Texas Childrens Hospital

“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: 37490 Based on interview and record review, the facility failed to ensure an appropriate medical screening exam (MSE) was conducted and documented for 1 of 25 sampled Emergency Department patients (ID#12). Findings included: Review of facility policy titled “Medical Screening Exam EC/OB Procedure,” showed the following: PROCEDURE STATEMENT: A Medical Screening Examination (“MSE”) is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition (EMC). The MSE must be conducted by an individual who is determined qualified by hospital rules and regulations or bylaws to be a Qualified Medical Personnel (“QMP”). The medical screening examinations is an ongoing process that ranges from a simple process involving only a brief history and physical examination to a complex process involving ancillary studies and procedures, depending on the individual ’ s presentation. 5. The QMP determines the requirements for the medical screening examination based upon his/her assessment of the patient ’ s medical condition, and will follow the Medical Screening Exam workflow for his/her respective Texas Children ’ s EC or the WAC. 6. Each individual ’ s MSE shall be documented in the electronic medical record. Review of facility Medical Staff Rules and Regulations showed the following: B. MEDICAL RECORDS B-1. Each and every member of the Medical Staff participating in the clinical care of a) patient is responsible for the complete, and therefore pertinent, accurate, timely and legible documentation of their portion of that care in the medical record. Whenever possible, clinical encounters should be documented immediately after their occurrence, at the point of care. B-2. Elements of the Medical Record b) Documentation of outpatient encounters (i.e., in clinics, same day surgery, emergency center and observation units) must include the reason for the encounter, pertinent history and physical examination findings, and the provider ’ s impression and plan of care. E. Emergency Services E-3. An appropriate medical record shall be kept for every patient receiving emergency service and shall be incorporated in the patient’s Hospital record, if such exists. The record shall include: a. Adequate patient identification; b. Information concerning the time of the patient’s arrival, means of arrival and by whom transported; c. Pertinent history of the injury or illness, including details relative to first aid or emergency care given the patient prior to his arrival at this Hospital; d. Description of significant clinical, laboratory and roentgenologic findings; Medical record review for patient (ID#12) for date of service 12/20/2025 showed the following: The patient is a 15-year-old male brought to the emergency room for a head injury/concussion at 23:52. Triage was completed 12/21/2025 at 00:39, Medical Screen Examination (MSE) complete at 00:40. The record showed no evidence of provider engagement or assessment or evaluation findings. 12/21/2026 at 02:26 the patients disposition was left without being seen (LWBS)/ left before treatment complete (LBTC). Interview with STAFF (ID#64) on 02/06/2026 at 1:20 PM stated 2/6/26 at 1:20 PM. She confirmed there was no evidence of a note by provider for MSE engagement for patient (ID#12). She stated that she would expect to see documentation by a provider for any patient assessment which was performed in the emergency department.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46010 Based on record review and interview, the facility failed to ensure staff followed policies and procedures to ensure care in a safe setting for 1 of 10 patients reviewed (Patient ID #1). The facility failed: 1) To document a nursing and/or provider assessment immediately after medical restraint application, obtain an order, in a timely fashion for application of medical restraints and failed to document the date/time, indication for placement of the restraints, as well as who applied them. 2) To fully investigate a grievance, including an allegation of physical assault by a staff member in the clinical setting of a patient developing a bruise, which extended from the right side of mandible, down onto neck and extending to right upper chest below clavicle, that had no known cause/etiology, while the patient was hospitalized at the facility. 