University Behavioral Health of Denton

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 Based on record review, interview, and observation, the hospital failed 1 of 1 Patient (Patient #1), by failing Patient #1 the right to receive care in a safe setting. Patient #1 was able to elope from the facility courtyard by pushing the gate open. Findings Include: During the Record Review of the Hospital Incident Log, Patient #1 was identified as fitting the description of the patient who eloped from the facility on 05/14/2026. During the interview on 05/19/2026 with Patient #1, it was reported that while outside on the evening of 05/14/2026, in the courtyard, Staff #7 was seated on the bench with the other peers. Patient #1 reported noticing that the gate on the side of the facility was not secured. Patient #1 reported pushing it open and departing from the facility. During the interview with Staff #7, at 9:00 AM on 05/21/2026, Staff #7 reported this was the first day on the job. Staff #7 reported being left outside in the courtyard alone to monitor Patients. Staff #7 reported that Patient #1 was observed while standing in the corner of the courtyard. Staff #7 reported that as she turned back, she witnessed Patient #1 exiting the gate, and Patient #1 took off running. Staff #7 indicated that she did not pursue Patient #1 past the parking lot. During observation, the video footage showed Patient #1 standing off behind the beam near the corner of the building. Patient #1 was then observed turning and exiting the side of the gate to elope from the facility. Staff #7 was initially observed seated on the bench facing the yard. Staff #7 was observed turning half around to see all patients. Staff #7 was then observed getting up and running to the fence and telling all the other patients to get inside. Staff #7 exited the gate. Policy The hospital Policy on Reporting Allegations of Abuse and Neglect 03/2026, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 4 hours of first suspecting abuse, neglect, or exploitation of a child or person 65 years or older, or an adult with disabilities.” The hospital’s Response to Patient Elopement 03/2026, “Staff will follow established protocol in the event of a patient elopement. III. Staff will search for the patient in the hospital and the immediate hospital Grounds. A. Staff members are not to follow, chase or look for patients beyond the limits of the hospital Grounds unless: 1. The Patient is under the age of 18 years. 2. The Patient is under protective custody. 3. The Patient is considered dangerous to self or others. B. In the case the Patient is a minor and there is cause to believe that the Patient is a danger to self or others, no more than 2 staff members are allowed to follow at a distance to give 911 operators up to date information about the location of the patient. C. At no time should staff run after patients or restrain patients on or off the facility.” The hospital’s Policy on Patient Observation 09/2024, It is the policy of University Behavioral Health of Denton (UBH - Denton) to provide a safe and secure environment for patients during their hospitalization. To ensure patient safety and to provide a process for observing and documenting patient location and behavior. Staff will conduct observation rounds on each patient as ordered while in treatment. The primary staff who are conducting rounds will be the Mental Health Technicians (MHT) and nurses (RN/LVN), but any staff can be utilized to complete patient rounds per the patient observation procedures. The hospital’s Policy on Physical Environment ‘Rated Door Inspection and Test” 03/2026. To manage inspection and testing of door assemblies at University Behavioral Health of Denton to comply with the Life Safety Code NFPA 101, 2012 edition, NFPA 80, 2010 edition and NFPA 105, 2010 edition as outlined in Joint Commission EC.02.03.05, EP 25.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 33579 Based on the interview and observation, the hospital failed 1 of 1 Patient, (Patient #1) by Patient #1 by the condition of the hospital’s environment not being maintained in such a manner that the safety and well-being of the patients is assured. Patient #1 was able to elope from the facility and was found at the Park on the Campus of Texas Women’s University. Findings Include: Based on an interview with Patient #1, the outside gate was not locked and Patient #1 was able to push the lever down and run off of facility grounds. Based on an interview with Staff #7, the outside gate was not secured, and Patient #1 was able to run out of the courtyard and elope off campus. Based on the interview with hospital Staff #5, while conducting EOC rounds, the lock was observed outside on the ground. The facility had already ordered additional bars/locks to secure the gate. Based on the observation, Patient #1 was observed in the video footage turning and running immediately out of the gate. Policy The hospital Policy on Reporting Allegations of Abuse and Neglect 03/2026, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 4 hours of first suspecting abuse, neglect, or exploitation of a child or person 65 years or older, or an adult with disabilities.” The hospital’s Response to Patient Elopement 03/2026, “Staff will follow established protocol in the event of a patient elopement. III. Staff will search for the patient in the hospital and the immediate hospital Grounds. A. Staff members are not to follow, chase or look for patients beyond the limits of the hospital Grounds unless: 1. The Patient is under the age of 18 years. 2. The Patient is under protective custody. 3. The Patient is considered dangerous to self or others. B. In the case the Patient is a minor and there is cause to believe that the Patient is a danger to self or others, no more than 2 staff members are allowed to follow at a distance to give 911 operators up to date information about the location of the patient. C. At no time should staff run after patients or restrain patients on or off the facility.” The hospital’s Policy on Patient Observation 09/2024, It is the policy of University Behavioral Health of Denton (UBH - Denton) to provide a safe and secure environment for patients during their hospitalization. To ensure patient safety and to provide a process for observing and documenting patient location and behavior. Staff will conduct observation rounds on each patient as ordered while in treatment. The primary staff who are conducting rounds will be the Mental Health Technicians (MHT) and nurses (RN/LVN), but any staff can be utilized to complete patient rounds per the patient observation procedures. The hospital’s Policy on Physical Environment ‘Rated Door Inspection and Test” 03/2026. To manage inspection and testing of door assemblies at University Behavioral Health of Denton to comply with the Life Safety Code NFPA 101, 2012 edition, NFPA 80, 2010 edition and NFPA 105, 2010 edition as outlined in Joint Commission EC.02.03.05, EP 25.