Baytown Medical Center LP

“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: 37490 The hospital failed to adhere to the provider’s agreement requiring hospital compliance with §42 CF R 489.24 (b) , Special Responsibilities of Medicare hospitals in emergency cases. The hospital failed to display proper signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX. Refer to tag A-2402 The hospital failed to provide an appropriate medical screening exam for 1 of 23 Emergency Department patients reviewed (Patient ID 2). Refer to tag A-2406”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 37490 Based on observation and interview the facility failed to ensure the required signage (per Section 1867 (a)(1)(N)(iii) of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), women in labor, and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX) was posted conspicuously for all patients entering the Emergency Department (ED) for health care services. Findings include: Observaton during the facility tour on 01/20/2026 at 8:45 AM showed no evidence of required signage posted in the patient waiting area (lobby) or patient treatment rooms. Interview wtih staff ID# 51 on 1/21/2026 at 4:05 pm confirmed the above findings.”

“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 23 sampled ED patients (ID#2). Findings include: Review of facility policy titled” Medical Screening Exam,” showed the following: PURPOSE: To establish the process in which every patient is offered a medical evaluation by the physician. POLICY: This facility shall provide to each patient, without regard to the individual’s ability to pay, an appropriate medical screening, examination, and stabilization within the facility’s capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists and shall provide any necessary stabilizing treatment. PROCEDURES: A. Patients present to Phoenix Health Management with a perceived emergency medical condition. B. Patient will be registered in the registration and / or EMR system. C. The patient will be triaged by a registered nurse. D. The patient will receive a medical evaluation by the emergency physician to determine whether an emergency medical condition exists. 1. If an emergency medical condition is determined to exist, the physician will explain the condition, its emergent nature and possible consequences if left untreated and the recommended treatment plan with the patient and family. a. The physician will discuss benefits and risks of care and / or refusal of care. b. After the MSE determination is complete and when patient status allows, registration personnel will complete the registration process, providing it does not interfere with patient care or stabilization of the patient’s condition. c. If the patient refuses care, the physician will discuss leaving AMA with the patient and family. The AMA form will be explained, signed, and witnessed as appropriate. d. The physician will provide instructions on further care and encouragement to return for worsening symptoms or condition. e. Nursing and / or registration staff will provide discharge instructions, information on resources for healthcare, and clinics available in the community. 2. If an emergency medical condition is determined to NOT exist, the physician will discuss the plan of care and treatment options. a. The registration personnel/House Supervisor will discuss the financial responsibility with the patient for services or tests indicated. b. The patient will be given the option to stay and continue care or seek alternative resources for healthcare services. c. If the patient chooses to leave, the patient will be encouraged to return for worsening symptoms or condition. d. Prior to leaving the patient will be given a copy of the physicians recommended discharge instructions, healthcare resources and, clinics available in the community. Review of medical record for patient (ID#2) for date of service 1/3/2026 showed patients reason for visit as “chest pain.” Arrival time was 14:26. Triage was completed by staff (ID# 53)at 14:32 with chief complaint listed as bilateral axillary pain, Discharge time was 14:58. There was no physician documentation of a Medical Screening Examination. A Self-Pay Election Form was completed with “non-emergent” condition was selected. There was a receipt for $99 issued at 14:59. Interview with staff (ID# 62) on 1/20/26 at 9:30 am stated that if a patient is a self-pay patient, they are given the a generic packet to complete at registration, but also a self-pay election form instead of the insurance specific form and let them know there will be a $99 fee for exam if their condition is deemed non emergent by the physician and they choose to forgo further treatment. If they do choose further treatment, we explain the fees then. Interview with facility Medical Director (ID# 52) on 1/20/26 at 1:40 pm, he stated that there should be a documented MSE for the patient (ID#2).”

