University of Texas Medical Branch Galveston

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46010 Based on observation, interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam for Patient IDs #1 and 23. Refer to tag A 2406 for additional information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) for Patient ID #1 and Patient ID # 23 who both presented to the facility with a licensed peace officer, with an emergency detention order, describing history and observations which would have required a comprehensive medical and psychiatric evlauation to arrive at the determination of whether an emergency medial condition exhisted or not. Patient ID #1 was discharged to law enforcement officer after an incomplete evaluation and Patient ID #23 was allowed to leave the facility against medical advice without a thorough evaluation. The facility failed to ensure a thorough medical screen evaluation by failing to assess for assessment of thought processes, thought content, delusions, hallucinations, judgement, insight, impulse control, reliability of the history, capacity for medical decision making and assessment of dangerousness. In addition, the facility failed to ensure a thorough physical examination, vital signs and assessment for potential medical contirbutors to the patient’s presentations were included in a thorough medical screen axamination. Findings included: Record review of facility policy “ Subject 9.1: Admission, Discharge, and Transfer. Title: Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA)”, last reviewed 9/1/2016, stated “Documentation. The screening of all individuals in the Emergency Department and in offsite clinics will include documentation of: If the individual has an emergency medical condition; Actions taken to make the determination; Results of diagnostic tests; Completion of Agreements, Authorizations, and Irrevocable Assignments, Disclosure and Consent for Medical and Surgical Procedures, and Against Medical Advice forms, if applicable; and Actions taken to stabilize and/or transfer the patient to UTMB’s Emergency Department, for those seen in the offsite clinics.” Record review of the facility “Medical Staff Rules and Regulations”, last adopted 03/17/2025, stated “7.B. MEDICAL SCREENING EXAMINATIONS: (1) A medical screening examination is performed on all patients who present to emergency care facilities of UTMB and request or have a request made on their behalf for an examination or treatment of a medical condition. (2) The medical screening examination is the process required to reach, with reasonable clinical confidence, a determination about whether the patient does or does not have an emergency medical condition. (3) The medical screening examination will include a statement from the patient about whether they are seeking emergency medical care, information about the chief complaint, the patient ’ s vital signs, mental status assessment, general appearance, and brief questioning by the qualified medical personnel to determine whether an emergency medical condition exists. If a physical examination is necessary to make a determination of an emergency medical condition, this will also be performed.” Record review of medical record for Patient ID #1. Patient ID #1 was brought into the facility Webster campus emergency department by law enforcement on 4/9/26 at 10:45 am with an emergency detention order, after history stating Patient ID #1 reportedly assaulted his mother in the setting of history of schizophrenia, medication noncompliance and insomnia, poor oral intake, and behavioral deterioration. The patient denied suicidal and homicidal ideation to the ED clinician. The patient denied suicidal and homicidal ideation. There were no vital signs documented, no appropriate physical examination and a limited psychiatric assessment/evaluation performed by the ED clinician. There was no assessment of mental status including thought process, thought content, delusions, hallucinations, judgment, insight, impulse control, reliability of the history, capacity for medical decision-making, and assessment of dangerousness utilizing available collateral information. The documented evaluation was limited primarily to the patient’s denial of suicidal and homicidal ideation and refusal of treatment. There was no documentation of the collateral history from law enforcement which was available, describing recent violent behavior and possibility of psychiatric decompensation. The patient was discharged to law enforcement officer on 4/9/2026 at 11:23 am. Record review of medical record for Patient ID #23. Patient ID #23 was brought into the facility Webster campus emergency department by law enforcement with an emergency detention order on 4/17/2026 at 2:04 pm. The history stated the patient had been running into traffic, attempting to open apartment doors, exhibiting paranoia, and expressing suicidal ideation. Upon arrival to the Webster campus ED, the patient denied suicidal and homicidal ideation, but remained agitated and verbally aggressive. The provider documented rapid, pressured speech, agitation, hyperactivity, paranoia, and noted that the history was limited by the patient’s mental status. Vital signs demonstrated mild tachycardia, and the differential diagnosis appropriately included psychosis, acute intoxication, thyroid derangement, endocrine abnormality, and dehydration. Suicide precautions were initiated, and olanzapine was offered but refused. Given the reported suicidal behavior preceding arrival, ongoing paranoia, agitation, abnormal mental status, and the limited reliability of the patient’s history, an appropriate medical screening examination required sufficient evaluation to determine whether the patient was experiencing an acute psychiatric emergency or an underlying medical condition contributing to his behavioral disturbance. The evaluation failed to address the reported delusions and paranoia, along with judgment, insight, thought process, thought content, and overall dangerousness, to determine whether the patient remained at risk from an acute psychiatric emergency or an underlying medical condition contributing to his behavioral disturbance. Although the physician performed a limited psychiatric assessment, obtained collateral information from law enforcement, and considered an appropriate differential diagnosis, the evaluation could not be completed because the patient refused laboratory testing, additional medical evaluation, and treatment. As a result, potential medical contributors identified in the differential diagnosis could not reasonably be excluded, and the available psychiatric assessment was insufficient to determine, within reasonable clinical certainty, whether an emergency medical condition was present. The medical record also contained differing assessments of the patient’s psychiatric status. Earlier in the encounter, a “Clinical Affirmation of Mental Health Status” documented that the patient posed a danger to self or others and lacked appropriate decision-making capacity. The attending physician documented that the patient denied suicidal and homicidal ideation, was alert and oriented, and had capacity to leave against medical advice. The patient signed against medical advice (AMA) paperwork and was allowed to depart the facility. The patient’s refusal of further testing and treatment prevented exclusion of potential medical contributors, and the psychiatric evaluation did not adequately address the reported delusions, paranoia, and discrepant prehospital versus ED findings. Interview 5/19/26 at 09:40 am with Physician System Medical Director Staff ID # 69. He confirmed that the Clear Lake facility campus is in Harris County, Texas. He confirmed that the main campus is in Galveston county. He confirmed that Galveston county has a “designated mental health authority” called Gulf Coast who assists with behavioral