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33579 Based on Interviews and Record Review, the hospital failed 1 of 1 Patient (Patient #1) by failing to provide adequate care to Patient #1’s needs. The staff must ensure that the nursing staff develops and keeps current, a nursing care plan for each patient that reflects patient’s goals and the nursing care to be provided to meet the patient’s needs. Findings Include: During an Interview with Hospital Staff #3 on 12/12/2025, it was reported, “Yes, there was a medical assessment missing from the nursing staff, and documentation was not properly noted in the Patient’s medical record. The medical record documentation is not present.” The Patient was lacking a documented medical assessment and orders to send the Patient to the ED. During the Interview with Hospital Staff #6 on 12/12/2025, reflected that Patient #1 was experiencing seizure-like activity. Staff #6 was asked to identify what seizure-like activity Patient #1 was experiencing. Staff #6 stated that the Patient was just staring into space and would not respond to anything. Staff #6 was then asked, “Where is your assessment of this Patient?” Staff #6 stated, ‘I did not write one.” Staff #6 was asked, What did you do? Staff #6 indicated, I contacted Staff #7. Staff #7 advised Staff #6 to they needed to send the Patient out to the ER. Staff #6 indicated that the Patient was sent out to the ER within 15 minutes. There was no further documentation or further treatment offered to the Patient. Staff #6 indicated not to complete a medical assessment, and Staff #7 did the assessment. Staff #6 indicated not being aware whether Staff #7 documented the incident anywhere. During an Interview with Hospital Staff #7, on 12/15/2025, reflected that I was notified that Patient #1 had a seizure. Staff #7 stated that upon arriving in the room, Patient #1 was lying on the bed. Patient #1 was unresponsive to any stimuli, including an intense sternum rub. Staff #7 was asked if there was a physician’s order received to send the Patient out; Staff #7 reported not receiving an order. Staff #7 stated the unit nurse, Staff #6, was supposed to be following up with that and documentation for Patient #1. Staff #7 indicated being busy trying to ensure the patient was breathing. Staff #7 indicated not following up with the patient’s medical record to ensure proper documentation was noted. Staff #7 indicated not documenting anything on the patient. Policy The hospital Policy on Nursing Services 10/2023, “The delivery of nursing care at University Behavioral Health of Denton shall be understood as a purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment of the health status of those entrusted to our care.” The hospital Policy Physician Orders 01/23/2025, “The communication of medical orders must be executed in a manner designed to ensure patient safety and eliminate misunderstanding. Orders shall be in writing by the physician, signed and dated. Orders that have been dictated verbally or by telephone must be cosigned within 48 hours.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 Based on record review, observation and interviews, the facility failed to ensure 2 of 2 (Patient #1 and Patient #2) recieved care in a safe setting. Patient #1. was able to enter into Patient #2’s room without staff knowledge or supervision, Patient #1 entered another patient room Patient #2’s and claimed she was sexually assaulted by Patient #1. Findings included: During record review the hospital Sexually Acting Out (SAO) - Allegation Response Form 02/23/2025 at 9:45 PM, “Patient #1 was found laying down on the floor of the restroom of a male Patient #2 naked and Patient #1 verbalized that she was raped by the male patient.” In observation of hospital video footage, the video footage is started at 8:31 PM. At 8:31:58sec Patient #1 enters into Patient #2’s assigned room directly across the hallway. Patient #1 did have a shirt on at that time. At 8:39 male Staff #7 comes over to assist Staff #6 open Patient #2’s room door. At 8:40 PM male Patient #2 exits assigned room. At 8:31 PM Staff #6 was observed walking up and down the hallway checking Patients on her clip board. As well as going to door to door searching for Patient #1. Staff #6 was also witnessed walking behind the MHT Desk, and overlooking the milieu and other patients approaching her and Patient #1 ran into the Patient #2’s room at that time. This was one incident just a different angle of observation from video footage. During interview conducted on 03/20/2025 at 4:20 PM with Staff #3 was asked about the Continued Plan of Corrections presented to the Surveyor. Staff #3 indicated having no knowledge of said Plan of Correction and no employee has been reprimanded in reference to this incident. During Interview conducted on 03/20/2025 at 4:00 PM with Staff #6, RN reported on the day in question admits to working the unit as a Mental Health Tech indicating Staff #6 not as a nurse as which Staff #3 is trained for. However, Staff #6 should be trained to over see the MHT’s on the unit as well. Staff #6 indicated not seeing the Patient #1 in assigned room. Stating she did not see Patient #1 in any other room. Staff #6 indicated noticed the room door was closed directly across from Patient #1’s assigned room. Staff #6 indicated approaching Patient #2’s room door but felt the pressures on the opposite side of the door holding the door closed. Staff #6 stated Staff #7 assisted in opening the door. The door came open when the Staff #7 opened it. Once the door was open Patient #2 was seated on assigned bed putting pants on. Staff #6 then went into the shower and found Patient #1 laying on the shower floor without any clothing on. When Patient #2 was questioned, it was reported while in assigned room, Patient #1 entered room and bent over in face and then they engaged in sexual activity (intercourse). Staff #6 indicated not being able to figure out how Patient #1 entered the room. Staff #6’s reports this was the main concern, Staff #6 had as Staff #6 had been monitoring the hallway and milieu. Staff #6 indicated this was the first time working as a Tech, Staff #6 indicated I am not trained as a Tech, I am a nurse. During interview was conducted on 03/20/2025 at 5:40 PM with Staff #3 informed that there is concern of all the sexual allegations listed on the hospital incident report. Staff #3 was informed this was due to the lack of Patient supervision and being short staffed. Staff #3 agreed with the finding. Staff #3 was surprised that the Staff #6 reported not knowing what to do as a Tech being a regular nurse on the unit. Staff #3 agreed that they should manage unit as well as the MHT’s working the unit. Staff #3 reported all nursing staff are trained on the MHT and operating systems. During Record Review presented