Baylor Scott and White Medical Center Sunnyvale

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 51905 Based on record review and interviews, Facility A failed to maintain accurately written and complete medical records for 3 of 20 patients when Patients #4, #7, and #8 did not have a documented physical examination or documentation of leaving against medical advice. Record Review: During the Patient Sample Chart Review, Patients #4, #7, and #8 had documentation of a medical screening exam being completed without documentation of a physical exam. Review of Patient #4 Medical Record Documentation gathered from Patient #4’s chart received, and Patient Sample chart review. No documentation of physical exam or documentation of left without treatment. 11/30/25 2:12 P.M.: Per Patient Sample Review - Patient #4 presented to Facility A. 3:00 P.M.: Per Patient Sample Review- Box checked for MSE, no documentation of physical exam 3:04 P.M.: Patient #4 triaged with chief complaint of “Reporting blood with bowel movements with associated abdominal cramping. Also reports frequency with urination. Also being treated for Hep C. Recent transfusions” (Triage, Page 7). 3:24 P.M.: Chest X-ray performed (Diagnostic Radiology, Page 3). 4:00 P.M: Patient #4 discharged as Left without Treatment (Discharged Information, Page 5). Diagnosis: “Patient left prior to Dr. exam” (Depart Reason, Page 5). Review of Patient #7 Medical Record Documentation gathered from Patient #7’s chart received, and Patient Sample chart review. No documentation of physical exam or documentation of elopement. 10/8/25 7:44 P.M.: Per Patient Sample Review - Patient #7 presented to Facility A. 7:53 P.M.: Per Patient Sample Review- Box checked for MSE, no documentation of physical exam 7:59 P.M.: Patient #7 triaged with chief complaint of “Burning w [with] urination x3 days hematuria or lower back pain, AOX$ [alert and oriented times 4] GCS 15 [Glasgow Coma Scale] ambulatory” (Triage, Page 6). 8:05 P.M.: Per Patient Sample Review: Discharge time of 8:05 P.M. Discharge Disposition: Eloped [Discharge Information, Page 4). Review of Patient #8 Medical Record Documentation gathered from Patient #8’s chart received, and Patient Sample chart review. No documentation of physical exam or documentation of left without treatment. 10/21/2025 2:26 P.M.: Per Patient Sample Review - Patient #8 presented to Facility A. 2:34 P.M.: Patient #7 triaged (Triage, Page 8). Per Patient Sample Review - Chief complaint of urinary retention. 2:38 P.M.: Per Patient Sample Review- Box checked for MSE, no documentation of physical exam 3:00 P.M.: Labs drawn - CBC, CMP (Laboratory, Page 3). 4:12 P.M.: Per Patient Sample Review: Discharge time of 4:12 P.M. Discharge Disposition: Left without Treatment (Discharge Information, Page 6). Review Rules and Regulations of the Medical Staff, Revised 3/29/2024: . “SECTION 2: ADMISSION AND DISCHARGE OF PATIENTS Standard Language . 2.9. Patient Discharges Patients shall be discharged only on the order of the Attending Physician or Advance Practice Allied Health Professional. The patient discharge plan should be reviewed with the Attending Physician prior to discharge. Should a patient leave the Hospital against medical advice, a notation of the incident shall be documented in the patient’s medical record. The patient or the patient’s surrogate decision maker (identified by hospital policy) shall be requested to sign a statement releasing the Hospital and Medical Staff members of any liability as the result of the patient’s action. Any refusal to sign this statement shall be documented in the medical record” (Page 10). . “5.6 Emergency Department a. The record for each Emergency Department visit will include at least the following: i. Adequate identification data, or if not obtainable, the reason indicated; ii. Time and means of arrival and who transported; iii. Pertinent history of the injury or illness and physical findings, including vital signs; iv. Allergy history; v. Listing of current medications; vi. Details of first and/or emergency care given the patient prior to arrival; vii. Evidence of general and appropriate informed consent, or if not obtainable, the reason indicated (see Informed Consent section); viii. Diagnostic and therapeutic orders; ix. Description of significant clinical, laboratory and radiological findings; x. Treatment given; xi. Clinical observations, including results of treatment; xii. Diagnosis or diagnostic impression; xiii. Conclusions at the termination of evaluation/treatment, including final disposition, patient’s condition on discharge or transfer, and instructions given to the patient and/or significant other for necessary follow-up care; xiv. Whether the patient left against medical advice” (Page 23). . Review of Medical Screening Examination Policy, Revised 3/2026: . “Documentation of Medically Emergency Condition: a.And the determination of the patient’s condition will be made by the Qualified Medical Professional and will become part of the Emergency Department Medical Record. . b.Documentation of the attempt to provide an MSE, but refused by the patients, will be made by the Qualified Medical Professional. The documentation will contain the risks and benefits of refusing this exam. If the patient is unwilling or, unable to sign, documentation of the circumstances and efforts made by the Emergency Department staff will be documented in the Emergency Department medical record” (Page 6). . Review of Patients Leaving Prior to Completion of Care or Against Medical Advice in the Emergency Department, Approved 10/2024: . “PROCEDURE A. If a patient is unable to be located in the ED or ED waiting room 1. ED staff will call the patient’s name and round in ED waiting room in attempt to locate. 