Baylor Scott and White Medical Center Mckinney

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to comply with CFR 42 482.23(b)(3) when staff did not appropriately assess and reassess patients on an ongoing basis. Nine of twenty patients (Patient #3, #4, #5, #6, #7, #10, #16, #18, #19) did not receive pain assessments and reassessments in response to interventions according to the accepted standards of care of nursing practice and hospital policy. . Record Review: Review of Patient #3’s medical record from Facility A: On 01/26/2025 at 7:23 P.M., Patient #3 presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s physical assessment noted abdominal tenderness to the right upper quadrant, rebound pain and guarding, diminished bowel sounds, and a positive Psoas test (tenderness to the hip flexors in the abdomen that may indicate appendicitis, inflammation of the appendix). At 9:30 P.M., Patient #3 had a pain level of nine (9) and was administered 640.9mg (milligrams) of Tylenol. There was no reassessment of pain after administration documented. . Review of Patient #4’s medical record from Facility A: On 03/31/2025 at 12:40 A.M., Patient #4 presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted abdominal tenderness along McBurney’s point (tenderness to a specific location on the lower right quadrant of the abdomen, that is significant to the diagnosis of appendicitis, inflammation of the appendix), and the right lower quadrant. There was no admission pain level documented. At 3:18 P.M., Patient #4 had a pain level of five (5) and was administered 12mg (milligrams) of Toradol. There was no reassessment of pain after administration documented. At 8:10 A.M., Patient #4 was administered 1.34mg (milligrams) of Morphine without a pain assessment documented. There was no reassessment of pain after administration documented. . Review of Patient #5’s medical record from Facility A: On 05/29/2025 at 9:24 P.M., Patient #5 presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted gradually worsening abdominal pain in the right lower quadrant. There was no admission pain level documented. On 05/30/2025 at 2:02 A.M., Patient #5 was administered 4mg (milligrams) of Morphine without a pain assessment documented. . Review of Patient #6’s medical record from Facility A: On 06/02/2025 at 5:11 P.M., Patient #6 presented to Facility A’s emergency department with a chief complaint of abdominal pain, emesis, and nausea. The physician’s assessment noted abdominal tenderness at McBurney’s point (tenderness to a specific location on the lower right quadrant of the abdomen, that is significant to the diagnosis of appendicitis, inflammation of the appendix), and rebound tenderness to the right lower quadrant. At 7:37 P.M., Patient #6 was administered 4mg (milligrams) of Morphine without a pain assessment documented. . Review of Patient #7’s medical record from Facility A: On 01/03/2025 at 12:05 A.M., Patient #7 presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted abdominal tenderness and left lower quadrant pain. At 2:41 A.M., Patient #7 was administered 9mg (milligrams) of Toradol without a pain assessment documented. There was no reassessment of pain after administration documented. . Review of Patient #10’s medical record from facility A: On 04/14/2025 at 2:33 P.M., Patient #10 presented to facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted mild tenderness to palpation of the right lower quadrant. At 6:28 P.M., Patient #10 was administered 500 mg (milligrams) of Tylenol without a pain assessment documented. There was no reassessment of pain after administration documented. . Review of Patient #16’s medical record from Facility A: On 07/08/2025 at 3:22 P.M., Patient #16 presented to Facility A’s emergency department with a chief complaint of heat exposure. The physician’s assessment noted bilateral lower quadrant tenderness. At 5:00 P.M., Patient #16 was administered 1,000mg (milligrams) of Ofirmev without a pain assessment documented. There was no reassessment of pain after administration documented. At 6:52 P.M., Patient #16 was administered 4mg (milligrams) of Morphine without a pain assessment documented. . Review of Patient #18’s medical record from Facility A: On 02/10/2025 at 5:03 A.M., Patient #18 presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted positive guarding and rebound to the right lower quadrant. At 6:01 P.M., Patient #18 was administered 4mg (milligrams) of Morphine without a pain assessment documented. There was no reassessment of pain after administration documented. . Review of Patient #19’s medical record from Facility A: On 02/20/2025 at 1:03 P.M., Patient #19 presented to Facility A’s emergency department with a chief complaint of abdominal pain. There was no admission pain level documented. The physician’s assessment noted right lower quadrant abdominal pain. At 1:47 P.M., Patient #19 had a pain level of eight (8) was administered 15mg (milligrams) of Toradol. There was no reassessment of pain after administration documented. . Pain Assessment and Management Guidelines Policy, Effective 10/10/2023: “A pain assessment using an assessment tool appropriate for patient age, condition, and ability to understand may be performed: Upon admission/transfer