Lake Granbury Medical Center

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 45521 Based on observation and interview, the hospital failed to maintain a safe physical environment in the emergency department under 42 CFR 482.41(a). On 03/10/2026, the surveyor found broken emergency call cords in two patient hall bathrooms: one next to exam room 5 and one across from trauma room 8. Because patients use these pull cords to summon help during an emergency, a patient in either bathroom could not reliably call for assistance. Findings included: On 03/10/2026 at about 10:15 AM, the surveyor toured the emergency department with Staff #9 (Emergency Department Director), Staff #10 (Quality Coordinator), and Staff #11 (Chief Quality Officer). The surveyor observed broken emergency call cords in both patient hall bathrooms: one next to exam room 5 and one across from trauma room 8. Patients use these pull cords to call for help during an emergency or when they need assistance. On 03/10/2026 at about 10:30 AM, Staff #9, the Emergency Department Director, stated she knew the bathroom near exam room 5 needed an emergency pull cord and said the hospital had submitted a work order. She stated she did not know the bathroom across from trauma room 8 also had a broken emergency pull cord.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 45847 . Based on a review of documentation and interview, the facility failed to ensure medical records documented information necessary to monitor the patient’s condition in 2 of 20 patients whose records were reviewed (Patient #1 and Patient #8). The facility nurses failed to: 1. Document on Patient #1 a “PO Challenge” (testing of the patient’s ability to tolerate an oral intake) that was pertinent to knowing the status of the patient’s medical condition. 2. Document appropriately on Patient #8 who left against medical advice (AMA). . Findings: Patient #1 Medical Record Review for 04/23/2025 Emergency Department (ED) Visit: A 4-year-old male (Patient #1) arrived at 7:43 AM - Patient #1 arrived as a walk-in patient with chief complaints of abdominal cramping, nausea, vomiting, and diarrhea. The medical screening examination began at 7:45 AM by Staff #9, the ED Provider. The physician notes included: “Several episodes of emesis this morning no antiemetics given will trial antiemetic and p.o. challenge (A “PO challenge” is a way to assess a patient’s ability to tolerate food and drink. It’s often used to determine if a patient can safely return home after an illness, especially when there’s a risk of dehydration or other complications from not being able to eat or drink.).” . The physician later documented: “ED Course: Other. Child was given multiple antiemetics and tolerating p.o. (oral intake) without emesis at the time of discharge she he has a benign abdominal exam.” . There was no “PO Challenge” found in the nursing documentation and no intake or output documented for Patient #1. . By failing to document a “PO Challenge”, there was no documented evidence that the patient was safe for discharge home. . Patient #8 Medical Record Review for 11/01/2024 ED Visit: A 32-year-old female (Patient #8) arrived as a walk-in patient at 2:10 AM with chief complaints of shortness of breath (SOB) and chest pain.; The triage began at 2:22 AM. An ESI level 3 (Urgent: Stable patients requiring multiple resources to investigate or treat, such as lab tests and imaging. Examples include abdominal pain, high fever with cough, or persistent headache.) was assigned. The medical screening exam began at 2:24 AM. The physician noted that the patient was getting angry and upset with x-ray tech, then became hostile with physician. The physician noted that the patient wanted to leave against medical advice (AMA), that the risks were explained, and that nursing should provide discharge information to the patient. Nursing documented that the patient left AMA at 2:54 AM and was given discharge instructions but did not state that the potential risks and consequences had been discussed with Patient #8. The patient left AMA at 3:02 AM. The AMA form was not found during the medical record review. The facility was asked to do a larger search for the document, but it could not be produced. Policy was not followed. . Policy Review: Facility A’s “ED Assessment and Reassessment” policy version 5, last reviewed and implemented on 02/25/2025 stated on page 2 of 2: “ ...12. RN will complete appropriate nursing records on ED patients. LPN’s and/or other licensed provider can assist in gathering data related to this process ...” . Facility A’s “Leaving Against Medical Advice - ED - Version 3” policy, last reviewed and implemented on 01/27/2025 stated on page 1 of 2: “ ...Purpose: I. Policy: A. When a patient leaves the Emergency Department against medical advice (AMA), the medical record should reflect exactly what treatment and instructions were advised, with thorough documentation. All patients indicating the desire to leave against medical advice shall be provided an AMA form to sign ... II. Procedure: B. The Registered Nurse and/or physician shall discuss and document, with the patient and/or family, the potential risks and consequences that may