“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: 35089 Based on review of documentation and interviews with facility staff, the Governing Body failed to ensure that 11 out of 11 medical staff members’ credential files reviewed had been appropriately credentialed and/or appointed to the Medical Staff in accordance with facility’s Medical Staff Bylaws, Rules, and Regulations. (Cross refer A0046)”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 35089 Based on review of documentation and interviews with facility staff, the medical staff failed to enforce facility’s Medical Staff Bylaws, Rules, and Regulations as evidenced by 11 out of 11 medical staff members’ credential files reviewed failed to include documented recommendation of the Emergency Department (ED) Medical Director or Chief of Staff prior to approval of temporary privileges. (Cross refer A0355)”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 35089 Based on review of documentation and interviews with facility staff, the facility failed to ensure that outdated and unusable drugs are not available for patient use as multiple expired medications were found in the adult and pediatric crash cart of Emergency Department. (Cross refer to A0505)”

“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: 35089 Based on review of documentation and interviews with facility staff, the facility failed to ensure that emergency services is organized under the direction of a qualified member of the medical staff as evidenced by the facility did not have an emergency department (ED) Medical Director since September 2023. (Cross refer A1102) Based on review of documentation and interviews with facility staff, the facility failed to ensure that the emergency services are supervised by a qualified member of the medical staff as evidenced by multiple days the Emergency Department (ED) did not have a physician scheduled or working to provide emergency care. (Cross refer A1111) Based on review of documentation and interviews with facility staff, the facility failed to ensure that adequate medical personnel were available to provide emergency care required by facility policies as evidenced by multiple days the Emergency Department (ED) did not have a physician scheduled or working to provide emergency care. (Cross refer A1112)”

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 35089 Based on review of documentation and interviews with facility staff, the Governing Body failed to ensure that 11 out of 11 medical staff members’ credential files reviewed had been appropriately credentialed and/or appointed to the Medical Staff in accordance with facility’s Medical Staff Bylaws, Rules, and Regulations. The findings were: The facility policy titled, “Medical Staff bylaws, rules, and regulations,” last amended on 5/23/18, states, “3.1 Nature of Medical Staff Membership ... No Practitioner shall admit or provide services to patients in the Hospital unless he or she is appointed to the Medical Staff or has been granted temporary privileges ... 7.4 Temporary Privileges. Temporary Clinical Privileges shall be granted only to individuals defined as Practitioners in these Bylaws, to fulfill an important patient care need that cannot be otherwise met by the existing members of the Medical Staff. Therefore, temporary Privileges shall be granted only rarely ... 7.4.2 Conditions and Authority for Granting Temporary Privileges. Temporary Privileges may be granted by the Administrator upon receiving a recommendation from the appropriate department chairperson or Chief of Staff ... Temporary Privileges granted under this condition shall not exceed one-hundred and twenty (120) days or the term of absence of the Medical Staff member, whichever is shorter ...” During the review of 11 ED physician credentialing records (Staff #17 to #27) on 1/30/24, it was observed that all 11 physicians’ temporary privileges were approved by the facility’s Administrator without proof of recommendation from the Emergency Department (ED) Medical Director or Chief of Staff. The surveyor interviewed Staff #3 (Hospital CEO) on 1/30/24 at 1506 and asked for documentation that the 11 ED physicians reviewed had received recommendation from the ED Medical Director or Chief of Staff prior to approving temporary privileges. Staff #3 stated, “During the transition of medical directors and MEC [Medical Executive Committee] members, administrators would assist in filling the schedule for the ED. Most all of the physicians named were part of the [named hospital system] and worked in other locations within the same governing structure and administration. There may be instance where local policy contradicts the approved policy. These occurrences were made by administrators with the purpose of improving patient care ... Most of these physicians were recommended by the Medical Director. However, the paper trail may be lacking to show this approval. As stated before, the 4 qt [quarter] of 2023 was a transitional period with new leadership focused on improving policy and procedures to better ensure compliance with state and federal codes. As we improve our medical staff, we will improve the processes for credentialing.” During the review of the physician schedule and ED log on 1/30/24, it was noted: - Staff #18 (ED physician) evaluated and treated 7 patients on 8/6/23 but Staff #18’s temporary privileges did not start until 8/21/23. - Staff #25 (ED physician) evaluated and treated 5 patients on 11/1/23; 1 patient on 11/2/23; 11 patients on 11/4/23; 4 patients on 11/7/23; 3 patients on 11/11/23; and 4 patients on 11/14/23 but Staff #25’s temporary privileges did not start until 11/16/23. The surveyor interviewed Staff #29 (Director of Credentialing) on 1/30/24 at 1400 and asked for documentation that the 11 ED physicians reviewed had received recommendation from the ED Medical Director or Chief of Staff prior to approving temporary privileges. Staff #29 was unable to provide documentation for the surveyor to review. The surveyor reviewed the 11 ED physicians’ schedule and patient records with Staff #29 and asked if the physicians should have been evaluating and treating patients before their temporary privileges were approved. Staff #29 stated, “No, that shouldn’t have happened.””

