USA Health HCA Providence Hospital, LLC

“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: 41624 Based on review of the emergency department (ED) Central Log, hospital EMTALA (Emergency Medical Treatment and Labor Act) policy, video surveillance footage, and interview, it was determined the hospital failed to: 1. Ensure every patient who presented to the hospital’s ED seeking assistance, including whether or not the patient refused or was refused treatment, or was admitted and treated, transferred or discharged, was maintained on the ED Central Log. 2. Adopt a policy for the requirement at CFR (Code of Federal Regulations) 489.20 to maintain a Central Log on each individual coming to the ED. This affected one of four patients with a chief complaint of animal bite, including Patient Identifier (PI) # 5, who presented to the ED for emergent care on 5/18/26 via privately owned vehicle after being bitten by a cat. This had the potential to negatively affect all patients who presented to this hospital requesting emergency care. Findings include: 1. A review of ED video surveillance conducted 7/7/26 at 4:10 PM revealed PI # 5 walked into the ED ambulatory entrance on 5/18/26 at 9:26 AM and went to the registration desk where he/she talked briefly with Employee Identifier (EI) # 2, Patient Care Assistant (PCA). PI # 5 then sat down in the ED waiting area at 9:29 AM without having received a patient armband. PI # 5 remained in the ED waiting area until 9:43 AM when he/she stood and walked to the ED entrance, raised his/her left arm over his/her head in a partial wave and exited the ED. Review of the ED Central Log dated 5/18/26 from 9:00 AM to 10:00 AM revealed no documentation of PI # 5. Review of the hospital policy entitled EMTALA, 2.01.72, with effective date 7/1/26, revealed the policy failed to include maintaining a central log on each individual that comes to the ED. On 7/15/26, the surveyor requested the hospital’s policy regarding maintaining a central log for patients presenting to the ED. No additional policy was received. The hospital failed to ensure every patient who presented to the ED seeking assistance and whether the patient refused treatment, was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged was maintained on the ED Central Log as evidenced by failing to maintain a Central Log on PI # 5 who presented to the ED on 5/18/26 seeking emergency assistance, and failed to adopt a policy for maintaining a Central Log. An interview was conducted on 7/9/26 at 1:30 PM with EI # 1, Director of Nursing for Emergency Services, who confirmed PI # 5 presented to the ED seeking treatment and was not registered on the ED central log. An interview was conducted via email with EI # 3, Coordinator of Clinical Compliance, on 7/15/26 at 2:54 PM. EI # 3 verbalized the hospital’s extensive EMTALA policy had been provided, and a Central Log was maintained consistent with CMS (Centers for Medicare and Medicaid Services) requirements under 42 CFR 489.24.”

“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: 40119 Based on review of the hospital policies and procedures, Medical Records (MR), Hospital Psychiatric On-call Services Agreement, hospital Transfer Center Log and documentation, hospital On Call Schedules, hospital bed and staffing census, transferring hospital, Hospital B, and receiving hospital, Hospital C, and interviews with staff it was determined the hospital failed to: 1. Place a patient who presented to the Emergency Department (ED) with suicidal ideation on an emergency hold; Patient Identifier (PI) # 10 did not have the mental competency to make the decision to leave the facility given the presenting signs and symptoms of suicidal ideations. 2. Encourage a patient who presented with Suicidal Ideation (SI) not to leave the ED prior to a telehealth Psychiatric consult to complete the Medical Screening Exam (MSE). 3. Ensure a patient who presented to the ED manifesting acute symptoms of sufficient severity of psychiatric disturbances received an appropriate MSE to determine whether or not an emergency medical condition existed for PI # 13 who presented to the ED with a psychiatric complaint. This deficient practice affected two of two MRs reviewed who presented to the ED with psychiatric complaints and who eloped (left ED without hospital staff knowledge), including PI # 10 and PI # 13, and had the potential to affect all patients served by the facility ED with a psychiatric complaint. Findings Include: Refer to A 2406 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: 40119 Based on review of the hospital policies and procedure, Medical Records (MR), Hospital Psychiatric On-call Services Agreement, and interviews with staff it was determined the hospital failed to: 1. Place a patient who presented to the Emergency Department (ED) with suicidal ideation on an emergency hold; Patient Idenitifer (PI) # 10 did not have the mental competency to make the decision to leave the facility given the presenting signs and symptoms of suicidal ideations. 2. Encourage a patient who presented with Suicidal Ideation (SI) not to leave the ED prior to a telehealth Psychiatric consult to complete the Medical Screening Exam (MSE). 