UT Health East Texas Athens Hospital

“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: 48653 Based on record review and staff interview, the hospital’s nursing staff failed to ensure patients presenting with complaints of pain were promptly treated and reassessed for the effectiveness of pain-alleviating interventions in 3 (Patient # 1, # 2, and # 3) of 20 patient medical records reviewed. Additionally, the hospital failed to follow the “Pain Management” policy. Findings include: During a review of patient medical records with Staff # 2 (Director of Quality) on 08/18/2025 at 12:45 PM in the administrative conference room. Patient # 1 A review of Patient # 1’s medical records revealed that the patient was a 13-month-old female who presented to the hospital’s emergency department on 07/21/2025vat 9:59 AM after a fall out of the bed. The patient was brought to the Emergency Room by her mother via private vehicle. At 10:21 AM, Staff # 9 (Triage RN) documented the following: “Patient crying while in triage, parents consoling patient.” At 10:23 AM, Staff # 9 (Triage RN) documented the following: “FLACC Pain Rating: Face: No particular expression or smile. Legs: Uneasy, Restless, Tense. Activity: Normal Position, Moves Easily. Cry: Moans or whimpers, occasional complaint. Consolability: Reassured by occasional touch, hug, or being talked to. Score: 3” A review of the Emergency Room Provider’s Note (Staff # 13) documented on 07/21/2025 at 10:30 AM revealed, “Review of Systems: Constitutional: Positive for crying and irritability. She is active and crying. She is irritable”. The patient was not given any pain medications, and no pain interventions were documented until 07/21/2025 at 1:53 PM (3 hours after a pain assessment was completed), when the patient was given oral Acetaminophen (Tylenol) 153.6 mg (milligrams) by Staff # 10 (Registered Nurse). The patient was discharged from the hospital’s Emergency Room on 07/21/2025 at 2:03 PM. Further review of the patient’s medical records revealed the patient was seen by the primary care physician on 07/22/2025 and was diagnosed with a femur fracture. Patient # 2 A review of Patient # 2’s medical records revealed that the patient was a 67-year-old who presented to the hospital’s Emergency Department on 07/03/2025 at 8:53 PM with complaints of a fall. At 9:06 PM, Staff # 11 (Triage RN) documented the following pain assessment: “Pain rated 8/10” At 10:34 PM, the patient was discharged home from the hospital’s Emergency Department. The patient was not given any pain medications, and no pain interventions were documented by the hospital’s staff. There was no reassessment of the patient’s pain before discharge. Patient # 3 A review of Patient # 3’s medical records revealed that the patient was a 15-year-old male presenting to the hospital’s Emergency Department on 07/01/2025 at 10:05 PM with a chief complaint of “right ankle pain”. At 10:10 PM, the triage nurse documented “Pain rated 5/10 to the right ankle”. An x-ray of the patient’s ankle was obtained at 10:40 PM, and confirmed that the patient had a closed fracture of the right fibula. The patient was given 800 mg (milligrams) of ibuprofen at 1:08 AM, almost 3 hours after the patient’s pain assessment was completed. There was no reassessment of the patient’s pain before the patient was discharged from the hospital’s Emergency Department on 07/02/2025 at 1:13 AM. A review of the hospital’s policy, “Pain Management,” with a date of 02/07/2025, revealed, “Purpose: To provide clinical guidance in facilitating the effective pain management of patients, thereby enhancing their comfort, function, outcomes, and personal/family satisfaction. Pain management is an organizational priority. Policy: 1. As an organization, UT Health East Texas recognizes the patient’s right to the appropriate assessment, management, and reassessment of pain. Caregivers from all disciplines will acknowledge, assess, and document, as appropriate, throughout the continuum of care, the patient’s self-report of pain or observable responses to pain utilizing cognitively and age-appropriate pain scales. Patient descriptors of pain may include existence, nature, location, intensity, aggravators, and relievers. Pain is to be recognized as the 5th vital sign and will be documented before and after pain medication and as indicated by the patient’s care, treatment, and services ....4. Nursing education will promote effective pain assessment, reassessment and management in the orientation process as indicated by ongoing staff competencies .... c. 3. FLACC (Face, Legs, Activity, Cry, Consolability) scale