Perimeter Behavioral Hospital of Dallas

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 37325 The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. Based on record review the facility failed to let 1 of 1 (Patient #1) patients request treatment when they presented to the facility on 09/06/25 with suicidal ideation. Findings included: On 09/06/25 Patient #1, a 17-yer-old male, was brought to the facility with an emergency detention order for suicidal ideation. The Preadmission Evaluation and Medical Clearance Screening dated 09/06/25 reflected ...”Admit patient under the care of the attending psychiatrist for further psychiatric evaluation” The Voluntary Consent for Treatment and Admission dated 09/06/25 at 10:09 AM reflected ...”Patient Signature APOWW [apprehension by police officer without warrant] ...” The facility’s consent packet is 22 pages in length. The packet includes voluntary consent for treatment and admission, hospital information and acknowledgements, financial policies, notice of privacy practice, advanced directives of organ donation, the calming engagement plan, consent for visitation and telephone contact, patient’s rights and responsibilities and grievance, personal property waiver, patient belongings and valuables, privacy policies, and a patient packing list. Patient #1 had signed all consents except the consent for the voluntary treatment consent. An email from Personnel #2, dated 09/09/25 at 02:57 PM regarding a grievance by Patient #1’s mother reflected ...”SW [Social Worker] received a call from pt’s mother (MOP) who advised that pt [patient] is not to be admitted to facility ... informed her that pt expressed interest in voluntary admission” During an interview on 09/29/25 at 02:29 PM Personnel #2 stated “there was no documentation in the record the patient wanted to check himself in because no one called the doctor to get an order for the patient to sign himself in as a minor ...” Health and Safety Code Sec. 572.001. REQUEST FOR ADMISSION. (a) A person 16 years of age or older may request admission to an inpatient mental health facility or for outpatient mental health services by filing a request with the administrator of the facility where admission or outpatient treatment is requested ...”

“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: 37325 Based on record review and interview the facility failed to have a well-organized service in that 1 of 5 (Patient #2) diabetic patients were admitted to the facility with an insulin pump. The facility failed to have nursing policies and training regarding the use of insulin pumps. Findings included: Patient #2 a 16-year-old Type 1 diabetic was admitted to the facility on 06/26/24. Patient #2 was wearing an insulin pump and a continuous glucose monitor. During an interview on 07/09/24 at 10:30 AM Personnel #1 stated the facility did not have any policies regarding patients with insulin pumps and continuous glucose monitoring systems.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 37325 Based on record review and interview the nurses failed to evaluate the care of 3 of 6 (Patient #2, #6 and #10) diabetic patients. Findings included: Patient #2 was admitted to the facility on 06/26/24 with a history of Type 1 Diabetes. The Physician’s Orders dated 07/02/24 reflected Sliding Scale Insulin Protocol...If patient has a single blood glucose > 400 mg/dl-notify physician...” The Diabetic Clinical Record reflected...07/03/24 06:00 AM Glucoscan Bloodsugar...525...” The Shift Progress Note for 07/03/24 does not reflect the physician was notified of the patient’s blood glucose level. Patient #6 was admitted to the facility on 04/03/24 with a history of Diabetes. The Physician’s orders dated 04/03/24 at 12:31 AM reflected...”Fingerstick blood glucose qAC (before meals), every bedtime...” The Diabetic Clinical Record does not reflect a Fingerstick blood glucose being performed on 04/05/24 before breakfast and at bedtime; on 04/06/24 at bedtime; on 04/07/24 before breakfast; on 04/10/24 before breakfast and at bedtime; on 04/11/24 before breakfast and at bedtime; on 04/12/24 before lunch; on 04/13/24 before breakfast; on 04/14/24 before breakfast and before dinner. Patient #10 was admitted on 06/29/24 with a history of diabetes. The Physician’s orders dated 06/29/24 at 06:11 PM reflected...”Fingerstick blood glucose qAC (before meals), every bedtime...” The Diabetic Clinical Record does not reflect a Fingerstick blood glucose being performed on 06/30/24 at bedtime, and on 07/04/24 there was not a documented blood glucose before breakfast, lunch or dinner. During an interview on 07/10/24 at 01:35 PM Personnel #1 verified the above findings.”

