Nacogdoches Memorial Hospital

“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: 48749 Based on a record review, policy review, and interview, the hospital’s emergency department physician failed to perform a complete medical screening before discharge in 2 (#1 and #2) of 2 patient charts reviewed. Findings include: Patient #1 Hospital #1 1204 Mound St. Nacogdoches, TX. 75961 A review of Patient #1’s medical record from Hospital #1 revealed the following; On 11/27/2024, Patient #1 presented to the Emergency Department (ED) at Hospital #1 via Emergency Medical Services (EMS) at 5:26 PM. The patient had been released from Hospital #1’s inpatient services earlier that day with a diagnosis of Hyperglycemia and Gastroparesis, which required the patient to be admitted for treatment. The EMS crew documented that the patient was found lying on his left side with his leg bent on the sidewalk and that the patient was complaining of right knee pain after falling from his motorized chair. A review of the EMS run sheet revealed the following: “Pt had a mild abrasion to his right elbow. No pelvic/GU/GI active bleeding noted to the elbow during left arm assessment. Pt c/o right knee pain and stated he was unable to straighten his leg and felt more comfortable with his right knee bent. No external right leg trauma was noted in either of the patient’s legs from the fall. No obvious deformities noted to the right knee. Pt had moderate to severe pedal edema to both of his lower legs and feet. Pt reported having PVD and neuropathy in his legs. Both of pt’s lower legs had capillary refill and were weeping a clear fluid. No redness noted to the right knee, and no obvious discrepancies noted to the lower legs when bilaterally compared. Blanket/sheet was rolled and placed under pt’s right knee to provide more comfort throughout transport. Pt reported slightly decreased pain with positional Interventions. Capillary refill was checked before and after positioning pt’s leg. No change in capillary refill pre- and post-adjustments. CMS Intact in all extremities. Pt reported no abnormal sensations in the extremities. The report was given to the Registered Nurse and Nurse Practitioner while pt was still on the EMS stretcher. Pt was assessed on the EMS stretcher and was informed that he was being discharged while on the EMS stretcher. Facility staff asked EMS to take pt to the lobby, where his motorized wheelchair was, and pt would receive discharge papers shortly. Pt refused to get off the EMS stretcher and pressed his “Life Alert” to speak with them about receiving another ambulance to be transported to ...Pt finally agreed to be assisted into his wheelchair.” The patient was triaged by the ED Registered Nurse (RN) at 5:26 PM. Vital signs recorded during triage were blood pressure 144/60, heart rate 80, respirations 15, oxygen saturation 95% on room air, temperature 98.1°F, and Glasgow Coma Scale score of 15. The patient told the ED RN that he fell from his motorized scooter and was experiencing pain in his right leg. A review of Patient #1’s medical record revealed no documentation to indicate that the Emergency Department nurse completed a pain assessment on the patient during triage. The patient was evaluated by the ED Physician at 5:27 PM on 11/27/2024. Further review of the ED Physician’s note revealed the following; “Provider Type Mid-Level Time Seen 11/27/202417:27. Medical Screening Start Time 11/27/2024 17:27. Medical Screening End Time 11/27/2024 17:31. HPI Primary Complaint Specified: knee pain, Onset: Prior to Arrival 30 Minutes, Onset Rate: Sudden, Timing Pattern Acute, Progression Constant; Occurred at Home, Pain: Yes, Location RLE, Radiating to None, Quality Ache, Severity Mild (1 - 3), Exacerbated by: Nothing, Relieved by: Nothing; Associated Symptoms: None. Primary Complaint Details: Pt arrived via EMS with a CC of right knee pain after slumping out of his wheelchair to the ground. Pt was discharged from inpatient care from this facility just a few hours ago. Diagnostic Impression Other Knee Pain. Medical Decision Making. Pt arrived via EMS with a CC of right knee pain after slumping out of his wheelchair to the ground. Pt was discharged from inpatient care from this facility just a few hours ago. On exam, no external trauma or swelling is observed to the right knee, bilateral lower ext. swelling is present and known to be baseline. Pt expresses pain with every touch. Case management was in the ED in the last few hours and had expressed to the staff that the pt was likely to return. Pt is homeless, and case management made arrangements to accommodate pt at a homeless facility after his discharge; however, he refused. After examination of the lower extremity, pt was informed that no imaging was warranted due to the lack of any visible trauma, abrasions, swelling outside of his regular edema. Pt expressed a desire to be taken to the hospital across town. He was then placed in his wheelchair, where