**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47061 Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 (Patient #1) patients, in that, Patient #1 did not receive accurate assessment and care for skin breakdown as required by hospital policy and procedure. Findings were: Review of Patient #1's medical record revealed that Patient #1 was admitted to the Geri-Psych Unit at Facility A on 1/18/2023 for Psychosis. Initial nursing assessment reflected the following, generalized weakness, gait unsteady, incontinent of urine, non-ambulatory, 2 person assist, skin condition: warm and dry, skin color: color within expectations for ethnicity, assistive devices used: wheelchair, and malnutrition risk. At admission and each day following, there was no documented sacral breakdown until 2/14/2023. There was no heel breakdown documented from admission, 1/18/2023, through day of discharge, 2/16/2023. Nursing skin assessments for the excoriation posterior buttock bilaterally were done on 2/14/2023, 2/15/2023, and 2/16/2023 for Patient #1. The nursing skin assessments/nursing documentation during Patient #1's admission did not document any skin issues with the patient's heels. The 2/14/2023 nursing assessment time at 4:00 AM reflected the following, .Skin alteration/Procedure site: Present/Exists, Skin alteration: Excoriation Posterior Buttock bilateral, Instant list status: Active, Related Clinical Factors: Incontinent bowel/bladder, Tissue type-worst: Red/moist/smooth/shallow, Wound base visible: No, Intact skin: Yes, Intact skin blanchable: Yes, Any open areas: No, Altered level/stage: Partial Thickness, Wound exudate amount/type: None, Date of last dressing change: 2/14/23, Time of last dressing change: 0400, Cleansed/applied: Perineal/skin cleanser, Dressing reinforcement type: barrier cream, Document advanced wound measurements: No, cm2 area: Cannot Calculate Area Yet, Worst tissue type score: 2, Intact value score: 0. The 2/15/2023 nursing assessment time at 8:11 AM reflected the following, .Skin alteration/Procedure site: Present/Exists, Skin alteration: Excoriation Posterior Buttock bilateral, Instant list status: Active, Related Clinical Factors: Incontinent bowel/bladder, Tissue type-worst: Red/moist/smooth/shallow, Wound base visible: Yes, Intact skin: Yes, Intact skin blanchable: Yes, Any open areas: No, Altered level/stage: Partial Thickness, Date of last dressing change: 2/15/23, Time of last dressing change: 0830, Wound/skin alteration comments: Cleansed and applied barrier cream liberally. Q (every) 2 hr (hour) turns, Document advanced wound measurements: No, cm2 area: Cannot Calculate Area Yet, Worst tissue type score: 2, Intact value score: 0 The 2/16/2023 nursing assessment time at 7:22 AM reflected the following, .Skin alteration/Procedure site: Present/Exists, Skin alteration: Excoriation Posterior Buttock bilateral, Instant list status: Active, Related Clinical Factors: Incontinent bowel/bladder, Tissue type-worst: Pink/red/moist/erythema/intact, Wound base visible: Yes, Intact skin: Yes, Intact skin blanchable: Yes, Any open areas: No, Altered level/stage: Superficial, Date of last dressing change: 2/16/23, Time of last dressing change: 0700, Wound/skin alteration comments: Applied barrier cream liberally. Encouraged q2h turns, redness decreased, Document advanced wound measurements: No, cm2 area: Cannot Calculate Area Yet, Worst tissue type score: 1, Intact value score: 0. Patient #1 was discharged [DATE] to a long-term care facility, Facility B, and noted by Facility B to have large wounds to her back, buttocks, and bilateral heels. On 2/17/2023, Patient #1 was transported back to the emergency room at Facility A and found by the wound care physician on 2/18/2023 to have, 1. Over the sacral area, there is a deep tissue injury measuring approximately 2 cm x 1.5 cm. There is also a small stage II right buttock decubitus ulcer measuring approximately 0.3 cm x 1 cm x 0.1 cm. There is no discharge from either wound. 