is recommended to use on patients aging from 2 months to 7 years who are unable to validate presence of or quantify the severity of pain. Use the FLACC scale to assess for observable signs or autonomic signs of pain recognizing that they are less reliable .... c.5.Patients greater than 9 years of age who are verbal and capable of using a numeric scale should rate the pain on a scale of 0-10, with 0 being no pain and 10 being the worst imagined ...vii. Reassessment/Evaluation should occur: 1. A reassessment for the presence of pain should be performed at least once every shift for inpatients and following any intervention intended to lessen the patient’s pain (for example: administration of pain medications, application of cold packs, repositioning). Reassessment should include the patient’s perception of the effectiveness or side effects of the therapy. 2. Such reassessment and documentation should take place within a clinically appropriate time frame, such as within an hour of the administration of oral medications or within a half hour of the administration of intramuscular pain medications ...” An interview was conducted with Staff # 2 and # 4 on 08/18/2025 at 1:30 PM in the hospital’s administrative conference room during the review of medical records. Staff # 2 and # 4 confirmed that there was no timely pain intervention or reassessment documented for the patients.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the hospital’s staff failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in the hospital’s Emergency Department. Findings include: During a tour of the hospital’s Emergency Department on 08/18/2025 at 9:45 AM with Staff # 2, the following infection control issues were identified: Triage Room # 2 -There was a thick build-up of dust, dirt, and other debris on the equipment used to monitor the patient’s vital signs, the suction cannister, and on the railing on the wall behind the head of the patient stretcher. -There was a white, disposable, single-patient-use blood pressure cuff lying on the floor next to the patient stretcher. -There was a black hair tie on the counter next to the computer. The hair tie had a piece of long hair attached to it. -There was a large purple water bottle on the desk next to the computer. The water bottle had a straw attached to the lid. -There were two wooden cabinets with missing doors. The supplies on the shelves of the cabinet were exposed, and many of the single-patient-use supplies (Barrier ointment and lotion) were open and had been used previously. There was a half-empty bottle of sterile water sitting on the shelves. It was unknown when it had been opened because there was no date on the bottle. The integrity of the sterile bottle was unknown. There was a coffee cup on the shelf sitting next to 3 sterile 10 ml (milliliter) normal saline 0.9% flushes. -There was expired hand sanitizer with a date of “09/2024” on the wall above the sink. Exam Room # 1 -There was a large white A/C return vent located above the head of the patient stretcher. The vent was covered in a thick layer of dust. -The computer had a thick layer of dust and other unknown debris on the top surface of the computer. Hallway Clean Equipment Storage Area -There was an ultrasound machine marked as “clean and ready for use” in the hallway. The basket attached to the bottom of the machine had several white washcloths and other patient linens stored in the basket. The linen was not covered and was close to the floor and the wheels of the machine. The two front wheels of the machine had a large clump of hair stuck in the wheels. There was also a dark red and brown substance splattered on the front right wheel of the machine. The splatter appeared to be blood. Clean/Sterile Storage # 1 -There was a large, clear bin on the floor in front of the sink. The bin contained patient linens and had a build-up of dust and other unknown debris in the bottom. The bin was not covered or labeled. The sink in front of the bin had an orange and brown splatter on the inside of the sink. Hallway # 2 -There were two large holes in the wall in the hallway outside of exam room # 8. The holes had exposed sheetrock, and the wall could not be cleaned and disinfected due to the exposed surface and holes. There was no work order placed for the wall damage at the time of the surveyor’s findings. An interview was conducted with Staff # 2 on 08/18/2025 at 10:05 AM during the tour of the Emergency Room, which confirmed the infection control findings. Staff # 2 alerted the director of Environmental Services and Infection Control to the findings.”

