Titus Regional Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36827 Based on review of patient records, video, policies and procedures, interview, and Texas State Law, the facility failed to: A) ensure that 14 patients (Patient #5, #6, #7, and #9 through #19) of 19 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault. Refer to Tag A0117 B) ensure 1 patient (Patient #9) out of 20 patient encounters reviewed was provided personal privacy when appropriately requested. Refer to Tag A0143 C) ensure patients were properly protected from abuse. The facility failed to ensure the state required mandatory report of suspected abuse to the Texas Department of Family Protective Services (DFPS), Child Protective Services (CPS) was made for 2 minor patients (Patient #7, #8) of 6 minor patients when there was a reasonable suspicion that abuse was involved. Refer to Tag A0145”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 36827 Based on review of records and interview, the hospital’s governing body failed to provide oversight and quality evaluation of services provided to patients in the hospital’s emergency department for 16 patients (Patients #2, #3, #4, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) out of 16 patients reviewed who received Sexual Assault Nurse Examination (SANE) examinations in the emergency department. Findings included: On the afternoon of 6-25-25, a tour of the Emergency Department was made with Staff #3 and Staff #5. While discussing the SANE nurse program, Staff #3 stated that if the patient did not want to report the sexual assault, the SANE nurses would not complete the examination. The patient would have to be transferred elsewhere. When asked why, Staff #3 stated she didn’t know why because the SANE nurses worked for the State not the hospital. When questioned further, Staff #3 stated the SANE nurses were not employed by the hospital and she did not know who paid them for their services. She only knew that without a Law Enforcement case number, they would not do the examination. Staff #3 was asked at that time to provide a hospital contract for SANE services. Staff #5 confirmed that the SANE nurses provided call coverage and routinely performed SANE examinations in the Emergency Department for patients of the hospital that presented to the Emergency Department after a sexual assault. Staff #5 provided call coverage schedules for March 2025 and June 2025. The call coverage schedule provided for coverage to multiple counties and hospitals in northeast Texas, not specific to Titus Regional Medical Center. Staff #5 explained the company providing call coverage was owned and operated by Staff #7. On 6-26-25, Staff #3 provided a copy of a contract for SANE examinations. Review of the contract showed that it was a “Forensic Nurse Examiners Memorandum of Understanding Training Agreement” dated December 17, 2020 that coincided with a grant received from the State for fiscal year 2021 to provide training at the hospital for SANE nurses. The company to provide the training was Forensic Nurse Examiners, a company operated by Staff #7. This contract did not provide for the contracted company’s nurses to work in the emergency department as SANE Nurses. Per the contract: “The Company is hereby retained by the above-named organization for the purpose of providing the 80-hour Sexual Assault Nurse Examiner (SANE) didactic education. The Company accepts such retention to provide quality, unbiased SANE Training that follows the Educational Guideline of the International Association of Forensic Nurses and completes the Didactic training to move the student towards certification as Adult/Adolescent and Pediatric certification through the Texas Office of the Attorney General. The company further agrees to act as a continued resource for the organization and the students trained.” Staff #4 was asked to provide any information from the hospital’s quality program for the evaluation of SANE services in the Emergency Department. Staff #4 and Staff #5 both confirmed that information about the SANE program was not tracked and reported through quality. Staff #3 confirmed that there was not a contract or employment agreement between the hospital and the company that provided SANE examinations, treatment, and care to sexual assault survivors in the hospital’s emergency department. Review was made of personnel files for Staff #6, #7, #8, and #9. The files did not initially contain the Office of Attorney General certification necessary in Texas to provide SANE examinations. However, certificates were provided by the company providing SANE coverage and all certificates were found to be current. The files did not contain job descriptions outlining what training and certifications were required to provide services in the Emergency Department to hospital patients, such as Basic Life Support, and no contractor orientation to the hospital was found in the files to indicate what the