Childrens Medical Ctr of Dallas

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45521 Based on a record review and interviews, the facility failed to perform and document an appropriate medical screening examination (MSE), including a complete psychiatric evaluation by qualified medical personnel for patients experiencing a psychiatric emergency, to determine if the patient was stable or had an emergency medical condition for 1 of 20 patients (Patient #13). Patient #13 presented to the emergency department under an Apprehension by Peace Officer without warrant (APOWW) with suicidal ideation and mental health concerns. The facility failed to conduct a psychiatric evaluation and allowed the patient to leave under the custody of the police. Based on a record review and interviews, the facility failed to provide an appropriate transfer for two of 20 patients whose records were reviewed (Patients #1 and #13). Facility A failed to: 1. Notify a receiving hospital and verify with the receiving facility that there was available space and qualified personnel for Patients #1 and # 13 to transfer and secure an accepting physician. 2. Indicate the risks and benefits of transfer in writing. 3. Complete the physician certification with a summary of risks and benefits. 4. Send the receiving facility all medical records related to the emergency medical condition of Patient # 1 and #13, who left against medical advice, being transported by the Dallas Police Department. Refer to A2406 for additional information. Refer to A2409 for additional information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45521 Based on a record review and interviews, the facility failed to perform and document an appropriate medical screening examination (MSE), including a complete psychiatric evaluation by qualified medical personnel for patients experiencing a psychiatric emergency, to determine if the patient was stable or had an emergency medical condition for 1 of 20 patients (Patient #13). Patient #13 presented to the emergency department under an Apprehension by Peace Officer without warrant (APOWW) with suicidal ideation and mental health concerns. The facility failed to conduct a psychiatric evaluation and allowed the patient to leave under the custody of the police. A review of Patient #13’s Medical Chart revealed the following; Patient #13, a 15-year-old female, arrived at Facility A on 12/12/2024 at 2:29 PM in the custody of the Dallas Police Department. The officer brought Patient # 13 to Facility A for Medical Clearance A review of the document titled “ED Care Timeline” on 12/12/2024 at 2:36 PM by Staff # 9, RN, revealed that Patient # 13 received a high-risk score for a Suicide Assessment. An order for constant visual observation was placed by Staff # 10, MD, at 2:44 PM. A review of the document titled “ED Provider Note” by Staff #8, MD-Emergency Medicine, on 12/12/2024 at 5:03 PM revealed the following: Patient #13 did not provide the necessary information for the assessment. A Dallas Police Officer provided the current history. Patient #13 appeared at school at 10:00 AM after running away around Thanksgiving. The police officer attempted to contact Patient #13’s mother to arrange a transfer of care, but she declined. Patient #13 was taken into custody at 12:30 PM, and it was planned to transfer the patient to residential treatment. Patient #13 told the police she smoked marijuana in the morning. The police brought Patient #13 to Facility A for medical clearance before the patient arrived at the residential treatment facility. Vital Signs: Patient Vitals for the past 24 hrs: 12/12/24 2:45 PM- Temp: 99.7 °F, Pulse: 71, Resp: 18, SpO2: 98 % 12/12/24 3:36 PM- Temp: 99 °F, Pulse: 108, Blood Pressure: 106/73, Resp: 20, SpO2: 98 % 12/12/24 5:08 PM- Temp: 98.6 °F, Pulse: 71, Blood Pressure: 125/69, Resp: 20, SpO2: 98 % Physical Exam: No abnormalities were noted. No diagnostics were done. Medical Decision Making: Patient # 13 is a 15-year-old female who is presenting as a runaway, here for a medical screening exam, and is screened as high risk for suicide. “1834[6:34 PM]: Law enforcement notified me that the patient has an outstanding warrant that will result in arrest and juvenile detention. Mental health evaluation has not been completed. I confirmed with officer at bedside that the Pt is being taken to a facility that has mental health evaluation capacity.” A review of the document titled “Emergency Notes” by Staff # 6, RN, on 12/12/2024 at 6:45 PM revealed the following: The Against Medical Advice form was signed. Patient # 13 left with the Dallas Police Department and the patient’s mother. Policy A review of the policy “AD 2.29.01 Emergency Medical Treatment (EMTALA) and Patient Transfer -Dallas” revealed the following: page 4, Section A, subsection A “PROCEDURE: A. Patient’s Rights and General Provisions A. Medical Screening. The Hospital recognizes the right of an individual to receive, within the capabilities and capacity of the Hospital: a. An appropriate MSE, including ancillary services routinely available to the Emergency Department, diagnostic testing and procedures, and physician consultative services to determine whether or not an emergency medical condition exists ; b. If an emergency medical condition exists, necessary stabilizing treatment (including treatment for an unborn child); and c. If necessary, an appropriate transfer of an individual with an emergency medical condition to another facility, even if the individual cannot pay, does not have medical insurance, or is not entitled to Medicare or Medicaid. The Hospital should not move individuals off-campus for the MSE.” This policy does not address the need for a psychiatric exam as part of the MSE for patients who were suspected to be suicidal, had taken a chemical/drug overdose, or were otherwise suspected to exhibit intentional self-harm behavior. A review of the document titled “Rules and Regulations of the Medical/Dental Staff,” approved on December 9, 2024, revealed the following: page 4, Section 1. Subsection 1.9: “Any patient who is evaluated in the Emergency Department (ED) or is being admitted to or is already an inpatient at [Facility A], and who is known or suspected to be suicidal, has taken a chemical/drug overdose, or is otherwise suspected of exhibiting intentional self-harm behavior, shall have a mental health assessment. The assessment may be performed by a mental health clinician (LCSW, LPC, LMFT, PhD, MD or DO) [Licensed Clinical Social Worker, Licensed Professional Counselor, Licensed Marriage and Family Therapist, Doctor of Philosophy, Medical Doctor or Doctor of osteopathic medicine] who will provide the findings of that assessment to the ED attending or the patient’s treating physician. The attending will determine if additional psychiatric consultation is needed. If this assessment is refused by the patient, parent, or other authorized party, the medical record shall indicate that the assessment was recommended, offered, and refused. A referral shall be made by the physician to Child Protective Services, if appropriate, and necessary suicide prevention precautions shall be taken according to [Facility A] policy and procedure.” Facility A failed to provide a mental health assessment for Patient # 13, who had a high risk score for suicide and had stated she had taken an illegal drug hours before arrival at the facility.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45521 Based on a record review and interviews, the facility failed to provide an appropriate transfer for two of the 20 patients whose records were reviewed (Patients #1 and #13). Facility A failed to: 1. Notify a receiving hospital and verify with the receiving facility that there was available space and qualified personnel for Patients #1 and # 13 to transfer and secure an accepting physician. 2. Indicate the risks and benefits of transfer in writing. 3. Complete the physician certification with a summary of risks and benefits. 4. Send the receiving facility all medical records related to the emergency medical condition of Patient # 1 and #13, who left against medical advice being transported by the Dallas Police Department. Findings included: Medical Records Review at Facility A: 20 patient charts were selected as the sample group. Two of the 20 had improper transfers (Patients #1 and #13). Both patients left the facility with the Dallas Police Department. Patient # 1: Summary: On the morning of 12/11/2024, the patient’s mother was unable to elicit a response from the patient and called an ambulance. The patient arrived at the facility on 12/11/2024 at 10:45 PM via Dallas Fire Rescue-EMS. Patient # 1’s chief complaint was “Intentional Ingestion of 15 Tylenol PM and 15-20 ibuprofen 500mg each.” Patient # 1 has a past medical history that includes anxiety and cutting. Patient # 1 was in the emergency room with two Dallas Police Department Officers under Constant Visual Observations for suicide precautions. Staff # 3, DO, Emergency Medicine, cleared Patient # 1 for discharge. Staff # 3, DO, Emergency Medicine, noted the Dallas Police Department plan to take her for a psychiatric evaluation after she is cleared medically. Patient # 1 was discharged from Facility A on 12/12/2024 at 5:57 AM and left with the police. The Dallas Police Department transported Patient #1 to Facility B after discharge from Facility A. Patient #1 was assessed at Facility B and then transferred to Facility C. Facility A failed to ensure that Patient # 1 would be transferred to a higher level of care that a suicidal patient would expect. A review of the document titled “ED Provider Notes” by Staff # 3, MD, Emergency Medicine, on 12/11/2024 at 10:48 PM revealed the following: Patient # 1 is a 16-year-old female with no significant past medical history. Patient # 1 arrived at the