health assessments and placements. He stated that Harris County does not have that same service or process. He stated that medical staff have been told by facility legal counsel that they are not designated as a psychiatric facility and that they may not detain or hold patients against their will. He stated that the facility does not have psychiatric consultant coverage consistently. He stated that medical school pyschiatry faculty are available Monday-Friday between 1-3 pm for telepsych consultation for this campus in Webster, Texas. He said outside those times, ED physicians are responsible for performing ED evaluations, completing medical screen examinations and determining safe discharge plans for patients/course of care. Interview on 5/20/26 at 11:15 am with ED Physician Staff ID # 62. Staff ID # 62 stated that there are 4 types of patients who could be designated as “imminent emergencies: suicidal and/or homicidal ideation, psychosis and mania.” He stated that the suicidal and homicidal are a “little easier from a legal/risk management standpoint.” He stated there are no facility policies, procedures or directives related to the psychotic and manic patient, and their detention/involuntary holding process. He stated there was a common misconception, that suicidal and homicidal patients are the only psychiatric emergency cases. He stated that active mania and psychosis could comprise psychiatric emergencies as well. Physician Staff ID # 62 stated that for patients who may require involuntary hold status, the ED provider has been asked by facility legal team, to write a “clinical affirmation statement” describing what is wrong with the patient. He stated that if the patient tries to leave against medical advice or elope, the facility staff have been instructed to let them leave and allow their facility police department to “interview the patient and decide if they meet threshold to leave.” He stated that we (ED providers) have been told by administration/facility legal team that “we don’t decide/hold patients against their will.” He confirmed that the facility does not have other psychiatric support services on the campus such as behavioral health clinicians, mobile assessment teams, telepsychiatry consultants, etc outside of social work team. ED Physician Staff ID # 62 confirmed he had recently “become familiar” with Patient ID #23 case related to his administrative review of the patient’s clinical care after a grievance filed on behalf of Patient ID #23. He stated that there were “definitely inconsistencies in the physician assessment and clinical affirmation statement.” He stated that a patient who did not have “mental capacity” would not be able to leave the facility Against Medical Advice (AMA) and sign AMA paperwork. He confirmed that the patient did not receive a thorough medical and psychiatric assessment per medical record review.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to ensure patients rights to care in a safe setting, by failing to ensure that suicide safety plans were implemented, prior to discharge from the emergency department, in 2 of 8 discharge records reviewed (Patient IDs # 24 and 26). Findings Included: Medical record review of patient ID #24 revealed she presented to the Clear Lake campus emergency department on 5/1/2026 at 12:25 pm with EMS and law enforcement with an emergency detention order. The chief complaint stated she had suicidal thoughts, had cut her left wrist and was off her psychiatric medications. Her SAFE-T Protocol with C-SSRS (Columbia Suicide Risk and Protective Factors) assessment tool completed by the provider identified she was “moderate risk for suicide.” The medical record stated “Develop safety plan (includes prevention strategies) and include counseling about restriction and removal of firearms, medications, means to hang oneself, large sharp objects, etc. See safety plan.” There was no evidence of a suicide safety plan and she was discharged home on 5/1/2026 at 15:04. Medical record review of patient ID #26 revealed she presented to the Clear Lake campus emergency department on 5/3/2026 at 20:14 with EMS and law enforcement with an emergency detention order. The chief complaint stated had “suicidal ideation.” Her SAFE-T Protocol with C-SSRS (Columbia Suicide Risk and Protective Factors) assessment tool completed by the by the provider identified at 20:32 revealed she was “high risk for suicide.” She was reassessed on 5/4/2026 by physician staff ID# 62 at 20:08 pm with the same tool identified to be at a “moderate risk.” The plan stated “Develop safety plan (includes prevention strategies) and include counseling about restriction and removal of firearms, medications, means to hang oneself, large sharp objects, etc. See safety plan.” There was no evidence of a suicide safety plan and she was discharged home on 5/4/2026 at 20:43. Record review of patient rights policy “IHOP 09.03.13 - Patient Rights and Responsibilities”, last reviewed 05/06/2022, stated “2.2.9 Continuity of Care: Access to and Transfer of Care. 2.2.9.2 With the exception of incarcerated patients, all patients must be informed of:...and post discharge continuing health care requirements, including contact information for physicians and the scheduling of appointments.” The policy further stated “...In return, practitioners should make every effort to adapt the plan to the specific needs and limitations of each patient;...” Record review of facility policy “IHOP 09.13.38 - Suicide Risk Screening and Suicide Precautions for Patients”, last reviewed 3/14/2025, stated “2.3.1.2 Determine appropriate plan of care and disposition based on level of risk and clinical judgment...2.6.2 Patient/family education regarding suicide will be documented in the appropriate location in the medical record. The education will include suicide prevention information such as a crisis hotline. Provide counseling and follow-up care instructions to the patient at time of discharge.” Interview with Quality RN Staff ID # 56 on 5/20/26 at 09:05 am with medical record review. She stated that the safety plan is typically completed and documented by the case manager or social worker for moderate to high risk patients prior to discharge. She confirmed she was unable to locate suicide safety plans for both Patient ID #24 and Patient #26 in their respective medical records.”

“PATIENT RIGHTS: ACCESS TO MEDICAL RECORD CFR(s): 482.13(d)(2) The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. If it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or if not, in a readable hard copy form or such other form or format as agreed by the facility and the individual, and within a reasonable timeframe. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. This Standard is not met as evidenced by: 46010 Based on review of facility records, policy and procedures and interviews, the facility failed to follow its own policy and procedure for a timely medical record access and retrieval for Patient ID # 2. Findings Included: Record review of HHSC complaint regarding Patient ID #2 included a copy of the “UTMB Release of Information form” for Patient ID #2, completed and signed by the patient’s mother. The accompanying certified US Post Office mail receipt showed it was received at the facility in person as “Delivered, left with individual.” Record review of facility policy “IHOP 09.03.13 - Patient Rights and Responsibilities”. last reviewed 5/6/2022, stated “1.3 Other aspects of patient ’ s rights such as advance directives and end of life care, informed consent, refusal of treatment, management of patient ’ s belongings, visitors, medical record review, billing questions, and patient privacy are covered in other policies. This policy is intended to service as a resource for all employees and to enable compliance with regulatory requirements.” Interview with HIM staff ID #76 on 5/26/26 at 2:10 pm regarding Patient ID #2. She stated that the Release of Information request had been scanned into the media tab of the patient’s medical record on 01/08/2026. However, this “had not been forwarded for processing.” She stated she “would get the request processed ASAP.