expectations of the SANE nurse’s role in the emergency department as a contractor would be. No annual evaluation was found in the employee files since the SANE nurses were not employees of the hospital. No annual contract evaluation made by hospital leadership on behalf of the Governing Body had been completed since there was no contract to evaluate. Staff #3 confirmed that SANE nurses were routinely providing examination, treatment, and care to hospital patients without any employment contract, memorandum of understanding, or cooperative agreement defining the role and responsibilities of the SANE nurses providing examination, treatment, and care to hospital patients in the emergency department and without evaluation from the hospital’s quality program and oversight from the Governing Body.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36827 Based on review of patient records, policies and procedures, interview, and Texas state law, the facility failed to ensure that 14 patients (Patient #5, #6, #7, and #9 through #19) of 19 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault. Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES, Subsection (b) requires: (b) A health care facility providing care to a sexual assault survivor shall provide the survivor with: ... (3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure; (4) the information form required by Section 323.005; (Sec. 323.005. INFORMATION FORM. (a) The commission shall develop a standard information form for sexual assault survivors ...) ... (7) the name and telephone number of the nearest sexual assault crisis center; and ... Findings included the following: On 6-25-25 during the entrance conference, the facility was asked to provide a list of all policies that pertained to the Emergency Department and to caring for the Sexual Assault patient. On 6-26-26, the facility provided the policy titled: Medical/Forensic Examination of the Adult Patient of reported Sexual Assault. The policy was last reviewed 11/2022 and the next review date was 11/2025. Review of the policy showed the Purpose to be: “Provide a timely Medical/Forensic Examination of the patient who presents with a history of sexual assault or abuse. Report concomitant injuries to the physician. Collect and document such evidence as is available for the prosecution or defense of sexual assault. Counsel the patient regarding follow up care.” The policy did not cover access to a sexual assault program advocate, if available, the time frame for notifying the local advocacy center, or who was required to make the notification. Review of patient medical records were made on 6-26-25 and 6-27-25. Review of patient medical records showed that Patients #5, #7, #10, #11, #12, #15, #16, #17, #18, and #19 received the outdated form without up-to-date information on their rights as a sexual assault survivor. Patients #6, #9, #15, and #16 did not receive the form. The State required information form explained to the patient their rights as a sexual assault survivor. Information on rights included: When an assault is required to be reported law enforcement (LE) and the Texas Department of Family and Protective Services (DFPS). The right to have an examination even if the assault was not reported to LE. The right to have someone with you during the examination. The right to have an advocate who “can answer any questions about the process and inform you of your options every step of the way.” A section on what advocacy is and how to access free services. Information on the benefits of a Medical Forensic Examination for a Sexual Assault. Information on Informed Consent. Information on what to expect during a Medical Forensic Examination for a Sexual Assault. Evidence storage. How to track your evidence kit. Sexually Transmitted Infections (STI)s and the right to receive testing and treatment. HIV/AIDS testing and treatment. Pregnancy and emergency contraception medication. What to do if you think drugs or alcohol were involved in the assault. Costs and Payments. Crime Victims’ Compensation Program. How to submit a complaint against a regulated health facility. The information contained in the State required information form was necessary for patients to be able to exercise all of their rights provided by Texas state law and make an informed decision about care they chose to receive. Review of patient records showed that Patient #6 and Patient #9 were not provided access to sexual assault program advocate. The right to access to a sexual assault program advocate provided the patient with a trained advocate who could answer any questions about the process and inform the patient of their options every step of the way. By delaying or never notifying a sexual assault program advocate, patients were left to make crucial decisions without all of the information and resources necessary. Law Enforcement (LE) #20 was interviewed on 6-20-25 at 12:09 PM at the Lone Star Police Department prior to on-site survey. LE #20 stated during interview that the hospital did not provide an advocate for Patient #9. LE #20 stated that he was the one who eventually called the local advocacy center at a later date so that Patient #9 could access that resource for care after her sexual assault. Review of patient records showed that Patient #6 and Patient #9 were not provided with the name and telephone number of the nearest sexual assault crisis center.