Memorial Hermann Katy Hospital

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 37490 Based on record review and interviews, the facility failed to have an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s Maternal and Neonatal programs failed to fully analyze and take appropriate actions aimed at performance improvement when gaps were identified. Findings included: Record review of the facility’s Performance Improvement and Patient & Employee Safety Plan FY 2023-2025 showed the following information: The intent of the Performance Improvement and Patient Safety Plan (hereinafter referred to as “the Plan”) is to outline the structure and processes by which Memorial Hermann will eliminate preventable harm, improve patient care and outcomes across the continuum of care, ensure employee safety, and reduce error and waste. This Plan describes the organizational structures used to achieve improvement and to communicate results. In addition, the Plan outlines improvement methodologies that are utilized, processes and outcomes that are monitored, and the training and education needed to achieve and sustain improvements. PERFORMANCE IMPROVEMENT, ROBUST PROCESS IMPROVEMENT AND PATIENT AND EMPLOYEE SAFETY. The governing body, administrative, and clinical leadership oversee quality and patient safety processes; using a collaborative and interdisciplinary approach to the continuous study and improvement of processes providing healthcare services to meet the needs of consumers and others. The leadership team is qualified and possesses the knowledge, skill, attitude, commitment and vision necessary to improve the quality and safety of patient care services and processes. They regularly evaluate their involvement and effectiveness in improving quality and safety by analyzing outcomes, processes and structures, and by using both external and internal opportunities for the growth and development of leaders. Continuous performance improvement activities focus on identifying, measuring, implementing, monitoring, analyzing, planning, and maintaining processes to maximize patient outcomes, patient care experiences and employee safety. The interdependence and shared responsibility of departments, services, units, support personnel and clinical disciplines in improving the quality of care, services and processes are acknowledged by all members of the organization. The level of performance can best be defined as patient centered, safe, effective, timely, efficient, and equitable. SYSTEM QUALITY, PATIENT SAFETY AND INFECTION CONTROL DEPARTMENT The System Quality, Patient Safety and Infection Control Department (“QPSIC”) includes performance improvement, patient safety, quality, infection control, data analytics, clinical quality review, and Regulatory and Registry functions. QPSIC staff support Performance Improvement and Patient Safety efforts as leaders, facilitators, educators and analysts as appropriate. In addition, System leadership supports and provides direction to the Care Delivery Sites (“CDS”) QPSIC staff, Service Line Quality Leadership, Ambulatory Quality Leadership, and assists clinical/ administrative leaders to review quality data, identify opportunities for improvement, and develop unique indicators of quality to support the implementation and monitoring of performance improvement and patient safety activities and initiatives. Record review of the facility’s NATURE AND SCOPE: MEMORIAL HERMANN KATY HOSPITAL WOMEN’S SERVICES MATERNAL PROGRAM PLAN showed the following: Social Work/Case Management: A social worker is available by telephone 24 hours per day, 7 days per week. PERINATAL QUALITY COUNCIL (PQC). PQC is a multidisciplinary committee led by the MMD and MPM that meets at least quarterly to assess the provision of maternal care provided at MHK. Outcomes are consistently measured, analyzed, and tracked. Opportunities for improvement are identified, and action plans are developed and monitored until outcome variances are resolved. Maternal quality assessment and review consists of the utilization of pre-selected performance improvement triggers and additional hospital and regional indicators. In addition, a process of tracking complications, systems issues, provider issues, and adverse events is determined. The Maternal Program Manager will report all issues and opportunities for improvement to the Maternal Medical Director for determination of the need for further review via the PQC. Documentation of resolution of identified issues (loop closure) is the responsibility of the Maternal Medical Director and the Maternal Program Manager. Record review of the facility’s MEMORIAL HERMANN KATY HOSPITAL NEONATAL PROGRAM PLAN showed the following: Ideally, maternal patients are delivered in Labor and Delivery (L&D). However, if a patient presents to Emergency Department (ED) with a precipitous delivery or s/p delivery at home, Maternal and Neonatal Services will collaborate with the ED team to ensure that the same level of care is provided as in L&D. Specialized equipment is