The Hospital at Westlake Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 36594 Based on observation, review of documents, and staff interview, the governing body failed to ensure hospital policies and procedures were implemented and followed when the facility’s ER closed on 12/29/23 at 8:00 pm. The facility failed to ensure services were rendered in a safe and effective manner, as evidenced by: 1. The facility failed to ensure the policies and procedures governing medical care provided in emergency service were established by and a continuing responsibility of the medical staff when the facility’s ER closed without discussion with the medical staff regarding updated policies and procedures (Cross Refer A1104). 2. The facility failed to ensure adequate medical personnel qualified in emergency care when there were no emergency physicians in the ER beginning on 12/29/23 at 8:00 pm (Cross Refer A1112). 3. The facility failed to maintain a central log on each individual who came to the emergency department seeking assistance for at least 4 patients (Patients #21, 22, 23, and 24) who presented after the ER closure date of 12/29/23 at 8:00 pm (Cross Refer A2405). 4. The facility failed to provide an appropriate medical screening examination by an individual determined qualified by hospital bylaws and rules and regulations to determine whether or not an emergency medical condition existed for at least 4 patients (Patients #21, 22, 23, and 24) who presented after the ER closure date of 12/29/23 at 8:00 pm. The facility did not have a qualified medical individual(s) in the ER since the closure date of 12/29/23 at 8:00 pm (Cross Refer A2406). These practices had the potential to adversely affect all patients presenting to the ER.”

“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: 36594 Based on observation, review of documents, and staff interview, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice as hospital policies and procedures were not implemented and followed when the facility’s ER closed on 12/29/23 at 8:00 pm. The facility failed to ensure emergency services were rendered in a safe and effective manner, as evidenced by: 1. The facility failed to ensure the policies and procedures governing medical care provided in emergency service were established by and a continuing responsibility of the medical staff when the facility’s ER closed without discussion with the medical staff regarding updated policies and procedures (Cross Refer A1104). 2. The facility failed to ensure adequate medical personnel qualified in emergency care when there were no emergency physicians in the ER beginning on 12/29/23 at 8:00 pm (Cross Refer A1112). These practices had the potential to adversely affect all patients presenting to the ER.”

“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: 36594 Based on observations, review of documents, and staff interview, the facility failed to ensure the policies and procedures governing medical care provided in emergency service were established by and a continuing responsibility of the medical staff when the facility’s ER closed on 12/29/23 at 8:00 pm without discussion with the medical staff and without the review or modification of policies and procedures to accommodate the ER closure. Findings were: The facility closed its ER at 8:00 pm on 12/29/23. There was no advanced notice to the public or the CATRAC [Capital Area of Texas Regional Advisory Council, the region’s trauma system organization]. The facility’s social media post dated 12/29/23 stated in part, “***Important Notification*** ...Effective Friday, December 29th, 2023 at 8pm the Emergency Department will be CLOSED until further notice.” In a telephone interview on the afternoon of 1/8/24, a CATRAC representative reported they received notification in writing from the facility regarding their ER closure on 12/29/23 at 6:42 pm. Observation of the outside of the facility ER on the morning of 1/3/24 revealed a locked door with 4 signs taped to it, all which stated, “Effective Friday, December 29th, 2023, at 8pm The Emergency Department at The Hospital at Westlake will CLOSE until further notice.” Observations of the facility ER on the afternoon of 1/4/24 and the morning of 1/5/24 with Staff #3, DON, revealed one ER RN present and no physician present. In an interview on the morning of 1/4/24 Staff #2, Director of Quality, Compliance and Risk, stated, “We are still staffing the ED with a nurse 24/7 ... We are still staffing the ED, we don’t have a physician in-house 24/7, but we have someone on-call.” When asked if the medical staff was involved in the decisions surrounding the ED closure, Staff #2 reported that between ownership and the governing body, they discussed the situation with the hospitalists. He went on to say it was a quick decision, but they’ve put on their website and social media to announce the closure of the ER to the public and if a patient walks up, they provide all the nearest urgent cares and ERs in the area to anyone who presents to the ER. On the morning of 1/5/24, Staff #2 verified the closing of the ER was an abrupt change and most policies were not reviewed and modified to accommodate the change. He reported there was a Medical Executive Committee meeting scheduled for later this month to go over those policies and procedures with the physician group. Facility