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 670069 (X3) Date Survey Completed 10/11/2023
Name of Provider or Supplier Methodist Mckinney Hospital Street Address, City, State 8000 W Eldorado Pkwy Bldg C Suite C, Mckinney, 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 An on-site unannounced EMTALA complaint survey was conducted beginning on the morning of October 10, 2023. An entrance conference was held in a conference room with Methodist McKinney Hospital's administrative staff members on October 10, 2023, at 10:30 AM. A survey investigation was conducted to determine the hospital's compliance with the Medicare Conditions of Participation set forth at 42 CFR Part 482 using the applicable survey report form. It was explained that the complaint survey would be conducted according to 42 CFR 489.24 and 42 CFR 489.20 (l), (m), (q), and (r) of the Emergency Medical Treatment and Labor Act, and section 5400, appendix V of the State Operations Manual. . 10/11/2023: EMTALA Complaint TX00469607 will be referred to CMS Regional Office for final compliance determination. . An exit conference was held with Methodist McKinney Hospital's administrative staff members at 10:30 AM and they were informed that CMS would make the final determination for complaint TX00469607. .
A2405 EMERGENCY ROOM LOG
CFR(s): 489.20(r)(3)

[The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services.


This STANDARD is not met as evidenced by:
Based on document review and staff interview, the facility failed to maintain medical records for one (Patient #1) out of 20 patients who presented to the hospital emergency department from August 25 1, through October 10, 2023. . The findings were as follows: . Document Reviews: 1. A review of the central log for August 28 - 30, 2023, revealed that Patient #1 presented to the Emergency Department on August 30, 2023, requesting medical care or treatment. . 2. A request for one of the medical records, the record for Patient #1, was made on October 11, 2023, at approximately 1200 PM. The facility was unable to produce the medical record. . 3. The Facility's policy titled, 'EMTALA - Patient Registration' (originating and last revised on 04/2016, last reviewed and effective on 12/2022), stated on page 1 of 2: " ...Rapid Registration information and a patient record shall be initiated for all patients who present to the ED, even if they choose to leave without being seen (LPMSE); leave prior to medical screening exam or before treatment is completed (LPT); or leave "against medical advice" (AMA). Partial records may be generated in these situations with as much information as available. Appropriate forms should be initiated with the patient by medical/nursing staff in these situations if possible. . "Reasonable" registration information may be obtained per EMTALA guidelines as long as there is no delay in care. That may include demographics such as name, address, phone number, birth date/age, and presenting medical problem(s). The Hospital will use a "Rapid registration' that may use some or all of what is considered "reasonable." Failure to provide registration information may not, at any time, delay the medical screening examination (MSE) or stabilizing treatment ..." . Emergency Room (ER) lobby and entrance security footage was reviewed: 4. A review of the facility's ER security camera footage on the afternoon of August 30, 2023, between 4:20 PM and 5:35 PM showed Patient #1, was at the Facility's ER for 62 minutes. . Interviews: 5. On October 11, 2023, at approximately 1200 PM, Staff #3 indicated there were no medical records for Patient #1. . Staff #3 stated that she did not know what happened to the handwritten paperwork that was seen on the facility's security footage given to Patient #1 or collected by a staff member. .
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 medical record reviews, facility documentation reviews, and interviews, the facility failed to provide an appropriate medical screening examination (MSE) for one (Patient #1) of 20 patients whose records were reviewed. This resulted in Patient #1 leaving to seek medical treatment at a different facility. . The findings were as follows: Medical Record Reviews: 1. There was no patient record located for Patient #1 at the facility. The facility's Emergency Room (ER) register/log shows that Patient #1 signed in on August 28 - 30, 2023. . Emergency Room (ER) lobby and ambulance bay security footage was reviewed: 2. A review of the facility's ER security camera footage on the afternoon of August 30, 2023, between 4:20 PM and 5:35 PM showed Patient #1, was at the Facility's ER for 62 minutes without receiving a medical screening exam. . Observation of the facility's ambulance bay video footage revealed that Patient #1 was on her phone at 4:54 PM. EMS arrived at 5:05 PM, placed Patient #1 on a stretcher at 5:07 PM, and transported Patient #1 to another facility to obtain treatment. . Policy Reviews: 3. The Facility's policy titled, 'EMTALA - Medical Screening Examination (MSE)' (originating and last revised on 04/2016, last reviewed and effective on 12/2022), stated on page one of three: " ...The Hospital shall provide each individual who comes to the dedicated ED with an appropriate medical screening examination (MSE), within its capabilities to determine whether the individual has an emergency medical condition, regardless of the individual's ability to pay, race, color, national origin, age, sex, religion, or disability ..." . And on page two of three: " ...The ED shall generate a medical record for each individual who presents to the department, documenting the MSE provided. Such records shall be maintained in compliance with the Hospital's record retention policy and procedure ..." . 4. The Facility's policy titled, 'Patient Assessment and Triage Policy' (originating on 07/2016, last revised on 01/2022, last reviewed and effective on 12/2022), stated on page one of three: " ...B. All patients presenting to the Emergency Department will be screened by priority placement (see Priority Patient Placement policy to define elements of triage) of sick, not sick while beds are open, when no beds open traditional triage will ensue as: triaged and categorized using the Emergency Injury Severity Index Scale known as ESI -5 level system ..." . Interviews: 5. On October 11, 2023, at approximately 1200 PM, Staff #3 indicated there were no medical records for Patient #1. . Staff #3 stated that she did not know what happened to the handwritten paperwork that was seen on the facility's security footage given to Patient #1 or collected by a staff member. .