2. If no response, ED staff will document in the medical record, the time called and unable to locate. This will occur three times with documentation each time. 3. If after three attempts the patient is still not located, ED staff will notify ED Charge RN and discharge the patient accordingly (LWBS, LWOT, or Elopement). . B. If patient or individual responsible for patient notify ED staff of their request to leave prior to treatment, ED staff will encourage patient to stay and document conversation. 1. If patient has MSE completed or has tests pending results - ED staff will notify ED Provider of patient’s request to leave. If possible, the ED Provider will encourage to stay, discuss risks of leaving, and if patient or individual responsible for patient do not wish to stay - request them to sign “AMA” form. a) ED Physician will, if possible, provide prescription, information on follow up care and to seek treatment if condition worsens or does not improve. b) RN assigned and ED Provider will document details and AMA form signed or refusal. c) If patient or individual responsible for patient refuses to sign AMA form, RN should document on form and have second RN witness. 2. If request is made to ED Registration staff, ED Charge RN will be notified to speak with patient, encourage to stay and document conversation. ED staff will follow processes above. . C. If patient or individual responsible for patient notify ED staff of their request to leave against medical advice (AMA): 1. ED staff will notify Physician. 2. If possible, the ED Physician will encourage to stay, discuss risks of leaving, and if patient or individual responsible for patient do not wish to stay - request them to sign “AMA” form. a) ED Physician will, if possible, provide prescription, information on follow up care and to seek treatment if condition worsens or does not improve. b) RN assigned and ED Provider will document details and AMA form signed or refusal. c) If patient or individual responsible for patient refuses to sign AMA form, RN should document on form and have second RN witness. 3. If request is made to ED Registration staff, ED Charge RN will be notified to speak with patient, encourage to stay and document conversation. ED staff will follow processes above” (Page 2). Interview: 1.On 4/13/26 at 1:00 P.M., the ED Director, Staff A, verified that 3 patients were missing a detailed MSE (medical screening exam). Staff A explained that for eloped patients, providers utilize a checkbox that states an MSE had been conducted, but do not document the exam. . 2.On 4/13/26 at 1:36 P.M., the ED Director, Staff A, verified that 3 patients were missing documentation by ED (emergency department) staff regarding elopement after seeing a provider. Staff A noted that left without being seen is documented when a patient leaves before seeing the physician, left without treatment is documented when the patient leaves after the MSE and before treatment, and eloped/against medical advice is documented when the patient leaves before treatment is completed. . 3.On 4/13/26 at 2:58 P.M., the ED Physician, Staff C, stated that if the patient stays for the entire treatment, a full MSE is documented in the chart. However, if the patient elopes or goes AMA (against medical advice), Staff C stated that there is a box in the chart that she selects that the MSE has been completed for a focus assessment only.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51905 . Based on record review, interviews, and Texas State Law, Facility A failed to ensure that 3 patients (Patient #2,#9, #11) of 20 patients who presented to the emergency department after a sexual assault were provided with the patient rights documents required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault. . Refer to Tag A0117 .”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 51905 . Based on record review, interviews, and Texas state law, Facility A failed to ensure that 3 patients (Patient #2, #9, #11) of 20 patients who presented to the emergency department after a sexual assault were provided with the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault. . Findings: Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES. (a) Except as otherwise provided by Subsection (a-2), after a sexual assault survivor arrives at a health care facility following a sexual assault, the facility shall provide care to the survivor in accordance with Subsection (b). . (b) A health care facility providing care to a sexual assault survivor shall provide the survivor with: . (1) subject to Subsection (b-1), a forensic medical examination in accordance with Subchapter B, Chapter 420, Government Code, and Subchapter G, Chapter 56A, Code of Criminal Procedure; . (2) a private area, if available, to wait or speak with the appropriate medical, legal, or sexual assault crisis center staff or