policy titled “Assessment of the Emergency Department Patient” Policy # ED-1011 last revised on 4/22 stated in part, “Policy/Procedure: ...All patients presenting to the Emergency Department will be triaged ...” Facility policy titled “Triage” Policy # GN-1081 effective 12/2023 stated in part, “The registered nurse will evaluate and categorize an individual upon arrival to the hospital, if seeking medical assistance and/or presenting in distress, into either emergency, urgent, semi-urgent, or routine categories ...” Facility policy titled “EMTALA, Admissions, Transfers, and Discharge” Policy #ED-1025 last revised 3/20/19 stated in part, “Purpose: To identify the procedures for admission to the emergency department, transport and monitoring while in the emergency department ... Definitions: ...Medical Screening Exam (MSE): an exam is conducted to determine whether or not an emergency medical condition exists or a woman is in labor. Qualified medical personnel perform this exam (Emergency Department Physician). The triage process determines the order of patients to be seen for a medical screening exam, not the presence or absence of an emergency medical condition. Qualified Medical Personnel: those personnel who have been determined by The Hospital at Westlake Medical Center to be capable of performing the medical screening examination; physicians. These qualified medical personnel will be on the premises and available to supervise the provision of emergency services at all times. ...Policy: Persons who present to The Hospital Emergency Department (ED) requesting examination or treatment for a medical condition will be provided an appropriate medical screening examination (MSE) within the capability of The Hospital qualified medical personnel. ...Procedure: ...a qualified registered nurse shall perform patient triage upon presentation to the emergency department. ...Triage does not qualify as a medical screening examination.””

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 36594 Based on observation, review of documents, and staff interview, the facility failed to ensure adequate medical and nursing personnel qualified in emergency care when the facility’s ER closed on 12/29/23 at 8:00 pm. Findings were: Observations of the facility ER on the afternoon of 1/4/24 and the morning of 1/5/24 with Staff #3, DON, revealed one ER RN present and no physician present. In an interview on the morning of 1/4/24, Staff #2, Director of Quality, Compliance and Risk, stated, “We are still staffing the ED with a nurse 24/7 ... We are still staffing the ED, we don’t have a physician in-house 24/7, but we have someone on-call.” In an interview on the afternoon of 1/4/24 with Staff #3, DON, when looking at the ER physician schedule for the evening of 12/31/23 and both shifts on 1/1/24, Staff #3 reported those shifts were not filled as the ER was closed at that time and stated, “We don’t have a doctor on-site 24/7.” When reviewing the ER physician schedule for January 2024, Staff #3 reported none of the ER physicians were working in January since the ER was closed. Facility policy titled “Plan for Providing Patient Care-Scope of Services” policy # NA-1009 stated in part, “Plan for Providing Care: ...Emergency Services (ED) consists of a 6 bed emergency department. Emergency services are available 24 hours a day, 7 days a week to render care within the scope of service of the facility, and to stabilize and transfer those patients requiring a higher level of emergency care, or a higher level of inpatient care that is beyond the scope of this facility ... Physicians are immediately available to render care in the emergency department. Emergency care is available to patients of all ages seeking emergency, urgent or non-urgent care.””

“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: 36594 Based on observation, review of documents, and staff interviews, the facility failed to maintain a central log on each individual who came to the emergency department seeking assistance for at least 4 patients (Patients #21, 22, 23, and 24) who presented after the ER closure date of 12/29/23 at 8:00 pm. Findings were: On a tour of the outside of the facility on 1/3/24 at 11:58 am revealed an awning above the ER that read, “The Hospital at Westlake Medical Emergency 24/7” and two doors, one labeled “Ambulance” and the other labeled “Emergency.” The “Emergency” door was locked and had 4 signs taped to the door, all which stated, “Effective Friday, December 29th, 2023, at 8pm The Emergency Department at The Hospital at Westlake will CLOSE until further notice.” There was a red button on the left side of the ER entrance that stated, “Push for Help.” When the button was pushed, the hospital operator answered and surveyor stated, “I need information concerning your ER;” the operator replied, “It’s closed.” Surveyor stated, “What am I supposed to do?” The operator stated, “Where are you?” Surveyor stated, “At your emergency entrance.” The operator stated, “Hold on, I will be right down.” A staff member opened the locked ER door and came into the parking lot and handed surveyor two lists titled “List of Nearest Urgent Care Centers” and “List of Nearest Emergency Departments.” The staff member closed the door. Observations on the afternoon of 1/4/24 and the morning of 1/5/24 revealed a triage area just inside