“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: 37325 Based on record review and interview the facility failed to ensure compliance with 42 CFR 489.20 (l) Compliance with 489.24 (e) (1) and (2) Appropriate Transfer, and 489.24 (a) (1) (i)) Medical Screening Exam, for 1 of 20 (Patient #1) patients when they presented to the facility on 06/21/24 for treatment. Patient #1 did not receive an appropriate transfer to an acute care facility and the facility failed to perform an appropriate medical screening exam, . 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: 37325 Based on record review and interview the facility failed to provide an appropriate medical screening exam on 1 of 20 (Patient #1) patients who presented to the facility for treatment on 06/21/24. Findings included: Patient #1 presented to the facility on 06/21/24 after being found standing in the street by police. The police transported Patient #1 to the facility and placed the patient under an emergency detention. The Initial Medical Screen dated 06/21/24 at 08:44 AM reflected ...”Vital Signs Patient refused. 142/74, 94, 98%...Additional Medical Information. Unknown. Per mom no med condx (medical conditions) ...Heart/circulation issues ...unknown pt ref (patient refused) ...Chest Pain ...unknown pt ref ...Respiratory issues ...unknown pt ref ...Current Prescribed Medications ...Unknown pt refusal ...” The Initial Medical Screen does not list reason the reason the patient presented to the facility. Their medical record did not reflect a behavioral health exam. The medical record did not contain a consultation with a physician. The Multidisciplinary Progress Notes dated 06/21/24 reflected ...”Pt presented as an APOWW (apprehension by police officer without warrant) w/ (with) Mesquite PD (police department) fighting police attempting to harm pd and clinical staff. Once uncuffed pt flipping chairs and other furniture in intake lobby requiring Mesquite PD to place pt back in handcuffs. Pt refusing all medical assessment and posturing as if to attack clinical staff. Pt combative, out of control while hand cuffed, barricading furniture against door...911 contacted for pt to be transferred to ED for med (medical) clearance. While waiting on EMS (emergency medical services) pt noted to be nodding off, then will wake up with sudden bursts of energy and bizarre behaviors AEB (as exhibited by) throwing furniture, flickering lights on and off. Pt refusing UDS (urine drug screen) but does allow BP, HR, SPO2, (blood pressure, heart rate, oxygen saturation) and temp to be taken....” The Notification-Emergency Detention 24052568 dated 06/21/24 at 08:37 AM completed by Officer #1 reflected ...”Patient #1 DOB 05/29/2008 ...I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to him/herself or others based upon the follow: Standing in the middle of a main road. Has not taken his medications since December. Stating he has metal illness ...” During an interview on 07/10/24 at 10:06 AM Personnel #3 stated the patient was brought in by Mesquite Police Department. The patient was brought back to the intake lobby so the handcuffs could be removed. When the handcuffs were removed the patient began to flip furniture and kick the walls. The police were called back into the intake lobby to replace the handcuffs. Personnel #3 stated she tried to deescalate the patient by offering him food and water. The patient was refusing to have his vital signs taken and refused to give a urine sample. Personnel #3 stated the patient was cursing at the police. Personnel #3 stated she called the patient’s mother, but she refused to come to the facility and was not helpful in obtaining the patient’s medical history. Personnel #3 stated when she realized she would not be able to get a full assessment on the patient she called for help from administration. Personnel #3 stated that Personnel #2 came into the lobby and spoke with the police officers and their Lieutenant about the need for medical assessment and 911 was called. Personnel #3 stated she could not make an assumption that the patient was just aggressive and admit him to the floor. There was no way to tell by a visual assessment if he was on something because he was refusing all care. The policy Titled Emergency Medical Treatment and Labor Act (EMTALA reviewed 06/10/24 reflected ...Perimeter Healthcare has an absolute duty to screen any individual that comes to the hospital who may be seeking treatment for an emergency medical condition. Psychiatric disturbances can be emergency medical conditions ...Transfers of individuals with emergency medical conditions beyond the hospital’s capacity to stabilize are initiated by (a) a written request for transfer or (b) a physician certification regarding the medical necessity for the transfer ...” The policy titled Emergency Medical Services effective 07/17/19 reflected ...” ...27 ...C. A medical screening evaluation is above and beyond the initial triage screening and may be conducted by Qualified medical persons (QMP), Intake Clinicians and/or registered nurses (RNs) with consultation with a staff physician ...””

