Evergreen 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: 41623 Based on Evergreen Emergency Department (ED) video and audio recordings, hospital policy and procedure, Medical Staff Bylaws and Rules and Regulations, ED Logs, Registration Logs, Medical Record review from Hospital B, Evergreen Medical Center Incident Investigation, and interviews with staff, it was determined Evergreen Medical Center failed to ensure an appropriate Medical Screening Examination (MSE) was provided within the capability of the hospital’s emergency department to determine whether or not an emergency medical condition exists for all patients who presented to the ED. This deficient practice affected one of one patient reviewed on recorded video and had the potential to affect all patients presenting to this hospital for emergency care, Patient #1. Findings include: Cross Refer to A 2406 for findings.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 41623 Based on observations, video recordings, and interviews with staff it was determined the hospital failed to ensure signage was posted at each Emergency Department (ED) entrance to inform patients of the Emergency Medical Treatment and Labor Act (EMTALA) rights for patients presenting for emergency medical treatment and for women in labor. This did affect one of one ED patient reviewed on recorded video entering the ED including Patient Identifier (PI) # 1 and had the potential to affect all patients presenting to this hospital. Findings include: 1. A tour of the ED was conducted on 7/21/25 at 1:55 PM with Employee Identifier (EI) # 1, ED Manager. The ED ambulance entrance door, the ED side patient entrance door, and the Triage Room did not have EMTALA signage informing the patients of their rights. EI # 1 stated the ambulance entrance was new and the side entrance was used for patients who arrive at night after 11:00 PM when the front entrance is closed. An interview was conducted on 7/22/25 at 9:00 AM with EI # 1 who stated the hospital had a power outage on 6/8/25 and were under emergency generator power. EI # 1 stated the hospital was on diversion from 8:10 PM on 6/8/25 until 7:30 AM on 6/9/25 due to the loss of power and inability to perform Computerized Tomography (CT) scans. Video recordings were requested for 6/8/25 through 6/9/25. Approximately five minutes of recorded video with audio was provided. No other video was available for those dates. A review of the recorded video of the ED side entrance and ED Hallway was conducted on 7/22/25 at 11:00 AM. On 6/9/25 at 1:52 AM a white male entered the ED side entrance. Review of the ED Hallway video revealed at 1:52 AM the patient was escorted down the hallway by a hospital staff member identified as EI # 5, Licensed Practical Nurse, to the triage room. At 1:56 AM the patient exited the ED. An interview was conducted on 7/23/25 at 7:50 AM with EI # 5 who stated he/she made copies of the patient’s driver’s license and insurance card and confirmed the patient in the video was PI # 1. There was no documentation or video evidence that PI # 1 was informed of his/her EMTALA rights. An interview was conducted on 7/23/25 at 9:00 AM with EI # 2, Director of Nurses who confirmed there was no current EMTALA signage informing patients of their rights at the ambulance entrance or the ED side entrance.”

“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: 41623 Based on video recordings, hospital policy, Emergency Department (ED) Logs, Registration Logs, and interviews with staff, it was determined the hospital failed to ensure each patient who arrived at the ED seeking emergency treatment was entered into the ED Log. This did affect one of one patient reviewed on video recordings of patients entering the ED including Patient Identifier (PI) # 1 and had the potential to affect all patients arriving at this hospital for emergent care. Findings include: Hospital Policy: Control Register/Log Policy Number: Not Listed Revised: 10/2023 Upon a patient seeking care, the patient’s information is entered into a control register (Triage Log) electronically. All required information is captured by the electronic health record. No manual log is required. The register includes the following information: Patient’s name ... Date Time Category (triage) ... Nature of complaint Disposition Time of departure. 1. An interview was conducted on 7/22/25 at 9:00 AM with Employee Identifier (EI) # 1, ED Manager, who stated the hospital had a power outage on 6/8/25 and the hospital was under emergency generator power. EI # 1 stated the hospital was on diversion from 8:10 PM on 6/8/25 until 7:30 AM on 6/9/25 due to the loss of power and inability to perform Computerized Tomography (CT) scans. Video recordings were requested for 6/8/25 through 6/9/25. Approximately five minutes of recorded video with audio was provided. No other video was available for those dates. A review of the recorded video of the ED side entrance and ED Hallway was conducted on 7/22/25 at 11:00 AM. On 6/9/25 at 1:52 AM a white male entered the ED side entrance. Review of the ED Hallway video revealed at 1:52 AM the patient was escorted down the hallway by a hospital employee identified as EI # 5, Licensed Practical Nurse, to the triage room. At 1:56 AM the patient exited the ED. An interview was conducted on 7/23/25 at 7:50 AM with EI # 5 who stated he/she made copies of the patient’s driver’s license and insurance card and confirmed the patient in the video was PI # 1. Review of the ED Logs and Registration Logs from 6/8/25 and 6/9/25 revealed no documentation PI # 1 was entered into the ED Log or Registration Log. An interview was conducted on 7/23/25 at 4:00 PM with EI # 1, ED Director, who confirmed a patient presented to the ED on 6/9/25 for emergency care and the patient was not entered into the ED Log or Registration Log.”