immediately available in the ED for this purpose. Once stable, mother and infants will transfer to Women’s and Children’s Services for continuation of care. MHK NEONATAL QAPI, NEONATAL QUALITY COUNCIL (NQC) Neonatal quality assessment and review consists of the utilization of pre-selected performance improvement triggers and additional hospital and regional indicators. In addition, a process of tracking complications, systems issues, provider issues, and adverse events is determined. The Neonatal Program Manager will report all issues and opportunities for improvement to the Neonatal Medical Director for determination of the need for further review via the NQC. Documentation of resolution of identified issues (loop closure) is the responsibility of the Neonatal Medical Director and the Neonatal Program Manager. The Neonatal Medical Director will review every transfer and death. In addition, the Neonatal Medical Director will review any chart submitted for review by the Maternal or Neonatal Program Manager to determine opportunities for improvement. A case evaluation with recommendations will follow each review. NQC is committed to a process-based, non-punitive approach to improvement. The committee focuses on process issues and system issues rather than individual behaviors or performances. The committee refers any individual behavior or performance issues to the appropriate nursing manager or to the medical staff office for follow up. Record review of Maternal program review involving precipitous delivery in patient ID# 1 showed multiple performance improvement (PI) events identified including documentation issues, lack of a social work consult and delay in identifying precipitous delivery. Record review Neonatal program review of neonatal death of patient ID#2, included but not limited to, process of precipitous delivery in OBED, mispatched intubation supplies and NRP (neonatal Resuscitation Program) not followed by provider. Record review Neonatal program review of neonatal death of patient ID#27 included but not limited to, delay in antibiotics from time of order. Interview with Director of Womens Services staff ID #63 on 9/16/2025 at 2:30 PM, she confirmed she had been personally contacted about the patient’s unexpected delivery/fetal demise via telephone call for patient(s) ID# 1 and #2. She stated she had been involved in case analysis after events occurred. She stated that the identification for opportunities for improvements included relocating the neonatal warmer and resuscitation supplies from an alcove around the corner to the hallway where OBED patients were kept for closer proximity for precipitous deliveries. She stated that the bereavement coordinator had contacted her about Patient ID# 1 verbalizing feeling like people were not as attentive to her upon arrival and this contributed to unnecessary delays and poor outcome. She stated that Patient ID#1 had been discharged so quickly (at patient’s request), and so she made contact with her 2 days later via telephone call to discuss. Staff ID # 63 stated that she felt it was obvious that even her skilled L&D nurse, working OBED, failed to recognize the pending delivery as she greeted the patient and her significant other and then asked her to change into a gown and provided a urine cup for a sample and then left the room. She did not feel she would have done that if she had realized she was so close to delivering. She confirmed she had been involved in the grievance response and the internal department-based quality review which is triggered from a fetal death. Staff # 63 was asked whether facility leadership had reviewed video camera footage for objective observations of patient encounter given her infant’s poor outcome, and she stated they did not. They also did not interview nurses directly involved in the care of the patient in ED or OB areas. Interview 9/19/2025 at 09:40 am with Maternal Program Manager Staff ID # 80. She confirmed she is responsible for the primary review performed on maternal cases who have identified “triggers.” She confirmed she did not evaluate ED triage/components of care and adherence to ED Triage of the OB patient’s protocol. Interview with Quality Director on 9/19/2025 at 9:45 AM she stated that all codes are reviewed by the hospital’s Code Blue Committee. Later when asked for the reviews performed by code blue committee for patient ID# 2, she stated that neonatal codes are not reviewed by the code blue committee, that neonatal code blue events are reviewed within the Neonatal program. Interview 9/19/2025 at 10:40 am with Neonatal Program Manager Staff ID # 85. She confirmed she is responsible for the primary review performed on neonatal cases who have identified “triggers.” She confirmed she had reviewed the post-delivery death of Patient ID #2 on 6/16/2025. She confirmed she had checked the box that “NRP (Neonatal Resuscitation Program guidelines) followed” as “yes.” She confirmed this was an error and she had identified that NRP were in fact not followed in the resuscitation