“MEDICAL STAFF PRIVILEGING CFR(s): 482.22(c)(2) [The bylaws must:] (2) Include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, etc.) This Standard is not met as evidenced by: 35089 Based on review of documentation and interviews with facility staff, the medical staff failed to enforce facility’s Medical Staff Bylaws, Rules, and Regulations as evidenced by 11 out of 11 medical staff members’ credential files reviewed failed to include documented recommendation of the Emergency Department (ED) Medical Director or Chief of Staff prior to approval of temporary privileges. The findings were: The facility policy titled, “Medical Staff bylaws, rules, and regulations,” last amended on 5/23/18, states, “3.1 Nature of Medical Staff Membership ... No Practitioner shall admit or provide services to patients in the Hospital unless he or she is appointed to the Medical Staff or has been granted temporary privileges ... 7.4 Temporary Privileges. Temporary Clinical Privileges shall be granted only to individuals defined as Practitioners in these Bylaws, to fulfill an important patient care need that cannot be otherwise met by the existing members of the Medical Staff. Therefore, temporary Privileges shall be granted only rarely ... 7.4.2 Conditions and Authority for Granting Temporary Privileges. Temporary Privileges may be granted by the Administrator upon receiving a recommendation from the appropriate department chairperson or Chief of Staff ... Temporary Privileges granted under this condition shall not exceed one-hundred and twenty (120) days or the term of absence of the Medical Staff member, whichever is shorter ...” During the review of 11 ED physician credentialing records (Staff #17 to #27) on 1/30/24, it was observed that all 11 physicians’ temporary privileges were approved by the facility’s Administrator without proof of recommendation from the Emergency Department (ED) Medical Director or Chief of Staff. The surveyor interviewed Staff #3 (Hospital CEO) on 1/30/24 at 1506 and asked for documentation that the 11 ED physicians reviewed had received recommendation from the ED Medical Director or Chief of Staff prior to approving temporary privileges. Staff #3 stated, “During the transition of medical directors and MEC [Medical Executive Committee] members, administrators would assist in filling the schedule for the ED. Most all of the physicians named were part of the [named hospital system] and worked in other locations within the same governing structure and administration. There may be instance where local policy contradicts the approved policy. These occurrences were made by administrators with the purpose of improving patient care ... Most of these physicians were recommended by the Medical Director. However, the paper trail may be lacking to show this approval. As stated before, the 4 qt [quarter] of 2023 was a transitional period with new leadership focused on improving policy and procedures to better ensure compliance with state and federal codes. As we improve our medical staff, we will improve the processes for credentialing.” During the review of the physician schedule and ED log on 1/30/24, it was noted: - Staff #18 (ED physician) evaluated and treated 7 patients on 8/6/23 but Staff #18’s temporary privileges did not start until 8/21/23. - Staff #25 (ED physician) evaluated and treated 5 patients on 11/1/23; 1 patient on 11/2/23; 11 patients on 11/4/23; 4 patients on 11/7/23; 3 patients on 11/11/23; and 4 patients on 11/14/23 but Staff #25’s temporary privileges did not start until 11/16/23. The surveyor interviewed Staff #29 (Director of Credentialing) on 1/30/24 at 1400 and asked for documentation that the 11 ED physicians reviewed had received recommendation from the ED Medical Director or Chief of Staff prior to approving temporary privileges. Staff #29 was unable to provide documentation for the surveyor to review. The surveyor reviewed the 11 ED physicians’ schedule and patient records with Staff #29 and asked if the physicians should have been evaluating and treating patients before their temporary privileges were approved. Staff #29 stated, “No, that shouldn’t have happened.””

