Texas Health Presbyterian Hospital Plano

“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: 33589 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. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements for Medical Screening Examination, citing 1 of 20 patients (Patient #2) that presented to the emergency department (ED) in need of a psychiatric evaluation and the hospital failed to keep the patient safe until the psychiatric evaluation could be achieved to determine if inpatient psychiatric care was required. Patient #2 on 12/13/2023 arrival to 12/14/2023 elopement, drove off in an unattended, running ambulance with another patient loaded in the back. Cross Reference to Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination”

“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: 33589 Based on record review and interview, the hospital failed to ensure each patient received an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department, citing 1 of 20 patients (Patient #2) that presented to the emergency department (ED) in need of a psychiatric evaluation and the hospital failed to keep the patient safe until the psychiatric evaluation could be achieved to determine if inpatient psychiatric care was required. Patient #2 on 12/13/2023 arrival to 12/14/2023 elopement; drove off in an unattended, running ambulance with another patient loaded in the back. Findings Patient #2 Arrived 12/13/2023 and Eloped 12/14/2023 On 12/13/2023 at 6:05 PM, Patient #2 arrived via ambulance under an EDO (Emergency Detention Order) No. 23-240854 at 6:07 PM for walking on Dallas North Tollway, intentionally trying to get hit, and jumping on moving vehicles. Patient #2’s MSE was started on 12/13/2023 at 6:28 PM by Physician #15 reflected the patient’s agitated and altered state. The 12/13/2023 MSE (first physician) reflected, “38 y.o. (year old) male with PMHx (Previous Medical History) of asthma, meth-use who comes to the ED (emergency department) as APOWW (Apprehension by Police Officer Without Warrant/Emergency Detention Order) today. Associated sx (symptoms) of AMS (Altered Mental Status). Police reports that pt was found walking in the Dallas north tollway...Physician Exam...Neurological: General: No focal deficit present. Mental Status: He is disoriented. Cranial Nerves: No cranial nerve deficit. Comments: Oriented x1 Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal...Lab results (included) Positive Amphetamines...Medical Decision-Making Problems Addressed: Psychosis, unspecified psychosis type: complicated acute illness or injury...Substance abuse: complicated acute illness or injury...Differential Diagnosis: Suicide ideation, homicidal ideation, acute psychosis, hallucinations, intoxication, and overdose. The ED physician does not document if the pt has suicide or homicide ideation. There are no history questions regarding delusions, hallucinations, judgment, or insight. The Physician orders included Geodon, Lab work, Sitter, and BHA (Behavioral Health Assessment/Psychiatric Evaluation). Geodon was given at 7:09 PM due to his agitated state on admission. Patient #2 attempted to elope multiple times. There was no elopement risk assessment completed. The initial (first nurse) Nurse Documentation on 12/13/2023 described the patient as, “confused, agitated, impulsive, apprehensive, irritable, restless, combative, unable to verbalize (emotional state)” and “patient behaviors: threatening, uncooperative, non-compliant, not participating in care, and aggressive verbally.” “Suicide Screening” was documented as all “no” answers which resulted in No risk (CSSR/Columbia suicide screen not listed as high-risk). The post Geodon (second nurse) Nurse reassessment at 11:30 PM reflected, “Pt is awake and calm and cooperative. Pt is laying in bed. Pt denies any si/hi (Suicide/homicide) at this time and has agreed to talk with the assessor...11:45 PM Pt at first would not talk to the assessor. Pt then started to mumble and no (sp: not) talk clear to the assessor and so they stated that they would call back...(12/14/2023) 12:00 AM/Midnight The patient got out of bed, and I called for the officer in the ER. The patient then started to proceed to the ER bay and walk out. The ER officer and I got the patient redirected and agreed to come back into his room to be assessed...12:15 AM Pt started to get agitated and attempting to redirect pt at this time. Trying to get a hold of the assessor to reassess pt...12:21 AM Security called to patient’s bedside (again)...12:30 AM Security and er officer trying to deescalate the pt...” There was no physician notification of the patient’s heighten agitation for additional medication. The Behavioral Health Assessment/Psychiatric Evaluation was not completed. On 12/14/2023 at 2:40 AM, Patient #2 was able to elope after breaking down the ambulance bay doors, and drove off in an unattended, running ambulance with another patient loaded in the back. Plano PD (Police Department) safely apprehended Patient #2. The 12/14/2023 Physician (second physician) post elopement documentation reflected, “Rechecks/Consults: ED Course 12:47 AM Patient apparently ran out of ED, stole an ambulance from the bay that had a 93yo F discharged in it. He reportedly took off with ambulance with patient in the back. More to follow. 