3) To notify the patient’s attending physician of an allegation of assault by a staff member and ensure attending physician involvement/record completion. Findings included: Record Review of facility policy titled “Patient Rights and Responsibilities”, updated 06/2023, stated “As a patient at Texas Children’s, each patient has the below rights: ... Right to information about patient rights: The patient has the right to receive, at the time of admission, information about the hospital’s patient rights policy(ies) and the mechanisms for initiation, review, and when possible, resolution for patient complaints concerning quality of care. Right to be free from abuse: The patient has the right to be free of all forms of abuse, neglect, harassment and exploitation. Right to be free from restrain or seclusion: The patient has the right to be free of restraints or seclusion, unless medically necessary.” It further stated “Rights of recourse: Each patient or medical decision maker has the right to: Voice a complaint about quality of care or service through the following process: If your concern is not resolved, you may file a grievance by submitting it verbally or in writing. The hospital will explain the grievance process and the timeframe for processing. The hospital will send a written response of its decision, which will include: Name of Hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process and date of completion.” Record Review of facility policy titled “Restraint Procedure”, effective 01/18/2023, stated “Definitions: Medical/Surgical Restraints: Use of mechanical device to involuntarily limit the movement of the whole or a portion of ta patient’s body as a means to protect and improve the patient’s well-being by preventing injury or the removal of lines/tubes needed for patient care and treatment. ... 6. Initiation and Ordering of Medical Surgical Restraints 6.1 The RN assesses the patient’s mental, behavioral, and physical status in an attempt to determine the appropriate use of a medical surgical restraint. 6.2 The assessment must determine the risks associated with the use of the medical surgical restraints. The determination to use medical surgical restraints should outweigh the risk of not using the treatment. 7. Ordering of Medical Surgical Restraints 7.1 The order for a medical surgical restrain must be obtained from a physician or APP involved in the care of the patient prior to the application of the restraint, except in emergent situations. 8. Application of Medical Surgical Restraints 8.1 Medical Surgical Restraints are applied and reapplied by an individual with assessed and validated competencies. 9. Assessment and Documentation of the patient in Medial Surgical Restraints. 9.1 Patients in medical surgical restraints will be assessed immediately after restraints are applied to assure safe application/initiation. 9.2 The following information should be documented in the electronic medical record at the time of initiation of medical surgical restraints: Clinical judgement for use, Less restrictive alternatives attempted/utilized and their effectiveness, Time of application and type of restraint applied, Patient/Caregiver notification and education, Patient’s response to restraints, Any and all orders related to medical surgical restraints, Care plan should be initiated within 24 hours of application, Physician or APP notifications regarding change in status, Skin assessment and Neurovascular status. 9.3 The RN will assess and document at least every 2 hours while the patient is in restraints...” Record review of facility policy titled “Patient Abuse involving Workforce Staff Members”, effective 09/26/2024, stated “1.2 Department/Unit Leadership 1.2.1 When allegations of suspected abuse are reported to leadership, the leadership should notify the House Supervisor and the affected patient’s Attending Physician.” Record review of facility “Medical Staff Rules and Regulations”, amended August1, 2020, stated “A-2. The attending physician shall be responsible for the overall medical care and treatment of each patient in the hospital, and for the prompt completion and accuracy of medical records.” Record review of Patient ID #1 electronic medical record on 7/23/2025 at 08:50 am with RN Staff ID #59 showed the following: Female toddler, admitted to facility on 6/8/2025 as a transfer into the Pediatric Intensive Care Unit. Medical restraints were documented on 6/9/2025 at 08:00 am in the nursing assessment as “continued” by Staff RN ID #72. The patient was extubated and subsequently transferred to the 10 West Tower medical floor on 6/11/2025 at 3:30 pm. Physician resident staff ID # 67 on 6/11/2025 at 4:28 pm stated “Bruising R side of neck and over neck and upper chest over collar bone.” The physician “Neurology transfer note” written by physician Staff ID #67 stated that the mother alleged PICU nurse had held child down aggressively to the bed and this caused bruising. He stated he informed charge nurse and patient advocate. There was no documented discussion or report to the patient’s attending physician of these allegations located in the medical record. The “Neurology transfer note” written by physician staff ID # 67 stated “Co-Sign Needed-Addendum.” Quality Staff ID # 57 confirmed there was no evidence of physician