by Staff #1 the training record did not reflect Staff #3 signed in as attending the training. During Record Review the hospital incident log was reviewed from January 1, 2025 through March 20, 2025 (79 days). There were 65 Incidents in the 79 days that involved Sexually Acting Out Behavior. This reflects 3 out of 4 incidents were sexual boundary issue. Policy The hospital Policy on Patient Rights 10/2022, “University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the ‘Patient Bill of Rights’ and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction.” The hospital Policy on Abuse, 12/2022, “University Behavioral Health Of Denton promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law. Threats or restrictive actions in response to patient’s request for discharge shall be considered abuse and are prohibited.” The hospital Policy on Nursing Services 10/2023, “The delivery of nursing care at University Behavioral Health of Denton shall be understood as a purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment of the health status of those entrusted to our care.” The Hospital Policy on Quality Care and Treatment ‘Plan for Patient Care and Professional Services’ 08/2023, “University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility’s mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals most effectively and efficiently possible.” The hospital Policy on Observation 09/2024, “It is the policy of University Behavioral Health of Denton (UBH-Denton) to provide a safe and secure environment for patients during their hospitalization. To ensure patient safety and to provide a process for observing and documenting patient location and behavior. Staff will conduct observation rounds on each patient as ordered while in treatment. The primary staff who are conducting rounds will be the MHT and nurses, but any staff can be utilized to complete patient rounds per the patient observation procedures.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 Based on Record Review, Interview and Observation the hospital failed 5 of 5 Patients the right to receive care in a safe setting. Findings Include: During Record Review in the Psychiatric Nursing Notes 11/21/2024, 9:10 AM, “Patient #1 reported that another patient (Patient #2) engaged in Sexually Acting Out behavior toward Patient #2. During Record Review a witness Statement written on 11/21/2024 at 9:21 AM, Patient #1 wrote, ‘Last night, ‘Patient #2’’ raped me. I (Patient #1) was half asleep in my bed. “ During Record Review a witness Statement written on 11/21/2024 at 9:10 AM, Patient #2 wrote, ‘Patient #1 and I made out x7. We gave each other hickeys, on right side of neck. Patient #1 said she wasn’t going to say anything and she agreed as well. We were touching each others thighs, vagina and titties. Patient #1 and I were biting each others lips and neck.” During Interview with hospital Staff #2 on 12/19/2024 at 11:30 AM. Staff #2 indicated that these two patients were roommates. Patient #2 was admitted the day the allegations occurred. The patients admitted the allegations occurred. Staff #2 further was questioned about Staff Observations and rounding. Staff #2 indicated that the staff were rounding but they were not changing their routine and they were predictable with their rounding, causing the patients to know when the staff were going to come into their room and check on them. During Interview with hospital Staff #8 on 12/19/2024 at 2:15 PM It was reported that Patient #1 and Patient #2 did confirm the incident happened. The Patients reported that the incident was consensual but they were angry with one another the following day and attempted to fight that next morning. Staff #8 reported that the patients did receive a medical assessment and from the nursing staff it was confirmed that hickey’s were discovered on each patient. Policy The hospital Policy on Abuse, 12/2022, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities.” The Hospital Policy on Quality Care and Treatment ‘Plan for Patient Care and Professional Services’ 08/2023, “University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility’s mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals in the most effective and efficient manner possible.” The hospital Policy on Patient Observation Levels 01/2024, “Patient observation levels are defined as specific levels of staff awareness and attention to patient safety/security needs that require the initiation of specific protocol and supplemental documentation.” The hospital Sexually Acting Out (SAO) Prevention and Incident/Allegation Response 09/2024, “It is the policy of this hospital to ensure provision of safety and therapeutic environment of care which includes prevention of patient to patient sexual incidents.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 33579 Based on Record Review, Interview and Observation the hospital failed 1 of 1 Patient (Patient #3) by failing Patient #3 the right to be free from all forms of abuse or harassment. Patient #3 was experiencing a psychotic episode and during the episode Patient #3 was not willing to comply with hospital staff and was combative towards staff. For Patient #3 to obtain his composure he was struck in the face by a peer causing the Patient #3 to have a blackeye. Findings Include: During Record Review the hospital Seclusion/Restraint/Emergency Medication Packet 11/21/2024, 4:34 AM. “Patient #3 Suddenly running to other patient without any reason to attack others ...MHT stopped him from attacking peer by restraining ...Seroquel 200mg, PO agitation at 11:07 AM ...Patient is pacing. Facial expressions, agitation. Ativan 2mg IM aggression. Patient assault peer and staff. During Record Review Witness Statement by Patient #31 reflected, “Patient #31 reported, I was asleep woke up to a guy (Patient #3) hitting the nurses. Me and my roommate (Patient #5) stepped in to help the nurses stop this fighting.” During Interview Staff #14 on 12/20/2024 at 12:30 PM, Patient #3 indicated working the unit along with another female Tech (Staff #15). Staff #14 indicated we were rounding together to try and ensure safety. While rounding we noticed Patient #3 on up on the unit and pacing and then sitting in the hallway. Patient #3 was inwas asked if he was okay and requested to go back to room and try and get some sleep and not to sit in hallway. Patient #3 did go into his room, but then he started to assault roommate. We heard the punches in the room. Staff #14 amd Staff #15 entered the room, and Patient #3 immediately stopped punching roommate and turned anger towards the staff. Patient #3 then started punching, pushing and kicking both Staff. Staff #14 reported being able to elude Patient #3 and enter into the nursing station and call a code. The response team responded but the incident was ended due to another male patient waking up and witnessing the event and the male Patient #5 