of Patient ID #2 performed on 6/14/2025 by Neonatal Nurse Practitioner Staff ID # 81. She confirmed the neonatal physician review performed on 6/19/2025 by NICU physician #89 identified lack of documentation by the provider and lack of adherence to NRP guidelines. She confirmed that Neonatal mock codes were being added as an action plan item. She also confirmed findings of delayed antibiotics for patient ID# 27. However, she was unable to articulate how/if provider care opportunities were tracked and trended and how/if feedback was provided. Interview 9/19/2025 at 11:15 am with Neonatal Medical Director Staff ID # 82. He confirmed that he participates in neonatal case analyses which do not include his care of the neonatal patient. He confirmed that he also participated in the neonatal review committee meetings with case reviews. He confirmed that he does not keep official records reflecting opportunities or care gaps provided by specific providers. He stated that when gaps or lapses are identified, he communicates these to the entire neonatal provider team via email. He stated if it is an egregious issue that it would be routed through medical staff formal peer review process. Interview 9/19/2025 at 2:30 pm with quality Manager Staff ID# 52 stated that the hospital’s maternal and neonatal programs have their own QAPI group and meeting. A member of the hospital quality staff “has a seat at the table” when maternal and neonatal QAPI meetings take place. She stated issues are only brought to the attention of the hospital’s quality department when gaps are identified. She stated that the department was not aware of the findings regarding patients ID#s 2 and #27. Interview 9/19/2025 at 2:40 pm with Quality Director Staff ID # 51. She confirmed that Patient ID #2 had been relayed to the quality department to be a “nonviable delivery” which meant the “baby died in-utero.” This guided the quality department’s decision to not fully investigate for opportunities.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 46010 Based on observation, interviews and records review, the facility failed to follow their protocol for an obstetric patient who presented > 14 weeks pregnant, with signs of imminent delivery, by failing to provide an accurate/proper triage and failing to ensure a timely medical screen examination was initiated in the Emergency Department. This failed practice could result in serious harm or death to a patient needing access to emergency stabilization. Refer to A 1115”

“PROTOCOLS CFR(s): Protocols must be consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies, complications, and immediate post-delivery care. This Standard is not met as evidenced by: 46010 Based on interviews and records review, the facility failed to follow their protocol for an obstetric patient who presented > 14 weeks pregnant, with possible signs of imminent delivery, by failing to provide an accurate/proper triage and failing to ensure a timely medical screen examination was initiated in the Emergency Department. This failed practice could result in serious harm or death to a patient needing access to emergency stabilization (Patient ID #1). Findings Included: Record review of medical record for Patient ID #1 for date of service 6/14/2025. Patient ID #1 arrived to the facility at 3:47 pm. Triage by Staff RN #77 was initiated at 3:56 pm. Triage completed at 4:01 pm. The patient arrived to OB triage at 4:12 pm. Patient ID #1 delivered a female premature infant neonate at 4:16 pm. The infant, Patient ID #2, expired in OBED area at 4:51 pm after resuscitation attempts failed. Record review of facility policy titled “Triage and Stabilization of obstetrical patients in ED and OBED”, reviewed 6/6/2025 stated “2. For patients > or = 14 weeks gestation arrival to MAIN ED ....c. Patients who are ill-appearing, have unstable vital signs, or are in danger of imminent delivery should remain in the MAIN ED for further evaluation and stabilization by the ED team. The OBED provider and team will respond to MAIN ED.” Record review of facility policy titled “ED: Patient Triage and Classification”, last reviewed 09/23/2022, stated “...4. The triage nurse will document the appropriate triage category on the electronic nursing record. The triage acuity level will then determine which patient care area the patient will move to in order to continue their care in the department.” It further stated “11. Level 1 patients will receive a medical screening exam immediately and be placed in a treatment area. 12. For Level 2 patients every effort will be made to provide a medical screening exam as soon as possible but expected to be within thirty (30) minutes of arrival. 13. The Charge Nurse and/or Attending Physician shall be notified of any delays in bedding Level 1 or Level 2 patients. 14. In high census/high acuity situations Level 2 patients may need to be prioritized based on clinical need and resources available.” Record review of facility policy titled “Patient Transfer Policy (EMTALA and Texas Transfer Act Compliance)”, last reviewed 03/29/2023 stated “B. PATIENT ’ S RIGHTS AND GENERAL PROVISIONS. 