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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 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam in 1 of 26 patients reviewed (Patient ID #1).

Refer to tag A 2406 for additional information.

Based on record review and interviews, Houston Methodist Baytown Hospital (Facility A) failed to provide an appropriate and thorough medical screening examination (MSE), within the capability of the hospital's emergency department, including neurology consultation available to the emergency department, to determine whether an emergency medical condition (EMC) existed for 1 of 26 patients who presented to the emergency department (ED). (Patient ID #1).

TX00493426
Findings included:

Record Review of Facility's EMTALA policy titled "System_PCPS002 EMTALA & Patient Transfers", date revised 11/6/2020, stated "This Policy and Procedure is based upon the federal law, Emergency Medical Treatment and Active Labor Act ("EMTALA"), and the Texas Administrative Code ("TAC") regarding the medical screening, stabilization and treatment or Transfer of individuals between hospitals in an appropriate manner .... Medical Screening Examination the on-going process required to reach with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists or a woman is in labor, within the facility's capabilities and available personnel, including on-call physicians. It represents a spectrum ranging from a simple process involving only a brief history and physical examination to a complex process involving the performance of ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and/or diagnostic tests and procedures. If a hospital applies its screening process in a nondiscriminatory manner (i.e., a different level of care must not exist based on payment status, race, national origin), it has met its EMTALA obligations ...
PRESENTMENT & EVALUATION: Any individual who Comes to the Emergency Department will receive an appropriate Medical Screening Examination and, if necessary, Stabilization and treatment or Transfer, within the Capability of the Hospital's Emergency Department ... Medical Screening Examination.
This screening is performed to determine if an Emergency Medical Condition exists."

Record Review of Patient #1's electronic medical record from Facility A was reviewed, Patient ID #1 was a 33 year old female who arrived to the ER on 02/26/2024 at 5:00 pm by ambulance with chief complaint of weakness. Triage notes reflected the patient arrived by ambulance. The patient was triaged upon arrival. The patient's chief complaint was "Pt coming in via EMS from home, reported that @ 4:00 pm pt was found unresponsive by 4yr old daughter who called dad to check on mom. Per him pt was unable to walk, or speak today and told EMS she had a facial droop x 3d ago. Upon EMS arrival, pt was very weak, unable to walk, was able to write on paper that her vision is 'diagonal.' In ED pt continues nonverbal, pt able to gesture." Per EMS report, "The patient was able to answer questions and follow commands appropriately; however did not respond to questions verbally"." Patient ID #1 was initially paged as a "code CVA," which is the acute activation for stroke team urgent analysis which happens immediately upon arrival. NIH stroke scale assessment done 2/26/24 5:48 p.m. by Staff RN # 72.
"Stroke Assessment NIH Stroke Scale
Interval: Change in condition
Level of Consciousness (1a.): 0
LOC Questions (1b.): 2
LOC Commands (1c.): 0
Best Gaze (2.): 0
Visual (3.): 1
Motor Arm, Left (5a.): 0
Motor Arm, Right (5b.): 0
Motor Leg, Left (6a.): 3
Motor Leg, Right (6b.): 3
Limb Ataxia (7.): 0
Sensory (8.): 0
Best Language (9.): 3
Dysarthria (10.): 2
Extinction and Inattention (11.) (Formerly Neglect): 0
NIH Total: 14." (This is falls within NIH Score 5-15 - "Moderate Stroke" severity).

The record reflects the patient had, "Severe dysarthria, patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric." The patient was also noted to have a "Partial hemianopia." Dysphagia screen done by Staff RN #72 2/26/24 5:49 p.m. demonstrated that the patient failed the dysphagia screening due to positive facial asymmetry/weakness, positive tongue asymmetry/weakness, and palatal asymmetry/weakness. On 2/26/24 5:51 p.m., Staff RN #72 documents a neurologic exam which included "unsteady gait, blurred vision, change in behavior, dizziness and headache. She was noted to use written communication and nod/gesture appropriately."

The History and Physical performed 2/26/2024 by Physician Staff ID #71 noted, "Otherwise health 33 year old female with history of anxiety, migraines, brought in by EMS for refusal to speak to her husband at home, questionable mouth deviation for the past 3 days." A neurologic exam demonstrated no focal deficit. Per the ED course @ 9:53 p.m., the patient was awake alert, speaking long in full sentences that are coherent, neurologic exam remains nonfocal. The MDM section notes, "Refusing to speak initially, however when encouraged and I explained that it would help her care, patient speaking long coherent sentences without dysarthria or aphasia."

Patient ID #1's medical screening exam included a CBC, a chemistry, drug screen, alcohol level, chest x-ray and CT brain. However, further evaluation for a possible TIA was not performed, including further symptom monitoring through observation/admission, MRI of the brain, vascular imaging, and/or neurology consultation.

No documentation indicated that neurology was consulted by the treating ED physician (Staff ID # 71). Review of the neurology on-call schedule for 2/26/2024 indicated a neurology physician was available for consults. The neurology consult could have assisted the ED physician in determining need for further testing, admission or discharge with prompt follow-up with neurology.

Medical Record Review for Facility B reflected that Patient #1 presented to Facility B Emergency Department, on 3/1/2024, with generalized progressive weakness, droopy eyelids and difficulty swallowing. The patient had a neurology consultation, labs, imaging and therapy evaluations and was diagnosed with myasthenia gravis. She received IVIG infusions, rehab therapy consultation and treatments and oral medications as well as close outpatient follow-up.

The surveyor reviewed Physician Staff # 71 analysis of her care for Patient ID#1 date of service 2/26/24. She stated that the patient did not have acute neurologic defects at the time of her Code Stroke evaluation and so the "Code Stroke was cancelled." She stated when she went into the patient's room to go over her results, she had the ability to form and speak in full coherent sentences. She stated that regarding the myasthenia gravis diagnosis provided a few days later, that diseases progress and pathology reveals itself over time, and that is why patients are given return to care precautions.