St Luke’s the Woodlands 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: 23032 Based on interview and record review, the hospital failed to comply with the EMTALA (Emergency Medical Treatment and Labor Act) requirements at 42 CFR §489.24(d)(1). The hospital failed to maintain an accurate & complete central log for each individual who came to the emergency department [ Patient # 1] Refer to Tag A-2405 The hospital failed to provide a medical screening exam to a patient who presented to the emergency room for for care & treatment [ Patient # 1] Refer to Tag A-2406”

“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: 23032 Based on interview and record review, the facility failed to maintain an accurate central log for each individual who comes to the emergency department. Patient ID # 1 was brought to the ER on 4/10/2026 for care and treatment and was not listed on the facility “EMTALA Log.” Findings concluded: Review of facility policy titled “ Emergency Treatment and Labor Act (EMTALA) Policy,” last reviewed December 11, 2024 showed: “GENERAL POLICIES: B. Hospitals are required to maintain a Central Log. The Central Log includes the patient logs from the dedicated emergency department (DED) and, either by direct or indirect reference, patient logs from any other areas of the hospital that may be considered DEDs, or where an individual may present for emergency services or receive an (sic) Medical Screening Denomination (MSE), such as the Labor & Delivery Department. The Central Log should include the following patient demographics ( age /sex /gender /record number); nature of complaint; time of departures /transfer.” ~~~~~~~~ Review of complaint intake TX00561865 showed allegation that Patient # 1 was brought to the ED on 4/10/2026 following a fall and was not examined and treated. Review of the facility “ EMTALA Logs” for April 9,10,11, 2026 failed to show Patient # 1 listed on any of those dates. Surveyor made a follow-up telephone call on 5/13/2026 to the complainant to verify the date the patient was brought to the ER. Complainant verified the date was 4/10/2026. Complainant stated she had the ID band that was placed on Patient #1 and emailed a photo of the ID Band to surveyor. Review of the photo of the ID band showed : Patient # 1’s name, date (4/10/2026), and medical record number (MRN). On 5/13/2-026 , Staff ID - G, patient access representative (rep), was given the MRN number and asked if she could locate the patient in the facility computer system. She located a computer entry for Patient ID # 1 (by name) but it was undated and incomplete. On 05/13/2026 at At 2:20 PM surveyor spoke with Staff ID-H, Patient Access Manager, as she looked up the MRN and account number on her computer. She found the account for Patient # 1 and reviewed the “audit trail “in real time with surveyor . She saw an entry for 4/10/2026 and read some of the information : - 1022 PM-arrival time: patient demographics - Patient Guarantor: name listed - 1030 PM- Provider added - Reason: Fall, head injury She went on to say it was confusing because there were 2 different accounts and several encounter cancellations for 4/10/2026. She stated the entries were made by registration Staff ID-I, patient access rep. Staff ID-H provided surveyor with documentation of the registration audit trail for Patient # 1. On 5/13/2026 at 2:35 PM surveyor conducted a telephone interview with Staff ID # I, patient access rep. He was provided the date and approximate age of the patient. He was asked what he recalled from this encounter. Staff ID-I said he remembered this patient and the grandmother. He said he was going to check him in. It was pretty unclear if the grandparents had genuine guardianship. We needed the guardianship papers first. He said he went and talked with the RN in the back. I was told to say there is a lot of liability, and we just want to make sure of the guardianship. I asked them to bring the papers. He said he recalled the grandparents brought the papers in at some point but refused to provide them to be scanned and they left. Staff ID-I said he canceled the registration. During an interview on 5/13/2026 with Staff -B, Director of Patient Care Services, she said registration staff has been trained to ensure patients see the providers for medical screening first and then worry about guardianship, insurance etc.. She went on to say that Staff-ID- I should not have canceled the registration. This was the reason this patient was not on the EMTALA Log for 4/10/2026.”