3. Ensure a patient who presented to the ED manifesting acute symptoms of sufficient severity of psychiatric disturbances received an appropriate MSE to determine whether or not an emergency medical condition existed for PI # 13 who presented to the ED with a psychiatric complaint. This deficient practice affected two of two MRs reviewed who presented to the ED with psychiatric complaints and who eloped (left ED without hospital staff knowledge), including PI # 10 and PI # 13, and had the potential to affect all patients served by the facility ED with a psychiatric complaint. Findings include: Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy Number: 2.01.72 Effective Date: 10/17/23 Purpose: This policy is to ensure compliance with the EMTALA requirements for any individual seeking emergency services from the Hospital... Policy: A. It is the policy of Providence Hospital that any individual who comes to the Hospital...and who is in need of, or requests emergency medical services will be provided necessary emergency medical services... 2. Patients with psychiatric symptoms must receive a MSE sufficient to assure that a medical condition that mimics a psychiatric condition is not present... Procedure: A. MSE. 1. The Hospital shall provide a MSE for every individual who comes to the ED seeking medical treatment... 6. Within the capability of the ED, using the resources routinely available in the Hospital, the MSE shall determine within reasonable clinical confidence whether an Emergency Medical Condition does or does not exit. 7. The MSE is an ongoing process. The MR must reflect continued monitoring, according to the individual’s condition, which must continue until...stabilized or appropriately admitted or transferred. The screening examination must be documented in the MR. ...Definitions: MSE is the process required to determine within reasonable clinical confidence whether an Emergency Medical Condition does or does not exist... Emergency Medical Condition means a medical condition manifesting it be acute symptoms of sufficient severity...psychiatric disturbance...that the absence of immediate medical attention could reasonable by expected to result in: 1. Placing the health of the individual...in serious jeopardy... Within the Capability of the Hospital means those services which the Hospital routinely has available...as well as on-call physician specialists and Hospital ancillary services routinely available. Hospital Policy: Suicide Risk Assessment & (and) Precautions. Policy Number: 5.01.247 Effective Date: 9/29/22 Purpose: To provide guidance to assist staff in identifying patients at risk for suicide and provide for a safe environment during the hospital stay... Definitions: ...Suicide Ideation describes the patient who expresses thoughts of suicide and/or has specific plans to harm self. Policy: A. An RN (Registered Nurse) will perform a suicide risk screen utilizing the Columbia Suicide Severity Rating Scale (CSSRS) during the initial assessment at the point of entry to the organization (e. g. ED)... Guidelines for Care for the Suicidal Patient: ...C. High Risk: Suicide precautions will be maintained on patients who are identified as exhibiting suicidal behavior with a specific plan for suicide based on the risk screen... This process will include: ...11. Provide information regarding community resources for crisis intervention before discharge. 12. Consult Case Management... Documentation: ...G. Reassessment for patients identified at risk for suicide prior to transfer to another facility or discharge from the hospital. Hospital Psychiatric On-call Services Agreement. Date: 9/17/18 ...1. Engagement... provide Psychiatric Services on an on-call basis to it’s...patients being seen in (the) Hospital’s ED. Psychiatric Services shall be defined as “any evaluation and/or treatment, prescribed by a Certified Registered Nurse Practitioner (CRNP) or Physician employed by (Psychiatric Company Identified), of any patient performed...in emergency department of (the) hospital for the diagnosis and treatment of psychiatric and mental health disorders. 2. Services... 2.1. The professional services contemplated herein will be directed by... and provided by a psychiatrist or CRNP... 2.2. Psychiatrist services will be provided utilizing a HIPAA (Health Insurance Portability and Accountability Act) compliant telehealth solution... These services will be provided on a 24-hour, 7 day per week basis... 5. Term. 5.1. This agreement shall be effective as of 9/17/18... the term of this agreement shall automatically renew for additional one-year periods... 