“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: 48653 Based on record review and staff interview, Provider # 13 (Nurse Practitioner) failed to perform an appropriate medical screening examination (MSE) for 1 (Patient # 1) of 20 patient medical records reviewed when Physician # 13 failed to identify and address Patient # 1’s ongoing clinical distress, indicated by a sustained elevated heart rate. Additionally, the hospital failed to follow the policy, “EMTALA-Medical Screening Examination and Stabilization”. Findings include: A review of Patient # 1’s medical records, conducted on 08/18/2025 at 11:00 AM with Staff # 2 (Director of Quality), revealed, Patient # 1 (13-month-old female) was brought to Hospital # 1’s Emergency Department (2000 South Palestine Street, Athens, Texas 75751) by her mother via private vehicle on 07/21/2025 at 9:59 AM with a chief complaint of “FALL”. A review of Staff # 9 (Registered Nurse) Triage notes on 07/21/2025 at 10:21 AM revealed, “Patient crying while in triage, parents consoling patient.” A review of Staff # 11 (Emergency Room Technician) Triage notes on 07/21/2025 at 10:27 AM revealed, “Patient arrives with parents. Mom stating that patient had kicked her in bed and fell off the bed onto the floor, unsure of what patient hit besides the floor and diaper bag”. A review of Provider # 13’s History of Present Illness Notes on 07/21/2025 at 10:30 AM revealed, “Patient is a 13-month-old white female patient who presents to the emergency department today via private vehicle from home with mother and father for a fall off the bed and a head injury. Mother states the bed was approximately 4 feet off the ground, and the patient fell, hitting the posterior portion of her head on a hardwood floor and a diaper bag. Mother states this happened approximately 6 AM in the morning. The patient immediately started crying. Mother had the patient stay awake for approximately 30 minutes, and then the patient went back down for a nap. At approximately 9:00 AM, when the patient woke up, she was inconsolable. Will not eat or drink. Denied any nausea or vomiting from the patient. Mother reports no listlessness. Mother and Father is very concerned for the patient’s well-being ...Physical Exam: She is active and crying. She is irritable .... Neurological: ...Motor: Motor function is intact. She sits. No weakness, tremor, atrophy, abnormal muscle tone, or seizure activity. Deep Tendon Reflexes: Reflexes are normal and symmetric ...Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm...” Patient # 1 had sustained tachycardia during the Emergency Room encounter on 07/21/2025. The patient’s vital signs were as follows: 07/21/2025 at 12:15 PM: Pulse 139 beats per minute (bpm), Respirations: 31, Oxygen Saturation 97% on room air (RA). 07/21/2025 at 1:00 PM: Pulse: 129 bpm, Respirations: 29, Oxygen Saturation 98% on RA. 07/21/2025 at 1:45 PM: Pulse: 141 bpm, Respirations: 30, Oxygen Saturation: 96% on RA. 07/21/2025 at 2:02 PM: Pulse: 141 bpm, Respirations: 30, Oxygen Saturation: 96% on RA. There were no blood pressures documented during the encounter. According to Physician # 13’s Provider Note on 07/21/2025, the patient’s cardiovascular assessment revealed, “Normal rate and regular rhythm”. Provider # 13’s cardiovascular assessment conflicts with the patient’s sustained tachycardia (elevated heart rate) from arrival to the hospital’s Emergency Room at 10:27 AM until discharge at 2:02 PM. Physician # 13 did not address the patient’s tachycardia, and the patient was discharged despite ongoing distress. A CT scan of the head and cervical spine was obtained on 07/21/2025 at 1:17 PM and revealed the patient had no acute fracture, subluxation, intracranial hemorrhage, or calvarial fracture. The patient was discharged home from Hospital # 1’s Emergency Department on 07/21/2025 at 2:02 PM with ongoing distress as evidenced by the patient’s tachycardia. Physician # 13 did not provide a reassessment to Patient # 1 before discharge. Further review of the patient’s medical records revealed the patient was taken to the Primary Care Provider’s office (117 Medical Cir., Athens, Texas 75751) on 07/22/2025 with complaints of “fall off bed with musculoskeletal pain, onset: 1 day ago”. A review of Primary Care Provider # 12’s encounter