Emergency Department for evaluation of intentional ingestion of pain pills on 12/12/2024 at 10:30 PM. Patient # 1 has complaints of dizziness and nausea, but denied headache or pain concerns. Patient # 1 denied past suicidal attempts but had self-inflicted cuts with a razor to her arms and thighs (done during Nov 2024). The patient lived with her mother and brother and says she gets along with her brother most of the time, but remains silent when asked with her mom. Her brother reported that Patient #1 had a verbal fight with mom while he was napping. Patient # 1 was reported as acting odd after ingesting Tylenol PM and Ibuprofen tonight. The Dallas Police Department reports that the mother called the ambulance due to intentional ingestion and brought her to Facility A for medical clearance. She is under an Apprehension by Police Officer Without Warrant. The Dallas Police Department plans to take her for a psychiatric evaluation after she is cleared medically. Patient #1 was noted as withdrawn and didn’t respond verbally to questions. A review of the document titled “ Body Image Diagram Note” by Staff # 1 on 12/11/2024 at 11:00 PM revealed the following: Superficial cut marks to bilateral anterior thighs and right anterior forearm. A review of the document titled “ Social Work Progress Note” by Staff # 4, LMSW, on 12/11/2024 at 11:54 PM revealed the following: The Dallas Police Officer was in the room when Patient #1 spoke with Staff #5, LCSW. Staff # 5 noted that the Dallas Police Officer made a full report and checked to see if Patient # 1 needed an APOWW due to the patient’s ingestion of medication. At 05:53 AM on 12/12/2024, Staff # 2, RN-ED, noted that verbal and written discharge instructions were given to the Dallas Police Department. Vital signs were noted as stable. Patient # 1 was stable for discharge. Facility B: A review of the document titled “Admission Information” on 12/12/2024 revealed the following: On 12/12/2024 at: “ 6:10 AM: Patient # 1 arrived at Facility B (ED) 6:41 AM: Triage started by Staff # B1, RN, Primary “ 7:20 AM: MSE started by Staff # B3, MD, Attending Physician “ 8:32 AM: by Staff # B3, Attending Physician: “Reassuring Tylenol and a salicylate level, Tylenol level of 17 per nomogram should be less than 30 at 12 hours post-ingestion, no signs of liver damage with bicarb of 21, do not feel need for further evaluation of drug ingestion. Patient medically cleared pending psychiatric evaluation.” “ 10:29 AM: Apprehension by Peace Officer Without Warrant, Active (APOWW) Order. EMERGENCY DETENTION - Dallas Police Department. “ 4:39 PM: by Staff # B5, RN Primary: Patient transferred to Dallas Behavioral Health Hospital “ Transportation Arrangements: CA1, Ambulance A review of the document titled “Department of Psychiatry, Social Work Discharge Summary” by Staff # 6, LMSW, on 12/12/2024 at 2:25 PM revealed the following: Patient # 1 arrived at Facility B from Facility A Emergency Department with no past psychiatric or medical history. Patient #1 is under apprehension by a peace officer without a warrant for a psych evaluation for attempted suicide by ingestion of Tylenol and ibuprofen. The patient’s mother reported her daughter had taken Tylenol and other pills in an attempt to kill herself around 8:15 PM on 12/11/24. During the initial assessment, Patient # 1 said she had a recent suicidal ideation attempt by intentional overdose on ibuprofen and Tylenol PM. Patient commented about sexual abuse history and was connected to trauma resources. Patient #1’s mother agreed with the treatment team’s recommendation for inpatient hospitalization. Patient was accepted to Facility C and will transfer for further treatment stabilization. Final Assessment of Risk: High Chronic Risk: Moderate A review of the document titled “ED Notes” by Staff # 5, RN Primary, on 12/12/2024 at 4:37 PM revealed the following: Report given to EMS personnel. Patient # 1 was transferred to the EMS stretcher with minimal assistance. Patient transferred to Facility C with mother at side. Patient # 13: A review of Patient #13’s Medical Chart revealed the following; Summary: Patient # 13 arrived at Facility A on 12/12/2024 at 3:27 PM. Her chief complaint was noted as “Medical Clearance (Pt stated she smoked marijuana this morning. +SI screening in triage). Visit Diagnosis: Behavior involving running away.” Patient # 13 was screened by Staff # 9, RN, and was noted as having a “Positive High-Risk Suicide Assessment,” and Staff # 10, MD, was notified by the RN. Staff # 10 placed the order for constant visual observation. The facility failed to provide a complete medical screening exam, including a psychiatric exam before Patient # 13 left the facility with the Dallas Police Department against medical advice on 12/12/2024 at 7:00 PM. A review of the document titled “Emergency Notes” by Staff # 6, RN, on 12/12/2024 at 6:45 PM revealed the following: The against medical advice form was signed. Patient # 13 left with the Dallas Police Department. The patients mother was present and aware. A review of the document titled “ED Provider Note” by Staff #8, MD-Emergency Medicine, on 12/12/2024 at 5:03 PM revealed the following: Patient #13 did not provide the necessary information for the assessment. A Dallas Police Officer provided the current history. Patient #13 appeared at school at 10:00 AM after running away around Thanksgiving. The police officer attempted to contact Patient #13’s mother to arrange a transfer of care, but she declined. Patient #13 was taken into custody at 12:30 PM, and it was planned to transfer the patient to residential treatment. Patient #13 told the police she smoked marijuana in the morning. The police brought Patient #13 to Facility A for medical clearance before the patient arrived at the residential treatment facility. Vital Signs: Patient Vitals for the past 24 hrs: 12/12/24 2:45 PM- Temp: 99.7 °F, Pulse: 71, Resp: 18, SpO2: 98 % 12/12/24 3:36 PM- Temp: 99 °F, Pulse: 108, Blood Pressure: 106/73, Resp: 20, SpO2: 98 % 12/12/24 5:08 PM- Temp: 98.6 °F, Pulse: 71, Blood Pressure: 125/69, Resp: 20, SpO2: 98 % Physical Exam: No abnormalities were noted. No diagnostics were done. Medical Decision Making: Patient # 13 is a 15-year-old female who is presenting as a runaway, here for a medical screening exam, and is screened as high risk for suicide. “1834[6:34 PM]: Law enforcement notified me that the patient has an outstanding warrant that will result in arrest and juvenile detention. Mental health evaluation has not been completed. I confirmed with officer at bedside that the Pt is being taken to a facility that has mental health evaluation capacity.” Policy: A review of the document titled “AD 2.29.01 Emergency Medical Treatment (EMTALA) and Patient Transfer -Dallas revealed the following. Page 3, Topic-Transfer “Transfer means the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated with) the hospital, but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person. (Pursuant to state hospital licensing regulations, the movement of a stable patient from the hospital to another medical facility is not considered to be a transfer if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital, provided that the patient remains stable during the transfer.) An appropriate transfer occurs when: a. The transferring hospital provides treatment within its capabilities to minimize risks to the Patient (and to the unborn child if the Patient is pregnant) b. The receiving facility agrees to the transfer and has the capability and capacity (bed and staff) to treat the Patient. c. The transferring hospital sends pertinent medical records and a completed Memorandum of Transfer (MOT). d. The transfer occurs with qualified personnel and equipment.” The facility failed to follow its policy regarding the movement of Patients #1 and #13 outside Facility A without a physician’s transfer order. Interviews: 1. An interview with Staff # 3, MD-Emergency Medicine, on 02/04/2025 at approximately 3:30 PM revealed the following information: Patient # 1 came in for an overdose; I did a workup, she was medically cleared, and I discharged her to the Dallas Police Department. The Police said they didn’t want to wait for a psych evaluation. They said they were going to take her to [Facility C]. Our leadership told us that if a patient was under an APOWW, we didn’t have to do a psych eval. My last EMTALA training was in December. We were told if we feel like they need a psych eval, we should do it; if the police are there, it’s ok to discharge a patient to the police. 2. An interview with Staff # 2, RN-ED, on 02/04/2025 at 3:00 PM revealed the following information: I came in and took over the patient. The patients mom and the Dallas Police Department were there. The doctor put in a discharge order. I asked Staff #3, MD, Emergency Medicine, if it was okay to discharge the patient without seeing MHAT. She said it should be okay because the Dallas Police Department was taking the patient. I also told the charge nurse.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45847 . Based on record review and interview the facility failed to abide by the provider’s agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review and interview, the facility failed to provide a complete emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed when: 1. Patient #1’s physical exam did not include a sufficient neurologic examination to determine if an emergency medical condition (EMC) was present following a physical altercation and possible traumatic event at home and chief complaints of choking without loss of consciousness. 2. No psychiatric evaluation for Patient #1 was found in the chart despite Staff #13 noting that Patient #1 would need a mental health evaluation and likely a psychiatric consult. 3. There was insufficient information obtained to rule out the emergency medical condition (EMC) of suicide or self-harm and an EMC was not clearly noted by any of the 3 physicians who examined Patient #1. . Based on record review and interviews, the facility failed to provide an appropriate transfer for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 did not receive an appropriate transfer to an acute psychiatric care facility when they failed to: . 1. Notify the receiving hospital, and verify the receiving facility had available space and qualified personnel for Patient #1’s transfer or secure an accepting physician. . 2. Indicate the risks and benefits of transfer in writing. . 3. Complete the physician certification with a summary of risks and benefits. . 4. Send the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility. . Cross refer A2406 and A2409. .”

