Texas Mental Health Code, Chapter 574, Subchapter B. Rights Relating to Treatment and hospital policy as follows: “SUBCHAPTER B. RIGHTS RELATING TO TREATMENT Sec. 576.021. GENERAL RIGHTS RELATING TO TREATMENT. (a) A patient receiving mental health services under this subtitle has the right to: ... (4) an individualized treatment plan and to participate in developing the plan; ... Sec. 576.025. ADMINISTRATION OF PSYCHOACTIVE MEDICATION. (a) A person may not administer a psychoactive medication to a patient receiving voluntary or involuntary mental health services who refuses the administration unless: (1) the patient is having a medication-related emergency; ... (4) the administration of the medication regardless of the patient’s refusal is authorized by an order issued under Section 574.106 (Court Ordered Mental Health Services); or ...” Hospital Policy Number 40039.5, Title: Restraint Policy-NS-MKT; Effective Date: 02/09/2024; Next Review Date: 02/09/2026 was as follows: Page 1 of 18 “Policy 1) All patients have the right to be free from restraint in any form, imposed as a means of coercion, discipline, convenience, or retaliation by the staff. 2) Restraints are only used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.” Page 3 of 18 “Risk of Restraint Use: The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death. The hospital takes these risks factors into account when assessing the need for, selecting they type of and determining the patient care needs relative to restraint.” The medical record did not reflect that the patient was in immediate physical safety or a threat to the safety of staff or others. The medical record indicated that laboratory samples of blood and urine were collected on 12-4-2025. Blood was collected first at 1:46 pm and the urine was collected at 1:59 pm. This was approximately an hour and forty minutes after receiving forced medication. The medical records indicated the patient was still unwilling to provide samples and did not reflect that the patient gave them willingly. Staff #17 documented, “Patient in his medically cleared for psychiatric admission. The urine I believe is due to the collection because the patient had to be restrained in 4 points to collect. Since getting the Benadryl lorazepam Haldol she has rested.” Staff #17 was interviewed by phone on 2-18-2026 at 10:37 am. Staff #17 confirmed that urine was collected by an invasive procedure called an in-and-out catheter where a thin, flexible tube is inserted through the urethra into the bladder and then removed once the urine has been collected. Staff #17 confirmed that 4 people held the patient down while a 5th person performed the procedure. Staff #17 stated he was not present for the procedure. No order for the procedure was found in the medical record. No order for the physical restraint of the patient was found in the record. Staff #17 stated they gave the medications and restrained the patient under the recommendation of Staff #26 in order to obtain laboratory specimens for medical clearance/transfer and not because the patient was in immediate danger of harm to self or others.”

“RESTRAINT AND SECLUSION CFR(s): 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: 36827 Based on review of medical records, policy review, and interview, one patient (Patient #11) out of 20 patients’ medical records reviewed the facility failed to ensure restraints were not used as a means of coercion or staff convenience to compel compliance with non-emergent medical treatment. This deficient practice resulted in staff administering psychotropic medication and applying physical restraint to force a patient to undergo laboratory testing against her expressed refusal. Findings include: Patient #11 presented to the emergency department on 12-3-25 at 9:08 PM under an Apprehension by a Peace Officer without a Warrant. On 12-4-25, the facility initiated an Application for Emergency Detention. The application was approved and signed by the County Judge on 12-4-25 with the following order: “It is therefore ordered that the aforementioned person be held at UT Health, Pittsburg for a preliminary examination by a physician.” Under Texas Health and Safety Code Chapter 573 (Emergency Detention), detention is authorized for evaluation of mental illness and risk, but it does not constitute a judicial finding of incompetency or removal of legal capacity. Therefore, a patient detained for mental health evaluation retains the presumption of legal competency and the right to refuse medical treatment unless a court has adjudicated the person incompetent or a true medical emergency exists. Medical record documentation showed the staff requested the patient provide blood and urine specimens for medical clearance prior to transfer to a psychiatric facility. The record documented that the patient was awake and verbally refusing laboratory testing. 12/4/25 at 7:10 AM - “Pt (patient) outside room talking to nurse. Pt states she will give urine sample after she eats breakfast. Pt still refuses blood work.” 12/4/25 at 11:15 AM - “This nurse, [name redacted] RN, and ERMD (Emergency Room Medical Doctor) spoke with Dr [name redacted] (psychiatrist who performed psych eval). Dr [name redacted] states pt needs to be involuntarily committed to an inpatient psychiatric facility, pt does not have any decision making capacity. Dr [name redacted] also recommends pt received IM haldol 5mg, Ativan 2mg, and 50mg benedryl to assist with cooperation for blood/urine collection, EKG.” 12/4/25 at 2:06 PM - “Pt yelling at nurses for giving medication. Pt ambulated to restroom and slammed door. Pt then ambulated back to room and slammed door multiple times yelling “I’m disappointed in you”. Pt now sitting in recliner yelling “give me my money back” and “ignorant”. Despite the patient’s refusal, staff administered intramuscular Haldol, Benadryl, and Ativan. The patient was still refusing to provide blood and urine specimens so the facility staff placed the patient in physical restraints, and proceeded to forcibly obtain laboratory specimens. The medical record did not document that the patient posed an immediate threat of harm to self or others at the time the medications and restraints were applied. Hospital Policy Number 40039.5, Title: Restraint Policy-NS-MKT; Effective Date: 02/09/2024; Next Review Date: 02/09/2026 was as follows: Page 1 of 18 “Policy 1) All patients have the right to be free from restraint in any form, imposed as a means of coercion, discipline, convenience, or retaliation by the staff. 