1. PI # 10 presented to the hospital ED on 3/31/24 at 4:44 PM via ambulance with a chief complaint of SI with no plan and drug use on 3/31/24. Review of the Triage Assessment dated 3/31/24 at 4:44 PM revealed a CSSRS was completed with the Suicide Risk Level of High risk for suicide and the patient was placed on suicide precautions. Review of the ED Physician Note dated 3/31/24 at 6:15 PM revealed the patient expressed SI. Review of the ED nursing note dated 3/31/24 at 8:14 PM revealed the patient was at the nurse’s station on one-to-one observation when the patient started throwing trash on the floor, yelling at the Employee Identifier (EI) # 2, RN, and making racial comments towards EI # 2. Employee Identifier # 3, ED Physician, then spoke with the patient to which the patient began yelling and cussing at EI # 3. The patient jumped off the stretcher and threatened to punch the RN. The patient was then “...escorted...” out the front door by EI # 3 and the police department was called. The patient was then “...escorted...” off the hospital property by the hospital security and police department. Further review of the ED Physician Note dated 3/31/24 at 6:15 PM revealed reexamination/reevaluation documentation of the patient eloped, and the RN notified the police department. Review of the MR revealed the hospital staff allowed PI # 10 to leave the hospital ED with presenting signs and symptoms of SI. There was no documentation the hospital staff encouraged PI # 10 to stay and receive a telehealth Psychiatric consult to complete the MSE and a reassessment was conducted for the presence of SI prior to PI # 10 leaving the hospital ED. Interviews: An interview was conducted on 6/18/24 at 4:18 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there was no documentation the hospital staff encouraged PI # 10 to stay and receive a telehealth Psychiatric consult to complete the MSE and no documentation a reassessment for the presence of SI was conducted prior to PI # 10 leaving the hospital ED. An interview was conducted on 6/18/24 at 6:06 PM with EI # 2, the RN who performed the discharge of PI # 10. EI # 2 verbalized after the patient jumped off the stretcher, EI # 3 followed the patient out of the ED and EI # 2 was told the patient was escorted off the hospital property by the hospital security. An interview was conducted on 6/19/24 at 10:26 AM with EI # 3, the ED physician who performed the discharge of PI # 10. EI # 3 verbalized if a suicidal patient refuses treatment and wants to leave the ED, it would be a violation of the patient’s rights to hold the patient against their will. EI # 3 verbalized, during the interview, letting a suicidal patient leave could result in the patient leaving the ED and hurting themselves. EI # 3 verbalized the ED physician has to make a decision in the moment to let the patient leave the ED or risk keeping them and doing treatment against their will. EI # 3 could not remember PI # 10 but verbalized “if I escorted (the patient) out, (the patient) must have been alert and oriented, and I was concerned (the patient) would assault the staff... I would try to...ask them if they want to be treated and if they say no, and they are violent I would escort them out. I’m not going to risk the staff.” Three additional ED provider interviews were conducted on 6/19/24. Two of the three ED providers verbalized a patient with SI could not be held if the patient was alert, oriented, and wanting to leave the ED. 2. PI # 13 presented to the hospital ED on 4/10/24 at 1:43 AM via ambulance with a chief complaint of SI. Review of the ED Provider Triage Note dated 4/10/24 at 1:45 AM the patient presented to the ED with SI. Review of the ED Triage Note dated 4/10/24 at 1:49 AM the patient presented to the ED with a history of Schizophrenia, living in a shed, hearing voices, and having “to much going on.” On arrival the patient denied SI or HI (Homicidal Ideation) at the present time. Review of the ED Provider Note dated 4/10/24 at 2:08 AM revealed the patient presented to the ED with auditory hallucinations, having a difficult time at home, methamphetamine use, and not taking his/her medications for Schizophrenia. The patient denied SI or HI. Further review revealed the patient was alert and oriented, cooperative, had an appropriate mood and affect, and was non-suicidal. There was no documentation the discrepancy between the patient arriving with a complaint of SI and the patient’s report of no SI was addressed and no documentation of what the auditory hallucinations were saying to the patient. Review of the ED Provider Note dated 4/10/24 at 6:03 AM revealed the patient was sitting in the hallway waiting for the case manager to arrive. Review of the ED Provider Note dated 4/10/25 at 9:12 AM revealed the patient had eloped. Review of the ED Nursing Note dated 4/10/24 at 9:18 AM revealed the patient was called three time and the ED staff was unable to locate the patient. The hospital failed determine if an emergency medical condition was present due to not appropriately evaluating the auditory hallucinations reported by the patient and determine if the patient had true SI due to the conflicting reports in the medical record. An interview was conducted on 6/19/24 at 3:27 PM with EI # 10, Director of Nursing, who confirmed there was no documentation the auditory hallucinations were evaluated and no documentation if the patient had true SI due to the conflicting reports in the medical record. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that patients who present to the ED manifesting acute symptoms of sufficient severity of psychiatric disturbances receive and appropriate medical screening that was within the capability of the hospital emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for PI #10 and PI # 13 when they presented to the ED with psychiatric complaints.”