punched Patient #3 to stop his assault on female staff. Staff #3 indicated that there was a radio (walkie-talkie) at the nursing station, but had never used it, had not been trained on it and had not witnessed anyone using it or heard it in use. Staff #14 confirmed Patient #3 was punched in the face by another Patient #5 in the hospital leaving Patient #3 with a blackeye. During Observation on 12/20/2024 at 11:00 AM, Staff #1 provided a laptop to watch video footage. Patient #3 was observed experiencing a psychotic break attacking staff with a closed fist, kicking, slapping at Staff. This causing the Staff #14 to go flying onto the floor and into the wall hitting head. Patient #3 was able to elude hospital Staff #14 and Staff #15 over powering them. Staff #14 was observed able to get into the nursing station and calling a code. The two male Patients awaoke Patient #31 and Patient #5. Patient #5 was observed striking Patient #3 in face causing his blackeye. Policy: The hospital Policy on Patient Rights 10/2022, “University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the ‘Patient Bill of Rights’ and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction.” The hospital Policy on Abuse, 12/2022, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities.” The hospital Policy on Nursing Services 10/2023, “The delivery of nursing care at University Behavioral Health of Denton shall be understood as a purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment of the health status of those entrusted to our care.” The Hospital Policy on Quality Care and Treatment ‘Plan for Patient Care and Professional Services’ 08/2023, “University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility’s mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals in the most effective and efficient manner possible”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 33579 During Record Review and Interview the hospital failed all patients by failing to ensure, the hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. The hospital failed to ensure a Master level nurse was on duty at the time complaint Investigation conducted. Findings Inlcude: During Interview on 12/19/2024 at 2:00 PM with Staff #6 information was verified that the employee Staff #6 was not a Master Level DON. Staff #6 is Bachelor Level RN. During Interview and Record Review on 12/20/2024 at 11:30 AM with Staff #5 information was verified through the Employee Human Resources Record Staff #6 was hired as Interim DON. Staff #6 is not a Master’s Level DON. Staff #6 is a Bachelor’s Level DON. Staff #6 was informed of Interim DON role and willingly relinquished those responsibilites. During Record Review the hospital Education Qualification calls for the following background: Bachelor’s degree from an accredited school of nursing; Master’s Degree in psychiatric nursing or related field preferred. Policy The hospital Policy on Nursing Services 10/2023, “The delivery of nursing care at University Behavioral Health of Denton shall be understood as a purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment of the health status of those entrusted to our care.” The Hospital Policy on Quality Care and Treatment ‘Plan for Patient Care and Professional Services’ 08/2023, “University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility’s mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals in the most effective and efficient manner possible.” The hospital Policy on Patient Rights 10/2022, “University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the ‘Patient Bill of Rights’ and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33579 Based on Interview, Record Review the hospital failed 1 of 1 Patient #3 by failing to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. The hospital Patient #3 was intermently taking his medications Zoloft, Seroquel and Trileptal. Findings Include. During interview with hospital Staff #8, LVN reporting while Patient #3 was intermittently taking his medication he complained about a headache. Staff #8 reported documenting only that the patient refused the medication. During interview with hospital Staff #8, LVN reported that there was no medical consult established to improve Patient #3’s goals and care. During Interview with hospital Staff #10, DON it was reported the physicians were aware Patient #3 was internmently taking their medication, but nothing was done to ensure the Patient’s goals were met or education the patient that headache’s may be a side affect. The DON was informed Patients Care Plan was not updated by nursing staff. During Record Review Patient #3, Medication Administration Record on 09/25 at 1:06PM, “Patient #3, refused to take Zoloft.” During Record Review Patient #3, Medication Administration Record reflected on 09/19/2024, at 9:32 AM. Patient #3 refused to take Catapres.” During Record Review Patient #3, Medical Administration Record reflected on 09/19/2024 at 9:29PM. Patient #3 refused to take Zoloft.” During Record Review Patient #3, Medical Administration Record reflected on 09/20/2024 at 8:56 AM, Patient #3 refused to take Trileptal. During Record Review Patient #3, Medical Administration Record on 09/20/25 8:56 AM. Patient #3 refused Seroquel.” Policy: The hospital Policy on Patient Rights 10/2022, “University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the ‘Patient Bill of Rights’ and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction.” The hospital Policy on Neglect, 12/2022, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law the requires professionals to make a report within 48 hours of first suspecting abuse, neglect or exploitation of a child or person 65 years or older or an adult with disabilities.” The hospital Policy on Coordination of Services 08/2023, “Individualized treatment is based on the findings of the completed assessments and is provided by a multi-disciplinary team and professional staff. This team includes but is not limited to, the psychiatrist, nursing staff, social services staff, dietitian, and recreational therapist. The primary object of the treatment team is the assessment, treatment, and rehabilitation of the patient in an environment that promotes positive behavioral changes. The hospital Policy on Clinical Records “Medical Record Completion, 01/2023,” ‘It is the Policy of University Behavioral Health of Denton that the medical records shall contain sufficient information to identify the Patient; support Patient Diagnosis, to justify admission and continued hospitalization and describe the patient’s progress and response to medical services accurately.” The hospital Policy on Pharmaceutical Services 07/2024, “Medication Administration and Management.’ The administration of medications shall conform with local and state Pharmacy regulations as well as meeting The Joint Commission guidelines of Pharmaceutical Services.