2) Restraints are only used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.” Page 3 of 18 “Risk of Restraint Use: The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death. The hospital takes these risks factors into account when assessing the need for, selecting they type of and determining the patient care needs relative to restraint.” Staff #17 was interviewed by phone on 2-18-2026 at 10:37 am. Staff #17 confirmed that urine was collected by an invasive procedure called an in-and-out catheter where a thin, flexible tube is inserted through the urethra into the bladder and then removed once the urine has been collected. Staff #17 confirmed that 4 people held the patient down while a 5th person performed the procedure. Staff #17 stated he was not present for the procedure. No order for the procedure was found in the medical record. No order for the physical restraint of the patient was found in the record. Staff #17 stated they gave the medications and restrained the patient under the recommendation of Staff #26 in order to obtain laboratory specimens for medical clearance/transfer and not because the patient was in immediate danger of harm to self or others.”

“RESTRAINT AND SECLUSION CFR(s): Staff training requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 36827 Based on review of medical records, facility policies and interview, the facility failed to ensure that staff were adequately trained and followed policies and procedures for the use of restraints and medications in emergency for 1 patient (Patient #11) of 20 patients reviewed. The facility failed to ensure that 5 out of 5 (Staff #15, #16, #17, #18, and #19) medical staff credentialing files reviewed contained the current training in the use of restraints. One (1) staff members (Staff #25) out of 4 staff involved in a physical hold of a patient did not have the appropriate training or demonstrate competency in the appropriate hold techniques to safely apply physical restraint holds to a patient. Findings include: Medical Staff Training On 2-18-2026 at 11:30 am, credential files for medical Staff #15, #16, #17, #18, and #19 were reviewed with Staff #3. During the review, it was noted that none of the medical staff members being reviewed had current Restraint and Seclusion training in their file. Review of Policy Number 40039.5, Title: Restraint Policy-NS-MKT; Effective Date: 02/09/2024; Next Review Date: 02/09/2026 was as follows: Page 3 of 18 “Risk of Restraint Use: The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death. The hospital takes these risks factors into account when assessing the need for, selecting they type of and determining the patient care needs relative to restraint.” Page 14 of 18 “2) Physicians who order restraints and providers who assess patients who are in restraints must have a working knowledge of the hospital policy. Training occurs during the on-boarding process. a) Training content will include relevant content from the hospital policy. Retraining will occur annually. An attestation that the provider understands the training will be secured. Retraining may include discussion or didactic methods. Evidence of training will be placed in the medical staff files.” Patient #11 Restraint Review of Patient #11’s medical record showed that she received medications normally given during a behavioral emergency against her will on two occasions during her stay. The medical record showed the patient received injections of the following medications, despite her objection. Benadryl, 50 milligrams injected into the right buttocks muscle on 12/04/2025 at 12:19 PM Haldol, 5 milligrams injected into the right buttocks muscle on 12/04/2025 at 12:18 PM Ativan, 2 milligrams injected into the right buttocks muscle on 12/04/2025 at 12:18 PM Benadryl, 25 milligrams injected into the left thigh muscle on 12/04/2025 at 6:50 PM Haldol, 5 milligrams injected into the left thigh muscle on 12/04/2025 at 6:50 PM Ativan, 2 milligrams injected into the left thigh muscle on 12/04/2025 at 6:50 PM Review of the medical record showed that the patient was held down while laboratory specimens were taken against her will. Staff #17 documented, “Patient in his medically cleared for psychiatric admission. The urine I believe is due to the collection because the patient had to be restrained in 4 points to collect. Since getting the Benadryl lorazepam Haldol she has rested.” (sic) The medical record did not identify the immediate threat to the physical safety of the patient, a staff member, or others. The medical record did not contain the required documentation for use of restraints and seclusion or the use of medication in a behavioral emergency. The medical record did not identify who was involved in the restraint or how long the restraint lasted. Staff #17 was interviewed by phone on 2-18-2026 at 10:37 am. Staff #17 confirmed that urine was collected by an invasive procedure called an in-and-out catheter where a thin, flexible