“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: 37325 Based on record review and interview the facility failed to contact the receiving facility to inquire about available space and obtain an acceptance of the transfer for 1 of 20 (Patient #1) patients. Findings included: Patient #1 presented to the facility on 06/21/24 after being found standing in the street by police. The police transported Patient #1 to the facility and placed the patient under an emergency detention. The facility failed to contact Medical City Dallas to request a transfer and receive acceptance of the transfer prior to placing the patient in an ambulance and sending them to Medical City Dallas Hospital. The facility failed to provide a Memorandum of transfer and did not get consent to transfer Patient #1. The Multidisciplinary Progress Notes dated 06/21/24 reflected ...Pt presented as an APOWW (apprehension by police officer without warrant) w/ (with) Mesquite PD (police department) fighting police attempting to harm pd and clinical staff. Once uncuffed pt flipping chairs and other furniture in intake lobby requiring Mesquite PD to place pt back in handcuffs. Pt refusing all medical assessment and posturing as if to attack clinical staff. Pt combative, out of control while hand cuffed, barricading furniture against door.... 911 contacted for pt to be transferred to ED for med (medical) clearance. While waiting on EMS (emergency medical services) pt noted to be nodding off, then will wake up with sudden bursts of energy and bizarre behaviors...EMS arrived with Garland PD. Pt placed on stretcher....” The body worn camera of Officer #1 202406210905_WFC1127854_66455931 reflected...”Personnel #3, stated “He is not meeting criteria out the door.” Officer #1 stated “My partner is talking to the Lieutenant now to see what we are allowed to do. Since we transported him to here by law, we are not allowed to APOWW (apprehension by police officer without warrant) him to another facility.” Personnel #3 stated, “I got you; I understand.” Officer #1 asked “Can you call Garland because we cannot APOWW to another facility? An unknown female stated, “Garland said they are not coming.” Personnel #4, stated “Legally we can’t touch him because he is not our patient.” Personnel #3 stated, “I can’t restrain him medically.” During this conversation the patient is being aggressive with the police and trying to get out of the room. The police close the door to the triage room, and you can hear banging sounds coming from the room. The officer is holding the door closed and then it gets quite in the room. An unidentified female looks in the window of the room and states the patient is pushing furniture in front of the door as if to barricade the door. Officer #1 goes into the hospital lobby and calls Officer #2 on the phone. Officer #2 asked Personnel #2, “is there a particular reason you are not admitting an APOWW?” Personnel #2 stated “When you bring an APOWW to us it is just a transportation method. This individual here is beyond our ability to treat based on our MSE (Medical Screening Exam) and what is going on with him right now. His extreme aggression right now we don’t have ...” Officer #2 asked, “did you perform a MSE already?” Personnel #2 stated, “no we did our visual MSE right now because we have no idea if he is on substances, psychosis. We can’t manage him. We don’t have the medications that they have even in an ER (Emergency Room) or devices to restrain him at all. He is that aggressive that he is having to be put back in handcuffs and that is beyond our ability to treat here. Okay and that is what falls under EMTALA. And that falls under why we can’t accept an APOWW.” Officer #2 stated, “Well at the same time under EMTALA since he is on your grounds EMTALA says you guys are responsible to transfer him. So, we are having a disagreement here. I guess my next call is to CMS.” Personnel #2 stated, “Right, it is not even necessary to call CMS, but feel free to do that. Basically, the thing is right now is that he can’t safe transport even to an ER because we have no idea what this person’s medical condition is or substances on here that to transport safely to an ER would be with the police department and not an ambulance right now.” Officer #2 stated, “We are not a transport and you’re saying that is the issue ...EMTALA states he is on your ground, correct? He is on your hospital campus, right?” Personnel #2 stated, “We can call an ambulance as long as your officers want to stay here and ensure this person gets in an ambulance to an ER. That is the problem, if you take him out of these handcuffs.” Officer #2 stated, “What you are telling me is you guys didn’t do a basic medical screening.” Personnel #2 stated, “ yes, we did it.” Officer #2 stated, “and you don’t want him there, so you want us to transport him from your campus to another hospital.” Personnel #2 stated, “again because we have no idea what this person’s medical condition is, okay?” Officer #2 stated, “What he needs is to be medically cleared ...We are not required to do