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Based on observation, interview, and review of records, the facility failed to enforce policies to ensure special responsibilities of Medicare hospitals in emergency cases under 482.24 were met.

The facility failed to:

A) post conspicuously 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 in 13 areas (10 treatment rooms, ambulance entrance, public entrance, and waiting area) of 14 required areas.

Refer to Tag C2402

B) ensure that the central log listed every individual who had come to the emergency department seeking assistance for 1 (Individual #21) of 1 individual who were known to have requested assistance but did not receive care at the facility.

Refer to Tag C2405

C) provide 2 individuals (Patient #2 and Individual #21) out of 21 emergency department encounters reviewed with a documented medical screening examination.

Refer to Tag C2406

Based on observation, interview, and review of records, the facility failed to post conspicuously 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 in 13 areas (10 treatment rooms, ambulance entrance, public entrance, and waiting area) of 14 required areas.

On 6-24-25 at 9:40 AM, a tour of the Emergency Department was made with Staff #9 and Staff #5 present. A large sign in the updated form specified by the Secretary was observed to be displayed in the registration area. It was not visible from the public entry or waiting area. No required signage was displayed at the public entry or in the waiting area.

The ambulance area entrance did not have the required signage posted. The trauma treatment room and one other treatment room were observed. Neither had the required signage posted.

Staff #5 was asked if any of the other occupied treatment rooms had signage. Staff #5 confirmed that none of the treatment rooms had signage posted. Staff #5 stated he didn't understand why they needed to be in the treatment rooms when it was displayed at the registration area. Staff #5 was asked if patients ever get escorted immediately straight back to a treatment room and were registered and triaged in the treatment room. Staff #5 confirmed that they do that routinely for certain emergent patients such as brought in by ambulance. Staff #5 acknowledged that the treatment room would be the only opportunity for patients to be able to view the required signage in those instances when a patient was taken straight back to a treatment room.

A review was made on 6-24-25 of Ut Health East Texas policy Title: EMTALA - Signage Policy - CD - MKT; Policy Number: 30523.2; Approved by: Market Director, Facilities Operation, Regional Director of Compliance, UTHET DCC; Market Approval Date: 04/30/2019; Effective Date: 01/26/2023; Next Review Date: 01/16/2026 . On Page 1, under the heading "Procedure:", item 2).

The policy stated the following:

"2) Location of Signage. Each Dedicated Emergency Department of UT Health East Texas will post Signage in places likely to be notices by all individuals entering the Dedicated Emergency Department, as well as those individuals waiting for examination and treatment, including the entrance, admitting area, waiting room, and treatment area, specifying the rights of individuals to examination and treatment for Emergency Medical Conditions and women in Labor."

Hospital Staff failed to follow hospital policy.

Based on review of records and interview, the facility failed to ensure that the central log listed every individual who had come to the emergency department seeking assistance for 1 (Individual #21) of 1 individual who were known to have requested assistance but did not receive care at the facility.

On 6-20-25 at 12:09 PM, prior to the on-site investigation, an interview was conducted with Law Enforcement (LE) #22 at the Lone Star Police Department. LE #22 stated he had taken a sexual assault survivor to the UT Health East Texas Pittsburg Emergency Department on 3-6-25. He stated she had been "brutally" assaulted, "writhing" in pain, and complaining of bleeding from her anus. LE #22 provided body-worn camera video of the encounter with hospital staff at the ambulance bay entrance of the hospital.
Note: time stamps on video indicate hours and minutes of video time and not hours and minutes of the day.

Review of body-worn camera video from 3-6-25 showed that at the 01:24:23 point of the video LE #22 and Individual #21 arrived at the ambulance entrance of the hospital. LE #22 could not get anyone's attention to allow them in the ambulance entrance. LE #22 walked around to the public entrance and made contact with Staff #11. Staff #11 could be seen later in the video at 01:31:24 asking for the name and date of birth of Individual #21 in order to register her. At the 01:34:42 mark of the video, Staff #11 could be seen coming back out to the ambulance bay with a set of patient stickers. LE #22 was told there was not a Sexual Assault Nurse Examiner (SANE) nurse available. LE #22 inquired if one was available in Greenville. Staff #11 volunteered that Hospital #2 had a SANE nurse and asked if LE #22 wanted her to call and verify.