tube is inserted through the urethra into the bladder and then removed once the urine has been collected. Staff #17 confirmed that 4 people held the patient down while a 5th person performed the procedure. Staff #17 stated he was not present for the procedure. No order for the procedure was found in the medical record. No order for the physical restraint of the patient was found in the record. Staff #17 confirmed they gave the medications and restrained the patient under the recommendation of Staff #26 in order to obtain laboratory specimens for medical clearance/transfer and not because the patient was in immediate danger of harm to self or others. On 2-18-2026 at 12:18, Staff #22 (Nurse Educator) was interviewed about nurse training for physical restraints and de-escalation. Staff #22 explained that Alternatives to Managing Aggression SAMA training program was used to train the staff. He explained that there were 4 parts to the training but the hospital only trained in 1 through 3. Part 1 was Assisting Verbal De-escalation. Part 2 was Protection of Self and Others. Part 3 was Containment (safe physical holds). Part 4 was Object Recovery (how to de-arm a person with a weapon). Staff #22 stated that staff were able to opt out of different parts of the training if they had physical limitations that would prevent them from performing those skills. That meant that not all staff had training on proper hold techniques. On 2-18-2026 at 1:49 pm, a phone interview was conducted with Staff #11 who was identified in the medical record as the nurse who collected the blood and urine. Staff #11 confirmed that four (4) staff members held the patient down while she collected the urine sample. She was able to identify three (3) staff members “for sure” and was unsure of the fourth member but had it narrowed down to two staff members who were on duty that shift. She was sure Staff #25 had been involved in the physical hold. Review of Staff #25’s Alternatives to Managing Aggression SAMA Certification showed that he had only been trained in the de-escalation portion of the training (Part 1). Part 3 of the training was the required part of the program necessary to be trained on proper physical hold techniques so that patients and staff were not injured in the physical restraint process. Review of Hospital Policy Number 40039.5, Title: Restraint Policy-NS-MKT; Effective Date: 02/09/2024; Next Review Date: 02/09/2026 was as follows: Page 1 of 18 “Policy 1) All patients have the right to be free from restraint in any form, imposed as a means of coercion, discipline, convenience, or retaliation by the staff. 2) Restraints are only used to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. ... 4) Only staff with demonstrated competencies can initiate the application of restraints for non-behavioral/non-violent/medical and behavioral/violent purposes. ... 7) Physical or mechanical devices used to involuntarily restrain the movement of part or the whole of the patient’s body during medical, diagnostic or surgical procedures is appropriate when it is associated with a procedure and the patient has consented to the treatment, with the exception of emergencies.” Page 10 of 18 “8) After the patient is released from behavioral restraint: i) Identify what led to the behavioral restraint ii) Identify strategies to prevent future restraint iii) Assure if the patient’s physical well-being, psychological comfort and right to privacy were protected iv) Identify if there were any injuries that resulted from the restraint and address those injuries v) Identify staff members who were present and involved in the restraint” Review of Policy Title: Emergency Behavioral Medications-NS-MKT; Policy Number 83537.1; Effective Date: 02/09/2024; Next Review Date: 02/09/2027 was as follows: Page 1 and 2 of 7 “Purpose: The purpose of this policy is to provide guidance on the safe and appropriate use of emergency behavioral medications. Policy: 1) Behavioral Emergency - A situation involving an individual who is behaving in a violent or self-destructive manner (excluding patient non-psychiatric medical diagnosis or symptomology) and in which preventive, de-escalative, or verbal techniques have been determined to be ineffective and it is immediately necessary to intervene with individual to prevent: a) Imminent probable death or substantial bodily harm to the individual because the individual is attempting to commit suicide or inflict serious bodily harm b) Imminent physical harm to others because of acts the individual commits 2) Emergency behavioral medications (EBM) can only be ordered by a physician for the immediate use to address a behavioral emergency. 3) Emergency behavioral medications should not be ordered PRN. When a patient is experiencing a behavioral emergency that requires the use of pharmaceuticals to address the behavior, the order should be written as ONCE STAT. Repeat one-time orders to treat ongoing behavioral issues are permissible, and must be based upon serial assessments of the patient and clinical need. Physician orders for PRN behavioral medications in this situation will not be accepted, and will prompt pharmacy to request an order clarification from the physician, to obtain a ONCE STAT or scheduled medication order to address the behavioral need. 4) Each instance of an Emergency Behavioral Medication will be documented on a central log in accordance with Texas Administrative Code Rule 415.271. Procedure for Violent/Behavioral Emergency requiring the use of an EBM: 1) De-escalate a) Make attempts to de-escalate the situation by using the least restrictive measures and crisis intervention techniques which may include the interventions listed below. Document description of the patient’s behavior, less restrictive alternatives utilized and patient’s response to interventions.” Page 3 and 4 of 7 “2) Observation a) ... b) A staff member who did not administer the EBM shall maintain continuous face-to-face observation of an individual after administration of the EBM. ... 