“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: 23032 Based on interview and record review the facility failed to provide an appropriate medical screening examination to a patient who was brought to to the emergency department (ED). Patient ID # 1 was brought to the ER on 4/10/2026 for care and treatment following a fall with head injury. He was not provided a medical screening examination. Findings concluded: Review of facility policy titled “ Emergency Treatment and Labor Act (EMTALA) PROCEDURE, Clinical A-5000P,” last reviewed December 11, 2024, showed: “PROCEDURE A. SCREENING and STABILIZATION REQUIREMENTS: 1. Medical Screening Examination: All individuals who come to the dedicated emergency department(DED) who present on Hospital Property requesting or requiring examination or treatment for an Emergency medical Condition (EMC) shall receive an appropriate Medical Screening Examination ( MSE) The scope of the MSE must be tailored to the presenting complaint and the medical history if the individual. It may range form a simple examination to a complex ecnaimation that may include laboratory tests, diagnostic imaging lumbar punctures, other diagnostic test and procedures and the use if in call physician specialists. ~~~~~~~~ Review of complaint intake TX00561865 showed allegation that Patient # 1 was brought to the ED on 4/10/2026 following a fall and was not examined and treated. Review of the facility “ EMTALA Logs” for April 9,10,11, 2026 failed to show Patient # 1 listed on any of those dates. Surveyor made a follow-up telephone call on 5/13/2026 to the complainant to verify the date the patient was brought to the ER. Complainant verified the date was 4/10/2026. Complainant stated she had the ID band that was placed on Patient #1 and emailed a photo of the ID Band to surveyor. Review of the photo of the ID band showed : Patient # 1’s name, date (4/10/2026), and medical record number (MRN). On 5/13/2-026 , Staff ID - G, patient access representative (rep), was given the MRN number and asked if she could locate the patient in the facility computer system. She located a computer entry for Patient ID # 1 (by name) but it was undated and incomplete. On 05/13/2026 at At 2:20 PM surveyor spoke with Staff ID-H, Patient Access Manager, as she looked up the MRN and account number on her computer. She found the account for Patient # 1 and reviewed the “audit trail “in real time with surveyor . She saw an entry for 4/10/2026 and read some of the information : - 1022 PM-arrival time: patient demographics - Patient Guarantor: name listed - 1030 PM- Provider added - Reason: Fall, head injury The Patient Access Manager went on to say it was confusing because there were 2 different accounts and several encounter cancellations for 4/10/2026. She stated the entries were made by registration Staff ID-I, patient access rep. Staff ID-H provided surveyor with documentation of the registration audit trail for Patient # 1. Review of the documented information shown in the audit trail included (*not all inclusive): Date/time of arrival: 04/10/2026 at 10:22 PM Patient name : Patient # 1 Date of Birth (DOB): 05/02/2024 Reason for visit: fall /head injury Name of Guarantor: name - (grandmother)-address and phone number was documented Provider assigned: Staff -ID-K, MD Insurance information: Medicaid of Texas (lapsed) and United Healthcare-MGD On 5/13/2026 at 2:35 PM surveyor conducted a telephone interview with Staff ID # I, patient access rep. He was provided the date and approximate age of the patient. He was asked what he recalled from this encounter. Staff ID-I said he remembered this patient and the grandmother. He said he was going to check him in. It was pretty unclear if the grandparents had genuine guardianship. We needed the guardianship papers first. Staff ID-H was asked if Patient # 1 was seen by a nurse or provider ? He said “no.” He said he went and talked with the RN in the back. “I was told to say there is a lot of liability, and we just want to make sure of the guardianship. I asked them to bring the papers.” He said he recalled the grandparents brought the papers in at some point but refused to provide them to be scanned and they left. Staff ID-I said he canceled the registration. During an interview on 5/13/2026 with Staff -B, Director of Patient Care Services, she said registration staff has been trained to ensure patients see the providers for medical screening first and foremost and then worry about guardianship, insurance etc.. She went on to say that Patient # 1 should have received a medical screening examination .”

“UPDATED EXAM CFR(s): Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies: (ii) An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within 24 hours after admission or registration when the medical history and physical examination are completed within 30 days before admission or registration and except as provided under paragraph (b)(1)(iii) of this section. This Standard is not met as evidenced by: 37490 Based on Medical Staff Bylaws review, medical record review, and interview, the hospital failed to ensure an updated examination of the patient, including any changes in the patient’s condition, was documented and in the medical record prior to the surgery when the medical history and physical examination (H&P) was completed within 30 days before admission or registration for one of six patient surgical records reviewed (ID# 1). Findings include: Review of facility Medical Staff Bylaws showed the following: The privilege to perform medical histories and physical examinations shall be granted to qualified applicants by the board. A medical history and physician examination shall be completed no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. Review of medical record for patient (ID # 1) for surgery date of service 12/13/2023 showed no updated History and physical prior to procedure. Interview with staff (ID#53) on 9/26/23 at 2:30 PM confirmed that if the H&P are completed 30 days prior to date of service the update must be completed after admission and before the surgery.”

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 37490 Based on record review and interview, the hospital failed to ensure that there was a properly executed informed consent for 2 of 6 surgical patient records reviewed (ID#s 3 and 5). Findings include: Record review of facility policy titled “Disclosure and Consent for Medical and Surgical Procedures (Informed Consents)” showed the following information: POLICY: A. It is the policy of St. Luke’s Health (St. Luke’s) Texas Division to comply with applicable regulatory and accreditation requirements pertaining to Disclosure and Informed Consent for medical treatment or care and surgical procedures, including specific procedures outlined by: -Code of Federal Regulations (42 CFR Part 482), CMS Conditions of Participation, Appendix A -Texas Administrative Code (TAC) Hospital Licensing Rules, Title 25 Chapter 133 PROCEDURES 2. Discussion for Informed Consent d. Verify that the consent form is completed and patient or his/her surrogate decision maker signed the consent form prior to commencing the medical treatment or surgical procedure. e. Sign with date and time ... 4. Preparation of the Consent Form b. Enter the following information on the consent form for the patient or surrogate decision maker to review, vi. Whether, as permitted by Texas law, qualified non physician healthcare providers (surgical technicians, surgical assistants, CRNAs and or AAs) we’ll be performing important tasks that are within their scope of practice, and for which they have been granted privileges by the hospital. ix. The name of the provider administering the anesthesia and/4 analgesia. 10.Witness a. A witness to the signature of the patient or his/ her surrogate decision maker is required on the consent form. c. The witness attest to the fact that the patient or his/ her surrogate decision maker is the person who signed the consent form in his/her presence. d. Date, time, sign and print his/ her full name, and enter his/her address is provided on the consent form. Medical record review for patient (ID #3)Disclosure and Consent -Anesthesia for date of service 9/26/23 showed the following: Physician Anesthesiologist and Certified Registered Nurse Anesthetist was left blank. Medical Record Review for patient (ID#5) for date of service 9/26/24 showed the following: Disclosure and Consent- Anesthesia- Physician Anesthesiologist and Certified Registered Nurse Anesthetist was left blank. Disclosure and Consent for Medical and Surgical Procedures showed no witness name, signature and time recorded. Interview with staff (ID 56) PACU manager on 9/26/24 at 12:37 PM confirmed the above findings.”