attestation or involvement documented on the transfer note and that it should have been completed. Record review of security detail report event #5624 completed on 6/12/2025 at 2:05 am regarding Patient ID #1 completed by Security officer Staff ID #91. Report stated “After completing the staff interviews, Security and TMC officers returned to West Tower to update (mom). Officers explained that based on information gathered “there was insufficient evidence to support criminal charges against Staff RN #70. The actions described by the medical staff were consistent with standard medical procedures and the bruising may not definitively indicate misconduct. Matter remains under review by family advocacy and hospital leadership and further investigation will be conducted as needed.” The report stated “reported to police yes, reported to supervisor yes, requires investigation No.” Interview 7/23/2025 09:20 am with PICU Staff RN #59. She stated that the order for medical restraints is fired as a task for physician order when the clinical staff chart “applied” in their nursing assessment. She stated that because the nursing staff failed to document, at the time of application, it likely did not trigger the physician team to enter the order at or near the time of application. She stated that the staff have 24 hours to obtain an order for medical restraints. Interview 7/23/2025 with Director of Quality (DQM) Staff ID # 57, she stated that the facility investigated a 30 minute period of time surrounding the time the mother reported observing clinical care in the Pediatric ICU unit with Staff RN #70. Staff ID # 57 was unable to provide evidence that the facility expanded the investigation to evaluate for other sources of bruising to the child’s neck related to aggressive staff contact, medical device failure, etc. Interview 7/24/25 at 5:00 pm with Police Officer Staff ID # 82. He stated the police investigation was dependent on the hospital’s investigative process as the police officers are “not medical experts.” He confirmed he observed bruising on the child’s neck when he responded to the facility’s call for officer assistance. He stated he felt that the bruising appeared “more fresh” as it had some reddened appearance to it and that the timeline did not match up. He confirmed he was the officer who wrote the official police report and participated in interviews of the witnesses. He confirmed there was no etiology provided for the bruising by the facility. He confirmed the case was closed based on the hospital’s declaration that the care provided was the “standard of care.” Interview with Director of Patient Advocacy Staff ID # 85 with review of grievance process on 7/23/25 at 12:30 pm. She confirmed a grievance was received on 6/11/2025. She reported records reflected physician staff ID # 67 had contacted patient advocacy on 6/11/2025 and relayed the mom expressed concern about PICU staff patient care/contact resulting in bruising on her child. Patient advocate staff ID # 92 met with the mother who relayed numerous concerns including staff referring to her child as a “wild child”, staff disagreement she witnessed about her child’s care between staff RN # 70 and Physician assistant staff ID #93 on the same shift where she reported observing Staff RN #70 be excessively forceful while restraining child in Pediatric ICU. Grievance was referred to clinical staff. Records reflected a “6222 Meeting” was assembled related to the allegation of abuse by a staff member. However, there was no investigation or follow-up related to mother’s other related concerns expressed in grievance. Staff ID #85 confirmed she did not have follow-up on those items (wild child, staff discord about care of Patient ID #1).”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 46010 Based on medical record reviews, audio record review, document reviews, and interviews, the facility failed to ensure a safe discharge for 1 of 24 patients reviewed (Patient #1). The facility failed to have a comprehensive Emergency Department (ED) discharge policy and procedure, which included coordination of ambulance discharges/transfers which are completed by Emergency Department staff. Findings included: Patient ID #1 arrived to Facility A ED on 10/2/24 at 00:22 am, under a Emergency Detention Order from Ft. Bend Sheriff department and accompanied by group home staff member, with complaints of suicidal and homicidal ideation. He had normal vital signs and was triaged and had a medical screen evaluation initiated. Records reflect he had a social work mental health assessment which revealed the patient had Attention Deficit Hyperactivity Disorder and no other mental health history. He was assessed and ofund to be no longer with suicidal or homicidal ideation. Medical record stated that it was believed that Patient ID #1 had