“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: 45847 . Based on record review and interview, the facility failed to provide a complete emergency medical screening examination (MSE) for one of 20 (Patient #1) patients whose records were reviewed when: 1. Patient #1’s physical exam did not include a sufficient neurologic examination to determine if an emergency medical condition (EMC) was present following a physical altercation and possible traumatic event at home and chief complaints of choking without loss of consciousness. 2. No psychiatric evaluation for Patient #1 was found in the chart despite Staff #13 noting that Patient #1 would need a mental health evaluation and likely a psychiatric consult. 3. There was insufficient information obtained to rule out the emergency medical condition (EMC) of suicide or self-harm and an EMC was not clearly noted by any of the 3 physicians who examined Patient #1. . Findings include: Review of Police Case DE2407320 on July 20, 2024, due to a report of a Major Disturbance: Police were dispatched to the residence of Patient #1 on (July 20, 2024) at approximately 3:52 PM due to a report of a major disturbance. Patient #1 had left his home and was located at an intersection nearby. Patient #1 stated that his mother was mad at him for throwing a water bottle at his stepfather after being pushed by him “hard”. Per the report, Patient #1 alleged that he was told to get off the couch, a verbal altercation ensued, Patient #1 reports he was pushed to the floor, Patient #1 threw the water bottle at his stepdad, his stepfather began choking Patient #1 by placing both hands around his neck. Patient #1 alleges that it happened quickly and did not cause him to blackout or stop breathing. Then, Patient #1 and his stepfather were choking each other. Patient #1 stated that his mother confronted him while holding an extension cord in her hand and waved it around in a whipping motion. Patient #1 grabbed the cord from his mother and stated, “I’m not afraid to die; you’re not fixing to hit me with no extension cord.” Patient #1 then hit himself on the right side of his neck and stated, “You’re not fixing to hit me with that, I will hit myself with it.” Additionally, it was noted in the officer’s report that patient’s mother “told the offender that she would be calling his probation officer and offender said ‘F all of this, I don’t care if I live or die, I’ll kill my motherf’n self’. After he grabbed the charger off her bed he placed it around his neck and ‘the boys’ took the cord from around his neck.” Patient #1’s mother then told Patient #1 she was going to take him to (a psych facility) because he was trying to kill himself. Patient #1 denied trying to hurt or kill himself. Officer #2 observed a scratch on the right side of Patient #1’s neck with broken skin. . Patient #1’s brothers witnessed the incident and mostly corroborated the report received. . Patient #1’s mother denied attempting to spank him and denied witnessing the stepfather choking him. Patient #1’s mother denied waving a charging cord at Patient #1 and stated that Patient #1 brought the cord into play. . Officer #2 stated the following: Due to his statements/actions about self-harm and his diagnosis of the offender, it was deemed the offender was a danger to himself and others. The offender was transported to Children’s Medical Center for APOWW and medical clearance by Ofc (Officer #1).” Refer to assisting officer badge #401 for details on this process. . The report by the assisting officer, Officer #1, alleges the following: On 7/20/24 at approximately 1552 hours, she (Officer #1) #401 was dispatched to a major disturbance at the home of Patient #1. Officer #1 stated that he was not there upon arrival at Patient #1’s house. Officer #1 stated that she was in a marked squad car and returned to it to search for Patient #1. Patient #1 relayed the above to Officer #1. Patient #1 was detained by Officer #1 and placed in the squad car. Once detained, Officer #1 “made contact with the siblings, who witnessed the confrontation for their side of the story, corroborating with Patient #1’s story”. The story told to Officer #1 by Patient #1’s mother differed from the above report. Based on her findings, Officer #1 “ ...determined that (Patient #1) would be transported to (Facility A) for further evaluation due to his statements/actions about self-harm and his diagnosis. Upon arrival, Officer (Staff #1) informed that (Facility A) no longer accepted APOWWs but could treat (Patient #1) medically. Once (Patient #1) was medically cleared by the doctors (at Facility A), he (Patient #1) was transported to (Facility B) for emergency detention ...” . Patient #1 was listed as the Offender, his stepfather as the Victim, and Patient #1’s mother and two brothers were listed as Witnesses. The offense was listed as “Emergency detention/mental illness/risk of harm. Patient #1 was “cleared by arrest” on 07/24/2024, at 9:59 AM. . Medical Record Review at Facility A: Patient #1 was a 16-year-old male who arrived at Hospital A in the custody of a police officer on 07/20/2024 at 5:21 PM with a chief complaint of “choking” per Staff #19 (Triage RN) on 07/20/2021 at 5:32 PM. Staff’s Initial Triage Notes included: “ED fellow notified of abrasions noted to pts neck. (Patient #1) stable to go to regular room at this time, per ED fellow. (Patient #1) stated he was choked by dad using his hands lasting about 10 secs” Staff #19 escalated the status of (Patient #1) as a “possible traumatic event”. A suicide screening exam was done at 5:33 PM and the patient answered no to all questions regarding suicidal ideation, present and past. Triage Notes also included at 5:41 PM “(markings on right side of neck ... No loss of consciousness ... Vital signs stable).” . At 5:47 PM, a Medical Screening Exam was initiated by Staff #13 (Treating ED Physician). The chief complaint at that time was choking. Notes included: “ ...(Patient #1) is a 16 y.o. male with a PMHx (past medical history) of psychiatric disorders including anxiety, bipolar disorder, depression, and ADHD (attention deficit and hyperactivity disorder), multiple psych admits most recently last month, on multiple medications and receives psych care at (named clinic). Pt with numerous domestic violence charges for violence against family members. Patient #1 presents today with police for medical clearance after an altercation at home. After the altercation, pt took a phone charger and pulled it around his neck, pt then stated he ‘didn’t care if (he) died”. Mom called 911 and pt brought to the ED by police for medical clearance. Noted to have ligature marks around his neck. Denies LOC, difficulty speaking, respiratory distress, abnormal voice change. No HA, visual changes, CP or SOB. Pt denies any SI, HI, denies intention of self-harm ...” . The physical examination was pertinent for a patient who was awake and answering questions during the examination. The neck exam revealed “superficial abrasions and ligature marks to the right neck, tenderness to palpation to the right neck, and no crepitus.” There was no C-spine tenderness. No evaluation of tenderness of the anterior neck or hyoid bone was done for possible choking events. Only an exam of the posterior neck was noted. There was no evaluation of the patient’s capacity to swallow or speak. . The Review of Systems revealed that a limited neurological exam was done for Patient #1stating, “he is alert.” No further neurologic exam was done. . The Psychiatric exam states only that Patient #1 was “calm, cooperative. No suicidal ideation, no homicidal ideation.” Following commands during the examination.” Patient #1 was also noted to have had a “flat affect.” . Per the ED physician’s medical decision-making: “ ...