2. Over the right heel, there is a deep tissue injury measuring approximately 4 cm x 4 cm. Over the left heel, there is a deep tissue injury approximately 5 cm x 5 cm. No drainage from either wound. On 2/27/2023 at 9:30 AM Personnel #1 was interviewed and was asked to review the medical record for documentation indicating Patient #1's physician or wound care nurse had been notified prior to discharge from the Geri-Psych Unit. Personnel #1 stated that review of physician orders and nursing notes for 1/18/2023-2/16/2023 revealed there was no documentation that the physician or wound care nurse was ever notified of altered skin integrity and there were no orders written for altered skin integrity. Personnel #1 was asked to review the medical record for documentation indicating Patient #1's wound identification. Personnel #1 stated that sacral wound in nursing documentation is first documented on 2/14/2023 and no documentation of heel wounds was found. On 2/27/2023 at 11:30 AM Personnel #2 was interviewed and was asked about medical record documentation for repositioning/turning of a patient. Personnel #2 stated that if a patient needs to be turned every 2 hours it falls under EBCD (evidence-based clinical documentation) which means it is assumed it's already being done so there will not be any documentation in the medical record. We chart by exception. On 2/27/2023 at 12:30 PM Personnel #4 was interviewed and acknowledged that the patient care policy, Pressure Injury Prevention was not followed by nursing personnel when Patient #1's skin breakdown was identified. Personnel #4 stated that if there is a wound identified the nurse should order a wound care consult to evaluate the wound and have measuring and pictures done. Personnel #4 stated a wound care consult was not entered on Patient #1 while admitted to the Geri-Psych Unit. On 2/27/2023 at 12:30 PM Personnel #3 was interviewed and asked to review the medical record for documentation indicating Patient #1's family had been notified per hospital policy of the wound development. Personnel #3 stated there is no documentation that Patient #1's family was notified of the wound development. Personnel #3 was asked to review the medical record for documentation that Patient #1 had a nursing plan of care for impaired skin integrity. Personnel #3 stated there is no documentation that Patient #1 had a nursing plan of care for impaired skin integrity. The facility policy on Pressure Injury Prevention effective date February 2022 required, POLICY AND PROCEDURE STATEMENTS: 1. All patients will be evaluated for skin breakdown through completion of a risk assessment process. This will occur upon admission; minimum of once per shift; following a change in medical condition and/or level of care; and at discharge. 2. Based on the level of skin risk, nursing interventions will be initiated and will be captured on the patient's plan of care .RISK ASSESSMENT: 1. Each patient with admission orders will be assessed for skin risk and the presence of any alterations in skin integrity. If a wound is identified, the following should be included in documentation: a. Wound type, b. Anatomic location of the wound; c. NE1 facilitated staging of wounds; d. Wound length and width; and e. Description of wound bed, drainage, tissue type present. 2. Reassessment of skin risk will occur, at minimum, once per shift; following a change in medical condition and/or level of care; and at discharge. STANDARD OF CARE: 1. Comprehensive skin and tissue assessments will be performed as outlined above and recorded in the electronic medical record. 2. The nurse will use visual, touch, palpation techniques to differentiate temperature and tissue differences .3. Interventions and an individualized plan of care will be implemented and documented as appropriate. 4. The nurse should notify the provider/practitioner of any new or existing wound. 5. The nurse will consult the Skin Care Champion or Wound Care professional for all pressure injuries stage 3 and above (including Deep Tissue Injuries) .HOSPITAL ACQUIRED PRESSURE INJURY .3. The attending provider/physician, unit-based leader, and patient's guardian will be notified as soon as possible. a. All notifications will be documented in the EHR (electronic health record). 4. Pressure injuries acquired throughout the hospital stay should be reported via the facility-specific event reporting system.

37325 Based on interview and record review, Hospital A failed to enforce its policy to ensure compliance with 489.24 (d) (1) (i) and 489.24 (a) (1) (ii). The Emergency Department (ED) did not provide appropriate medical screening examination to Patient #3 on 12/14/2020. The patient presented to the hospital on an Emergency Detention Order after being found laying in the middle of the road. The patient was discharged to the jail with an unstable medical condition the same day. Cross refer A2406 and A2409.