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 35089 Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure that outdated and unusable drugs are not available for patient use as multiple expired medications were found in the adult and pediatric crash cart of Emergency Department (ED). The findings were: The facility policy titled, “Crash Cart,” last updated on 2/1/23, states, “Emergency equipment, supplies and drugs are readily accessible at all times to ensure staff’s ability to respond immediately to life threatening situations. Emergency equipment supplies and drugs will be routinely checked to ensure proper working order. The Crash Cart will be appropriately stocked and checked monthly on a scheduled basis and all required checks will be documented on the Crash Cart Checklist.” The facility policy titled, “Crash Cart and Specialty Drug Cart Replacement,” last updated on 2/1/23, states, “The integrity of the crash cart and hyperthermia cart must be maintained to assure that all emergency drugs are available at all times ... The drugs & IV fluids will be monitored monthly for expiration dates by the House Supervisors or designee.” During the tour of the facility on 1/29/24 with Staff #1 (Director of Nursing) and Staff #2 (ED Manager), the following expired medications were found: Adult Crash Cart: - Dextrose 50% 50mL syringe x2 expired 4/1/23 - Magnesium Sulfate 50mL bag x1 expired 11/23 - Calcium Chloride 10mL syringe x2 expired 12/23 - Atropine Sulfate 10mL syringe x2 expired 8/1/23 - Epinephrine 10mL syringe x2 expired 8/1/23 - Norepinephrine Bitartate 4mL vial x2 expired 7/23 - Heparin 5000U 1mL vial x2 expired 9/1/23 - Lidocaine (4mg/mL) 500mL bag x1 expired 10/23 - Dopamine (450mg/250mL) 250mL bag x1 expired 9/1/23 - 0.9% Sodium Chloride 1000mL bag x2 expired 9/23 - 0.9% Sodium Chloride 250mL bag x4 expired 11/23 - 0.9% Sodium Chloride 100mL bag x4 expired 10/23 Pediatric Crash Cart: - Atropine Sulfate 5mL syringe x1 expired 1/1/24 - Magnesium Sulfate (2g/50mL) 50mL bag x1 expired 11/23 - Dobutamine (1mg/1mL) 250mL bag x1 expired 1/1/24 Staff #1 and #2 acknowledged all the expired medications found during the tour.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 35089 Based on observation and interviews with facility staff, the facility failed to ensure that medical supplies were maintained to ensure an acceptable level of safety and quality as evidenced by multiple expired supplies found in the Emergency Department (ED). During the tour of the facility on 1/29/24 with Staff #1 (Director of Nursing) and Staff #2 (ED Manager), the following expired supplies were found: CT Room: Revital-Ox (high level disinfectant) bottles x6 expired 1/1/24 Lab: Red top test tubes x100 expired 12/31/23 Staff #1 and #2 acknowledged all the expired supplies found during the tour.”

“ORGANIZATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(1) [If emergency services are provided at the hospital --] (1) The services must be organized under the direction of a qualified member of the medical staff. This Standard is not met as evidenced by: 35089 Based on review of documentation and interviews with facility staff, the facility failed to ensure that emergency services is organized under the direction of a qualified member of the medical staff as evidenced by the facility did not have an emergency department (ED) Medical Director since September 2023. The findings were: The facility policy titled, “Medical Staff bylaws, rules, and regulations,” last updated on 5/23/18, states, “Emergency Services: 1. The Medical Director shall have overall responsibility for emergency care for patients ... i. The emergency services shall be appropriate to the scope of the services offered. ii. The services shall be organized under the direction of the Medical Director ...viii. There shall be on duty at all times at least one person qualified as determined by the Medical Staff to initiate immediate appropriate lifesaving measures.” The surveyor interviewed Staff #3 (Chief Executive Officer) on 1/30/24 via email. The surveyor mentioned that there were 7 shifts in November 2023 and 5 shifts in December 2023 that had no ED physician scheduled. The surveyor asked if the lack of ED physicians were discussed during Governing Body or Medical Executive Committee meetings. Staff #3 stated, “The meeting scheduled for November 28 was canceled due to lack of participation. The same for the Governing Board meeting scheduled for the same day.” The surveyor also asked what interventions were done when the hospital leadership found out there were no ED physician scheduled or available to cover shifts. Staff #3 stated, “When I assumed the position of CEO in September 2023, I greeted with issues in payroll which included the ER physicians compensation. When I enquired about the members of the MEC and Board of Directors, I was informed that all of the MEC members had resigned and were moving much of their practice to other locations. In the last month, I have recruited new members for the MEC and Hope to restructure the Board of Governers [sic] to include Ownership, members of the community, and industry experts. Our next MEC and Board of Governors Meeting are scheduled for February 2024.” The surveyor interviewed Staff #3 (Chief Executive Officer) on 2/14/24 via email and received a response on 2/21/24. The surveyor asked, “Between August 2023 to January 2024, who was the Emergency Department (ED) Medical Director?” Staff #3 replied, “When I arrived in August 2023, the Medical Director of the ED was an open position. We recruited for a qualified ED Director and interviewed a few candidates. One candidate was selected in September. Dr. [Staff #20]. He set the schedule for September and October. However, in October Dr. [Staff #20] resigned from his position and left our organization to seek other opportunities. We began looking for a new ED Director immediately. During this vacancy, the schedule was filled by the Chief Nursing Officer, and ER manager from the approved / credentialed ER physicians. Currently Dr. [Staff #30] is the ED Director.” The surveyor asked, “When did this physician get appointed as the ED Medical Director?” Staff #3 replied, “Dr. [Staff #30] accepted the position in January 2024.” The surveyor asked, “Can you please provide a copy of Governing Body meeting minutes that discussed the appointment of ED Medical Director?” Staff #3 replied, “Dr. [Staff #30]’s appointment was approved by the CEO with notification to the Medical staff and the board, pending a vote at the next scheduled board meeting. An ad hoc board meeting was convened on February 15, 2024. Dr. [Staff #30]’s appointment was placed on the agenda. The board unanimously approved the appointment.” The surveyor asked, “Is this physician still the current ED Medical Director?” Staff #3 replied, “Yes. Currently we are reviewing our bylaws and policies to ensure we do not have this type issue in the future. Additionally, we are making provisions in the policy for an interim ED Director to be named when there is an absence in the position.””

