Ascension Seton Medical Center Austin

“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: 51020 Based on record review and interview, the facility did not comply with 42 CFR §489.24, Special Responsibilities of Medicare Hospitals in emergency cases, in that, the facility did not provide a medical screening examination that is appropriate for their medical condition within the capability of the hospital’s emergency department for 1 of 20 patients (Patient #1) who presented at the ER (emergency room) on 01/29/26. (Cross Refer to Tag 2406 - 489.24(a) and 489.24(c) Medical Screening Exam)”

“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: 51020 Based on record review and interview, with regard to Complaint #TX00561251, the hospital failed to abide by the provider’s agreement that required a hospital to comply with §42 CFR 489.24 Medical Screening Exam. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements in that, 1 of 20 patients (Patient #1) who presented to the emergency department on 01/29/26 with a chief complaint of right thigh pain was not provided with an appropriate medical screening examination within their capability. Findings were: The medical record for Patient #1 revealed they arrived at Ascension Seton Main [Hospital A] emergency department (ED) via emergency medical services (EMS) on 01/29/26 at 09:58 a.m. with a chief complaint of right thigh pain, rated 7/10 on pain scale. Patient #1 received a medical screening examination (MSE) at 10:04 a.m. by Staff #6. Diagnostics were ordered and resulted as follows: *Ultrasound lower extremity venous duplex right-side stat. Reason: thigh pain, possible swelling. Resulted diagnostic impression on 01/29/26 at 11:14 a.m. “no evidence of DVT.” *X-ray femur 2 view right stat. Reason: right thigh pain. Resulted diagnostic impression on 01/29/26 at 12:02 p.m. “no acute fracture, dislocation or radiopaque foreign body is present. Normal study.” The evaluation lacked a documented focused hip examination, assessment of weight-bearing and ambulation, and imaging appropriate to evaluate for an occult hip fracture in a patient with hip pain and known avascular necrosis. Patient #1 was discharged from Hospital A on the same day at 12:35 p.m. with a diagnosis of: acute pain, uncertain cause. Pain remained 7/10 on pain scale. There were no medications prescribed at discharge. Ambulance Run Sheet for Patient #1 dated 01/29/26 at 10:47 revealed, in part, “Chief complaint: leg pain. Signs and Symptoms: Leg pain swelling. Assessment: 9:42 a.m. swelling in right leg. Narrative: Pt reported pain in right hip and in her upper right thigh; slight swelling noted in right leg compared to left leg, no discoloration, obvious injury, or deformity noted; no falls reported.” On 01/31/26 at 11:13 a.m. Patient #1 presented to Ascension Seton Northwest [Hospital B] ED with a chief complaint of right hip pain. Following an MSE the ED physician ordered the following diagnostics: “ computed topography (CT) of hip without contrast right (completed) ASAP. Reason: avascular necrosis. “ MRI femur with and without contrast right (completed) routine. Reason: rule out DVT, right hip pain. Resulted diagnostic impressions revealed Patient #1 had a “non-displaced fracture of the right mid femoral neck.” On 01/31/26 at 2:39 p.m. Patient #1 was admitted to Hospital B’s inpatient Med/Surg Unit and subsequently underwent the following surgical procedure: closed reduction and pinning of right femoral neck fracture, stress fracture. Patient #1 was discharged home in stable condition on 02/05/26 at 12:20 p.m. During an interview with the ED physician at Hospital A (Staff #4) on 05/26/26 at 1:51 p.m. stated in part, “on 29th presented to ER, evaluated for right mid-thigh pain. History lupus, chronic. Had been seen at another hospital and urgent care for the same issue. Swelling of leg, received US, no blood clot. Tenderness femur, received x-ray, normal study. Pain mid-thigh thinking blood clot screening, patient can walk, yes, care appropriate.” MD brought laptop computer to surveyor, with the x-ray of Patient #1 right femur on screen and stated, “A right femur x-ray includes [visualization of] hip. Not primary way to rule out hip fracture but can see the hip.””