volunteer until a physician, nurse, or physician assistant is able to treat the survivor; . (3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure; . (4) the information form required by Section 323.005; . (5) a private treatment room, if available; . (6) if indicated by the history of contact, access to appropriate prophylaxis for exposure to sexually transmitted infections; . (7) the name and telephone number of the nearest sexual assault crisis center; and . (8) If the health care facility has shower facilities, access to a shower at no cost to the survivor after the examination described by Subdivision (1). . Review of Sexual Assault Policy, Origination Date 08/27/2019 On 10/13/2025 during the entrance conference, Facility A was asked to provide all policies that related to Sexual Assault. Facility A failed to develop, implement, and enforce policies and procedures to ensure that after a sexual assault survivor presents to the hospital following a sexual assault, the hospital shall provide the care specified under Texas Health and Safety Code (HSC) Chapter 323. . The policy did not meet the requirements that would allow the facility to provide the care specified under Texas Health and Safety Code Chapter 323. The policy failed to address the following: . The policy did not address the patient’s option or request of transfer to a Safe-Ready facility. . The policy did not address the examination of a sexual assault survivor by a Safe-Ready or Non-Safe-Ready facility. The policy did not address how the exam would be presented to the patient, who would be responsible for presenting to the patient, or how the selected option of the patient would be documented in the patient’s chart. . The policy reviewed did not address patients’ privacy to wait or speak with the appropriate medical, legal, or sexual assault crisis center staff or volunteer until a physician, nurse, or physician assistant is able to treat the survivor. . The policy did not address the option to contact a sexual assault program advocate nor describe the role of a sexual assault program advocate. . The policy did not address the requirement to provide sexual assault survivors with the required information form. The policies did not address who would be responsible for ensuring the most current information form, who would be responsible for providing the information form to the patient, or how the receipt of the information form would be documented in the patient’s chart. . The policy did not address the requirement to provide patients with the name and telephone number of the nearest sexual assault crisis center. The policy did not address who would be responsible for providing the contact information or how the provision of information would be documented in the patient’s chart. . The policy did not address access to a shower at no cost after the examination. . Review of Patient #2’s Medical Record On 07/12/2025 at 6:24 P.M., Patient #2, a 20-year-old female, presented at Facility A’s emergency department with a chief complaint of sexual assault. At 7:13 P.M., Patient #2 received a medical screening by the emergency department physician assistant, Staff W. The chart revealed no documentation indicating that Patient #2 received sexual assault survivor patient rights, the option of a patient advocate, the option of an examination at Facility A, or the option of prophylaxis. The medical decision-making documentation detailed that Staff W notified Patient #2 that Facility A does not have SANE (sexual assault nurse examiner) registered nurses and that a transfer would be initiated. On 07/13/2025 at 12:09 A.M., Patient #2 was transferred to another facility to receive further treatment. . Review of Patient #9’s Medical Record On 09/16/2024 at 12:11 P.M., Patient #9, a 22-year-old female, presented at Facility A’s emergency department with a chief complaint of sexual assault. At 12:41 P.M., Patient #9 received a medical screening by the emergency department physician, Staff I. The chart revealed no documentation indicating that Patient #9 received sexual assault survivor patient rights, the option of a patient advocate, or the option of prophylaxis. The medical decision-making documentation detailed that Staff I offered a sexual assault examination and that Patient #9 did request a transfer to another facility. At 2:30 P.M., Patient #9 transferred via private vehicle with appropriate transfer documents and medical paperwork to another facility for further treatment. . Review of Patient #11’s Medical Record On 02/27/2025 at 1:14 P.M., Patient #11, a 22-year-old female, presented at Facility A’s emergency department with a chief complaint of sexual assault. At 2:26 P.M., Patient #11 received a medical screening by emergency department physician, Staff J. A urine pregnancy test resulted was documented as negative. The chart revealed no documentation indicating that Patient #11 received sexual assault survivor patient rights, the option of a patient advocate, the option of an examination at Facility A, or the option of prophylaxis. The medical decision-making documentation detailed that Staff J initiated Patient #11’s transfer to another facility with a SANE registered nurse. At 3:28 P.M., Patient #11 transferred via private vehicle with appropriate transfer documents and medical paperwork for further treatment. . Interviews: An interview was conducted on 10/13/2025 at 12:43 P.M. with the Emergency Department Manager, Staff A. Staff A stated that they “didn’t know there was a packet (patient rights information).” . An interview was conducted on 10/13/2025 at 11:13 A.M. with the Emergency Department Director, Staff C. Staff C stated that staff do not provide patients with the sexual assault survivor patient rights information. . An interview was conducted on 10/13/2025 at 2:40 P.M. with the Emergency Department Manager, Staff A. During patient chart reviews, Staff A confirmed that there was no documentation of patient advocacy, patient rights, or offer of prophylaxis in Patient #2, #9, and #11’s charts. .”