occur if the patient leaves prior to the physician discharging the patient ... D. The Registered Nurse shall provide instructions to the patient to follow up with his/her family physician or return to the Emergency Department if his/her condition worsens ... E. If the patient refuses to sign the form, complete the form except for the patient’s signature, write across the signature area that the patient refuses to sign and have a second witness sign the form ...” . Policy Review: Facility A’s “ED Assessment and Reassessment” policy version 5, last reviewed and implemented on 02/25/2025 stated on page 2 of 2: “ ...12. RN will complete appropriate nursing records on ED patients. LPN’s and/or other licensed provider can assist in gathering data related to this process ...” . Interviews: An interview with the Treating Physician (Staff #9) was conducted on 05/28/2025 at 10:10 AM. Staff #9 indicated that he was verbally told by nursing that a PO challenge had been completed. Staff #9 indicated that he did not know where the PO challenge should have been documented. Staff #9 indicated that no emergency medical condition (EMC) was identified in Patient #1 and that Patient #1 had no signs or symptoms of hypoglycemia or any other EMC during his ED visit at Facility A. . An interview with the Chief Quality Director (Staff #2) was conducted during the investigation beginning on 05/27/2025 at 1:15 PM. Staff #2 was asked where a PO challenge should be documented. Staff #2 indicated that it should be found in the nursing notes. The medical record for Patient #1 was reviewed again. Staff #2 could not locate any nursing notes by either of the treating RN’s (Staff #7 or Staff #8) documenting the PO challenge that was indicated by the treating physician, Staff #9. . An interview with one of the treating Registered Nurse (RN) (Staff #8) was conducted on 06/03/2025 at 11:19 AM. Staff #8 indicated that she was not the primary nurse for Patient #1. Staff #8 indicated that a PO challenge should have been documented by marking the orders for it as complete and later documented in the nursing notes. . An interview with one of the treating Registered Nurse (RN) (Staff #7) was conducted on 06/03/2025 at 11:28 AM. Staff #7 indicated that he was the triage nurse and not the primary nurse for Patient #1. Staff #7 indicated that a PO challenge should have been documented under interventions in the nursing notes. .”

“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: 45847 Based on record review and interview the facility failed to abide by the provider’s agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #11) patients whose records were reviewed. Patient #11 presented to the facility’s emergency department (ED) with complaints of abdominal cramping, vomiting, and chest pain on 12/1/2024. The patient did not receive further imaging (x-ray) or advanced imaging (CT/CTA) of their chest to rule out emergency medical conditions (EMCs). Based on record review, facility policy, and interviews, Facility A failed to provide an appropriate transfer for 3 of 20 patients (Patient #7, #11, and #13) whose records were reviewed. Patients #7, #11, and #13 were all transferred with an incomplete memorandum of transfer (MOT). The MOT was missing a summary of risks, benefits, and a signed physician’s certification. Cross Reference: Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination. Tag A-2409 - §489.24 (e)(1) and (2) Appropriate Transfer”

“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: 45847 Based on record review and interview, the facility failed to provide an appropriate emergency medical screening examination (MSE) for one of 20 (Patient #11) patients whose records were reviewed. Patient #11 presented to the facility’s emergency department (ED) with complaints of abdominal cramping, vomiting with blood, and chest pain on 12/1/2024. The patient also endorsed coffee ground emesis and was noted to have medical history of esophagitis and gastritis. The patient did not receive further imaging (x-ray) or advanced imaging (CT/CTA) of their chest to rule out emergency medical conditions (EMCs). Findings include: Patient #11, a 76-year-old female, presented to the emergency department on 12/1/2024 at 8:30 AM with complaints of abdominal pain and blood in vomit. The patient’s HPI documented at 12/1/2024 at 9:28 AM (history of the preset illness) indicated, “76-year-old female with history of risks of gastritis, hiatal hernia developed with abdominal pain and hematemesis last night ....Also complaining of substernal chest pain radiating down into her left arm. No known history of coronary artery disease.” Vital Signs documented for the patient from 12/1/2024 at 8:34 PM through 10:32 AM indicated 30-minute interval readings of: 193/87, 176/98, 189/75, 138/83, 187/89, 201/79, and 189/90. The patient’s EKG and troponin resulted with normal findings. The patient was diagnosed with an upper GI (gastrointestinal) hemorrhage as noted on the patient’s MOT. ED Physician documentation on 12/1/2024 at 9:34 AM indicated a differential diagnosis of GI bleed, hemorrhagic shock, ACS (acute coronary disease). At 9:35 AM, the ED course is documented as, “Final Impression Primary 