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 36827 Based on review of video and interview, the facility failed to ensure 1 patient (Patient #9) out of 20 patient encounters reviewed was provided personal privacy when appropriately requested. Findings were as follows: On 6-20-25 at 12:09 PM, prior to the on-site investigation, an interview was conducted with Law Enforcement (LE) #20 at the Lone Star Police Department. LE #20 stated he had taken a sexual assault survivor to Titus Regional Medical Center Emergency Department (ED) on 3-6-25. He stated she had been “brutally” assaulted, “writhing” in pain, and complaining of bleeding from her anus. LE #20 provided body-worn camera video documentation of the encounter with hospital staff at the ambulance bay entrance of the hospital. Note: Time stamps on video indicate hours, minutes, seconds of video time and not hours and minutes of the day. Video #1 was events prior to arrival at Titus Regional Medical Center. Video #2 was events after arrival to Titus Regional Medical Center. Prior to transport, LE #20 called the ED to advise he was bringing the patient in. Review of police body-worn camera Video #1 was made. At 01:37:23 (hour/min/sec) LE #20 could be seen placing the call. Corresponding phone call log was provided by LE #20 to show that it was, in fact, Titus Regional Medical Center Emergency Department being called. He told the person on the phone who he was and that he was enroute with a Sexual Assault Trauma victim. He provided them with her name and date of birth. He asked to verify “I can bring her in the EMS (emergency medical service - ambulance) entry?” He then told the person on the phone that he was enroute and would be there in 15 to 20 minutes. Review of Video #2 was made. At 15:51 (min/sec), Patient #9 could be heard explaining to LE #20 that she had previous experience with the hospital and staff that had not been a good experience. She was worried that they would not be nice to her because of the previous negative experience with the hospital and staff. At 17:49 in the video, Patient #9 and LE #20 were at the ambulance entrance. Pt #9 could be heard saying, “Oh God no. I know him. I know those people. That’s [Staff #10]. That’s the house supervisor. He’s an LVN (licensed vocational nurse) instructor at [local community college]. They’re going to judge me.” At 18:41, Patient #9 and LE #20 were discussing whether to go to another hospital. Patient #9 decided to stay because she was in pain. She told LE #20 “I need something for my ass”. She explained that she was worried Staff #10 would retaliate of her previous negative experience with the hospital and staff. “It was unsafe.” At 20:38, Staff #10 opened the door to the ambulance entrance and the following conversation could be seen/heard: Staff #10: “Yes Sir” LE #20: “I called about a patient that I was bringing here.” Staff #10: “Lets go on down and like check” pointing to the patient’s left where the public entrance to the emergency department lobby was. LE #20: points inside the ED ambulance entrance and says “In there”, indicating he wanted to bring her into the ED through the ambulance entrance rather than the public entrance. Staff #10: “What?” LE #20: “In there”, pointing again inside the ED ambulance entrance. Staff #10: “Well I know but she has to check in” LE #20: “She doesn’t have to go through there”, referring to going through registration in the main lobby rather than a process called “straight back” where a patient is taken to an exam/treatment room and registered and triaged in the room privately. Staff #10: “Why?” LE #20: “I called ahead.” Staff #10: “You still have to check in” LE #20: “OK, get your boss.” Staff #10: “I am the boss.” Patient #9: looked at Staff #10 and called him by his name. “He is the House Supervisor” and called him by his name again. She shook her head. Staff #10: “Is it somebody in there you’re worried about? I mean, I understand why you called” Staff #10 can be heard sighing. Patient #9 then asked LE #20 to take her to another hospital. She turned and looked at Staff #10 and called him by his first name. Staff #10: “We can still put you in as a No Contact patient, but you still have to check in. That’s all I’m saying.” Patient #9: “I’m bleeding from my butt.” Staff #10: “All we have to do is put your, get your information in there.” LE #20: “Come on, [Patient #9]. We’ll go to [names another hospital]. Patient #9 turns to Staff #20 and called his