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Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination within the capability of the hospital's emergency department to determine whether an emergency medical condition existed for 1 of 21 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1 presented to the ED with psychosis, aggressive behavior, paranoid delusions, hallucinations, and what appeared to be self-inflicted wrist wounds. Patient #1 was allowed to leave against medical advice (AMA) even though the patient was a danger to themselves and others.

The findings were:

The facility document titled, "Medical Screening Examination and Patient Transfers," [Last Reviewed Date: 10/7/22] states, "2.1 Performing medical screening exams of persons who seek examination or treatment for a medical condition ... 3.1 Hospital will provide, without discrimination, care for emergency medical conditions regardless of whether or not the patient is eligible for financial assistance. Hospital will not engage in any actions that would discourage individuals from seeking emergency medical care ... 4.1.1. Any person who comes to Hospital Emergency Department (ED) and requests an examination or treatment for a medical condition shall receive an appropriate Medical Screening Examination by a physician or other Qualified Medical Person as defined in Section 5.0, within the Capability of the ED, including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition."

The facility document titled, "Behavior Health Crisis Clinician Provision of Services Plan," [Last Reviewed Date: 7/30/21] states, "4.3.2 ...BHCC [Behavioral Health Crisis Clinician] will assess the patient and communicate the findings and Recommendation to the physician and nurse as appropriate."

Patient #1 was brought to the ED by emergency medical services (EMS) after being found on the side of the highway with wounds to both wrists and paranoia. The ED physician performed a limited psychiatric exam with no comment on the patient's thought content, judgment, insight or delusions/hallucinations. The clinical staff noted several times that patient is psychotic and aggressive and notified the ED physician but no documentation could be found regarding ED physician reassessments. Patient #1 required inpatient psychiatric treatment due to an emergency medical condition (auditory hallucinations and high suicide risk), the facility staff with police officers escorted the patient off the emergency department (ED) area due to the patient's verbal aggressiveness towards ED staff and attempted physical assault of ED staff. The ED staff documented that the patient "eloped." No physician order for physical holding or chemical sedation to facilitate safety for patient's psychotic, uncooperative behavior could be found. While the patient was outside by the ED ambulance bay area, the local police officers arrested the patient and returned the patient into the ED department. The ED staff then discharged the patient "against medical advice" without discussing the risk and complications of not following the medical treatment or transfer to an inpatient psychiatric treatment facility with the patient or the fact that the patient was a danger to themselves and others. The ED physician did not request an emergency detention order even though the patient had an emergent psychiatric condition (high suicide risk). The local police officers then transported the patient to an inpatient psychiatric facility.

The complete medical record of Patient #1's ED visit on 11/20/23 was reviewed. It was noted:
- ED registered nurse (RN) [Staff #5] note at 7:11PM states, "EMS report completed. EMS report states, '4 inch laceration to each wrist' 4 inch laceration to bilateral wrists present upon arrival and assessment. This RN able to see cuts on wrists and unable to complete full assessment due to pt behavior at this time. Pt states, 'stop asking me questions, I just want to sleep' Treatment offered to patient and patient refused at this time. Unable to complete full triage due to patient refusing questions. CPI [Crisis Prevention Institute, a de-escalation technique] verbal intervention used."
- ED physician's initial assessment at 7:35PM states, "[Patient #1] is a 42 y.o. female BIB [brought in by] EMS [emergency medical services] with paranoia. She was reportedly found on the side of the road. Pt [patient] denies SI [suicidal ideation] or HI [homicidal ideation]. Pt reports she has not done anything to hurt herself. Pt denies any significant PMHX [past medical history]. Pt denies alcohol use or drug use. However, EMS report states pt has been having hallucinations with suicidal ideations and has been cutting herself, which pt denies. HPI [history of present illness] limited d/t [due to] poor pt cooperation ... Physical Exam: Psychiatric: Pt is agitated and uncooperative with exam ... Differential Diagnosis: suicidal ideation, paranoia, hallucinations, psychosis, intoxication ..."
- Behavioral Health (BH) assessment at 8:41PM showed that the patient was a "High Suicide Risk" and scored a "24" on the Columbia Suicide Severity Rating Scale [which is consider as Very Severe - 34x times the risk of suicide]. The Licensed Professional Counselor (LPC) [Staff #6] that completed the BH assessment recommended that the patient receive inpatient BH treatment and the ED physician's notes agreed with this recommendation. The LPC notified the transfer center of transfer request.
- ED physician's note at 9:26 PM states, "Consult with [Staff #6], crisis clinician, about pt's case. She recommends inpatient treatment. Will initiate process."
- RN note [Staff #5] at 9:30PM states, "This RN at bedside and reassessing pt and asked if we could obtain blood work, complete EKG, get an UA, and retake vitals. Pt refusing at this time. Patient states, 'don't you fucking dare touch me.' Patient throwing herself from side to side in stretcher. Unsafe for staff to treat patient at this time. MD notified and aware. Charge nurse notified and aware. Multiple RN's at bedside. Patient states, 'you have to treat me I am mentally unstable.' Explained to patient we have orders from MD to treat her in order to complete transfer to another facility. Pt states, 'you are not a real nurse. All I want to do is sleep for a few hours.' 'do you know how hard it is to come by sleep these days' 'leave me the fuck alone' CPI verbal intervention used. ED security called.
- Charge RN note [Staff #3] at 9:40 PM states, "Responded to pt being verbally aggressive towards staff regarding medical clearance to begin psychiatric transfer process. Several RNs attempted to explain why pt must be medically cleared. Pt continued to be verbally aggressive with staff. This RN responded to pt in an attempt to explain process and necessity for lab/urine. Pt was verbally aggressive stating 'Y'all can't clear me, I aint Sane,' then stated, 'I should just punch you in the face.' At this time security alert was activated. Continued to attempt to assist in managing situation, pt jumped out of bed, lunged at this RN and made an attempt to punch this RN in the face. Security interfered and staff assisted in demobilizing the patient until additional security. Pt escorted off the property with security, belongings provided. MD made aware.
- RN note [Staff #5] at 9:40PM states, "AMA form completed without patient signing. [name], RN second witness. Patient escorted out by ED officers."