37325 Based on interview and record review, the hospital failed to provide appropriate medical screening examination to 1 of 1 (Patient #3) patients that arrived at the Emergency Department (ED)on 12/14/2020. Findings: Patient #3 arrived at the ED on 12/14/2020 at 0828 on an Emergency Detention Order after being found lying in the middle of the road by police officers. Patient #3 was placed on a stretcher in the hallway until a room was available. Patient #3 was placed in a room approximately 45 minutes after arrival to the ED . At 0920, Personnel #6 charted the patient became violent and kicked a nurse and the patient's condition was noted as worsening. The hospital called the police and discharged the patient to be transported to jail. No lab work was completed. Patient #3 received Ativan 1 mg Intramuscularly at 0943 and was discharged into police custody at 0956. There was no document of the patients reaction to the medication. During an interview on 12/28/2020 at 1105 Personnel #1 stated the labs were canceled and not resulted. Personnel #6 stated .he wanted to get blood work and a psychiatric evaluation on the patient but when he was moved into a room he began to destroy the room . The police were called, four police officers subdued the patient. A mutual decision was made to take the patient to jail. The patient was too dangerous to have around the staff .Personnel #6 stated the police can stabilize a psychiatric patient. At the time of discharge the patient was medically cleared. When asked how the patient was medically cleared with no lab work, Personnel #6 stated he was medically cleared . Medical Records obtained from Facility B reflected the patient had attempted to hang himself using the seatbelt of the police car during transport to the jail. The patient had to be emergently medicated and restrained after hitting his head and body against the cell wall. During an interview on 12/29/2020 at 1535, via telephone with Personnel #11 from Facility B stated .the patient was brought to the jail and was given several emergency injections and he ended up on a restraint bed. The patient was taken to a different hospital for medical clearance . the officers only have de-escalation training they would be unable to stabilize a patient . During an interview on 12/30/2020 at 1135 Personnel #9 stated .the patient was still very agitated when he arrived at the jail. The patient was unable to be booked into jail and was taken straight to the infirmary. The internal SWAT team had to be called to control the patient until he could be emergently medicated .

37325 Based on interview and record review, the hospital discharged 1 of 1 (Patient #3) patient that arrived the Emergency Department (ED)on 12/14/2020 in an uneatable condition. Findings: Patient #3 arrived at the ED on 12/14/2020 at 0828 on an Emergency Detention Order after being found lying in the middle of the road by police officers. At 0920, Personnel #6 charted that the patient became violent and kicked a nurse and the patient's condition was noted as worsening. The hospital called the police and discharged the patient to be transported to jail. No lab work was completed. No medical screening was conducted. Patient #3 received Ativan 1 mg Intramuscularly at 0943 and was discharged into police custody at 0956. There was no document of the patients reaction to the medication. Patient #3 remained in a psychiatric crisis status at discharge. Personnel #6 stated . he wanted to get blood work and a psychiatric evaluation on the patient, but when he was moved into a room he began to destroy the room . The police were called, four police officers subdued the patient. The patient was too dangerous to have around the staff .Personnel #6 stated the police can stabilize a psychiatric patient. At the time of discharge the patient was medically cleared. When asked how the patient was medically cleared with no lab work, Personnel #6 stated he was medically cleared . There was no appropriate medical screening performed. There was no documentation to justify how Patient #3 was medically cleared. Medical Records obtained from Facility B reflected the patient had attempted to hang himself using the seatbelt of the police car during transport to the jail. The patient had to be emergently medicated and restrained after hitting his head and body against the cell wall. During an interview on 12/29/2020 at 1535 via telephone Personnel #11 from Facility B stated . the patient was brought to the jail and was given several emergency injections and he ended up on a restraint bed. The patient was taken to a different hospital for medical clearance . the officers only have de-escalation training they would be unable to stabilize a patient . During an interview on 12/30/2020 at 1135 Personnel #9 stated .the patient was still very agitated when he arrived at the jail. The patient was unable to be booked into jail and was taken straight to the infirmary. The internal SWAT team had to be called to control the patient until he could be emergently medicated .

