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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)

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."

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)

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."

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)

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.

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.

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)

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."

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."

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."

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)

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."

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."