St Luke’s Sugar Land 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: 46010 Based on record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) for Patient #18, who arrived by ambulance on 3/12/26 with agitation, confused behavior, recent history of abdominal and dental pain. The patient was allowed to leave the facility against medical advice, after receiving a chemical restraint for his agitation, and prior to completion of the medical screen examination to exclude an emergency medical condition. Findings include: Record review of the facility policy titled “EMTALA Emergency Medicine Treatment and Labor Act”, last revised 12/11/24, stated “Except where otherwise permitted by law, Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at CommonSpirit Dedicated Emergency Departments (DED) requesting or requiring examination or treatment of a medical condition, and to individuals presenting on hospital property (including parking lots, sidewalks and driveways on all CommonSpirit campuses) within 250 yards of the hospital requesting or requiring examination or treatment of an Emergency Medical Condition (EMC), and if one exists, either to stabilize the emergency condition or to transfer the individual appropriately and in conformity with the legal and regulatory requirements, without regard to their age, race, color, creed, national origin, immigration status, insurance, disability, handicap, diagnosis, sexual orientation, or ability to pay.” Record review of medical record for patient ID #18 showed he arrived at the facility on 3/12/26 at 09:04 am via EMS with agitation, altered mental status, abdominal and dental pain. He was agitated and uncooperative, cursing at staff and refused to provide additional history or cooperate with examination. ED RN Staff ID # 69 stated “Patient resting in his room, had to be medicated, earlier he was uncooperative, aggressive, cursing. It was difficult to draw blood and give medications on him. Patient threatened to leave the facility.” Patient ID #18 was given lorazepam 2mg intravenous at 09:20 am, haloperidol 5 mg intravenously at 09:53 am and diphenhydramine 50 mg intravenously at 09:53 am to facilitate his evaluation. The patient lab studies which were completed showed the following abnormalities in the comprehensive metabolic panel: CO2 18, Creatinine 1.73, AST 47 and an elevated lipase of 118. His urinalysis was non-specific with following abnormalities: Protein 100 mg/dL, Blood, Moderate and Leukocytes, Trace. Cat Scan of the brain and abdomen pelvis were ordered but refused. The patient’s agitation and confusion was attributed to “drug intoxication” (cocaine) however underlying emergency medical conditions were not excluded including infectious processes, acute abdomen, pancreatitis, encephalopathy, delirium and/or acute drug intoxication. The patient departed the facility on 3/12/26 at 11:24 am “against medical advice”, prior to the completion of a medical screen exam completion. ED MD Staff ID # 66’s note stated at “1042 Attempted to obtain CT scans for further evaluation of symptoms, however patient still uncooperative and refusing. Discussed with patient’s emergency contact, (redacted) who stated that patient is his own legal guardian and able to make decisions for himself. She also reports patient having history of crack cocaine use. 1123 At this time, low suspicion for any acute or life-threatening condition. Suspect symptoms are secondary to cocaine use. Patient is alert, oriented to person, place, time, current events, and provides correct demographic data and past medical history without apparent hesitation. The patient has capacity to make decisions regarding their medical care. The risks of refusing recommended treatment was discussed in full detail with patient and patient expressed understanding. At this time, patient is choosing to leave AGAINST MEDICAL ADVICE. Patient has remained hemodynamically stable while in the emergency department.” Interview on 4/7/2026 at 11:15 am with ED Charge RN Staff ID # 60 with Medical Record review. She confirmed that Patient ID #18’s disposition is set to “discharge” by the ED physician staff ID # 66 but that the verbiage in physician’s medical decision making reflects that patient ID #18 is leaving against medical advice (AMA). She confirmed she was unable to locate a signed against medical advice form. She confirmed it is the facility policy and procedure to have the patient sign a completed form prior to departing the facility. She confirmed that if the patient refused to sign the AMA form, this should be reflected in the medical record. Interview with ED Medical Director Staff ID # 55 on 4/7/26 at 9:50 am. He confirmed the process for evaluation of patients who arrive with behavioral health complaints or altered mental status. He stated that all patients are “arrived” in the electronic medical record system by registration staff, triaged by nursing staff and have medical screen examinations performed by an ED provider. He stated that patients with behavioral health complaints, often will need medical clearance, with indicated labs, testing and/or consults, prior to a disposition determination.