he was instructed to have an ambulance take him to another hospital. He would need to contact them from off the hospital property, for which he expressed compliance.” Patient #1 was discharged from the ED on 11/27/2024 at 5:45 PM. Patient #1 was in Hospital #1’s Emergency Department for a total of 20 minutes for this encounter. A review of Patient #1’s medical record revealed there was no documentation to support that the patient received an X-ray of his right leg or received pain medication for his right leg pain. An interview was conducted with Staff #10 on 09/05/2025 at 10:00 AM. Staff #10 reported that, through chart audits, an issue was identified that nursing staff had not been completing pain assessments on patients in the emergency department. An interview was conducted with Staff #1, Staff #6, and Staff #10 on the morning of 09/05/2025. The surveyor asked whether it was a normal procedure for the hospital’s ED physicians to perform a medical screening while a patient was still on an EMS stretcher. Staff #10 reported that no, that was not something that has been witnessed or done routinely. Staff #6 reported that the patient was known to the hospital as a “frequent visitor” and did not believe that the patient was examined on the EMS stretcher. Hospital #1 has 21 Emergency Department beds. A review of the ED census on 11/27/2024 at the time the patient was receiving care showed there were only 5 patients in the ED when Patient #1 arrived via EMS. A review of the medical file for Staff #13 (nurse practitioner) was completed on the morning of 09/05/2025. A Peer Review for Staff #13 was completed by the hospital’s senior medical staff on March 13, 2025, regarding the care provided to Patient #1 in the Emergency department on 11/27/2024. Further review of the Peer Review revealed the following: “Based on the Committee’s discussion, it has concluded there were opportunities for improvement with respect to care given to this patient who complained of right knee pain. There is a concern that an X-ray was not ordered. The patient was discharged, and the next day went to another hospital. He was diagnosed with a right knee fracture, and surgery was performed.” An interview was conducted with Staff #9 (Emergency Department Medical Director) on 09/05/2025 at 11:10 AM. Staff #9 reported that the patient was well known to the ED and hospital. Staff #9 stated, “The mid-level reported the findings to me, but I did not examine the patient myself. An X-ray should have been ordered.” Also, Staff #9 reported seeing the Paramedics with Patient #1 while the patient was in the ED but was unaware if the patient was evaluated on the EMS stretcher. The surveyor asked how Staff #9 was made aware that Patient #1 had a fracture. Staff #9 reported that Staff #14 (Hospitalist) has admission privileges at Hospital #1 and Hospital #2. Staff #14 (Hospitalist) reported the incident to Staff #9. Hospital #2 4920 NE Stalling Drive Nacogdoches, TX. 75965 A review of Patient #1’s medical record from Hospital #2 revealed the following; Patient #1 arrived at Hospital #2’s ED on 11/27/2024 at 8:39 PM via EMS with a chief complaint of right leg pain after falling from a motorized chair two and a half hours earlier. The patient’s triage vital signs were blood pressure:146/66, heart rate:86, respirations:19, oxygen saturations: 96 % on room air, and a Glasgow Coma Scale:15. Patient #1 was evaluated by Hospital #2’s ED Physician on 11/27/2024 at 9:35 PM. The ED Physician documented the following: “Chief Complaint: Patient reports being thrown out of his wheelchair 2 1/2 hours ago. Patient reports that bystanders helped him back in his chair and that he has right leg pain. Hasn’t taken meds in 4 days. Goes to Texas Quick Care. HISTORY OF PRESENT ILLNESS; A 59 y/o male with PMH of AKI, HTN, unspecified disability, which requires a wheelchair, presents to the ED with c/o R leg pain onset approx. 2.5 hours PTA. Pt says he was on the sidewalk going down the street when he was thrown from his wheelchair. Pt says some bystanders who witnessed his fall helped him back up into his chair. Pt says he began experiencing severe R leg pain, so he went to the nearby Urgent Care, but was unable to receive care because they do not take his insurance. Pt says he then came here. Pt reports he was at Memorial seeing his PCP, and as he was going back home, he fell. Extremities: no deformity, no trauma. Non-pitting edema in bilateral lower extremities MEDICAL DECISION MAKING; History provided by the patient. Patient Presentation: A 59 y/o male with PMH of AKI, HTN, unspecified disability, which requires a wheelchair, presents to the ED with c/o R leg pain onset approx. 