Texas Health Presbyterian Hospital Rockwall

“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: 33326 Based on record reviews and interviews, the hospital’s medical staff failed to establish policies and procedures governing the medical care provided in the emergency service or emergency department. The medical staff failed to provide an ongoing/continuing assessment of the medical care provided in the emergency service for department for 2 out of 5 high risk patients placed out in the patient waiting room; the patients were not reassessed at least every 2 hours, as the facility’s assessment policy required, and the patients left without being seen by a provider. (Patients #11, and #13) Findings include: Review of the facility provided Policy “Nursing Triage Process Assessment”, dated (2/4/2026) reflected, “I. PURPOSE The purpose of this structure standard is to ensure high quality, efficient, consistent triage procedures for all patients presenting to the ER. III. POLICY: Triage will involve a rapid, directed patient assessment which provides an assignment of acuity level for each patient arriving in the unit. A Registered Nurse will perform patient assessments. Acuity levels and disposition will be assigned to patients based on the revised Emergency Severity Index (ESI) algorithm found in Attachment A. The triage assessment does not constitute a medical screening exam. IV. PROCEDURE: 1. Acuity Level Definitions and Assignment: a. ESI Level 1: The patient presents upon arrival with the need for immediate life-saving interventions. See Attachment B for examples of interventions that are categorized as life-saving. i. Patients will be placed immediately in a patient care area for definitive assessment and intervention. The ER physician and Shift Supervisor should be notified of the patient’s arrival and condition immediately. ii. It is understood that many of these patients will not need a complete triage assessment before they are recognized as a Triage Level One (Resuscitation). The required triage assessment can be accomplished during the provision of life saving interventions. b. ESI Level 2: The patient presents with a high risk situation potentially including a threat to life, limb, or function and requires rapid medical intervention. i. Patients will placed in the first available appropriate patient care area. ii. The triage RN will notify the Shift Supervisor of these patients c. ESI Level 3: The patient presents with a condition that could progress to a serious problem requiring emergency intervention. The vital signs of a Level Three patient may or may not be outside normal parameters and the presenting condition is anticipated to require the utilization of two or more resources ... 6. Reassessment by Triage RN: a. Patients triaged in the waiting room: Vital signs, as well as condition status, should be reassessed at a minimum of every 2 hours until brought back into the ED. 7. Assessment by Emergency Room Physician: a. Once placed in a treatment room, patients should be assessed by an ER physician based on their triage level: i. ESI Level One (Resuscitation): 1. Immediately ii. ESI Level Two (Emergent): 1. Within five (5) minutes iii. ESI Level Three (Urgent): 1. Within thirty (30) minutes iv. ESI Level Four (Semi-Urgent): 1. Within thirty (30) minutes v. ESI Level Five (Non-Urgent): 1. Within thirty (30) minutes 8. Reassessment of patients vital signs by Primary RN: a. ESI Level 1: Every 5 to 15 minutes as needed based on clinical presentation and no less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable. b. ESI Level 2: As with ESI Level 1, vital signs should be reassessed no less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable. c. ESI Level 3: Patients with normal vital signs should be reassessed at the discretion of the nurse, but no less frequently than every 4 hours. Patients with abnormal vital signs should be reassessed no less frequently than every 2 hours for the first 4 hours, then every 4 hours if clinically stable.” Patient #11 Review of patient #11’s medical records reflected an arrival to the emergency room on 5/22/26 at 7:24 pm with a complaint of “ Numbness: LUE numbness x1 day that has resolved now with intermittent 5/10 CP (chest pain). Reports recent viral illness x2 months ago. Reports recent viral illness x2 months ago. Facial symmetry, full strength/sensation, no dizziness or HA.” Patient #11 was assigned an ESI 2(emergency severity index, used to categorize a patients needs in the emergency room). Review of patient #11’s medical records reflected an assessment, an EKG was performed on 5/22/26 at 7:30 pm and vital signs were taken at 7:35 am, the patient’s condition status was not documented. The patient’s condition status and vitals were not documented at 9:30 am or 11:30 am, as the policy required. Review of the nurses note dated 5/22/2026 at 11:31 PM reflected, “Pt called from waiting room, no answer at this time. Review of the nurses note dated 5/22/2026 at 11:32 PM reflected, “Left Without Being Seen. The condition of the patient at this time is left without being seen by a physician. ... and no physician-patient relationship was established. Patient #13 Review of Patient #13’s medical records reflected an admission to the emergency department on 3/23/26 at 5:28 PM. Patient #13 was designated an ESI 2 for High Blood Pressure. Nurse’s note dated 3/23/2026 at 5:28 pm reflected, “Reason for Visit *Hypertension (145/104 BP today at home. Never dx(diagnosed) with HTN no meds ...” The patient’s condition status and vitals were not documented at 6:28 am, 8:30 am, as the policy required. Review of the Nurse’s note dated 03/23/26 10:15 pm reflected, “Called pt from waiting room, pt not in department. Will try again” “Disposition: The condition of the patient at this time is left without being seen by a physician ...and no physician-patient relationship was established” During an interview on, 06/22/26 at 1:30 pm in the facility’s conference room, Staff #1, ED Director, confirmed the patients with an ESI 2 are considered high-risk patients and vital signs and the condition of the patient were not documented for patient #11 and 13#. During this interview on, 06/22/26 at 1:30 pm in the facility’s conference room, Staff #1, ED Director, when asked about the Emergency Department’s (ED) Operations stated in part, “The patients in the waiting room are reassessed every two hours.” Staff #1 confirmed the facility’s reassessment policy does not detail if an ESI 2 patient is located in the waiting room if the patient should be reassessed according to the facility’s “Nursing Triage Process - Assessment & Reassessment according to ESI” policy, which states, “ ...vital signs should be reassessed no less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable.””