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46010 Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to accept a pediatric patient in transfer, when they had the capacity and capability of providing care for emergency medical condition for Patients ID #1 and #8. Refer to tag A 2411 for additional information.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 46010 Based on review of documents and interviews with Facility A staff, Facility A failed to accept appropriate transfer of pediatric patients with emergency medical conditions, who required specialized capabilities, which Facility A had the capability and capacity to treat in 2 of 7 transfer in requests reviewed. Facility A’s 1) On-call pediatric critical care medicine physician (Staff ID # 73) and pediatric hematologist/oncologist (Staff ID # 72) refused to accept a pediatric patient with concern for pneumonia, sepsis and anemia. (Patient ID #1). 2) On-call pediatric hospital medicine physician (Staff ID #83) refused to accept a patient who may have required pediatric surgery consultation and/or surgery, stating they did not have the capability of providing care for the likely diagnosis of biliary atresia (Patient ID #8). Findings Included: Patient ID #1 Record review of Facility B ED Medical Record for Patient ID #1 reflected she was a 6-year-old female with a history of leukemia who completed chemotherapy six months prior, who presented to Facility B with ongoing cough, fever, and new pallor in the context of recent influenza illness and subsequent pneumonia on outpatient antibiotics. She was found to be septic from pneumonia and had pancytopenia with neutropenic fever and anemia with hemoglobin of 5.7. Medical records reflect transfer to Facility A was declined due to lack of bone marrow transplant services. However, Facility A had the capability and capacity to stabilize and treat the patient’s Emergency Medical Conditions (EMC) of possible sepsis due to pneumonia, fever and anemia. Review of facility A document labeled “Transfer Center Timeline for (redacted) Patient ID #1” reflected Facility B contacted Facility A on 2/20/2025 at 3:27 pm. Record stated “Capacity MC (Main Campus - PED (Pediatrics floor)/PICU (Pediatric Intensive Care Unit) open.” The Transfer record reflected Facility B ED Staff Physician ID # 89 requested transfer to Facility A for higher level of care for Patient ID #1 through the patient placement center (transfer center). Transfer center records reflected Pediatric Hematology/Oncology specialist Staff ID # 72 and Pediatric Critical Care Medicine physician Staff ID # 73 participated in the recorded doctor to doctor call with Facility ED Staff Physician ID #89. “4:09 pm Transfer record stated “Transfer Request Canceled. Reason: Service Unavailable.” Records reflect Facility A refused transfer for Patient ID #1 on 2/20/2025 at 4:09pm due to lack of capability. Record review of Facility A pediatric critical care medicine call schedule for 2/20/2025 reflected pediatric critical care medicine Staff ID # 73 was on call for 24 hour period for Facility A’s main campus pediatric critical care unit, which had pediatric inpatient capacity and capability. Record review of Facility A pediatric hematology/oncology call schedule for 2/20/2025 reflected pediatric hematology/oncology Staff ID # 72 was on call for 24 hour period for Facility A’s main campus. Telephone Interview with Facility A Hematology/Oncology Physician Staff ID # 72 on 4/8/25 at 3:35 pm. He confirmed that he participated in the transfer center phone call for Patient ID #1. He stated that he believed the facility did not have capability to provide the bone marrow transplant that the patient may need for likely relapsed leukemia. He confirmed that the facility had pediatric medicine, pediatric intensive care medicine and unit and pediatric infectious disease consultants. He confirmed he was aware that patient had infection, concern for sepsis and anemia. However, he felt the care needed to be provided at a comprehensive center that could manage the patient’s likely leukemia reoccurrence. He confirmed Facility A had the ability to perform diagnostic hematologic testing such as bone marrow aspirations, peripheral smears, etc. He stated he felt that should be perfromed by the center who would be responsible for definitive bone marrow transplant. Patient ID #8: Review of facility A document labeled “Transfer Center Timeline for (redacted) Patient ID #8” stated “13:36 Call for Capacity - As of 0400, the outside hospital transfer status is as follows: MC (Main campus)- ... PED (Pediatric) open; PICU (Pediatric Intensive Care Unit) saturation; CLC (Clear Lake Campus) ... PED case by case. (Redacted) House Supervisor Staff ID # 82 from Facility A states “capacity available.” 13:38 Call (redacted) Facility C. Nurse Practitioner Staff ID #90 (referring provider) connected to Facility A Pediatric Hospitalist Staff ID # 83. Clinicals discussed. Physician Staff ID # 83 “states no service available due to concern for biliary atresia.” 13:53 per Patient Placement Center Rep Staff ID #84, “request cancelled, reason: service unavailable.” Record review of facility pediatric surgery call schedule for 03/02/2025 reflected pediatric surgeon Staff ID # 86 was on call for 24 hour period for Facility A’s main campus and clear lake campuses, which had pediatric inpatient capacity and capability. Review of facility A policy “Admissions, Transfers, Discharges”, last reviewed 11/17/2017, stated “Policy: In accordance with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA), the (facility) is committed to accepting patients with emergency medical conditions from other facilities when (the facility) has capacity, its medical services are available and the transferring facility represents it cannot provide the medical services required by the patient. (The facility) accepts interfacility patient transfers for patients with emergency medical conditions. All interfacility patient transfers for patients with emergency medical conditions are arranged through the Patient Placement Center (PPC) and must have a bed assignment prior to transfer to (the facility).” It further stated “When the PPC receives a call from a facility requesting the transfer of a patient with an emergency medical condition in an Emergency Room, the PPC, in conjunction with the Clinical Operations Administrator (COA)/House Supervisor, will determine capacity at (the facility). If capacity is available, the PPC will contact the facility physician assigned to the call coverage and connect the facility physician with the transferring facility physician to discuss patient care issues. Once the clinical discussion has taken place, the PPC will secure a bed assignment and will provide to the referring facility the administrative approval and bed assignment information for the direct admission.” Record review of Facility A Patient Placement Center (Transfer Center) Pediatric Algorithm provided by Director Staff ID # 56 signed by “PPC Leadership” and dated 3/6/25. The algorithm for pediatric floor requests for Clear Lake Campus stated “Is Bed available? - Yes” then states “Connect referring provider with pediatrician on-call and subspecialist as needed.” Interview with Patient Placement Center (Transfer Center) Manager Staff ID # 66 on 4/8/2025 at 11:50 am. She confirmed that requests for transfer in, which involve possible need for subspecialist, include the subspecialist on the intake call to assist with determining capability. She confirmed that the hospitalist or intensivist has admitting privileges and may serve as the primary service once the patient arrives to the facility. Telephone Interview with Facility A Pediatric Surgery Staff ID # 85 on 4/8/25 at 3:25 pm. He confirmed that Facility A has the capability of caring for infants with biliary atresia and has provided care for neonates and infants with this diagnosis. He confirmed that the transfer center recording did not include a pediatric surgery staff consultation, prior to hospitalist staff #83 stating that “the service is unavailable” and recommending transfer of the patient to another pediatric institution in the region. Telephone Interview with Facility A Transfer Center Medical Director Staff ID # 71 on 4/8/25 at 3:50 pm. She confirmed that Patient IDs # 1 and 8 denials for “the service is unavailable” had not been reviewed or evaluated through the transfer center committee which meets monthly.