to the patient care unit At least once a shift Prior to the administration of medications ordered for Pain Management After each intervention at a time appropriate to the route of administration, to evaluate the effect and determine whether modification is needed Upon establishment of care in an outpatient setting and at each visit thereafter for Pain Management. During emergency department visits” . “Pain Assessment Conduct comprehensive pain assessments that guide clinical decisions before pain medication administration: Assess patient-specific factors (such as age, quality of pain, sedation level, respiratory status, functional status, tolerance, drug-drug interactions, reaction/response to prior opioid treatment, physical and psychiatric co-morbidities, genitourinary status, cardiovascular status). Assess and document for pain such as: Words used by the patient to describe the pain Intensity using a 0-10 scale whenever possible Location, including radiation Duration, including persistent continuous pain and intermittent pain Aggravating and Alleviating factors” . “Reassess and respond to patient’s Pain through the following: Evaluation and documentation of response to pain intervention(s). Progress toward Pain Management goals including functional ability to take a deep breath, turn in bed, walk with improved pain control Side effects of treatment” . Review of May 2025 ED Staff Meeting Minutes On slide 22 of the ED staff meeting powerpoint, ED leadership identified failures to document pain reassessments. On the slide, a graph shows the trending pain reassessment documentation audits. The goals for the audits were 100% documentation of pain for reassessments for three (3) months. Percentages were as follows: January only 57% of pain documentation were completed., February only 67% of pain documentation were completed, March only 30% of pain documentation were completed, and April only 62% of pain documentation were completed. . Interviews: On 07/28/2025 a conversation with ED Manager, Staff I was held regarding the patients’ pain assessments. Staff I was asked if there was documentation of pain assessments prior to the administration of medication for Patients #3, #4, #7, #10, #16, #18, and #19. Staff I indicated that there was no documentation. Staff I was asked if there was documentation of pain reassessments after administration of medication for Patients #4, #5, #6, #7, #10, #16, and #18. Staff I indicated that there was no documentation.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to provide stabilizing treatment for three of twenty patients (#2, #3, and #5). . Facility A failed to provide stabilizing treatment to Patients #2 and #5 as the patients did not receive antibiotics for appendicitis [inflammation of the appendix] prior to transfer to ensure no material deterioration from the emergency medical condition. . Facility A failed to provide stabilizing treatment to Patient #3 when treatment was refused, as there were no documented risks and benefits of refusal of treatment, reason for refusal, description of the refused treatment, or attempt to secure a written informed refusal of treatment. . Based on observation, record review, and interviews, Facility A failed to initiate an appropriate transfer to a facility with pediatric surgery capabilities for five of twenty patients (Patient #2, #3, #4, #5, #6) when the certification of transfer, outlining the risks and benefits for the patient to transfer, was not documented. . See Tag 2407 and 2409 .”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to provide stabilizing treatment for three of twenty patients (#2, #3, and #5). . Facility A failed to provide stabilizing treatment to Patients #2 and #5 as the patients did not receive antibiotics for appendicitis [inflammation of the appendix] prior to transfer to ensure no material deterioration from the emergency medical condition. . Facility A failed to provide stabilizing treatment to Patient #3 when treatment was refused, as there were no documented risks and benefits of refusal of treatment, reason for refusal, description of the refused treatment, or attempt to secure a written informed refusal of treatment. . Review of Records: Review of Patient #2’s medical record from Facility A: On 01/20/2025 at 8:59 P.M., Patient #2, an eleven (11) year old male weighing ninety-five (95) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain and sore throat. The physician’s physical assessment noted abdominal tenderness in the right lower quadrant. At 10:26 P.M., Patient #2’s CT [computed tomography] scan indicated findings of acute appendicitis [inflammation of the appendix]. Patient #2’s monocyte level was elevated to 1.24, which may indicate the body is fighting an infection. At 11:53 P.M., Patient #2 was transferred to another facility for an emergent appendectomy , a surgery to remove the appendix. Patient #2 did not receive stabilizing treatment as antibiotics were not administered prior to transferring. . Review of Patient #3’s medical record from Facility A: On 01/26/2025 at 7:23 P.M., Patient #3, a ten (10) year old male weighing ninety-two (92) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s physical assessment noted abdominal tenderness to the right upper