76-year-old female with history of erosive gastritis developed epigastric and sternal pain last night, and multiple episodes of coffee-ground emesis. She is not on blood thinners. She is hemodynamically stable, hemoglobin at baseline, 13.7. She was given a pantoprazole bolus followed by continuous drip. We do not have Gastroenterology on-call today, discussed need for transfer to higher level of care for, family and patient are agreeable.” The medical record does not contain evidence to support that the patient’s complaints of chest pain were addressed with a chest x-ray and/or CT (computed tomography) imaging of the chest was not completed to further rule out any additional emergency medical conditions the patient may have been experiencing. On 12/1/2024 at 9:52 PM, transfer orders were entered for the patient with a reason noted as, “GI- higher level of care.” Policy Reviews: Facility A’s “ESI (emergency severity index) Triage - Version 3” policy, last reviewed and implemented on 11/11/2024, stated on page 1 of 3: “Acuity levels will be assigned based on the Emergency Severity Index (ESI) algorithm found in Attachments A and B.” The attachments (pages 2 and 3) were reviewed, appeared vague, and did not reveal specific meanings for each ESI level. The footnoted ESI levels were found on the NIH (National Institutes of Health) website. . Facility A’s “ED Assessment and Reassessment - Version 5” policy, last reviewed and implemented on 03/04/2025, stated on page 1 of 2: “ ...4. Each patient should have a Medical Screening Examination (MSE) by a physician, physician extender or an RN as approved by hospital bylaws. 5. The Medical Screening Examination (MSE) may include, but is not limited to diagnostic laboratory testing, cardiac testing, radiology, and other invasive and non-invasive procedures as indicated to determine the patient’s health care or treatment needs ... ...8. The assessment of infants, children, and adolescents begins at triage and is individualized. Refer to Emergency Department pediatric reference manual for required additional assessment ...” . And on page 2 of 2: “ ...13 In addition, all patients should have vital signs (blood pressure, pulse, respirations, temperature and paan) monitored as follows: Pain using appropriate pain scale Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR) Temperature (Temp) Pulse OX Weight Height Repeat vital signs q1 hour and/or as appropriate to chief complaint Repeat assessment q1 hour for level 2-3 patients Repeat assessment q2 hour for level 4-5 patients Monitoring as appropriate to chief complaint All patients on Oxygen will have a respiratory assessment completed and reassessed as necessary Repeat pain scale per Pain Assessment and Management policy ... . ... 14. Pediatric patients - refer to pediatric manual for guidelines ...” . Facility A’s “Standing Medical Orders - Version 3” policy, last reviewed and implemented on 01/27/2025 stated on page 2 of 2: “ ...2. Abdominal Pain a. Pulse Ox Continuous b. CBC, CMP, Lipase, Serum, UA, UPT (if female of childbearing age), PIV saline lock ...” Facility A’s “Medical Staff Rules and Regulations” policy, last reviewed and implemented in November 2021 stated on page 21 of 25: “ ...6.1(a) Screening (1) Any individual who presents to the Emergency Department of this Hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an “emergency medical condition” is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child. (2) Examination and treatment of emergency medical conditions shall not be delayed in order to inquire about the individual’s method of payment or insurance status, nor denied on account of the patient’s inability to pay. (3) All patients shall be examined by qualified medical personnel, which shall be defined as (i) a Physician; (ii) AHPs where permitted by State law and Hospital policy; and (iii) in the case of a woman in labor, a registered nurse trained in obstetric nursing where permitted under State law and Hospital policy. (4) Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department, even if not directly located in the department ...” Interviews: An interview with the Chief Quality Director (Staff #2) was conducted during the investigation beginning on 05/27/2025 at 1:15 PM. Staff #2 indicated Patient #11 was transferred in stable condition. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 Based on record review, facility policy, and interviews, Facility A failed to provide an appropriate transfer for 3 of 20 patients (Patient #7, #11, and #13) whose records were reviewed. Patients #7, #11, and #13 were all transferred with an incomplete memorandum of transfer (MOT). The MOT was missing a summary of risks, benefits, and a signed physician’s certification. Findings: Patient #7 Medical Record Review: Patient #7 was admitted to the ED on 04/23/2025 at 10:37 AM as a walk-in with chief complaints of weakness. Patient #7 was diagnosed with an AVF (arteriovenous fistula) malfunction and weakness. Patient #7 was transferred for an AVF replacement at 9:39 PM. The MOT was reviewed. The risks or benefits were not noted, and the document did not contain a physician signature on the physician’s certification. The MOT indicated