Fayette Medical Center

“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: 39098 Based on Medical Record (MR) review, hospital policy, and staff interview it was determined the hospital failed to: 1. Provide an appropriate Medical Screening Exam (MSE) within the capability of the hospital to determine whether or not an emergency medical condition (EMC) existed for all patients who presented for emergency services or document a description of the MSE which was attempted and refused by the patient to include the patient was competent to make a decision to the leave the Emergency Department (ED) and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE. 2. Ensure an appropriate transfer was arranged and completed for a patient who presented to the ED for chest pain and Myocardial Infarction. This deficient practice affected two of four MRs reviewed who left without being seen, including Patient Identifier (PI) # 1 and PI # 3, and one of four patients requiring a transfer to another hospital, including PI # 13, and had the potential to affect all patients served by the hospital ED. Findings include: Cross Refer to A 2406 and A 2409 for findings.”

“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: 49797 Based on Medical Record (MR) review, hospital policy, and staff interview it was determined the hospital failed to provide an appropriate Medical Screening Exam (MSE) within the capability of the hospital to determine whether or not an emergency medical condition (EMC) existed for all patients who presented for emergency services or document a description of the MSE which was attempted and refused by the patient to include the patient was competent to make a decision to the leave the Emergency Department (ED) and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE. This deficient practice affected two of four MRs who left without being seen (LWBS), including Patient Identifier (PI) # 1 and PI # 3, and had the potential to affect all patients served by the hospital’s ED. Findings include: Hospital policy: Statement on Emergency Medical Treatment and Active Labor Act (EMTALA) Revised: October 2024 ...Medical Screening Examination: Druid City Hospitals (DCH) must provide a Medical Screening Examination to any individual to which the obligations of EMTALA apply, subject to the following: -The purpose of the MSE is to determine the existence or absence of an EMC. The scope of the MSE must be sufficient, based on individual circumstances, to accomplish this purpose... -Triage is NOT an MSE... Refusal of MSE, Stabilizing Treatment, or Transfer: Every patient has the right to refuse the MSE, required stabilizing treatment or an appropriate transfer. If an individual presents to a DCH Emergency Department initially seeking emergency treatment or having requested on his/her behalf, and subsequently refused further treatment, the following procedures should be followed: 1. If the patient is triaged, the patient must be registered consistent with the established registration processes, utilizing information available to the staff... 3. If the patient wants to leave after examination, ED staff should: a. Inform the patient of the hospital’s obligation under the law to provide a medical screening and stabilizing treatment regardless of his/her ability to pay for that service. b. Offer treatment, welcome the individual to return at any time. c. Explain the risks and benefits specific to the individual’s complaint so that he/she can make an informed decision. d. Determine if the individual is competent to refuse the MSE, treatment, or transfer. e. Secure the individual’s written informed consent, on the appropriate forms to refuse the MSE, treatment, or transfer. f. Specifically document the interaction in the hospital record... 1. PI # 1 presented to the ED on 3/22/26 at 5:21 PM with a chief complaint of ear pain and drainage. Review of the triage dated 3/22/26 at 5:48 PM revealed the patient presented to the ED with complaints of ear pain and drainage for three days. Review of the physician’s ED note dated 3/22/26 at 7:18 PM revealed the physician documented the patient was belligerent and rude. The patient was complaining of the wait time and people passing them in the hallway. The physician asked if the patient would like to be seen. The patient then became more sarcastic and belligerent and said they were going to leave. Review of the MR revealed no documentation an appropriate MSE within the capability of the hospital was provided to determine whether or not an EMC existed or a description of the MSE which was attempted and refused by the patient to include the patient was competent to make a decision to the leave the ED and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE. An interview was conducted on 4/16/26 at 10:31 AM with Employee Identifier (EI) # 2, Interim ED Manager, who confirmed there was no documentation an appropriate MSE was provided to determine whether or not an EMC existed or a description of the MSE which was attempted and refused by the patient to include