an episode of aggression following a pillow fight. The medical team and mental health social worker felt it was appropriate to discharge patient home to the group home and provided outpatient follow-up mental health resources. The group home staff agreed with the plan of care presented. The ED charge nurse, Staff ID # 79, called the contracted EMS agency and stated a need for an ambulance to bring patient to Facility B as she stated this was the origin of patient. Facility A medical record stated the patients disposition was “discharged.” There was no Memorandum of Transfer located in Facility A Medical Record and no documentation of acceptance by FAcility B administration. Record Review: Review of Contracted EMS Ambulance Medical Records: “Prehospital Care Report Summary stated Date:10/02/2024 Call #:0198 Booklet:59900978 Branch: Houston Time Zone:GMT-06:00 Central. Call Information: Billing Disposition: Treated/Transported Unit Disposition: Patient Contact Made Patient Evaluation/Care Disposition: Patient Evaluated and Care Provided Crew Disposition: *Initiated and Continued Primary Care Transport Disposition: *Transport by This EMS Unit (This Crew Only) Unit #: XB971 - XB971, Ground-Ambulance Trip Type: Initial Trip Service Requested: Hospital-to-Hospital Transfer Incident Facility: (Redacted) Facility A with physcial address listed . NPI: 1184078743 Incident Location Type: Hospital Receiving Facility: (Redacted - Facility B with physical address listed) Destination Type: Hospital Emergency Department Dest. Reason: Specialist Care Condition of Patient At Destination: Unchanged Loaded Mileage: 21.0 (Total Mileage: 21.0) Resource Code: Psychiatric Care Call Received: 04:20:11 Dispatched: 06:46:51 En Route: 06:47:00 At Staging Area: On Scene: 07:43:59 Patient Contact: 07:46:10 Transfer of EMS Patient Care: Left Scene: 08:10:49 At Destination: 08:52:38 Narrative History Text from EMS Run Record: XB971 was dispatched non-emergency to (redacted) Facility A to transfer a patient for mental/psychiatric care at (redacted) Facility B for a higher level of mental/psychiatric care not available at Facility A. HPI: Patient was brought in by police under EDO (Fort Bend Sheriff) from patient’s group home with c/o: SI/ HI. Patient made statement of “wanting to harm other residents and staff members.” Diagnosis: Behavioral Issues. Per Facility A nurse patient is returning to facility for continued treatment ....” Patient contact was made; Upon entering the patient’s room.... Patient report was given & patient paperwork, nurse contacted case worker for MOT: crew was informed MOT was not necessity due to patient had come from Facility B.” Audio Transcript from Facility A ED Charge Nurse Staff ID #79 to EMS Dispatch reviewed: EMS (company redacted) dispatch:” Inaudible, how can I help?” Facility A Charge Nurse: “Hey this is (redacted, Staff ID #79) at Facility A (redacted). I need a truck please.” EMS dispatch: “Where is it going to?” Facility A Charge Nurse: “Redacted (Facility B) in the med center” EMS dispatch: “Is that like a psych facility?” Facility A Charge Nurse: “Yes” EMS dispatch: “Female or Male” Facility A Charge Nurse: “Male” EMS dispatch: “Voluntary?” Facility A Charge Nurse: “Yes, yeah he came from that facility” EMS dispatch: “Less than 300 pounds?” Facility A Charge Nurse: “Yes” EMS dispatch: “Last name? First Name?” Facility A Charge Nurse: (Redacted) Patient ID #1, name was spelled out EMS dispatch: “What’s your name? “ Facility A Charge Nurse: Redacted (Staff ID #79 provides her first name) EMS dispatch: “Your title?” Facility A Charge Nurse: “I’m the charge nurse ...” EMS dispatch: “Where we going?” Facility A Charge Nurse: “To redacted (Facility B)” EMS dispatch: “Do you have a room number there?” Facility A Charge Nurse: “No, he’s just going to intake?” EMS dispatch: “Diagnosis?” Facility A Charge Nurse: “Behavioral problem” Facility B Medical Record Review of Patient ID #1 was performed for date of service 10/2/24 at 09:35 am by Staff Physician # 99. The Emergency Department physician note stated “Per the admin and EMS, (Facility A) then sent/transferred the patient to us for a psychiatric evaluation under the false belief that (Redacted -Facility B) was an inpatient psych facility. Please note that our ED never received any communication or transfer request from TCH-West prior to the patient’s arrival.” Facility A occurrence log identified Patient ID #1 with an occurrence entered by ED Manager Staff ID # 79 on 10/2/24 and this was labeled “transfer issue.” This occurrence entry was signed off by ED Manager Staff ID #79, who was also functioning in the charge role per facility records, as “reviewed and completed.” However, Facility A failed to complete a thorough internal investigation, which fully identified the problem with the discharge via EMS services and