3) Orders ... e) Face-to-face evaluation within one hour of administration of the EBM is required to be completed by the Physician or a competent provider or RN. i) As authorized by statutory regulations and this policy, the physician may delegate the face-to-face evaluation to an Advanced Practice Registered Nurse (APRN), a physician assistant (PA), or an RN who has current competency on performing the evaluation. ... iv) The face-to-face evaluation must include the individual’s immediate situation, the individual’s response to the intervention and individual’s medical and behavioral condition.” Page 5 of 7 “4) Documentation a) An RN must document the patient’s response, behavior, any adverse side effects, and validation that the patient’s rights, dignity, well-being and safety have been maintained every 15 minutes for one hour after administration of an EBM, or longer if clinically necessary. ... 6) Debriefing a) After the administration of an EBM: i) Identify what led to the behavioral intervention ii) Identify strategies to prevent further interventions iii) Validate that the patient’s physical well-being, psychological comfort and right to privacy were protected iv) Identify if there were any injuries that resulted from the interventions and address those injuries v) Identify staff members who were present and involved in the intervention.””

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36827 Based on review of patient records, policies and procedures, and interview, the facility failed to: A) ensure that 5 patients (Patient #1, #2, #13, #14 and #15) of 5 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault. Refer to Tag C2502 B) ensure patients were properly protected from abuse. The facility failed to ensure the state required mandatory report of suspected abuse to the Texas Department of Family Protective Services (DFPS), Child Protective Services (CPS) was made for 2 minor patients (Patient #6, Patient #15) of 4 minor patients when there was a reasonable suspicion that abuse was involved. Refer to Tag C2525”

“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: 36827 Based on observation, interview, and review of records, the facility failed to enforce policies to ensure special responsibilities of Medicare hospitals in emergency cases under 482.24 were met. The facility failed to: A) post conspicuously a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor in 13 areas (10 treatment rooms, ambulance entrance, public entrance, and waiting area) of 14 required areas. Refer to Tag C2402 B) ensure that the central log listed every individual who had come to the emergency department seeking assistance for 1 (Individual #21) of 1 individual who were known to have requested assistance but did not receive care at the facility. Refer to Tag C2405 C) provide 2 individuals (Patient #2 and Individual #21) out of 21 emergency department encounters reviewed with a documented medical screening examination. Refer to Tag C2406”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 36827 Based on observation, interview, and review of records, the facility failed to post conspicuously a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor in 13 areas (10 treatment rooms, ambulance entrance, public entrance, and waiting area) of 14 required areas. On 6-24-25 at 9:40 AM, a tour of the Emergency Department was made with Staff #9 and Staff #5 present. A large sign in the updated form specified by the Secretary was observed to be displayed in the registration area. It was not visible from the public entry or waiting area. No required signage was displayed at the public entry or in the waiting area. The ambulance area entrance did not have the required signage posted. The trauma treatment room and one other treatment room were observed. Neither had the required signage posted. Staff #5 was asked if any of the other occupied treatment rooms had signage. Staff #5 confirmed that none of the treatment rooms had signage posted. Staff #5 stated he didn’t understand why they needed to be in the treatment rooms when it was displayed at the registration area. Staff #5 was asked if patients ever get escorted immediately straight back to a treatment room and were registered and triaged in the treatment room. Staff #5 confirmed that they do that routinely for certain emergent patients such as brought in by ambulance. Staff #5 acknowledged that the treatment room would be the only opportunity for patients to be able to view the required signage in those instances when a patient was taken straight back to a treatment room. A review was made on 6-24-25 of Ut Health East Texas policy Title: EMTALA - Signage Policy - CD - MKT; Policy Number: 30523.2; Approved by: Market Director, Facilities Operation, Regional Director of Compliance, UTHET DCC; Market Approval Date: 04/30/2019; Effective Date: 01/26/2023; Next Review Date: 01/16/2026 . On Page 1, under the heading “Procedure:”, item 2). The policy stated the following: “2) Location of Signage. Each Dedicated Emergency Department of UT Health East Texas will post Signage in places likely to be notices by all individuals entering the Dedicated Emergency Department, as well as those individuals waiting for examination and treatment, including the entrance, admitting area, waiting room, and treatment area, specifying the rights of individuals to examination and treatment for Emergency Medical Conditions and women in Labor.” Hospital Staff failed to follow hospital policy.”

