Houston Methodist Baytown Hospital

“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: 37490 Based on observation, interview and record review, the facility’s nursing staff failed to provide a safe environment to minimize a patient’s risk of falling in 2 of 3 patients (ID#s 3 and 4). Findings include: Observation on 7/8/2026 12:45 PM showed a laminated sign on several patients rooms on 2 E. Nurse Manager (ID# 56) stated that the sign indicated patients that are high risk for falls. The sign read FALL Precautions HIGH RISK. Before mobilizing see the Partnering for safety tool inside the patients room for individualized plan. 1. Please call, Don’t FALL 2. Yellow socks 3. Yellow wristband 4. Within arm’s reach 5. Bed in lowest position 6. Chair alarm 7. Bed exit alarm 8. Gait Belt At the time of observation nurse manager (ID# 56) stated that all interventions should be in place for patients that are high risk for falls. She went on to say that the facility was rolling out a new fall risk score today and the facility is now using the Morse Fall Risk Score. Upon entering patient ‘s (ID# 3) room nurse manager (ID# 56) confirmed the patient was a high fall risk. Patient (ID# 3) did not have on yellow non-skid socks or yellow fall risk wristband. Observation in patient’s (ID# 4) room nurse manager (ID# 56) confirmed the patient was a high fall risk. Patient (ID# 4) did not have a yellow fall risk wristband on, and his yellow non-skid socks were on his bedside table still in the package. Record review of facility policy titled “PCPS161 Patient Fall Prevention” showed the following information: POLICY AND GENERAL STATEMENT Houston Methodist Hospital is committed to the safe care of patients. To this end, a comprehensive Fall Prevention Program involving employees who come in contact with patients is described in this policy. Each patient is considered at risk for falling by virtue of being in a new environment. Some patients are at a higher risk than others. III. Staff Competence Upon hire, staff are provided education, and competence validated, for the fall risk assessment tool(s) they will use and associated measures for fall prevention. A. Assessment and Reassessment In the emergency room, an RN will complete the EDFRAT when the patient is triaged; when the primary nurse completes their assessment; after the administration of a CNS, CV, or Diuretic medication; during bedside shift report;, when there is a change in the patient ’ s condition; and after any fall. An RN will complete the Hester Davis Fall Risk Assessment when a patient is admitted to the hospital, at least once each shift, when there is a change in their condition, with transfers to another unit or higher level of care, and after any fall. B. Patient/Family Teaching Upon admission the nurse will instruct the patient and family in fall precautions based on the patient ’ s Fall Risk and the appropriate interventions for the patient ’ s level of risk and provide appropriate fall prevention information/materials. Additional risk factors to be to be considered include the patient assessment, diagnosis medications and other related factors. C. Documentation in the electronic medical record 1. Document the Hester Davis Fall Risk Scores or EDFRAT Scores. 2. Document the appropriate interventions based on the patient ’ s level of fall risk and risk of injury 3. Document patient/family education.”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to ensure medical staff maintained a complete and accurate medical record for Patient ID #3. Findings Included: HHSC Intake received via email on 8/6/2025 regarding patient ID #3 alleged the facility “failed to provide appropriate medical care and follow-up.” It stated that “On September 1, 2023, (redacted) Patient ID #3 received an MRI and CT scan. A 1.1 cm lesion was visible on imaging, yet the hospital reported the scans were clear. (Redacted) Patient ID #3 was never informed” ... The allegation stated, that as a result of the oversight, Patient ID #3 “experienced a seizure on July 15, 2025, was transported by ambulance to the ER, and found that the tumor had grown to 1.8 cm.” Medical Record Review of Patient ID #3 showed she presented on 9/1/23 with chief complaints of headache and vomiting, which had started that morning. The medical record reflected she had a declared “history of seizures and prior brain tumor with craniotomy 6 yrs prior.” She endorsed blurry vision R eye and photophobia to ED physician. Patient ID #3 stated she had no follow-up due to insurance issues. Her vital signs were stable. MRI was performed on 9/1/25 revealed “postsurgical changes with small 1 cm enhancing extra-axial lesion with no significant mass effect. No prior exams available for comparison.” CT brain was normal. The repeat physical exam by the ED physician Staff ID # 73 showed improvement in symptoms with normal neurologic exam. Patient ID #3 was discharged with referral to follow-up with neurology in 1 week and return to care precautions. The ED discharge diagnoses included headache and UTI (urinary tract infection) as diagnoses. There was no mention of the enhancing lesion being disclosed to the patient. There was no mention of the enhancing lesion in the discharge instructions/after-care summary provided to the patient. Record review of facility “Medical Staff Rules and Regulations”, approved 5/15/2025 stated “2. Each patient shall be the responsibility of a member of the Medical Staff. Such practitioner shall be responsible for the medical care and treatment decisions of their patients, for the completeness and accuracy of the medical record, for communicating with consultants and other health care practitioners, and the relatives of the patient.” Interview with ED Manager Staff ID # 69 on 5/5/26 at 11:05 am with record review of Patient ID #3. He confirmed he noted an MRI brain report from 9/1/23 which stated “postsurgical changes at the vertex as detailed above with small 1 cm enhancing extra-axial lesions with no significant regional mass effect.” He confirmed that he was unable to locate physician documentation reflecting notification to the patient of this finding, discharge education or paperwork, which included this diagnosis to correspond with imaging finding. Telephone Interview with ED Medical Director Staff ID # 72 on 5/5/26 at 4:20 pm. He stated that the workup was very thorough and identified that an MRI of the brain was obtained that visit (9/1/23) and did show a brain lesion. He stated that the provider no longer worked at the facility so he was unable to speak to the provider from the 2023 visit so would be unable to speak to any conversations or discussions that had been had. He confirmed he was unable to locate documentation that the finding was discussed with the patient from the medical record review.”