33589 Based on observation, record review, and interview, the facility failed to ensure that the quality assessment and performance improvement program involves all hospital departments and services, in that, A) there were no quality checks completed on the floor to ensure warm food at the bedside for the patient; and B) no quality data for the dietary department being reported through the Quality program. Findings included During a tour of the dietary kitchen on 4/12/18 at 11:10 AM with Personnel #10 and visualized by Personnel #1, once the carts of patient trays were delivered to the floor, the nurses were visualized while delivering them to the patients without delay. There were no temperatures checked of the food on the patient floor. There were no records of temperature checks on the patient floors to ensure warm food at bedside. During an interview on 4/12/18 at 12:20 PM, Personnel # 8 was asked if the nurses always deliver the patient trays. Personnel #8 stated, Yes.Personnel #8 was asked how they make sure the food is at the right temperature. Personnel #8 stated, We don't. We don't even have a thermometer to check. I don't know. During a patient interview on 4/12/18 at 1:01 PM, Patient #5 was asked about food temperature (door was open). Patient #5 stated, The food is cold sometimes. The soup sometimes like cream of chicken. During an interview on 4/12/18 ending at 1:03 PM, Personnel #1, #3, and #4 was informed the patient said food was sometimes cold. They were reminded the nurses stated they pass the trays and dietary does not. They were asked what was done to ensure warm food to patients at the main hospital. Personnel #1 stated, They (main campus) do checks to ensure. Personnel #1 was reminded whatever is done at the main campus needs to be completed here as well. Personnel #1 stated, Yes. I know. Personnel #1 was asked for the policy and quality metrics for dietary. During an interview on 4/12/18 ending at 2:05 PM, Personnel #5 (Personnel #1 was present) was asked about no quality checks on the floor to ensure warm food at bedside for the patient. Personnel #5 stated, At the main campus, my FAN (Food and Nutrition) manager completes monthly temperature checks on the (patient) floors to ensure warm food at the bedside. The FAN had not done that (temperature checks on the floor) at this campus. There is not a policy, just our practice. During an interview on 4/12/18 at 2:22 PM, Personnel #6 (Personnel #1 and #5 were present) was asked what quality metrics dietary collected and reported through the quality process. Personnel #6 stated, We realized that we don't report up to quality. We collect patient satisfaction survey data that is reviewed thru the EOC (Environment of Care) meeting but it doesn't go through Quality. We have done a PI Project for dining on demand but it was not reported through Quality.

33589 Based on observation, record review, and interview, the facility failed to ensure the administrative and technical personnel competent to conform to food handling techniques, in that, A) the gravy was poured out of the heating container into a plastic salad dressing container; B) gloves were not changed with hands washed after completing and documenting food temperatures prior to food plating; C) gloves were not changed with hands washed after using a marker to write on Styrofoam cups; and D) no quality checks completed on the floor to ensure warm food at the bedside for the patient. Findings included During a tour of the dietary kitchen on 4/12/18 at 11:10 AM with Personnel #10 and visualized by Personnel #1, the process of receiving food delivery including checking temperatures, plating food, and the cart delivery to the floor was visualized. The dietary tech took the temperatures of each food in the heating pan and document them with a pen on the paper log. The dietary tech did not change gloves or wash her hands. The dietary tech poured the gravy into a plastic salad dressing dispenser from the silver heating pan. During the plating of food, the dietary tech would reach for a marker and use it to write on Styrofoam cups. The dietary tech did not change gloves or wash her hands and continued to plate food. Once delivered to the floor, the nurses were visualized while delivering them to the patients without delay. No temperatures were checked on the floor. There were no records of temperature checks on the patient floors to ensure warm food at bedside. During an interview on 4/12/18 at 12:20 PM, Personnel # 8 was asked if the nurses always deliver the patient trays. Personnel #8 stated, Yes. Personnel #8 was asked how they make sure the food is at the right temperature. Personnel #8 stated, We don't. We don't even have a thermometer to check. I don't know. During a patient interview on 4/12/18 at 1:01 PM, Patient #5 was asked about food temperature (door was open). Patient #5 stated, The food is