“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: 36827 Based on review of records and interview, the facility failed to ensure that the central log listed every individual who had come to the emergency department seeking assistance for 1 (Individual #21) of 1 individual who were known to have requested assistance but did not receive care at the facility. On 6-20-25 at 12:09 PM, prior to the on-site investigation, an interview was conducted with Law Enforcement (LE) #22 at the Lone Star Police Department. LE #22 stated he had taken a sexual assault survivor to the UT Health East Texas Pittsburg Emergency Department on 3-6-25. He stated she had been “brutally” assaulted, “writhing” in pain, and complaining of bleeding from her anus. LE #22 provided body-worn camera video of the encounter with hospital staff at the ambulance bay entrance of the hospital. Note: time stamps on video indicate hours and minutes of video time and not hours and minutes of the day. Review of body-worn camera video from 3-6-25 showed that at the 01:24:23 point of the video LE #22 and Individual #21 arrived at the ambulance entrance of the hospital. LE #22 could not get anyone’s attention to allow them in the ambulance entrance. LE #22 walked around to the public entrance and made contact with Staff #11. Staff #11 could be seen later in the video at 01:31:24 asking for the name and date of birth of Individual #21 in order to register her. At the 01:34:42 mark of the video, Staff #11 could be seen coming back out to the ambulance bay with a set of patient stickers. LE #22 was told there was not a Sexual Assault Nurse Examiner (SANE) nurse available. LE #22 inquired if one was available in Greenville. Staff #11 volunteered that Hospital #2 had a SANE nurse and asked if LE #22 wanted her to call and verify. At 01:35:46, Staff #11 returned and told LE #22 that Hospital #2 had a SANE nurse on call. LE #22 stated he was going to take Individual #21 there. At 01:39:06, LE #22 could be seen getting into his truck and leaving to go to Hospital #2. On 6-24-25, a review of the Central Log was made. Individual #21 could not be found on the log. Staff #1 and Staff #2 were told that there was video of Individual #21 interacting with their staff and were asked to investigate it. On 6-24-25 at 11:59 Staff #1 reported that she had looked up Individual #21 by name and found that on 3-6-25 Individual #21 had been registered, but the registration had been cancelled by Staff #11. Staff #1 stated she was going to have Information Technology (IT) figure out what happened “in the background). Staff #2 reported later that day that it was documented the reason for cancellation of registration was that information was entered in error. On 6-24-25, Staff #11 was interviewed in the conference room. Staff #11 confirmed that she had volunteered to call Hospital #2 to see if a SANE Nurse was available. Staff #11 confirmed that she cancelled the admission. “If they were not seen, I cancel the encounter. If there is no charting and don’t want to bother the nurses, I just remove them off the board.” Staff #1 was asked to provide a list of cancelled admissions. Staff #1 stated they did not have a report that could provide that list. Staff #1 stated there would be no way of knowing if an admission was truly cancelled due to information entered in error of if the individual had left before being seen. Review of the encounter for Individual #21 showed that Staff #11 created an Emergency Room Encounter on 3-6-25 at 6:45 PM. Staff #11 cancelled the encounter on 3-6-25 at 6:53 PM. Review of UT Health East Texas policy Title: EMTALA - Central Log - CD - MKT; Policy Number 30518.3; Approved by: Regional Director of Compliance, UTHET DCC; Market Approval Date: 04/30/2019; Effective Date: 04/12/2023; Next Review Date: 04/12/2026 was made on 6-24-25. Under the heading “Procedure:”, number 8), the policy stated: “8) A Central Log entry should be made at the patient’s first point of contact with UT Health East Texas. This would normally take place at Triage and be finalized after the Medical Screening Examination and/or any necessary