name. Staff #20 stepped outside of the ambulance entrance doorway and started walking towards the main ED lobby entrance. LE #20: “Do you want to go with him?” Patient #9: Shook her head no. LE #20: “We don’t have to” Staff #10: Was seen walking back towards patient #9 and asked, “Do you need a wheelchair.” Patient #9 to LE #20: “I just want to go home.” She appeared tearful and was shaking. LE #20 to Patient #9: “What can we do to help?” Patient #9 looked at Staff #10, crying, and said, “It hurts bad.” Staff #10: “Well OK” pause “All right, come on” At 23:00 (min/sec) Staff #10 opened the ambulance entrance and escorted them into the ED. At that time, Staff #10 still did not allow Patient #9 to go straight back to a private area. She was taken into a hallway between the ED and the main ED waiting area where two registration areas were. The hallway was closed off on either end by locked doors. The Triage Nurse, Staff #26, could be seen standing in the open doorway between the registration hallway and the emergency room across from the nurses station where nursing staff were working, with no privacy, questioning LE #20 and Patient #9. Staff #26: “Is this a doctor or just a SANE (Sexual Assault Nurse Examiner)” LE #20: “Well, it’s going to be a SANE but she needs to be evaluated too.” Staff #26: “OK” LE #20: “Trauma. Rectal trauma” Staff #26: “OK come with me. We’re just going to sign in at the front desk so I can have a chart on you. OK?” Patient #9 complained about pain and not being able to sit down while two registration staff were entering her information into the computer. Patient #9 bent over in pain. Staff #26 observed this and told the patient at 25:05 (min/sec) “Don’t fall. Don’t fall” Staff #26 went into the triage room at the other end of the hallway and started asking questions from the other room about the patient’s pain and not being able to sit down while the patient was outside the triage room, still in the registration hallway. Patient #9 could be seen sliding down the wall to the floor and sitting on her right hip with her legs tucked to keep the weight off the buttocks area and started crying. Staff #26 came out of the triage room and asked if the patient had fallen. LE #20 told her no and she responded “Ohhhh, I’ll be right back.” Staff #26 left the area and left the patient sitting on the floor of the registration hallway. During video review, it was clear that upon arrival no one asked her about the sexual assault or why she was presenting to the Emergency Department at the ambulance entrance for care. Staff #10 stated to Patient #9 that he knew why she had called ahead and never questioned what her reason for needing care was, and Staff #26 knew she was there for a SANE exam without asking the patient prior. Despite knowing she had been assaulted and witnessing her emotional state of shaking and crying, staff did not provide her with the privacy she requested, continuing to question Patient #9 and LE #20 about her condition in public areas around staff not directly involved with her treatment and care. On the morning of 6-26-25, Staff #10 was interviewed in the conference room. Staff #20 stated that he had not been called by the first hospital that Patient #9 had gone to for care and he didn’t know why she was there. He stated that maybe someone in the Emergency Department had been contacted, but he hadn’t. Staff #10 stated that the SANE exam room was dirty and all they had were examination bays called “fast track” beds with not much privacy. She was not offered to wait in a fast-track bed until the SANE exam room was cleaned and then start the registration and triage process in the privacy of the SANE exam room. Staff #10 stated he had intended for her to go directly to the triage room for privacy. He said after Patient #9 left with Triage Nurse Staff #26 he left the ED and didn’t know what happened after that. Staff #10 was asked if ED staff had specific training regarding trauma informed care as related to sexual assault survivors. He stated not to his knowledge. He stated he didn’t have it. Interview was conducted with Staff #3 and Staff #5 on the morning of 6-26-25 in the ED. Staff #5 had said that the ED was at capacity on 3-6-25 and there had not been any private area available. After review of the ED census for 3-6-25, Staff #5 stated that the only open rooms clean were 2 trauma bays and the 4 fast track beds. The SANE room was open but still needed to be cleaned. When asked how long that took, Staff #5 stated it would depend on the availability of housekeeping or nursing staff but could take up to 30 minutes. On 6-26-25, the fast-track beds were observed to be stretchers with curtains that provided limited privacy. Staff #3 stated they couldn’t use them for sexual assault patients because everything being said between patient and provider could be heard in the ER. Staff #5 stated the trauma bays couldn’t be used because they had to remain open in case a “true” trauma patient came in. When asked if the patient could have been placed there for privacy and comfort and not interviewed until the SANE exam room had been cleaned and patient moved, Staff #3 conceded that would have provided the patient with the privacy she requested.