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Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.
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Based on record review and interviews, Facility A failed to perform and document a complete medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for three of twenty patients (Patient #1, #3, #7). Patients #1, #3, and #7 did not receive a behavioral health consult or assessment when presenting to the emergency department with a mental health crisis.
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Facility A failed to initiate an appropriate transfer to a behavioral health facility for three of the twenty patients (Patient #3, #7, #10). Patients #3, #7, and #10 were all under an EDO (emergency detention order) and transferred to known behavioral health facilities.
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See Tags 2406 and 2409

Based on observation, record review, and staff interviews, Facility A failed to provide adequate physician on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists. Failure to staff on-call gastroenterologists at night subjects patients needing specific gastrointestinal emergent treatment to probable harm.
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Findings:
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1.Record Review
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Review of the on-call physicians' schedule at Facility A:
a.October: twenty-two (22) of twenty-two (22) days there was no Gastroenterology provider on-call at night.
b.November: thirty (30) of thirty (30) days there was no Gastroenterology provider on-call at night.
c.December: thirty-one (31) of thirty-one (31) days there was no Gastroenterology provider on-call at night.
d.January: thirty-one (31) of thirty-one (31) days there was no Gastroenterology provider on-call at night.
e.February: twenty-eight (28) of twenty-eight (28) days there was no Gastroenterology provider on-call at night.
f.March: thirty-one (31) of thirty-one (31) days there was no Gastroenterology provider on-call at night.
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Review of Facility A's EMTALA- Provision of On-Call Coverage Policy, 911.500.002 - Revised 07/2024:
Page 2 of 5:
"Procedure:
Maintain a List: Each hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC." "The hospital is expected to provide adequate specialty on-call coverage consistent with the services provided at the hospital and the resources the hospital has available."
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2.Interview:
a.04/17/2025 at 9:53 P.M. in an interview with Medical Staff Director Staff G, Staff G explained the colors of the schedule provided. Staff G stated, " ...the orange is a change in schedule, blue is the original schedule, green means there's a back-up provider, and red means there is no coverage." Staff G was asked to verify that there was no coverage for gastroenterology. "Yes, that's right. We do not have GI (gastroenterologists) at night."
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b.04/17/2025 at 10:00 A.M. in an interview with Director of Emergency Services Staff C, Staff C indicated that if a gastroenterologist was needed at night for a patient with a gastrointestinal emergent medical condition, the facility would stabilize the patient and transfer them to a higher level of care.

Based on record review, facility policy, and interviews, Facility A failed to perform and document a complete medical screening examination (MSE) in the emergency department (ED) to determine if the patient was stable or had an emergency medical condition for three of twenty patients (Patient #1, #3, #7). Patients #1, #3, and #7 did not receive a behavioral health consult or assessment when presenting to the emergency department with a mental health crisis.
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Findings:
1.Medical Record:
a.Review of Patient #1's medical record from Facility A:
On 03/09/2025 at 9:14 P.M., Patient #1 presented to Facility A's emergency department. Patient #1 was under an EDO (emergency detention order) and accompanied by police. Patient #1's chief complaint was suicidal ideation. Patient #1 had run away from home and threatened family he was going to kill himself by laying in the road and getting hit by a car. At 9:17 P.M., Patient #1 received a physical assessment and a detailed suicide risk screening that scored "low risk" from the physician though Patient #1 voiced suicidal ideation and plan. A suicide screening completed by the nurse screened positive. Per, Staff J, Patient #1 denied suicidal ideation at the time of assessment.
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At 9:28 P.M. All labs resulted within normal limits aside from a urine drug screen being positive for THC (Tetrahydrocannabinol ).
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A police report created 03/09/2025 at 9:29 A.M., scanned in the chart, states that the officer has "reason to believe and do believe that the above-named (Patient #1) evidences a substantial risk of serious harm to himself/herself or to others." Additionally reported that the officer has "reason to believe and do believe that the above (Patient #1) risk of harm is imminent."
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At 10:20 A.M. Lamotrigine was administered to the patient.
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Staff J noted, "Patient here with suicidal ideations. Says he was going to lay down in traffic. History of psychiatric illness in the past. PD (police department) involved, and a detention order placed and patient discharged to police custody."
