Houston Methodist Clear Lake Hospital

“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 observation, 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: 1) have required EMTALA regulatory signage in the ambulance entrance. 2) record Patient ID #1, who presented for emergency departement care, on their central log and 2) failed to provide an appropriate medical screen exam for Patient ID #1. Refer to tag A 2402, A 2405 and A 2406 for additional information.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 46010 Based on observation, record review and interview, the facility failed to post conspicuously the required signage (per section 1867 of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC) and women in labor and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX). The hospital failed to post signage in a manner that was noticeable and visible to individuals arriving to the ER via for examination and treatment via the ambulance entrance. TX00507286 Findings included: Observation on tour conducted 08/27/2024 at 1:35 pm, the ambulance entrance had none of the EMTALA required wall signage. At the time of observation, Staff ID #51, ED Nurse Manager, confirmed there was no EMTALA signage. He confirmed the facility was aware of the absence of signage from a recent accreditation survey visit at the beginning of August and had them ordered. Record review of Medicare Provider Agreement [Code of Federal Regulations (CFR) 42 CFR 489.20(q) ] “requires a hospital to post conspicuously a sign(s) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor and to indicate whether or not the hospital participates in the Medicaid program. The letters within the signs must be clearly readable at a distance of 20 feet or the expected vantage point of the emergency departments clients..”. Interview with Director of Quality Staff ID #56 on 8/27/2024 at 1:45 pm, she confirmed the facility had no policy which governed EMTALA/mandatory regulatory posting/disclosures.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to maintain an accurate Emergency Department Central Log for 1 of 24 patients reviewed. Patient ID #1 drove to the facility in the early am hours of 6/23/2024 and presented inside facility lobby to staff with complaints of chest pain and concern for pacemaker/defibrillator malfunction. There was no evidence of patient ID #1 presenting for care, in the facility’s ED Central Log. TX00507286 Findings included: Record review of HHSC Intake received by email from complainant who stated on “6/23/24 at approx. 2 am, Patient ID #1 “sought care at the facility emergency department. She went there seeking help for left sided chest pain and “buzzing or vibrating” feeling in her chest. She has a pacemaker/defibrillator and was concerned it could be related to that. When she arrived, she was registering at the front desk. A nurse came from the back asking why she was there. She explained her symptoms and concerns and was promptly told ‘they don’t deal with pacemakers, and she would need to go to a hospital.’ She asked what hospital, to which they replied ‘probably anyone.’ They proceeded to walk away, leaving Patient ID #1 alone and confused. Ultimately she went back outside and called 911.” Telephone interview with Patient ID #1 on 8/15/24 at 1:30 pm. She confirmed that she had driven to the facility ED in early hours of 6/23/2024 with chest pain and concern about possible problem with pacemaker/defibrillator. She stated that she stood in the empty lobby with no other patients, families or employees noted. She stated that she said “hello, hello” a few times and a male employee came to the desk through a door behind the desk from the clinical treatment area. She stated he persistently asked for her drivers license and refused to register her for treatment without it. She reiterated to him that she had it but was having difficulty retrieving it from the compartment in her wallet. She stated a female employee, believed to be a Registered Nurse, came through the door and stood behind the glass/desk and asked what she was here for. She stated that after telling her about chest pain and concern for pacemaker/defibrillator, she was directed to “go to an ER.” She asked where she should go and the female employee stated “probably anyone.” She stated she was shocked that she was not assessed or evaluated and that no attempts were made to assist her by calling 911. She stated she “was left standing in an empty waiting room” as both employees exited back through doors to the treatment area. Patient ID #1 confirmed that she then went out to her car and called her son for advice. She stated her son told her to call 911. She then hung up and called 911 for care/assistance as she “didn’t feel safe driving” and was concerned she “could have an accident and hurt someone.” Record review of the facility policy titled “System_PCPS002 EMTALA & Patient Transfers”, last reviewed 04/2024, stated “1. Log-In and Triage. A central log must be maintained for all individuals who come to the Emergency Department seeking evaluation and treatment. The individual’s arrival time, complaint, diagnosis and disposition shall be recorded in the log.” During a telephone interview on 7/16/24 at 5:00 p.m. with Deer Park Fire Department Paramedic Staff ID #73, she stated she was dispatched to Patient ID #1 via 911 activation call. She stated they “ran with lights and sirens” and found the patient in the parking lot of the facility’s Emergency Department “seated in driver seat of her vehicle with door open.” Paramedic ID #73 stated that Patient ID #1 was “upset” and stated she had been told they don’t have cardiac capabilities and was “told to go to a hospital ER.” She stated the patient expressed concern that it was not safe for her to drive since she knew she had a “bad heart” and therefore she called 911 to get transport to a hospital. Paramedic ID # 73 stated the patient was complaining of chest pain and expressed concern regarding her pacemaker possibly malfunctioning. She stated that they proceeded to “load patient in ambulance”, assess patient, provide aspirin dose per protocol and perform EKG. She confirmed that no one from the facility staff or security, came out to see what was occurring in the parking lot and engage with them. She confirmed that the patient was transported to Facility B Emergency Department, who assumed care. Record review on 8/28/24 at 10:45 a.m. of Facility A Central Log dated for 6/22/24 through 6/24/24, failed to reveal documentation of registration of Patient ID #1 on the central log. Interview 8/26/2024 at 09:30 am with ED Manager Staff ID #51, he confirmed that all patients who present for care should be registered and receive triage and medical screen exam. He stated the facility would provide stabilizing treatment and transfer, if the patient’s needs exceeded the facility’s capabilities. Interview 8/27/24 at 09:45 am, ED Manager Staff ID #51, confirmed he could not locate patient ID #1 on the central log. Interview 8/27/2024 at 07:35 am with ED Registered Nurse Staff ID #66. She stated that she had called ED Manager Staff ID #51 on the telephone to inquire about whether the facility had a “pacemaker interrogator.” She stated he said “no.” She stated she could not remember her exact dialogue with Patient ID #1. She confirmed that Patient ID #1 was not registered for triage, medical screen exam or care. She confirmed that she was aware that patient had “called 911” and she and staff observed on facility’s cameras their response to the parking lot.”