(Patient #1) Pt here with police for medical clearance. Patient meets trauma activation criteria based on mechanism. Plan for CTA, urine drug screen. Per police, when medically clear, will discharge to police custody. No concern for SI or HI, mom states police were called due to dangerous behavior/ activity at home. No indication for MHAT (mental health assessment team) evaluation ...” . A second physician (Staff # 17) assessed Patient #1 at 6:34 PM and notes include: “ ...16-year-old male with a past medical history of bipolar, ADHD presents after strangulation. Per patient, he got into an argument with his mom. Afterwards, they were sitting on the cough and his stepdad told him to get off the couch, they got into an altercation, and he threw a water bottle at stepdad. Stepdad then went and put his hands around his neck, strangled him for about 5-10 seconds. Patient denies SOB or LOC. Complains of some discomfort in throat but denies any sore throat, pain in neck, vocal changes. No other injuries or traumas. Patient says after he was strangled, his mom and him got into another argument. She tried to hit him with a phone charger and so he took the phone charger and put it around his neck posteriorly. He said he did not do this with an intention to strangle himself or end his life. He denies any current or previous SI. Denies any HI. No other complaints at this time. ...” . Review of Systems: HENT: Positive for sore throat. Negative for congestion, trouble swallowing and voice change. Neurological: Negative for speech difficulty and headaches. Psychiatric/Behavioral: Negative for behavioral problems. There was no assessment of potential hallucinations, delusions, depression, or anxiety. . Physical Assessment: Neck: Thyroid: No thyromegaly. Vascular: No JVD. Trachea: No tracheal deviation. Comments: Ligature marks to right side of neck Psychiatric: Comments: Flat affect . Medical Decision Making: (Patient #1) “16-year-old male with a history of bipolar presents after strangulation. Reportedly strangled by stepdad, no LOC. No other injuries. Then got into argument with mom and placed cord around his neck, concern for possible SI though patient denies this. Well appearing on exam though visible ligature marks. Will obtain CTA, medically clear, and consult social work/behavioral health.” . SW Reassessment Note by Staff #16 at 6:48 PM: “ ...HPI: Pt (Patient #1) shared that he was sitting on a couch and pt mother wanted him to sit right (something amongst the lines), (Patient #1) was shoved by stepfather, who retaliated by throwing water with ice on him, pt stepfather in returned choked (Patient #1). Visible marks are on his neck. SW spoke to officer (Officer #1) from DeSoto PD #401 #214-663-5236 aware of CPS report being made. (Officer #1) able to confirm exact story (Patient #1) shared, pt mom story deviated, favoring stepfather. (Patient #1) mom not supportive, challenging staff. Living Status: Patient lives at home with mother, stepfather and 3 siblings. (10,13 and 14) Clinical Impressions: (Patient #1) has a history of mental health support, currently has a case open already with probation, takes medication for various psych diagnosis. Officer at bedside is familiar with family, shares that mother has high involvement and history of being unsupportive towards patient. SW also spoke and updated medical team. Plan: Social Worker will follow up as needed to assess for coping and any other resources. Please contact social worker with any immediate needs or concerns while patient is admitted ...” . The ED Care Timeline notes that at 7:17 PM Staff #14 (ED RN) discussed Patient #1 with Staff #16 (Licensed Medical Social Worker), Officer 1 (DPD), and Staff #13. An order was received for continuous visual observation (CVO). Staff #14 then “Called (an unidentifiable Staff RN) at flow (patient flow) to request CVO at bedside. Pt calm and cooperative with this RN.” . An Emergency Note by Staff #14 at 10:10 PM noted that Patient #1 was wearing a purple gown. (Many facilities use “purple gowns” to denote behavioral health patients who are a flight risk or risk for self-harm.) . At 7:30 PM, a CVO note by Staff #21 (Patient Care Technician) noted that “(Patient #1) Pt becoming increasingly anxious about transferring to another facility.” . At 7:45 PM a “Trauma Activation Alert” (Due to concern for strangling) was initiated by Staff #22 (RN) . At 7:45 PM Trauma Services Provider Assessment by Staff #18 (Trauma Physician). The notes included: “(Patient #1) a 16 y.o. male with significant history of bipolar disorder, ADHD, anxiety, depression, multiple psych admits, and multiple prior domestic violence charges who presents with police after self-inflicted strangulation with phone charger during altercation with mother and stepfather. No loss of consciousness. No current suicidal ideation.” . The physical examination noted that Patient #1’s eyes opened spontaneously, and he had normal verbal responses. The examination also noted that Patient #1 was moving spontaneously, his head was normocephalic and atraumatic. The examination noted that a C-collar was in place, mild tenderness of the neck was noted, and marks to the neck were present. Staff #18 noted that Patient #1 was alert with normal mood and behavior. . Plan: “C-collar ...CT angio (angiogram) neck ...Pain control ... ...Medically clear for discharge from the ER ... without acute injury. Okay to clear collar clinically ...” . A Nursing note at 19:50 noted, “ Aspen collar (C-collar) was placed for spine precautions. . At 8:18 PM the CT Arteriogram of the neck returned with normal results. . At 8:57 PM a SW Progress Note by Staff #15 noted the following: “ ...Assessment Completed: in the Emergency Room ... (Patient #1) is a 16 y.o. male presented to ED for concerns of strangulation. Social worker received handoff from day shift social worker, informed CPS reported needed regarding patient reporting of altercation with stepfather. . An Addendum note at this time by Staff #15 noted the following: “1030pm: Patient medically cleared for discharge. Social worker received update from RN that patient will be discharging with Desoto PD to Hospital for APOWW (Apprehension by Police Without a Warrant).” . “1130: Called received from current CPS worker (name and number), update provided (name) states patient can discharge from (Facility A) to Desoto PD and will follow-up with Desoto PD after (Patient #1) arrives.” . At 11:30 PM, Patient #1 was discharged home by Facility A. . Discharge Notes by Staff #14: “(Patient #1) Pt alert/awake. Respirations unlabored. Discussed patient with (Staff #15), social worker. States that per CPS, patient can be discharged to Desoto Police. Desoto Police officer, (DPD Staff #4) (badge #371) at bedside. States they want patient placed under APOWW and therefore they will take him to a PSYCH facility after medical discharge. (Staff #10), ED Charge aware. Pt ready for discharge. Discharge instructions reviewed with mom. Signed by Desoto Police officer. Pt in his custody. Pt ambulatory around room with steady gait. Appears in no acute distress. Getting dressed. Pt out of ED in no acute distress. With Desoto Police.” . Diagnoses made for this visit: 1. Asphyxiation due to mechanical threat to breathing due to other causes, assault, initial encounter. 2. Parent-step child conflict. 3. Assault by strike against or bumped into another person, initial encounter. . No involuntary hold for Patient #1 was implemented to assure safety until such time as appropriate psychiatric evaluation was performed. No involuntary hold paperwork was found in the chart for Patient #1 despite a justifiable concern and an appropriate notification of CPS. No psychiatric evaluation for Patient #1 was found in the chart despite Staff #13 noting that Patient #1 would need a mental health evaluation and likely a psychiatric consult. There was insufficient information obtained to rule out the emergency medical condition (EMC) of suicide or self-harm and an EMC was not clearly noted by any of the 3 physicians who examined Patient #1. . Facility B Medical Record Review: On July 21, 2024, at 12:03 AM, Patient #1 arrived at Facility B in police custody. . On July 21, 2024, at 12:04 AM, Staff #22, the triage nurse, noted that Patient #1 arrived in police custody for being suicidal and had “reportedly got into an altercation with his stepfather in which (Patient #1) states his stepfather choked him. (Patient #1) states about 5 minutes after that he wrapped a cord around his neck. (Patient #1) states his mother thought he was trying to harm himself. (Patient #1) denies attempting to harm himself. (Patient #1) states he did not wrap the cord completely around his neck. No bruising or ligature marks noted. (Patient #1) states he is not suicidal ...” . On July 21, 2024, at 12:42 AM, Staff #24, the ED Physician, noted: “presents under emergency detention for concern for SI (suicidal ideation). He currently denies SI. He reports he wrapped a cord around his neck tonight and told his mom that he wasn’t afraid to die. He has never tried to hurt himself before. He was unsure what medications he was supposed to be on. He denies any auditory hallucinations. He has no medical complaints.” He was medically cleared for psychiatric evaluation ...” . On July 21, 2024, at 3:12 AM, Staff #25 (Psychiatry) cleared the involuntary psychiatric hold and suicide risk. . On July 21, 2024, at 3:20 AM, an addendum per Staff #24 (ED physician) noted the following: I discussed patient with psych faculty Staff #25 (Psychiatry). Patient will be cleared. Discharge. . On July 21, 2024, at 5:00 AM, Patient #1 was discharged home after the APOWW was discontinued. . Policy Review: Facility A’s “Emergency Medical Treatment (EMTALA) and Patient Transfer - Dallas Policy, last reviewed and effective on 05/03/2024, stated on page 1 of 16: “ ...Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy; b. Serious impairment to any bodily functions; c. Serious dysfunction of any bodily organ or part, or d. With respect to a pregnant woman who is having contractions: i. That there is inadequate time to affect a safe transfer to another hospital before delivery, or ii. That the transfer may pose a threat to the health or safety of the woman or the unborn child ...” . And on page 2 of 16: Medical Screening Examination (MSE) means the process to reach, with reasonable clinical confidence, the point at which it may be determined whether or not an individual has an emergency medical condition. An MSE is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage. An MSE has the following elements: a. Log Entry and Disposition b. Triage Record c. Ongoing recording of vital signs and ongoing monitoring of Patient’s medical condition d. History e. Physical Examination f. Use of available ancillary services, diagnostic testing and procedures, and physician consultative services as relevant to check for an emergency medical condition. g. Adequate documentation of all the above elements and the determination regarding the emergency medical condition ...” . And page 3 of 16: “ ...To stabilize means, with respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to a pregnant woman in labor, that the woman has delivered the child and the placenta. To be considered stable, the emergency medical condition that caused the Patient to seek care in the Emergency Department must be resolved, although the underlying medical condition may persist ...” . And page 4 of 16: “ ...A. Medical Screening. The Hospital recognizes the right of an individual to receive, within the capabilities and capacity of the Hospital: a. An appropriate MSE, including ancillary services routinely available to the Emergency Department, diagnostic testing and procedures and physician consultative services to determine whether or not an emergency medical condition exists; b. If an emergency medical condition exists, necessary stabilizing treatment (including treatment for an unborn child); and c. If necessary, an appropriate transfer of an individual with an emergency medical condition to another facility even if the individual cannot pay, does not have medical insurance, or is not entitled to Medicare or Medicaid. . The Hospital should not move individuals off-campus for the MSE ...” . And on page 5 of 16: “ ...C. Depending on the individual’s presenting signs and symptoms to the Emergency Department, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, such as (but not limited to) lumbar punctures, x-rays, CT scans, clinical laboratory tests, and/or other diagnostic tests and procedures. The MSE may require use of physician consultative services ...” . And on pages 5 - 6 of 16: “ ...D. Documentation of the MSE should reflect the clinical components of the MSE and the physician’s or QMP’s assessment and plan of care for the Patient, including presenting signs and symptoms for the visit, ongoing monitoring of the Patient’s vital signs and needs of the patients throughout the Emergency Department visit until the point of admission, discharge, or transfer. The physician or QMP’s documentation of the MSE should address the elements of the examination that support the evaluation of whether or not the emergency medical condition exists and addressing the Patient’s presenting signs and symptoms, including, but not limited to, past medical history, physical exam of the patient, ordered and completed laboratory and/or diagnostic testing and/or procedures, inquiries or consults with on-call physician specialists, the medical decision making regarding the differential diagnosis and reasoning and final assessment results of the MSE and whether or not an emergency medical condition exists, address any unresolved items that were determined to be non-emergent medical conditions, the discharge plan (including outpatient referrals for follow up and/or continuum of care services to address the Patient’s signs and symptoms and any non-emergent medical condition for further evaluation and treatment, or transfer of the Patient to another medical facility to care and treatment of the Patient’s emergency medical condition), and disposition ...” . Interviews: On September 24, 2024, at 10:45 AM, the treating ED Physician (Staff #13) was interviewed. The Surveyor and Staff #13 reviewed the case for Patient #verbally, and Staff #13 was asked if she remembered the case. Staff #13 stated that she remembered Patient #1. Staff #13 was asked what she remembered about his presentation. Staff #13 indicated that the story relayed by police and Patient #1’s mother and the story of Patient #1 was not in sync. Staff #13 further indicated that Patient #1 had marks on his neck consistent with ligature marks. . Staff #13 was asked to explain an Emergency Medical Condition (EMC). Staff #13 stated, “Anyone who needs immediate or emergent medical or psych care and if not stable for transfer, we stabilize.” . Staff #13 was asked to explain what stabilizing an EMC meant. Staff #13 stated, “We would provide any medical or psych transfer within capability. Anything with ABC’s is stabilized, eminent delivery if needed.” . Staff #13 stated that Patient #1 “ ...was psych and medically stable, he was calm and cooperative, answered questions, followed commands. . On 09/24/2024 at 11:00 AM, Staff #12 (Emergency Department Manager) was interviewed. Staff #12 was asked to explain what an EMC was. Staff #12 stated, “Providing enough care and intervention to transfer them to another facility if we don’t provide that service or admit them if we do.” .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 . Based on medical record reviews, document reviews, and interviews, Facility A failed to complete an appropriate transfer for one of 20 patients whose records were reviewed (Patient #1) when they failed to: . 1. Notify the receiving hospital, and verify the receiving facility had available space and qualified personnel for Patient #1’s transfer or secure an accepting physician. . 2. Indicate the risks and benefits of transfer in writing. . 3. Complete the physician certification with a summary of risks and benefits. . 4. Send the receiving facility all medical records related to the emergency medical condition for Patient #1 who was being transferred for inpatient care at the psychiatric facility. . Findings included: Review of Police Case DE2407320 on July 20, 2024, due to a report of a Major Disturbance: Police were dispatched to the residence of Patient #1 on (July 20, 2024) at approximately 3:52 PM due to a report of a major disturbance. Patient #1 had left his home and was located at an intersection nearby. Patient #1 stated that his mother was mad at him for throwing a water bottle at his stepfather after being pushed by him “hard”. Per the report, Patient #1 alleged that he was told to get off the couch, a verbal altercation ensued, Patient #1 was pushed to the floor, Patient #1 threw the water bottle at his stepdad, his stepfather began choking Patient #1 by placing both hands around his neck. Patient #1 alleges that it happened quickly and did not cause him to blackout or stop breathing. Then, Patient #1 and his stepfather were choking each other. Patient #1 stated that his mother confronted him while holding an extension cord in her hand and waved it around in a whipping motion. Patient #1 grabbed the cord from his mother and stated, “I’m not afraid to die; you’re not fixing to hit me with no extension cord.” Patient #1 then hit himself on the right side of his neck and stated, “You’re not fixing to hit me with that, I will hit myself with it.” Patient #1’s mother then told Patient #1 she was going to take him to (a psych facility) because he was trying to kill himself. Patient #1 denied trying to hurt or kill himself. Officer #2 observed a scratch on the right side of Patient #1’s neck with broken skin. . Patient #1’s brothers witnessed the incident and mostly corroborated the report received. . Patient #1’s mother denied attempting to spank him and denied witnessing the stepfather choking him. Patient #1’s mother denied waving a charging cord at Patient #1 and stated that Patient #1 brought the cord into play. . Officer #2 stated the following: Due to his statements/actions about self-harm and his diagnosis of the offender, it was deemed the offender was a danger to himself and others. The offender was transported to Children’s Medical Center for APOWW and medical clearance by Ofc (Officer #1).” Refer to assisting officer badge #401 for details on this process. . The report by the assisting officer, Officer #1, alleges the following: On 7/20/24 at approximately 1552 hours, she (Officer #1) #401 was dispatched to a major disturbance at the home of Patient #1. Officer #1 stated that he was not there upon arrival at Patient #1’s house. Officer #1 stated that she was in a marked squad car and returned to it to search for Patient #1. Patient #1 relayed the above to Officer #1. Patient #1 was detained by Officer #1 and placed in the squad car. Once detained, Officer #1 “made contact with the siblings, who witnessed the confrontation for their side of the story, corroborating with Patient #1’s story”. The story told to Officer #1 by Patient #1’s mother differed from the above report. Based on her findings, Officer #1 “ ...determined that (Patient #1) would be transported to (Facility A) for further evaluation due to his statements/actions about self-harm and his diagnosis. Upon arrival, Officer (Staff #1) informed that (Facility A) no longer accepted APOWWs but could treat (Patient #1) medically. Once (Patient #1) was medically cleared by the doctors (at Facility A), he (Patient #1) was transported to (Facility B) for emergency detention ...” . Patient #1 was listed as the Offender, his stepfather as the Victim, and Patient #1’s mother and two brothers were listed as Witnesses. The offense was listed as “Emergency detention/mental illness/risk of harm. Patient #1 was “cleared by arrest” on 07/24/2024, at 9:59 AM. . Medical Record Review at Facility A: Patient #1 was a 16-year-old male who arrived at Hospital A in the custody of a police officer on 07/20/2024 at 5:21 PM with a chief complaint of “choking” per Staff #19 (Triage RN) on 07/20/2021 at 5:32 PM. Staff’s Initial Triage Notes included: “ED fellow notified of abrasions noted to pts neck. (Patient #1) stable to go to regular room at this time, per ED fellow. (Patient #1) stated he was choked by dad using his hands lasting about 10 secs” Staff #19 escalated the status of (Patient #1) as a “possible traumatic event”. A suicide screening exam was done at 5:33 PM and the patient answered no to all questions regarding suicidal ideation, present and past. Triage Notes also included at 5:41 PM “(markings on right side of neck ... No loss of consciousness ... Vital signs stable).” . At 5:47 PM, a Medical Screening Exam was initiated by Staff #13 (Treating ED Physician). The chief complaint at that time was choking. Notes included: “ ...