Aurora Baycare Medical Ctr

“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: 47413 Based on record review and interview, facility staff failed to ensure that the patient’s parent/legal guardian was kept informed regarding the treatment plan in 1 of 10 patients (Patient #1) and failed to obtain informed consent for treatment for 1 of 10 patients (Patient #6) and in a sample of 10 records reviewed. Findings Include: A review of the facility’s policy titled, “Patient Rights and Responsibilities Policy ...” last revised 10/07/2025 revealed, “ ... C. Patient and/or Family Involvement in Decision Making (Advance Directive and Informed Consent); 1. The patient and his/her legal decision maker and the patient representative have the right and responsibility to be involved in decision-making about his/her care. This includes being informed about health status, diagnosis and prognosis ...” A review of the facility’s policy titled, “Informed Consent Informed Refusal Policy/Procedure...” last revised 05/29/2024 revealed, “... 5. Obtaining Informed Consent: The Provider... is responsible for obtaining the patient/SDM’s (substitute decision maker) agreement to the proposed treatment... 2. Facilitating Documentation: Teammate may provide the patient/SDM with a written consent form to sign and will ensure that a properly executed consent form is in the medical record... If a consent form is required... the consent form must be completed in its entirety...” Example of failure to ensure that the patient’s parent/legal guardian was kept informed of the treatment plan: A review of Patient #1’s medical record revealed she was born at the hospital on 03/03/2026 at 34w6d (34 weeks and 6 days) and was admitted to the NICU (Neonatal Intensive Care Unit) after birth for health complications. Patient #1 developed arm weakness on 03/13/2026 and a right arm fracture was discovered on x-ray on 03/15/2026. An x-ray of Patient #1’s right arm was ordered on 03/15/2026 at 10:40 AM by Neonatologist F and performed at 10:52 AM and revealed, “... Findings: There is a fracture through the midshaft of the right radius with 1 shaft width displacement (radius bone in the middle of the forearm is broken into two pieces) ...” A review of Patient #1’s medical record revealed, “Progress Note” on 03/15/2026 at 1:24 PM by Neonatologist F: “... Interval changes: ... Tolerating current feedings ... Right arm weakness noted on limb exam last night, X-ray done this morning showed right radial fracture. Orthopedics consulted and limb now immobilized. Parents updated by phone...” A review of Patient #1’s medical record revealed no notification to Patient #1’s Mother B and Patient #1’s Father C prior to obtaining Patient #1’s x-ray. During a telephone interview on 04/14/2026 at 12:52 PM with Patient #1’s Mother B and Patient #1’s Father C, both stated the hospital obtained an x-ray on Patient #1’s arm without talking to them first and only informed them that they performed an x-ray after the arm fracture was discovered. During an interview on 04/14/2026 at 2:12 PM with NICU Manager D, she stated that the expectation is that physicians contact the family via phone if they are unable to be at the hospital as part of their daily rounding. Example of failure to obtain informed consent for treatment: A review of Patient #6’s medical record revealed that he was born on 02/26/2026 at a different local hospital. Patient #6 was transferred to the admitting hospital for admission to the NICU on 02/26/2026. Review of the medical record revealed, “Neonatal Intensive Care Unit (NICU) Authorization and Consent Form” was signed by the “Provider” (unknown) on 02/26/2026 at 12:45 PM. There was no “Parent/Guardian” or “Witness” signature. During an interview on 04/14/2026 at 1:49 PM, NICU RN (Registered Nurse) Educator P stated that the informed consent for treatment is missing a signature from the parent/guardian.”

“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: 47413 Based on record review and interview, the facility staff failed to inform the physician/nurse practitioner of abnormal findings in 1 of 1 patients (Patient #1) with abnormal findings in a sample of 10 medical records reviewed. Findings Include: A review of Patient #1’s medical record revealed she was born at the hospital on 03/03/2026 at 34w6d and was admitted to the NICU after birth for health complications. Patient #1 developed arm weakness on 03/13/2026 and a right arm fracture was discovered on x-ray on 03/15/2026. “Musculoskeletal Flowsheets” revealed on 03/13/2026 at 10:30 PM the following abnormal findings were documented by NICU RN (Registered Nurse) H and revealed, “RUE (right upper extremity); RUE Muscle Movement: Weakness.” There was insufficient evidence found in the medical record that NICU RN H notified the physician or nurse practitioner of the right arm weakness. “Progress Note” on 03/14/2026 at 2:58 AM by Neonatology NP (Nurse Practitioner) W: “ ... [NICU RN H] notified me of mild increase in desaturations (low oxygen) over the course of the last several hours and mostly after feeds with O2 (oxygen) saturations upper 80s to low 90s. Many times these [desaturations] are noted after feeds with other reflux symptomatology present ... When I review desats with lower goal of 90% there are only 4% desats. On exam infant has comfortable respirations, breasth [sic] sounds clear... Reported these findings to [Neonatologist F]. Will monitor closely for now ...” There was no evidence found in the medical record that NICU RN H notified Neonatology NP of Patient #1’s right arm weakness. During an interview on 04/14/2026 at 12:30 PM with NICU RN H stated that when she unswaddled Patient #1 on 03/13/2026 Patient #1 was lifting her left arm more than her right arm and that Patient #1’s grasp in her right arm was weaker. She stated that Neonatology NP W assessed Patient #1 and performed the “Moro” reflex test (a test to assess the startle reflex on a baby, when the baby’s head falls backward or an abrupt sound startles them, they should extend their arms and legs and then bring their arms back together) on Patient #1 and reviewed her chart based on NICU RN H’s assessment of the weakness. There was insufficient evidence found in the medical record that NICU RN H notified the physician or nurse practitioner of the abnormal findings on 03/13/2026.”