“SUPERVISION OF EMERGENCY SERVICES CFR(s): 482.55(b)(1) The emergency services must be supervised by a qualified member of the medical staff. This Standard is not met as evidenced by: 35089 Based on review of documentation and interviews with facility staff, the facility failed to ensure that the emergency services are supervised by a qualified member of the medical staff as evidenced by multiple days the Emergency Department (ED) did not have a physician scheduled or working to provide emergency care. The facility policy titled, “Scope of Services - Emergency Room,” last updated on 4/2023, states, “The Emergency Room will be staffed by a qualified Physician from the Medical Staff. The medical staff shall designate a ‘back-up’ process should the in-house ER physician should be unable to respond due to unforeseen circumstances such as tending to another emergency.” The facility policy titled, “EMTALA,” last updated on 4/2023, states, “”It is the policy of the BMC [Baytown Medical Center] that all patients requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act ... Federal law requires hospitals with emergency rooms to provide a Medical Screening Examination (MSE) to every patient who comes to the hospital requesting emergency examination or treatment and to provide the patient with the necessary stabilizing treatment that is within the capabilities of the hospital until the patient is stable for transfer or discharge ... Qualified Medical Person at Altus emergency Room means physician in the hospital ... Only physicians, in-house or on-call physicians and house staff are allowed to perform an MSE at BMC.” The surveyor reviewed the ED physician staffing schedule and ED log from August 2023 to January 2024. It was noted: - There were no ED physicians scheduled/worked on November 5, 8, 9, 12, 22, 23, and 24 - There were no ED physicians scheduled/worked on December 10, 12, 18, 26, and 31 The surveyor interviewed Staff #10 (Emergency Room Tech) on 1/29/24 at 1505 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #10 stated, “Yes, but I don’t remember when. But I’m pretty sure there were at least three shifts. It started around August 1st when there was a transition with the new owners.” The surveyor interviewed Staff #13 (Radiology Tech) on 1/29/24 at 1555 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #13 stated, “We’ve never been closed but there were shifts there was no ED physician. We would tell patients the system was down and we are unable to see patients. I have worked these shifts but not many. It’s either we were short or can’t find a physician to work the shift.” The surveyor interviewed Staff #14 (Radiology Tech) on 1/29/24 at 1722 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #14 stated, “I worked at least one shift there was no doctor. It was a night shift, which usually is super slow. As far as I know, no patient ever walked in. When I left that morning, there was still no doctor until incoming doctor came for the day shift.” The surveyor interviewed Staff #23 (ED physician) on 1/30/24 at 1639 and asked if they recalled any shifts in the last 6 months where there was no ED physician working the shift. Staff #23 stated, “Yes, I heard a couple of times they had a problem with staffing a physician. I know I’ve been asked a few times to cover those holes but I wasn’t able to do it.” The surveyor interviewed Staff #28 (Chief Nursing Officer) on 1/30/24 via email. The surveyor mentioned that there were 7 shifts in November 2023 and 5 shifts in December 2023 that had no ED physician scheduled. The surveyor asked if the lack of ED physicians were discussed during Governing Body (GB) or Medical Executive Committee (MEC) meetings. Staff #28 stated, “The MEC and GB meeting was cancelled that was scheduled for November 28, 2023. The next scheduled meetings are in February 2024.” The surveyor also asked what interventions were done when the hospital leadership found out there were no ED physician scheduled or available to cover shifts. Staff #28 did not provide a response. The surveyor interviewed Staff #3 (Chief Executive Officer) on 1/30/24 via email. The surveyor mentioned that there were 7 shifts in November 2023 and 5 shifts in December 2023 that had no ED physician scheduled. The surveyor asked if the lack of ED physicians were discussed during Governing Body or Medical Executive Committee meetings. Staff #3 stated, “The meeting scheduled for November 28 was canceled due to lack of participation. The same for the Governing Board meeting scheduled for the same day.” The surveyor also asked what interventions were done when the hospital leadership found out there were no ED physician scheduled or available to cover shifts. Staff #3 stated, “When I assumed the position of CEO in September 2023, I greeted with issues in payroll which included the ER physicians compensation. When I enquired about the members of the MEC and Board of Directors, I was informed that all of the MEC members had resigned and were moving much of their practice to other locations. In the last month, I have recruited new members for the MEC and Hope to restructure the Board of Governers [sic] to include Ownership, members of the community, and industry experts. Our next MEC and Board of Governors Meeting are scheduled for February 2024.” The surveyor asked what happens when a patient comes to the ED seeking evaluation and treatment and