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1. Based on a review of facility documents, and interviews with staff it was determined that facility failed to provide an appropriate transfer of patient.

Findings:

1. Reviewed medical records for both patients and found that in both cases a proper transfer was not done, a memorantum of transfer was not found in either medical record. Patient became aggressive and disruptive and staff called San Antonio Police who arrested patient and took them to another facility.

2. Interviews with staff revealed that in both cases patients became aggressive and staff called San Antonio Police who took patient into custody for an emergency detention due to danger to self and others.

Based on a review of facility documents, and interviews with staff it was determined that facility failed to provide an appropriate medical screening of patient.

Findings:

1. Reviewed medical records for both patients and found that in both cases a proper medical screening was not conducted, both patients reported to the emergency room for conditions that required a psychiatric evaluation, and the facility did not provide a psychiatric evaluation.

2. Interviews with staff #3. revealed that in patient #1, physician was not able to conduct a full evaluation due to other staff calling San Antonio Police when patient became aggressive, when physician returned to patient room, patient had been arrested and taken out of facility.