the reason for transfer was for, “medical necessity/upgrade in care” and that the patient was in “stable condition”, however the transfer was an “emergency transfer and the patient’s EMC persisted . Patient #11 Medical Record Review: Patient #11 was admitted to the ED on 12/01/2024 at 8:24 AM with chief complaints of vomiting and abdominal pain. Patient #11 was diagnosed with a gastrointestinal hemorrhage. The risks or benefits were not noted, and the document did not contain a physician signature on the physician’s certification.The MOT indicated the reason for transfer was for “medical necessity/upgrade in care” and that the patient was in “stable condition”, however the transfer was an “emergency transfer.” . Patient #12 Medical Record Review: Patient #12 was admitted to the ED on 12/01/2024 via EMS at 9:29 AM with chief complaints of “feeling weird” like his heart racing. Patient #12 was diagnosed with ventricular tachycardia and atrial fibrillation. The patient was transferred on an amiodarone drip at 1:47 PM. The MOT was reviewed. The risks or benefits were not noted, and the document did not contain a physician signature on the physician’s certification. The MOT indicated the reason for transfer was for “medical necessity/upgrade in care” and that the patient was in “stable condition”, however the transfer was an “emergency transfer”. . Patient #13 Medical Record Review: Patient #13 was admitted to the ED on 12/08/2024 via EMS at 5:53 PM with chief complaints of generalized pain. Patient #13 was diagnosed with rhabdomyolysis, acute kidney failure, dehydration, UTI, fall, hypokalemia, and acute ganglionic intercranial hemorrhage. The patient was transferred at 9:09 PM. The MOT was reviewed. The risks or benefits were not noted, and the document did not contain a physician signature on the physician’s certification. The MOT indicated the reason for transfer was for “medical necessity/upgrade in care” and that the patient was in “stable condition”, however the transfer was an “emergency transfer.”. The patient was transferred via “ground ambulance requiring cardiac monitoring capabilities. . Policy Review: Facility A’s “Transfer” policy version 4, last reviewed and implemented on 11/26/2024 stated on page 3-4 of 7: “ ...C. Physician Certification - If the physician on call issues orders for the transfer of an individual by telephone or radio, those orders shall be reduced to writing in the patient’s medical record, signed by the Hospital staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible. In addition, a patient transfer certification form must be signed by the Hospital personnel effecting the transfer and the transferring physician. The physician certification shall include a summary of risks of benefits that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer ...” And on page 4 of 7: “ ...2. Transfer Prior to Stabilizing an Individual with an Emergency Medical Condition or a Woman in Labor An individual with an emergency medical condition, or a woman in labor, must be stabilized prior to transfer, unless: A. The patient, or a legally responsible person acting on the patient’s behalf, after being informed of the Hospital’s obligations under this policy and of the risks and benefits of transfer, requests transfer to another hospital in writing, or B. A licensed physician evaluates the individual and signs a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of the transfer, the medical benefits reasonably expected from the provision of the appropriate medical treatment at another hospital outweighs the increased risks to the patient, or in the case of labor, to the unborn child from effecting the transfer; or ...” . Facility A’s “Transfer or Admission of Trauma Patients - ED” policy version 3, last reviewed and implemented on 01/27/2025 stated on page 1 of 3: “ ...7. A memorandum of transfer will accompany the patient to the receiving facility. (The white copy is sent with patient and the yellow copy is retained and sent to Quality.) 8. If the patient arrives via EMS to (Facility A) and is then transferred to another facility, a copy of the EMS Run Report will be sent with the patient to the accepting facility as available. 9. The consent for transfer is signed by the patient or guardian if the patient is underage or unable to sign for self, or implied consent is evoked if the patient is unresponsive and no family is available. 10. The Emergency Room physician will need to sign the memorandum of transfer. 11. The Memorandum of Transfer, nursing documentation, physician documentation, lab, and radiology studies on a disc will be sent with the patient. 12. When transferring to any hospital the transfer procedure is followed ...” Interviews: In an interview with Staff #2, Chief Quality Officer and Staff #3, Quality Coordinator, Staff #2 indicated that all 4 patients (Patient #7, #11, #12, and #13) were discharged in stable condition and the facility policy was to not have the risks and benefits listed or the certification signed by the treating physician if the patients were stable. Staff #2 indicated that all 4 patients (Patient #7, #11, #12, and #13) were stable upon discharge and that their policy was followed.”