1:09 AM Reportedly (named patient) is now in custody of police. The 93yo F (year old Female) patient in back of ambulance is reportedly unharmed. Unclear disposition of both patients. 2:34 AM: Patient reportedly in PD (Police Department) custody. He is going to need further psychiatric evaluation at some point, though he is not appropriate for our facility at this time.” During record review and interview on 4/04/2024 at 10:45 AM, Personnel #4 and #5 were present. Personnel #4 reviewed that there had been no previous care or visit for this patient...They were asked about elopement risk. Personnel #4 stated the ED doesn’t do an elopement risk. No elopement screening was completed. A nurse could enter information in their notes...Personnel #4 stated we have to do everything in our power to keep him safe. They were asked if precautions were implemented. Personnel #4 stated no, it does not appear so, because SI (suicide) risk was low. No order for monitoring. No order for safety sitter because it is a nursing judgement. They were asked if a Sitter is required to complete documentation. Personnel #4 stated no, only if it was a Psych 1:1 sitter. They were asked if a Monitoring order was placed. Personnel #4 stated there was no order for monitoring by the MD...They were asked if the Behavioral Assessment (BHA) was ordered and completed. Personnel #4 stated ordered at 10:51 PM but not completed. Several attempts were made to complete the BHA, but the patient was not able at 11:52 PM not cooperative/not answering question. During a tour of the Emergency Department on 4/04/2024 at 1:37 PM, Personnel #1 and #6 were present. The videos were reviewed (see below)...Personnel #6 stated we have had multiple patients crash/break through the door to exit/elope through the ambulance entry. Personnel #6 stated there was not a safety switch for the ambulance bay door like the safety switch for exiting to the lobby. The 2 (saved) videos were viewed prior to the tour. The videos were of the ambulance bay that showed the patient at a full sprint to the running ambulance and driving off. The crew was unaware and loading a patient. One behind, male EMT and one on side door, female. The female was in the side door and backing out. While backing out she looked into the cab area like she saw or heard something. Then she exited the van and closed the door. She moved to the passenger side window looking into it as the ambulance drove off. The male attendant ran back to the back door in time to open the door. The door was ajar when the van left. No other videos were kept. During a telephone interview on 4/05/2024 at 11:30 AM, Personnel #9 (oncoming/2nd ED Physician) was asked about the patient. Personnel #9 stated, “I was tertiarily to his care. I did not see him. Personnel #15 (outgoing ED Physician) assessed him and directed his care. I took report. Normally that is around 11:30 to midnight. The (ED Provider) note is Personnel #15’s and the Recheck notes are mine. I was not a party to or informed of what occurred with the patient leaving until after the fact...I was in what we call the Doc box, a common area to chart. I started to hear a commotion. He ran out and police ensued...From the documentation, he was on a Meth bender, there was a struggle with authorities, and he came in with an APOWW. He got Geodon, came to, and bolted. They were waiting on him to wake up after Geodon to do the BHA. At almost 11 o’clock the Behavioral Health Assessor attempted to do the BHA and wasn’t able to get him to participate.” Personnel #9 was asked how an APOWW patient is handled. Personnel #9 stated, “normally there is a behavioral health sitter with them and an officer in the area as well. They take the belongings and have them wear green paper scrubs.” Personnel #9 was asked if the patient should be pacing in the hallway versus in the ED room. Personnel #9 stated, “pacing in the hallway is not normal. That would be a pretty big deal and I would want to be aware of that. I would deal with de-escalation for that. Every patient is different. They could be jonesing or sizing up if they could make it out. I did not see that happening and was not notified of that.” During a telephone interview on 4/05/2024 at 2:20 PM, Personnel #7 stated, “I have worked for the hospital for about 2 years when I am off duty at the Department.” Personnel #7 was asked about the patient situation. Personnel #7 stated, “I was told he was on an APOWW which means once the hospital accepts them, he can’t leave until the hospital evaluates him and tells him he can leave. APOWW patients are to be prevented from leaving.” Personnel #7 was asked if the patient was in green paper scrubs. Personnel #7 stated, “I am pretty sure he was in his own clothes.” During a telephone interview on 