“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: 51020 Based on record review, policy and procedure review, and interview(s), the facility failed to provide a safe environment for one of ten patient charts reviewed (patient number 2) when the patient was discharged home with a central venous catheter (CVC) in the right internal jugular. Findings were: Review of Patient #2’s nursing discharge flowsheet titled “Central Venous Catheter - Lines View” dated 01/15/26 at 6:33 p.m. stated the following: “line necessity reviewed w/Provider - yes. Site condition: no complications. Equipment Supplies: Lock. Dressing Description: dry, CHG (antimicrobial) impregnated. Number of Lumens: triple. Flow/Patency: All ports patent. Intervention &/or Notes: DC (discharge) w/cath (CVC) in place.” Review of Patient #2’s discharge summary titled “clinical discharge information”, by staff #13, dated 01/15/26 at 3:48 p.m. stated in part, “Discharge To: To a hospice company for care. Devices & Equipment: No Discharge Devices Documented. Discharge Treatments/Special Instructions: No Discharge Treatments/Special Instructions.” The facility-provided policy titled “Procedures for Care and Maintenance of Non-Tunneled Central Vascular Access Devices (CVADs) and Central Lines” Last Reviewed Date: 01/29/26, stated in part, “Removal of Central Lines Procedure: obtain provider’s order...” During an interview on 04/13/26 at 4:30 p.m., When asked if he was aware patient #2 discharged home with a CVC in place, Staff #13, Patient #2’s physician, stated, “No. It was not my intention for (patient #2) to go home with the IJ [intrajugular] in place, there would typically be an order for that.” When asked how it would be conveyed to the nursing staff that a CVC should be removed prior to discharge, he responded, “I get alerted that the patient is discharging by the bedside nurse or charge nurse via a phone call or a message on the Volte system (secure message platform), then I would put in an order to discontinue or leave in place.” Patient #2 was discharged on 01/15/26 at 6:00 p.m. with an IJ CVC in place. There was no order to discontinue the CVC, nor was there an order to leave it in place.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 51020 Based on record review, policy and procedure review, and interview(s), the facility failed to supervise and evaluate the nursing care furnished for one of ten patient charts reviewed (patient number 2) when wound care was not documented per physician orders. Findings were: Review of the medical record for Patient #2 revealed she was admitted on 01/03/26 at 6:50 p.m. and discharged home on 01/15/26 at 6:30 p.m. Patient #2 had 7 wounds: Bilateral (both) Heels, Left Elbow, Bilateral Buttock, Right Hip, Right Trunk, Left Medial Leg, Left Coccyx. Patient #2’s initial wound care order dated 01/04/26 at 1:54 p.m. stated in part, “Wound Care Instructions - Nursing. Frequency: qDay (daily). Special Instructions: &PRN (and as needed)” which remained in place until her discharge on 01/15/26. Review of Patient #2’s nursing flowsheet titled “Wound Care View” revealed inconsistent documentation of wounds: *01/05/26: no documentation of any wounds *01/06/26: no documentation of Right Hip wound *01/07/26: only documentation of Bilateral Buttock and Left Coccyx *01/08/26: only documentation of Bilateral Buttock and Left Coccyx *01/09/26: no documentation of Right Trunk *01/10/26: only documentation of Bilateral Buttock and Left Coccyx *01/11/26: only documentation of Bilateral Buttock and Left Coccyx *01/12/26: no documentation of any wounds *01/13/26: no documentation of Right Hip wound *01/14/26: no documentation of any wounds *01/15/26: no documentation of any wounds Inpatient Wound Care Notes dated 01/13/26 at 12:18 p.m. stated, in part, “New Treatment Plan Details - WOCN (wound, ostomy, and continence nurse): Tuesdays & Fridays. Treatment Plan: Continue skin bundle orders, Positioning, Pressure Injury management, Pressure Injury prevention, Skin care management, Wound care. From head to toe, the patient is covering [sic] in generalized cuts and scrapes. Too many to count and describe. Below are the major wounds that required skilled inpatient wound care follow up. In general, when the bandages were removed today, there was a malodor present. Most likely due to the fact that most of the dressings in place were from 1/9 (the last time we saw the patient).” Review of Policy - Pressure Injury Prevention - Management of - Acute Care (Skin) *Excluding Pediatrics, ID # 17863817, effective: 03/26/25, states in part, “Skin Assessment. B. Skin assessment should be conducted at a minimum of the following: 2. Every shift ...and, Skin and Braden Scale Risk Assessment: HAPI Prevention Documentation. B. Interventions, rendered treatments, and education ...are documented in the patient’s medical record.” During an interview on 04/06/26 at 2:00 p.m., When asked to verify the wound care order, Staff #1 stated, “daily and prn.” When asked if the wound care order had been followed, she replied, “it would appear that it didn’t happen as it wasn’t documented. Tuesday, 01/13/26 was the last recorded note documented by the wound care nurse.””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 31974 Based on review of documentation and interviews, the facility failed to ensure that all patient medical record entries were complete, as evidenced by the failure to document Animal Control had been notified of a stray dog bite for one of one patient reviewed (Patient #14) for animal bites. Findings were: Facility policy entitled “Reportable Conditions and/or Crimes - Identifying and Managing” last revised 11/21/2023 reflected in part, “Animal Bites/Exposure: 1. Animal bites (possible rabies exposures) are reportable to the appropriate Animal Control officer in the county where the incident occurred. Reporting is mandatory...” Review of the medical record for Patient #14 revealed in part, “Admission 2/22/2024 11:45 Chief Complaint: complains of dog bite to L (left) shin...Was seen in urgent care yesterday was bit by a stray. Unable to find dog...Medication Administration: rabies immune globulin, human 1500 Units, IM (02/22/24 12:38 CST), rabies vaccine, purified chick embryo cell, 1 ml, IM (02/24/2024 12:48 CST)...” During an interview on the morning of 3/20/24, Staff #2 stated, “When a patient comes to the Emergency Department due to an animal bite, we have a packet that is completed. The packet is sent to Animal Control in the county where the incident occurred. The packet we complete is not a part of the patient’s record. And, a copy of the packet is not kept. The nurse should document that the packet was sent to Animal Control and it was reported, but in the case of Patient #14,, it was not documented that this was done.” During an interview on the morning of 3/20/2024, Staff #1 stated “When a patient comes in with an animal bite, the expectation is that the incident is reported to Animal Control. If it is not documented, we cannot prove it was done. Documentation is part of the process. Our policy and procedure states that reporting is mandatory.” The above findings were verified with Staff members #1 and #2 on the morning of 3/20/2024.”