The surveyor reviewed the security body camera film footage from 11/20/23 that starts outside ED in the parking lot. The police officer asks the patient, "Do you want to hurt yourself?" The patient replies, "I want to kill you ... I want to kill myself, I want to kill you and I want to kill [difficult to understand] ..." The patient is informed that they are going to return to the ED for treatment for her homicidal and suicidal statements. The patient states, "No, I'm going to jail ... No, not here. I'm homicidal ... I just threatened a nurse in there and you're going to put me back in there with her?" The patient is escorted back by police officers back inside the ED. Someone asks, "Is she already charted out?" And someone replies, "I'm doing it right now." The film does not show any ED staff member discussing the AMA form with the patient. The patient is escorted out of the ED by wheelchair by police and security. The film also shows that the security officer retrieves a blank copy of the Notice of Emergency Detention (NED) form and provides it to the police officer with the patient. The police officer appears to be filling out the form but the film ends and it is unknown if the NED was shown to the ED staff.



The surveyor interviewed the Licensed Professional Counselor (Staff #6) that performed Behavioral Health Assessment on Patient#1 on 11/20/23 via email. Below is Staff #6's response on 1/8/24:

Surveyor: What do you remember about this particular patient?
Staff #6: "I remember the patient due to the fact that she was brought in from walking on a freeway and had lacerations on her wrists. She was very guarded in her responses to the assessment and had to be encouraged to participate. She was not willing to give me any details of her suicide attempt or why she was walking there, except to say she was 'trying to get away from a dangerous situation.' She stated a few times that she did not want to talk about her situation. She did participate as far as answering the suicide screening questions and endorsed a past attempt about a month previous by overdosing. She endorsed current demeaning auditory hallucinations. Pt refused to share any details about her mental health treatment. Substance use was denied and the labs were pending when I spoke to her. She was angry, labile, yelled yes or no when asked to repeat or clarify, but did agree with the recommendation for Inpatient psych treatment."

Surveyor: Did this patient have an emergency psychiatric condition?
Staff #6: "The patient had an emergency psychiatric condition, and my recommendation was admission to inpatient Psych treatment. She endorsed SI [suicidal ideation] and had 4 inch wrist lacerations, active hallucinations and was brought in by EMS from a situation where she was a danger to self and others."