so. If you want him to be, you guys are supposed to have him transported elsewhere, not us.” Personnel #2 stated, “Well we can’t release him from the handcuffs that’s the problem and I can’t medicate him, he is not admitted to our facility.” At this point Officer #1 spoke with Officer #2 off speaker. Officer #1 tells Officer #2 the patient is just aggravated and does not want to be at the facility. Officer #1 says he thinks the patient is just mental and worked up. The patient stated he has bipolar and has not been taking his medications. Officer #1 said the facility contacted the guardians and they will not come get him. The police had responded to the residence twice in five hours. The patient was in the middle of the street saying he was going to jump when the police left. Officer #1 told #2 that about two minutes after they walked outside someone from the facility came out and asked them to transport the patient to another facility. After Officer #1 finished his conversation with Officer #2, he approached Personnel #2 and stated they were going to take the patient to Hickory Trail Hospital. Officer #1 asked “do you have a business card? Can I get the name of the nurse that did the visual?” Personnel #2 stated, “No they completed the MSE. As far as EMTALA is concerned we are not ...we do not have to accept someone who is beyond our ability to treat. So, he is welcome to do anything. I am very familiar with this. I have been in this for 30 years ...” Officer #1 then goes into the Intake Department to get the patient with Personnel #2. Personnel #2 is heard having a conversation with an unknown male employee. The employee stated the patient is being triggered by the police. Personnel #3 enters the intake lobby and speaks to Personnel #2. Personnel #3 stated, “mom is refusing to come up here ...his bizarre behavior and lack of suicidality I feel it appropriate for an ambulance to take him for medical clearance.” Personnel #2 stated, “They are going to transport him to Hickory Trail. You’re going to face, end up facing the same kind of response there ...you guys are kind of stuck in the middle here ...we have done our process ...we can’t transport. I don’t even know if an ambulance can transport because of his bizarre behavior because he is so aggressive ...hey law enforcement we need you to help us get him to the next level of care ...” Officer #1 asked, “can’t you call an ambulance and talk to them about the situation?” Personnel #2 stated, “We can but they will refuse because they will be in fear ...” Officer #1 stated, “there have been plenty of times I have ridden in the back of an ambulance because this person has been handcuffed ...” Personnel #2 stated, “We can call ...we may waste their resources ...APOWW is to the nearest accepting facility. We are not an accepting facility because he is beyond our ability to treat ...It would be best to see about getting him to an ER because we have no idea. These kids smoke and do these drugs and all kinds of stuff ...” Officer #1 stated, “He wasn’t intoxicated when we were on, when we were out there for the first three hours ...he had a normal conversation with us, no slurred speech or anything like that ...If there was a medical reason why, we would have taken him to Baylor or Children’s ...” Personnel #2 stated, “We know nothing about him today except this is beyond what we can treat ...” Personnel #3 stated, “ I feel as if he is medically stable enough, but obviously he refused to let me take his vital signs. I did as much of his medical screening as I could ...” The staff leave the Intake lobby at this time, Officer #1 his heard talking with another police officer stating “There is nothing medically wrong with him, he is worked up. His calm now.” Personnel #2 reentered the Intake lobby and stated, “They are trying to reason with him now. What there saying is concerning him now is because he will try to dose off and everything else. He has barricaded himself in the room ...and not responding, so they are thinking there is something onboard ...So I told them to go ahead and call an ambulance and let’s see ...” The facility called an ambulance to transport the patient for medical clearance and the Personnel #4 goes into the triage room and removes the handcuffs from the patient and takes out to the police officer. During an interview on 07/09/24 at 11:30 AM Personnel #2 stated the patient was brought to the facility by Mesquite Police Department. The patient was in handcuffs and was combative. The police took the patient into the Intake Department and removed the handcuffs. The police went back into the lobby to wait. The police had to go back into the Intake Department and place the handcuffs back on the patient. The patient was combative, throwing furniture, and broke the door to the intake. Personnel #2 stated the patient was about 5’ 9” tall but not overly muscular. Personnel #2 stated he busted through the door of the Intake Department by body slamming the door. The patient busted the mag lock and the pin lock that was installed on the door. Personnel #2 stated when she was called about the situation she went and spoke with the police officers. Personnel #2 stated the patient was refusing a Medical Screening Exam and refusing to have his vital signs taken. Personnel #2 stated you could tell something was going on with this patient. Personnel #2 stated she told the police that the patient needed to be medically cleared. Personnel #2 stated they could not emergently medicate the patient not knowing if the patient was on something because that could cause a problem. Personnel #2 stated the officers at the facility called their Sargent. Personnel #2 stated she could hear the conversation with Officer #2 because the officer had him on speaker. Personnel #2 stated that Officer #2 told his officer if the facility refused to take the patient or get medical clearance to take the patient to Hickory Trail Hospital. Personnel #2 stated she told Officer #2 that she would call the ambulance, and taking the patient to Hickory Trail would just delay the patient’s treatment. Personnel #2 stated when the ambulance arrived so did Garland Police. The medics were concerned about the patient being combative in the ambulance. Personnel #2 stated Mesquite Police and Garland Police had a conversation about where the patient was to be taken and who was responsible for them. Finally, the ambulance left with the patient, and he was not brought back to the facility...” During an interview on 07/10/24 at 10:06 AM Personnel #3, stated the patient was brought in by Mesquite Police Department. The patient was brought back to the intake lobby so the handcuffs could be removed. When the handcuffs were removed the patient began to flip furniture and kick the walls. The police were called back into the intake lobby to replace the handcuffs. Personnel #3 stated she tried to deescalate the patient by offering him food and water. The patient was refusing to have his vital signs taken and refused to give a urine sample. Personnel #3 stated the patient was cursing at the police. Personnel #3 stated she called the patient’s mother, but she refused to come to the facility and was not helpful in obtaining the patient’s medical history. Personnel #3 stated when she realized she would not be able to get a full assessment on the patient she called for help from administration. Personnel #3 stated the Personnel #2 came into the lobby and spoke with the police officers and their Lieutenant about the need for medical assessment and 911 was called. Personnel #3 stated she could not make an assumption that the patient was just aggressive and admit him to the floor. There was no way to tell by a visual assessment if he was on something because he was refusing all care. The policy titled Emergency Medical Services effective 07/17/19 reflected ...”Perimeter Healthcare does not provide or have the capacity to provide extensive medical/emergency care for patients ...Medical emergency services other than basic cardiopulmonary resuscitation (CPR) are not provided at Perimeter healthcare ...Emergency medical conditions that are beyond the capacity of staff at Perimeter Healthcare to treat and/or manage will be transferred per hospital policy to a higher level of care by EMS through the actitation of 911 ...The transfer of patients from Perimeter Healthcare to another hospital is to be medically appropriate and is to follow state and federal statutes, Perimeter Healthcare policies and procedures regarding patient transfers ...1. An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or 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 other sin serious jeopardy; B. Serious impairment to bodily functions; C. Serious dysfunction of any bodily organ or part ...2. An Emergency Medical Condition may include, but is not limited to: significant change in level of/loss of consciousness, severe and/or unresolved chest pain or abdominal pain, significant and profound difficulty in breathing, significant loss of blood, any major physical trauma, (i.e., severe lacerations, suspected fractures), recurrent seizures, and any life threatening condition ...27 ...C. A medical screening evaluation is above and beyond the initial triage screening and may be conducted by Qualified medical persons (QMP), Intake Clinicians and/or registered nurses (RNs) with consultation with a staff physician ...” The policy Titled Emergency Medical Treatment and Labor Act (EMTALA reviewed 06/10/24 reflected ...Perimeter Healthcare has an absolute duty to screen any individual that comes to the hospital who may be seeking treatment for an emergency medical condition. Psychiatric disturbances can be emergency medical conditions ...Transfers of individuals with emergency medical conditions beyond the hospital’s capacity to stabilize are initiated by (a) a written request for transfer or (b) a physician certification regarding the medical necessity for the transfer ...” The facility’s website, https://www.perimeterhealthcare.com/dallas-assessment, reflected...”Often these assessments are for suicidal, homicidal or for aggressive behaviors...””