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36827 Based on review of records, state law, and interview, the facility failed to ensure patients were properly protected from abuse. The facility failed to ensure the state required mandatory report of suspected abuse to the Texas Department of Family Protective Services (DFPS), Child Protective Services (CPS) was made for 2 minor patients (Patient #7, #8) of 6 minor patients when there was a reasonable suspicion that abuse was involved. Findings included: Review of Texas state law was as follows: Texas Family Code, Title 5, Subtitle E, Chapter 261 Investigation of Report of Child Abuse or Neglect, Subchapter A General Provisions, Section 261.101 Sec. 261.101. PERSONS REQUIRED TO REPORT; TIME TO REPORT. (a) A person having reasonable cause to believe that a child’s physical or mental health or welfare has been adversely affected by abuse or neglect by any person shall immediately make a report as provided by this subchapter. (b) If a professional has reasonable cause to believe that a child has been abused or neglected or may be abused or neglected, or that a child is a victim of an offense under Section 21.11, Penal Code, and the professional has reasonable cause to believe that the child has been abused as defined by Section 261.001, the professional shall make a report not later than the 48th hour after the hour the professional first has reasonable cause to believe that the child has been or may be abused or neglected or is a victim of an offense under Section 21.11, Penal Code. A professional may not delegate to or rely on another person to make the report. In this subsection, “professional” means an individual who is licensed or certified by the state or who is an employee of a facility licensed, certified, or operated by the state and who, in the normal course of official duties or duties for which a license or certification is required, has direct contact with children. The term includes teachers, nurses, doctors, day-care employees, employees of a clinic or health care facility that provides reproductive services, juvenile probation officers, and juvenile detention or correctional officers. Review of medical records for patients who had presented to the Emergency Department for examination and care after sexual assault was started on the morning of 6-26-25 in the conference room. Upon review, the charts did not reflect if abuse / neglect was suspected and if the appropriate reporting had been made. Staff #5 asked if the surveyors wanted to review the sealed Sexual Assault Nurse Examiner records. The surveyors stated they did not. Staff #5 stated that the hospital needed to know if the required care had been provided and obtained the sealed records. Review of sealed record for Patient #7 showed that the patient had been assaulted by a family member. No evidence was found to show that the facility staff had made a CPS report. Review of sealed record for Patient #8 showed that the patient had been sexually assaulted by someone who may have lived in the home. No evidence was found to show that the facility staff had made a CPS report.”

“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: 36827 Based on observation, interview, and review of records, the facility failed to enforce policies to ensure special responsibilities of Medicare hospitals in emergency cases under 482.24 were met. The facility failed to: 1) ensure Medical Screening Examinations (MSE) for individuals presenting at the emergency department after a sexual assault and requesting a Sexual Assault Forensic Examination (SAFE) were documented in the patient record for 9 patients (Patients #2, #3, #4, #5, #7, #10, #11, #17, and #18) of 20 patient encounters reviewed. Refer to Tag A2406 2) have the required signage conspicuously placed in 17 of 17 treatment rooms and 4 of 4 fast track examination and treatment areas. Refer to TAG A2402”

“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: 36827 Based on observation and interview, the facility failed to have the required signage conspicuously placed in 17 of 17 treatment rooms and 4 of 4 fast track examination and treatment areas. Findings included: On the afternoon of 6-25-25, a tour of the Emergency Department was conducted with Staff #5 present. During the tour, it was observed that signage required by the Emergency Medical Treatment and Labor Act (EMTALA) was not displayed in the treatment rooms and fast track examination and treatment areas. This was confirmed by Staff #5. Staff #5 was interviewed during the tour. Staff #5 stated that the signs were in the waiting areas and not necessary in the treatment rooms or fast track area. When asked, Staff #5 confirmed that it was common in certain situations for a patient to brought directly to a treatment room or fast track area, registered, triaged, and treated in that room/area. Staff #5 then acknowleged that would be the only place the patient would have time to observe and read the signage that explained their rights under EMTALA.”