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 During Record Review Observation and Interview the hospital failed 1 of 1 Patient the Right to recieve care in a safe setting. Findings Include During Record Review the Psychiatric Evaluation 06/20/2024 reflected Patient #1 was non compliant, nonverbal, and admitted on an involuntary basis. It was requested that Patient #1 be admitted involuntary. The request was denied by the District Attorney’s Office. Regardless the Patient was reassed in the Intake department and readmitted into the hospital. During Record Review 06/20/2024 the Hospital Incident Report 06/20/2024 at 2:23PM second shift. Patient Fall observed. “Patient was in the day area, staggered, and fell on the floor by the nursing station door. No injury noted. Vital signs checked BP 109/59, P 107, R 18, 02 99%. Medical doctor notified, MD came to the unit and assessed patient. No new orders.” During Observation of video footage, Patient #1 fell on her right side at 2:23Pm on 6/20/2024. There is no video footage of the doctor on the unit examining Patient at this time. The video footage revealed Patient #1 seated for short period of time. Staff attempting to adjust the patient seated in the chair, and pushing another chair to elevate the Patients legs/feet. The patient did get up shortly after and ambulate on own accord. During Interview with Staff #1 they were informed the phyicians wanted to readmit Patient #1 on an involuntary status. However, Why did they think it was not important to send the patient out or have a mobile x-ray unit arrive to the facility to further assess this Patient head and neck areas after the fall. There was a previous head and neck x-ray at previous referring hospital allegedly due to being a victim of domestic violence, which revealed they were unremarkable. Why did the hospital not follow up with another evaluation to enusre Patient safety. Policy The hospital Policy (UBH-Denton) Patient Rights 08/2023, Recognizing the importance of a patient’s privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that patient’s privacy rights are protected. Below is a summary Patient Rights and the polices that address them. Patients will receive a description of their individual privacy rights in the Facility’s notice of privacy practice. The hospital Policy on Patient and Family Grievances/the Role of the Patient Advocate, ‘08/2023, “It is the policy of UBH Denton to encourage responsive and open communication with patients at all levels in the hospital with the objective of resolving grievances through appropriate problem solving actions. All patients shall be informed of the grievance process and the availability of the Patient Advocate upon admission. It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients and their families no matter how trivial the complaint may appear to be. Presentation of a grievance will not, in itself, serve to compromise a patient’s future access to care.” The hospital Policy on Neglect 12/2022, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting neglect of a child or person 65 years or older or an adult with disabilities.” The hospital Policy on Quality Assurance and Performance Plan 08/2023, “UBH Denton is committed to providing high quality and efficient care for its patients and other consumers. The Quality Assurance & Performance Improvement Plan (QAPI) developed by UBH Denton guides the facility’s efforts in achieving excellence in patient care and is in accordance with the mission and vision of the organization and that of Universal Health Services, Inc.” The hospital Policy on Falls Prevention & Management 08/2023, “during their inpatient stay, patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring, using an evidence based tool that is approved by the medical staff. Patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 33579 Through Record Review, Observation, and Interview the hospital failed 1 of 1 Patient (Patient #1), (3) That clear expectations for safety are established. Findings Include: During Record Review there was no documentation that reflected there is a Falls committee in place to address hospital falls, standardized or treatment. There is a Fall Precaution Policy. During Record Review Hospital Incident Report 06/20/2024 at 2:23PM second shift. Patient Fall observed. “Patient was in the day area, staggered, and fell on the floor by the nursing station door. No injury noted. Vital signs checked BP 109/59, P 107, R 18, 02 99%. Medical doctor notified, MD came to the unit and assessed patient. No new orders. “ During Observation nursing notes Patient was noted as being drowsy, but there is no documentation of a falls assessment completed. Patient is not identified during the first admission with a high risk for Falls, but there is no Falls Assessment completed after identifying Patient is drowsy and she had an unsteady gate. During Interview with hospital Staff #7, Patient #1 non-compliant and she was drowsy. Staff #7 reported that she did not document that information in medical notes and it was not reported to the physician. Staff #7 reported that Patient #1 is non-compliant and unable to assess. During Interview with hospital Staff #6 it was reported that Patient #1’s fall was not witnessed but it was heard. “I heard the slap onto the ground.” Policy The hospital Policy (UBH-Denton) Patient Rights 08/2023, Recognizing the importance of a patient’s privacy rights, UHS maintains a comprehensive system of policies and procedures to help ensure that patient’s privacy rights are protected. Below is a summary Patient Rights and the polices that address them. Patients will receive a description of their individual privacy rights in the Facility’s notice of privacy practice. The hospital Policy on Neglect 12/2022, “To establish a uniform policy and procedures for reporting and responding to all allegations of abuse and neglect. To comply with Texas law that requires professionals to make a report within 48 hours of first suspecting neglect of a child or person 65 years or older or an adult with disabilities.” The hospital Policy on Quality Assurance and Performance Plan 08/2023, “UBH Denton is committed to providing high quality and efficient care for its patients and other consumers. The Quality Assurance & Performance Improvement Plan (QAPI) developed by UBH Denton guides the facility’s efforts in achieving excellence in patient care and is in accordance with the mission and vision of the organization and that of Universal Health Services, Inc.” The hospital Policy on Falls Prevention & Management 08/2023, “during their inpatient stay, patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring, using an evidence based tool that is approved by the medical staff. Patients are continually assessed/reassessed throughout their admission to identify fall risk factors that prompt initiation of/or change in fall precaution/levels of monitoring.””