1. Medical Screening. The Hospital recognizes the right of an individual to receive, within the capabilities of the Hospital’s staff and facilities: a. An appropriate medical screening examination; b. Necessary stabilizing treatment (including treatment for an unborn child);...” It further stated “C. DEFINITIONS: 1. “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy...” Interview with Staff RN ID # 77 on 9/17/2025 at 09:05 am. He confirmed he was the nurse who had triaged Patient ID #1 in the Main Emergency Department. He stated after reviewing the medical record for the interview, he should have triaged the patient as an ESI 2 instead of ESI 3. He confirmed he did not perform fetal heart tones on Patient ID #1. He confimed he had documented Patient ID #1 had abdominal cramping with pain 10/10. He did not provide any interventions for pain. He confirmed he did not have discussions with the ED charge nurse, any ED provider or OB provider regarding Patient ID #1. He stated post-triage, he called the OBED nurse to give report and facilitate them coming to get the patient and that he had placed her in the designated “OB chairs” in the lobby, to await OBED staff arrival to assume care of patient in OBED department. Interview with ER Manager Staff ID # 58 on 9/17/2025 at 10:20 am. He stated that Patient ID #1 should have had fetal heart tones performed but confirmed he was unable to locate that information in the medical record. He confirmed the medical record reflected the patient arrived to the facility main ED on 6/14/2025 at 3:47 pm, she had triage started at 3:56 pm, triage completed at 4:01 pm, she arrived to the OBED unit at 4:12 pm and delivered at 4:16 pm. He could find no evidence of communication with an ED or OBED provider or provider medical screen initiation during the 29 minute encounter between time of arrival to the facility and to delivery in the 3 West Tower OBED room. He confirmed there were no specific history or examination parameters established in the policy which defined “imminent delivery” to assist with ED triage nursing staff decision making. Interview with ED Medical Director Staff ID # 59 on 9/16/2025 at 1:05 pm. He confirmed there was no evidence in the medical record that ED provider staff had been notified of any concerns regarding Patient ID #1. Therefore, there had been no engagement or assessment performed by ED provider staff prior to moving the patient to OBED unit in the 3 West tower. He stated that the “imminent delivery” descriptor used in the facility’s triage and stabilization policy, as a determinant of whether to remain in the Main ED and have obstetric and neonatal staff respond to the ED for patient care, was “subjective.” He stated that typically implies the “patient is crowning.” However, he confirmed this is not an assessment typically performed in the triage area of the main emergency department.”

“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 an accurate triage and timely medical screening examination (MSE) for Patient ID #1 who arrived by personal vehicle on 6/14/2025 with chief complaint of 24 weeks 3 days pregnant with abdominal cramping, with pain 10/10 and stated contractions of 2 minutes apart. Findings included: Record review of medical record for Patient ID #1 for date of service 6/14/2025. Patient ID #1 arrived to the facility at 3:47 pm. Triage by Staff RN #77 was initiated at 3:56 pm. Triage completed at 4:01 pm. The patient arrived to OB triage at 4:12 pm. Patient ID #1 delivered a female premature infant neonate at 4:16 pm. The infant, Patient ID #2, expired in OBED area at 4:51 pm after resuscitation attempts failed. Record review of facility policy titled “Triage and Stabilization of obstetrical patients in ED and OBED”, reviewed 6/6/2025 stated “2. For patients > or = 14 weeks gestation arrival to MAIN ED ....c. Patients who are ill-appearing, have unstable vital signs, or are in danger of imminent delivery should remain in the MAIN ED for further evaluation and stabilization by the ED team. The OBED provider and team will respond to MAIN ED.” Record review of facility policy titled “ED: Patient Triage and Classification”, last reviewed 09/23/2022, stated “...4. The triage nurse will document the appropriate triage category on the electronic nursing record. The triage acuity level will then determine which patient care area the patient will move to in order to continue their care in the department.” It further stated “11. Level 1 patients will receive a medical screening exam immediately and be placed in a treatment area. 12. For Level 2 patients every effort will be made to provide a medical screening exam as soon as possible but expected to be within thirty (30) minutes of arrival. 13. The Charge Nurse and/or Attending Physician shall be notified of any delays in bedding Level 1 or Level 2 patients. 