Texas Health Presbyterian Hospital Dallas

“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: 51905 Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on observation, record review, and interviews, Facility A failed to perform a medical screening examination (MSE) on Patient #1, who presented to the emergency department (ED) after a 15-foot fall from a ladder. Facility A failed to determine if 1 of 20 patients (Patient #1) had an emergency medical condition (EMC ) when chest imaging was not performed. See Tag 2406”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to perform a medical screening examination (MSE) on Patient #1, who presented to the emergency department (ED) after a 15-foot fall from a ladder. Facility A failed to determine if 1 of 20 patients (Patient #1) had an emergency medical condition (EMC ) when chest imaging was not performed. . Record Review: . Review of Patient #1’s Facility A Medical Record: On 12/7/2025, at 3:09 P.M., Patient #1 presented to Facility A’s emergency department (ED) after a 15-foot fall from a ladder and a head strike. Patient #1 complained of back and scapula pain and denied loss of consciousness (Chief Complaint, Page 9). . Patient #1’s physical exam revealed no acute distress, normal mentation, and no external signs of trauma. The exam noted tenderness to the scapula, thoracic region, shoulder, and left flank (Physical Exam, Page 15). . Patient #1 received a CT (computed tomography) scan of the head, cervical spine, abdomen, and pelvis. Findings from the imaging revealed lumbar fractures in vertebrae 2 through 4 (Imaging Results, Page 22). . Patient #1 did not receive a CT or an X-ray of the chest to rule out any thoracic emergency medical conditions. . Patient #1 was treated with pain medications throughout his admission and discharged home with prescriptions for pain relief and a follow-up with an orthopedic office. . Review of Patient #1’s Facility B Medical Record” On 12/09/2025 at 11:05 P.M., Patient #1 presented to Facility B’s emergency department (ED) with a chief complaint of back pain. The provider documented, “Male with history of transverse process fractures and retroperitoneal bleeding presents with persistent pain and dyspnea. Patient fell 10-15 feet into a ladder hole on 12/07/2025 landing on his right side. Scan revealed left transverse process fractures and minor retroperitoneal hematoma. Persistent right-sided chest pain in mid-axillary region of the sixth intercostal space, not imaged. Reports point tenderness and dyspnea (HPI, Page 1). . Testing results noted, “Stable fractures, no change in Retroperitoneal bleed, no rib fractures, small bilat [bilateral] pleural effusions” (Assessment & Plan, Page 2). . Medical decision making documented, “Pt [patient] with pain improvement, stable known fractures, no evidence of pulm [pulmonary] contusion on imaging or clinically sig [significant] changes. Plan for pain management and outpatient follow up with spine. Pt stable for discharge” (Medical Decision Making, Page 2). . Review of Medical Screening Examinations and Patient Transfers Policy, Effective 2/3/2025: “4.0 Policy Guidance: 4.1.1 General a. Persons coming to the Emergency Department and Labor and Delivery Department. Any person who comes to Hospital Emergency Department (ED) and requests an examination or treatment for a medical condition shall receive an appropriate Medical Screening Examination by a physician or other Qualified Medical Person as defined in Section 5.0, within the Capability of the ED, including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition” (General, Page 3). . “5.0 Definitions: 5.10 Medical Screening Examination - Means the process to determine, with reasonable clinical confidence, whether the patient is suffering from an Emergency Medical Condition. Depending on the individual’s presenting symptoms, the Medical Screening Examination represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as lumbar punctures, clinical laboratory tests, CT scans, and/or diagnostic tests or procedures. A medical screening exam is not an isolated event, but an ongoing process” (Definitions, Page 22). . Interview: On 2/17/2026 at 12:41 P.M.: ED Physician, Staff C, stated that Patient #1 received a series of imaging, which revealed lumbar 2 through 4 vertebrae fractures. Staff C stated that they had no concerns regarding Patient #1’s care. Staff C indicated that CT scans of the head, neck, and abdomen included imaging of the chest. Staff C stated that, though no chest CT was performed, the chest was able to be visualized through other scans. Staff C stated that EMTALA means that patients must be provided a medical screening exam when they present to the hospital.