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Based on observation, interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases.
1) The facility failed to register patient ID #24 on the central log for treatment.
2) The facility failed to provide an appropriate medical screen exam for Patient ID #14, 23 and 24.

Refer to tag A 2405 and A 2406 for additional information

A2405 ER Log
Based on interview and record review, the facility failed to maintain an accurate Emergency Department Central Log. Patient ID #24 was found in Facility A's hospital lobby by campus police and security staff, displaying evidence of behavioral health emergency, and was transported to Facility B via campus police department personnel for evaluation and care on 7/30/24. There was no evidence of Patient ID #24 recorded in Facility A's Emergency Department Central Log.

Findings included:

Record Review of Facility Policy titled "Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA)" last reviewed, 9/1/2016, stated "Definitions Campus: the physical area immediately adjacent to the UTMB's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office,
to be part of the provider's campus." It further stated "Policy A. Healthcare workers in the Emergency and Nursing Service departments and Off Site Clinics will ensure that all individuals who come to the UTMB Emergency Department (ED), or on UTMB property, for an examination or treatment for a medical condition will be screened to determine whether an emergency medical condition exists. When a woman presents in labor, the OB/Gyn resident on-call will be paged immediately. For purposes of this section, ''property'' means the entire main hospital campus, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined to be a department of the hospital. B. All individuals who present to a provider-based clinic either on or off campus for emergency medical care will be screened to determine whether a medical emergency does or does not exist. At least one individual on duty during the clinics regular hours of operation must be a designated qualified medical person (QMP). Clinics that are not routinely staffed with MD's, RN's, PA's or LVN's must have a written protocol to provide guidance as to what actions to take. These can include contacting the UTMB Emergency Department for guidance. If it is determined that a medical emergency does exist and EMS is called and the patient transported to UTMB or another hospital, the UTMB Emergency Department must be notified of the individual's arrival to the
clinic and the handling of the case, which will be noted in the hospital's emergency department central log."

Record Review of Facility Police Log titled "Log of EAD related transfers by UTMB PD for Period 07/29 to 08/05". The list included "Date 7/30/24; Pickup Location: (Facility A) University Plaza Garage; Pickup Time: 22:43:23; Drop Off location (Facility B); Dropoff time: 23:35:30."

Interview with Director of Quality Staff ID #51 on 9/18/24 at 10:20 am. She confirmed there was no evidence of Patient ID #24 on facility central log.

Interview with Chief of Police Staff ID #75 on 9/18/24 at 09:35 am. He confirmed that Patient ID #24 had been brought by police department squad car on 7/30/24 to Facility B Emergency Department by Facility A police staff and checked-in for care and evaluation at Facility B on 7/30/24. He confirmed that Patient ID #24 was engaged by police department staff in the lobby of Jennie Sealy hospital building Facility A and was displaying signs and symptoms of a behavioral health problem upon field mental health assessment. He confirmed that the responding officers completed an Emergency Order and took Patient ID #24 fifty-four miles to Facility B Emergency Department.

Telephone Interview with Facility Police Officer Staff ID # 80 on 9/19/24 at 6:10 pm. He confirmed that he was dispatched after a 911 call regarding a man "cursing and screaming at people" in a nearby area. He arrived on scene to Facility A hospital lobby and encountered Patient ID#24 "reciting Spanish prayers, shaking, unable to identify where he was and 'asking for help' " on 7/30/24 night shift. He stated that he spoke with his supervisor and prepared an Emergency Detention Order based on his field mental health assessment. He confirmed he drove the patient 54 miles to Facility B Emergency Department for evaluation at his supervisor's direction.

Based on record review and interview, the facility failed to provide a medical screening examination (MSE) for 3 of 23 patients reviewed, who arrived or were located on facility property, with request for evaluation (Patient ID # 14, 23 and 24).