2.5 hours PTA. Pt says he was on the sidewalk going down the street when he was thrown from his wheelchair. PT says some bystanders who witnessed his fall helped him back up into his chair. Pt says he began experiencing severe R leg pain, so he went to the nearby Urgent Care, but was unable to receive care because they do not take his insurance. Pt says he then came here. Pt reports he was at Memorial seeing his PCP, and as he was going back home, is when he fell. I independently interpreted and evaluated the following, but will defer to the radiologist for formal interpretation of the radiograph studies.” At 11:27 PM, the ED Physician consulted with the Hospitalist for admission, and the patient was accepted for admission. At 12:03 AM, the ED Physician consulted with the Orthopedic Surgeon, who recommended placing the patient in an immobilizer splint until hardware was ordered for repair. Further review of Hospital #2’s ED Physician’s note revealed the following: “IMPRESSION/PLAN; 1. Fracture, femur, distal 2. Fall from chair 3. Type 2 diabetes mellitus with insulin therapy 4. Benign essential HTN RADIOLOGY DIAGNOSTIC RESULTS: CT Lower Extremity W/O Contrast Right (11/28 09:38) FINDINGS: Technically limited examination due to large field-of-view imaging. Acute, markedly comminuted, and segmental fracture involving the distal femoral metaphysis with disruption of the superior margins of the lateral and midline femoral trochlea. Posterior angulation of the femoral condyles noted. No fracture extension into the articular surfaces of the medial or lateral femoral condyles was identified. Lipohemarthrosis presents with Scattered subcutaneous edema about the knee. Mild tricompartmental joint space narrowing of the right knee. IMPRESSION: 1. Technically limited examination due to large field-of-view imaging. 2. Acute markedly comminuted and segmental fracture involving the distal femoral metaphysis with disruption of the superior margins of the lateral and midline femoral trochlea. Posterior angulation of the femoral condyles noted. No fracture extension into the articular surfaces of the medial or lateral femoral condyles was identified 3. Lipohemarthrosis present 4. Scattered subcutaneous edema about the knee. 5. Mild tricompartmental joint space narrowing of the right knee.” RADIOLOGY/DIAGNOSTIC RESULTS XR Knee 3 Views Right (11/27 23:39) FINDINGS: BONES: Comminuted distal femoral metaphyseal fracture with intra-articular extension. There is associated apex anterior angulation. JOINTS: Lipohemarthrosis present. Mild tibiofemoral osteoarthritis SOFT TISSUES: Diffuse subcutaneous edema, nonspecific IMPRESSION: Intra-articular distal femoral fracture as above MEDICATIONS ADMINISTERED.... - Acetaminophen-HYDROcodone 325 mg-7.5 mg oral tablet For: femur, distal fracture from a fall from a chair. - Ancef, IV piggyback. - Atorvastatin 40 mg, oral. - busPIRone 5 mg, oral. - Dilaudid 0.5 mg, IV push. - glipiZIDE 10 mg, oral. - HumaLOG sliding scale, resistant/medium, 12 units, subcut. - Lantus, SO units - ISINOPRIL 20 mg, oral. - Norco 325 mg-5 mg oral tablet - Pregabalin 75 mg, oral. - Procardia XL 60 mg, oral. - Reglan 10 mg, oral. - Sertraline 25 mg, oral. - Sodium chloride 0.9% flush, 10 ml, IV push. - Toradol 10 mg, oral. For: Fracture, femur, distal, Fall from chair” Patient #1 was admitted to Hospital #2 for a Right Femur Fracture on 11/27/2024. A review of the Orthopedic Surgeon’s consult note is as follows: “Ortho Consult H&P 11/28/2024 08:50:43 REASON FOR CONSULT: Femur fracture, right side HPI: This is a 59-year-old patient who is a functional quadriplegic who fell from his electric chair onto the concrete. Patient with a long medical history including diabetes, gastroparesis quadriplegia. Patient evaluated the ER with a comminuted distal femur fracture right side. The patient was admitted to the hospital, I was consulted for managing the fracture. Patient only complains of right lower extremity pain. Placed in a knee immobilizer.” Patient #1 had surgical repair of the right femur fracture on 11/30/2024 at Hospital #2 and was discharged to a skilled nursing home for rehabilitation on 12/04/2024. Patient #2 Hospital #1 1204 Mound St. Nacogdoches, TX. 75961 A review of Patient #2’s medical record revealed the following: Patient #2 arrived at the ED at 6:02 PM on 08/15/2025 with a chief complaint of right arm, right side chest pain, and right leg pain after a motor vehicle accident. Patient #2 was seen by the triage Registered Nurse at 6:08 PM. Per the triage RN’s notes, Patient #2 was a restrained driver, struck on the rear driver side of the car with air bag deployment. The patient’s vital signs during triage were blood pressure:119/71, heart rate: 86, respirations:18, oxygen saturation: 98% room air, temperature: 98.6, and a pain scale of 8/10. The patient had a Glasgow Coma Scale: 15. The patient was evaluated by the ED Physician at 6:18 PM on 08/15/2025 and documented the following; “HPI Primary Complaint: Motor Vehicle Accident at 1700; MVA Details Restrained: Yes, Type Automobile, Position: Vehicle Driver, Comment restrained, and pulling out and rearended, states airbags deployed; Accident Details Type: Collision, Velocity Low, Impact Location Driver, Safety