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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.

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 ..."

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..."