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to comply with the Code of Federal Regulations §482.55(a)(3). Facility A failed to establish policies and procedures governing the medical care provided in the emergency service or emergency department for sexual assault survivors as specified under Texas Health and Safety Code (HSC) Chapter 323 Emergency Services for Survivors of Sexual Assault.. . Findings: Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault . Sec . 323.002. PLAN FOR EMERGENCY SERVICES. (a) Each health care facility that has an emergency department shall comply with Sections 323.004 and 323.0044. At the request of the department, a health care facility that has an emergency department shall submit to the department for approval a plan for providing the services required by Section 323.004 to sexual assault survivors who arrive for treatment at the emergency department of the health care facility. . Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES. (a) Except as otherwise provided by Subsection (a-2), after a sexual assault survivor arrives at a health care facility following a sexual assault, the facility shall provide care to the survivor in accordance with Subsection (b). . (b) A health care facility providing care to a sexual assault survivor shall provide the survivor with: . (1) subject to Subsection (b-1), a forensic medical examination in accordance with Subchapter B, Chapter 420, Government Code, and Subchapter G, Chapter 56A, Code of Criminal Procedure; . (2) a private area, if available, to wait or speak with the appropriate medical, legal, or sexual assault crisis center staff or volunteer until a physician, nurse, or physician assistant is able to treat the survivor; . (3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure; . (4) the information form required by Section 323.005; . (5) a private treatment room, if available; . (6) if indicated by the history of contact, access to appropriate prophylaxis for exposure to sexually transmitted infections; . (7) the name and telephone number of the nearest sexual assault crisis center; and . (8) If the health care facility has shower facilities, access to a shower at no cost to the survivor after the examination described by Subdivision (1). . Findings: Review of Sexual Assault Policy, Origination Date 08/27/2019 On 10/13/2025, during the entrance conference, Facility A was asked to provide all policies related to Sexual Assault. Facility A failed to establish policies and procedures governing the medical care provided in the emergency department for sexual assault survivors. . The policy failed to address the following: . The policy did not address the patient’s option or request for transfer to a Safe-Ready facility (a facility with a sexual assault registered nurse examiner available for patients). . The policy did not address the examination of a sexual assault survivor by a Safe-Ready or Non-Safe-Ready facility. The policy did not address how the exam would be presented to the patient, who would be responsible for presenting to the patient, or how the selected option of the patient would be documented in the patient’s chart. . The policy reviewed did not address patients’ privacy to wait or speak with the appropriate medical, legal, or sexual assault crisis center staff or volunteer until a physician, nurse, or physician assistant is able to treat the survivor. . The policy did not address the option to contact a sexual assault program advocate nor describe the role of a sexual assault program advocate. . The policy did not address the requirement to provide sexual assault survivors with the required information form. The policies did not address who would be responsible for ensuring the most current information form, who would be responsible for providing the information form to the patient, or how the receipt of the information form would be documented in the patient’s chart. . The policy did not address the requirement to provide patients with the name and telephone number of the nearest sexual assault crisis center. The policy did not address who would be responsible for providing the contact information or how the provision of information would be documented in the patient’s chart. . The policy did not address access to a shower at no cost after the examination. . Interviews: An interview was conducted on 10/13/2025 at 11:50 A.M. with the Emergency Department Manager, Staff A. Staff A verified that a plan had not been developed for providing medical services to sexual assault survivors who arrive for treatment at the emergency department. Staff A confirmed that no additional policies or procedures are established for sexual assault survivors other than the “Sexual Assault Policy,” Origination Date 08/27/2019, provided. .”