(Patient #1) is a 16 y.o. male with a PMHx (past medical history) of psychiatric disorders including anxiety, bipolar disorder, depression, and ADHD (attention deficit and hyperactivity disorder), multiple psych admits most recently last month, on multiple medications and receives psych care at (named clinic). Pt with numerous domestic violence charges for violence against family members. Patient #1 presents today with police for medical clearance after an altercation at home. After the altercation, pt took a phone charger and pulled it around his neck, pt then stated he ‘didn’t care if (he) died”. Mom called 911 and pt brought to the ED by police for medical clearance. Noted to have ligature marks around his neck. Denies LOC, difficulty speaking, respiratory distress, abnormal voice change. No HA, visual changes, CP or SOB. Pt denies any SI, HI, denies intention of self-harm ...” . The physical examination was pertinent for a patient who was awake and answering questions during the examination. The neck exam revealed “superficial abrasions and ligature marks to the right neck, tenderness to palpation to the right neck, and no crepitus.” There was no C-spine tenderness. No evaluation of tenderness of the anterior neck or hyoid bone was done for possible choking events. Only an exam of the posterior neck was noted. There was no evaluation of the patient’s capacity to swallow or speak. . The Review of Systems revealed that a limited neurological exam was done for Patient #1stating, “he is alert.” No further neurologic exam was done. . The Psychiatric exam states only that Patient #1 was “calm, cooperative. No suicidal ideation, no homicidal ideation.” Following commands during the examination.” Patient #1 was also noted to have had a “flat affect.” . Per the ED physician’s medical decision-making: “ ...(Patient #1) Pt here with police for medical clearance. Patient meets trauma activation criteria based on mechanism. Plan for CTA, urine drug screen. Per police, when medically clear, will discharge to police custody. No concern for SI or HI, mom states police were called due to dangerous behavior/ activity at home. No indication for MHAT (mental health assessment team) evaluation ...” . A second physician (Staff # 17) assessed Patient #1 at 6:34 PM and notes include: “ ...16-year-old male with a past medical history of bipolar, ADHD presents after strangulation. Per patient, he got into an argument with his mom. Afterwards, they were sitting on the cough and his stepdad told him to get off the couch, they got into an altercation, and he threw a water bottle at stepdad. Stepdad then went and put his hands around his neck, strangled him for about 5-10 seconds. Patient denies SOB or LOC. Complains of some discomfort in throat but denies any sore throat, pain in neck, vocal changes. No other injuries or traumas. Patient says after he was strangled, his mom and him got into another argument. She tried to hit him with a phone charger and so he took the phone charger and put it around his neck posteriorly. He said he did not do this with an intention to strangle himself or end his life. He denies any current or previous SI. Denies any HI. No other complaints at this time. ...” . Review of Systems: HENT: Positive for sore throat. Negative for congestion, trouble swallowing and voice change. Neurological: Negative for speech difficulty and headaches. Psychiatric/Behavioral: Negative for behavioral problems. There was no assessment of potential hallucinations, delusions, depression, or anxiety. . Physical Assessment: Neck: Thyroid: No thyromegaly. Vascular: No JVD. Trachea: No tracheal deviation. Comments: Ligature marks to right side of neck Psychiatric: Comments: Flat affect . Medical Decision Making: (Patient #1) “16-year-old male with a history of bipolar presents after strangulation. Reportedly strangled by stepdad, no LOC. No other injuries. Then got into argument with mom and placed cord around his neck, concern for possible SI though patient denies this. Well appearing on exam though visible ligature marks. Will obtain CTA, medically clear, and consult social work/behavioral health.” . SW Reassessment Note by Staff #16 at 6:48 PM: “ ...HPI: Pt (Patient #1) shared that he was sitting on a couch and pt mother wanted him to sit right (something amongst the lines), (Patient #1) was shoved by stepfather, who retaliated by throwing water with ice on him, pt stepfather in returned choked (Patient #1). Visible marks are on his neck. SW spoke to officer (Officer #1) from DeSoto PD #401 #214-663-5236 aware of CPS report being made. (Officer #1) able to confirm exact story (Patient #1) shared, pt mom story deviated, favoring stepfather. (Patient #1) mom not supportive, challenging staff. Living Status: Patient lives at home with mother, stepfather and 3 siblings. (10,13 and 14) Clinical Impressions: (Patient #1) has a history of mental health support, currently has a case open already with probation, takes medication for various psych diagnosis. Officer at bedside is familiar with family, shares that mother has high involvement and history of being unsupportive towards patient. SW also spoke and updated medical team. Plan: Social Worker will follow up as needed to assess for coping and any other resources. Please contact social worker with any immediate needs or concerns while patient is admitted ...” . The ED Care Timeline notes that at 7:17 PM Staff #14 (ED RN) discussed Patient #1 with Staff #16 (Licensed Medical Social Worker), Officer 1 (DPD), and Staff #13. An order was received for continuous visual observation (CVO). Staff #14 then “Called (an unidentifiable Staff RN) at flow (patient flow) to request CVO at bedside. Pt calm and cooperative with this RN.” . An Emergency Note by Staff #14 at 10:10 PM noted that Patient #1 was wearing a purple gown. (Many facilities use “purple gowns” to denote behavioral health patients who are a flight risk or risk for self-harm.) . At 7:30 PM, a CVO note by Staff #21 (Patient Care Technician) noted that “(Patient #1) Pt becoming increasingly anxious about transferring to another facility.” . At 7:45 PM a “Trauma Activation Alert” (Due to concern for strangling) was initiated by Staff #22 (RN) . At 7:45 PM Trauma Services Provider Assessment by Staff #18 (Trauma Physician). The notes included: “(Patient #1) a 16 y.o. male with significant history of bipolar disorder, ADHD, anxiety, depression, multiple psych admits, and multiple prior domestic violence charges who presents with police after self-inflicted strangulation with phone charger during altercation with mother and stepfather. No loss of consciousness. No current suicidal ideation.” . The physical examination noted that Patient #1’s eyes opened spontaneously, and he had normal verbal responses. The examination also noted that Patient #1 was moving spontaneously, his head was normocephalic and atraumatic. The examination noted that a C-collar was in place, mild tenderness of the neck was noted, and marks to the neck were present. Staff #18 noted that Patient #1 was alert with normal mood and behavior. . Plan: “C-collar ...CT angio (angiogram) neck ...Pain control ... ...Medically clear for discharge from the ER ... without acute injury. Okay to clear collar clinically ...” . A Nursing note at 19:50 noted, “ Aspen collar (C-collar) was placed for spine precautions. . At 8:18 PM the CT Arteriogram of the neck returned with normal results. . At 8:57 PM a SW Progress Note by Staff #15 noted the following: “ ...Assessment Completed: in the Emergency Room ... (Patient #1) is a 16 y.o. male presented to ED for concerns of strangulation. Social worker received handoff from day shift social worker, informed CPS reported needed regarding patient reporting of altercation with stepfather. . An Addendum note at this time by Staff #15 noted the following: “1030pm: Patient medically cleared for discharge. Social worker received update from RN that patient will be discharging with Desoto PD to Hospital for APOWW (Apprehension by Police Without a Warrant).” . “1130: Called received from current CPS worker (name and number), update provided (name) states patient can discharge from (Facility A) to Desoto PD and will follow-up with Desoto PD after (Patient #1) arrives.” . At 11:30 PM, Patient #1 was discharged home by Facility A. . Discharge Notes by Staff #14: “(Patient #1) Pt alert/awake. Respirations unlabored. Discussed patient with (Staff #15), social worker. States that per CPS, patient can be discharged to Desoto Police. Desoto Police officer, (DPD Staff #4) (badge #371) at bedside. States they want patient placed under APOWW and therefore they will take him to a PSYCH facility after medical discharge. (Staff #10), ED Charge aware. Pt ready for discharge. Discharge instructions reviewed with mom. Signed by Desoto Police officer. Pt in his custody. Pt ambulatory around room with steady gait. Appears in no acute distress. Getting dressed. Pt out of ED in no acute distress. With Desoto Police.” . Diagnoses made for this visit: 1. Asphyxiation due to mechanical threat to breathing due to other causes, assault, initial encounter. 2. Parent-step child conflict. 