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At 10:40 P.M. Staff I noted, PT (patient) A&Ox4 (alert and oriented times 4) NAD (no acute distress) PT (patient) VSS (vital signs stable) PT (patient) verbalized understanding of discharge." "Patient Instructions: ED suicidal, 72-Hour hold."
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Patient #1 presented with suicidal ideation. Patient #1 was not provided a behavioral health consult to adequately rule out an emergency medical condition of suicidal ideation before Patient #1 was discharged. Facility A failed to provide an appropriate medical screening exam.
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b.Review of Patient #1's medical record from Facility B:
On 03/09/2025 at 11:17 P.M., Patient #1 presented to Facility B's emergency department. Patient #1 was under an EDO (emergency detention order) and accompanied by police. Patient #1's chief complain was suicidal ideation. Patient #1 stated "he was going to lie in the road to kill himself." Additional "reason for visit" included "aggressive behavior, autism disorder, and impulse control disorder."
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On 03/10/2025 at 1:16 A.M., behavioral health was consulted and assessed Patient #1. Per the assessment, "Pt (patient) denied SI (suicidal ideation) however per report pt threatened his family to kill himself by being hit by a car after a disagreement." "Pt is not currently under the care of a therapist or psychiatrist." "Pt is recommended for inpatient BH (behavioral health) Invol (involuntary) admit." "Risk level: High Suicide Risk."
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At 5:06 P.M., Patient #1 was transferred to an inpatient behavioral health facility.
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c.Review of Patient #3's medical record from Facility A:
On 03/12/2025 at 5:46 P.M., Patient #3 arrived at Facility A's emergency department with the chief complaint of a fall and a suicide attempt. Patient's physical assessment, labs, and imaging were all within normal limits aside from an alcohol level of 4.
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At 6:30 P.M., an EKG and suicide assessment were documented. Patient #3 was "calculated suicide risk level: High Risk."
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At 6:44 P.M., Per the ED (emergency department) physician, Staff K, "Patient has no discernible injuries or complaints other than states he was suicidal and wanted to kill himself. He claims that he jumped off a third story building, but he has no injuries that would be consistent with the story. I do not believe he actually did that. Patient is being transported by police who has ...directly to psychiatric facility."
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Patient #3 presented with a suicidal attempt. Patient #3's psychological screening was limited. Patient #3 was not provided a behavioral health consult or a physician risk assessment and conflicting exam findings were insufficient to determine if there was a psychological emergency medical condition before Patient #3 was discharged. Facility A failed to provide an appropriate medical screening exam.
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d.Review of Patient #7's medical record from Facility A:
On 03/20/2025 at 11:53 P.M., Patient #7 arrived at Facility A's emergency department. Patient #7 was under an EDO (emergency detention order) and accompanied by police. Patient #7's chief complaint was "medical clearance for psychiatric admission."
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Fire Department report included in Patient #7's medical record states, "The Pt (patient) tonight had threatened to barricade himself in the house when PD contacted him. At this point the Pt was writhing on the ground handcuffed and had hit his head on the baseboard causing a cut that prompted PD (police department) to call EMS (emergency medical services). EMS went upstairs where the Pt was found cuffed behind the back laying on his right-side thrashing from side to side. The Pt had an apparent open airway and was yelling incoherently. The Pt allowed EMS to apply diagnostic equipment and inspect the wound to the head. An approximate 1 cm length laceration was seen over the right eye that was not bleeding. EMS acquired all necessary signatures and began to leave the scene when the Pt reported pain to the chest. The need for EMS transport to a higher level of care to receive a full medical clearance was clearly identified and PD prepped the Pt for transport. At one point the Pt expressed that they did not want to go to Facility A and would prefer another hospital. EMS clearly stated that due to the Pt's mental status and the fact he was in police custody, he did not have the decision-making capacity."
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At 12:04 A.M., Per Staff L, "objective assessment: word salad, non-cohesive words, rambling, hyper talking, VS (vital signs) stable No acute distress, dried blood around the mouth, no eye contact. Blood pressure 130/69. Heart rate 113. Respiratory rate 18. Temperature 37.1 Celsius. Oxygen Saturation 96%."