At 01:35:46, Staff #11 returned and told LE #22 that Hospital #2 had a SANE nurse on call. LE #22 stated he was going to take Individual #21 there.

At 01:39:06, LE #22 could be seen getting into his truck and leaving to go to Hospital #2.

On 6-24-25, a review of the Central Log was made. Individual #21 could not be found on the log. Staff #1 and Staff #2 were told that there was video of Individual #21 interacting with their staff and were asked to investigate it.

On 6-24-25 at 11:59 Staff #1 reported that she had looked up Individual #21 by name and found that on 3-6-25 Individual #21 had been registered, but the registration had been cancelled by Staff #11. Staff #1 stated she was going to have Information Technology (IT) figure out what happened "in the background). Staff #2 reported later that day that it was documented the reason for cancellation of registration was that information was entered in error.

On 6-24-25, Staff #11 was interviewed in the conference room. Staff #11 confirmed that she had volunteered to call Hospital #2 to see if a SANE Nurse was available. Staff #11 confirmed that she cancelled the admission. "If they were not seen, I cancel the encounter. If there is no charting and don't want to bother the nurses, I just remove them off the board."

Staff #1 was asked to provide a list of cancelled admissions. Staff #1 stated they did not have a report that could provide that list. Staff #1 stated there would be no way of knowing if an admission was truly cancelled due to information entered in error of if the individual had left before being seen.

Review of the encounter for Individual #21 showed that Staff #11 created an Emergency Room Encounter on 3-6-25 at 6:45 PM. Staff #11 cancelled the encounter on 3-6-25 at 6:53 PM.

Review of UT Health East Texas policy Title: EMTALA - Central Log - CD - MKT; Policy Number 30518.3; Approved by: Regional Director of Compliance, UTHET DCC; Market Approval Date: 04/30/2019; Effective Date: 04/12/2023; Next Review Date: 04/12/2026 was made on 6-24-25.

Under the heading "Procedure:", number 8), the policy stated:
"8) A Central Log entry should be made at the patient's first point of contact with UT Health East Texas. This would normally take place at Triage and be finalized after the Medical Screening Examination and/or any necessary treatment to Stabilize the Emergency Medical Condition, as applicable. An individual should be recorded in the Central Log even if he/she leave the UT Health East Texas before Triage or receiving a Medical Screening Examination."

Hospital Staff failed to follow hospital policy.

Review of Staff #11's personnel file showed that she was a contract employee and had a limited contractor file. Per the contract, the contractor was responsible for training. Staff #11 had a training Standard Operating Procedure (SOP) titled Patient Access: EMTALA Registration. The training did not address that an individual presenting to the Emergency Department could not be removed from the Central Log. No evidence was presented to show that the hospital had trained Staff #11 on their internal policies and procedures.

During personnel file reviews on 6-25-25 at 11:55 with Staff #7, Staff #7 stated that all training for Patient Access staff to include Staff #11 was provided by the contractor.

Based on review of records and interview, the facility failed to provide 2 individuals (Patient #2 and Individual #21) out of 21 emergency department encounters reviewed with a documented medical screening examination.

Findings were as follows:

On 6-20-25 at 12:09 PM, prior to the on-site investigation, an interview was conducted with Law Enforcement (LE) #22 at the Lone Star Police Department. LE #22 stated he had taken a sexual assault survivor to the UT Health East Texas Pittsburg Emergency Department on 3-6-25. He stated she had been "brutally" assaulted, "writhing" in pain, and complaining of bleeding from her anus. LE #22 provided body-worn camera video of the encounter with hospital staff at the ambulance bay entrance of the hospital.

Note: time stamps on video indicate hours and minutes of video time and not hours and minutes of the day.

Review of body-worn camera video from 3-6-25 showed that at the 01:24:23 point of the video LE #22 and Individual #21 arrived at the ambulance entrance of the hospital. LE #22 could not get anyone's attention to allow them in the ambulance entrance. LE #22 walked around to the public entrance and made contact with Staff #11.