“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: 28141 Based on observation, record review, and interview, the facility (Hospital A) failed to comply with 489.24 and provide an appropriate medical screening exam for three of 32 patients (Patients #6, #26, #29) 1. Hospital A failed to provide an appropriate medical screening for Patient #6 to determine the presence of a medical emergency. On 10/01/23 Patient #6 was brought to Hospital A by Police who requested care on behalf of the patient. Patient #6 had been emergently detained, made nonsensical statements regarding God’s creation, Satan, the matrix and three universes. Intake and Administrative Staff at Hospital A told the officers that they did not have a bed for Patient #6 and to take him to Hospital B more than 47 miles away. Police and Patient #6 arrived at Hospital B 73 minutes later. At that time, Patient #6 was in a psychotic state, extremely paranoid and agitated, and required inpatient stabilization due to his life threatening and destructive behavior to himself and others. Within less than an hour after admission, Patient #6 required emergency behavior and medication interventions when Patient #6 became an imminent danger to others in the treatment environment. 2. Hospital A failed to provide a medical screening examination for Patient #26 on 10/02/23 to determine whether or not an emergency medical condition existed. 3. Hospital A failed to provide evidence that a medical screening had been completed for Patient #29 to determine the existence of an emergency medical condition on 10/28/23. Refer to A2406 Hospital A failed to complete appropriate transfer forms and /or complete a Memorandum of Transfer (MOT) for seven out of 32 patients who required emergency medical treatments. Refer to A2409”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 41108 Based on observation, record review, and interview, the hospital failed to maintain a central log on each individual who came to the emergency department for 1 of 20 (Patient #6) patients in that, on 10/01/2023, Patient #6 presented to the hospital for evaluation and was not listed on the hospital’s central log. Findings included: On 10/01/23 at approximately 4:56 AM, Patient #6 arrived at Hospital A (University Behavioral Health) via Flower Mound Police Department. Officers #1, #2, and #3 were observed via body camera surveillance video escorting Patient #6 into Hospital A to be evaluated for a psychiatric medical condition. The body camera video surveillance revealed Officers #1, Officer #2, and Officer 3# were informed by Staff #9 (Intake Nurse) and Staff #6 (Chief Executive Officer) that a bed was not available for a male patient and requested that the officers seek care at another facility. Shortly after, Patient #6 is seen being escorted off of the Hospital premises by Flower Mound Police Officers. A review of the facility EMTALA Intake Log on 11/14/2023 revealed on 10/01/2023, the document did not note Patient #6 as having come to the hospital for the evaluation of a psychiatric medical condition, as their name was not listed on the EMTALA Intake Log. A review of the facility policy titled “Memorandum of Transfer (MOT)” status active, last revised on 5/2017 revealed, Pg. 2. “PROCEDURE: Responsibilities of Hospital Administration ...A central log must be kept in the intake/assessment area noting each individual who comes to the hospital seeking treatment. (This log must be kept for a minimum of 5 years). Document in the log whether the individual: Refused treatment Was refused treatment Was transferred, admitted and treated, or stabilized and transferred Was discharged Any other significant related information...” In an interview with Staff #1 (Director of Intake) on 11/14/2023at 5:00 PM, he verified Patient #6’s name was not listed on the EMTLA Intake Log on 10/01/23 even though it was confirmed Patient #6 had arrived seeking evaluation for a psychiatric medical condition.”

“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: 41108 Based on observation, medical record reviews, facility documentation reviews, and interviews, the facility (Hospital A) failed to provide a medical screening examination (MSE) for three (Patients #6, #26, and #29) of 20 patients whose records were reviewed. Patient #6 left the facility via police escort to seek treatment at Hospital B, where his admitting diagnosis to Hospital B included Bipolar Disorder, Manic, severe with psychotic features. Patient #6 was hospitalized for four days with an acute psychiatric life-threatening illness. Within less than one hour after admission, Patient #6 required emergency behavioral and medication interventions after disrobing, making graphic threats to the safety of other patients, and initiating a physical altercation. Patients #26 and #29 left Hospital A via 911/Emergency Medical Service transport with no documented evidence of ever receiving a medical screening examination. Findings included: Hospital A Review A review of the bodycam video surveillance at Hospital A on 10/01/2023 provided by Officer #1, Officer #2, and Officer #3 from Flower Mound Police Department from 4:56:10 am to 5:12:30 am revealed the following: 4:56:10 AM- Patient #6 exits the back of the police vehicle, escorted by Officers. 4:56:30 AM - Officers #1, #2, and #3 and Patient #6 arrived at Hospital A. The front of Hospital A can be seen in the video. 4:56:57 AM - Officers and patient enter the first door corridor and press the on-call button on the right wall. 4:58:18 AM - Staff member #9, Intake Registered Nurse, in gray scrubs, is seen approaching the locked facility door to open it and allowing officers and patients into the lobby intake area. 4:58:37 AM - Officer #2 provides Staff #9 with paperwork and introduces the patient. 4:58:57 AM - Staff #9 reviews paperwork and informs Officer #3 that the facility has no beds and cannot take Patient #6. The House Supervisor states Hospital B is the facility that would accept the patient. Patient #6 asks, “Can you please take me? I am so thirsty. I’ll be good.” 4:59:27 AM - Staff #9 exits the intake area and states she will return. Patient #6 is seen walking down the hall away from the officers. 5:01 AM - Staff # 11, House Supervisor, approaches and introduces herself as House Supervisor. She informs the officers that the facility does not have any beds except a female bed. Officer #3 informs Staff # 11 of the requirement to provide a medical screening. 