cold sometimes. The soup sometimes like cream of chicken. During an interview on 4/12/18 ending at 1:03 PM, Personnel #1, #3, and #4 was informed the patient said food was sometimes cold. They were reminded the nurses stated they pass the trays and dietary does not. They were asked what was done to ensure warm food to patients at the main hospital. Personnel #1 stated, They (main campus) do checks to ensure. Personnel #1 was reminded whatever is done at the main campus needs to be completed here as well. Personnel #1 stated, Yes. I know. Personnel #1 was asked for the policy and quality metrics for dietary. During an interview on 4/12/18 ending at 2:05 PM, Personnel #5 (Personnel #1 was present) was asked about the gravy in the plastic salad dressing container, not changing gloves/washing hands after completing temperatures and documenting them, not changing gloves/washing hands after using a marker to write on Styrofoam cups, and no quality checks on the floor to ensure warm food at bedside for the patient. Personnel #5 stated, She should have left the gravy in the pan in the water bath to maintain the temperature. She should have changed gloves and washed her hands both times. At the main campus, my FAN (Food and Nutrition) manager completes monthly temperature checks on the (patient) floors to ensure warm food at the bedside. The FAN had not done that (temperature checks on the floor) at this campus. There is not a policy, just our practice. During an interview on 4/12/18 at 2:22 PM, Personnel #6 (Personnel #1 and #5 were present) was asked what quality metrics dietary collected and reported through the quality process. Personnel #6 stated, We realized that we don't report up to quality. We collect patient satisfaction survey data that is reviewed thru the EOC (Environment of Care) meeting but it doesn't go through Quality. We have done a PI Project for dining on demand but it was not reported through Quality. Personnel #1 added, No. They don't now, but they will bi-annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33579 Based on record review, interviews, and observation, the hospital failed to provide care to patients in a safe environment for 4 of 4 patients (Patient #1, Patient #3, Patient #7, Patient #9) in that, 1) Shortly after receiving an emergency administration of a sedating medication mixture, Patient #3 eloped through the window in his assigned room by prying the expanded metal away from the window and forcing the window open. 2) 3 of 3 patients (Patient #1, #7, #9) were observed with their room doors closed on 04/30/15. Although identified as a ligature in 03/2015, the gaps observed in the expanded metal in front of windows of 3 patients on suicide precautions (Patients #1, #7, #9) provided potential for self harm. Findings included 1. Patient #3's Coding Summary dated 02/12/15 reflected Patient #3's diagnoses included, Psychosis, Cannabis Dependence, and Attention Deficient with Hyper-Activity. Patient #3's Clinical Documentation Record dated 02/07/15 reflected, Patient #3 eloped through the window in his assigned room, by prying the expanded metal away from the window and forcing the window open. Patient #3 received a cocktail (medication administration of Haldol, Ativan, Benadryl) prior to his elopement. Patient #3 jumped out of the second story to the ground level. He left the hospital grounds and was located by the police on the opposite side of the Expressway. Patient #3 was returned to the hospital by the Police Department within 30 minutes of his elopement. Patient #3 was noted to have an abrasion to the left leg, and bruise to his right face by the eye upon returning to the unit. During an interview at 9:25 AM on 04/29/15, Personnel #6 was asked how long it would take for the cocktail to effect Patient #3. Personnel #6 responded, It is a sedative drug, and it would take effect within 15 to 30 minutes. It has a possibility to be dangerous. During an interview with Personnel #4 at 9:30 AM on 04/29/15, Personnel #4 was asked if she was aware when the incident took place. Personnel #4 indicated, The event took place in the middle of the night .I think it was between rounds, and he was kicking the window open. During an Interview with Personnel #1 at 9:35 AM on 04/29/15, Personnel #1 stated expandable metal covers were identified as an issue during the hospital facility quality assurance meeting on 12/12/14. During an interview on 04/29/15 at 01:10 PM, Personnel #7 stated the windows had been replaced only on the 5th floor. During two separate tours of the hospital's second floor on 04/29/15 at 9:35 AM and 04/30/15 at 10:40 AM, the following was observed: All of the windows in patient rooms were bolted down with the expanded metal in front of the windows bolted to the walls, ceilings, and window base. There were openings where fingers could force the expanded metal away from the window so that the window was accessible for elopement. 