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to provide stabilizing treatment for 3 of 20 patients (Patient #2, #9, and #11) experiencing an emergency medical condition. . Patients #2, #9, and #11 presented at Facility A with chief complaints of sexual assault. Facility A failed to provide stabilizing treatment when prophylaxis for potential sexually transmitted infections was not provided prior to transfer to ensure no material deterioration. . See Tag 2407”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 51905 Based on observation, record review, and interviews, Facility A failed to provide stabilizing treatment for 3 of 20 patients (Patient #2, #9, and #11) experiencing an emergency medical condition. . Patients #2, #9, and #11 presented at Facility A with chief complaints of sexual assault. Facility A failed to provide stabilizing treatment when prophylaxis for potential sexually transmitted infections was not provided prior to transfer to ensure no material deterioration. . Record Review: . Review of Patient #2’s Medical Record On 07/12/2025 at 6:24 P.M., Patient #2, a 20-year-old female, presented at Facility A’s emergency department with a chief complaint of sexual assault. At 7:13 P.M., Patient #2 received a medical screening by the emergency department physician assistant, Staff W. The chart revealed no documentation indicating that Patient #2 received prophylaxis for potential sexually transmitted infections. On 07/13/2025 at 12:09 A.M., Patient #2 was transferred to another facility with sexual assault nurse examiner [SANE] exam capabilities. Facility A had the capability to provide prophylaxis prior to transfer to ensure no material deterioration from the emergency medical condition. . Review of Patient #9’s Medical Record On 09/16/2024 at 12:11 P.M., Patient #9, a 22-year-old female, presented at Facility A’s emergency department with a chief complaint of sexual assault. At 12:41 P.M., Patient #9 received a medical screening by the emergency department physician, Staff I. The chart revealed no documentation indicating that Patient #9 received prophylaxis for potential sexually transmitted infections. At 2:30 P.M., Patient #9 was transferred to another facility with sexual assault nurse examiner [SANE] exam capabilities. Facility A had the capability to provide prophylaxis prior to transfer to ensure no material deterioration from the emergency medical condition. . Review of Patient #11’s Medical Record On 02/27/2025 at 1:14 P.M., Patient #11, a 22-year-old female, presented at Facility A’s emergency department with a chief complaint of sexual assault. At 2:26 P.M., Patient #11 received a medical screening by emergency department physician, Staff J. The chart revealed no documentation indicating that Patient #11 received prophylaxis for potential sexually transmitted infections. At 3:28 P.M., Patient #11 was transferred to another facility with sexual assault nurse examiner [SANE] exam capabilities. Facility A had the capability to provide prophylaxis prior to transfer to ensure no material deterioration from the emergency medical condition. . Review of Facility A’s Emergency Medical Treatment and Labor Act of 1986 Policy, Approved 07/2023: “V. Procedure: B. Subject to the patient’s right to refuse treatment, [Facility A] will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including admission for inpatient care, or arrange an appropriate transfer of the individual to another medical facility with the Capability to provide the stabilizing care” (Procedure, Page 3). . Interview: . 10/13/2025 at 2:40 P.M. with the Emergency Department Manager, Staff A: During patient chart reviews, Staff A confirmed that there was no documentation of prophylaxis in Patient #2, #9, and #11’s charts. .”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45521 Based on a review of documents and staff interviews with facility staff, they failed to ensure staff followed policies and procedures for medical care in the emergency room when staff failed to monitor and retake vitals for 1 of 20 patient reviewed (Patient #1) with an emergency acuity level 3, which applies to “conditions that could potentially progress to a serious problem requiring emergency intervention.” To arrive at an emergency acuity level, the patient’s vital signs are taken to include: temperature, heart rate (HR) / pulse, blood pressure (BP), respiratory rate (RR), oxygen saturation (O2 sat), pain scale score or the absence of pain as applicable; and Glasgow Coma Scale (GCS). GCS is an assessment tool that healthcare providers use to measure decreases in consciousness. The findings were: A review of the medical record for Patient # 1 revealed he was a 56-year-old male who arrived at the facility on 08/10/20224 at 1:32 AM. The patient’s chief complaint was severe pain in the right ribs. The patient was triaged at 1:47 AM with an increased blood pressure of 172/104 and an elevated pulse of 104 beats per minute. Also, Patient # 1 reported a pain level of 10 with right upper quadrant pain; he states it hurts to breathe, and he cannot lie down or sit down. The patient remained