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At 12:07 A.M., Per Staff M, with hx (history) of bipolar and schizophrenia and mania, police were called to the home as the pt (patient) was "manic" according to family because he had not taken his psych meds for days, he threatened to barricade himself in his room and would not come out." "Police brought him in as they have an EDO (emergency detention order), he was not cooperative and was placed in a wrap as the pt was not cooperating with leaving home. They state he may have hit his head on the headboard, did not struggle, and did not fall on the ground. Pt did not want to be here and wants to leave." "Risk-Psychiatric Illness. Detailed Suicide Risk. Pos (positive) Nur (nurse) Sui (suicide) Risk Screen? No. Overall level suicide risk: unable to clinically assess." "Physical assessment within normal limits. NP notes "behavior: restless, uncooperative." "Psychiatric Abnormal Mood/Affect: Fearful, Flight of ideas. Abnormal Thinking/Perception: Delusions - grandeur. Negative: Suicidal, no plan, Homicidal, no plan." "The pt was brought in wrapped because he was not cooperative and in a manic state, according to them. Pt refused care." "Primary Impression: Medical Clearance for psychiatric admission. Discharge to home: Yes."
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At 12:11 A.M., Per Staff L, "Patient has been medically cleared and discharged to go psychiatric facility with PD (police department) via EDO (emergency detention order)."
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Patient #7 presented with bizarre behavior with police and complaints of pain and laceration to the eye. There was no sufficient screening for suicide ideation, complaints of chest pain, laceration over the eye, examination of Patient #7's head, blood in the mouth, or documented tachycardia to rule out an emergency medical condition. Patient #7's signs and symptoms reflected that he lacked the capacity to refuse care. Patient #7 was discharged. Facility A failed to provide an appropriate medical screening exam.
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e.Review of Facility A's Texas EMTALA - Medical Screening Examination 911.500.001 - Revised 07/2024:
Page 6 of 11
"Procedure:
3.Extent of the MSE
ii. Individuals with psychiatric or behavioral symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The MSE includes assessment of suicidal or homicidal thoughts of gestures that indicated danger to self or others."
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2.Interview:
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a.04/16/2025 at 9:00 A.M. in an interview with VP Quality Staff B, Staff B explained that Facility A does not have a specific EDO policy.
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b.04/17/2025 at 10:00 A.M. in an interview with ED Physician Staff J, Staff J explained that an MSE (medical screening exam) is "no different than any other patient. The patient first must stabilize and then [we] determine if they require further care (i.e. admission to a psych facility or admission for medical stabilization. Staff J stated that "an emergency detention order is a process that PD (police department) uses to get patients the appropriate treatment if PD believes a patient is a harm to themselves or others, and the patient is not willing to voluntary get the appropriate treatment." Staff J stated that, it does not affect the patients care. The patient requires the same MSE and stabilization as any other patient." When asked if a behavioral health consult would be considered part of the treatment plan for a mental health patient, Staff J said, "yes, in most cases."
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c.04/17/2025 at 9:35 A.M. in an interview with ED Nurse Practitioner Staff H, Staff H indicated that "behavioral health consults come after medical clearance when they don't need ICU (intensive care unit) or to be admitted. Staff H states that when police take the patient, the police will tell them [staff] which facility [they go to]. The police don't leave with the patient unless they know exactly where they are going."
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d.04/16/2025 at 1:30 P.M. in an interview with Director of Emergency Services Staff C, Staff C was asked if the facility knows where the patient goes once the patient is discharged to police. Staff C explains that "they [the police] might mention the name, but they do tell us, yes. We are not choosing the facility because we haven't done the consult to see if they qualify."
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e.04/16/2025 at 2:15 P.M. in an interview with ED Manager Staff D, Staff D was asked if patients can transfer to behavioral health facilities without a behavioral health consult. Staff D indicated that "if no [psychological] evaluation has been done, there is no way to transfer" the patient.
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f.06/04/2025 at 12:34 P.M. in an interview with the Director of Quality Resource Staff E, Staff E was asked who is responsible for conducting the behavioral health consults and if any policies state such. Staff E indicated that they "do not have a policy that states who conducts behavioral health exams. The provider completes a medical screening exam, and at that time, the provider may review whether an additional, more comprehensive behavioral health assessment is needed, based on the provider's clinical judgement."
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g.06/04/2025 at 12:34 P.M. in an interview with the Director of Quality Resource Staff E, Staff E was asked what the process is to obtain a behavioral health consult. Staff E stated, "Behavioral health consults are ordered by the provider, after their assessment of the patient. It may be included as a component of the ED psych workup but would be determined on an individual patient basis, per their clinical judgement, and then will be completed by the consulted entity, if ordered.