“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: 33326 Based on record review, and interview, the facility failed to provide an organized Emergency department when, (2) two High risk patients out of (20) twenty emergency room patients were left to wait in the facility’s emergency room’s waiting lobby for over two hours, and were not reassessed according to the facility’s reassessment policy. Patients #14 and 15 left the emergency room without being seen by a medical provider. This failure places patients at risk of deteriorating conditions. (Patients #14 and 15) Findings include: Review of the facility provided policy, “Medical Screening Examinations and Patient Transfers” (Last Reviewed Date: (02/03/2025) reflected: 4.1.5 Evaluating the patient and performing a Medical Screening Examination. a. Evaluation. Each patient who arrives at the Hospital ED or Labor and Delivery will be evaluated by a physician or Qualified Medical Personnel (in the ED or Labor and Delivery as applicable) or evaluated by a physician on the medical staff ...” Review of the facility provided policy “Nursing Triage Process - Assessment & Reassessment according to ESI” (Last Revised Date: 02/04/2025) reflected, “POLICY: Triage will involve a rapid, directed patient assessment which provides an assignment of acuity level for each patient arriving in the unit. A Registered Nurse will perform patient assessments. Acuity levels and disposition will be assigned to patients based on the revised Emergency Severity Index (ESI) algorithm found in Attachment A. The triage assessment does not constitute a medical screening exam b. ESI Level 2: The patient presents with a high risk situation potentially including a threat to life, limb, or function and requires rapid medical intervention. i. Patients will placed in the first available appropriate patient care area. ii. The triage RN will notify the Shift Supervisor of these patients.” Review of the facility provided policy, “Nursing Triage Process - Assessment & Reassessment according to ESI (revised 02/04/25) reflected, “Reassessment of patients vital signs by Primary RN: a. ESI Level 1: Every 5 to 15 minutes as needed based on clinical presentation and no less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable. b. ESI Level 2: As with ESI Level 1, vital signs should be reassessed no less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable. During an interview on 12/10/2025 at 10:31 pm, in the facility’s conference room, when asked how often patients are reassessed in the waiting room, Staff #2, Emergency room director stated, “Patient’s vitals should be taken every 2 hours, depending on their condition.” Patient #14 Review of Patient #14’s medical records reflected a 59-year-old male with a history of Congestive Heart Failure arrive on 11/16/2025 at 2:12 PM, “Reason for Visit, Chest Pain (Adult-age 12&>) Shortness of Breath (Pt reports chest pain that started around 5 am this morning) history of Congestive heart failure.” The patient was triaged as Acuity 2-Emergent. Review of the Temperature at 2:24 pm revealed, “96 degrees Fahrenheit! Temporal Artery.” There were no additional vital signs available. The protocol standing ordered laboratory test reflected WBC (white blood cells) 12.1 High reference range 3.9 -10.9. Discharge Information: Date/Time: 11/16/2025 6:30 PM was unable to be found in the emergency waiting room. Comment: The condition of the patient at this time is left without being seen by a physician. A treatment protocol may have been started[sic] before the patient left. The name of the emergency department medical director is attached to any orders initiated as the orders were pursuant to a standing order approved by the medical director, and no physician-patient relationship was established.” Patient #15 Review of Patient #15’s medical records reflected a 20 year old female with an arrival on 11/16/2025 at 4:56 pm, “Arrival complaint: Chest Pain, Shortness of Breath (Pt reports chest pain with shortness of breath that came in the middle of the night last night., pt states she is also feeling very fatigue since her surgery from an ectopic pregnancy about 2 weeks ago.” The patient was triaged as an acuity 2-Emergent. Review of the initial vital signs taken on 11/16/25 at 5:00 pm reflected, Blood pressure 131/63, Heart rate, 126! Respirations, 20, 97% 0xygen saturation, and temperature 101.4! Blood chemistry was ordered, then cancelled. Discharge Information: Date/Time: 11/16/2025 7:16 pm, Left without being seen. “Comment: The condition of the patient at this time is left without being seen by a physician. A treatment protocol may have been started[sic] before the patient left. The name of the emergency department medical director is attached to any orders initiated as the orders were pursuant to a standing order approved by the medical director, and no physician-patient relationship was established.” During an interview on 12/10/2025 at 10:31 pm, in the facility’s conference room Staff #4, Emergency Department Medical Director, when asked if the physicians were aware of standing orders being placed and that ESI 2 patients were being placed back into the waiting room for over 4 hours, stated in part, “The physician’s would be aware the orders were placed under their names. The expectation is to treat the ESI 2 patients in the room, attempt to get a history and physical, medical screening exam and discuss the plan of care with the patient ...We need to do a better job, we need to help our staff out in front find the best place for a patient.””