“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 interview, the facility failed to provide a medical screening examination (MSE) for 1 of 24 patients reviewed, who arrived ambulatory to the facility with complaints of chest pain. Patient ID #1 returned to her vehicle and called 911 for care and assessment and was transported to a Facility B (acute care hospital) for ongoing care. (Patient ID #1). TX00507286 Findings Included: Telephone interview with Patient ID #1 on 8/15/24 at 1:30 pm. She confirmed that she had driven to the facility ED in early hours of 6/23/2024 with chest pain and concern about possible problem with pacemaker/defibrillator. She stated a female employee, believed to be a Registered Nurse, came through the door and stood behind the glass/desk and asked what she was here for. She stated that after telling her about chest pain and concern for pacemaker/defibrillator problems, she was directed to “go to an ER.” She asked where she should go and the female employee stated “probably anyone.” She stated she was not assessed or evaluated and that no attempts were made to assist her by calling 911. She stated she “was left standing in an empty waiting room” as both employees exited back through treatment doors. Patient ID #1 confirmed that she then went out to her car and proceeded to call 911 for care/assistance as she “didn’t feel safe driving” and was concerned she “could have an accident and hurt someone.” Record Review of Deer Park Fire Department EMS Run Record stated “Location Type Freestanding ER Disposition PSAP Call 02:22:30 Location METHODIST ER- parking lot Unit Disposition Patient Contact Made Dispatch Notified Address 3701 CENTER ST Patient Evaluation and/or Care Disposition Patient Evaluated and Care Provided Call Received 02:22:30 Deer Park Emergency Services (Fire, EMS and Fire Marshal) Patient Care Record Name: (Redacted, Patient ID #1) Incident #: REDACTED Date: 06/23/2024 Call Received: 02:22:30 am Call Dispatched: 02:26:05 am En route: 02:28:32 On scene: 02:32:12 @ patient: 02:34 Depart scene: 02:44:46 Arrive @ destination: 03:04:29 Chief Complaint: Chest Pressure The record written by Deer Park Fire Department Paramedic Staff ID # 73 stated “Dispatched to 3701 Center in the parking lot for a female having chest pain. M2 responded without delay. Arrived on scene to find the patient (Patient ID #1) sitting in her vehicle. She advised she went in but advised her they did not have cardiac capabilities that she needed to go somewhere else so she called EMS. Patient is complaining of chest pressure with an abnormal feeling on her left side possibly coming from her pacemaker. Started approximately midnight and it scared her so she drove herself to Methodist Deer Park then called EMS. She wants her pacemaker checked. Patient is alert and oriented, She is able to talk in complete sentences without difficulty. Skin color and feel is normal, She denies dizziness or injury of any kind. She is able to ambulate without difficulty.” Record review 7/1/22 of the facility policy “System_ED001 Emergency Department Medical Screening Procedure, last reviewed 11/2021, stated the following: “ PROCEDURE: General Procedure: Pursuant to HM Official Procedure PCPS002, when an individual Comes to the Emergency Department, the ED must provide an appropriate Medical Screening Examination within the capability and capacity of the ED, including ancillary services routinely available to the ED, to determine whether or not an Emergency Medical Condition exists. The Medical Screening Examination must be conducted by a Qualified Medical Personnel, as permitted in the applicable hospital’s rules, bylaws or regulations.” The policy further stated “ ESI AND MSE: All individuals who come to the Emergency Department will be triaged utilizing the Emergency Severity Index (“ESI”) five level triage tool and will receive an MSE by a QMP to screen for an Emergency Medical Condition. An individual who Comes to the Emergency Department and who, after undergoing an MSE by a QMP, is deemed to have an Emergency Medical Condition will be provided with any necessary stabilizing treatment, or transferred to another facility in accordance with PCPS002.” Interview 8/26/2024 at 09:30 am with ED Manager Staff ID # 51, he confirmed that all patients who present for care should be registered and receive triage and medical screen exam. He stated the facility would provide stabilizing treatment and transfer, if the patient’s needs exceeded the facility’s capabilities. Interview 8/27/2024 at 07:35 am with ED Registered Nurse Staff ID #66. She stated that she had called ED Manager Staff ID #51 on the telephone to inquire about whether the facility had a “pacemaker interrogator.” She stated he said “no.” She stated she could not remember her exact dialogue with Patient ID #1. She confirmed that Patient ID #1 was not registered for triage, medical screen exam or care. She confirmed that she was aware that patient had “called 911” and she and staff observed on facility’s cameras their response to the parking lot. Interview 8/27/2024 at 09:45 am with ED Educator Staff ID #63 with chart reviews. She confirmed she could not locate a patient encounter or medical record for Patient ID #1 at the facility. Therefore there was no evidence of triage or medical screen examination by a qualified medical provider.”