Findings included:
Record Review of facility policy titled "Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA)", last reviewed 9/1/2016, stated "II. Policy A. Healthcare workers in the Emergency and Nursing Service departments and Off Site Clinics will ensure that all individuals who come to the UTMB Emergency Department (ED), or on UTMB property, for an examination or treatment for a medical condition will be screened to determine whether an emergency medical condition exists. When a woman presents in labor, the OB/Gyn resident on-call will be paged immediately. For purposes of this section, ''property'' means the entire main hospital campus, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined to be a department of the hospital...B. All individuals who present to a provider-based clinic either on or off campus for emergency medical care will be screened to determine whether a medical emergency does or does not exist. At least one individual on duty during the clinics regular hours of operation must be a designated qualified medical person (QMP). Clinics that are not routinely staffed with MD's, RN's, PA's or LVN's must have a written protocol to provide guidance as to what actions to take. These can include contacting the UTMB Emergency Department for guidance. If it is determined that a medical emergency does exist and EMS is called and the patient transported to UTMB or another hospital, the UTMB Emergency Department must be notified of the individual's arrival to the clinic and the handling of the case, which will be noted in the hospital's emergency department central log...Personnel Authorized to Perform Medical Screening Exam. The following personnel are authorized to perform medical screening exams at UTMB: Faculty physicians; Residents assigned to the ED; Physician's Assistants employed in the ED under the direct supervision of the Emergency Medicine Faculty; Advanced Nurse Practitioners; or Staff designated in offsite clinics as Qualified Medical Personnel (QMP). Documentation The screening of all individuals in the Emergency Department and in offsite clinics will include documentation of:
If the individual has an emergency medical condition; Actions taken to make the determination; Results of diagnostic tests; Completion of Agreements, Authorizations, and Irrevocable Assignments, Disclosure and Consent for Medical and Surgical Procedures, and Against Medical Advice forms, if applicable; and Actions taken to stabilize and/or transfer the patient to UTMB's Emergency Department, for those seen in the offsite clinics....Medical screening exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. It is an ongoing process and must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. The exam will include information about the chief complaint, the patient's vital signs, mental status assessment, general appearance, and a focused physical exam related to the patient's complaint. Note: Triage is not the equivalent of a medical screening examination. The medical screening exam must be the same that UTMB would perform on any individual coming to the ER with those signs and symptoms regardless of the individual's ability to pay for medical care.Qualified Medical Personnel (QMP): An MD, RN, Advanced Practice Nurse, PA, or LVN at an off-site clinic who has been educated on the process for medical screening and trained in the appropriate handling of emergency situations within the scope of their education and experience."

Record review of Patient ID #14 electronic medical record revealed patient ID #14 arrived to the facility on 9/2/2024 at 2:33 pm by personal vehicle and was arrived by Registration Staff ID#83 with chief complaint "burn." ED Staff RN #79 documented Patient ID #14 is a "23 year old male Patient arrives via personal means with complaint of burns on bilateral legs and left arm, 'There was a fire and I didn't want my baby momma to get burned.' Pt said the fire was from oil. Patient is alert and oriented times X4, even and unlabored respirations visualized. Pt taken to burn unit. Triage was documented as initiated by ED Staff RN ID #79 on 9/2/2024 at 2:54 pm. She documented the disposition "triaged to the burn unit." The medical record stated Patient ID #14 was transported to facility burn unit by transportation staff. There was no medical screen exam located.

Record review of Patient ID #23 electronic medical record revealed patient ID #23 arrived to the facility on 8/7/2024 at 1:21 pm by personal vehicle with chief complaint "burns" and was entered by registration staff ID #83. Patient ID #23 was roomed in Room 109 by Staff RN #85 at 1:22 pm. Triage was initiated by ED Staff RN ID # 85 and stated (redacted patient name) is a 64 year old male presents to ED c.o right foot burning and swelling that started last night. Pt reports "everytime I have something happen they take me straight back to the unit since I am a burn patient". Redness, warmth and swelling noted to right leg and foot. Pt screaming and crying in pain. Aox4 with gcs 15 skin warm and dry resp even and unlabored. Report called to Burns, taken via wc by ER RN. He was transported to facility burn unit by facility staff. There was no medical screen exam located. 1:31 pm Disposition was set to "triaged to burn unit" by Staff RN # 85. Medical record entry 8/19/24 at 06:10 am for Patient ID# 23 by Staff ED physician ID # 87 stated "Pt was taken straight to burn unit without ED evaluation."

Record review of Facility A central log dated 7/30/2024 and 7/31/24 failed to locate patient ID #24 on the central log. Facility A was unable to locate Patient ID# 24 in their EPIC electronic medical record at all per Director of Quality Staff ID #51.

Interview with Nursing Director of Emergency Department Staff ID # 53 on 9/17/2024 at 2:30 pm. He confirmed he was unable to locate medical screen exam for Patients ID# 14 on date of service 9/2/2024 and Patient ID #23 on 8/7/2024. He stated the facility had a process/procedure in place at triage where patients who presented with burns, and had stable airways, would be sent to the burn unit for prompt, specialized evaluation and care. He reported the triage Emergency Department registered nurse would call the Burn Unit charge nurse to arrange for the patient to go to the burn unit for evaluation and care. He confirmed the Emergency Department providers were not routinely involved in the decision to transfer/relocate patients to the burn unit.