therefore failed to implement corrective actions to reduce the chance of this occurring again. Policy Reviews: Facility A’s “ Transfer of Patients to and from (Redacted - Facility A)’s Hospital Procedure”, version 5, stated “2.2. The Hospital’s Mission Control will coordinate all requests for transfers of individuals between Facility A’s Hospital and other healthcare facilities. “ Interviews: Interview with Medical Record Review of Patient ID #1 with Facility A Clinical Specialist #53 on 11/18/24 at 12:35 pm. She confirmed she was unable to locate and Memorandum of Transfer (MOT) form for Patient ID #1 for date of service 10/2/2024. She stated that Physician ID #75 had ordered Patient ID #1 to be discharged and stated she would not expect to locate a Memorandum of Transfer (MOT). Telephone Interview on 10/29/2024 at 2:30 pm with Facility B CNO Staff ID #100. She stated that Patient ID #1 arrived at the Facility B ED with (redacted) EMS ambulance personnel on a stretcher and companied by a caregiver. She stated that Facility B had no knowledge of the patient’s transfer. The house supervisor had not received a transfer request. She stated the facility has an inpatient geriatric psychiatric unit and would not have accepted a teenage patient for inpatient psychiatric care. She stated the patient arrived with no medical records, no MOT (memorandum of transfer form). She stated that the caregiver accompanying patient had requested of Facility A staff for patient to be discharged home and had been told by Facility A staff that “he must be transferred.” She stated she called Facility A’s Emergency Department Charge Nurse at approximately 10:00 am, when the patient arrived to Facility B for more information, and was told this was a night shift mistake and they had no other information. Interview with Director of Transfer (also known as “Mission Contol”) Center Staff ID # 60 on 11/18/2024 at 12:50 pm. She confirmed there was no evidence of Facility A transfer center involvement in coordination of transfer of care for Patient ID #1 from Facility A to Facility B via EMS service. Telephone Interview with ED Nurse Manager Staff ID # 79 on 11/18/2024 at 2:25 pm. She stated she was not aware that Facility B was a hospital. She confirmed she is an ED Night Shift Manager at Facility A, who was also functioning in the ED Charge Nurse Role on 10/2/2024 when Patient ID #1 was seen and evaluated. She stated she had called Facility A’s contracted EMS service to bring patient to Facility B, after he was discharged from the ED of Facility A, because she believed he had originated from Facility B. Interview with Director of Accreditation Staff ID # 51 on 11/19/24 at 3:30 pm. She confirmed the facility does not have a policy, procedure or protocol which guides discharge of patients from the ED, utilizing EMS services, and coordinated by ED clinical staff. Interview with Patient Safety Manager Staff ID # 81 on 11/18/2024 at 2:45 pm. She confirmed that she had signed off on the incident report, which included improper discharge from the ED and allegation of EMTALA violation, based on comment provided by ED Nurse Manager Staff ID # 79 which stated “Address written on MOT was verified with caregiver at bedside. Review of face sheet lists different address from group home.” She confirmed she was unaware ED Nurse Manager Staff ID #79 was involved in the patient’s care and improper discharge coordination. She confirmed she was unaware that the comments stating” MOT had incorrect address” was inaccurate because there was no MOT for this patient located in the medical record. She confirmed that staff members, involved in reported occurrences, should not be solely responsible for investigation and follow-up. However, confirmed this is not stipulated in facility’s occurrence policy.””

“A complaint investigation survey was conducted at the facility on 11-4-2024, with the Director of Safety, Assistant Director of Safety, Food Service company, and the Director of Food & Nutrition, to discuss the purpose of the complaint investigation survey and the survey process. An opportunity was provided for questions and discussion. The complaint investigation survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital ’ s compliance. A complaint investigation survey exit conference was conducted on 11-4-2024, with the Director of Safety, Assistant Director of Safety, Food Service company, and the Director of Food & Nutrition. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 28433 Based on observations during the tour of the facility on the afternoon of 11-4-2024, with the Director of Safety, Assistant Director of Safety, Morrison Healthcare Food Services, and the Director of Food & Nutrition, the facility failed to provide acceptable cleaning of the burner flue vent. Vent should be cleaned on a regular basis.”