4/05/2024 at 6:00 PM, Personnel #8 was asked her understanding of an APOWW. Personnel #8 stated, “obviously the legal ability to hold the patient.” Personnel #8 was asked if that included the duty to keep him safe. Personnel #8 stated, “yes.” Personnel #8 was asked what the Keep me safe checklist was and entailed. Personnel #8 stated, “the check and balance for the room made safe for Psych patient.” Personnel #8 was asked if normally they take belongings, give paper scrubs, etc. Personnel #8 stated, “typically yes. So, this patient did not screen high risk for suicide. So, no paper scrubs. After several hours then I woke him to assess him. At that time, he was talking to me. He did not remember what happened prior that brought him in. I started to build rapport with him. I attempted to have him complete his Behavioral Health Assessment, but he was mumbling. I encourage him to speak to them, but the assessor decided he was not able.” Personnel #8 was asked not able functionally. Personnel #8 stated, “yes ma’am. I attempted again later after reorienting him to the process. I was trying to get the assessor on the phone and that was when he took off.” Personnel #8 was asked if he was agitated at that time. Personnel #8 stated, “he was in the doorway, anxious, and wanting to get it all over with. He was starting to escalate. The police officer was with me and redirect/de-escalate him. Security came as well.” Personnel #8 was asked if she notified the physician and asked for medication for the agitation. Personnel #8 stated, “it happened very quickly. I was on phone at the same time. I didn’t have 15 minutes to escalate. I had been able to redirect him. I did not think he would run.” During an interview and record review on 4/08/2024 at 8:50 AM, Personnel #6 was asked about the 3 psychiatric patients and the use of the green paper scrubs. Personnel #6 stated, “I don’t think any of them had the paper scrubs on, only their cloths.” The facility’s internal investigation did not interview the sitter, identify use or non-use of environmental controls (green paper scrubs, elopement risk assessment, and precautions) or evaluate the need for further medication for increased agitation (notify physician/missed opportunity). The hospital’s 10/07/2022 last reviewed “Medical Screening Examinations and Patient Transfers” policy required, “shall receive an appropriate Medical Screening Examination...including ancillary services routinely available to the ED to determine whether or not the person has an Emergency Medical Condition...The physician will determine if an Emergency Medical Condition exits and if so, initiate necessary stabilizing treatment or arrange for a transfer to another hospital as appropriate.”

“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: 37325 Based on record review and interview the facility failed to provide an appropriate Medical Screening Exam on 1 of 20 (Patient #1) patients when they presented to the emergency department on 03/25/24. The hospital failed to keep the patient safe until the complete medical screening exam could be achieved to determine if the patient had a medical or psychiatric emergency. The patient eloped from the hospital and was hit by a motor vehicle a killed on 03/25/24. Findings included: Patient #1 was transferred to the facility via ambulance from an inpatient psychiatric facility on 03/25/24 at 12:27 AM after falling twice. The Emergency Department (ED) record reflected...”Chief Complaint Fall...Upon arrival to ED patient jumped off stretcher and ran out ambulance bay. Paramedic able to speak to patient and bring her back inside and she agreed to stay. Pt (patient) reports, ‘I don’t want to go back to (inpatient psychiatric hospital)...Something doesn’t feel right’... “ The ED Provider Notes by Personnel #6 dated 03/25/24 at 12:46 AM reflected...”presents via EMS (no APOWW, or police accompaniment) [emergency medical service/apprehension by peace officer without a warrant] from (inpatient psychiatric hospital). She was reportedly admitted on 03/17/24 for bipolar/depression per their nurse report...she also swallowed quarters a week ago...she referred to herself in the third person...Patient screened low risk for SI (suicidal ideation) and was not accompanied by police...Review of Systems...Musculoskeletal: Negative for back pain and neck pain...Neurological: negative for light-headiness and headaches. Psychiatric...decreased concentration and dysphoric mood...nervous/anxious...Physical Exam...Head: Normocephalic and atraumatic...Musculoskeletal: General : Normal range of motion. Cervical back: Normal range of motion and neck supple...Neurological: Mental Status: She is alert and oriented to person, place and time....No cranial nerve deficit...Psychiatric...Mood is anxious. Affect is Labile. Behavior normal...Thought content does not include homicidal or suicidal ideation...ED Course...01:29 AM Per nursing the patient may have eloped... 