At approximately 01:26:46, Staff #22 could be seen outside of the ambulance entrance telling LE#22 that Individual #21 would have to go through the public entrance and register. LE #22 informed Staff #22 that Individual #21 was a "sexual assault trauma".
Staff #11 could be seen later in the video at approximately 01:31:24 asking for the name and date of birth of Individual #21 in order to register her.

At the approximately 01:34:42 mark of the video, Staff #11 could be seen coming back out to the ambulance bay with a set of patient stickers. LE #22 was told there was not a Sexual Assault Nurse Examiner (SANE) nurse available. LE #22 inquired if one was available in Greenville. Staff #11 volunteered that Hospital #2 had a SANE nurse and asked if LE #22 wanted her to call and verify.
At approximately 01:35:46, Staff #11 returned and told LE #22 that Hospital #2 had a SANE nurse on call. LE #22 stated he was going to take Individual #21 there. Individual #21 could be heard saying, "It hurts really bad".

At approximately 01:36:48, Individual #21 could be seen vomiting. LE #22 told Staff #22 and Staff #11 that Individual #21 had been vomiting all day and didn't have anything left in her to throw up. Individual #21 told Staff #22 and Staff #11 "My butthole hurts really bad."

At approximately 01:39:06, LE #22 could be seen getting into his truck and leaving to go to Hospital #2.

At no time during the interaction did a nurse or physician come outside to assess Individual #21.

On 6-24-25, Staff #11 was interviewed in the conference room. Staff #11 confirmed that she had volunteered to call Hospital #2 to see if a SANE Nurse was available. Staff #11 stated she had worked at Hospital #2 and knew they had one over there and "we didn't have one". When asked if the triage nurse had seen Individual #21, she stated she could not remember.

On 6-24-25 a review was made of the Encounter Event Summary for Individual #21. The record showed that Staff #11 created an Emergency Room Encounter on 3-6-25 at 6:45 PM. Staff #11 cancelled the encounter on 3-6-25 at 6:53 PM. No other emergency department staff accessed the encounter during that time. No triage examination was documented. No Medical Screening Examination was documented. The encounter had been cancelled with an annotation "Created in error" under the Event Management tab for the encounter.

On 6-24-2025, Patient #2's medical chart was reviewed. Patient #2 was an 8-year-old child brought in by the father on 6-18-25 at 9:44 PM. Patient #2 was discharged on 6-19-25 at 1:00 AM.

The computer showed that a provider was assigned at 10:03 PM and labs were ordered by the physician at 10:14 PM. The triage nurse documented at 10:04 PM the following note:
"Pt amb to ER1 with steady gait, accompanied by dad. Dad reports that pt has been experiencing some changes in mood and behavior such as anger issues, disobedience, and has begun bedwetting and hiding the wet clothes. Dad state that pt went to the bathroom and when she pulled her shirt from her pant, there was a spot on the lower front and he noticed a bad smell coming from the area. Dad expressed concern for SA because pt's mother has a new boyfriend that moved into the house pt lives in approx 8 months ago, located in (redacted for patient privacy). Dad also reports his 13 and 14 year old daughters say they have kissed mother's boyfriend. Pt denies complaints. Dad denies PMH. UTD on vaccines."

The complete paper chart was requested and provided on 6-25-2025.

Upon review of the completed paper chart it was found that no Medical Screening Examination was documented.

At the bottom of page 1 of the chart, it was documented:
"ED Provider Note No documentation."

On page 3 on the upper half of the page the following was documented:
"H&P Notes No documentation"
"Clinical Notes No documentation"
"Discharge Summary Note No documentation"
There were Discharge Instructions documented by the physician that stated:
"Follow up with law enforcement and with child advocacy as instructed."

Other than the discharge instructions, no documentation from the physician about the patient's condition was found in the chart.