“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: 45847 . 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). . On 10/02/2024 and 10/03/2023, Patient #1 presented to the emergency department with complaints of lethargy and dizziness in a 3-year-old and possibly still being intoxicated/affected by the pills (possibly Ativan or Adderall) taken (by accidental ingestion) the night before. Medical records show that Patient #1 was not provided with an appropriate MSE (medical screening examination) at either ED visit, and left from the ED without being seen (LWBS) without ever being examined by a physician/medical provider. There were no documented follow-ups to the patient’s status during either visit and there were no reassessments of patient vital signs during the second visit. Furthermore, there was no thorough history and physical examination identified in the provided medical records that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history, etc. . 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: 45847 . Based on interview and record review, the hospital failed to provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1). Patient #1 presented to the emergency department (ED) with complaints of lethargy and dizziness in a 3-year-old and possibly still being intoxicated/affected from an accidental ingestion (possibly Ativan or Adderall). Patient #1 was not assessed by a physician or qualified medical person (QMP) to determine if they had an emergency medical condition (EMC) and left from the ED without being seen (LWBS) without ever being examined by a physician/medical provider. . The Findings Included: Medical Record Review, Visit #1: A medical record for Patient #1 for a visit on 10/02/2023 at 2358 PM was conducted. The medical record shows that Patient #1 arrived via EMS (Emergency Medical Services) at 2358 PM following complaints of lethargy and dizziness in a 3-year-old. Patient #1 was thought to have possibly taken some of the grandfather’s pills the night before, possibly Ativan. A Medical Screening Exam (MSE) was initiated by ED RN (Staff #10) and vital signs were obtained. The vital signs were as follows: Blood pressure 114/71, pulse 132, respirations 28, temperature 98.5, oxygen saturation 98% on room air (RA). FLACC Score = 0, and a Glasgow Coma Scale = 15. . Staff #10 did not complete the focused triage assessment per their policy. Staff #10 did not document medications or allergies, a weight or height, and there was no documented pain assessment per the facility’s policies. Staff #10 documented that there was no Emergency Medical Condition (EMC). No ED Physician ever evaluated Patient #1. There was insufficient data to make the determination that an EMC did not exist. . There was no evidence found that a Primary QMP (qualified medical personnel) was readily available and an ED physician/provider did not provide a medical screening exam or evaluate Patient #1 for symptoms per the facility’s policies. There was no thorough history and physical examination identified in the provided medical record that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history etc. There was no documented physical assessment or reassessment per the facility’s policies, and no testing was ordered or completed during this visit. There was insufficient data to make the determination that an EMC did not exist. . The acuity was not documented during this visit per the facility’s policies. . Patient #1 was taken by her mother and the medical record notes it as a “LWBS” (left without being seen) on 10/03/2023 at 0324 AM after waiting three hours and 25 minutes to be seen. . Medical Record Review, Visit #2: Patient #1 returned with her mother the following morning, 10/03/2023 at 1134 AM. Patient #1’s mother was concerned that the child woke dizzy and possibly was still intoxicated/affected by the pill taken the night before. The chief complaints were noted as “accidental substance ingestion at 9 PM. Vital signs documented at 1135 AM are as follows: blood pressure 108/65, pulse 122, and respirations 18. It was documented that a MSE was initiated at 1135 AM by an ED RN (Staff #11). Vital signs were obtained again at 1349 PM and 1641 PM. The acuity documented on 10/03/2023 at 1138 AM was (3) Emergent and at 1144 AM (2) Critical. . Staff #11 did not complete the focused triage assessment per their policy. Staff #11 did not document medications or allergies, a weight or height, and there was no documented pain assessment per the facility’s policies. Staff #11 documented that “Emergency Medical Condition (EMC) does not exist”. No ED Physician ever evaluated Patient #1. There was insufficient data to make the determination that an EMC did not exist. . There was no evidence found that a Primary QMP was readily available, and an ED physician/provider did not provide a medical screening exam or evaluate Patient #1 for symptoms per the facility’s policies. There was no thorough history and physical examination identified in the provided medical record that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history etc. There was no documented physical assessment or reassessment per the facility’s policies, and no testing was ordered or completed during this visit. . Patient #1 was again taken from the ED by her mother, and it was documented at 1801 PM that Patient #1 departed the ED (left without being seen) LWBS after waiting six hours and 27 minutes to be seen. During that time, no thorough history and physical examination identified in the provided medical record that could have identified the underlying cause of lethargy and dizziness, no onset or duration of symptoms was noted, no pre-existing or chronic conditions were identified, no documented developmental delays were found, and no feeding history etc. There