“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: 31974 Based on review of documentation and interviews, the facility failed to provide an appropriate medical screening examination within the capability of the hospital’s emergency department when 1 of 20 patients reviewed (Patient #1) presented to the Emergency Department (ED) and did not receive a medical screening examination when presenting to the ED on 2/1/24. Findings were: Review of the facility provided policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) and Transfer”, last revised 6/8/2023 reflected in part, “...Standards for Medical Screening Examinations: 1. Patients who come to a dedicated Emergency Department requesting examination and treatment will be Triaged and receive a Medical Screening Examination by a QMP (Qualified Medical Professional). 2. The Medical Screening Examination (MSE) extends until the point that the QMP determines that an Emergency Medical Condition does or does not exist. A patient should continue to be monitored based on the patient’s needs, and monitoring should continue until the individual is stabilized or admitted or appropriately transferred. 3. When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition (EMC). 4. If the Medical Screening Examination does not reveal the existence of an Emergency Medical Condition, the patient may, if appropriate, be referred for further non-emergency treatment through the Hospital’s facilities or a private physician and/or may be discharged with appropriate follow-up instructions documented according to department procedures...” A review of the emergency department record for Patient #1 revealed in part, “...2/1/24 8:54 “M08 (EMS) arrived on scene to find a 50 y/o (year old) female c/o (complaining of abdominal pain. She said she has gastroparesis, and this happens to her frequently. She has been to the ER multiple times for this problem and to a GI (gastro-intestinal) doctor. She has Vicodin for the pain, and she tried to take it this morning but vomited it up. She said today she cannot stop dry heaving. She said her GI doctor told her to just continue the cycle of going to the hospital and taking pain meds when this happens. She said today it started around 5:30 am. She has not missed any dialysis or been sick recently. She said the pain feels the same as it was in the past. She denied shortness of breath, chest pain, numbness, tingling, headache, recent trauma. Patient was found sitting down on her couch in her living room. She was awake and tracking and answered when spoken to. Patient airway was patent, and she was able to maintain it on her won. Patient breathing was unlabored and of equal rate and depth. Patient skin was pink and dry... Triaged 2/1/24 8:58 am. Vitals: Blood pressure: 198/77. Respiratory rate: 26 br/min (breaths per minute). Pulse 90 Complaints of abdominal pain. Chief complaint: gastroparesis flare up at 0500; took Vicodin without relief, hasn’t missed dialysis, EMS reports refused pain medications. History of present illness: 50 year old female with pmhx (past medical history) of bipolar, ESRD (End-Stage Renal Disease), dialysis Monday Wednesday Friday presents to ED with chronic abdominal pain via EMS. Denies any missed dialysis. States she took her medications this morning without relief. Discharge diagnosis: Abdominal pain, anxiety. Discharge education provided 2/1/24 at 17:40 hours.” During an interview on the afternoon of 3/19/24, Staff #3, ED Physician stated, “I do know this patient. I have seen her many times. On that particular day (2/2/2024), I met her at the door and evaluated her when she came in via ambulance. I told her she has a High Alert Plan and that he couldn’t give her certain medications. So, she decided to leave. There were other things we could have done, other than just medications. She is a dialysis patient. She does have multiple medical issues. We could have treated her vomiting and abdominal pain. She was at the ED the day before (2/1/2024) and she got a full work-up.” Patient #1 presented to the ED on 2/1/24 with abdominal pain, cramping, and vomiting, had an elevated blood pressure on arrival, and had a history of ESRD with dialysis use, DKA [diabetic ketoacidosis], and hypertensive urgency; however, Patient #1 did not receive an appropriate MSE, as there was no thorough review of systems related to Patient #1’s chief complaint and elevated blood pressure, lab work was not included in the evaluation, including an initial blood glucose level. Without these components completed, an EMC could not be determined.”