14. In high census/high acuity situations Level 2 patients may need to be prioritized based on clinical need and resources available.” Record review of facility policy titled “Patient Transfer Policy (EMTALA and Texas Transfer Act Compliance)”, last reviewed 03/29/2023 stated “B. PATIENT ’ S RIGHTS AND GENERAL PROVISIONS. 1. Medical Screening. The Hospital recognizes the right of an individual to receive, within the capabilities of the Hospital ’ s staff and facilities: a. An appropriate medical screening examination; b. Necessary stabilizing treatment (including treatment for an unborn child);...” It further stated “C. DEFINITIONS: 1. “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy...” Interview with Staff RN ID # 77 on 9/17/2025 at 09:05 am. He confirmed he was the nurse who had triaged Patient ID #1. He stated after reviewing the medical record for the interview, he should have triaged the patient as an ESI 2 instead of ESI 3. He confirmed he did not perform fetal heart tones on Patient ID #1. He confimed he had documented patient had abdominal cramping with pain 10/10. He did not provide any interventions for pain. He confirmed he did not have discussions with the ED charge nurse, any ED provider or OB provider regarding Patient ID #1. He stated post-triage, he called the OBED nurse to give report and facilitate them coming to get the patient and that he had placed her in the designated “OB chairs” in the lobby, to await OBED staff arrival to assume care of patient in OBED department. Interview with ER Manager Staff ID # 58 on 9/17/2025 at 10:20 am. He stated that Patient ID #1 should have had fetal heart tones performed but confirmed he was unable to locate that information in the medical record. He confirmed the medical record reflected the patient arrived to the facility main ED on 6/14/2025 at 3:47 pm, she had triage started at 3:56 pm, triage completed at 4:01 pm, she arrived to the OBED unit at 4:12 pm and delivered at 4:16 pm. He could find no evidence of communication with a provider or provider medical screen initiation during the 29 minute encounter between time of arrival to the facility and to delivery in the 3 West Tower OBED room. Interview with ED Medical Director Staff ID # 59 on 9/16/2025 at 1:05 pm. He confirmed there was no evidence in the medical record that ED provider staff had been notified of any concerns regarding Patient ID #1. Therefore, there had been no engagement or assessment perfromed by ED provider staff prior to moving the patient to OBED unit.”

“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: 46010 Based on observation with tour of the facility, interview, and record review, the physical plant and overall hospital environment were not maintained in such a manner that the safety and well-being of patients and staff were assured. The facility had uncontrolled access to facility electrical control panel room, facility chiller room, facility roof and emergency department clinical, supply and medication areas. The facility had unsecured access to the hospital facility through the loading dock. Findings included: Observation on 2/5/2025 at 08:10 am. Surveyor accessed exterior door labeled “Stair G” which was closed and unlocked. This stairwell led to the facilities electrical control panel room which had an unlocked door and was unattended. In addition, it led to a large facilities workroom with chiller controls for the facility. Lastly, it led to a rooftop access, above the emergency room, where surveyor walked through a roof access door, propped open with a piece of wood, onto the facility’s roof. Observation on 2/5/2025 at 08:20 am. Survey team entered the loading dock doors in the rear of the facility, which had signage stating they were locked and to press button for assistance. However, the left door opened when attempted to enter. Survey team walked down hallway, which had numerous linen carts, lined up on the right side of the hallway. The last linen cart was observed to have numerous sets of teal hospital issued scrubs which were unsecured. Survey team continued straight and turned right into West tower first floor. Survey team walked through the hallways and entered the emergency department clinical areas, medication preparation area with pyxis and unsecured patient care supplies which included numerous IV catheter needles and butterfly needles situated on adjacent counter. Observation on 2/5/2025 at 08:30 am. Survey team encountered a male (he identified himself as Vendor Staff ID #92). He was dressed in navy blue scrubs with a disposable red bouffant cap in place. He did not have a visible ID badge. He walked directly into the loading dock doors to access the facility. Survey team confirmed his status as a vendor and he stated he was “going to the operating room.” He stated this was the “closest entrance so he wouldn’t get lost.” Observation on 2/5/2025 at 10:20 am. Surveyor re-toured the prior accessed areas with ED Director Staff ID #76 and Patient Safety Specialist Staff ID #55. Surveyor accessed exterior door labeled “Stair G” which was now propped open with a yellow plastic “caution” floor sign. This stairwell led to the facilities electrical control panel room which had an unlocked door and was unattended. The central door was propped open with a fire extinguisher. In addition, it led to a large facilities workroom with chiller controls for the facility. Lastly, it led up another set of steps to a rooftop access, above the emergency room, where surveyor walked through a roof access door, propped open with a piece of wood, onto the facility’s roof. The roof was noted to have numerous air conditioning units. Record review of NFPA 99 Health Care Facility Code, 2012 edition stated “Chapter 13 Security Management.” It stated “13.4 Security-Sensitive Areas. 