3. Assault by strike against or bumped into another person, initial encounter. . There were no documented attempts for an appropriate transfer, no documentation of an accepting physician, and no evidence that medical records were provided to the receiving facility. There was no memorandum of transfer (MOT) with a physician’s certification, notification of the risks and benefits of a transfer, and no signed patient refusal of a transfer found in the medical record review. . Facility B Medical Record Review: On July 21, 2024, at 12:03 AM, Patient #1 arrived at Facility B in police custody. . On July 21, 2024, at 12:04 AM, Staff #22, the triage nurse, noted that Patient #1 arrived in police custody for being suicidal and had “reportedly got into an altercation with his stepfather in which (Patient #1) states his stepfather choked him. (Patient #1) states about 5 minutes after that he wrapped a cord around his neck. (Patient #1) states his mother thought he was trying to harm himself. (Patient #1) denies attempting to harm himself. (Patient #1) states he did not wrap the cord completely around his neck. No bruising or ligature marks noted. (Patient #1) states he is not suicidal ...” . On July 21, 2024, at 12:42 AM, Staff #24, the ED Physician, noted: “presents under emergency detention for concern for SI (suicidal ideation). He currently denies SI. He reports he wrapped a cord around his neck tonight and told his mom that he wasn’t afraid to die. He has never tried to hurt himself before. He was unsure what medications he was supposed to be on. He denies any auditory hallucinations. He has no medical complaints.” He was medically cleared for psychiatric evaluation ...” . On July 21, 2024, at 3:12 AM, Staff #25 (Psychiatry) cleared the involuntary psychiatric hold and suicide risk. . On July 21, 2024, at 3:20 AM, an addendum per Staff #24 (ED physician) noted the following: I discussed patient with psych faculty Staff #25 (Psychiatry). Patient will be cleared. Discharge. . On July 21, 2024, at 5:00 AM, Patient #1 was discharged home after the APOWW was discontinued. . Facility A Policy Reviews: Facility A’s “Emergency Medical Treatment (EMTALA) and Patient Transfer - Dallas Policy, last reviewed and effective on 05/03/2024, stated on page 3 of 16: “...Transfer means the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated with) the hospital but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person. (Pursuant to state hospital licensing regulations, the movement of a stable patient from the hospital to another medical facility is not considered to be a transfer if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital, provided that the patient remains stable during the transfer.) An appropriate transfer occurs when: a. The transferring hospital provides treatment within its capabilities to minimize risks to the Patient (and to the unborn child if the Patient is pregnant) b. The receiving facility agrees to the transfer and has the capability and capacity (bed and staff) to treat the Patient. c. The transferring hospital sends pertinent medical records and a completed Memorandum of Transfer (MOT). d. The transfer occurs with qualified personnel and equipment...” . And on page 8 of 16: “ ...D. When a Patient has an emergency medical condition that has not been stabilized, the Patient may be transferred if: a. The Patient requests transfer against medical advice and the physician or Hospital informs the Patient of the Hospital’s responsibility to provide stabilizing treatment to the Patient and the risks and benefits of transfer and obtain the patient’s or legally responsible person’s request for transfer in writing; or b. The transferring physician completes a certification statement (as set out in c. below), which includes a summary of risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the patient, and in the case of labor, to the unborn child from effecting the transfer. Other qualified medical personnel may complete the certification statement on behalf of the physician after consultation with the physician if the physician is not present in the emergency room at the time of the transfer. The physician shall countersign the certification as soon as possible if it is completed initially by Hospital personnel. i. Certification of Risks and Benefits should be documented on the Memorandum of Transfer ...” . And on page 9 - 10 of 16: “ ...F. Memorandum of Transfer (MOT) is necessary to transfer a patient: a. Children’s Medical Center of Dallas will provide a MOT, as prescribed by state law. b. The MOT will be signed by the transferring physician, approved, and signed by the Children’s Medical Center of Dallas administration, and a copy must accompany the Patient being transferred, along with the appropriate medical record information. c. Transfers into Children’s Medical Center of Dallas will require an MOT from the transferring hospital and will accompany the Patient along with pertinent medical record information. It is the Children’s Medical Center of Dallas accepting unit’s responsibility to record the date and time of Patient arrival and to obtain the receiving physician’s signature on the MOT. d. MOTs will be maintained in both the Patient’s medical record and separately from the medical record. Health Information Management (HIM) shall retain the separate copies of the MOT with the transfer record for a minimum of five years. These records shall be available for review and inspection as necessary by the Texas Health and Human Services Commission. e. The MOT document will follow the standard form established by the Texas Health and Human Services Commission, but shall include the following information (if known) but not limited to: i. Full Name; ii. Race, religion, national origin, age, sex, physical handicap; iii. Address and next of kin, address, and phone number; iv. Names, telephone numbers and addresses of the transferring and receiving physicians; v. Names, telephone numbers and addresses of the transferring and receiving hospitals; vi. Time and date on which the Patient first presented or was presented to the transferring physician and transferring hospital; vii. Time and date on which the transferring physician secured a receiving physician; viii. Name, date and time hospital administration was contacted in the receiving hospital; ix. Signature, time and title of the transferring hospital administration official who contacted the receiving hospital; x. Certification by the transferring physician (if applicable); xi. Time and date on which the receiving physician assumed responsibility for the patient; xii. Time and date on which the Patient arrived at the receiving hospital; xiii. Signature and date of receiving hospital administration official; xiv. Type of vehicle and company used; xv. Type of equipment and personnel needed in transfers; xvi. Name and city of hospital to which the Patient was transported; xvii. Diagnosis by the transferring physician; and xviii. Attachments by transferring hospital ...” . And on page 13 of 16: “...K. Medical Records A. A copy of the Patient’s medical records related to the emergency medical condition and relevant to the transfer and continuing care that are available at the time of transfer (including medical records, test results, informed written consent or physician certification, and name and address of any on-call physician who refused or failed to appear within a reasonable time to provide necessary stabilizing treatment) will be sent to the receiving physician and hospital. ...” . Interviews: On September 24, 2024, at 10:45 AM, the treating ED Physician (Staff #13) was interviewed. The case for Patient #1 was reviewed verbally and Staff #13 was asked if she remembered the case. Staff #13 stated that she remembered Patient #1. Staff #13 was asked what she remembered about his presentation. Staff #13 stated that the story relayed from police and Patient #1’s mother and the story of Patient #1 were not in sync. Staff #13 further stated that Patient #1 had marks on his neck consistent with ligature marks. . Staff #13 was asked if transfer was arranged through the transfer coordinators (in keeping with Facility A’s policy) or a doctor-to-doctor report had been called. Staff #13 stated, “This patient was medically cleared and discharged from our Emergency Department; he was not transferred.” Staff #13 further stated that a doctor-to-doctor report “would apply to patients being transferred. As this patient was discharged, we did not go through the transfer process, arrange transfer, obtain an accepting physician, or give doc-to-doc hand off ...” . On 10/01/2024 at 4:20 PM, Staff #6 (Vice President of Accreditation) was interviewed. Staff #6 was asked about patient transfers. Staff #6 indicated that transfers should include: “ ...The MOT and a copy of the medical records will be transported with the patient. Regardless of the mode of transportation for the transfer, the MOT and a copy of the medical records will be transported with the patient. If by chance, some information is not available at time of transport such as an x-ray report that information would be faxed/sent to the facility.” Staff #6 was asked if a doctor-to-doctor report and securing a bed with the receiving facility should be completed upon transfer. Staff #6 confirmed that it should. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45521 Based on review of documentation and interviews with the facility staff, the facility failed to perform an appropriate transfer as evidence by a 2 of 20 patients were improperly transferred to Facility B. Patient # 1 required a transfer to a higher acuity facility after slicing his fingers tips off. Facility A was attempting to transfer the patient but two facilities declined. Facility A then called 911 for a transfer for Patient # 1. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form. Facility B accepted the patient, treated his wounds and discharged him home. The facility also failed to perform an appropriate transfer of Patient #2 to an inpatient psychiatric treatment facility after the patient’s medical screening examination determined Patient #2 required inpatient psychiatric treatment. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form. Facility B accepted the patient, transferred him to their Psychiatric Emergency Department (ED) and when a bed opened, he was transferred to a Psychiatric Hospital. The findings include: Patient # 1 Record Review Facility A: The complete medical record review of Patient #1’s Emergency Department (ED) visit on 12/15/2023 was performed on 03/04/2024. The facility failed to document how the facility secured a transfer to an accepting hospital or physician; a nurse to nurse or physician to physician report was performed; or a patient’s request/refusal/consent to transfer was completed prior to the Patient #1’s discharge to police. Patient #1 was transported by the police from transferring hospital to receiving hospital. No Memorandum of Transfer (MOT) form could be found for the surveyors to review. A review of the document titled, “ ED Provider Notes” by Staff # 2, MD-ED on 12/15/2023 at 7:29 PM revealed the following: Patient (PT) # 1, “is a 57 y.o. male presenting with L[left] hand injury. Pt got his pinky, ring and middle finger (3rd, 4th and 5th digit) caught in an envelope machine. The machine sliced the tips of his fingers off. This occurred 20 minutes [prior to admission] (PTA). He brought the fingertips to the ED with him.” ... “The management and plan of care for this patient consists of the following immediate interventions: Transfer to adult facility for xrays[sic], hand consult.” A review of the documents titled “ED Notes” by Staff # 4, RN -ED on 12/15/2023 at 8:35 PM revealed the following ...”patient’s hand wrapped with ace wrap and gauze.” ... “Dallas fire rescue(DFR) arrived to pick up patient. Finger in possession of fire department in specimen bag on ice. Bleeding of hand controlled at this time.” An interview with Staff # 5, Medical Doctor (MD), ED Medical Director on 03/05/2024 at approximately 10:35 AM revealed the following: Surveyor: How would you proceed with an adult patient that had their 3rd, 4th and 5th fingertips sliced off and the patient has the fingertips? MD-ED Director: I would assess to see if the injuries were life threatening, complete an evaluation, have the charge nurse use the Access Center to find a hospital that can treat the patient. If there was a behavioral health symptom, I would call the Mental Health Assessment Team to find the best place for the patient. Surveyor: Do you have a physician staffed in the Emergency Department (ED) 24 hours a day? MD-ED Director: We have a minimum of three attending physicians that staff the ED 24 hours a day. Surveyor: Are you familiar with this case? MD-ED Director: Yes, I am. Surveyor: Can you tell me why the patient was not accepted at Parkland or Clements hospitals? MD-ED Director: Parkland hospital said the injury was not a high enough trauma for them to accept the transfer from us. Clements Hospital said they refused the transfer because the trauma was too great. Facility B, Patient # 1 A review of the document tiled “ ED Notes” by Staff # 11, Registered Nurse-Emergency Department (RN-ED) on 12/15/2023 at 9:03 PM revealed the following: “Pt brought by DFR from Childrens Medical Center (CMC), not an official transfer or MOT present. Approx. [Approximately] [7:15 PM] 1915 pt’s L 3-5th digits partial amputation from an envelope cutter. Last meal was last night. Tetanus updated at CMC. No antibiotics (abx) given.” At 11:22 PM, Staff # 12, MD-ED noted, “ Hand evaluated patient - dressed with xeroform and kerlex. will give 1 week of PO [Oral] abx and dc. Will have pt follow up in clinic. All questions answered.” Facility A, Patient # 2: The complete medical record review of Patient #2’s Emergency Department visit on 01/17/2024 was performed on 03/04/2024. It was noted that Staff # 1, ED Provider Note recommended that the patient receive inpatient Behavior Health (BH) treatment and the Staff # 8, DO-Resident, is noted to agree with this finding. No documentation could be found for the surveyor to review and indicate that the facility secured a transfer to an accepting hospital or physician; a nurse to nurse or physician to physician report was performed; or a patient’s request/refusal/consent to transfer was completed prior to the Patient #2’s discharge to police on emergency detention. Patient #2 was transported by the police from the transferring hospital, Facility A, to receiving hospital, Facility B. No memorandum of transfer (MOT) form could be found for the surveyors to review. A review of the document titled “Emergency Notes” by Staff # 7, RN-ED on 1/19/2024 at 12:15 AM revealed the following: “ Pt unable to explain what happened to his thumb other than he tried to kill himself. Pt states to this RN that “he wants to be put down” after redirecting pt states that “he wants an injection to end his life”, pt has some sort of sediment to entire body, dried blood noted to hands and multiple old marks noted to hands and arms, will need to clean pt up to determine extent of old injuries or scars.” A virtual interview via Zoom with Staff # 1, MD-ED on 03/05/2024 at approximately 12:20 PM revealed the following: Surveyor: Can you explain your process while with the patient? Doctor: The patient was brought to the exam room. I talked to the patient and asked him about his history and he was unable to answer my questions. I am not sure if he was unable to answer or if he didn’t want to answer. When I examined him originally, he was compliant. I examined him for his original complaint and told the nurse the patient needed to change his clothes to see his lower extremities. I also asked the nurse to clean the cut to the patients finger. I left the exam room, talked with the Resident, and entered orders. The patient was not fully oriented. He had no account of events. I ordered labs and a CT scan and the patient would not lie down and was brought back to the ED. The patient did not want to comply with medical requests. I talked with the charge nurse about a transfer to an adult facility. Charge Nurse said the patient was trying to elope. Security was called and stayed with the patient so he could be an [Administrative Protective Order] APO and he continued refusing treatment. Surveyor: Did you sign any papers? Doctor: Not that I can remember. Facility B, Patient # 2 A review of the document titled “ED Triage Note” by Staff # 10, RN-ED on 01/18/2024 at 1:55 AM revealed the following: “Multiple nurses, officers, and MD at bedside. Pt noted to have dried blood on right wrist and fingers. Laceration noted on right thumb. Per officer, patient was dropped off at children’s hospital by a UHAL truck for wrist and finger laceration. Was treated at Children’s hospital for cuts and brought here for hx of schizophrenia, paranoia related to substance abuse. Denies any substance use today. Pt noted to be cuffed by officer. Pt states “can you take the cuffs off’. Pt is [alert to: self, place, time and situation], AOx4. RR [respirations] even and unlabored. Pt noted to be tachycardic. ABCS [airway, breathing, circulation] intact. A review of the document titled “ED Triage Note” by Cindy RN -ED on 01/18/2024 at 2:05 AM “Medicated pt per MAR by Cindy RN on right deltoid 5mg Haloperidol 50mg benadryl 5mg Versed Added to ED Triage Note: January 18, 2024 at 2:2O AM 2 point restraint applied, notified MD. Pt noted to be calm and cooperative.” ... “The patient was monitored at 4:19 and care plan was not met and was revisited. At 6:19 AM Plan of Care was noted as resolved.” Staff # 10 reported at 6:24 AM, “Able to comply with instructions; No longer attempting to dislodge essential Medical Device(s). Restraints were removed.” ... A review of the document titled “ ED Notes” by Staff # 11, PA-C-Psychiatry on 01/18/2024 at 4:55 PM revealed the following: Patient # 2, “presented to the ED on 01/18/2024 under emergency detention. The patient was transferred to the psychiatric emergency room on emergency detention. After being assessed by the psychiatric team, it was determined that the patient required inpatient hospitalization. Based on the patient’s behavior and symptoms the patient requires involuntarily hospitalization as they too high risk for voluntarily hospitalization.” On 01/21/2024 at 12:18 PM, Patient # 2 was transferred to a Psychiatric Hospital with transport. It was noted that no available beds were available at Facility B Inpatient or Crisis Residential. A review of the policy titled “AD 2.29.01 Emergency Medical Treatment (EMTALA) and Patient Transfer - Dallas” revealed the following: pg. 3 Facility A did not follow their own policy. The policy reads: “Transfer means the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated with) the hospital but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person. (Pursuant to state hospital licensing regulations, the movement of a stable patient from the hospital to another medical facility is not considered to be a transfer if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital, provided that the patient remains stable during the transfer.) An appropriate transfer occurs when: a. The transferring hospital provides treatment within its capabilities to minimize risks to the Patient (and to the unborn child if the Patient is pregnant) b. The receiving facility agrees to the transfer and has the capability and capacity (bed and staff) to treat the Patient c. The transferring hospital sends pertinent medical records d. The transfer occurs with qualified personnel and equipment. Patient # 1: Patient # 1 was not accepted to two of the facilities contacted by Facility A. Facility A called 911 for a patient transfer for Patient # 1. This is a violation of their policy above. Patient # 2: Facility A failed to perform an appropriate transfer of Patient #2 to an inpatient psychiatric treatment facility after the patient’s medical screening examination determined Patient #2 required inpatient psychiatric treatment. The facility failed to notify the receiving hospital of patient transfer or secured an accepting physician at the receiving hospital or complete a memorandum of transfer form. .”