was no documented physical assessment, and no testing was ordered or completed. . Policy Review: The Medical Staff Bylaws, last reviewed, amended, and effective on October 3, 2023, includes a process by which a Nurse may be a QMP and do the MSE. On page 57 it states the following: . “ ...15.1 Definition of Qualified Medical Personnel. The term “Qualified Medical Personnel” (QMP) means individuals who are qualified to perform a Medical Screening Examination (“MSE”) pursuant to (Facility’s name) Medical Screening Exam EC/OB Procedure (Procedure #1357) ... . ...15.1.2 Secondary QMP. In order to qualify to be a Secondary QMP in the Emergency Center department (EC) or the Women’s Assessment Center (WAC), an individual must be a: 15.1.2.1 Registered Nurse - a registered nurse authorized by the Texas Board of Nursing to practice nursing who: 15.1.2.1.1 is a member of the core QMP group as designated by Emergency Center, Labor, Delivery, Recovery and Postpartum (“LDRP”) Triage and/or WAC leadership; 15.1.2.1.2 has one-year minimum experience as a RN; 15.1.2.1.3 has a minimum of six months of triage experience at an Emergency Center department (“EC”) or an obstetric triage department; 15.1.2.1.4 has no performance issues; 15.1.2.1.5 has approval by the RN’s Manager; 15.1.2.1.6 has completed the required QMP training which includes case scenarios, online modules, and chart audits. 15.1.2.1.7 successfully performs the yearly QMP maintenance training. 15.1.2.1.8 has a Primary QMP readily available to answer questions or perform a MSE ...” . The Medical Screening Exam EC/OB Procedure, last reviewed and effective on 09/11/2023, states on pages 1 & 2 of 3: . “ ...1.2. In order to qualify to be a Secondary QMP, an individual must be a: 1.2.1. Registered Nurse- a registered nurse authorized by the Texas Board of Nursing to practice nursing who: 1.2.1.1. is a member of the core QMP group as designated by Emergency Center (EC)/Obstetric (OB) Leadership; 1.2.1.2. has one-year minimum experience as a RN; 1.2.1.3. has a minimum of six months of triage experience at an Emergency Center (“EC”), or Pavilion for Women OB Triage; 1.2.1.4. has no performance issues; 1.2.1.5. has approval by the RN’s Manager; 1.2.1.6. has completed the required QMP training which includes case scenarios, online modules, and chart audits; 1.2.1.7. successfully performs the yearly QMP maintenance training; 1.2.1.8. has a Primary QMP readily available to answer questions or perform a MSE; ...” . And on page 2 of 3: “ ...2. A medical screening exam will be performed on all individuals who: 1.1. present to a (Facility’s name) dedicated EC, or Pavilion for Women OB Triage and request care for a medical condition; 1.2. are outside the dedicated emergency department but on hospital property within 250 yards of the main building and presents with an emergency medical condition;... . 2.3. are in a hospital-owned and operated ambulance for purposes of examination or treatment of a medical condition even if the hospital is not on hospital property; or 2.4. are in a non-hospital-owned ambulance that has arrived on hospital property for examination and treatment of a medical condition at the hospital’s dedicated emergency department ...” . The facility’s Triage Assessment Reassessment EC Procedure, last reviewed and effective on 09/20/2023, stated: . “PROCEDURE STATEMENT: A Registered Nurse (RN), who has successfully completed the departmental requirements needed to assume the role of a triage nurse, will provide triage to patients presenting to the Emergency Center (EC). Decisions of acuity ratings are made in response to the patient’s presenting signs or symptoms, necessity for time, critical interventions, potential to life/limb, or need to relieve suffering. Emergency Severity Index (ESI) triage guidelines assist the RN in assignment of acuity. Documentation of the triage process will be done utilizing the EC computerized system. 1. Focused Triage Assessment 1.1. Patients presenting to the EC should have a focused triage assessment completed by a RN. 1.2. The focused triage assessment and documentation consists of: Time of arrival Patient name Date of birth Chief complaint Risk Assessment Focused assessment related to presenting complaint Pertinent vital signs that will assist in making triage decision Allergies Weight Pain assessment Triage location decision . Triage Reassessment ... ...2.2. The protocol/designee nurse and/or reassessment nurse is responsible for the reassessment, including vital signs as necessary, and documentation of reassessment findings for patients in the waiting area. 2.3. Guidelines for reassessment at triage are: 2.3.1. Emergent patients: Every hour or as determined by the nurse/provider 2.3.2. Urgent/ Non-urgent patients: Every 4 hours or more frequently as determined by the nurse/provider ...” . Interviews: During an interview the afternoon of November 30, 2023, ED RN (Staff #11) confirmed that an EMC was based on a focused history and physical assessment, which were not found during medical record reviews. Staff #11 confirmed that there needs to be a primary QMP available to answer any questions that might come up. Staff #11 was asked if she could see by the documentation in Patient #1’s medical record that a primary QMP was present. Staff #11 stated that she did not. . During an interview the afternoon of November 30, 2023, ED RN (Staff #10) confirmed that an MSE was “an ongoing process that starts with the first look at the patient, whether it be on paper or face to face, and ends once the emergent condition has been stabilized” and that this was not found for Patient #1 during medical record reviews. Staff #10 further confirmed that if the patient was not medically screened by the ED and was sent away it would create an EMTALA violation. .”