the patient was competent to make a decision to the leave the ED and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE. 2. PI # 3 presented to the ED at 7:56 PM on 12/16/25 with a chief complaint of coughing and body aches. Review of the triage dated 12/16/25 at 8:11 PM revealed the patient presented to the ED with complaints of body aches, fever, cough, and sneezing, he/she had seen a teledoc (Physician visit over the telephone) two days prior with medication prescribed. Review of the ED note dated 12/16/25 at 8:23 PM revealed the patient informed the registrar they were leaving and would see urgent care the next day. Review of the MR revealed no documentation an appropriate MSE within the capability of the hospital was provided to determine whether or not an EMC existed or a description of the MSE which was attempted and refused by the patient to include the patient was competent to make a decision to the leave the ED and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE. An interview was conducted on 4/16/26 at 10:12 AM with EI # 2, who confirmed there was no documentation an appropriate MSE was provided to determine whether or not an EMC existed or a description of the MSE which was attempted and refused by the patient to include the patient was competent to make a decision to the leave the ED and the patient was informed of the risks and benefits of leaving prior to the completion of the MSE.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49797 Based on Medical Record (MR) review, hospital policy, and staff interview it was determined the hospital failed to ensure an appropriate transfer was arranged and completed for a patient who presented to the Emergency Department (ED) for chest pain and Myocardial Infarction. This deficient practice affected one of four patients requiring a transfer to another hospital, including Patient Identifier (PI) # 13, and had the potential to affect all patients requiring a transfer from this hospital’s ED. Findings include: Hospital policy: Statement on Emergency Medical Treatment and Active Labor Act (EMTALA) Revised: October 2024 ...Medically Indicated Transfers The transferring hospital’s duties are to: 1. Certify that the benefits of transfer outweigh the risks. 2. Obtains the patient’s informed consent. a. Written consent of patient or guardian, if available... 3. Arrange appropriate transfer... b... specifically document all conversations... c. Send documentation with the patient. i. complete medical information ii. informed consent to transfer iii. certification that transfer is medically indicated... 1. PI # 13 presented to the ED on 3/22/26 at 5:02 PM with a chief complaint of chest pain. Review of the triage note dated 3/22/26 at 5:02 PM revealed the patient presented to the hospital ED via private vehicle with complaints of chest pain and indigestion. Review of the ED physician note dated 3/22/26 at 5:10 PM revealed the patient was diagnosed with an ST Elevation Myocardial Infarction and required transfer to a higher level of care at the receiving hospital. Review of the MR revealed no documentation the patient consented to the transfer, the risk and benefits of the transfer, the medical record was sent to the receiving hospital, or a physician signed certification the medical benefits outweighed the risks of the transfer. An interview was conducted on 4/16/26 at 10:30 AM with Employee Identifier # 2, Interim ED Manager, who confirmed there was no documentation the patient consented to the transfer, the risk and benefits of the transfer, the medical record was sent to the receiving hospital, or a physician signed certification the medical benefits outweighed the risks of the transfer.”

“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: 46290 Based on review of hospital policy and procedure, medical records (MR), video footage, and interviews with staff, it was determined the hospital failed to: Provide an appropriate medical screening examination within the capability of the hospital’s Emergency Department (ED) for one of 12 MRs reviewed who presented to the ED with psychiatric complaints of Suicidal Ideations including Patient Identifier (PI) # 1. This deficient finding had the potential to negatively affect all patients served by the hospital ED. Findings include: Refer to 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: 46290 Based on Medical Record (MR) review, hospital policy and procedure, staff interviews, video surveillance footage, Emergency Department (ED) bed census and staffing, it was determined the hospital failed to ensure that a medical screening examination (MSE) was provided that was 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 existed on a patient who presented to the ED for Suicidal Ideations (SI). This affected Patient Identifier (PI) # 1, one of 12 MRs reviewed who presented to the ED with psychiatric complaints and had the potential to negatively affect all patients seeking treatment for psychiatric illnesses. Findings Include: Hospital Policy: DCH (Druid City