there is no ED physician available. Staff #3 stated, “If a physician is un-available for any reason, The staff is to greet the patient when they arrive and inform the patient there is no physician in the facility. If the patient is having an emergency the staff can give aid and call for assistance through emergency services.” The surveyor interviewed Staff #2 (ED Manager) on 1/30/24 via email. The surveyor asked if the front door of the ED was ever locked or closed for any reason including no physician staff on duty. Staff #2 stated, “This door has never been locked to ED. There was no physcian [sic] available or scheduled on November 5,8,9,12,22,23,24. December 10, 12, 18, 26 31.” The surveyor asked what happens when a patient comes to the ED seeking evaluation and treatment and there is no ED physician available. Staff #2 stated, “Notify the patient there is not a doctor on site. We can render aid if needed.””

“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: 35089 Based on review of documentation and interviews with facility staff, the facility failed to ensure that adequate medical personnel were available to provide emergency care required by facility policies as evidenced by multiple days the Emergency Department (ED) did not have a physician scheduled or working to provide emergency care. The facility policy titled, “Scope of Services - Emergency Room,” last updated on 4/2023, states, “The Emergency Room will be staffed by a qualified Physician from the Medical Staff. The medical staff shall designate a ‘back-up’ process should the in-house ER physician should be unable to respond due to unforeseen circumstances such as tending to another emergency.” The facility policy titled, “EMTALA,” last updated on 4/2023, states, “”It is the policy of the BMC [Baytown Medical Center] that all patients requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act ... Federal law requires hospitals with emergency rooms to provide a Medical Screening Examination (MSE) to every patient who comes to the hospital requesting emergency examination or treatment and to provide the patient with the necessary stabilizing treatment that is within the capabilities of the hospital until the patient is stable for transfer or discharge ... Qualified Medical Person at Altus emergency Room means physician in the hospital ... Only physicians, in-house or on-call physicians and house staff are allowed to perform an MSE at BMC.” The surveyor reviewed the ED physician staffing schedule and ED log from August 2023 to January 2024. It was noted: - There were no ED physicians scheduled/worked on November 5, 8, 9, 12, 22, 23, and 24 - There were no ED physicians scheduled/worked on December 10, 12, 18, 26, and 31 The surveyor interviewed Staff #10 (Emergency Room Tech) on 1/29/24 at 1505 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #10 stated, “Yes, but I don’t remember when. But I’m pretty sure there were at least three shifts. It started around August 1st when there was a transition with the new owners.” The surveyor interviewed Staff #13 (Radiology Tech) on 1/29/24 at 1555 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #13 stated, “We’ve never been closed but there were shifts there was no ED physician. We would tell patients the system was down and we are unable to see patients. I have worked these shifts but not many. It’s either we were short or can’t find a physician to work the shift.” The surveyor interviewed Staff #14 (Radiology Tech) on 1/29/24 at 1722 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #14 stated, “I worked at least one shift there was no doctor. It was a night shift, which usually is super slow. As far as I know, no patient ever walked in. When I left that morning, there was still no doctor until incoming doctor came for the day shift.” The surveyor interviewed Staff #23 (ED physician) on 1/30/24 at 1639 and asked if they recalled any shifts in the last 6 months where there was no ED physician working the shift. Staff #23 stated, “Yes, I heard a couple of times they had a problem with staffing a physician. I know I’ve been asked a few times to cover those holes but I wasn’t able to do it.” The surveyor interviewed Staff #28 (Chief Nursing Officer) on 1/30/24 via email. The surveyor mentioned that there were 7 shifts in November 2023 and 5 shifts in December 2023 that had no ED physician scheduled. The surveyor asked if the lack of ED physicians were discussed during Governing Body (GB) or Medical Executive Committee (MEC) meetings. Staff #28 stated, “The MEC and GB meeting was cancelled that was scheduled for November 28, 2023. The next scheduled meetings are in February 2024.” The surveyor also asked what interventions were done when the hospital leadership found out there were no ED physician scheduled or available to cover shifts. Staff #28 did not provide a response. The surveyor interviewed Staff #3 (Chief Executive Officer) on 1/30/24 via email. The surveyor mentioned that there were 7 shifts in November 2023 and 5 shifts in December 2023 that had no ED physician scheduled. The surveyor asked if the lack of ED physicians were discussed during Governing Body or Medical Executive Committee meetings. Staff #3 stated, “The meeting scheduled for November 28 was canceled due to lack of participation. The same for the Governing Board meeting scheduled for the same day.” The surveyor also asked what interventions