“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: 37325 Based on record review and interview the hospital failed to keep current 1 of 1 (Patient #1) care plan when Patient #1 was diagnosed with a fracture of the 5th metacarpal of the right hand. Findings included: on 03/28/24 Patient #1 received a medical evaluation for a complaint of right hand pain. The radiology report dated 03/28/24 reflected the patient had a fracture of the 5th metacarpal of the right hand. Patient #1’s treatment plan did not reflect the fracture had been added to the treatment plan. During an interview on 04/03/24 at 10:40 AM Personnel #1 reflected the treatment plan had not been updated to include the metacarpal fracture. The policy titled Treatment Plan: Interdisciplinary Master Treatment Plan reviewed 04/07/22 reflected...”8. The treatment plan shall be revised, if necessary, based on the findings of any assessment, reassessment, evaluation, or re-evaluation, or as otherwise clinically indicated...””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 37325 Based on record review and interview the hospital failed to maintain a medical record for 1 of 1 (Patient #1) patients that supported the diagnosis of a right 5th metacarpal fracture. The nursing record did not contain an assessment of the patient’s right hand. Findings included: On 03/28/24 Patient #1 received a medical consultation for right hand pain. The Shift Progress notes for 03/28/24 did not reflect an assessment of Patient #1’s right hand nor a reason for a medical consultation. The medical record did not reflect a follow-up medical progress note evidencing the x-ray had reflected the patient had a fracture of the right 5th metacarpal; nor a plan for treatment of the fracture. The Shift Progress Note dated 03/30/24 at 09:00 AM reflected the patient complained of pain to the right hand. The note reflected the nurse had wrapped the right hand, but no assessment of the hand was evidenced. On 03/30/24 at 04:14 PM The Physician’s Order reflected...”Tramadol 50mg PO ( by mouth) once a day PRN (as needed) for breakthrough pain. The chart did not evidence a medical progress note that justified a need for pain medication. During an interview on 04/03/24 at 10:40 AM Personnel #1 verified the above findings. During an interview on 04/03/24 at 11:30 AM Personnel #3 stated Patient #1 had approached them on 03/29/24 and asked to have their right hand bandaged. Personnel #3 stated Patient #1’s hand was swollen approximately half way up the hand and their was bruising present to the fingers. The policy titled Documentation Requirements revised 05/02/22 reflected...15. The medical record must contain documentation of complications...20. Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability of care...Whenever possible each of the patient’s clinical problems shall be clearly identified in the progress notes and correlated with specific orders with reasons for instituting various tests or treatment given and results of test...””

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 37325 Based on interview and record review the facility failed to provide adequate staffing on 4 of 4 days, in that the facility failed to follow the facility’s staffing matrix on 09/20/23, 09/22/23, 09/24/23/, and 09/25/23. Findings included: On 09/20/23 The Positivity Point unit staffing sheet reflected the unit had 11 patients on the night shift and was staffed with 1 Registered Nurse (RN) and 1 Mental Health tech. (MHT). The Magnolia Mountain (geriatric) unit staffing sheet reflected the unit had 8 patients on the night shift and was staffed with 1 RN and 1 MHT. On 09/22/23 The Positivity Point unit staffing sheet reflected the unit had 15 patients on the day shift and was staffed with 1 RN and 2 MHTs. On 09/24/23 The Stargazers unit staffing sheet reflected the unit had 16 patients on the day shift and was staffed with 1 RN and 2 MHTs. The Trailblazers and Hope Mountain staffing sheet reflected 20 patients on the day shift and the night shift. The staffing sheets for both the day shift and the night shift reflected the unit was staffed with 2 RNs and 2 MHTs. On 09/25/23 The Positivity Point staffing sheet reflected the unit had 13 patients and was staffed with 1 RN and 2 MHTs. The staffing matrix that was not dated reflected “...Nurse ratio is 1 to 12. MHT ratio Geri... 1 to 6, Trailblazers 1 to 8, Hope Mountain 1 to 8, Stargazers 1 to 8, Positivity Point 1 to 8...” During the record review on 11/21/23 ending at 02:40 PM Personnel #3 verified that the above findings. Personnel #3 stated that Trailblazers and Hope Mountain unit census are sometimes combined since there is only one nursing station on that floor.”