“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: 23032 Based on record review and interview, RN nursing staff failed to evaluate the care for 2 sampled patients. Physician orders for daily weights were not fully implemented for 2 of 5 current sampled patients ( Patient ID 5, 6) Findings included: Record review of professional guidelines established by the American Nurses Association (ANA) titled :” Principals of Nursing Documentation: Guidance for Registered Nurses,” 2010, showed: -Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice; -The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient’s health record: assessments; order acknowledgement, implementation, and management [*not all inclusive ]. ~~~~~~~~~ Record review on 4/26/2024 of five (5) current patient clinical records with Staff -C, RN on Unit 2-South showed the following : Patient # 5 : Patient # 5 was a 63 year-old male, admitted on 4/21/2024 for “congestive heart failure exacerbation with shortness of breath and likely fluid over load.” Physician admission orders, dated 4/21/2024 included: fluid restriction of 1.2 Liters daily; Lasix 40 mg IV twice daily; intake and output monitoring; and daily weights. Staff-C, RN was unable to locate documentation of daily weights on 2 of 5 days reviewed: April 24 and 26, 2024. Patient # 6 : Patient # 6 was a 87 year-old male, admitted on 4/19/2024 ( to 2 South Unit) for “symptomatic bradycardia, lower leg edema, reports chest tightness and shortness of breath; dizziness.” Physician admission orders included: cardiology consult, lower extremity Doppler; bedrest; and fluid restriction of 1500 ml. Staff-C reported all patients on fluid restriction had I & O and daily weight recorded. Staff-C, RN was unable to locate documentation of a daily weight for 1 of 13 days reviewed: April 22, 2024 During an interview at the time of the record review, Staff-C, RN said the expectation was the daily weight for Patient # 5, 6 would have been measured and recorded by nursing staff.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46010 Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam in 1 of 26 patients reviewed (Patient ID #1). Refer to tag A 2406 for additional information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 46010 Based on record review and interviews, Houston Methodist Baytown Hospital (Facility A) failed to provide an appropriate and thorough medical screening examination (MSE), within the capability of the hospital’s emergency department, including neurology consultation available to the emergency department, to determine whether an emergency medical condition (EMC) existed for 1 of 26 patients who presented to the emergency department (ED). (Patient ID #1). TX00493426 Findings included: Record Review of Facility’s EMTALA policy titled “System_PCPS002 EMTALA & Patient Transfers”, date revised 11/6/2020, stated “This Policy and Procedure is based upon the federal law, Emergency Medical Treatment and Active Labor Act (“EMTALA”), and the Texas Administrative Code (“TAC”) regarding the medical screening, stabilization and treatment or Transfer of individuals between hospitals in an appropriate manner .... Medical Screening Examination the on-going process required to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists or a woman is in labor, within the facility’s capabilities and available personnel, including on-call physicians. It represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process involving the performance of ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and/or diagnostic tests and procedures. If a hospital applies its screening process in a nondiscriminatory manner (i.e., a different level of care must not exist based on payment status, race, national origin), it has met its EMTALA obligations ... PRESENTMENT & EVALUATION: Any individual who Comes to the Emergency Department will receive an appropriate Medical Screening Examination and, if necessary, Stabilization and treatment or Transfer, within the Capability of the Hospital’s Emergency Department ... Medical Screening Examination. This screening is performed to determine if an Emergency Medical Condition exists.” Record Review of Patient #1’s electronic medical record from Facility A was reviewed, Patient ID #1 was a 33 year old female who arrived to the ER on 02/26/2024 at 5:00 pm by ambulance with chief complaint of weakness. Triage notes reflected the patient arrived by ambulance. The patient was triaged upon arrival. The patient’s chief complaint was “Pt coming in via EMS from home, reported that @ 4:00 pm pt was found unresponsive by 4yr old daughter who called dad to check on mom. Per him pt was unable to walk, or speak today and told EMS she had a facial droop x 3d ago. Upon EMS arrival, pt was very weak, unable to walk, was able to write on paper that her vision is ‘diagonal.’ In ED pt continues nonverbal, pt able to gesture.” Per EMS report, “The patient was able to answer questions and follow commands appropriately; however did not respond to questions verbally”.” Patient ID #1 was initially paged as a “code CVA,” which is the acute activation for stroke team urgent analysis which happens immediately upon arrival. NIH stroke scale assessment done 2/26/24 5:48 p.m. by Staff RN # 72. “Stroke Assessment NIH Stroke Scale Interval: Change in condition Level of Consciousness (1a.): 0 LOC Questions (1b.): 2 LOC Commands (1c.): 0 Best Gaze (2.): 0 Visual (3.): 1 Motor Arm, Left (5a.): 0 Motor Arm, Right (5b.): 0 Motor Leg, Left (6a.): 3 Motor Leg, Right (6b.): 3 Limb Ataxia (7.): 0 Sensory (8.): 0 Best Language (9.): 3 Dysarthria (10.): 2 Extinction and Inattention (11.) (Formerly Neglect): 0 NIH Total: 14.” (This is falls within NIH Score 5-15 - “Moderate Stroke” severity). The record reflects the patient had, “Severe dysarthria, patient’s speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric.” The patient was also noted to have a “Partial hemianopia.” Dysphagia screen done by Staff RN #72 2/26/24 5:49 p.m. demonstrated that the patient failed the dysphagia screening due to positive facial asymmetry/weakness, positive tongue asymmetry/weakness, and palatal asymmetry/weakness. On 2/26/24 5:51 p.m., Staff RN #72 documents a neurologic exam which included “unsteady gait, blurred vision, change in behavior, dizziness and headache. She was noted to use written communication and nod/gesture appropriately.” The History and Physical performed 2/26/2024 by Physician Staff ID #71 noted, “Otherwise health 33 year old female with history of anxiety, migraines, brought in by EMS for refusal to speak to her husband at home, questionable mouth deviation for the past 3 days.” A neurologic exam demonstrated no focal deficit. Per the ED course @ 9:53 p.m., the patient was awake alert, speaking long in full sentences that are coherent, neurologic exam remains nonfocal. The MDM section notes, “Refusing to speak initially, however when encouraged and I explained that it would help her care, patient speaking long coherent sentences without dysarthria or aphasia.” Patient ID #1’s medical screening exam included a CBC, a chemistry, drug screen, alcohol level, chest x-ray and CT brain. However, further evaluation for a possible TIA was not performed, including further symptom monitoring through observation/admission, MRI of the brain, vascular imaging, and/or neurology consultation. No documentation indicated that neurology was consulted by the treating ED physician (Staff ID # 71). Review of the neurology on-call schedule for 2/26/2024 indicated a neurology physician was available for consults. The neurology consult could have assisted the ED physician in determining need for further testing, admission or discharge with prompt follow-up with neurology. Medical Record Review for Facility B reflected that Patient #1 presented to Facility B Emergency Department, on 3/1/2024, with generalized progressive weakness, droopy eyelids and difficulty swallowing. The patient had a neurology consultation, labs, imaging and therapy evaluations and was diagnosed with myasthenia gravis. She received IVIG infusions, rehab therapy consultation and treatments and oral medications as well as close outpatient follow-up. The surveyor reviewed Physician Staff # 71 analysis of her care for Patient ID#1 date of service 2/26/24. She stated that the patient did not have acute neurologic defects at the time of her Code Stroke evaluation and so the “Code Stroke was cancelled.” She stated when she went into the patient’s room to go over her results, she had the ability to form and speak in full coherent sentences. She stated that regarding the myasthenia gravis diagnosis provided a few days later, that diseases progress and pathology reveals itself over time, and that is why patients are given return to care precautions.”