13.4.2 Emergency department security shall include appropriate protection, including the following: 1. Control and limitation of access by the general public ... 3. Access control of the treatment area.” It further stated “13.4.4 Medication storage and work areas shall be secured against admittance of unauthorized personnel through the use of the following: 1) access control 2) unique identification for the area 3) secure storage ...” NFPA Security Management code stated “13.5.3 Health care facility security controls and procedure shall comply with life safety requirements for egress.” It further stated “13.8.2 The security management plan shuld include processes and procedures fro controlling access to the health care facility. 13.8.2.1. Exterior entrances shall be provided with locking devices. 13.8.2.2. Locking devices shall comply with applicable federal, state and local requirements. 13.8.2.3 Locking devices shall be properly installed and be in good working order.” Record review of facility’s “Security Officer Duty Schedule” provided by Director of Security Staff ID # 63. It stated “Daily: ... Ensures security of all designated areas and access points.” The description of assigned duties further stated “Controls access of areas and of materials by administering and enforcing building visitors and materials pass programs.” Record review of facility procedure “Hospital Visitation: General, After Hours and Access Control”, last revised 11/14/2023, stated “Procedure Purpose: To provide after-hours visiting and access control measures that expedite patient care and provide for the security and safety of visitors, patients and staff of (facility).” It further stated “Employees, contract labor, and medical staff members must display an approved identification badge during these times to be allowed access. Visitation access for visitors may be made through the main entrance until 9:00 p.m.” Interview with Contractor Staff ID #78 on 2/5/2025. He confirmed he was a contracted vendor who had been working in the facility for “months.” He stated that the electrical control panel room and chiller control rooms had remained “unlocked for 3 months.” Interview with ED Director Staff ID # 76 on 2/5/2025 at 10:40 am while on tour. She confirmed surveyors finding of access to the building from the unlocked loading dock doors and walking through the hallways allowed access to the emergency department clinical areas, medication preparation area with pyxis and unsecured patient care supplies including numerous IV catheter needles and butterfly needles which were situated on adjacent counter. She confirmed that the current construction in the emergency department had caused controlled access doors to be removed. Interview with Director of Security Staff ID #63 on 2/5/2025 at 12:45 pm. He confirmed that all exterior entrances to the facility should be secured or locked except for the main West tower lobby entrance, ED entrance which was manned by security staff and a badge only access entrance for employees in the East Tower. He confirmed that exterior doors with controlled access, locks or badge readers, should not be propped open and accessible to enter the facility. Interview with Chief Operating Officer Staff ID #74 on 2/5/2025 at 2:10 pm. She confirmed that the West Tower has emergency department and operating room expansion/construction efforts under way. She confirmed that the facility should not have doors propped open and unlocked despite the construction in progress.”

“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: 48885 Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant 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 when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1). Patient #1, a four month old, arrived to the facility on 01/09/2024. A review of the patient’s medical record revealed there was no patient history documented related to patient chief complaint of diarrhea, blood in the stool or Patient #1’s dehydration status. The patient was discharged to the care of their gastroenteritis and subsequently admitted by the gastroenteritis on 01/09/2024 at 1440 PM, two hours and 28 minutes following his ED discharge on the same day. Patient #1 remained in the Hospital for 2.5 days. The admitting diagnoses included dehydration, irritability, and absence of tears. Cross reference to Tag A2406 CFR §489.24(c).”