“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: 36827 Based on review of records, the facility failed to ensure Medical Screening Examinations (MSE) for individuals presenting at the emergency department after a sexual assault and requesting a Sexual Assault Forensic Examination (SAFE) were documented in the patient record for 10 patients (Patients #2, #3, #4, #5, #7, #9, #10, #11, #17, and #18) of 20 patient encounters reviewed. Findings included: (Note: Patients #2, #3, and #4 had been together when all three had been sexually assaulted and arrived together at the emergency department with their parents/guardians) Patient #2 On 6-25-25, Patient #2 arrived at the Emergency Department at 4:37 PM. Under the section labeled “Providers as of 6/25/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #11 was the only team member listed. Staff #11 was active from 6/25/2025 at 4:48 PM to 7:00 PM. The patient was a minor. Chief Complaint was listed as “other (Sent by police for sane [Sexual Assualt Nurse Exmaminer] exam, [name of Sane nurse redacted] sane nurse aware to pt [patient] coming to ER. Mother [name of mother redacted] present with child.) No provider was assigned to this patient encounter. MD Staff #12 placed medication orders at 5:41 PM and Labs at 5:49. Physician Assistant (PA) Staff #13 placed discharge order at 6:57 PM. No medical provider examination note was found in the chart. A nursing note was found that read “Pt parents and pt have declined examination for strangulation injury by ER MD. Pt and parents educated on s/sx [signs and symptoms] to watch for and verbalized understanding of all items discussed.” Patient #3 On 6-25-25, Patient #3 arrived at the Emergency Department at 4:41 PM. Under the section labeled “Providers as of 6/25/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #14 was the only team member listed. Staff #14 was active from 6/25/2025 at 5:09 PM to 6:57 PM. The patient was a minor. Chief Complaint was listed as “other (Sent by police for sane exam, [name of Sane nurse redacted] sane nurse present in er. Grandmother [name of mother redacted] present with child.)” No provider was assigned to this patient encounter. MD Staff #12 placed medication orders at 5:33 PM. Physician Assistant (PA) Staff #13 placed discharge order at 6:30 PM. No medical provider examination note was found in the chart. A note by RN Staff #15 was placed at 7:00 PM that read, “PT and family refusing medical exam by provider just requesting prophylactic treatment for STI.” Patient #4 On 6-25-25, Patient #4 arrived at the Emergency Department at 4:34 PM. Under the section labeled “Providers as of 6/25/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #14 was the only team member listed. Staff #14 was active from 6/25/2025 at 4:44 PM to 6:57 PM. The patient was a minor. Chief Complaint was listed as “other (Sent by police for sane exam, adoptive mother- [name redacted] present with child,)” No provider was assigned to this patient encounter. MD Staff #12 placed medication orders at 5:22 PM. Physician Assistant (PA) Staff #13 placed discharge order at 6:29 PM. No medical provider examination note was found in the chart. A note by RN Staff #14 was placed at 7:00 PM that read, “Confirmed with PT and Family that they decline medical exam by provider and just request prophylactic treatment for STI [sexually transmitted infection].” Patient #5 On 5-5-25, Patient #5 arrived at the Emergency Department at 10:22 AM. Under the section labeled “Providers as of 5/5/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #16 was the only team member listed. Staff #16 was active from 5-5-25 at 10:43 AM to 1:15 PM. The patient was an adult. Chief Complaint was listed as “Sane (PT sent by MPPD [Mount Pleasant Police Department] for Sane Exam)” No provider was assigned to this patient encounter. MD Staff #12 placed medication orders at 1:14 PM. At 2:28 PM RN Staff #15 documented “Patient discharged” and then “Patient Ready to Go”. At 2:28 PM, RN Staff #15 selected ED Disposition set to Discharge”. No provider discharge orders were found. No medical provider examination note was found in the chart. No other notes were found in the chart. Patient #7 On 4-21-25, Patient #7 arrived at the Emergency Department at 10:21 AM. Under the section labeled “Providers as of 4/21/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #11 was the only team member listed. Staff #11 was active from 4-21-25 at 10:44 AM. The patient was a minor. Chief Complaint was listed as “other (Here for sane exam, accompanied by mt pleasant police officer, the