were done when the hospital leadership found out there were no ED physician scheduled or available to cover shifts. Staff #3 stated, “When I assumed the position of CEO in September 2023, I greeted with issues in payroll which included the ER physicians compensation. When I enquired about the members of the MEC and Board of Directors, I was informed that all of the MEC members had resigned and were moving much of their practice to other locations. In the last month, I have recruited new members for the MEC and Hope to restructure the Board of Governers [sic] to include Ownership, members of the community, and industry experts. Our next MEC and Board of Governors Meeting are scheduled for February 2024.” The surveyor asked what happens when a patient comes to the ED seeking evaluation and treatment and there is no ED physician available. Staff #3 stated, “If a physician is un-available for any reason, The staff is to greet the patient when they arrive and inform the patient there is no physician in the facility. If the patient is having an emergency the staff can give aid and call for assistance through emergency services.” The surveyor interviewed Staff #2 (ED Manager) on 1/30/24 via email. The surveyor asked if the front door of the ED was ever locked or closed for any reason including no physician staff on duty. Staff #2 stated, “This door has never been locked to ED. There was no physcian [sic] available or scheduled on November 5,8,9,12,22,23,24. December 10, 12, 18, 26 31.” The surveyor asked what happens when a patient comes to the ED seeking evaluation and treatment and there is no ED physician available. Staff #2 stated, “Notify the patient there is not a doctor on site. We can render aid if needed.””

“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: 35089 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. The deficient practices identified were determined to pose a severe risk to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Cross reference to Tag A2405 CFR §489.20(r)(3), Tag A2408 CFR §489.24(d)(4-5)”

“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: 35089 Based on observation, review of documentation, and interviews with facility staff, the facility failed to maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment or was refused treatment. The findings were: The facility policy titled, “EMTALA,” last updated on 4/2023, states, “It is the policy of the BMC that all patients requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act ... Federal law requires hospitals with emergency rooms to provide a Medical Screening Examination (MSE) to every patient who comes to the hospital requesting emergency examination or treatment and to provide the patient with the necessary stabilizing treatment that is within the capabilities of the hospital until the patient is stable for transfer or discharge. These services must be provided to each patient regardless of the patient’s financial condition ... Medical Screening Examinations: All persons seeking emergency care shall receive an appropriate Medical Screening Examination (‘MSE’) to determine whether an emergency medical condition exists, without regard to a patient’s ethnicity, religion, national origin, citizenship, age, gender, sexual orientation, preexisting medical condition(s), physical or mental disability, insurance status, economic status or ability to pay for medical treatment ... Qualified Medical Person at Altus emergency Room means physician in the hospital ... BMC staff must not delay the process of providing an MSE or necessary stabilizing treatment in order to inquire about an individual’s method of payment or insurance status. Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussion until after the completion of the Medical Screening Examination. These patients will be told that the hospital will provide an MSE and stabilizing treatment, regardless of their ability to pay ... Only physicians, in-house or on-call physicians and house staff are allowed to perform an MSE at BMC. A triage is NOT synonymous with a Medical Screening Examination ...” The surveyor entered the facility without identification badge on 1/29/24 at 11:37 AM. The surveyor was greeted by Staff #11 (Admitting Receptionist / Medical Records Clerk). Surveyor: Are you guys an emergency room? Staff #11: “Yes, we are.” Surveyor: Do you guys take Medicaid? Staff #11: “We do not take Medicaid.” Surveyor: You don’t take Medicaid? Staff #11: “No.” Surveyor: If I don’t have a lot of money, can I still be seen by somebody? Staff #11: “There is a fee of $350 just to see the doctor. After that, any labs or test they do need to be added.” Surveyor: So I have to pay $350 just to see the doctor? Staff #11: “Yes, so probably across the street at Methodist, it’s better to go there and they accept Medicaid as well.” Staff #11 never asked the surveyor their name or the reason they are seeking treatment at the ED. The surveyor interviewed Staff #13 (Rad Tech) on 1/29/24 at 1555 and asked if they recalled any work shift they worked in the last 6 months where there was no ED physician working the shift. Staff #13 stated, “We’ve never been closed but there were shifts there was no ED physician. We would tell patients the system was down and we are unable to see patients. I have worked these shifts but not many. It’s either we were short or can’t find a physician to work the shift.””