2) The hospital's Daily Census/Bed Board dated 04/30/15 indicated 3 patients (Patient #1, #7 and #9) were on suicidal precautions. During a tour of the hospital's second floor on 04/30/15 at 9:25 AM, Patient #1 was in her room with the door closed. The window had an expanded metal screen cover. On 04/30/15 at 9:30 AM, Patient #7 was observed in his room with the door closed. The patient stated he was depressed. The window had an expanded metal screen cover. On 04/30/15 at 09:32 AM Patient #9 was observed in his room with the door closed. The room for Patient #9 had a window with expanded metal screens. During observations 04/30/15 at 12:15, personnel #11 had three patient rounds sheets with 15 minute observational checks updated at 11:45 AM. Personnel #11 stated there was a medical emergency on the unit, and she was doing them [the round sheets] now. During an interview on 04/29/15 at 9:30 AM, Personnel #4 was asked, how patients on suicide precautions were kept safe and stated, Patients are kept safe by continuously monitoring the floor and keeping patients out of their rooms until bedtime at 10:00 PM. During an interview on 04/29/15 at 12:55 PM, Personnel #4 stated patients on suicide precaution had to be out of their rooms on all waking hours. During an interview on 04/29/15 at 1:10 PM, Personnel #7 stated the windows were first identified as a risk in the hospital on 12/12/14. Record review of the hospital's risk assessment dated [DATE] noted .cage protecting the windows is ligature risk . The hospital's policy Special Precautions approved 10/2014 included, Patient should remain in the day area during daytime hours . The hospital's policy General Safety of the Psychiatric Units revised 10/2014 noted the policy to provide a safe physical environment for patients .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28141 Based on record review and interview, Hospital B failed to enforce its policy to ensure compliance with 42 CFR 489.24 for one of one patient (Patient #1). Patient #1 had been admitted to Hospital B from Hospital A to provide stabilizing treatment to an emergency medical condition. The patient was in pain, and unable to walk. Discharge with Home Health [NAME] was recommended. Although Patient #1 refused to leave the hospital and struggled to stand up, he was discharged from Hospital B four days after admission still in severe pain, unable to walk and with high blood pressure. Within three hours of the Hospital B discharge, Patient #1 sought emergency care at Hospital A again. Patient #1 was assessed to have a severe spinal canal compromise with sensory loss in both legs, the same condition he had when he was tranferred to Hospital B. Patient #1 was in danger of permanently losing his bladder function. The patient underwent decompression surgery at Hospital A and was discharged three days later after the provision of an stabilizing treatment to an emergecy medical condition. Patient #1 was able to stand, walk, and had intact sensation in his legs. Cross refer to A2407 and A 2409

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28141 Based on record review and interviews, the hospital (Hospital B, Medical Center of [NAME]), after admitting one of one patient (Patient #1) to the hospital's inpatient unit, failed to stabilize the emergency medical condition in that Patient #1 was discharged home in severe pain and with high blood pressure. The required surgical intervention for the emergency medical condition of this uninsured patient was not provided. Therefore, the patient was not admitted to the hospital in good faith. The patient returned to Hospital A's Emergency Department (ED) to seek further care and was admitted . The required surgical intervention for the emergency medical condition was performed within three hours after discharge from Hospital B. Findings included: Hospital A ED Physician Report dated 04/25/14 at 11:14 by Hospital A, Personnel MD #15, noted that Patient #1 was previously treated for low back pain prior to presentment at the hospital. The patient had been unable to walk, defecate, or urinate for a few days prior to presentment. Magnetic Resonance Imaging (MRI) reflected .severe impingement at L4-L5 . Patient' #1's admitting diagnoses dated 04/25/14 at 16:31 by Hospital A Personnel MD #15 included Back Pain, Disc Herniation, Cauda Equina, and Chronic Back Pain. The patient was accepted at Hospital B for neurosurgical emergency. Hospital A's ED Clinical Summary dated 04/25/14 at 16:32 by Hospital A, Personnel #19, noted that Patient #1 left Hospital A's ED to be transferred to Hospital B. Patient #1's discharge information included Cauda Equina Syndrome, a neurosurgical emergency (http://www.aans.org). Hospital B's ED Provider Report dated 04/25/14 at 17:46 by Hospital B, Personnel #9, reflected Patient #1 was transferred from Hospital