Finding: Ambulatory at Accident Site; Pain Yes Location RUE, Severity Mild (1-3), Relieved by: nothing; Associated Symptoms: None. Primary Complaint Details: pt was in an MVC about 15 minutes pta when he was traveling about 20 mph when a car hit the rear driver side of his vehicle. Pt was restrained, denies loc. Complains of right arm pain, right-sided chest pain, and right leg pain. No major damage to the vehicle. Exam Comment: pt lying on gurney on cell phone and eating fast food, in no distress, but co pain to rue. Extremities: No Cyanosis, Clubbing, or Edema. Musculoskeletal: No Injury or Deformity, Comment co pain with ROM right shoulder and elbow. ED Course ED Course Time 8/16/2025 19:05, Findings advised pt likely no fx and no significant injury as his vitals are stable and he is eating fast food, not even stopping to give hx or during exam, suspect malingering for legal reasons. ED Course Time 8/16/2025 19:35, Clinical Status Stable, Findings NO OBVIOUS FX OR ABNORMALITY ON XRAY OR CT PLAN DC TO HOME. Diagnostic Impression Prior Known Problem: Motor Vehicle Traffic Accident, Pain in Upper Limb. Medical Decision Making: contusion, strain, fx, malingering Disposition: Disposition Discharge Details Decision Time 8/16/2025 19:36, Discharged to Home, Patient Condition Stable.” During the visit to Hospital #1’s Emergency Department, the patient was ordered the following tests; UA, CT Head w/o contrast, 2-view chest x-ray, 2-view right elbow x-ray, 2-view right shoulder x-ray, and Ibuprofen 600 mg PO. At 7:20 PM, Patient #2’s nurse documented the following; “Collected On: 08/16/2025 19:20 Patient complains of right leg pain and states that “it hurts to walk on it”. Dr. Vinson notified and stated that there was no need to x-ray the right leg at this time.” Further review of Patient #2’s chart revealed that Patient #2 was discharged from the emergency department at 7:40 PM. Patient #2 reported 8/10 right leg pain upon arrival to the ED and inquired about a leg x-ray. A review of Patient #2’s medical record revealed no documentation to support that a leg x-ray was ordered or performed. Also, there was no documentation found to support that a reassessment of the right lower extremity was performed. Patient #2 and Patient #2’s mother filed a complaint with Hospital #1. A review of the complaint log revealed no documentation that the complaint had been resolved.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 29191 Based on a record review and staff interviews, the hospital failed to ensure the prompt resolution of complaints and grievances for two of the six sampled patients (Patients #1 and 2). The hospital staff failed to ensure: A. a grievance involving patient care was properly identified as a complaint/grievance, logged in the complaint/grievance log, and thoroughly investigated and resolved for patients listed on the “Complaint Report”. B. the grievances regarding patient mistreatment and care complaints for two patients (Patient # 1 and 2) out of six were thoroughly investigated within the timeframe in accordance with the facility policy titled “Patient Complaint and Grievance Process.” Findings include: A. There were 22 entries on the “Complaint Report” from June through August of 2025. Only 2 were listed as grievances, and the other 20 entries were listed as complaints. A review of the complaints revealed that only 2 were addressed with a staff member present and resolved. The other complaints should have been categorized as grievances according to the facility’s policy. Patient # 1 A review of the hospital’s “Complaint Report,” dated 06/10/2025, revealed that Patient #1 was in the emergency room on 11/27/2024, having fallen out of his wheelchair. EMS told him his leg looked broken. The patient was assessed in the emergency department and discharged. The patient left the emergency department and went to another local hospital emergency room and diagnosed with a broken leg. The patient spent several months in the rehab unit. A letter was sent within the 7-day timeline. There was documentation of the investigation, but no 30-day to 45-day follow-up. The next date was a resolution date of 8/1/2025 with no documentation of the outcome. Patient #2 A review of the hospital’s “Complaint Report,” dated 06/12/2025, revealed that Patient #2 was in the emergency room on 06/09/2025. The patient was there due to vomiting, diarrhea, dizziness, and headache. The complaint was from the spouse, who stated she did not want medication administered to her partner. Additionally, the spouse complained that the physician was rude. A review of the Complaint intake was dated 06/11/20258. During an interview on 09/05/2025 at 9:30 AM, Staff #11 confirmed there was no documentation of the allegation being addressed. This complaint was categorized as a complaint and should have been a grievance. The resolution date was 7/25/2025. This complaint was not handled at the time the incident happened. A review of a