safe-t advocate , sane nurse are already present in er)” No provider was assigned to this patient encounter. The record showed the following: Outpatient Medication List had a note “Medications not reviewed this encounter”. “Medication Comments - ** No Medication Comments Found **” “Discharge Orders (720h ago, onward)-None” “ED Prescriptions-None” “Discharge Instructions - None” “Follow-up Information - None” “Questionnaires - No completed forms available for this encounter.” No medical provider examination note was found in the chart. No other notes were found in the chart. Patient #9 On 3/6/25, Patient #9 arrived at the Emergency Department at 7:20 PM with a Chief Complaint of Alleged Sexual Assault, “Pt is traumatized and having rectal pain. Pt also reports rectal bleeding”. Per the Emergency Department Provider Note on 3-6-25 at 9:58 PM, the physician documented the following as part of the Chief Complaint for the Medical Screening Examination, “Patient (Patient #9 - information redacted for privacy) presents emergency with the police sane exam. Patient reports being sexually assaulted overnight with most likely rectal penetration as she woke up today with rectal pain and bleeding. Patient continues to have bleeding from her rectum per her report.” The following was documented as the physical examination: “Physical Exam Nursing note and vitals reviewed. Constitutional: She appears well-developed and well-nourished. HENT: Head: Normocephalic and atraumatic. Neck: Neck supple. Normal range of motion. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Pulmonary/Chest: Breath sounds normal. Abdominal: Abdomen is soft. Bowel sounds are normal. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion and neck supple. Neurological: She is alert and oriented to person, place, and time. She has normal strength. Skin: Skin is warm and dry. Psychiatric: Her mood appears anxious. She is withdrawn.” The Emergency Department Course, Plan was documented at 8:06 PM as: “Patient is complaining of rectal pain. Patient will be given ibuprofen for pain.” The MSE did not contain information about the physician performing any type of rectal examination. No information was found about an examination of the rectal area for possible injuries causing the pain or address the patient’s repeated complaint of rectal bleeding. Per the medical record, the patient was not provided prophylaxis (medication given to prevent sexually transmitted infection) for sexually transmitted infection despite the emergency medical conditon of possible exposure. Patient #10 On 1-30-25, Patient #10 arrived at the Emergency Department at 12:05 PM. Under the section labeled “Providers as of 1/30/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #17 was the only team member listed. Staff #17 was active from 1-30-25 at 12:11 PM. Patient #10 was an adult. No Chief Complaint was listed. An ED Triage Note was made at 12:13 PM as follows: Patient was brought in from MPISD [Mount Pleasant Independent School District] police, they report county should come to ER. SANE nurse in department aware of pt. Pt reports unknown pregnancy, states last period “beginning of December” Doctor of Osteopathic Medicine (DO) Staff #18 gave a verbal order for labs at 12:13 PM. No notes from DO Staff #18 were found in the chart. No medical provider examination note was found in the chart. No other notes were found in the chart other than the triage note. Patient #11 On 1-24-25, Patient #11 arrived at the Emergency Department at 5:47 PM. Under the section labeled “Providers as of 1/24/2025” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #19 was the only team member listed. Staff #19 was active from 1-24-25 at 6:11 PM to 6:26 PM. Patient #11 was and adult brought in by prison transport with a chief complaint of “SANE” (Sexual Assault Nurse Examiner). No medical provider was assigned to this encounter. MD Staff #20 placed medication orders at 7:40 PM and set the disposition to “ED Disposition set to Discharge” at 8:48 PM. Patient discharged at 8:58 PM. No medical provider examination note was found in the chart. No other notes were found in the chart. Patient #17 On 9-25-25, Patient #17 arrived at the Emergency Department at 2:07 PM. Under the section labeled “Providers as of 9/25/2024” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #21 was the only team member listed. Staff #21 was active from 9-25-24 at 2:15 PM. The patient was an adult. The patient’s “Arrival Complaint” was SANE. At 2:15 PM, RN Staff #21 documented under “Rounding and Updates” “Quick Updates - Free Text: pt did not need medical treatment and was assessed by SANE nurse” MD Staff #12 placed orders for medications at 5:30 PM. RN Staff #22 set the disposition to discharge and made the following note at 5:40 PM: “Per SANEprotocol: RX of Doxycycline 100mg PO BID x 7 days and Flagyl 500mg PO BID x 7 days called into [local retail] pharmacy see [RN Staff #8] (SANE) order by [MD