A with complaints including back pain and numbness and tingling in both legs. Patient #1 was unable to walk or stand up. Hospital B's patient data information sheet noted Patient #1 was uninsured and did not have a primary or family physician. The History and Physical Exam dated 04/25/14 at 22:39 by Hospital B, Personnel MD #12, noted Patient #1 had Chronic Back Pain with Radiculopathy (pinched nerve). Brief Consultation Note dated 04/25/14 at 21:29 by Hospital B, Personnel MD #11, noted the patient had .acute on chronic back pain . and bulging discs in the lower back. Hospital B, Personnel MD #1,2 noted on 04/27/14 at 16:43 that Patient #1 was .probably not a surgical candidate . and noted social services involvement for .home health [NAME]. Hospital B's Case Management Report dated 04/28/14 at 15:45 reflected Patient #1 was not scheduled for surgery and .has been told he may follow up as an outpatient. The document noted that Patient #1 .refused to leave the hospital stating he is unable to walk .continues to complain of severe pain and became tearful .struggled to stand up .[NAME] pending. Hospital B Personnel MD #12's discharge summary dated 04/28/14 at 11:42 noted Patient #1's condition at discharge was fair, improved. Follow up appointments included a primary care physician and .neurosurgery as recommended. Hospital B clinical documentation records dated 04/29/14 at 10:45 reflected Patient #1 complained of a pain level of 8 on a 1 to 10 pain scale (10 being the highest level of pain). At 12:17, Patient #1 rated his pain level a 9 on the pain scale of 1 to 10. The notes reflected the physician denied another dose of Dilaudid (pain medication) .and will not provide any further narcotic medication as the patient is discharged . The clinical documentation reflected Patient #1's blood pressure readings were 181/92 at 07:23 and 192/97 at 11:17. The notes timed at 12:45 reflected Patient #1 had high blood pressure and received medication. Patient #1 .refused BP [blood pressure] recheck and was discharged off the unit. Patient #1 left at 12:45 in stable condition. Hospital B's Patient Referral Emergency Department Policy PC.PP.108 dated 02/2014 reflected the purpose to ensure Hospital B .complies with the intent of EMTALA and other related federal/state/local regulations in providing care to patients who present to the Emergency Department. Hospital B's EMTALA Texas Transfer Policy PC.PP.104 dated 05/2013 noted that the transfer of an individual shall not consider/insurance status, economic status or ability to pay for medical services . Hospital B's Pain Management Policy PC.PP.104 dated 03/2014 noted .severe pain corresponds to pain scale of 7-10 . Hospital A Personnel MD #15 ED Physician Record Final Report dated 04/29/14 at 15:52 reflected Patient #1 was .unable to walk due to the pain . and unable to void. Patient #1 was admitted to the hospital with diagnoses including Cauda Equina Syndrome, Emergency. Hospital A's MRI spine report dated 04/29/14 at 16:43 by Hospital A Personnel MD #14 noted .no significant change has occurred since prior examination. Patient #1's History and Physical reports dated 04/29/14 at 19:51 by Hospital A Personnel MD #13 reflected the patient had a severe lumbar spinal stenosis with cauda equine [equina] syndrome. The Final Report of Consultation dated 04/29/14 at 19:34 by Hospital A Personnel MD #16 reflected Patient #1 had .severe spinal canal compromise .a dense sensory loss around the perineal area .and both lower extremities .may have permanently lost bladder function at this point. Hospital A's Preliminary Discharge Summary dated and signed by Hospital A Personnel MD #13 on 05/09/14 at 18:14 reflected Patient #1's discharge diagnoses included Cauda Equina Syndrome with Cauda Equina Compression, Urinary Retention, Urinary Tract Infection, and Hypertension. Decompression laminectomy surgery was performed on 04/30/14. After the surgery Patient #1 was able to void without catheterization and up and walking . Patient #1 was discharged on [DATE] with the ability to .stand and walk .raise his legs against gravity .[and] has intact sensation in his lower extremities bilaterally.