facility’s policy titled “Patient Complaint and Grievance Process” dated 12/21 revealed the following: “Complaint -A verbal concern issued on behalf of a patient or patient’s representative that can be resolved at the time by staff present. Grievance -A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the Complaint is not resolved at the time of the Complaint by the staff present), abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing Complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489. * “Staff Present” includes any hospital staff present at the time of the Complaint or who can quickly be at the patient’s location (i.e. Nursing, Administration, Nursing Supervisors etc .. ) to resolve the patient’s Complaint. * If a verbal patient care Complaint cannot be resolved at the time of the Complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action for resolutions, then the Complaint is a Grievance for the purpose of these requirements. * A billing issue is not usually considered a Grievance unless it contains elements concerning quality of care or service issues or is Medicare Beneficiary billing Complaint related to rights and limitations provided by 42 CFR (Code of Federal Regulations) 489. Billing issues that do not meet the definitions of a Grievance may be referred to the department responsible for billing. * A written Complaint is always considered a Grievance, whether from an inpatient, outpatient, releases/discharged patient or a patient’s representative regarding the patient care provided, abuse, neglect, or the hospital’s compliance with CMS Conditions of Participation (CoPs ). For purposes of this requirement an email or fax is considered “written.” * Information obtained from patient satisfaction surveys usually does not meet the definition of a Grievance. However, must be managed as a Grievance if a patient or patient’s representative: * Writes or attaches a written Complaint on the survey and request resolution or * Writes or attaches a Complaint to a survey, does not request resolution, but the event would typically be treated as a Grievance by the hospital * Patient Complaints that are considered Grievances also include telephone, verbal or written Complaints regarding patient care, allegations of abuse, neglect, patient harm or hospital compliance with CMS requirements *Post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay/visit are not required to be defined as a Grievance *Whenever the patient or the patient’s representative requests that his/her complaint be handled as a formal Complaint or Grievance or when the patient or patient’s representative requests a response from the hospital, then the Complaint is a Grievance and all the requirements apply. d. The Department Director/Manager under the direction of the Grievance Committee responds to the Grievance with written notice to the patient or their representative within seven (7) calendar days of receipt of the Grievance. The notice is provided in a language and manner the patient or patient’s representative understands and includes: i. The name of the hospital contact person ii. The steps taken on behalf of the patient or patient’s representative to investigate the Grievance; iii. The results of the Grievance process; and iv. The date of completion e. If the Grievance is not able to be resolved within seven(?) calendar days, a written acknowledgment shall inform the patient or the patient’s representative that the hospital is still working to resolve the Grievance and that the hospital will follow up with a written response within 30 calendar days or within 45 days if special circumstances require an extension.” Etc. During an interview on 09/05/2025 at 10:00 AM, Staff #1 confirmed that the timeframes were not met according to the hospital policy and that the complaints should have been categorized as grievances under the Hospital policy “Patient Complaint and Grievance Process.””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 29191 Based on record review and staff interview, the hospital’s staff failed to ensure a properly executed informed consent was completed in 2 (# 6 and # 20) of 20 patient medical records. Also, the hospital staff failed to follow the “Informed Consent” policy. A review of medical records was conducted with Staff #1 on 09/04/2025 at 3:30 PM. Findings include: Patient # 6 Patient #6 arrived at the emergency room on 07/02/2025 with complaints of weakness. The patient was brought by ambulance from an assisted living center. According to the nurses’ and physicians’ notes, the patient was alert and oriented. The patient was not in acute distress and was discharged back to the assisted living where he resides. A review of the consent for the emergency visit on 07/02/2025 showed that the patient’s signature was left blank, and it was documented as due to weakness. Patient #6 arrived at the emergency room on 08/29/2025 with complaints of nausea and vomiting. The patient