“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: 53566 Based on record review and interview, facility staff failed to perform a complete Medical Screening Examination and failed to consider and rule out a diagnosis of aortic dissection for 1 (Patient #1) of 20 patients in a total sample of 20 medical records reviewed. A review of the facility’s policy titled “EMTALA (Emergency Medical Treatment and Active Labor Act) Policy” last revised 9/26/2025 revealed, “...Emergency Medical Condition: 1. A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in...a. placing the health of the patient (or, with respect to a pregnant patient, the health of the woman or her unborn child) in serious jeopardy...Medical Screening Examination (MSE): an examination performed by a licensed physician or a Qualified Medical Person (QMP) to determine with reasonable clinical confidence whether an Emergency Medical Condition does or does not exist. Depending on the patient’s presenting symptoms, an appropriate Medical Screening Examination can involve a wide spectrum of actions ranging from a simple process involving only a brief history and physical examination to a complex process that involves performing ancillary studies and procedures such as laboratory tests, x-rays, and/or other diagnostic tests and procedures...Stabilized: with respect to an Emergency Medical Condition: 1. That no material deterioration of the condition is likely, with reasonable medical probability...Stable for Discharge: 1. the physician or QMP has determined, within reasonable clinical confidence, that the patient has reached the point where his/her continued medical treatment, including diagnostic work-up or treatment, could reasonably be performed as an outpatient...as long as the patient is given a plan for appropriate follow-up care with discharge instructions...C. Medical Screening Examination. 1. The hospital provides a Medical Screening Examination for every patient who comes to the Emergency Department...E. Patients Who Have an Emergency Medical Condition. 1. When the emergency physician or QMP determines the patient has an Emergency Medical Condition, the hospital: a. within the capability of the staff and facilities available at the hospital, stabilizes the patient to the point where the patient is...”stable for discharge”...as defined above...” A review of the facility’s policy titled “Obstetrical Patient Emergency Management Policy/Procedure” last revised 9/25/2025 revealed, “...To provide safe and appropriate care to the obstetrical patient presenting for treatment to the Emergency Department...V. Procedure...B. Patients who present to the ED for treatment that are 20 weeks gestation or greater...3. Non-obstetrical complaints: Patients will be treated in the ED by the ED physician and consult with the OB/Laborist as needed...” A review of Patient #1’s medical record from 1st visit on 2/8/2025 revealed: A review of ED “Patient Care Timeline” revealed that on 2/8/2025 at 12:22 AM, Patient #1 presented to the ED with a concern of chest pain radiating into her jaw. Patient #1’s initial care during triage included an electrocardiogram (EKG) and labs (CBC, CMP, troponin, and magnesium (often measured as a part of monitoring cardiac stability)). At 12:43 AM, ED Physician R was present at the bedside, started the MSE, and ordered a chest x-ray. Note from ED RN P at 1:45 AM revealed, “Provider notified of patient’s B/P (BP) continuing to be questionable for pre-eclampsia at 135/98. Patient now stating that she is seeing flashing lights in her vision.” On 2/8/2025 at 3:22 AM, Patient #1 discharged from ED. A review of “ED Provider Note” written on 2/8/2025 between 12:53 AM and 3:16 AM by ED Physician R revealed, “...presents for chest pain and associated dyspnea (shortness of breath) and ‘seeing stars’...onset 2345 (11:45 PM) approximately 1 hour PTA (prior to arrival)...Pain is located as middle chest and radiating to jaw, it is qualified as sharp...Pain has improved but persisted since onset. [Patient #1] denies any exacerbation to pain...[Patient #1] states intermittent dyspnea and heart fluttering have been typical with this pregnancy...multiple diagnoses considered...not limited to musculoskeletal pain, anxiety, pneumothorax (collapsed lung), acute coronary syndrome (a life-threatening, emergency condition involving sudden, reduced blood flow to the heart). Doubt PE (pulmonary embolism: blood clot in the lung) based on history and physical exam and vital signs...transient elevation in blood pressure. I did speak with [OB Physician T] of OB regarding this who does not believe she needs further evaluation regarding this...Initial labs and chest x-ray are reassuring...” A review of Patient #1’s medical record revealed she was discharged on 2/8/2025 at 3:22 AM and “After Visit Summary” revealed, “...No signs of heart attack or collapsed lung or other serious cause of chest pain...” On 2/8/2025 at 5:43 PM, Patient #1 returned to the ED, unresponsive and determined by ED staff to be in cardiac arrest. On 2/8/2025 at 6:22 PM, Patient #1 was pronounced deceased. Patient #1’s cause of death was later identified by autopsy as an undiagnosed aortic dissection. During an interview on 2/17/2026 at 12:32 PM, CMO (Chief Medical Officer) M discussed the peer review of Patient #1’s medical care on 2/8/2025. When asked, CMO M stated he would not have considered aortic dissection as a likely diagnosis based on Patient #1’s presenting symptoms during her two visits on 2/8/2025 because her symptoms did not match the “classic” aortic dissection symptoms of chest pain radiating to the back or ST changes on an EKG. Despite physician documentation of Patient #1’s symptoms of persistent and sharp chest pain radiating to her jaw and seeing stars and flashing lights in her visual field, there is no evidence that facility staff identified her emergency medical condition or ruled out the diagnosis of aortic dissection.”