notes from 07/22/2025 at 10:51 AM revealed, “Fell from bed that was double her height onto the floor at 6:00 AM yesterday. Has not walked on her left leg since then. Mom took patient to the ER, where they did a CT head and cervical spine. These were normal. Per mom, they did not do a physical exam on her or any further workup. Patient is here for pain in leg from a fall ...MUSCULOSKELETAL: Normal tone and motor strength. Joints, bones, and muscles: no malalignment or bony abnormalities. Will not bear weight on the left leg. NEUROLOGIC: Patient will not put weight on left leg. Cries when trying to stand ...ASSESSMENT/PLAN: 1. Left leg pain: XR of LLE due to inability to bear weight ...2. Closed Fracture of left lower extremity: STAT referral to hospital # 2 ...) A review of the X-ray of the patient’s left lower extremity, taken on 07/22/2025 at 10:24 AM revealed, “Left Femur X-ray, 2 views. Findings: There is a transverse fracture through the distal diaphysis of the left femur. The fracture fragments are mildly displaced and angulated ...No additional fractures are identified ...Impression: Transverse fracture of the distal left femoral shaft, without involvement of the growth plate. No additional osseous abnormalities identified.” The patient arrived at Hospital # 2 (2222 Welborn Street, Dallas, Texas 75219) on 07/23/2025 with complaints of “closed fracture of distal end of left femur”. A review of Provider # 14’s Progress Note on 07/23/2025 at 12:30 PM revealed, “Patient is a 13-month-old female who presents for fracture evaluation. Patient fell off of bed on 07/21/2025. They were seen in emergency department for evaluation of head injury. She then had discomfort over her left distal femur, and x-rays were taken at an outside facility. Family was unable to bring imaging to the facility today for further evaluation. PHYSICAL EXAM: Tender over distal femur. Warm to touch over distal femur. Mild edema over distal femur. Findings: Distal femur fracture identified and appears to be in acceptable alignment .... Diagnosis: Left Femur Fracture .... Weight Bearing: Non-weight bearing to: LLE (left lower extremity) ...Supportive Devices: Cast ...” The patient was discharged from Hospital # 2 on 07/23/2025 with immobilization of the left lower extremity via spica cast for 4 weeks. The patient was given instructions for a non-weight-bearing status and repeat imaging in 1 week. A review of Hospital # 1’s policy “EMTALA-Medical Screening Examination and Stabilization” with a date of 04/19/2023 revealed, “Purpose: To ensure that all individuals who come to the Emergency Department receive an appropriate Medical Screening Examination and further examination and Stabilizing Treatment as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder. Policy: 1. Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual is determined to have an Emergency Medical Condition, UT Health East Texas will provide further examination and treatment necessary to stabilize the Emergency Medical Condition, within UT Health East Texas’s capability and capacity. 2. UT Health East Texas will not delay the Medical Screening Examination in order to inquire about an individual’s method of payment or insurance status. UT Health East Texas is discouraged from asking any questions about payment or insurance until after the Medical Screening Examination is completed and appropriate, and any Stabilizing treatment is initiated .... Procedure: ...2. Performance of the Medical Screening Examination. The Dedicated Emergency Department must provide for an appropriate Medical Screening Examination within the Capabilit of the Dedicated Emergency Department, including ancillary services routinely available to the Dedicated Emergency Department, to determine whether or not an individual has an Emergency Medical Condition, or with respect to a pregnant woman having contractions, whether the woman is in Labor, where the individual comes to the Emergency Department ....Scope of the Medical Screening Examination: a. A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition does or does not exist. b. The scope of the Medical Screening Examination must be tailored to the presenting complaint and the medical history of the individual. Depending on the individual’s presenting symptoms, the Medical