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)
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. .