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 37490 Based on interview and record review, the facility failed to ensure patients received assessments and interventions to prevent and treat pressure related injuries in 3 of 3 patients (ID#s 2, 12 and 13). Findings included: Review of facility document titled “ Non-Institutional Handbook of Operating Procedures Nursing Service Policy 7.2.62 Pressure Injury Prevention:” showed the following information: I. Title Pressure Injury Prevention. II. Policy The purpose of this policy is to provide direction to identify individuals at risk for pressure injury development and provide guidelines for assessment and intervention. Pressure injury is best prevented by first identifying risk with the help of a validated risk assessment tool, a comprehensive skin assessment with re-assessment at defined intervals and providing interventions in line with the risk level. - Nurses shall assess and manage skin integrity for the prevention and treatment of pressure injuries. - Pressure Injury is to be staged according to the National Pressure Injury Advisory Panel (NPIAP)definition of pressure injury. -Risk for pressure injury development shall be evaluated using the Braden Scale for Adult population (> 18 years old), Braden QD Scale for pediatric population (premature to 18 years old) and Neonatal Skin Score (NSS) for Neonates (birth to 28 days). On admission and during hospitalization, assessment/re-assessment shall include: - Skin assessment (includes all bony prominences, under tubes, orthopedic, and positioning devices) - The primary physician service shall be notified upon discovery of any pressure injury found on the skin assessment -A two-person skin assessment should be utilized when a patient is admitted or transferred from another unit or procedure/surgery. Two-person skin assessment refers to two staff visualizing the patient ’ s skin to identify any areas of skin breakdown. - Risk assessment using one of the age-appropriate risk scales identified above. - The frequency of assessment/re-assessment should be conducted as follows: -ON ADMISSION: Skin assessment, Risk Assessment, Risk Factors -DAILY: Risk Assessment -EVERY SHIFT: Skin Assessment - EVERY 2-3 HOURS: Redistribution of pressure from sacrum and heels on all immobile patients, unless unstable -PRN: When the patient has a change in status that affects mobility, stability, nutrition, or skin integrity Non-IHOP Nursing Policy 7.2.62 If a wound or pressure injury exists: - Refer to the UTMB Wound Care guidelines to initiate treatment and consult recommendations - A pressure injury shall be documented in the EMR (electronic medical record) by initiating an LDA for pressure injury upon discovery of the wound. If a Pressure Injury (PI) is present on admission document PI “present on admission” or “nosocomial” if PI developed during stay at UTMB. If discovered when patient transfers to a new unit or from a procedure, the LDA should be identified as “Upon Transfer to Current Unit”, which is considered nosocomial -Care Plan for Risk of or Actual Impaired Skin Integrity will be initiated for all patients at risk for pressure injury and all patients with pressure injury III. Procedures Interventions for prevention of pressure injury in moderate to very severe risk patients should be implemented and documented in the EMR. Patients considered moderate to high risk for pressure injury should be: -Evaluated for specialty support surface -Turned or assisted with turn on a regular schedule (Q2-3 hours based on pt need and risk) - Protected from friction and shear to areas of high risk (i.e. sacrum, lower buttocks, or heels) using a prophylactic silicone multi-layer foam dressing -Cleaned promptly with appropriate moisture barriers applied after each incontinent episode -Screened for nutrition risk per IHOP Policy 09.13.09 Referrals to other health care professionals should be completed based on the result of the risk assessment. IV. Definitions The standards of care that our policy is based on are from National Pressure Injury Advisory Panel International Clinical Practice Guideline. Review of facility document titled “Wound Care Guidelines,” showed the following: The WOC Nurse will provide guidance for appropriate care/referrals, dressing selection, ostomy pouch selection, support surface selection, and coordination of care for patients with a wound, ostomy, and/or continence issues. The WOC Nurse should be consulted for: · Pressure injuries: Stage 3, 4, Unstageable or DTI (refer to UTMB Skin Care Guide and/or Specialty Bed Algorithm for Stage 1 & 2 pressure injury nursing interventions) · Non-healing wounds · Lower-extremity ulcerations · Wounds with slough or eschar · Moderate to heavy draining wounds · Post-op Ostomy patients · Ostomy pouching system evaluation · Ostomy troubleshooting (routine pouch changes are done by bedside staff) · Peri-stomal skin issues · Specialty Bed Considerations · Negative pressure dressing evaluations for appropriateness, troubleshooting or suggestions for optimizing therapy · Skin care and prevention issues related to incontinence, excessive moisture, pressure, shear, and friction which are not responding to bedside prevention/treatment guidelines · Other wound, ostomy, or continence-related issues **Surgical wounds are typically managed by the surgical team that performed the procedure. The surgery team may consult the WOC Nurse for optimization of care or troubleshooting difficult wounds. Consults to specialty services such as Plastic Surgery, Podiatry, General Surgery, Dermatology, or Vascular Surgery will supersede the WOC Nurse consult as they represent a higher level of care. Please refer to the UTMB Skin Care Guide, Low Air Loss Specialty Bed Algorithm, & the Skin Care Resources website for additional resources. Medical record for patient (ID# 2) showed the following: Initial Skin Assessment when arriving to the unit 11D on 12/16 2024 showed assessment not completed by two RNs as required. Documented skin assessments were inconsistent. Deep Tissue Injuries were noted 12/20/2024 to the patients bilateral heel and sacrum. Wound care was consulted on 12/20/2024. WOC Nurse Note 12/20/24 RECOMMENDATIONS: Sacrum: Cleanse with foam cleanser or saline and pat dry. Dress with Medihoney and cover with mepilex daily. Heel wounds, protect with mepilex heel. Float heels off mattress at all times while in bed. Will order a low air loss mattress. Continue to turn and reposition pt every 2 hours while in bed. Optimize nutrition for healing. Dietary consult if not done. 12/20/2024 2:14 PM Order placed for honey (MEDIHONEY (HONEY)) 80 % topical gel Frequency: PRN Admin Instructions: To be applied at least 3mm in depth, unless otherwise specified by provider. Wound care note written 12/27/24 showed the following: WOC Nurse Note Follow up per daughter request to talk to wound care. Daughter concerned because she has been getting differing instructions from different staff members. States the nurses haven’t been putting a dressing on, stated they did not