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 35089 Based on observation, review of documentation, and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination within the capability of the hospital’s emergency department as evidenced by the surveyor being told by Emergency Department (ED) staff that the surveyor must pay $350 before being evaluated by the ED physician and that the surveyor should consider going to the hospital across the street instead. The findings were: The facility policy titled, “EMTALA,” last updated on 4/2023, states, “It is the policy of the BMC that all patients requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act ... Federal law requires hospitals with emergency rooms to provide a Medical Screening Examination (MSE) to every patient who comes to the hospital requesting emergency examination or treatment and to provide the patient with the necessary stabilizing treatment that is within the capabilities of the hospital until the patient is stable for transfer or discharge. These services must be provided to each patient regardless of the patient’s financial condition ... Medical Screening Examinations: All persons seeking emergency care shall receive an appropriate Medical Screening Examination (‘MSE’) to determine whether an emergency medical condition exists, without regard to a patient’s ethnicity, religion, national origin, citizenship, age, gender, sexual orientation, preexisting medical condition(s), physical or mental disability, insurance status, economic status or ability to pay for medical treatment ... Qualified Medical Person at Altus emergency Room means physician in the hospital ... BMC staff must not delay the process of providing an MSE or necessary stabilizing treatment in order to inquire about an individual’s method of payment or insurance status. Patients who inquire about financial responsibility for emergency care will be encouraged to delay such discussion until after the completion of the Medical Screening Examination. These patients will be told that the hospital will provide an MSE and stabilizing treatment, regardless of their ability to pay ... Only physicians, in-house or on-call physicians and house staff are allowed to perform an MSE at BMC. A triage is NOT synonymous with a Medical Screening Examination ...” The surveyor entered the facility without identification badge on 1/29/24 at 11:37 AM. The surveyor was greeted by Staff #11 (Admitting Receptionist / Medical Records Clerk). Surveyor: Are you guys an emergency room? Staff #11: “Yes, we are.” Surveyor: Do you guys take Medicaid? Staff #11: “We do not take Medicaid.” Surveyor: You don’t take Medicaid? Staff #11: “No.” Surveyor: If I don’t have a lot of money, can I still be seen by somebody? Staff #11: “There is a fee of $350 just to see the doctor. After that, any labs or test they do need to be added.” Surveyor: So I have to pay $350 just to see the doctor? Staff #11: “Yes, so probably across the street at Methodist, it’s better to go there and they accept Medicaid as well.” The surveyor reviewed Staff #11’s employee record on 1/30/24 and it was noted that Staff #11 participated in the 2023 Skills Fair on 9/19/23 and one of the topics was EMTALA training. It was also noted that Staff #11 attended an additional EMTALA training on 10/16/23. During the tour of the facility on 1/29/24, the surveyor noted that the EMTALA sign by ED lobby entrance stated, “This hospital does participate in the Medicaid program.” The surveyor interviewed Staff #3 (Chief Executive Officer) on 1/30/24 via email. The surveyor asked if the ED evaluated and treated patients with Medicaid. Staff #3 stated, “Yes.” The surveyor interviewed Staff #2 (ED Manager) on 1/30/24 via email. The surveyor asked if the ED evaluated and treated patients with Medicaid. Staff #2 stated, “Yes, everyone is offered a free medical screening.””