The surveyors interviewed the ED physician (Staff #4) that took care of Patient #1 on 11/20/23 via email. Below is Staff #4's response on 1/9/24:
Surveyor: What do you remember about this particular patient?
Staff #4: "This was a female patient brought in by EMS after being found walking down the side of the road. EMS reported to the nursing staff who took report, a call was made for suicidal ideation. When I assessed the patient, EMS had already left, the patient had already been changed out of her street clothes and she was lying in a hallway stretcher. She was lying with her eyes closed and did not want engage with much of the assessment, giving only brief answers. When asked directly about suicidal ideation and the report from EMS, she denied this stating 'No, i was just walking down the road to get away from some people.' She also denied any homicidal ideation, but would not answer questions regarding hallucinations or substance abuse. She instead rolled over with her eyes closed stating she did not want to be bothered and did not want to be here. Her physical exam was limited by the blanket she would not remove, but I did not some superficial cuts to her arms, which she said, 'happened trying to get away from those people.' I ordered basic psych labs and an assessment by our crisis clinician. A quick review of her medical records noted a history of amphetamine abuse. I was later called by the crisis clinician after the patient had been assessed who reported the patient had not provided any additional information beyond what I had garnered, and confirmed the patient had denies suicidal or homicidal ideation to her, but since we could not get collateral information the recommendation was to transfer her to a psychiatric facility for further assessment and treatment. I assessment base on the limited information was the patient likely had a mood disorder exacerbated by substance abuse. After some time, I was then called by a member of the nursing staff who stated the patient had become aggressive and eloped, with her location being unknown."

Surveyor: Did this patient have an emergency psychiatric condition?
Staff #4: "Yes. I believe she had a decompensated mood disorder, likely with self-harm given the cuts on her arms, which were likely self-inflicted. She however eloped from the ED prior to transfer. A warrant detention was not requested after my assessment or the crisis clinicians assessment, because she did not appear to be a flight risk at that time and denied suicidal/homicidal ideation."

Surveyor: Did you initiate a hospital-to-hospital transfer of this patient? If no, why not?
Staff #4: "Yes. A transfer was initiated within the Texas Health system, but the status was pending at the time the patient left the ED. The transfer was initiated to have the patient assessed and treated for a mood disorder exacerbated by substance abuse."

Based on review of documentation and interviews with the facility staff, the facility failed to perform an appropriate transfer of Patient #1 to an inpatient psychiatric treatment facility after the patient's medical screening examination and behavioral assessment determined Patient #1 required inpatient psychiatric treatment due to an emergency medical condition (auditory hallucinations and high suicide risk).

The findings were:

The facility document titled, "Medical Screening Examination and Patient Transfers," [Last Reviewed Date: 10/7/22] states:
"4.2.3 Transferring a patient with an Emergency Medical Condition that has not been stabilized when the transferring physician recommends the transfer: b. If the patient has an Emergency Medical Condition which has not been stabilized, no transfer can take place unless: 2) the physician informs the patient that the medical benefits reasonably expected from the provision of medical treatment at another hospital outweigh the increased risks to the patient (and in the case of labor, to the unborn child) and, therefore, transfer is recommended. The physician's certification is documented on the Memorandum of Transfer form...
4.2.4 Physicians' responsibilities
b. The transferring physician shall:
4) Prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care. The transfer should minimize the risk to the patient.
4.2.5 Hospital responsibilities
a. Arranging for transportation
b. Providing medical records to the receiving hospital
c. Form to be completed
1) Memorandum of Transfer
2) Patient's Request/Refusal/Consent to Transfer"


The facility document titled, "Behavior Health Crisis Clinician Provision of Services Plan," [Last Reviewed Date: 7/30/21] states:
"4.3.2 ...BHCC [Behavioral Health Crisis Clinician] will assess the patient and communicate the findings and Recommendation to the physician and nurse as appropriate.
4.3.4 Patients who are medically cleared at the conclusion of the Assessment and for whom inpatient behavioral health or substance use disorder treatment is recommended, BHCC will enter a Transfer Center Notification order to initiate the transfer process."



Patient #1 was brought to the ED by emergency medical services (EMS) after being found on the side of the highway with wounds to both wrists and paranoia. The ED physician performed a limited psychiatric exam with no comment on the patient's thought content, judgment, insight or delusions/hallucinations. The clinical staff noted several times that patient is psychotic and aggressive and notified the ED physician but no documentation could be found regarding ED physician reassessments. Patient #1 required inpatient psychiatric treatment due to an emergency medical condition (auditory hallucinations and high suicide risk), the facility staff with police officers escorted the patient off the emergency department (ED) area due to the patient's verbal aggressiveness towards ED staff and attempted physical assault of ED staff. The ED staff documented that the patient "eloped." No physician order for physical holding or chemical sedation to facilitate safety for patient's psychotic, uncooperative behavior could be found. While the patient was outside by the ED ambulance bay area, the local police officers arrested the patient and returned the patient into the ED department. The ED staff then discharged the patient "against medical advice" without discussing the risk and complications of not following the medical treatment or transfer to an inpatient psychiatric treatment facility with the patient or the fact that the patient was a danger to themselves and others. The ED physician did not request an emergency detention order even though the patient had an emergent psychiatric condition (high suicide risk). The local police officers then transported the patient to an inpatient psychiatric facility.