treatment to Stabilize the Emergency Medical Condition, as applicable. An individual should be recorded in the Central Log even if he/she leave the UT Health East Texas before Triage or receiving a Medical Screening Examination.” Hospital Staff failed to follow hospital policy. Review of Staff #11’s personnel file showed that she was a contract employee and had a limited contractor file. Per the contract, the contractor was responsible for training. Staff #11 had a training Standard Operating Procedure (SOP) titled Patient Access: EMTALA Registration. The training did not address that an individual presenting to the Emergency Department could not be removed from the Central Log. No evidence was presented to show that the hospital had trained Staff #11 on their internal policies and procedures. During personnel file reviews on 6-25-25 at 11:55 with Staff #7, Staff #7 stated that all training for Patient Access staff to include Staff #11 was provided by the contractor.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 36827 Based on review of records and interview, the facility failed to provide 2 individuals (Patient #2 and Individual #21) out of 21 emergency department encounters reviewed with a documented medical screening examination. Findings were as follows: On 6-20-25 at 12:09 PM, prior to the on-site investigation, an interview was conducted with Law Enforcement (LE) #22 at the Lone Star Police Department. LE #22 stated he had taken a sexual assault survivor to the UT Health East Texas Pittsburg Emergency Department on 3-6-25. He stated she had been “brutally” assaulted, “writhing” in pain, and complaining of bleeding from her anus. LE #22 provided body-worn camera video of the encounter with hospital staff at the ambulance bay entrance of the hospital. Note: time stamps on video indicate hours and minutes of video time and not hours and minutes of the day. Review of body-worn camera video from 3-6-25 showed that at the 01:24:23 point of the video LE #22 and Individual #21 arrived at the ambulance entrance of the hospital. LE #22 could not get anyone’s attention to allow them in the ambulance entrance. LE #22 walked around to the public entrance and made contact with Staff #11. At approximately 01:26:46, Staff #22 could be seen outside of the ambulance entrance telling LE#22 that Individual #21 would have to go through the public entrance and register. LE #22 informed Staff #22 that Individual #21 was a “sexual assault trauma”. Staff #11 could be seen later in the video at approximately 01:31:24 asking for the name and date of birth of Individual #21 in order to register her. At the approximately 01:34:42 mark of the video, Staff #11 could be seen coming back out to the ambulance bay with a set of patient stickers. LE #22 was told there was not a Sexual Assault Nurse Examiner (SANE) nurse available. LE #22 inquired if one was available in Greenville. Staff #11 volunteered that Hospital #2 had a SANE nurse and asked if LE #22 wanted her to call and verify. At approximately 01:35:46, Staff #11 returned and told LE #22 that Hospital #2 had a SANE nurse on call. LE #22 stated he was going to take Individual #21 there. Individual #21 could be heard saying, “It hurts really bad”. At approximately 01:36:48, Individual #21 could be seen vomiting. LE #22 told Staff #22 and Staff #11 that Individual #21 had been vomiting all day and didn’t have anything left in her to throw up. Individual #21 told Staff #22 and Staff #11 “My butthole hurts really bad.” At approximately 01:39:06, LE #22 could be seen getting into his truck and leaving to go to Hospital #2. At no time during the interaction did a nurse or physician come outside to assess Individual #21. On 6-24-25, Staff #11 was interviewed in the conference room. Staff #11 confirmed that she had volunteered to call Hospital #2 to see if a SANE Nurse was available. Staff #11 stated she had worked at Hospital #2 and knew they had one over there and “we didn’t have one”. When asked if the triage nurse had seen Individual #21, she stated she could not remember. On 6-24-25 a review was made of the Encounter Event