in the waiting room standing (due to pain). The patient’s past medical history was noted as unknown. The patient’s acuity level was 3-urgent. Per policy, “reassessment of vitals and written documentation is to occur every 120 -180 minutes or more frequently based on clinical judgment.” The Patient’s total time in the ER was 185 minutes. The patient left without being seen. The ER central log revealed that 20 patients were in the ER while Patient # 1 was waiting. A review of the document titled “Vital Signs” by Staff # 2, Emergency Medical Technician (EMT) on 08/10/2024 at 1:32 AM revealed the following: “Temperature Fahrenheit: 97.7 Peripheral Pulse Rate:102 Respiratory Rate: 20 SpO2: 98% Systolic Blood Pressure:172 Diastolic Blood Pressure: 104 Oxygen Therapy: Room air” A review of the document titled “Triage” by Staff # 1, RN-ED, on 08/10/2024 at 1:47 AM revealed the following: ... “ESI ls This Patient Dying?: No Does This Patient Need Immediate Treatment?: No How Many Resources Will This Patient Need?: Many What are the Patient’s Vital Signs?: Does not meet defined danger zone limits Triage Acuity Level: 3-Urgent Recommended ESI Level: 3.” A review of the document titled “ Patient Summary ED” by Staff # 5, RN-ED, on 08/10/2024 at 4:37 AM revealed the above time and date for providing the patient discharge summary. A review of the policy titled “ED-700.84, Vital Signs, Acuity Levels & Triage Emergency Severity Index (ESI) in the Emergency Department”: revealed the following: page 3: Appendix A: Frequency of Post Triage Reassessment and/or Vital Signs “ ESI 3- Reassessment of vitals and written documentation is to occur every 120 -180 minutes or more frequently based on clinical judgment.” An interview with Staff # 1, RN-ED on 09/18/2024 at approximately 7:30 AM revealed the following: “I remember the patient from triage. It seemed odd that he stood behind the chair out of my eyesight. He reported right lower rib pain.” I was talking to him, and he denied trauma and said it felt like he pulled a muscle. He added he took an Excedrin and a muscle relaxer but didn’t remember the muscle relaxer’s name. He was alert and oriented. This was at about 1:45 AM, and we were about to lose a mid-level. The ER was very busy. He said his pain was at a level 10. I did not provide any pain medication as he was in the waiting room and couldn’t be monitored.”

“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: 27128 Based on interview and record review the hospital failed to provide a safe setting for staff, visitors, and patients. Security was not provided between 7 am-3 pm Monday through Friday. Findings included: Security Schedule Review Dated: 01/01/2024. Monday through Friday security guards were scheduled from 3:00 PM-7:00 AM. Security guards were scheduled Saturday and Sunday for 24 hours each day. No security guards were scheduled 7:00 AM-3:00 PM. Interviews: During interviews on 1/08/24 with Personnel #1 she said from 7:00 AM through 3:00 PM the director of facilities (Personnel #2) acted as security along with other “males” in the hospital. All other times are covered by contracted security guards. She confirmed the Emergency Management plan had not been updated since 02/2022. The director of facilities had not received hospital security training from the hospital. She had requested multiple times that the hospital hire off duty police, but the requests were denied. During an interview on 1/08/24 at 3:24 PM with Personnel #3, Interim ED Director she said sometimes the police were called for security. During an interview on 1/08/24 at 4:02 PM with Personnel #4, ED Supervisor she said she has never been told to call the director of facilities for security. “As far as I know there’s no security during the day.” She said she was concerned one day that something could happen with no security available. There have been times when patients have gotten aggressive and there was no security that she was aware of. ED staff had called the police when there were security concerns. During an interview on 1/08/24 at 4:30 PM with Personnel #6, RN-ED she said she was working on a Sunday and there was a very aggressive patient who was pinning people against the wall. She got punched in the chest. 911 was called and there was no answer for 12 minutes. It took 15 minutes for police to arrive. That patient could have seriously injured staff and/or patients. She did not report the incident. Security was a big concern. Emergency Management Program/Emergency Operations plan had a revision date of 02/2022. Workplace Violence Risk Assessment Dated 7/31/23 The assessment determined there was a high degree of risk in reception/interdisciplinary team station/waiting area design, visibility and signage. There was a high degree of risk in treatment rooms. Potential Solutions included implementing regular security patrols and ensure a security presence in high-risk areas. Establish a protocol for requesting security backup as needed. Violence in the Workplace hospital policy, with approval date of 4/10/23, “Facilities operated by Tenet Entities (each a ‘Facility’) must be prepared to respond to reports of violence in the workplace by developing and implementing a Workplace Violence prevention program that includes support from appropriate disciplines and functional areas.””