the ER with a notebook paper on a clipboard that was blank except the title, “Log/MSE [Medical Screening Exam], etc.” In an interview on the morning of 1/4/24, Staff #3, DON, stated, “We have not been logging those knocking on the door.” She went on to say the ER continued the same process and they “can still call the hospitalist and can direct admit to the floor.” She reported they do not get a lot of walk-ups, their ER patients were generally “community that’s been here that knows us; we do not have a lot of foot traffic.” When asked how many patients had presented since their closure on 12/29/23 at 7:00 pm, she stated, “Saturday, we had three walk-ups, but I’ll have to check on that.” When asked if any of those people had been logged or given a Medical Screening Exam, she reported they did not log them and “when they hear that the ER is closed, they [the patients] understand. The papers [of the nearest emergency rooms and urgent cares] are given to them.” In an interview on the afternoon of 1/4/24 with Staff #6, ER RN, he reported he had two people present to the ER since the ER closure on 12/29/23, both on 12/30/23. Staff #6 stated, “ ...that first day, we had 2 people show up. One came in [Patient #22] and said, ‘Oh, you’re closed? So where do I need to go?’ and she didn’t want to elaborate. I showed her the forms for the nearest ER and I said, ‘there’s not anything I can help you with other than that,’ she took the information and left. Another rang the bell and said, ‘Are you closed?’ I said, ‘Yes, I’ll come right out.’ The son had a laceration on his finger [Patient #23]. He noted there was only one sign up on the door, so I put 4 signs up.” When asked about the laceration, Staff #6 stated, “It was pretty non-existent ... He was a teenager, I took a look at it. He had a band-aid on it; I didn’t see any blood.” Staff #6 reported he did not log the patient into the ER log. When asked at what point would a patient go on the log, Staff #6 stated, “For me, anyone I was going to spend time with, I’d get their name, etc.” In an interview on the morning of 1/5/24 with Staff #10, ER RN, when asked if he had anyone present to the ER since the ER had been closed, Staff #10 stated there was “one person on [January] 2nd that came in with a laceration on their hand [Patient #24]. I told them they’d probably be better off going to one of the bigger ERs” and that “they were disappointed. They like it here.” He reported there have been calls, but “no one’s really walking up.” When asked about the ER log sheet and at what point he would log a patient, he stated, “I haven’t used it yet” but would, “if I call 911.” Facility policy titled “Assessment of the Emergency Department Patient” Policy # ED-1011 last revised on 4/22 stated in part, “Policy/Procedure: ...All patients presenting to the Emergency Department will be triaged ...” Facility policy titled “Triage” Policy # GN-1081 effective 12/2023 stated in part, “The registered nurse will evaluate and categorize an individual upon arrival to the hospital, if seeking medical assistance and/or presenting in distress, into either emergency, urgent, semi-urgent, or routine categories ...” Facility policy titled “EMTALA, Admissions, Transfers, and Discharge” Policy #ED-1025 last revised 3/20/19 stated in part, “Purpose: To identify the procedures for admission to the emergency department, transport and monitoring while in the emergency department ... Policy: The Hospital has the responsibility and must abide by the Emergency Treatment and Labor Act (EMTALA). It is intended to reinforce that the EMTALA responsibility of the hospital with a dedicated emergency department begins when an individual arrives on hospital property (ambulance arrival) and not when the hospital ‘accepts’ the individual from the gurney. Persons who present to The Hospital Emergency Department (ED) requesting examination or treatment for a medical condition will be provided an appropriate medical screening examination (MSE) within the capability of The Hospital qualified medical personnel. Person who present [sic] inside The Hospital but outside of the ED, or on hospital property within 250 yards of the main building, for examination or treatment of what may be an emergency medical condition will be provided an appropriate medical screening examination within the capability of the facilities [sic] qualified medical personnel, as defined by the facility, a physician. When a MSE has determined that a patient has an emergency medical condition, the ED will provide necessary stabilizing treatment within the capability of the hospital, or an appropriate transfer. Failure to meet these requirements constitutes a potential violation of EMTALA. This hospital will not rely on 9-1-1 to provide appraisal and/or initial treatment of medical emergencies that occur at the hospital. Procedure: Persons Adequate medical and nursing staff qualified in emergency care, as outlined in the written scope of service, must be present to meet the written emergency procedures and needs determined by the organization. A qualified registered nurse shall perform patient triage upon presentation to the emergency department. ...Documentation of the following, with time noted, will be logged and reviewed: -Patient arrival -Patient discharge -Patients refusing medical screening following presentation -Patients leaving AMA (Against Medical Advice ) -Patients leaving without being seen or unable to locate after triage or exam -Patients requiring transfer for care/procedures not available at the current facility -Patients refusing transfer for emergency medical conditions -Patients requesting transfer for payment or personal reasons -Patients being transferred following stabilization -Patients being admitted and treated””