“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: 47413 Based on record review and interview, nursing staff failed to complete vital sign monitoring and document reassessment after medication administration per policy and guidelines for 1 of 2 patients (Patient #1) who received IV (intravenous-into the blood stream) Ativan (a medication that can be given for dizziness) in a total sample of 10 medical records reviewed. Findings Include: A review of the facility’s document titled, “[Facility Name] Emergency Department Guidelines” last updated 12/2024 revealed, “... Assessment: ... 3. Reassessment should be done after every intervention ... Documentation should reflect but is not limited to a patient’s: ... b. Response to interventions, treatment, and/or medications ...” A review of the facility’s document titled, “MW Regional Adult Intravenous (IV) Medication Administration Guidelines” last reviewed 12/30/2024 revealed, “LORazepam (Ativan)... Monitoring: ... IV push: HR (heart rate), BP (blood pressure), RR (respiratory rate) x1 approx. (approximately) 5-15 min after each dose recommended...” Review of the medical record revealed that Patient #1 presented to the facility’s Emergency Department (ED) on 01/30/2025 at 9:05 PM with a chief complaint of syncopal episode (fainting) and subsequent dizziness. “LORazepam (ATIVAN) injection 1mg (milligram)” was ordered by ED PA (Physician Assistant) B on 01/30/2025 at 11:15 PM. Review of the record revealed that ED RN (Registered Nurse) G administered “LORazepam (ATIVAN) injection 1mg” on 01/30/2025 at 11:23 PM. Review of the medical record revealed that Patient #1 did not have any documented vital signs after medication administration per facility guidelines or a reassessment from nursing to how Patient #1 responded to the medication after it was administered per facility policy. Patient #1 was discharged from the ED (Emergency Department) on 01/31/2025 at 12:13 AM. During an interview on 03/04/2025 at 12:39 PM, the medical record findings were reviewed with ED Manager H and Quality Director A who stated that the vital signs after IV Ativan administration are just a guideline and that nursing staff should use their judgement regarding reassessment of vital signs.”

“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: 47413 Based on record review, observation and interview facility staff failed to ensure all patients who present on hospital property with an emergent medical condition were documented on the Emergency Department (ED) central log for 1 of 20 patients (Patient #1), and failed to complete a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the Emergency Department in a total sample of 20 medical records reviewed. Findings include: The facility staff failed to ensure a patient who presented on hospital property with an emergent medical condition was documented on the ED central log. See Tag A-2405. The facility staff failed to provide a Medical Screening Exam for a patient who presented to the Emergency Department. See Tag A-2406.”