On 6-24-25, a review was made of UT Health East Texas Policy Title: EMTALA - Medical Screening Examination and Stabilization-CD-MKT; Policy Number: 30519.3; Approved by: Regional Director of Compliance, UTHET DCC; Market Approval Date: 10/22/2019; Effective Date 04/19/2023; Next Review Date: 04/19/2026.

Page 1 under Policy stated:
"1) Any individual who comes to the Emergency Department will be provided an appropriate Medical Screening Examination performed by a Physician or Qualified Medical Person to determine if the individual has an Emergency Medical Condition. If an individual has an Emergency Medical Condition, UT Health East Texas will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition, within UT Health East Texas's Capability and Capacity."

Page 2 under Procedure stated:
"2) Performance of the Medical Screening Examination. The Dedicated Emergency Department must provide for an appropriate Medical Screening Examination within the Capability of the Dedicated Emergency Department, including ancillary services routinely available to the Dedicated Emergency Department, to determine whether or not an individual has an Emergency Medical Condition, or with respect to a pregnant woman having contractions, whether woman is in Labor, ..."

Page 4, item 4) stated:
4) Personnel who may Perform the Medical Screening Examination.
a) The Medical Screening Examination may be performed by a Physician or Qualified Medical Person who is qualified to conduct such examination.
b) UT Health East Texas and its Medical Staff will determine the categories of Qualified Medical Person who may perform the Medical Screening Examination. The Medical Staff bylaws or rules and regulations, as approved by UT Health East Texas governing body, will designate categories of Qualified Medical Persons in each Dedicated Emergency Department who are authorized to perform the Medical Screening Examination."

No evidence was found that either Individual #21 or Patient #2 received the required Medical Screening Examination from a physician or qualified medical person per hospital policy.

Based on review of patient records, policies and procedures, and interview, the facility failed to:

A) ensure that 5 patients (Patient #1, #2, #13, #14 and #15) of 5 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault.

Refer to Tag C2502

B) ensure patients were properly protected from abuse. The facility failed to ensure the state required mandatory report of suspected abuse to the Texas Department of Family Protective Services (DFPS), Child Protective Services (CPS) was made for 2 minor patients (Patient #6, Patient #15) of 4 minor patients when there was a reasonable suspicion that abuse was involved.

Refer to Tag C2525

Based on review of patient records, policies and procedures, and interview, the facility failed to ensure that 5 patients (Patient #1, #2, #13, #14 and #15) of 5 patients who presented to the emergency department after a sexual assault were provided with all the patient rights required by state law in the Texas Health and Safety Code, Chapter 323, Subchapter A. Emergency Services for Survivors of Sexual Assault.

Sec. 323.004. MINIMUM STANDARDS FOR EMERGENCY SERVICES, Subchapter (b) requires:
(b) A health care facility providing care to a sexual assault survivor shall provide the survivor with:
...
(3) access to a sexual assault program advocate, if available, as provided by Subchapter H, Chapter 56A, Code of Criminal Procedure;

(4) the information form required by Section 323.005; (Sec. 323.005. INFORMATION FORM. (a) The commission shall develop a standard information form for sexual assault survivors ...)
...
(7) the name and telephone number of the nearest sexual assault crisis center; and
...

Findings included the following:

On 6-24-2025 during the entrance conference, the facility was asked to provide a table of contents of all policies that pertained to the operations of the Emergency Department. Staff #1 provided that list on the afternoon of 6-24-2025 and confirmed it was the table of contents for all Emergency Department Policies. Review of the Table of Contents for UT Health East Texas Emergency Department Policies was reviewed. It contained only 1 policy pertaining to Sexual Assault, Titled "FNE/SANE - Drug Facilitated Sexual Assault - ED - MKT

Review was made on 06-24-2023 of the Policy Title: FNE/SANE - Drug Facilitated Sexual Assault - ED - MKT; Policy Number: 48445.2. The "Objective" of the policy was stated as "To obtain blood and/or urine specimen for toxicology and maintain chain of custody.

The policy did not contain information or procedures for ensuring patients were provided the following patient rights as required by state law:
access to a sexual assault program advocate, if available;
the information form required by the commission detailing survivor rights and required information; or
the name and telephone number of the nearest sexual assault crisis center.