Staff #12]. No medical provider examination note was found in the chart. Patient #18 On 8-31-24, Patient #18 arrived at the Emergency Department at 11:52 AM. Under the section labeled “Providers as of 8/31/2024” the chart stated, “No admitting provider found”, “No attending providers found”, and for Treatment Team, RN Staff #16 was the only team member listed. Staff #16 was active from 8-31-24 at 11:58 AM. The patient was an adult. The triage note stated, “Patient reporting that she is here from SANE exam, also reporting right wrist pain with movement from incident of which brought her here for SANE exam, patient has full ROM [range of motion], no deformity noted, pulses in right wrist intact.” At 1:40 PM Advanced Practice Nurse (APN) Staff #23 placed a medication order. At 2:17 PM, RN Staff #24 set the disposition to Discharge and discharged the patient. No medical provider had been assigned to this encounter. No medical provider examination note was found in the chart. Policy Review Review of Titus Regional Medical Center (TRMC) policy Titled: Emergency Department Medical Screening Exam, last approved 01/2025, next review 01/2028, was made on 6-26-25. The policy was as follows: “Purpose: Any individual presenting to the Emergency Department will be provided a medical screening exam to determine the presence or absence of an emergency medical condition. Based on the patient’s presenting symptoms, the screening may consist of a simple exam or a complex process that involves ancillary studies in accordance with federal EMTALA guidelines. Policy: It is the policy of TRMC [Titus Regional Medical Center] to provide services to any individual seeing treatment for an emergency medical condition. This policy will define guidelines to determine if an emergency condition exists. ... Medical Screening: MSE is a process utilized by qualified staff to determine if an emergent condition exists in individuals presenting to the ED seeking medical treatment. The process will include a minimum of a physical assessment related to the presenting chief complaint, signs and symptoms, vital signs including O2 Saturation, history of complaint, past medical history, and any further information needed to determine patient’s condition. Responsibility: ER Physician, Physician Assistant, Nurse Practitioner Procedure: A. The Rapid Medical Evaluation (RME) process will be utilized during the hours of 11 am-11 pm (peak times). During this time the MSE will be completed by the mid-level or physician. ... 2. The triage nurse will obtain the chief complaint, history of complaint and other information necessary to determine an Emergency Severity Index (ESI) level. ... ... 4. Patients determined to have an ESI [Emergency Severity Index] level 1, 2, or 3 will be considered to have a medical emergency condition and will be evaluated and treated in the Emergency Department by the ED physician. 5. If it is determined an emergency medical condition exists, the patient will receive diagnostic/treatment/disposition as ordered by the practitioner/physician.” Review of charts showed Patient #17 was triaged with an ESI score of level 2. Patients #2, #3, #4, #7, and #18 were triaged with an ESI score of level 3. Patients #5, #10, and #11 were not provided an ESI score level.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 36827 Based on review of records and interview with staff, the facility failed to ensure methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings as documented in 1 (Policy ID 13092753 Infection Prevention & Control Program) of 4 reviewed Infection Control policies was implemented. Review of Policy ID 13092753 Infection Prevention & Control Program, Last Approved 04/2024, revealed the following on page 3 of 21: “Risk Assessment and Prioritization of Goals The infection control team identifies risks for transmitting and acquiring infections agents throughout the hospital based on many factors. The infection control team will develop a risk assessment at least annually or whenever significant changes occur in the factors noted below using information from all applicable committees and individuals as appropriate. ... At least annually the Infection Control Committee will review the risk assessment and develop action plans to address issues. These assessments and plans are shared with nursing administration.” Review of the Risk Assessment for Infection Surveillance, Prevention and Control Programs in Ambulatory Healthcare Settings showed that it was for 2023 and dated 12/15/23. Review of the Titus Regional Medical Center Infection Prevention & Control Plan Review - 2024 revealed that this plan had become effective January 1, 2024. Interview with Staff #2, Chief Nursing Officer, and Staff #14, Senior Director of Quality confirmed that these were the most recent approved documents and that an assessment and plan for 2025 had not been accomplished per the Infection Prevention & Control Program policy.”