The complete medical record of Patient #1's ED visit on 11/20/23 was reviewed. It was noted:
- ED registered nurse (RN) [Staff #5] note at 7:11PM states, "EMS report completed. EMS report states, '4 inch laceration to each wrist' 4 inch laceration to bilateral wrists present upon arrival and assessment. This RN able to see cuts on wrists and unable to complete full assessment due to pt behavior at this time. Pt states, 'stop asking me questions, I just want to sleep' Treatment offered to patient and patient refused at this time. Unable to complete full triage due to patient refusing questions. CPI [Crisis Prevention Institute, a de-escalation technique] verbal intervention used."
- ED physician's initial assessment at 7:35PM states, "[Patient #1] is a 42 y.o. female BIB [brought in by] EMS [emergency medical services] with paranoia. She was reportedly found on the side of the road. Pt [patient] denies SI [suicidal ideation] or HI [homicidal ideation]. Pt reports she has not done anything to hurt herself. Pt denies any significant PMHX [past medical history]. Pt denies alcohol use or drug use. However, EMS report states pt has been having hallucinations with suicidal ideations and has been cutting herself, which pt denies. HPI [history of present illness] limited d/t [due to] poor pt cooperation ... Physical Exam: Psychiatric: Pt is agitated and uncooperative with exam ... Differential Diagnosis: suicidal ideation, paranoia, hallucinations, psychosis, intoxication ..."
- Behavioral Health (BH) assessment at 8:41PM showed that the patient was a "High Suicide Risk" and scored a "24" on the Columbia Suicide Severity Rating Scale [which is consider as Very Severe - 34x times the risk of suicide]. The Licensed Professional Counselor (LPC) [Staff #6] that completed the BH assessment recommended that the patient receive inpatient BH treatment and the ED physician's notes agreed with this recommendation. The LPC notified the transfer center of transfer request.
- ED physician's note at 9:26 PM states, "Consult with [Staff #6], crisis clinician, about pt's case. She recommends inpatient treatment. Will initiate process."
- RN note [Staff #5] at 9:30PM states, "This RN at bedside and reassessing pt and asked if we could obtain blood work, complete EKG, get an UA, and retake vitals. Pt refusing at this time. Patient states, 'don't you fucking dare touch me.' Patient throwing herself from side to side in stretcher. Unsafe for staff to treat patient at this time. MD notified and aware. Charge nurse notified and aware. Multiple RN's at bedside. Patient states, 'you have to treat me I am mentally unstable.' Explained to patient we have orders from MD to treat her in order to complete transfer to another facility. Pt states, 'you are not a real nurse. All I want to do is sleep for a few hours.' 'do you know how hard it is to come by sleep these days' 'leave me the fuck alone' CPI verbal intervention used. ED security called.
- Charge RN note [Staff #3] at 9:40 PM states, "Responded to pt being verbally aggressive towards staff regarding medical clearance to begin psychiatric transfer process. Several RNs attempted to explain why pt must be medically cleared. Pt continued to be verbally aggressive with staff. This RN responded to pt in an attempt to explain process and necessity for lab/urine. Pt was verbally aggressive stating 'Y'all can't clear me, I aint Sane,' then stated, 'I should just punch you in the face.' At this time security alert was activated. Continued to attempt to assist in managing situation, pt jumped out of bed, lunged at this RN and made an attempt to punch this RN in the face. Security interfered and staff assisted in demobilizing the patient until additional security. Pt escorted off the property with security, belongings provided. MD made aware.
- RN note [Staff #5] at 9:40PM states, "AMA form completed without patient signing. [name], RN second witness. Patient escorted out by ED officers."