quadrant, rebound pain and guarding, diminished bowel sounds, and a positive Psoas test (tenderness to the hip flexors in the abdomen, which may indicate appendicitis). At 8:57 P.M., Patient #3’s abdominal ultrasound indicated findings of concern for acute appendicitis (inflammation of the appendix). Documented in the “ED (emergency department) Provider Note,” the provider noted that the “father declined workup/interventions/studies.” Patient #3 did not receive IV (intravenous) antibiotics. At 10:26 P.M., Patient #3 was transferred to another facility for an emergent appendectomy, a surgery to remove the appendix. Patient #3’s medical record did not document the risks and benefits of refusal of antibiotics, the reason for refusal, the description of the refused treatment, or attempt to secure a written informed refusal of treatment. . Review of Patient #5’s medical record from Facility A: On 05/29/2025 at 9:24 P.M., Patient #5, a twelve (12) year old female weighing one hundred (100) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted gradually worsening abdominal pain in the right lower quadrant. Patient #5’s white blood cell count was elevated to 13.9, and the absolute neutrophil count was elevated to 11.40. Both lab results may indicate the body is fighting an infection. At 1:24 A.M., on 05/30/2025, Patient #5’s CT [computed tomography] scan indicated findings of acute appendicitis [inflammation of the appendix]. AT 3:00 A.M., Patient #5 was transferred to another facility for an emergent appendectomy, a surgery to remove the appendix. Patient #5 did not receive stabilizing treatment as antibiotics were not administered prior to transferring. . Review of “Patient Transfer (EMTALA)” [emergency medical treatment and labor act], Effective 05/27/2025: “Patient transfers - Out 2. Additional Transferring physician duties include: a. The Transferring physician determines the order of life support measures which are medically appropriate to Stabilize the Patient prior to Transfer and sustain the Patient during Transfer, and order the utilization of appropriate staff and equipment for the Transfer.” . Review of “Acute appendicitis in children: Management,” updated 01/27/2025, and found at https://www.uptodate.com/contents/acute-appendicitis-in-children-management?search=appendicitis%20in%20children&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 “Uncomplicated Appendicitis Preoperative antibiotics - We recommend administration of broad-spectrum antibiotics to cover colonic flora as soon as the diagnosis of appendicitis is established. Acceptable antibiotic choices include: Cefoxtin, Ceftriaxone, Cefotetan, Ciprofloxacin, Metronidazole, Piperacillin-tazobactam.” “If surgery occurs within six hours of antibiotic administration, evidence suggests that a single dose of preoperative antibiotics is associated with a low risk of postoperative surgical site infection and intraabdominal abscess for most of the above regimens.” . Interview: An interview with Staff D, an Emergency Department Physician, was conducted on 07/31/2025 at 1:19 P.M. Do you have an example of a patient who would be unstable while being transported? “Well, by definition of EMTALA, the goal is to provide stabilization of a patient, basically before transferring. The only I guess would be a reason would be if there was an absolute no possibility of a facility being able to perform a procedure that I guess particularly needed to be transferred to another facility.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and interviews, Facility A failed to perform an appropriate transfer to a facility with pediatric surgery capabilities for five of twenty patients (Patient #2, #3, #4, #5, #6) when the certification of transfer , outlining the risks and benefits for the patient to transfer, was not documented by physicians. . Record Review: Review of Patient #2’s medical record from Facility A: On 01/20/2025 at 8:59 P.M., Patient #2, an eleven (11) year old male weighing ninety-five (95) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain and sore throat. The physician’s physical assessment noted abdominal tenderness in the right lower quadrant. At 10:26 P.M., Patient #2’s CT (computed tomography) scan indicated findings of acute appendicitis (inflammation of the appendix). At 11:53 P.M., Patient #2 was transferred to another facility for an emergent appendectomy a surgery to remove the appendix.. Patient #2’s memorandum of transfer documented that the patient was stable for transfer. The certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Review of Patient #3’s medical record from Facility A: On 01/26/2025 at 7:23 P.M., Patient #3, a ten (10) year old male weighing ninety-two (92) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s physical assessment noted abdominal tenderness to the right upper quadrant, rebound pain and guarding, diminished bowel sounds, and a positive Psoas test (tenderness to the hip flexors in the abdomen that may indicate appendicitis). At 8:57 P.M., Patient #3’s CT (computed tomography) scan indicated findings of acute appendicitis (inflammation of the appendix). At 10:26 P.M., Patient #3 was transferred to another facility for an emergent appendectomy a surgery to remove the appendix. Patient #3’s memorandum of transfer documented that the patient was stable for transfer. The certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Review of Patient #4’s medical record from Facility A: On 03/31/2025 at 12:40 A.M., Patient #4, an eight (8) year old male weighing fifty-eight (58) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted abdominal tenderness along McBurney’s point (tenderness to a specific location on the lower right quadrant of the abdomen, that is significant to the diagnosis of appendicitis), and the right lower quadrant. At 4:06 A.M., Patient #4’s CT (computed tomography) scan indicated findings of early acute appendicitis (inflammation of the appendix). At 9:14 A.M., Patient #4 was transferred to another facility for an emergent appendectomy a surgery to remove the appendix. Patient #4’s memorandum of transfer documented that the patient was stable for transfer. The certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Review of Patient #5’s medical record from Facility A: On 05/29/2025 at 9:24 P.M., Patient #5, a twelve (12) year old female weighing one hundred (100) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain. The physician’s assessment noted gradually worsening abdominal pain in the right lower quadrant. At 1:24 A.M., on 05/30/2025, Patient #5’s CT (computed tomography) scan indicated findings of acute appendicitis (inflammation of the appendix). At 3:00 A.M., Patient #5 was transferred to another facility for an emergent appendectomy a surgery to remove the appendix. Patient #5’s memorandum of transfer documented that the patient was stable for transfer. The certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Review of Patient #6’s medical record from Facility A: On 06/02/2025 at 5:11 P.M., Patient #6, a twelve (12) year old female weighing sixty-three (63) pounds, presented to Facility A’s emergency department with a chief complaint of abdominal pain, emesis, and nausea. The physician’s assessment noted abdominal tenderness at McBurney’s point, (tenderness to a specific location on the lower right quadrant of the abdomen, that is significant to the diagnosis of appendicitis), and rebound tenderness to the right lower quadrant. At 7:05 P.M., Patient #6’s CT (computed tomography) scan indicated findings of appendicitis (inflammation of the appendix). At 8:55 P.M., Patient #6 was transferred to another facility for an emergent appendectomy a surgery to remove the appendix. . At 8:55 P.M., Patient #6 was transferred to another facility for an appendectomy. Patient #6’s memorandum of transfer documented that the patient was stable for transfer. The certificate of transfer was not completed and did not document the risks and benefits of the transfer. . Patient Transfer (Emergency Medical Treatment and Labor Act) Policy, Effective 05/27/2025: “Emergency Medical Condition - means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy; Serious impairment to any bodily functions; Serious dysfunction of any bodily organ or part, or With respect to a pregnant woman who is having contractions: That there is inadequate time to effect a safe Transfer to another medical center before delivery, or That the Transfer may pose a threat to the health or safety of the woman or the unborn child.” . “Transfer of Patients with Emergency Medical Conditions The medical center may not Transfer a Patient with an Emergency Medical Condition unless: The Patient (or a legally responsible person acting on the Patient’s behalf), after being informed of the medical center’s obligations under this section and of the risk of Transfer, requests the Transfer, in writing and indicates the reasons for the request, as well as that he or she is aware of the risks and benefits of the Transfer; A physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical center outweigh the increased risks to the Patient and, in the case of labor, to the unborn child from effecting the Transfer; or If the physician who made the determination to Transfer a Patient with an emergency condition is not physically present in the emergency treatment area at the time of Transfer, a QMP may sign a certification after consultation with the physician. The physician countersigns the physician certification within a reasonable period of time.” . Interviews: On 07/30/2025 at 2:30 P.M., a conversation with the Vice President of Compliance, Staff L, was held regarding the patient’s memorandum of transfers. Staff L stated, “We need to use the EMTALA definition of stable, not the medical physician definition of stable. We looked at a few examples in an EMTALA book and thought we did right and went in the right direction.” Staff L indicated that Facility A had met with the CMS Regional Officer to better understand EMTALA and had updated the memorandum of transfer multiple times to be compliant. . On 07/29/2025 at 12:55 P.M., a conversation with the Director of Nursing, Staff A, was held regarding the patient’s memorandum of transfers. Staff A agreed that the certificate of transfers was not completed, however they also indicated that the certification of transfer does not have to be completed if the patient is stable and that the physician had documented that the patients were stable at the time of transfer.”