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Based on record review, facility policy, and interviews, Facility A failed to initiate an appropriate transfer to a behavioral health facility for three of the twenty patients (Patient #3, #7, #10). Patients #3, #7, and #10 were all under an EDO (emergency detention order) and transferred to known behavioral health facilities without appropriate transportation, medical records, or a memorandum of transfer.
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Findings:
2.Medical Record:
d.Review of Patient #3's medical record from Facility A:
On 03/12/2025 at 5:46 P.M., Patient #3 arrived at Facility A's emergency department with the chief complaint of a fall and a suicide attempt. Patient's physical assessment, labs, and imaging were all within normal limits aside from an alcohol level of 4.
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At 6:08 P.M.: CT L-Spine (lumbar), T-Spine (thoracic), Chest, C-Spine (cervical), and Brain, all within normal limits.
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At 6:30 P.M., an EKG and suicide assessment were documented. Patient #7 was "calculated suicide risk level: High Risk."
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At 6:44 P.M., Per the ED (emergency department) physician, Staff K, "Patient has no discernible injuries or complaints other than states he was suicidal and wanted to kill himself. He claims that he jumped off a third story building, but he has no injuries that would be consistent with the story. I do not believe he actually did that. Patient is being transported by police who has ...directly to psychiatric facility."
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Patient #3 presented with a suicide attempt. Patient #3 was experiencing an emergent medical condition. Patient #3 was documented as discharged home. Patient #3 was transported by police to a known behavioral health facility for a psychiatric assessment without medical records or a memorandum of transfer. Facility A failed to initiate an appropriate transfer.
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e.Review of Patient #7's medical record from Facility A:
On 03/20/2025 at 11:53 P.M., Patient #7 arrived at Facility A's emergency department. Patient #7 was under an EDO (emergency detention order) and accompanied by police. Patient #7's chief complaint was "medical clearance for psychiatric admission."
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Fire Department report included in Patient #7's medical record states, "The Pt (patient) tonight had threatened to barricade himself in the house when PD contacted him. At this point the Pt was writhing on the ground handcuffed and had hit his head on the baseboard causing a cut that prompted PD (police department) to call EMS (emergency medical services). EMS went upstairs where the Pt was found cuffed behind the back laying on his right-side thrashing from side to side. The Pt had an apparent open airway and was yelling incoherently. The Pt allowed EMS to apply diagnostic equipment and inspect the wound to the head. An approximate 1 cm length laceration was seen over the right eye that was not bleeding. EMS acquired all necessary signatures and began to leave the scene when the Pt reported pain to the chest. The need for EMS transport to a higher level of care to receive a full medical clearance was clearly identified and PD prepped the Pt for transport. At one point the Pt expressed that they did not want to go to Facility A and would prefer another hospital. EMS clearly stated that due to the Pt's mental status and the fact he was in police custody, he did not have the decision-making capacity."
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At 12:04 A.M., Per Staff L, "objective assessment: word salad, non-cohesive words, rambling, hyper talking, VS (vital signs) stable No acute distress, dried blood around the mouth, no eye contact. Blood pressure 130/69. Heart rate 113. Respiratory rate 18. Temperature 37.1 Celsius. Oxygen Saturation 96%."
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At 12:07 A.M., Per Staff M, with hx (history) of bipolar and schizophrenia and mania, police were called to the home as the pt (patient) was "manic" according to family because he had not taken his psych meds for days, he threatened to barricade himself in his room and would not come out." "Police brought him in as they have an EDO (emergency detention order), he was not cooperative and was placed in a wrap as the pt was not cooperating with leaving home. They state he may have hit his head on the headboard, did not struggle, and did not fall on the ground. Pt did not want to be here and wants to leave." "Risk-Psychiatric Illness. Detailed Suicide Risk. Pos (positive) Nur (nurse) Sui (suicide) Risk Screen? No. Overall level suicide risk: unable to clinically assess." "Physical assessment within normal limits. NP notes "behavior: restless, uncooperative." "Psychiatric Abnormal Mood/Affect: Fearful, Flight of ideas. Abnormal Thinking/Perception: Delusions - grandeur. Negative: Suicidal, no plan, Homicidal, no plan." "The pt was brought in wrapped because he was not cooperative and in a manic state, according to them. Pt refused care." "Primary Impression: Medical Clearance for psychiatric admission. Discharge to home: Yes."