Screening Examination may range from a simple examination (such as a brief history and physical) to a complex examination, such as clinical laboratory tests, MRI or diagnostic imaging, lumbar punctures, and/or other diagnostic tests and procedures ....e. A Medical Screening Examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the individual’s needs until it is determined whether or not the individual has an Emergency Medical Condition and, if he/she does, until he/she is stabilized or appropriately transferred. There should be evidence of this ongoing monitoring documented in the medical record prior to discharge or Transfer. However, if the Medical Screening Examination determines that the individual does not have an Emergency Medical Condition, then UT Health East Texas’s EMTALA obligations have been satisfied ...” An interview was conducted with Staff # 1, # 2, and # 3 on 08/18/2025 at 2:30 PM in the hospital’s administrative conference room. The staff were informed that CMS would make the final determination for the complaint.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47892 Based on document review and interview nursing staff failed to ensure an assessment and reassessment was completed before discharging Patient #1 (1 of 1 patient’s patient medical records reviewed). Failure to complete the assessment resulted in Patient #1 being discharged with an intravenous (IV) catheter left in place (a small plastic tube placed into a vein and used to administer medications, fluids, and blood) in his left forearm. Findings: A review of Patient #1’s chart was conducted on 1/06/2025 after 12:00 PM with Registered Nurse (RN) Staff #2. A review of the nursing documentation revealed RN Staff #11 inserted an IV in the left forearm on 12/11/2024 at 3:25 PM and RN Staff #10 removed the IV in the left forearm on 12/12/2024 at 1:08 PM. Further review revealed RN Staff #12 documented on 12/12/2024 at 1:08 PM that “No biobutton or telemetry. No IVs to remove ...” and RN Staff #12 transported Patient #1 by wheelchair and placed him in a taxi on 12/12/2024 at 3:23 PM to be discharged home. A grievance filed by Patient #1’s mother was reviewed on 1/06/2025 after 12:00 PM with RN staff #2. The grievance investigation revealed that Patient #1’s mother called to report that an IV had been left in her son’s arm. The patients mother stated she called and spoke with the house supervisor and the charge nurse. Patient #1’s mother reported that the charge nurse stated, “It has been documented that his IVs were removed” and repeatedly said, “What do you want me to do?” The mother then called and requested to speak to administration and was told to “call 911 if you can’t remove it”. Who did she speak with in administration and who told her to call 911. The mother called 911 and the IV was removed from his arm. A review of the documentation provided by the ambulance service revealed that Unit 954 was called to Patient #1’s residence on 12/12/2024 at 5:34 PM. The documentation was as follows, “EMS responded to call and arrived on scene to a female standing in the driveway, upon Ems exiting the ambulance the female stated that a stretcher was not needed and that the sick person her male middle age son was only needing to have iv’s removed from his arm. Ems entered residence and found the male pt sitting on the couch who refused any kind of treatment and transport to hospital, he only wanted the IV in his left arm removed, mother of pt stated that he was just discharged from hospital in Athens and iv was left in his arm. 954 medic removed the iv safely and properly disposed of the iv, a 4x4 and tape was placed on the iv site. Pt refused any other treatment and refusal form was signed by pt and witnessed by mother by her signature. Ems was cleared of call”. An interview was conducted with RN staff #2 on 1/06/2025 after 12:00 PM. RN Staff #2 was asked if she spoke to the nursing staff during the investigation of the grievance. RN Staff #2 confirmed she spoke with the RNs involved with the care of Patient #1. RN Staff #2 confirmed the IV was not removed before discharge. RN Staff #2 confirmed there was no documentation regarding the conversation she had with the nurse and no re-education was given to the nursing staff on assessing patients before discharge.”