have dressing orders so Medihoney dressing was not started. Instructions provided in WOCN note and sticky note. ASSESSMENT: Sacral wound transitioning as expected, improved appearance today with epidermal sloughing, purple discoloration fading. Pink tissue exposed in some area. No signs of infection. Heel pressure injury remains intact. Review of skin care and pressure ulcer prevention done. Discussed the importance of turning off of pressure area frequently every 2-3 hours. Continue Medihoney and mepilex every 1-2 days. Please send enough dressing supplies home with pt to last until home care readmits pt. Please write dressing orders for bedside RN or write to follow wound care instructions posted on sticky note.. 12/27/2024 5:42 PM Interventions and assessments were not consistently performed and documented. Wound care recommendations were not consistent with orders written. Medical record review for patient (ID#12) showed the following: Initial skin assessment performed on 11/18/2024 was not completed by 2 Regestered Nurses (RNs) as required. Skin assessments were documented inconsistently throughout her stay. Offloading Prevalon boots were ordered 11/18/2024, the medical record showed no documentation of intervention until 12/1/2024, the day prior to discharge. There was inconsistent documentation of turning the patient every 2-3 hours as per policy and recommendation of wound care team. Medical record for patient (ID# 13) showed the following: Initial skin assessment on 1/11/2025 showed skin abnormality but it not documented where or what the abnormality is. There are no pictures of wound or skin abnormality in the medical record. No wound care consult was placed. On 1/12/2025 a blister is noted on the patient’s buttock and dressing change was performed. Throughout the patients inpatient stay there is inconsistent charting of skin assessments and interventions performed. Interview with quality staff (ID#51) on 3/5/2025 at 12:30 PM confirmed the above findings. Interview 3/4/25 at 10:35 am with ACNO (ID#96). She described herself as Asst Chief Nursing Officer and stated that wound care was her selected/appointed leadership project. She was asked to discuss wound care with surveyors. She stated there had been considerable work efforts and attempts to build infrastructure surrounding wound care program and to decrease hospital acquired pressure injury. She stated that the facility utilizes Braden assessments to determine which patients are at higher risk for HAPI. She stated Braden scores > 13 are identified as higher risk populations. She stated presently there was not a pathway or guideline which provided clinical decision making or specific clinical interventions for patients. She stated the wound care policy provided many options for implementation. She stated they had implemented the process which required 2 RNs on admission to perform and document a head to toe skin assessment. She stated that she believed we would still find opportunities surrounding this process. She stated UTMB had implemented “skin care champions” which she described as unit based clinical RNs who had received additional education on skin assessment and wound care. She confirmed there remains inconsistency with nursing practice and documentation related to their goals for 2 person assessments on admission. She stated that the expectation was that patients who were new admissions, transferred to new level of care/new unit and patients at discharge, would receive comprehensive skin assessment with accurate documentation of their wounds. This included photographs of aberrant skin lesions/wounds. She stated she believed there was still opportunities with the assessments, adherence to performing and documenting turning/repositioning every 2 hours and inclusion of PT/OT/nutrition for high-risk patients.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 46010 Based on interviews and record review, the facility failed to ensure patient’s discharge plans were re-evaluated and updated by the multi-disciplinary team to reflect occurrences/care/education provided at the facility in preparation for discharge. (Patient ID # 1, 12, 13, 24 and 32). Therefore, patients and/or families failed to receive: 1) thorough comprehensive disease, complex wound care and tracheostomy specific care instructions prior to discharge home (Patient 1) 2) wound care instructions and follow-up instructions related to hospital acquired pressure wounds (Patient ID # 12 and 13). 3) safe discharge planning from the Emergency Department after a Childrens Protective Services case was called in post-discharge (Patient ID # 32) 4) follow-up for and safe discharge planning for a positive meconium drug screen test result in a newborn (Patient ID #24). Findings included: Record review of facility policy # 09.01.14 titled “Patient Discharge”, last reviewed, 03/21/2020, stated “Policy: To optimize compliance with a patient’s post-hospital plan of care, an assessment of the patient’s actual and potential discharge planning needs shall be initiated upon admission. A multidisciplinary team that may include the physician, registered nurse, care manager, and social worker, together with the other members of the health care team, shall perform the assessment. A plan to meet these needs shall be developed, and interventions to meet specific discharge planning goals shall be designed. The plan shall be monitored and revised as necessary throughout the patient’s hospital stay. Verbal communications concerning discharge or the discharge planning process shall be conducted in layman’s terms using the patient’s preferred language. Written discharge instructions shall also be provided, using materials that have been translated into the patient’s preferred language whenever possible. If the patient is a minor, the preferred language of the responsible parent or guardian shall be used.” It further stated “Roles in Discharge Planning At the time of discharge, the following tasks will be accomplished by the disciplines indicated, as 2 necessary: Nurse Care Manager (NCM) or Social Worker (SW): 1. Complete a Case Management Social Functional Assessment to evaluate and reassess post discharge needs. 2. Identify payor to determine discharge options based on the patient needs. 3. Refer unfunded patients and patients with limited resources to government program(s) or other community resource options. 4. Verify and confirm the patient/family discharge plan is safe, smooth, and sustainable. Provide education regarding continuing care, treatment, and services that the patient will need. Confirm transportation, DME, supplies, and medications. 5. Confirm understanding of discharge plan with patient/family. 6. Document discharge plan/disposition in the EMR. Physicians: 1. Inform the patient and family/caregiver(s) of the discharge date (except for TDCJ offender patients). 2. Discuss the post-discharge plan of care. 3. Establish time for follow-up appointment(s), if applicable. Nurses: 1. Complete the discharge planning screening to identify those patients identified as being at risk for adverse health consequences upon discharge without adequate discharge planning. 2. Ensure that all necessary patient teaching has occurred. 3. Assist in contacting the patient’s family or caregiver(s) to inform them of the discharge date and confirm transportation arrangements. 4. The nurse caring for the patient must complete the discharge instructions. 5. Provide patient and family/caregiver(s) with the discharge instruction sheet on prescribed treatments, medications, diet, activity level, and scheduled follow-up appointments, if any. Provide written discharge instructions to discharged TDCJ offender patients and their health unit providers using Patient Discharge Instructions Medical Record Form. 4. Ask the patient and family/caregiver(s) to verbalize their understanding of the discharge instructions and give a demonstration of any care procedures. 