Summary for Individual #21. The record showed that Staff #11 created an Emergency Room Encounter on 3-6-25 at 6:45 PM. Staff #11 cancelled the encounter on 3-6-25 at 6:53 PM. No other emergency department staff accessed the encounter during that time. No triage examination was documented. No Medical Screening Examination was documented. The encounter had been cancelled with an annotation “Created in error” under the Event Management tab for the encounter. On 6-24-2025, Patient #2’s medical chart was reviewed. Patient #2 was an 8-year-old child brought in by the father on 6-18-25 at 9:44 PM. Patient #2 was discharged on 6-19-25 at 1:00 AM. The computer showed that a provider was assigned at 10:03 PM and labs were ordered by the physician at 10:14 PM. The triage nurse documented at 10:04 PM the following note: “Pt amb to ER1 with steady gait, accompanied by dad. Dad reports that pt has been experiencing some changes in mood and behavior such as anger issues, disobedience, and has begun bedwetting and hiding the wet clothes. Dad state that pt went to the bathroom and when she pulled her shirt from her pant, there was a spot on the lower front and he noticed a bad smell coming from the area. Dad expressed concern for SA because pt’s mother has a new boyfriend that moved into the house pt lives in approx 8 months ago, located in (redacted for patient privacy). Dad also reports his 13 and 14 year old daughters say they have kissed mother’s boyfriend. Pt denies complaints. Dad denies PMH. UTD on vaccines.” The complete paper chart was requested and provided on 6-25-2025. Upon review of the completed paper chart it was found that no Medical Screening Examination was documented. At the bottom of page 1 of the chart, it was documented: “ED Provider Note No documentation.” On page 3 on the upper half of the page the following was documented: “H&P Notes No documentation” “Clinical Notes No documentation” “Discharge Summary Note No documentation” There were Discharge Instructions documented by the physician that stated: “Follow up with law enforcement and with child advocacy as instructed.” Other than the discharge instructions, no documentation from the physician about the patient’s condition was found in the chart. On 6-24-25, a review was made of UT Health East Texas Policy Title: EMTALA - Medical Screening Examination and Stabilization-CD-MKT; Policy Number: 30519.3; Approved by: Regional Director of Compliance, UTHET DCC; Market Approval Date: 10/22/2019; Effective Date 04/19/2023; Next Review Date: 04/19/2026. Page 1 under Policy stated: “1) Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual has an Emergency Medical Condition, UT Health East Texas will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition, within UT Health East Texas’s Capability and Capacity.” Page 2 under Procedure stated: “2) Performance of the Medical Screening Examination. The Dedicated Emergency Department must provide for an appropriate Medical Screening Examination within the Capability of the Dedicated Emergency Department, including ancillary services routinely available to the Dedicated Emergency Department, to determine whether or not an individual has an Emergency Medical Condition, or with respect to a pregnant woman having contractions, whether woman is in Labor, ...” Page 4, item 4) stated: 4) Personnel who may Perform the Medical Screening Examination. a) The Medical Screening Examination may be performed by a Physician or Qualified Medical Person who is qualified to conduct such examination. b) UT Health East Texas and its Medical Staff will determine the categories of Qualified Medical Person who may perform the Medical Screening Examination. The Medical Staff bylaws or rules and regulations, as approved by UT Health East Texas governing body, will designate categories of Qualified Medical Persons in each Dedicated Emergency Department who are authorized to perform the Medical Screening Examination.” No evidence was found that either Individual #21 or Patient #2 received the required Medical Screening Examination from a physician or qualified medical person per hospital policy.”