The surveyor reviewed the security body camera film footage from 11/20/23 that starts outside ED in the parking lot. The police officer asks the patient, "Do you want to hurt yourself?" The patient replies, "I want to kill you ... I want to kill myself, I want to kill you and I want to kill [difficult to understand] ..." The patient is informed that they are going to return to the ED for treatment for her homicidal and suicidal statements. The patient states, "No, I'm going to jail ... No, not here. I'm homicidal ... I just threatened a nurse in there and you're going to put me back in there with her?" The patient is escorted back by police officers back inside the ED. Someone asks, "Is she already charted out?" And someone replies, "I'm doing it right now." The film does not show any ED staff member discussing the AMA form with the patient. The patient is escorted out of the ED by wheelchair by police and security. The film also shows that the security officer retrieves a blank copy of the Notice of Emergency Detention (NED) form and provides it to the police officer with the patient. The police officer appears to be filling out the form but the film ends and it is unknown if the NED was shown to the ED staff.



The surveyor interviewed the Licensed Professional Counselor (Staff #6) that performed Behavioral Health Assessment on Patient#1 on 11/20/23 via email. Below is Staff #6's response on 1/8/24:

Surveyor: What do you remember about this particular patient?
Staff #6: "I remember the patient due to the fact that she was brought in from walking on a freeway and had lacerations on her wrists. She was very guarded in her responses to the assessment and had to be encouraged to participate. She was not willing to give me any details of her suicide attempt or why she was walking there, except to say she was 'trying to get away from a dangerous situation.' She stated a few times that she did not want to talk about her situation. She did participate as far as answering the suicide screening questions and endorsed a past attempt about a month previous by overdosing. She endorsed current demeaning auditory hallucinations. Pt refused to share any details about her mental health treatment. Substance use was denied and the labs were pending when I spoke to her. She was angry, labile, yelled yes or no when asked to repeat or clarify, but did agree with the recommendation for Inpatient psych treatment."

Surveyor: Did this patient have an emergency psychiatric condition?
Staff #6: "The patient had an emergency psychiatric condition, and my recommendation was admission to inpatient Psych treatment. She endorsed SI [suicidal ideation] and had 4 inch wrist lacerations, active hallucinations and was brought in by EMS from a situation where she was a danger to self and others."



The surveyors interviewed the ED physician (Staff #4) that took care of Patient #1 on 11/20/23 via email. Below is Staff #4's response on 1/9/24:
Surveyor: What do you remember about this particular patient?
Staff #4: "This was a female patient brought in by EMS after being found walking down the side of the road. EMS reported to the nursing staff who took report, a call was made for suicidal ideation. When I assessed the patient, EMS had already left, the patient had already been changed out of her street clothes and she was lying in a hallway stretcher. She was lying with her eyes closed and did not want engage with much of the assessment, giving only brief answers. When asked directly about suicidal ideation and the report from EMS, she denied this stating 'No, i was just walking down the road to get away from some people.' She also denied any homicidal ideation, but would not answer questions regarding hallucinations or substance abuse. She instead rolled over with her eyes closed stating she did not want to be bothered and did not want to be here. Her physical exam was limited by the blanket she would not remove, but I did not some superficial cuts to her arms, which she said, 'happened trying to get away from those people.' I ordered basic psych labs and an assessment by our crisis clinician. A quick review of her medical records noted a history of amphetamine abuse. I was later called by the crisis clinician after the patient had been assessed who reported the patient had not provided any additional information beyond what I had garnered, and confirmed the patient had denies suicidal or homicidal ideation to her, but since we could not get collateral information the recommendation was to transfer her to a psychiatric facility for further assessment and treatment. I assessment base on the limited information was the patient likely had a mood disorder exacerbated by substance abuse. After some time, I was then called by a member of the nursing staff who stated the patient had become aggressive and eloped, with her location being unknown."

Surveyor: Did this patient have an emergency psychiatric condition?
Staff #4: "Yes. I believe she had a decompensated mood disorder, likely with self-harm given the cuts on her arms, which were likely self-inflicted. She however eloped from the ED prior to transfer. A warrant detention was not requested after my assessment or the crisis clinicians assessment, because she did not appear to be a flight risk at that time and denied suicidal/homicidal ideation."

Surveyor: Did you initiate a hospital-to-hospital transfer of this patient? If no, why not?
Staff #4: "Yes. A transfer was initiated within the Texas Health system, but the status was pending at the time the patient left the ED. The transfer was initiated to have the patient assessed and treated for a mood disorder exacerbated by substance abuse."


No documentation could be found for the surveyor to review to indicate that the facility secured a transfer to an accepting hospital or physician; a nurse-to-nurse or physician-to-physician report was performed; or a memorandum of transfer (MOT) form was completed.