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At 12:11 A.M., Per Staff L, "Patient has been medically cleared and discharged to go psychiatric facility with PD (police department) via EDO (emergency detention order)."
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Patient #7 presented with bizarre and erratic behavior, with complaints of pain and laceration of the eye. Patient #7 was experiencing an emergent medical condition. Patient #7 was documented as being discharged home. Patient #3 was transported by police to a known behavioral health facility for a psychiatric assessment without medical records or a memorandum of transfer. Facility A failed to initiate an appropriate transfer.
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f.Review of Patient #10's medical record from Facility A:
On 02/03/2025 at 11:18 A.M., Patient #10 arrived at Facility A's emergency department. Patient #10's chief complaint of suicide attempt.
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At 11:23 A.M., Per Staff N Patient #10 was "found in his car with a hose from his exhaust pipe into his car. He reports he was in the care for approximately 45 minutes prior to their arrival."
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At 12:30 P.M., Per Staff O, "Ongoing signs/symptoms: Suicidal Ideations" "PT medically cleared by Staff N. PT (patient) taken by PD (police department) for psych treatment. In PD (police department) custody."
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Patient #10 presented with a suicide attempt. Patient #10 was experiencing an emergent medical condition. Patient #10 was documented as discharged home. Patient #10 was transported by police to a known behavioral health facility for a psychiatric assessment without medical records or a memorandum of transfer. Facility A failed to initiate an appropriate transfer.
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g.Review of Facility A's Medical Staff Rules & Regulations - Approved 08/2024:
"Emergency Services
11.4 Admissions and Transfers:
(c) A transfer of a patient that occurs after the completion of the medical screening examination will be initiated in accordance with Medical Center Policy 911-500.003 entitled EMTALA - Texas Transfer Policy of Patients Between Hospitals With or Without Emergency Medical Conditions.
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h.Review of Facility A's EMTALA - Texas Transfer Policy of Patients Between Hospital with and Without Emergency Medical Conditions 911.500.0003 - Revised 06/2024:
"1. Transfers of Individuals Who Have Not Been Stabilized
b. A transfer will be an appropriate transfer if:
i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child;
ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment;
iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer as well as the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment; and
iv. The transfer is affected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport."
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"Requirements Prior to Transfer
i.Minimize the Risk
j.Individual's Request of Physician's Order
k.Request to Transfer Made to Receiving Facility
l.Document Request
m.Send Medical Records
n.Physician Certification of Risks and Benefits
o.QMP Certification
p.Send Memorandum of Transfer"

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3.Interviews
a.04/17/2025 at 10:00 A.M. in an interview with Director of Emergency Services Staff C, Staff C was asked if patients could transfer to a behavioral health facility before having a behavioral health consultation and assessment. Staff C explained that, "No, we can't transfer them without us having the consult and recommendation for inpatient." Staff C went on to say that "transporting patients by police gets them there (behavioral facility) quicker. It ensures the patient gets to where they need to be. They (behavior facility) don't turn them (patients) away once they get to intake." Whereas "the hospital has to go through a process to transfer patients to a behavioral health facility. They have to get approval from the AOC (administrator on call), the doctors have to agree, and of course they have to have a bed all prior to transfer."
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b.04/16/2025 at 1:30 P.M. in an interview with Director of Emergency Services Staff C, Staff C was asked if the facility knows where the patient goes once the patient is discharged to police. Staff C explains that "they [the police] might mention the name, but they do tell us, yes. We are not choosing the facility because we haven't done the consult to see if they qualify." Staff C also explained that "when the doctor deems them (the patients) medically clear, the police hear that and they say, 'okay, we can take this patient now that they are medically cleared.'"
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c.04/17/2025 at 7:31 P.M. in an interview with ED Registered Nurse Staff I, Staff I was asked if patients have previously been discharged without having a behavioral health consult. Staff I indicated yes.
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d.04/17/2025 at 10:00 A.M. in an interview with ED Physician Staff J, Staff J was asked if any patients under an EDO have left before without a behavioral health consult. Staff J explained, "if a patient has declined the behavioral health consult, usually uncooperative and refuses to do a BH (behavioral health) consult then it [is] possible that patients have been taken "into custody" by PD."