5:02:15 AM - Staff # 11 is seen calling someone on her phone and then exits the intake area. 5:02:51 AM - Staff #9 brings Patient #6 water. Officers attempt to provide water. The patient sniffs the cup and refuses to drink properly. Officers informs him that they would not provide water if he was uncooperative. 5:03:18 AM - Staff #9 informs officers that everyone is being sent to Facility B. Staff #9 exits the intake area and returns to the back. 5:05:30 -5:08:50 AM - Patient #6 begins to tell the officers, “Adam and Eve created a baby, and that baby is Satan ...son of God is [expletive].” Patient #6 continues to speak about God’s creation, Satan, the matrix, and three universes. Patient #6 is seen rocking back and forth, talking about Satan. 5:08:50 AM - Patient #6 sits on the ground against the intake counter. 5:09:11 AM - Staff # 11 enters the intake area and indicates Staff #6 was on the phone. 5:09:29 AM (View from Officer #3’s Body Camera) - Officer #3 asks Staff #11 to identify themselves and Staff # 9. Staff #11 indicates she does not know who Staff #9 is. Staff #11 makes a call and hands the phone to Officer #2. Officer #3 asks Staff #11 if she was refusing to provide medical treatment. Staff # 6, Chief Executive Officer, is heard on the phone stating, “We have to do a medical screening. We can do that, but we cannot accept the patient because we do not have a bed. We can do a medical screening.” 5:09:49 AM - Officer #3 asks Staff #6, “So yes, you are refusing him?” Staff #6 responds, “Yes.” Officer #2 asks Staff #6 to state their name and notates it on Officer #2’s notepad. 5:10:09 AM - Staff #11 shrugs her shoulders, states, “We can’t do anything,” and walks away. Officer #2 is seen assisting Patient #6 and asks him to stand. Patient #6 states he does not want to get up. Patient #6 is assisted by Officers #1 and #3. 5:12:30 AM - Staff #11 returns to the lobby and unlocks the door. Officers #1, #2, #3, and Patient #6 exit the building. Video ends. A review of Hospital A policy titled “Appropriate Us of Involuntary Commitment,” Status Active, ID 12148859, Last Revised on 08/2020 revealed, “WHEN A PATIENT COMES TO THE HOSPITAL - EMTALA SCREEN TO IDENTIFY AN EMERGENCY CONDITION The federal Emergency Medical Treatment and Labor Act (EMTALA) requires a medical screening examination (MSE) for every person who presents to the Hospital and requests an assessment, whether the person presents on his/her own or is brought in by a peace/police officer. The purpose of the MSE is to determine whether the person has an emergency condition, which includes both medical and psychiatric/ substance abuse emergencies. Thus, an EMTALA MSE includes a preliminary psychiatric assessment.” Record review of Patient #6’s medical record (Hospital B): A review of the Patient Demographic Profile for Patient #6 at Hospital B reflected the patient was brought in by Police involuntarily for inpatient admission on 10/01/23 at 6:38 AM. He was discharged on 10/05/23 at 10:40 AM. Patient #6’s Hospital B Preadmission Evaluation and Medical Clearance Screening dated 10/01/23 at 6:36 AM revealed the patient had arrived at Facility B at 6:25 AM on an Emergency Detention Order (EDO). Staff noted the patient’s delusional thinking and stated the patient believed he was “God.” The patient displayed “rambling speech” and made “nonsensical statements ... incoherent ... believes he is 17 years old ...per EDO believes officers are from a different timeline ...” Patient #6 stated that he was a “Super hero,” believed people were “on Universe one and he is preventing Universe two and three from taking over Universe one ...”. Patient #6 was noted to be “extremely paranoid, has hallucinations and presents with agitation ...” Hospital B Physician’s Preadmission Examination and Admitting Orders dated 10/01/23 at 7:52 AM reflected Patient #6 was admitted to inpatient psychiatric care as an involuntary patient with preliminary psychiatric impressions that included Schizophrenia Paranoid Type. The patient’s precautionary status included staff observation for assault/homicide, elopement, and self-harm. Hospital B Standardized Intake Assessment dated 10/01/23 at 6:42 AM reflected Patient #6 was brought to the Hospital by Police and appeared to be in a psychotic state on arrival and asking whether staff were on his or “Satan’s side.” Staff noted that Patient #6 was “ ...confused ...” and stated that he was there “to prevent timeline 2 and 3 to take over ...” Patient #6 needed inpatient acute psychiatric care and 24-hour monitoring for “life threatening, destructive or disabling [behavior] to self or others” and “acute behavioral control.” Seclusion/Restraint/Emergency Medication Order dated 10/01/23 at 7:15 AM reflected Patient #6 received intramuscular administration of Haldol 10mg, Lorazepam, 2mg, and Benadryl 50mg for “agitation.” Nursing noted Patient #6 was of “imminent danger to self ...imminent danger to others ....pt [Patient#6] newly admit to unit, dysregulated the unit by making graphic threats to harm peers ...took off his pant in the hallway ...attacking peer ...unable to redirect ...” Patient #6’s Nursing Progress Notes, undated, reflected “at around 0715 patient [was] brought to unit by Intake staff ...patient began to pacing the hallway, yelling, making graphic threats to harm peers, took off his pants on the hallway, naked, dysregulated the unit by following peers and attempted to hit them, peer retaliated by hitting him on the hallway. All attempts to redirect failed. On call provider notified with order of emergency meds...” Patient #6’s Comprehensive Psychiatric Evaluation dated 10/01/23 at 2:00 PM reflected the reason for current hospitalization was Psychosis and Aggression. The patient believed he was “God” and “from a different timeline ...” The patient had asked the Police to take him to the Hospital. The patient had multiple cuts on his arms. Patient #6 had an “unkempt” appearance, was “agitated” and had “pressured speech.” He was in an “angry” mood and with “labile” affect. The initial plan of care was to reduce the patient’s “hallucinations agitation” and “minimize aggressive behavior.” The patient was physician noted to be a danger to himself and others. Patient #6’s Hospital B Discharge Summary, signed by the attending physician on 10/28/23 at 12:51 PM, reflected Patient #6’s initial and discharge diagnoses included Bipolar Disorder, Manic, severe with psychotic features. The reason for the patient’s admission included “ ...increased mood instability ... disturbance in thought process ...had physical altercation, believing he was God ...being from a different timeline ...continued to make odd references ...impairments