was brought by ambulance from home. According to the nurses’ and physicians’ notes, the patient was alert and oriented. The patient was not in acute distress and was discharged back to the assisted living where he resides. A review of the consent for the emergency room visits on 08/29/2025 showed that the patient’s signature was left blank. The consent showed that the patient was unable to sign due to weakness. Patient # 20 Patient # 20, age 39-year-old, came to the Emergency Room on 08/08/2025. Patient complains of not being able to speak for 2 days and having trouble walking for one day. Hypertensive in triage. Patient is eating normally, per the friend who is with him. Patient nods and shakes his head to answer questions. Patient denies abdominal pain or vomiting. The assessment by the nurse and physician showed no reason the patient could not sign. A review of the consent for the emergency visit on 08/08/2025 showed that the patient’s signature was left blank. The consent showed that the patient was unable to sign due to the patient having a possible stroke/weakness/no family. A review of the hospital’s policy titled “Informed Consent” with a date of 12/2024 revealed the following: “Policy: This policy describes responsibilities and the authority for obtaining or giving consent to treatment. The parameters of consent are clearly stated and authorized for the protection of the patient, physician, staff, and hospital. Definition: “Consent” or “informed consent” to treatment means the individual understands and agrees to any physical contact or other treatment. The concept of consent to treatment is of fundamental importance to the hospital-patient relationship. Informed consent should be obtained from patients prior to treatment. The legal relationship between the hospital and the patient is a contractual one. The patient has a basic right to self-determination. Consent may be either expressed or implied. If expressed, it may be either written or oral. Implied consent arises from the nature of the situation such as when a patient holds out an arm for a shot, but where the patient has made no affirmative statement of consent. While expressed consent is best evidenced by a signed consent form, the written form or authorization is not the “consent”, but merely evidence of the fact that the patient has made the decision to proceed with or refuse the anticipated procedure. Informed Consent Consent is only possible when the person consenting has enough information to understand the proposed treatment and the alternatives. Informed consent requires that the patient is informed of the nature of the contemplated treatment, the potential risks, the prospects for success, the possibility of complications, the risks and benefits of available alternatives, and the results likely if the patient remains untreated. Extremely remote possibilities that might falsely or detrimentally alarm the patient need not be disclosed. In general, the patient’s informed consent should be obtained before treatment is performed. An exception to this is an emergency situation (a condition which constitutes a substantial and immediate threat to the life or health of the patient so that delay to obtain consent would jeopardize the health of the patient (See “Emergency Procedures”) or when the patient is incapable of consenting. The person authorized to consent for the patient shall be given the relevant information in these circumstances. Written Consent A properly signed consent form, obtained prior to treatment, is the most effective manner in which to provide a valid authorization for a medical procedure. The patient should sign a consent for medical treatment and disclosure form at the time of registration or admission to the hospital. A “Disclosure and Consent for Medical and Surgical Procedures” should be obtained for the patient before any surgical or invasive medical procedures are undertaken or if special circumstances arise. The consent form is kept in the patient’s medical record. The patient’s signature should be provided freely and of his or her own accord and witnessed by at least one staff person. Verbal Consent A verbal consent may be obtained if the patient is competent but is unable to write. If the patient or legal representative is unable to sign the general consent for medical treatment, the reason should be indicated on the consent form, and if possible, signed by two (2) witnesses. For medical and surgical procedure consenting, the conversation should be noted in the patient’s medical record, indicating the time and nature of the consent, and, if possible, the conversation should be witnessed by at least two (2) persons.” An interview was conducted with Staff #1 on 09/04/2025 at 3:45 PM, and confirmed that the hospital staff were not obtaining proper consent before performing treatment and care on patients at the hospital. Staff # 1 confirmed that the hospital staff were not following the hospital’s Informed Consent policy in obtaining two signatures if a patient could not sign.”