5. For follow-up appointments at UTMB clinics, verify that a follow-up appointment has been made. 6. Document discharge in the medical record. 7. Confirm correct discharge status completed in the medical record. Respiratory Therapists: 1. Determine home respiratory medical equipment needs. 2. Provide patient/family education on medications, medical equipment, and therapy procedures to be performed at home. 3. Participate in interdisciplinary assessments to help determine necessity of home oxygen. 4. Participate in interdisciplinary discharge planning rounds and conferences.” The discharge policy stated “Required Documentation The following information must be documented in the patient’s discharge note or on appropriate approved forms in the medical record: 1. Provision of all discharge-related patient/family/caregiver education. 2. Availability of transportation. 3. Assessment of availability and readiness of family or other caregiver(s) to assist with the care of the patient at home. 4. Availability of assistance from community resources, including referrals to other health care agencies, as appropriate. 5. Availability of medical equipment, supplies, and medication as indicated. 6. Follow-up plan.” Record review of facility policy titled “Case Management/ Social Services/ Pastoral Care Consult (Angleton Danbury campus)” last revised 5/31/2024, stated “Social Services Consultation shall be obtained on a routine basis if any concern for the patient/family’s financial welfare or personal safety exists; physicians, nurses, and ancillary health care providers may initiate a consultation. Additionally, Social Services function as a support and referral source for the following: 1) History of maternal drug use in pregnancy with a positive Urine Drug Screen in the mother. 2) History of maternal drug use other than marijuana in pregnancy with a negative maternal Urine Drug Screen. 3) History of Post-Partum Depression with previous child or children. 4) Previous CPS (Child Protective Services) history and mother’s previous children no longer in the care of the mother or if there is an ongoing CPS case currently. 5) Maternal history of anxiety, depression, schizophrenia and/or bipolar when mother’s mental condition is not currently stable and additional resources may need to be provided. This includes but is not limited to suicidal/homicidal ideation and need for treatment when mother has not established care and needs resources for mental healthcare. If a mother does not have a diagnosis of a mental illness, but is displaying psychotic features, a Social Services Consult is warranted. 6) Social Services Consult is not warranted for a history of anxiety and/or depression in the past that is not an issue anymore. It is also not warranted if mother’s condition is stable, and she is receiving ongoing mental health care. 7) No PNC (Prenatal Care) - not limited but no PNC .... Safety Concerns and CPS Referral Texas Mandatory Reporting Law (261.101 of the Texas Family Code) Healthcare Providers are mandated reporters. Texas Law requires anyone with knowledge of suspected child abuse or neglect to report it to the appropriate authorities. This mandatory reporting applies to all individuals and is not limited to teachers or healthcare professionals. The law even extends to individuals whose personal communications may be otherwise privileged, such as attorneys, clergy members and health care professionals. “Professionals must make a report of first suspecting that a child has or may have been abused or neglected. “ duty to report be delegated, and the professional cannot rely on another person to make the report. CM/SW will make the reports as soon as reasonably possible with clear documentation by the provider regarding the concerns. If there are imminent concerns, evening hours or over the weekend the CM/SW may not be available, and the provider may need to make their own report. Please notify CM/SW if you make a CPS report to complete the follow up. “ Abuse “ Neglect “ Non-accident injury ...” Interview with Respiratory Educator Staff ID # 70 on 3/4/25 at 12:30 pm while reviewing patient ID #1 medical record. He confirmed there was no tracheostomy education guideline, checkoff tool or framework which was utilized by multi-disciplinary team to ensure comprehensive patient/caregiver tracheostomy education prior to discharge home. He confirmed that staff document education in the medical record however the medical record stated “Education provided. Verbalized Understanding.” He confirmed he was unable to ascertain what elements of education were provided for each entry. He confirmed that tracheostomy written instructions were included in the after-visit summary provided to the patient on the day of discharge. Interview with Nurse Manager Staff ID # 73 on 3/5/2025 at 12:20 pm during record review for Patient ID #32. He confirmed that Patient ID # 32 was seen in the Facility B emergency department on 2/9/2025. He confirmed the patient was discharged 2/9/25 at 5:45 pm by ED nurse practitioners Staff ID #94 and dispositioned out of the ED by staff RN ID # 92. He confirmed that ED staff charge nurse ID # 93 documented “CPS intake number #(redacted) on 2/9/25 at 5:53 pm (after the patient was discharged.) He confirmed there is no provider discussion of the CPS notification and no evidence of social work consultation or involvement ID #32 medical record. Interview with Case Management Director Staff ID # 95 on 3/5/2025 at 1:35 pm. She confirmed that the facility policy requires social work consultation/notification for cases of Childrens Protective Services (CPS) involvement due to concern for non-accidental trauma to ensure proper follow-up/safe discharge planning. She confirmed that patients who had concern for inflicted injuries should not be allowed to discharge home from the facility without CPS engagement/instructions. Interview with Nurse Manager Staff ID #72 on 3/5/2025 at 11:20 am. She confirmed the facility has a policy in place which required Childrens Protective Service (CPS) notification for infant’s who are born to mothers with no prenatal care and infants who have meconium positive drug screens at the facility. She confirmed there was no evidence of CPS notification for the lack of prenatal care for Patient ID #24’s mother and the positive drug screen in Patient ID # 24. She confirmed there was no evidence of lab notification to facility staff that the meconium positive drug screen resulted after patient was discharged home from the facility. There was no evidence of social work awareness of meconium drug positive status for Patient ID #24. Interview with Quality Staff ID # 51 with record review of Patient ID #12 and 13 records on 3/5/2025 at 12:30 pm. She confirmed there was no evidence of wound care instructions, dressing changes and post-discharge follow-up for the patient/caregiver related to the hospital acquired skin injuries for Patient ID #12 and 13 per record review.”