of thought process ...to include increased risk of harm to others ...presented with cuts to arms and legs as well ...decompensated and admitted for inpatient crisis stabilization ...” The patient’s prognosis at discharge was “fair.” A review of the medical record for Patient #26 revealed, the patient arrived to the facility on 10/2/2023. The patient was sent via 911/EMS (Emergency Medical Services) for difficulty breathing. The medical record did not include documentation to support a 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. A review of the medical record for Patient #29 revealed, the patient arrived to the facility on 10/28/2023. The patient was sent via 911/EMS (Emergency Medical Services) for chest paint. The medical record did not include documentation to support a 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. Interviews: In an interview with Staff #6, Chief Executive Officer (CEO), on 11/14/2023, he revealed he was on call the weekend of 10/1/2023. Staff #6 stated his understanding is that everyone has to have a medical screening, even if they do not have a bed. He reviewed the video surveillance. He confirmed he did advise the Police that the patient was being refused. He did not know that they (facility staff) did not make a phone call to the other facility. He also revealed intake staff did not indicate that they needed stabilizing treatment; otherwise, they would have followed EMTALA. In an interview with Staff #4, the Chief Nursing Officer stated on 11/14/2023, “I would have expected the House Supervisor to provide an MSE. In this situation, she escalated to the CEO, and the officers cut it and turned around and left. Everyone, at minimum, needs to get a medical assessment. If the facility is at capacity, they can take the patient in. They have the ability to consolidate. They will still admit the patient and transfer after that. They might have a quick phone call, reach out to MD, and be okay to consolidate people in. We are required to provide a medical screening exam.””

“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: 47578 Based on record review and interviews with staff, the Hospital failed to follow facility policy when they did not complete appropriate transfers for seven out of 32 records (Patients #3, #25, #26, #27, #28, #29, and #30) requiring emergency medical treatments and continuity of care. The facility failed to notify the receiving Hospital of patient transfer, failed to secure an accepting physician at the receiving Hospital, and did not complete a Memorandum of Transfer (MOT) form. The findings included: Record Review Memorandum of Transfer records were reviewed for 32 patients between June 26, 2023, through October 11, 2023. Patient #3 Date of Visit 10/23/2023- The patient was transferred to another facility for continuity of care. MOT did not include a physician’s signature. Patient #25 Date of Visit 11/2/2023- The patient was sent out on emergent transfer for blood pressure 157/105. MOT was missing the acceptance of the Hospital and transfer of hospital information. The Physician’s signature was also missing. Patient #26 Date of Visit 10/2/2023- The patient was sent via 911/EMS (Emergency Medical Services) for difficulty breathing. The MOT does not include any hospital information regarding transferring or accepting physicians. The Physician’s signature was missing. The patient’s signature was missing, and a checked box on the form indicated that he refused transfer. The medical record did not include any information regarding an assessment being completed. Patient #27 Date of Visit 10/14/2023 - The patient was sent via doctors’ orders for continuity of care. The patient’s diagnosis was not provided. MOT did not include a physician’s signature. Patient #28 Date of Visit 10/17/2023 - The patient was sent via 911/EMS for chest pains as an emergent transfer. MOT did not include transfer/accepting facility information. Patient #29 Date of Visit 10/28/2023- The patient was sent via 911/EMS for chest pain. Patient records do not include any information to support that intake was complete or that vitals were taken. MOT did not include any information regarding the receiving or transferring facility. The Physician’s signature was also missing. Patient consent was also not provided. Patient #30 Date of Visit 11/2/2023 - The patient was sent out via 911 due to low blood pressure and experiencing withdrawals. MOT did not include accepting Hospital or transferring hospital information. The Hospital’s policy titled Memorandum of Transfer (MOT), last revised 05/2017, effective 10/2023, shows: Page 3, section titled Transfer of Patients with Emergency Medical Conditions (EMC), includes, “If a patient at UBH has an emergency medical condition which has not been stabilized or when stabilization of the patient’s condition is not possible ...the transfer shall be carried out as quickly as possible.” Page 6, section titled Memorandum of Transfer, includes the following: “Memorandum of Transfer must be completed for every patient transferred and must contain ...time and date which the transferring physician secured a receiving physician, signature, time and title of transferring hospital administration, a certification signed by the transferring physician who includes summary of risk and medical benefits.” Interviews In an interview with the Intake Director, Staff # 1, on the afternoon of 11/14/2023, Staff #1 indicated the Intake Team oversees the completion of transfers at intake and completes the memorandum of transfer forms. Staff #1 indicated transfers are conducted for patients with medical emergencies, and an MOT is completed for each transfer. Staff #1 indicated this includes both emergent and non-emergent transfers. Staff #1 indicated that if a patient has a medical emergency, 911 is called, and the accepting Hospital is noted as 911. Staff #1 acknowledged the MOTs were incomplete and may not include the receiving hospital information due to a patient being transferred by ambulance and the Hospital not providing the name of a physician. Interviews with Staff # 4 (Chief Nursing Officer), and Staff # 9 (Intake Nurse) revealed inconsistency of their understanding of the EMTALA requirements. Staff #9 stated “if we do not have a bed or accommodations then the officers have to be present during the MSE”, while Staff #4 stated, “we will still admit the patient and transfer if you do not have a bed for them; we are required to provide a medical screening. We have a lot of contingency plans in place to address situations like this.””