“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: 49344 Based on record review and interview, the hospital failed to comply with the provider agreement under 42 CFR §489.24, which outlines the special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) requirements for 1 of 1 patient (Patient #1). Patient #1 presented to the emergency department (ED) on March 18, 2024, with a chief complaint of abdominal pain, nausea, and vomiting. These symptoms occurred in the context of a motor vehicle accident in February 2024 that resulted in significant injuries, including pelvic fractures, rib fractures, and a splenic laceration, which had required surgical intervention. Cross refer to Tag: A 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: 49344 Based on the record review and interview, the facility’s emergency department physician failed to provide an appropriate medical screening examination (MSE) within the hospital’s (1 of 1 patient) capability. Finding include: A review of the medical record for Patient #1 revealed the following; Patient #1 was a 36-year-old female who presented to the Emergency Department (ED) on 03/18/24 at 2:15 PM, with complaints of 4 days of epigastric abdominal pain and vomiting. Patient #1 had been in a motor vehicle accident that had occurred in February 2024 and the patient had undergone a Cesarean section. The motor vehicle accident resulted in significant injuries, including pelvic fractures, rib fractures, and splenic laceration, which required surgical intervention. A review of Physician #10 provider notes revealed the following: “Provider note on 3/18/2024 at 3:49 PM: Patient C/O onset N/V and epigastric pain x 4 days, reports recent MVC she had x I month ago ... DX of left of fractured pelvis with screw placement, rib fractures, and a spleen laceration. Pain to epigastric is 10/10, sharp, constant. The patient is unable to hold down oral intake. Denies any blood in vomit or stool. The last bowel movement was today but very small. The patient is unable to walk yet and reports she can’t start physical therapy until 2 weeks from now. PRN Norco at home for pain.” “Respiratory: CT A BIL Cardiovascular: RRR; Normal S2, S2 Gastrointestinal: Abdomen son, non-tender, positive bowel sounds. “State has not had a “good bowel movement x 6 days”. Bowel sounds hyperactive, borborygmi (a rumbling or gurgling noise made by the movement of fluid and gas in the intestines).” A review of the CT (computed tomography) revealed the following: “CT Angio Chest, CT abdomen/pelvis with contrast was completed on 3/18/2024, at 5:45 PM Impression: “Large left diaphragmatic hernia containing the majority of the stomach, that extends into the major fissure and causes atelectasis of the left lower lobe.” The patient was treated in the Emergency room with anti-emetics and intravenous fluid for her presenting symptoms. Patient #1 had not had a normal bowel movement in 6 days. The patient did not receive gastric decompression in the form of a Nasal gastric or oral gastric tube. There was no documentation that the patient could tolerate oral fluids during the emergency visit, which would have lowered clinical suspicion for an obstruction. A review of the on-call log for the surgery consult revealed that Surgeon #11 was on call but there was no documentation of a surgical consult. Patient #1 was discharged home on 3/18/2024 at 7:21 PM with instructions for GERD (Gastroesophageal Reflux Disease) and to follow up with her primary care physician and return if symptoms worsen. There was documentation about the herniation of the Gastrointestinal tract into the chest cavity. Patient #1 continued to have symptoms and went to another facility on 03/19/2024 at 12:40 PM less than 24 hours from discharge from the first facility. Patient #1 was diagnosed with Gastrointestinal tract obstruction and was found to have herniation of the Gastrointestinal tract into the chest cavity and diaphragmatic rupture. Patient #1 was taken to the Operating room for surgical intervention. An interview with Patient#1 revealed that she went to the hospital because it was close to her home and the patient was “vomiting a lot” and it “hurt to breathe and move’’. The patient was vomiting about every 30 minutes. The physician told me my stomach was shoved up underneath my lung and discharged me and told me to follow up with my primary doctor. I couldn’t have gotten any worse than just dying. Vomiting continued at home. The facility gave me oral medication in the emergency room, and I ended up throwing it all back up. The facility did not offer any help to me, so I went home and tried to do what they said, which was to call my doctor. I just couldn’t wait any longer and had to seek treatment in Tyler where they took good care of me after my wreck in February.” The patient confirmed she had emergent surgery and was now recovering at home.”