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28141 Based on record review and interviews, Hospital B failed to stabilize an emergency medical condition for one of one patient (Patient #1) in that the patient had been admitted with severe back pain and inability to walk. The patient was discharged home four days later although still in severe pain and hypertensive. Patient #1 sought emergency care at Hospital A and was admitted for emergency neurosurgical intervention within three hours of discharge from Hospital B. Findings included: Hospital A ED Physician Report dated 04/25/14 at 11:14 by Hospital A Personnel MD #15 noted Patient #1 was treated for low back pain. The patient had been unable to walk, defecate, or urinate for a few days. Magnetic Resonance Imaging (MRI) reflected .severe impingement at L4-L5 . Patient' #1's admitting diagnoses dated 04/25/14 at 16:31 by Hospital A Personnel MD #15 included Back Pain, Disc Herniation, Cauda Equina, and Chronic Back Pain. The patient was accepted at Hospital B for neurosurgical emergency. Hospital A's ED Clinical Summary dated 04/25/14 at 16:32 by Hospital A Personnel #19 noted Patient #1 left Hospital A's ED to be transferred to Hospital B. The patient's discharge information included Cauda Equina Syndrome, a medical emergency (http://www.aans.org). Hospital B's ED Provider Report dated 04/25/14 at 17:46 by Hospital B Personnel #9 reflected Patient #1 was transferred from Hospital A with complaints including back pain and numbness and tingling in both legs. Patient #1 was unable to walk or stand up. Hospital B's patient data information sheet noted Patient #1 was uninsured and did not have a primary or family physician. The History and Physical Exam dated 04/25/14 at 22:39 by Hospital B Personnel MD #12 noted Patient #1 had Chronic Back Pain with Radiculopathy (pinched nerve). Brief Consultation Note dated 04/25/14 at 21:29 by Hospital B Personnel MD #11 noted the patient had .acute on chronic back pain . and bulging discs in the lower back. Hospital B Personnel MD #12 noted on 04/27/14 at 16:43 that Patient #1 was .probably not a surgical candidate . and noted social services involvement for .home health [NAME]. Hospital B's Case Management Report dated 04/28/14 at 15:45 reflected Patient #1 was not scheduled for surgery and .has been told he may follow up as an outpatient. The document noted that Patient #1 .refused to leave the hospital stating he is unable to walk .continues to complain of severe pain and became tearful .struggled to stand up .[NAME] pending. Hospital B Personnel MD #12's discharge summary dated 04/28/14 at 11:42 noted Patient #1's condition at discharge was fair, improved. Follow up appointments included a primary care physician and .neurosurgery as recommended. Hospital B clinical documentation records dated 04/29/14 at 10:45 reflected Patient #1 complained of a pain level of 8 on a 1 to 10 pain scale (10 being the highest level of pain). At 12:17, Patient #1 rated his pain level a 9 on the pain scale of 1 to 10. The notes reflected the physician denied another dose of Dilaudid (pain medication) .and will not provide any further narcotic medication as the patient is discharged . The clinical documentation reflected Patient #1's blood pressure readings were 181/92 at 07:23 and 192/97 at 11:17. The notes timed at 12:45 reflected Patient #1 had high blood pressure and received medication. Patient #1 .refused BP [blood pressure] recheck and was discharged off the unit. Patient #1 left at 12:45 in stable condition. Hospital B's Patient Referral Emergency Department Policy PC.PP.108 dated 02/2014 reflected the purpose to ensure Hospital B .complies with the intent of EMTALA and other related federal/state/local regulations in providing care to patients who present to the Emergency Department. Hospital B's EMTALA Texas Transfer Policy PC.PP.104 dated 05/2013 noted that the transfer of an individual shall not consider/insurance status, economic status or ability to pay for medical services . Hospital B's Pain Management Policy PC.PP.104 dated 03/2014 noted .severe pain corresponds to pain scale of 7-10 . Hospital A Personnel MD #15 ED Physician Record Final Report dated 04/29/14 at 15:52 reflected Patient #1 was .unable to walk due to the pain . and unable to void. Patient #1 was hospital admitted with diagnoses including Cauda Equina Syndrome, Emergency. Hospital A's MRI spine report dated 04/29/14 at 16:43 by Hospital A Personnel MD #14 noted .no significant change has occurred since prior examination. Patient #1's History and Physical reports dated 04/29/14 at 19:51 by Hospital A Personnel MD #13 reflected the patient had a severe lumbar spinal stenosis with cauda equine [equina] syndrome. The Final Report of Consultation dated 04/29/14 at 19:34 by Hospital A Personnel MD #16 reflected Patient #1 had .severe spinal canal compromise .a dense sensory loss around the perineal area .and both lower extremities .may have permanently lost bladder function at this point. Hospital A's Preliminary Discharge Summary dated and signed by Hospital A Personnel MD #13 on 05/09/14 at 18:14 reflected Patient #1's discharge diagnoses included Cauda Equina Syndrome with Cauda Equina Compression, Urinary Retention, Urinary Tract Infection, and Hypertension. Decompression laminectomy surgery was performed on 04/30/14. After the surgery Patient #1 was able to void without catheterization and up and walking . Patient #1 was discharged on [DATE] with the ability to .stand and walk .raise his legs against gravity .[and] has intact sensation in his lower extremities bilaterally.