Baylor Scott & White Medical Center 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: 51905 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to complete an appropriate transfer to a facility capable of services not offered at Facility A. The physician’s certification of transfer, outlining the risks and benefits for the patient to transfer, was not documented for three of twenty patients (Patient #11, #13, #14). . Based on observation, record review, and interviews, Facility A failed to perform an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if a patient had an emergency medical condition for 1 of 20 patients (Patient #11). . See Tag 2406 and 2409”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to perform an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if a patient had an emergency medical condition for 1 of 20 patients (Patient #11). . Record Review: . Review of Patient #11’s Medical Record: On 05/08/2025 at 5:13 A.M., Patient #11, a fifty-seven (57) year old male, presented to Facility A’s emergency department with a chief complaint of suicide ideation under an emergency detention order. Patient #11 was ordered a behavioral health consult. At 8:48 A.M., the psychiatrist’s assessment noted Patient #11 had a past medical history of bipolar disorder. Patient #11 indicated that he had a plan to kill himself with a gun, but instead called authorities. Patient #11’s diagnostic impression was “bipolar 1 disorder, current episode manic, with psychotic features.” The psychiatrist recommended “intensive psychiatric treatment” due to the “imminent high risk of harm to self.” Patient #11 was administered medications, including Ativan and Seroquel. At 9:36 P.M., Patient #11 was subsequently transferred to a psychiatric facility for emergent psychiatric care. . At 5:23 A.M., Patient #11’s initial blood pressure was elevated at 197/136. Patient #11 did not have any past medical history documented in his chart, though he stated that his blood pressure is always high and does not take medication for it. At 7:56 A.M, Patient #11’s blood pressure was 201/123. At 1:11 P.M. Patient #1’s blood pressure was 182/114. At 4:11 P.M., Patient #11’s blood pressure was 198/120. At 4:32 P.M., Patient #11 was administered 10 milligrams of Norvasc [for blood pressure]. At 6:53 P.M., Patient #11’s blood pressure was 190/114. At 7:18 P.M., Patient #11 was administered 0.1 milligrams of Clonidine [for blood pressure]. At 8:14 P.M., Patient #11’s blood pressure was 169/97. Patient #11’s hypertension was not directly addressed in the physical exam or medical decision-making. . Patient #11 complained of foot pain throughout his admission. Patient #11 takes Colchicine [for gout] at home. Patient #11 had a limited assessment of the musculoskeletal system, which noted a normal range of motion. Patient #11’s foot pain was not directly addressed in the physical exam or medical decision-making. . Patient #11 had abnormal labs. An elevated white blood cell count, an elevated anion gap, and elevated creatinine. Patient #11’s abnormal labs were not directly addressed in the physical exam or medical decision-making. . Facility A failed to complete a medical screening exam when there was a lack of assessment of the patient’s foot pain, hypertension, and lab abnormalities. . Review of “Medical Staff Rules and Regulations” Approved 07/30/2024: “11.B. MEDICAL SCREENING EXAMINATIONS84 (1)Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. The Medical Screening Examination will be provided to any individual regardless of diagnosis (e.g., labor, AIDS), financial status (e.g., uninsured, Medicaid), race, and color, national origin (e.g. Hispanic or Native American surnames), and/or disability. 85 .” (3) The results of the medical screening examination must be documented in the medical record.” . Review of Patient Transfer (EMTALA) Effective 05/27/2025: “ 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: 1. 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; 2. Serious impairment to any bodily functions; 3. Serious dysfunction of any bodily organ or part, or 4. With respect to a pregnant woman who is having contractions: a. That there is inadequate time to effect a safe Transfer to another medical center before delivery, or b. That the Transfer may pose a threat to the health or safety of the woman or the unborn child.” . “Patient Rights [Facility A] recognizes the right of an individual to receive, within the capabilities of the medical center’s staff and facilities: 1. An appropriate medical screening examination; 2. Necessary stabilizing treatment (including treatment for an unborn child); and, 3. If necessary, an appropriate Transfer to another facility even if the individual cannot pay, does not have medical insurance, or is not entitled to Medicare or Medicaid.” . “Medical Screening When a Patient comes to a [Facility A’s] medical center’s dedicated emergency department requesting examination or treatment for emergency care, the Patient must be evaluated with a medical screening exam by qualified medical personnel (“QMP”), as authorized by the medical center’s Governing Body. Following examination and assessment of the patient by an Registered Nurse (“RN”) QMP, the RN communicates with the physician to apprise him/her of the findings. Based on this assessment, the physician determines disposition and gives appropriate orders.” . Interviews: 09/09/2025 at 11:49 A.M: ED Medical Director, Staff A stated that EMTALA [emergency medical treatment and labor act] means that every patient who enters the facility has a right to a medical screening exam. Staff A stated that a patient would have to be medically stable in order to be transferred. For a normal patient, that would include stable vital signs, and with critical patients, the facility would stabilize them to the best of its capability. . 09/09/2025 at 10:40 A.M.: ED Registered Nurse, Staff B stated that EMTALA means that every patient has the right to be seen and examined by a medical provider.