Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670068 (X3) Date Survey Completed 12/23/2020
Name of Provider or Supplier Texas Health Presbyterian Hospital Flower Mound Street Address, City, State 4400 Long Prairie Road, Flower Mound, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000 Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation (s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An unannounced complaint survey was conducted on site. An entrance conference was held with the hospital representative on the morning of 12/23/2020. The hospital representative was informed that the survey would be conducted according to 42 CFR 489.24 and 42 CFR 489.20 (1), (m), (q), and (r) of the Emergency Medical Treatment and Labor Act (EMTALA), and Section 5400, Appendix V of the State Operations Manual. An exit conference was conducted the afternoon of 12/23/2020 with the hospital representatives. The hospital representatives were informed that CMS would make the final determination of the hospital's compliance with EMTALA regulations for Complaint TX00368732.
A2400 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:
Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply 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, citing 1 of 20 patients (Patient #1) that presented to the emergency department (ED) on 12/17/2020. Findings included Cross Refer to Tag 2406
A2406 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:
Based on record review and interview, the facility failed to ensure 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 for each patient, in that, 1 of 20 patients (Patient #1) did not receive a medical screening examination on 12/17/2020. Findings included The facility's emergency log reflected Patient #1's visit on 12/17/2020. There were 63 patients listed for 12/17/2020. Patient #1 presented to the emergency room on 12/17/2020 at 16:16 PM. There was no Medical Screening Examination completed for Patient #1. During an interview on 12/23/2020 ending at 10:35 AM, Personnel #4 was asked about Patient #1. Personnel #4 stated, "She wouldn't wear a mask. Hers was clear plastic from her chin to nose, around her face, but open. Patients come in with their own mask. Most are okay. Cloth, mesh. This one was not okay. They told me she wouldn't put on a mask. She said she was having anxiety, and blood pressure issues. I asked her to put on a mask and she said she was too anxious. I said sorry. She said it would make her have higher anxiety and she was very rude. I told her we have to protect others. She would not and left." During an interview on 12/23/2020 at 10:54 AM, Personnel #1 and #2 reviewed the record and were informed of the finding. They were asked if it had been known and if there were other patients that had been sent away. Personnel #1 stated, "No. It wasn't known. We are not aware of others." Personnel #1 stated, "We don't have a policy about patients unable to wear the approved masks."