“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: 36594 Based on observation, review of documents, and staff interviews, the facility failed to provide an appropriate medical screening examination by an individual determined qualified by hospital bylaws and rules and regulations to determine whether or not an emergency medical condition existed for at least 4 patients (Patients #21, 22, 23, and 24) who presented after the ER closure date of 12/29/23 at 8:00 pm. The facility did not have a qualified medical individual(s) in the ER since the closure date of 12/29/23 at 8:00 pm. Findings were: On a tour of the outside of the facility on 1/3/24 at 11:58 am, surveyor [Patient #21] presented to the ER and stated, “I need information concerning your ER;” the operator replied, “It’s closed.” Surveyor stated, “What am I supposed to do?” The operator stated, “Where are you?” Surveyor stated, “At your emergency entrance.” The operator stated, “Hold on, I will be right down.” A staff member opened the locked ER door and came into the parking lot and handed surveyor two lists titled “List of Nearest Urgent Care Centers” and “List of Nearest Emergency Departments.” The staff member closed the door. There was no discussion, no assessment. In an interview on the afternoon of 1/4/24, Staff #6, ER RN, reported two patients presented to the ER on 12/30/23. Patient #22 inquired if the ER was closed and Staff #6 stated, “She didn’t want to elaborate. I showed her the forms for the nearest ER and I said, ‘there’s not anything I can help you with other than that,’ she took the information and left.” Regarding Patient #23, Staff #6 stated, “The son had a laceration on his finger [Patient #23] ... It was pretty non-existent ... He was a teenager, I took a look at it. He had a band-aid on it; I didn’t see any blood.” In an interview on the morning of 1/5/24 with Staff #10, ER RN, when asked if he had anyone present since the ER had been closed, Staff #10 stated there was “one person [Patient #24] on [January] 2nd that came in with a laceration on their hand. I told them they’d probably be better off going to one of the bigger ERs” and that “they were disappointed. They like it here.” Since the closure of the ER on 12/29/23 at 8:00 pm, the ER had been staffed with one RN and no ER physicians. In an interview on the morning of 1/4/24, when asked how many patients had presented since their closure on 12/29/23 at 7:00 pm, Staff #3, DON, stated, “Saturday, we had three walk-ups, but I’ll have to check on that.” When asked if any of those people had been logged or given a Medical Screening Exam, she reported they did not log them and “when they hear that the ER is closed, they [the patients] understand. The papers [of the nearest emergency rooms and urgent cares] are given to them.” In an interview on the afternoon of 1/4/24, when asked about the physician schedule indicating an “Open Shift” for 12/21/23 pm shift and 1/1/24 am and pm shifts, Staff #3, DON, reported those shifts were not filled as the ER was closed at that time. When asked who responds in an emergency, Staff #3 reported the hospitalists, even though they were internal medicine and not emergency physicians. Staff #2 reported the surgeons and CRNAs [Certified Registered Nurse Anesthetist] were on-site during the daytime and if something were to happen, staff could reach out to any of them [surgeons and CRNAs] and they would respond. She reported, if any emergency, there were lots of staff, including her, to respond. Facility policy titled “EMTALA, Admissions, Transfers, and Discharge” Policy #ED-1025 last revised 3/20/19 stated in part, “Purpose: To identify the procedures for admission to the emergency department, transport and monitoring while in the emergency department ... Definitions: ...Medical Screening Exam (MSE): an exam is conducted to determine whether or not an emergency medical condition exists or a woman is in labor. Qualified medical personnel perform this exam (Emergency Department Physician). The triage process determines the order of patients to be seen for a medical screening exam, not the presence or absence of an emergency medical condition. Qualified Medical Personnel: those personnel who have been determined by The Hospital at Westlake Medical Center to be capable of performing the medical screening examination; physicians. These qualified medical personnel will be on the premises and available to supervise the provision of emergency services at all times. ...Policy: Persons who present to The Hospital Emergency Department (ED) requesting examination or treatment for a medical condition will be provided an appropriate medical screening examination (MSE) within the capability of The Hospital qualified medical personnel. ...Procedure: ...a qualified registered nurse shall perform patient triage upon presentation to the emergency department. ...Triage does not qualify as a medical screening examination.””