03:17 AM Still refusing all care...03:22 AM The patient eloped from the ED (had sitter). She refused MAT (mental health) assessment and said she did not have SI...” The ED Notes dated 03/25/24 at 12:45 AM reflected...” Suicide Screening. Within the past month have you wished your were dead or wished you could go to sleep and not wake up? No...” The patient was admitted to an inpatient psychiatric hospital on 03/17/24 for Bipolar Depression The ED Notes dated 03/25/24 at 12:51 AM reflected...”I don’t people. My mom put me in Carrollton Springs because she is a narcissist and I don’t trust the people at Carrollton Springs and I don’t want to go back...” The ED Notes Safety Assessment dated 03/25/24 at 01:20 AM reflected...”WDL (within defined limits)...Fall Risk...Low...” The patient was transferred to the hospital from an inpatient psychiatric hospital for 2 falls prior to transfer. The patient eloped from the ambulance stretcher upon arrival at the hospital. There was not a documented elopement risk on the patient. The ED Notes dated 03/25/24 at 01:29 AM reflected...”Behavioral health called for assessment-notified them pt no longer in the room...0215 Patient found by...PD (police department) at McDonald’s and returned to ED...02:32 AM Pt asked ‘what are my rights to leave AMA.’ Pt was asked if she’s willing/agreeable to get behavioral health assessment and pt agreed to do so...02:41 AM Pt now at nurses station stated she is going to leave...03:01 AM Patient does not want to wait for behavioral health assessment...Patient walking out of ED...” The Behavioral Health Assessment was not completed; the patient was allowed to leave the hospital undeterred. The ED Provider Notes dated 03/25/24 at 05:42 AM reflected...”arrives unresponsive. Reportedly she was struck by a car. Circumstances unknown at this time...The patient had significant trauma...she had no signs of life since trauma...ED Disposition...Deceased...” During an interview with Personnel #5 on 03/28/24 at 11:30 AM Personnel #5 told the surveyor “when the patient arrived at the hospital they immediately jumped off the stretcher and ran outside. Personnel #5 said the patient stated she did not want to return to the psychiatric hospital. Personnel #5 said she told the patient they were sent to the hospital because of her falling earlier in the day. If the patient would agree to let the doctor see them, the hospital could get another behavioral health exam and if they agreed with the patient she could go home. Patient #1 came inside but eloped about five minutes before the behavioral health assessor called. Personnel #5 stated she called security and the police. The police found the patient across the street and brought her back to the ED. Personnel #5 said she asked the police officer that brought her back to write an APOWW, but they refused. Personnel #5 said the police officer told her that they had had an in-depth conversation with the patient and they were not suicidal and they had nothing to write an APOWW for. Personnel #5 said she asked the off duty police officer that works in the ED to write an APOWW and they also refused stating the patient was not suicidal. Personnel #5 said she called the psychiatric hospital to make sure the patient was a voluntary admission. The supervisor at the psychiatric hospital stated the patient was a voluntary admission. The patient had asked to leave the psychiatric hospital on 03/21/24 AMA. The supervisor stated they would have let the patient leave because she was no longer suicidal. Personnel #5 said the patient had been assigned a safety sitter because of her history of swallowing things. The safety sitter would not have prevented the patient from leaving the hospital without an APOWW. Personnel #5 said she had nothing to hold the on. Personnel #5 said the patient requested to sign out AMA and then walked back to their room with the sitter. The patient then eloped from the ED again. Personnel #5 said a couple of hours later the patient came back to the hospital after being hit by a car. The patient was deceased.” During an interview on 03/28/24 at 12:01 PM Personnel #6 told the surveyor “when the patient arrived at the hospital they immediately jumped off the stretcher and eloped out of the ambulance bay doors. Personnel #6 said he had the charge nurse call the psychiatric hospital to make sure the patient was a voluntary admission to that hospital. The charge nurse was told the patient was a voluntary admission for suicidal ideation. The patient had asked to leave AMA on 03/21/24 and would have been discharged AMA because they were no longer suicidal. The patient retracted the AMA and stayed at the facility. Personnel #6 told the survey two police officers refused to write an APOWW stating the patient was not suicidal. Personnel #6 stated he did not have a legal way to hold the patient without an APOWW.” Medical Screening Examinations and Patient Transfers policy. Last reviewed 10/07/2022. 5.10 Medical Screening Examination - Means the process to determine, with reasonable clinical confidence, whether the patient is suffering from an Emergency Medical Condition.”