“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: 47413 Based on record review and interview, facility staff failed to ensure all patients who presented on hospital property with an emergent medical condition are documented on an Emergency Department (ED) central log for 1 of 1 patients (Patient #1) in a total of 20 medical records reviewed. Findings Include: A review of the facility’s policy titled, “”ABMC EMTALA (Emergency Medical Treatment and Labor Act)” last reviewed 01/27/2025 revealed, “... Record-Keeping... b) A recording of everyone who came to the hospital’s Dedicated Emergency Department seeking screening or treatment... The log will include the patient’s name and medical record number (if available) and indicate whether he/she (a) was refused treatment...” Review of the facility’s video recording (no audio) from 12/18/2024 revealed Patient #1’s mother presented back Hospital A’s ED (Emergency Department) registration desk on 12/18/2024 at 7:26 PM. Patient #1’s Mother B exited Hospital A on 12/18/2024 at 7:28 PM. Review of the facility’s ED log for 12/18/2024 revealed Patient #1 presented to the ED on 12/18/2024 at 4:14 PM. There was no documentation on the log indicating Patient #1 re-entered the ED or that Patient #1’s Mother B requested Patient #1 wanted to be seen again at 7:26 PM. An interview was conducted on 01/28/2025 at 11:06 AM with CMO (Chief Medical Officer) E. When asked Patient #1, CMO E stated, “We have already established through video footage that [Patient #1’s Mother B] came back into the ER requesting her daughter be seen again.””

“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: 47413 Based on record review, observation and interview the facility staff failed to complete a Medical Screening Exam for 1 of 20 patients (Patient #1) who presented to the Emergency Department in a total sample of 20 medical records reviewed. Findings Include: A review of the facility’s policy titled, “ABMC EMTALA (Emergency Medical Treatment and Labor Act)” last reviewed 01/27/2025 revealed, “ ... Comes to the Dedicated Emergency Department; when an individual, who is not a hospital patient, does one of the following: 1. Presents to a hospital’s Dedicated Emergency Department and requests, or has a request made on his/her behalf, an examination or treatment for a medication condition ... Policy: A. Hospital staff will provide an appropriate Medical Screening Examination for all individuals who present to the DED (Dedicated Emergency Department) with a medical condition ...” A review of Patient #1’s medical record revealed that Patient #1 was a 34-year-old female with a medical history of bipolar disorder who presented to Hospital A on 12/18/2024 at 4:14 PM via ambulance and in police custody under an EM-1 hold (Emergency detention) for medical clearance and anxiety for involuntary admission to an inpatient behavioral health facility. Patient #1 was discharged in stable condition into the custody of her parents for a safety plan to home on 12/18/2024 at 7:15 PM, after police lifted the EM-1 hold. Patient #1’s mother presented back Hospital A’s ED registration area on 12/18/2024 at 7:26 PM, requesting Patient #1 be evaluated again. Patient #1’s Mother B exited Hospital A on 12/18/2024 at 7:28 PM. Patient #1 presented to Hospital C on 12/18/2024 at 9:10 PM where she was admitted for suicidal ideation. A review of Facility A’s adverse event filed on 12/19/2024, “SE-24-035296” revealed that Risk Manager F spoke with Patient #1’s Mother B on 12/20/2024 who stated that Patient #1 froze on the sidewalk and wanted to come back into the ER. Review of the event revealed that security footage was reviewed on 01/03/2025 confirming that Patient #1’s Mother B spoke with registration. Observation of the security footage in the ED on 12/18/2024 revealed: 12/18/2024 at 7:15 PM: Patient #1, Patient #1’s Mother B, and Patient #1’s father walk out of the ED. Patient #1 and Patient #1’s Mother B are standing outside of the ED. Patient #1 and Patient #1’s mother enter the vestibule area of the ED. 12/18/2024 at 7:26 PM: Patient #1’s Mother B comes back into the ED and has a conversation with registration (PSR H). No audio. 12/18/2024 at 7:28 PM: Patient #1’s Mother B leaves the ED. During an interview on 01/28/2025 at 10:11 AM with PSR H (PSR who had contact with Patient #1 on 12/18/2024), when asked about Patient #1, PSR H stated, “[Patient #1] and her family were discharged and walked past the desk and then a bit later the patient was upset and crying. [Patient #1’s Mother B] came back to the desk and said that [Patient #1] didn’t want to leave. The mom said she didn’t know what the patient wanted to do. I know the police spent some time talking with the patient and then she left with her parents.” When asked about the situation with Patient #1, PSR H stated, “I should have ensured that the patient either wanted to be checked back into the ER or not.” An interview was conducted on 01/28/2025 at 11:06 AM with CMO (Chief Medical Officer) E. When asked about the incident with Patient #1, CMO E stated, “We have already established through video footage that [Patient #1’s Mother B] came back into the ER requesting her daughter be seen again.” During an interview on 01/28/2025 on 2:53 PM with Patient #1, when asked about her ED visit at Hospital A on 12/18/2024, Patient #1 stated, “I wanted to be seen again. They told my mom that I was already discharged. They told me to go to another hospital.” During an interview on 01/28/2025 at 3:16 PM with Patient #1’s Mother B, when asked about Patient #1’s ED visit at Hospital A on 12/18/2024, Patient #1’s Mother B stated, “I told the registration desk that my daughter wanted to come back in, and they told me that she was already discharged.””