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 27128 Based on interview and record review the hospital failed to include complete discharge instructions for 1 of 2 patients (Patient #1) that reflected documentation regarding Patient 1’s burn diagnosis and follow-up treatment of the burns. This failure prevented the patient from participating in his developement and inplementation of his discharge plan. Findings included: A review of Patient #1’s medical record on 11/29/2023 indicated the patient was a 65-year-old male who presented to the Emergency Department on 12/12/2022 with “concerns of not being himself per wife, acting weird and confused with some agitation. Wife says he wasn’t cooperating over there [local hospital] and they even couldn’t get VS on him. Per wife pt has hx of Crohn’s, s/p ileoscopy and colonic resection; patient currently self catheterized to release fecal matter x 2 a day, epilepsy, RA.” 12/14/22. Wound Care Note. “Spoke with RN, reported that patient had spilled hot chicken broth on himself early this morning the area is now blistering and red. Small serous fluid filled blisters to mid chest and right and left chest, some ruptured, some intact and new blisters forming. Moist but no active drainage. First degree partial thickness burns... Recommend medihoney gel and telfa guaze daily. “ 12/17/22. Discharge Summary. Patient #1 “is a 65 y.o. male with Bowel obstruction and possible stenosis to the Kock pouch. Patient presents with a history of Crohn’s disease and status post colonic resection with ileostomy with Kock pouch. Patient self catheterizes himself twice a day however he is noted decreased stool output and concern for possible volvulus.” There were no discharge instructions for follow-up daily wound care treatment of his burns. There was no diagnosis or mention of Patient #1’s burns. During Patient #1’s medical record review on 11/29/2023 at 1:15 PM with Personnel #3 and Personnel #4 they confirmed the patient’s discharge summary did not include a burn diagnosis or follow-up wound care instructions for the patient’s burns. The Hospital’s Documentation Standards policy, revision date of 10/2021, reflected, “The minimum required content of the inpatient care record includes ... Summarization of the patient’s hospital course to include final diagnosis, condition on discharge and discharge/ follow up instructions.” The Hospital’s Patient Rights & Responsibilities policy with a revision date of 11/11/2020 reflected, “...You have the right to the information necessary for you to make informed decisions, in consultation with your physician, about your medical care including information about your diagnosis, the proposed care and your prognosis in terms and a manner that you can understand before the start of your care. You also have the right to take part in developing and carrying out your plan of care...””

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 27128 Based on interview and record review the hospital failed to include a complete discharge summary for 1 of 2 patients (Patient #1) that reflected documentation regarding Patient 1’s burn diagnosis and follow-up treatment of the burns. Findings included: A review of Patient #1’s medical record on 11/29/2023 indicated the patient was a 65-year-old male who presented to the Emergency Department on 12/12/2022 with “concerns of not being himself per wife, acting weird and confused with some agitation. Wife says he wasn’t cooperating over there [local hospital] and they even couldn’t get VS on him. Per wife pt has hx of Crohn’s, s/p ileoscopy and colonic resection; patient currently self catheterized to release fecal matter x 2 a day, epilepsy, RA.” 12/14/22. Wound Care Note. “Spoke with RN, reported that patient had spilled hot chicken broth on himself early this morning the area is now blistering and red. Small serous fluid filled blisters to mid chest and right and left chest, some ruptured, some intact and new blisters forming. Moist but no active drainage. First degree partial thickness burns... Recommend medihoney gel and telfa guaze daily. “ 12/17/22. Discharge Summary. Patient #1 “is a 65 y.o. male with Bowel obstruction and possible stenosis to the Kock pouch. Patient presents with a history of Crohn’s disease and status post colonic resection with ileostomy with Kock pouch. Patient self catheterizes himself twice a day however he is noted decreased stool output and concern for possible volvulus.” There were no discharge instructions for follow-up daily wound care treatment of his burns. There was no diagnosis or mention of Patient #1’s burns. During Patient #1’s medical record review on 11/29/2023 at 1:15 PM with Personnel #3 and Personnel #4 they confirmed the patient’s discharge summary did not include a burn diagnosis or follow-up wound care instructions for the patient’s burns. The Hospital’s Documentation Standards policy, revision date of 10/2021, reflected, “The minimum required content of the inpatient care record includes ... Summarization of the patient’s hospital course to include final diagnosis, condition on discharge and discharge/ follow up instructions.””