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to complete an appropriate transfer to a facility capable of services not offered at Facility A. The physician’s certification of transfer, outlining the risks and benefits for the patient to transfer, was not documented for three of twenty patients (Patient #11, #13, #14). . Record Review: . Review of Patient #11’s medical record from Facility A: On 05/08/2025 at 5:13 A.M., Patient #11, a fifty-seven (57) year old male, presented to Facility A’s emergency department with a chief complaint of suicide ideation under an emergency detention order. At 6:25 A.M., Patient #11 received a medical screening exam and was ordered a behavioral health consult. At 8:48 A.M., the psychiatrist’s assessment noted Patient #11 had a past medical history of bipolar disorder. Patient #11 indicated that he had a plan to kill himself with a gun, but instead called authorities. Patient #11’s diagnostic impression was “bipolar 1 disorder, current episode manic, with psychotic features.” The psychiatrist recommended “intensive psychiatric treatment” due to the “imminent high risk of harm to self.” Patient #11 was administered medications, including Ativan and Seroquel. At 9:36 P.M., Patient #11 was transferred to a psychiatric facility for emergent psychiatric care. Patient #11’s memorandum of transfer documented that the patient was being transferred and considered stabilized. The physician’s certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Review of Patient #13’s medical record from Facility A: On 07/06/2025 at 12:18 A.M., Patient #13, a fifty-six (56) year old female, presented to Facility A’s emergency department with a chief complaint of domestic violence. At 12:27 A.M., Patient #13 received a medical screening exam and was ordered a behavioral health consult.” At 9:29 A.M., the psychiatrist noted that Patient #13 had a history of previous psychiatric treatment and hospitalizations. Patient #13 was experiencing hallucinations and tested positive for cocaine during this admission. Patient #13’s diagnostic impression was “psychotic disorder, unspecified.” The psychiatrist recommended “intensive psychiatric treatment” due to the “imminent high risk of harm to self or others.” The ED physician indicated that, “I do not see obvious signs of assault, nor did I see signs of assault when I saw this patient yesterday. Per (the psychiatric) assessor, patient advised (them) that her plan to escape these frequent assaults is to drive fast and erratically. Therefore, patient is not only a threat to herself but a threat to others. APOWW (apprehension by police officer without warrant) signed.” Patient #13 was administered medications throughout the visit, including Benadryl, Haldol, Hydroxyzine, Geodon, and Ativan for behavioral symptoms. At 5:29 P.M., Patient #13 was transferred to a psychiatric facility for emergent psychiatric care. Patient #13’s memorandum of transfer documented that the patient was being transferred and considered stabilized. The physician’s certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Review of Patient #14’s medical record from Facility A: On 07/31/2025 at 4:35 P.M., Patient #14, a sixty-one (61) year old male, presented to Facility A’s emergency department with a chief complaint of a cardiac problem. At 4:59 P.M., Patient #14 received a medical screening exam, which noted Patient #14’s extensive cardiac history, including a history of coronary artery disease, angioplasty, heart artery stent placement, myocardial infarction, and a coronary artery bypass graft times four. Patient #14’s primary cardiologist was consulted, who stated Patient #14 was seen in the office the same day and was referred to Facility B’s emergency department for increased cardiac symptoms to undergo a cardiac catheterization that had been pending. Patient #14’s diagnostic impression was “unstable angina.” At 7:24 P.M., Patient #14 was transferred to Facility B for an emergent cardiac catheterization. Patient #14’s memorandum of transfer documented that the patient was being transferred and considered stabilized. The physician’s certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Patient Transfer (EMTALA) (Emergency Medical Treatment and Labor Act) Policy, Effective 05/27/2025: “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: 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; Serious impairment to any bodily functions; Serious dysfunction of any bodily organ or part, or With respect to a pregnant woman who is having contractions:” . “Transfer of Patients with Emergency Medical Conditions The medical center may not Transfer a Patient with an Emergency Medical Condition unless: The Patient (or a legally responsible person acting on the Patient’s behalf), after being informed of the medical center’s obligations under this section and of the risk of Transfer, requests the Transfer, in writing and indicates the reasons for the request, as well as that he or she is aware of the risks and benefits of the Transfer; A physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical center outweigh the increased risks to the Patient and, in the case of labor, to the unborn child from effecting the Transfer; or If the physician who made the determination to Transfer a Patient with an emergency condition is not physically present in the emergency treatment area at the time of Transfer, a QMP may sign a certification after consultation with the physician. The physician countersigns the physician certification within a reasonable period of time.” . Review of the Memorandum of Transfer (MOT) Form: For patient’s #11, 13, and 14, the patients were documented as “being transferred and the patient is considered stabilized...” The physician’s certificate of transfer including the risks and benefits of transfer were not documented and signed. The certificate of transfer portion of the form indicates that it should be completed “if patient’s emergency medical condition has not been stabilized prior to transfer. Physician’s certification: based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks of the transfer of the patient and, in the case of labor, to the unborn child from effecting the transfer.” . Interviews: . On 09/09/2025 at 11:49 A.M., a conversation with the ED (emergency department) Medical Director, Staff A, was held. Staff A indicated the definition of a stable patient transfer “is being stabilized to the best of our ability such under reasonable determination that no significant deterioration or risk will happen.” Dr. Weier explained that the patient would have to be medically stable in order to transfer. . On 09/08/2025 at 2:48 P.M., a conversation with the Director of Nursing, Staff E was held. While discussing Patient #14’s MOT (memorandum of transfer) and the incomplete risks and benefits, Staff E stated, “Yes, but I don’t see this guy being unstable at all.” In addition, “The physician thinks he is stable.” .”