“NOTICE OF RIGHTS CFR(s): A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under state law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible This Standard is not met as evidenced by: 36827 Based on review of patient records, policies and procedures, and interview, the facility failed to ensure that 5 patients (Patient #1, #2, #13, #14 and #15) of 5 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault. Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES, Subchapter (b) requires: (b) A health care facility providing care to a sexual assault survivor shall provide the survivor with: ... (3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure; (4) the information form required by Section 323.005; (Sec. 323.005. INFORMATION FORM. (a) The commission shall develop a standard information form for sexual assault survivors ...) ... (7) the name and telephone number of the nearest sexual assault crisis center; and ... Findings included the following: On 6-24-2025 during the entrance conference, the facility was asked to provide a table of contents of all policies that pertained to the operations of the Emergency Department. Staff #1 provided that list on the afternoon of 6-24-2025 and confirmed it was the table of contents for all Emergency Department Policies. Review of the Table of Contents for UT Health East Texas Emergency Department Policies was reviewed. It contained only 1 policy pertaining to Sexual Assault, Titled “FNE/SANE - Drug Facilitated Sexual Assault - ED - MKT Review was made on 06-24-2023 of the Policy Title: FNE/SANE - Drug Facilitated Sexual Assault - ED - MKT; Policy Number: 48445.2. The “Objective” of the policy was stated as “To obtain blood and/or urine specimen for toxicology and maintain chain of custody. The policy did not contain information or procedures for ensuring patients were provided the following patient rights as required by state law: access to a sexual assault program advocate, if available; the information form required by the commission detailing survivor rights and required information; or the name and telephone number of the nearest sexual assault crisis center. Review of charts for Patient #1, #2, #13, #14 and #15 showed no documentation of patients receiving the required notice of rights titled “Information for Survivors of Sexual Assault” required by the Texas Health and Safety Code Chapter 323. No evidence was found that the facility had attempted to provide the patients with access to a sexual assault program advocate. No evidence was found that the facility provided the patients with the name and telephone number of the nearest sexual assault crisis center as required. Interview was conducted with Staff #5 on the morning of 6-24-25 in the Emergency Department. Staff #5 was asked if there were information forms provided to patients who presented to the Emergency Department after sexual assault. Staff #5 stated there was no “set document list” for resources for sexual assault victims. Later that afternoon, Staff #1 provided a copy of the State required information form titled “Information for Survivors of Sexual Assault” and stated this form was available in the Emergency Department for patients who had been sexually assaulted. However, it was dated 2/25/2020. The current version of the form with correct information was dated 12/20/23. Staff #1 confirmed the facility was unaware that it had changed. Interview was conducted on 6-25-25 with Staff #1, Staff #2, Staff #4 and Staff #5. All confirmed that they were not familiar with the Texas Health and Safety Code Chapter 323 and had not developed policies and procedures to ensure the patients received the required notice of rights through the State required information sheet.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36827 Based on review of records and interview, the facility failed to ensure patients were properly protected from abuse. The facility failed to ensure the state required mandatory report of suspected abuse to the Texas Department of Family Protective Services (DFPS), Child Protective Services (CPS) was made for 2 minor patients (Patient #6, Patient #15) of 4 minor patients when there was a reasonable suspicion that abuse was involved. Findings were as follows: Review was made of Patient #6’s medical record on 6-24-25. Patient #6 was a 17 year old male who had been drinking alcohol. He was brought to the Emergency Department on 6/8/25 by ambulance at 3:25 AM. Per the chart, “pt arrived to ED by EMS after he got into a fight at 0230 this morning. Pt was drinking and tried to drive a friend home when his grandfather tried to stop him. They got into a physical altercation. EMS reports pt was non-responsive on their arrival. Pt stated he just remembers waking up in the ambulance. Unknown quantity of ETOH consumed by pt.” 6/8/25 at 4:55 AM the nurse charted, “Pt’s mother attempted to leave the ED while PPD officers x2 at bedside. She walked to the waiting area at that time I walked out and told the pt’s mother he is a minor and she was his legal guardian and she has to stay. Pt’s mother is standing outside pt’s room.” No evidence of a report being made to CPS was found in the chart. Review of Patient #15’s medical record on 6-24-25. Patient #15 was an 11 year old. Patient #15 presented to the Emergency Department on 2/13/25 at 6:56 PM. Patient #15 claimed an 11 year old cousin had been sexually assaulting Patient #15 since the age of 6. No evidence of a report being made to CPS was found in the chart. Staff #1 and Staff #5 confirmed there was not evidence of CPS being involved in either case. Both stated that since Law Enforcement had been contacted, they believed the duty to report had been met. In fact, it had not. A separate report to DFPS, CPS was required per Texas Family Code 261.103(c). Staff #5 made the required report on 6-24-25 for patient #6 and on 6-25-25 for patient #15. Review was made on 6/25/2025 of UT Health East Texas policy Title: Special Cases to be Reported - ED - MKT; Policy Number: 49997.2; Approved by: UTHET CNO Council, UTHET DCC; Market Approval Date: 11/22/2019; Effective Date: 06/05/2023; Next Review Date: 06/05/2026. The policy contained the following: “Policy: The law requires that special cases be reported to the appropriate authority. Procedures: Case Agency 1) Deaths Law Enforcement 2) Death with Possible Criminal Involvement Law Enforcement 3) Death of a Person Not Yet Identified Justice of the Peace 4) Animal Bites Animal Control 5) Child, Elderly Abuse > 65 or mentally Child or Adult Handicapped Protective Services 6) Any extenuating circumstances or suspect cases Law Enforcement Hospital Staff failed to follow hospital policy.”