“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: 48885 Based on the record review and interviews, the facility failed to complete an appropriate Medical Screening Exam, within the capability of the Hospital Emergency Department for one of 20 patients (Patient #1) with medical emergency medical conditions, including dehydration and salmonella detection, before Patient #1 was discharged. Patient #1 met with their gastroenterologist on the same day of the emergency room visit at Hospital A. The gastroenterologist directly admitted the patient to Hospital A, where the patient was treated as an inpatient for 2.5 days for a medical condition. Findings included: Record Review: A review of Chart #1 at Facility A: A review of the Emergency Department medical record (Chart #1) for Patient #1 revealed a four-month-old boy presented with “diarrhea since last night and noted blood in the diaper this morning.” The emergency department medical provider notes (MD Staff #1) on 01/09/2024 from 0956 AM - 1213 PM included the following: “Loose stools with increased volume and foul smell have been evident since yesterday ... mucus and blood streaks were observed in the stool ... Differential diagnosis includes but is not limited to infectious colitis, evolving IBD, intussusception, doubt bowel obstruction, less likely from anal fissure ... I am concerned about a severe complexity problem, evidenced by the differential noted above, and associated workup for bloody stools in the setting of fever, URI, and diarrhea, which is a new problem for this patient as evidenced by onset two days ago with progression.” A review of the Emergency Department medical record (Chart #1) for Patient #1 revealed there was no patient history documented related to patient chief complaint of diarrhea, blood in the stool or Patient #1’s dehydration status. A review of Chart #2 at Hospital A: A review of documented provider history and physical notes by the Admitting Physician (MD Staff#2) for patient #1 on January 9, 2024, revealed that the admitting medical doctor identified several symptoms of dehydration in Patient #1, including irritability, decreased fluid intake, and the absence of tears. A review of the medical record for Patient #1 from the Hospital Admission at Hospital A shows that Patient #1 was directly admitted by the gastroenterologist on 01/09/2024 at 1440 PM, just two hours and 28 minutes following her ED discharge on the same day. Patient #1 remained in the Hospital for 2.5 days. The admitting diagnoses included dehydration, irritability, and absence of tears. The Assessment/Reassessment Procedure -Emergency Center: [Last revised 09/01/2022] stated that: Vital Signs Policy: Vital Signs: A complete set of vital signs, including pulse oximetry and pain scale, should be obtained as appropriate for the patient’s level of care. Reassessment: This should occur upon arrival, every shift, or when there is a change of caregiver or status of the patient. It should also include the patient’s vital signs and the Glasco Coma Scale. Abnormal vital signs should be reported to the provider before departure from the emergency center and documented in the Physician Communication Log. The EMTALA POLICY -Emergency Center: [Last revised 09/01/2022] states that: The EMTALA Policy at Memorial Hermann mandates that all patients, regardless of payment method or insurance status, receive an immediate Medical Screening Examination (MSE) upon seeking emergency medical treatment. Stabilizing treatment must not be delayed for any reason. Interviews: During an interview with Hospital admitting Pediatrician MD Staff#2 on 02/06/2024 at 12:00 PM “Q: What are the symptoms of dehydration for a 4.3-month-old baby? A: Less than six wet diapers daily, Dry mouth and tongue, Sunken fontanelle, no tears when crying, Sunken eyes, Irritability and fussiness, Lethargy and drowsiness, Cool, clammy skin, Rapid breathing and heartbeat, Sunken cheeks, and abdomen. Q: Did you see any of those symptoms in this baby when the patient was admitted? A: Yes, a few. The baby was fussy, and the RNs complained of being unable to get an IV. There were no tears. Q: In your opinion, Are these symptoms minor-moderate-severe? A: Moderate, no matter what, because of the baby’s age and mother’s concerns, I would admit. MD Staff #1 must have admitted the patient.” During an interview with Staff #6 an emergency room Registered Nurse, on 02/06/2024 at 1155 AM, found that the patient was always crying in her care. Drinking little milk, fussy. We ran the fluids ASAP after establishing an IV. The mother is frustrated because the patient is cranky, and she is worried about the baby. During an interview with Emergency Department Pediatrician MD, Staff #1 On 02/06/2024 at 01:35 PM Q: Do you recall an incident involving a patient being discharged to the GI office who was a direct admit from the GI clinic? A: Emergency department Pediatrician MD, Staff #1 recalls the patient incident and mentioned communicating with the patient’s mother and the doctor for gastroenterology several times that day. Q: Was there consideration for admitting the patient with dehydration? A: Emergency department Pediatrician MD, Staff #1 mentioned that despite displaying stable vitals, the doctor for gastroenterology guided her to send the patient to his office. Q: Is a 101.7 fever stable for a 4.3-month-old? Isn’t this a sign of infection? A: Tylenol 180mg Po was given before discharge. Q: Can the gastroenterology doctor see patients in this Hospital? A: Yes, he does and directly admits many pediatric patients. I believed it was the best course of action for the patient at the time, and the mother agreed with the care plan. Q: Why did you not admit the patient instead of the doctor for gastroenterology? A: According to the mother, the patient only had two blood-stained diapers, and Salmonella was detected after the patient left. Both the RN and I reported it to the GI doctor’s office. The patient did not show signs of dehydration, was drinking milk, and remained calm and alert.”