Hospital) Emergency Department Statement on “EMTALA” Emergency Medical Treatment and Active Labor Act Policy Number: None Date Revised: October 2024 ... Medical Screening Examinations: DCH hospitals must provide an MSE to any individual to which the obligations of EMTALA apply... : The purpose of the MSE is to determine the existence or absence of an EMC. The scope of the MSE must be sufficient, based on individual circumstances, to accomplish this purpose. EMC: ... A psychiatric patient with the following conditions, as determined by a physician, is considered to have an EMC (Emergency Medical Condition): ... Expresses suicidal thoughts or gestures... Determining Competence to Make Informed Decision: ... If an individual presents to the ED and is complaining of or appears to be suffering from A psychiatric or psychotic condition(s)... He/she should not be allowed to leave the hospital without examination or treatment until it is determined that he/she is legally competent to make such a decision... Hospital Policy: Triage Guidelines Policy Number: None Date Adopted: 4/2024 I. Purpose: The purpose of triage is to prioritize incoming patients and identify those patients who cannot wait to be seen... II. Policy: A. Every patient will have an initial screen (chief complaint, vital signs, and visual observation) followed by a triage assessment of their physical and psychosocial problems by a Registered Nurse (RN)... III. Procedure: A. Triage Assessment: The purpose of triage in the emergency department is to prioritize incoming patients and to identify those who cannot wait to be seen... The triage nurse will assign the patient a triage acuity level, which is a proxy measure of how long an individual patient can safely wait for an MSE and treatment... the triage nurse may take the patient to an appropriate treatment area or have the patient return to the waiting area until a room is available... B. Ongoing Monitoring of Triage Patients: ...2. Vital sign measurements, as well as visual monitoring while interacting with the patient, will take place every two hours or more frequently as indicated. C. Patients Who Leave without Being Seen: 1. If the triage nurse is notified about the patient’s wish to leave prior to seeing a provider, the nurse should take the opportunity to discuss the situation with the patient and encourage him/her to stay. If the patient chooses to leave after talking with the triage nurse, the triage nurse should notify the ED provider... 2. If a patient walks out of the department without notifying staff, the nurse will document the time it was first noted that the patient was no longer in the ED. Also, the nurse will document efforts to locate the patient... Hospital Policy: Suicide Risk Assessment/Suicide Precautions Policy Number: None Date Revised November 14, 2024 I. Purpose: A. To provide a mechanism to screen and assess a patient’s suicidal risk in a non-behavioral unit. B. To provide the patient who has been identified at high risk for suicide with an environment that is as safe as possible. To protect the patient from him/herself until the physician states that the suicidal crisis is passed and discontinues the order, or the patient is moved to a more secure environment... II. Policy: A suicide risk screen is performed on all patients... triaged in the ED... 1. PI # 1 presented to the ED on 12/14/24 at 7:42 PM with a stated complaint of suicide and do not feel safe at home. Review of the MR and video surveillance revealed the patient arrived on 12/14/24 at 7:42 PM and left on 12/15/24 at 1:19 AM. Review of the documentation by the nurse dated 12/15/24 at 1:49 AM revealed, “Patient called 911 from (the) lobby. (Name) PD (Police Department) responded without nursing staff knowledge. PD contacted (EMS Emergency Medical Services) to transfer (the) patient to BMU (Behavioral Medical Unit).” Further review of the MR revealed there was no documentation the patient received triage or a MSE. Review of the ED Discharge documentation revealed the patient left before triage. A phone interview was conducted on 12/19/24 at 9:01 AM with EI # 3, ED registered nurse (RN), who confirmed PI # 1 was not triaged. An interview conducted on 12/19/24 at 2:30 PM with EI # 4, ED physician revealed the ED physician was not made aware there was a patient in the ED with SI and a MSE was not performed. An interview was conducted on 12/20/24 at 2:28 PM with EI # 5, Systems Director of Emergency Services, who confirmed the hospital failed to perform a MSE on PI#1. The facility failed to ensure that their policy and procedures were followed as evidenced by failing to provide a MSE within the capability of the hospital’s ED to determine whether or not an emergency medical condition existed for patient #1 on 12/14/2024. Patient #1 presented to the hospital’s ED expressing suicidal ideations and was allowed to leave the hospital’s ED without receiving examination or treatment until it was determined he was legally competent to make such decisions as stated in the hospital’s policy and procedure.”