“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: 41623 Based on video review, hospital policy, Medical Staff By-Laws and Rules and Regulations, Diversion Log, facility investigation, staffing schedules, and interviews with staff, it was determined the hospital failed to ensure a Medical Screening Examination (MSE) was performed for each patient who presented to the Emergency Department (ED) for emergency care. This deficient practice did affect one of one patient reviewed on recorded video presenting to the ED, Patient Identifier (PI) # 1, and had the potential to affect all patients presenting to this ED. Findings include: Evergreen Medical Center Medical Staff By-Laws and Rules and Regulations Approved: 2/1/25 ... Medical Staff Rules and Regulations (page 47) ... Screening, Treatment, and Transfer All individual(s) seeking emergency services will be provided with a Medical Screening Examination (MSE) performed by qualified medical personnel ... The condition of all ill or injured persons presenting to the Emergency Department shall be determined by the MSE and the patient will be either treated or referred to an appropriate facility as indicated ... Hospital Policy: Appropriate Medical Screening Exam Program Policy Number: Not Listed Reviewed: 3/1/25 Purpose: To define an effective and consistent method in caring for those patients who present to the Emergency Department ... Policy: All patients who present to the Emergency Department will have a Medical Screening Examination completed by the Emergency Room Physician/Nurse Practitioner ... Procedure: ...2. Documentation of the Medical Screening Exam must be on the patient’s record ... 1. An interview was conducted on 7/22/25 at 9:00 AM with Employee Identifier (EI) # 1, ED Manager, who stated the hospital had a power outage on 6/8/25 and were under emergency generator power. EI # 1 stated the hospital was on diversion from 8:10 PM on 6/8/25 until 7:30 AM on 6/9/25 due to the loss of power and inability to perform Computerized Tomography (CT) scans. Video recordings were requested for 6/8/25 through 6/9/25. Approximately five minutes of recorded video with audio was provided. No other video was available for those dates. A review of recorded video of the ED side entrance and ED Hallway was conducted on 7/22/25 at 11:00 AM. On 6/9/25 at 1:52 AM a white male entered the ED side entrance. At 1:52 AM, review of the ED Hallway video revealed the patient was escorted down the hallway by a hospital employee identified as EI # 5, Licensed Practical Nurse, to the triage room. At 1:53 AM, EI # 6, Registered Nurse entered the triage room. Review of the Physician Schedule for 6/8/25 and 6/9/24 revealed Employee Identifier (EI) # 10, ED Physician, was the ED provider on 6/9/25 at 1:52 AM. There was no video evidence EI # 10 entered the triage room with the patient. At 1:56 AM the patient exited the ED. An interview was conducted on 7/23/25 at 7:15 AM with EI # 6, Registered Nurse, who was asked if the patient had been seen by the ED Doctor of Medicine (MD). EI # 6 responded, “No.” An interview was conducted on 7/23/25 at 7:50 AM with EI # 5 who stated he/she made copies of the patient’s driver’s license and insurance card and confirmed the patient in the video was PI # 1. EI # 5 further stated that he/she did not notify the ED MD of the patient in the ED until the following morning after the patient had left the ED. There was no documentation of an ED medical record, including a MSE, was completed for PI # 1. An interview was conducted on 7/23/25 at 10:00 AM with EI # 10 who stated he/she was not aware the patient was in the ED. Review of the Diversion Log revealed the hospital lost power on 6/8/25 at 8:10 PM and were on diversion from 9:15 PM on 6/8/25 until 7:30 AM on 6/9/25. Review of the ED Log revealed a total of four patients arrived at the ED during the times of diversion. Three of the patients were treated and released and the fourth patient, with a complaint of ear pain, left without being seen. Documentation of the Facility Investigation dated 6/9/25 revealed the hospital was informed by Hospital B, (Receiving Hospital) that a patient had presented to their ED for treatment and was told by a nurse at Evergreen Medical Center that they were not able to do anything for him because of a power outage and (he/she) would do better if (he/she) just went somewhere else for treatment. Review of the Facility Investigation, Investigation Results revealed the hospital documented “After reviewing video footage and interviewing staff, it appears that staff did not discourage the patient in any way or encourage (him/her) to leave. It was storming, the power was off, the patient was escorted into the facility, insurance cards were being copied, and information was being gathered per policy. During the conversation the subject of the power limiting CT capabilities did come up. The patient chose to leave at that point and called his ride. (He/She) asked the nurses who else has CT and they listed area facilities. One of the nurses pointed out that (Hospital B) does have urology services and may be more beneficial.” An interview was conducted on 7/23/25 at 4:00 PM with EI # 1, ED Manager, who confirmed there was no documentation a MSE was completed on PI # 1.”