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to ensure 2 of 8 patients had specific risks of surgical procedures disclosed as required by the Texas Medical Disclosure Panel and documented on the informed consent (ID#s 5 and 9). Findings Include: Record review of facility policy titled, “Consent - Overview and Basic Requirements,” showed the following information: II. Policy In accordance with state and federal law, prior to providing care, treatment, or services, informed consent must be obtained from the patient or the person with the right to provide consent on behalf of the patient (e.g., parent in the case of a minor patient or surrogate decision maker for an incapacitated patient), in that person’s preferred language. The informed consent process includes a discussion about the potential benefits, risks, and side effects of the patient’s proposed care, treatment, and services, as well as any reasonable alternatives (including not receiving the proposed care); the likelihood of the patient achieving his or her goals; and any potential complications that might occur during recuperation. UTMB respects the diverse cultural needs, preferences, and expectations of the patients and families it serves to the extent reasonably possible while appropriately managing available resources and without compromising the quality of health care delivered ... III. General Consent A. When is Informed Consent Required and Implied Consent is not enough? 1. Physicians are required to obtain written consent for procedures or treatments indicated by the Texas Medical Disclosure Panel (TMDP). 2. Informed consent must be obtained for all procedures listed in The Texas Medical Disclosure Panel List A (Procedures Requiring Full Disclosure of Specific Risks and Hazards). 3. Procedures not requiring disclosure of specific risks and hazards are contained in List B (Procedures Requiring No Disclosure of Specific Risks and Hazards). D. Written Consent 1. A Disclosure and Consent for Medical and Surgical Procedures form must be used to document consent if: a) The procedure or treatment is included in List A; b) The procedure requires the administration of general, spinal, epidural, or regional anesthesia, other than local infiltration. c) The procedure (invasive or non-invasive) involves more than a slight risk of harm to the patient’s body structure (i.e., a risk is more than slight if its disclosure would be material to a reasonable patient’s decision whether to accept or reject a treatment option); or d) The procedure is experimental. 2. Consent forms must be signed by the patient (or person providing consent on behalf of the patient) and a competent witness. Review of the Texas Medical Disclosure Panel (TMDP) showed the following information: §601.1 General (a) The purpose of this chapter is to implement the requirements of Texas Civil Practice and Remedies Code, Chapter 74, Medical Liability, Subchapter C, §74.102 (relating to Texas Medical Disclosure Panel). (b) The treatments and procedures requiring full disclosure by a physician or health care provider to a patient or person authorized to consent for the patient are found in §601.2 of this title (relating to Procedures Requiring Full Disclosure of Specific Risks and Hazards--List A). (9) Tendonitis, tendon release, and trigger releases. (A) Recurrence of symptoms. (B) Damage to blood vessels, nerves, tendons, or muscles. (C) Worsening function. (12) Tendons, nerves, or blood vessel repair. (A) Damage to nerves. (B) Deep vein thrombosis (blood clot in legs or arms). (C) Rupture of repair. (D) Worsening of function. (1) Laparoscopic/Thoracoscopic risks. The following shall be in addition to risks and hazards of the same surgery when done as an open procedure. A) Damage to adjacent structures. (B) Abscess and infectious complication s (C) Trocar site complications (e.g., hematoma/bleeding, leakage of fluid, or hernia formation). (D) Cardiac dysfunction. (E) Postoperative pneumothorax. (F) Subcutaneous emphysema. (G) Conversion of the procedure to an open procedure. Medical record review for patient (ID# 5) showed consented procedure as left ring finger trigger finger release. Risks disclosed included infection, bleeding, damage to surrounding structure, need for “illegible”, reoccurrence. Medical record review for patient (ID# 9) showed consented procedure as Laparoscopic possible open umbilical hernia repair. Risks disclosed included: infection, blood clots in veins, lungs or other organs, hemorrhage, allergic reactions, poor wound healing, and death. Two additional handwritten complications were written in but were illegible. Interview with Director of perioperative services (ID # 56) on 12/5/24 at 11:10 AM acknowledged the above findings. Interview with pre-op holding nurse (ID# 65) on 12/5/24 at 11:00 stated that some patients have consents filled out at clinic visits, those typical are service specific and have the list A information included. Patients who do not have the consent completed will get a general consent completed and the risk information has to be written in.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46010 Based on observation, interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. 1) The facility failed to register patient ID #24 on the central log for treatment. 2) The facility failed to provide an appropriate medical screen exam for Patient ID #14, 23 and 24. Refer to tag A 2405 and A 2406 for additional information”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 46010 A2405 ER Log Based on interview and record review, the facility failed to maintain an accurate Emergency Department Central Log. Patient ID #24 was found in Facility A’s hospital lobby by campus police and security staff, displaying evidence of behavioral health emergency, and was transported to Facility B via campus police department personnel for evaluation and care on 7/30/24. There was no evidence of Patient ID #24 recorded in Facility A’s Emergency Department Central Log. Findings included: Record Review of Facility Policy titled “Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA)” last reviewed, 9/1/2016, stated “Definitions Campus: the physical area immediately adjacent to the UTMB’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus.” It further stated “Policy A. Healthcare workers in the Emergency and Nursing Service departments and Off Site Clinics will ensure that all individuals who come to the UTMB Emergency Department (ED), or on UTMB property, for an examination or treatment for a medical condition will be screened to determine whether an emergency medical condition exists. When a woman presents in labor, the OB/Gyn resident on-call will be paged immediately. For purposes of this section, ’’property’’ means the entire main hospital campus, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined to be a department of the hospital. B. All individuals who present to a provider-based clinic either on or off campus for emergency medical care will be screened to determine whether a medical emergency does or does not exist. At least one individual on duty during the clinics regular hours of operation must be a designated qualified medical person (QMP). Clinics that are not routinely staffed with MD’s, RN’s, PA’s or LVN’s must have a written protocol to provide guidance as to what actions to take. These can include contacting the UTMB Emergency Department for guidance. If it is determined that a medical emergency does exist and EMS is called and the patient transported to UTMB or another hospital, the UTMB Emergency Department must be notified of the individual’s arrival to the clinic and the handling of the case, which will be noted in the hospital’s emergency department central log.” Record Review of Facility Police Log titled “Log of EAD related transfers by UTMB PD for Period 07/29 to 08/05”. The list included “Date 7/30/24; Pickup Location: (Facility A) University Plaza Garage; Pickup Time: 22:43:23; Drop Off location (Facility B); Dropoff time: 23:35:30.” Interview with Director of Quality Staff ID #51 on 9/18/24 at 10:20 am. She confirmed there was no evidence of Patient ID #24 on facility central log. Interview with Chief of Police Staff ID #75 on 9/18/24 at 09:35 am. He confirmed that Patient ID #24 had been brought by police department squad car on 7/30/24 to Facility B Emergency Department by Facility A police staff and checked-in for care and evaluation at Facility B on 7/30/24. He confirmed that Patient ID #24 was engaged by police department staff in the lobby of Jennie Sealy hospital building Facility A and was displaying signs and symptoms of a behavioral health problem upon field mental health assessment. He confirmed that the responding officers completed an Emergency Order and took Patient ID #24 fifty-four miles to Facility B Emergency Department. Telephone Interview with Facility Police Officer Staff ID # 80 on 9/19/24 at 6:10 pm. He confirmed that he was dispatched after a 911 call regarding a man “cursing and screaming at people” in a nearby area. He arrived on scene to Facility A hospital lobby and encountered Patient ID#24 “reciting Spanish prayers, shaking, unable to identify where he was and ‘asking for help’ “ on 7/30/24 night shift. He stated that he spoke with his supervisor and prepared an Emergency Detention Order based on his field mental health assessment. He confirmed he drove the patient 54 miles to Facility B Emergency Department for evaluation at his supervisor’s direction.