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 23032 Based on interview and record review, the hospital failed to ensure an appropriate medical screening exam was conducted for 1 of 22 sampled ED patients [Patient ID 2 ]. The hospital discharged Patient ID # 2 after she expressed suicidal ideation (SI). They failed to obtain an appropriate psychiatric or mental health evaluation after the patient verbalized SI intent. Findings included : Review of a facility document titled “ Emergency Medical Treatment and Labor Act (EMTALA) Procedure, Clinical A-5000P,”dated December 11, 2024, showed: PROCEDURE: A. SCREENING AND STABILIZATION: All individuals who come to the DED ( dedicated emergency department) and all individuals who present on Hospital Property requesting or requiring examination or treatment of an Emergency Medical Condition (EMC) shall receive an appropriate Medical Screening Examination (MSE). Scope of MSE: The scope of the MSE must be tailored to the presenting complaint and the medical record history of the individual. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include laboratory tests, diagnostic imaging, lumbar punctures, other diagnostic tests and procedures and the use of on-call physician specialists. DEFINITIONS: “Emergency Medical Condition “(EMC) means a medical condition manifesting itself by acute symptoms of sufficient severity ( including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the heath of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. ~~~~~~~~~~~~ The ED record of Patient ID # 2 reviewed on 1/21/2026 at 2:15 PM with Staff-E, ER Manager showed : Patient ID # 2 was a 41 year-old female who arrived voluntarily by ambulance on 9/23/2025: 9:16 AM : arrived by ambulance; chief complaint: abdominal pain; chest pain 9:23 AM: Triage complete; Acuity Level -3; suicide risk assessment showed no risk. 9:33 AM: Medical Screening Exam (MSE) initiated; documented history of Bipolar disorder and schizophrenia 9:33 AM: EKG performed; lab tests ordered 10:05 AM: nurses’s note: patient refused to sign paperwork, refused lab draws. On phone with friend asking to be picked up. 10:06 AM: MD discharge order 10:35 AM: Nurses note: “MD medically cleared. Pt. on phone stated we are discharging her after she expressed suicidal ideation.” 10:45 AM: CIT officer at bedside 10:47 AM: MD note: “updated by nursing staff. She is (sic) voiced suicidal ideation. Pt. is medically cleared. 11:00 AM: nurses note read: “states having thoughts of harming self, Stated plans on taking pills like I did last year.” 11:32 AM: MD provider note: “Updated by nursing staff again. States she wants psych help but does not wish to receive it here. States she is willing to get help. Police officers at bedside. She is being evaluated by police and Texana by the phone. Patient was taken by the police. Patient wishes to be discharged.” Further review failed to show any documented conversation by the MD provider with Patient ID #2 after she expressed suicidal ideation. There was no documentation of a psychiatric evaluation or assessment by a mental health specialist after Patient ID # 2 expressed suicidal ideation. ~~~~~~~~~~~ During an interview at the time of review with the ER Manager, she verified this patient expressed suicidal ideation with a plan, immediately prior to discharge to CIT police custody. She also verified there was no documented copy of the Texana mental health evaluation obtained by the CIT officer.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 37322 Based on record review and interview the governing body failed to ensure patient grievance process was followed up by the quality committee and the emergency department nursing director where 3 of 3 patients (#11,12,13) complained about the care they recieved while in the emergency department during January to present. Thus, no changes in procedure or process occurred. Findings Include: Record review of 3 of 3 patient grievances (patient #11,12,13), stated a root cause analysis was completed resulting in a need for policy enforcement and education of staff. Record review facility policy “Event Reporting and Management” stated the policy is utilized for quality and patient safety improvements and is applicable to all patients within Common Spirit Departments. Interview on 03/20/2025 at 1352 with the ED staff (#J), stated they have not had a meeting for February and were not aware of the results of the grievances. Interview on 03/20/2025 at 1355 with the quality manager (staff #E) verified that these changes have not been shared with the quality committee or the ED nursing staff at this time.”