Review of charts for Patient #1, #2, #13, #14 and #15 showed no documentation of patients receiving the required notice of rights titled "Information for Survivors of Sexual Assault" required by the Texas Health and Safety Code Chapter 323. No evidence was found that the facility had attempted to provide the patients with access to a sexual assault program advocate. No evidence was found that the facility provided the patients with the name and telephone number of the nearest sexual assault crisis center as required.

Interview was conducted with Staff #5 on the morning of 6-24-25 in the Emergency Department. Staff #5 was asked if there were information forms provided to patients who presented to the Emergency Department after sexual assault. Staff #5 stated there was no "set document list" for resources for sexual assault victims. Later that afternoon, Staff #1 provided a copy of the State required information form titled "Information for Survivors of Sexual Assault" and stated this form was available in the Emergency Department for patients who had been sexually assaulted. However, it was dated 2/25/2020. The current version of the form with correct information was dated 12/20/23. Staff #1 confirmed the facility was unaware that it had changed.

Interview was conducted on 6-25-25 with Staff #1, Staff #2, Staff #4 and Staff #5. All confirmed that they were not familiar with the Texas Health and Safety Code Chapter 323 and had not developed policies and procedures to ensure the patients received the required notice of rights through the State required information sheet.

Based on review of records and interview, the facility failed to ensure patients were properly protected from abuse. The facility failed to ensure the state required mandatory report of suspected abuse to the Texas Department of Family Protective Services (DFPS), Child Protective Services (CPS) was made for 2 minor patients (Patient #6, Patient #15) of 4 minor patients when there was a reasonable suspicion that abuse was involved.

Findings were as follows:

Review was made of Patient #6's medical record on 6-24-25. Patient #6 was a 17 year old male who had been drinking alcohol. He was brought to the Emergency Department on 6/8/25 by ambulance at 3:25 AM. Per the chart, "pt arrived to ED by EMS after he got into a fight at 0230 this morning. Pt was drinking and tried to drive a friend home when his grandfather tried to stop him. They got into a physical altercation. EMS reports pt was non-responsive on their arrival. Pt stated he just remembers waking up in the ambulance. Unknown quantity of ETOH consumed by pt."

6/8/25 at 4:55 AM the nurse charted, "Pt's mother attempted to leave the ED while PPD officers x2 at bedside. She walked to the waiting area at that time I walked out and told the pt's mother he is a minor and she was his legal guardian and she has to stay. Pt's mother is standing outside pt's room."

No evidence of a report being made to CPS was found in the chart.

Review of Patient #15's medical record on 6-24-25. Patient #15 was an 11 year old. Patient #15 presented to the Emergency Department on 2/13/25 at 6:56 PM. Patient #15 claimed an 11 year old cousin had been sexually assaulting Patient #15 since the age of 6.

No evidence of a report being made to CPS was found in the chart.

Staff #1 and Staff #5 confirmed there was not evidence of CPS being involved in either case. Both stated that since Law Enforcement had been contacted, they believed the duty to report had been met. In fact, it had not. A separate report to DFPS, CPS was required per Texas Family Code 261.103(c). Staff #5 made the required report on 6-24-25 for patient #6 and on 6-25-25 for patient #15.

Review was made on 6/25/2025 of UT Health East Texas policy Title: Special Cases to be Reported - ED - MKT; Policy Number: 49997.2; Approved by: UTHET CNO Council, UTHET DCC; Market Approval Date: 11/22/2019; Effective Date: 06/05/2023; Next Review Date: 06/05/2026.

The policy contained the following:
"Policy: The law requires that special cases be reported to the appropriate authority.
Procedures:
Case Agency
1) Deaths Law Enforcement
2) Death with Possible Criminal Involvement Law Enforcement
3) Death of a Person Not Yet Identified Justice of the Peace
4) Animal Bites Animal Control
5) Child, Elderly Abuse > 65 or mentally Child or Adult
Handicapped Protective Services
6) Any extenuating circumstances or suspect cases Law Enforcement

Hospital Staff failed to follow hospital policy.