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to provide a medical screening examination (MSE) for 3 of 23 patients reviewed, who arrived or were located on facility property, with request for evaluation (Patient ID # 14, 23 and 24). Findings included: Record Review of facility policy titled “Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA)”, last reviewed 9/1/2016, stated “II. Policy A. Healthcare workers in the Emergency and Nursing Service departments and Off Site Clinics will ensure that all individuals who come to the UTMB Emergency Department (ED), or on UTMB property, for an examination or treatment for a medical condition will be screened to determine whether an emergency medical condition exists. When a woman presents in labor, the OB/Gyn resident on-call will be paged immediately. For purposes of this section, ’’property’’ means the entire main hospital campus, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined to be a department of the hospital...B. All individuals who present to a provider-based clinic either on or off campus for emergency medical care will be screened to determine whether a medical emergency does or does not exist. At least one individual on duty during the clinics regular hours of operation must be a designated qualified medical person (QMP). Clinics that are not routinely staffed with MD’s, RN’s, PA’s or LVN’s must have a written protocol to provide guidance as to what actions to take. These can include contacting the UTMB Emergency Department for guidance. If it is determined that a medical emergency does exist and EMS is called and the patient transported to UTMB or another hospital, the UTMB Emergency Department must be notified of the individual’s arrival to the clinic and the handling of the case, which will be noted in the hospital’s emergency department central log...Personnel Authorized to Perform Medical Screening Exam. The following personnel are authorized to perform medical screening exams at UTMB: Faculty physicians; Residents assigned to the ED; Physician’s Assistants employed in the ED under the direct supervision of the Emergency Medicine Faculty; Advanced Nurse Practitioners; or Staff designated in offsite clinics as Qualified Medical Personnel (QMP). Documentation The screening of all individuals in the Emergency Department and in offsite clinics will include documentation of: If the individual has an emergency medical condition; Actions taken to make the determination; Results of diagnostic tests; Completion of Agreements, Authorizations, and Irrevocable Assignments, Disclosure and Consent for Medical and Surgical Procedures, and Against Medical Advice forms, if applicable; and Actions taken to stabilize and/or transfer the patient to UTMB’s Emergency Department, for those seen in the offsite clinics....Medical screening exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. It is an ongoing process and must reflect continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. The exam will include information about the chief complaint, the patient’s vital signs, mental status assessment, general appearance, and a focused physical exam related to the patient’s complaint. Note: Triage is not the equivalent of a medical screening examination. The medical screening exam must be the same that UTMB would perform on any individual coming to the ER with those signs and symptoms regardless of the individual’s ability to pay for medical care.Qualified Medical Personnel (QMP): An MD, RN, Advanced Practice Nurse, PA, or LVN at an off-site clinic who has been educated on the process for medical screening and trained in the appropriate handling of emergency situations within the scope of their education and experience.” Record review of Patient ID #14 electronic medical record revealed patient ID #14 arrived to the facility on 9/2/2024 at 2:33 pm by personal vehicle and was arrived by Registration Staff ID#83 with chief complaint “burn.” ED Staff RN #79 documented Patient ID #14 is a “23 year old male Patient arrives via personal means with complaint of burns on bilateral legs and left arm, ‘There was a fire and I didn’t want my baby momma to get burned.’ Pt said the fire was from oil. Patient is alert and oriented times X4, even and unlabored respirations visualized. Pt taken to burn unit. Triage was documented as initiated by ED Staff RN ID #79 on 9/2/2024 at 2:54 pm. She documented the disposition “triaged to the burn unit.” The medical record stated Patient ID #14 was transported to facility burn unit by transportation staff. There was no medical screen exam located. Record review of Patient ID #23 electronic medical record revealed patient ID #23 arrived to the facility on 8/7/2024 at 1:21 pm by personal vehicle with chief complaint “burns” and was entered by registration staff ID #83. Patient ID #23 was roomed in Room 109 by Staff RN #85 at 1:22 pm. Triage was initiated by ED Staff RN ID # 85 and stated (redacted patient name) is a 64 year old male presents to ED c.o right foot burning and swelling that started last night. Pt reports “everytime I have something happen they take me straight back to the unit since I am a burn patient”. Redness, warmth and swelling noted to right leg and foot. Pt screaming and crying in pain. Aox4 with gcs 15 skin warm and dry resp even and unlabored. Report called to Burns, taken via wc by ER RN. He was transported to facility burn unit by facility staff. There was no medical screen exam located. 1:31 pm Disposition was set to “triaged to burn unit” by Staff RN # 85. Medical record entry 8/19/24 at 06:10 am for Patient ID# 23 by Staff ED physician ID # 87 stated “Pt was taken straight to burn unit without ED evaluation.” Record review of Facility A central log dated 7/30/2024 and 7/31/24 failed to locate patient ID #24 on the central log. Facility A was unable to locate Patient ID# 24 in their EPIC electronic medical record at all per Director of Quality Staff ID #51. Interview with Nursing Director of Emergency Department Staff ID # 53 on 9/17/2024 at 2:30 pm. He confirmed he was unable to locate medical screen exam for Patients ID# 14 on date of service 9/2/2024 and Patient ID #23 on 8/7/2024. He stated the facility had a process/procedure in place at triage where patients who presented with burns, and had stable airways, would be sent to the burn unit for prompt, specialized evaluation and care. He reported the triage Emergency Department registered nurse would call the Burn Unit charge nurse to arrange for the patient to go to the burn unit for evaluation and care. He confirmed the Emergency Department providers were not routinely involved in the decision to transfer/relocate patients to the burn unit.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 37322 Based on observation and interview, the facility failed to post conspicuously required signage in the ambulance entrance. Finding Included: Observation on 11/07/2023 at 1215 of the ambulance entrance leading to the emergency triage center, revealed no federal signage noted in the areas. Interview on 11/07/2023 with the staff (ID# 56) who stated we have the signs in the main lobby but not here.”