Mercy Hospital Fort Smith

“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: 17281 Based on record review, interview, observation, and policy review, the hospital failed to ensure compliance with the requirements of §489.24 (EMTALA). Specifically, the hospital failed to implement and enforce policies and procedures necessary to ensure all patients presenting to the Emergency Department (ED) received appropriate screening and stabilization as required under EMTALA. These deficient practices had the potential to place all patients who present to the ED seeking care for an Emergency Medical Condition (EMC) at risk for harm. Findings include: 1. The hospital must post signs 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 (e.g., entrance, admitting area, waiting room, treatment area). Cross Reference A2402- Posting of Signs. 2. The hospital must screen individuals to determine if an EMC exists. Cross Reference A2406- Medical Screening Exam. 3. The hospital must provide stabilizing treatment within its capability and capacity. Cross Reference A2407-Stabilizing Treatment.”

“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: 25065 Based on observations, policy review, and interview, the facility failed to post in a conspicuous place in the emergency department (ED) in a place likely to be noticed by all individuals entering the emergency department and in treatment areas a sign specifying the rights of individuals to examination and treatment of an emergency medical condition (EMC) and indicating whether or not the hospital participated in the Medicaid program. This failure had the potential to affect all patients presenting to the ED for treatment of a potential EMC. Findings include: Observation on 05/11/26 at 9:55 AM in the ED waiting room with Quality Lead (QL) and ED Director of Nursing (ED DON) revealed the required Emergency Medical Treatment and Labor Act (EMTALA) signage was posted on the wall behind the patient registration desk. The desk was approximately 20 feet from where the patient would stand, and there were two registration clerks seated at the desk. Observation revealed that while a patient stood at the registration desk looking down at the registration clerk, the EMTALA sign was not in a conspicuous location to be easily seen. There was no other signage in the ED During an interview on 05/11/26 at 9:55 AM, the ED DON confirmed no other rooms had EMTALA signage. Review of the hospital’s policy titled, “MW [hospital name ministry] COMPL [complete] EMTALA Requirements” approved 08/27/25 indicated, “. . . Each [name of hospital] shall have appropriate signage notifying individuals of their right to a Medical Screening Examination and Stabilization Treatment as specified under EMTALA as well as information indicating whether the hospital participates in the Medicaid program . . . The signs must be posted in a place easily noticed by all individuals entering the facility. The sign must also be posted in a place where it will be noticed by individuals waiting for treatment.””

“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: 25065 Based on observations, record review, policy review, and interviews, the hospital failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department (ED) to determine whether or not an emergency medical condition (EMC) existed for three (Patient (P) 5, P8 and P12) of 20 ED patient records reviewed for provision of MSE. The failure had the potential to place all patients presenting to the ED for examination of an EMC at risk for harm. Findings include: 1. Review of the “ED Care Timeline” located in the EMR navigated by RN1 revealed P5 arrived at the ED on 01/02/26 at 3:01 PM with an arrival complaint of fall, pain in the left side, hit his/her head, no loss of consciousness and was not taking blood thinners. Review of the “Triage Note” nurse assessment located in the EMR dated 01/02/26 at 3:57 PM revealed an updated chief complaint, “Fall, Pt [patient] reports having a fall 3 days ago and pain under [his/her] left arm and side have been persistent. Pt denies SOB [shortness of breath], but reports pain when coughing. Wife reports that pt also hit head ‘a couple of days ago.’ Old abrasion visible on left forehead ...Acuity: 3 Urgent to waiting room ...” Review of the “Orders” section located in the EMR revealed to obtain complete blood count (CBC) with differential; complete metabolic panel (CMP) and x-ray order for a left-sided rib series using two different angles. Review of P5’s “x-ray” revealed, “Multiple lateral acute rib fractures with small pneumothorax. Emergency room nurse [name] notified at time of dictation.” Review of the “ED Care Timeline” revealed P5 was placed in a room at 6:22 PM. Review of the “ED Nurse Note” dated 01/02/26 at 6:23 PM located in the EMR revealed, “Pt states that [he/she] fell Tuesday night and hit the foot board of the bed on [his/her] left side. C/O pain to left ribs. Reports chronic cough from smoking. Denies SOB. Pt states that [he/she] fell two days later and hit [his/her] face on a door frame. Denies LOC [loss of consciousness] and anticoagulants. Reports chronic dizziness. Denies headache and visual changes.” Review of “Flowsheet” located in the EMR revealed vital signs were obtained at 6:34 PM which included temperature: 97.5 degrees Fahrenheit (F), heart rate: 96 beats per minute, Blood Pressure (BP): 163/76, Respiration; 18, and SpO2 (Oxygen saturation): 92% on room air. Review of the “ED Care Timeline” dated 01/02/26 at 6:33 PM revealed the ED Med Dir was assigned as P5’s attending physician. Review of the “ED Nurse Note” dated 01/02/26 at 7:20 PM revealed, “Pt requesting pain medication. Dr. [name] notified via secure chat. No new orders at this time.” Review of the “ED Nurse Note” dated 01/02/26 at 8:30 PM reveled, “Pt on call light requesting nurse. Pt and family were upset and stating ‘I have not seen a doctor since I’ve been here. I cannot get any pain medication, and nothing is being done.’ This nurse attempted to educate patient on ER [emergency room] process. No evidence of learning. Unable to locate Dr. [name]. Another secure chat sent to [him/her] Pt and family walked out. Pt is alert/orient x4 ambulated with strong steady gate and refused to sign AMA [against medical advice] paperwork.” Review of the “ED Note” written by ED Med Dir dated 01/02/26 at 8:38 PM located in the EMR revealed, “Patient was roomed in room 12. I was assigned as patient’s physician. Unfortunately, due to high level of volume and acuity, the patient had prolonged wait in room before I was able to assess [him/her] in person. When I went to assess the patient, [he/she] had eloped. I called [his/her] home phone twice to inform [him/her] of [his/her] results of rib fractures and pneumothorax and advised [him/her] to return to the emergency department but there was no answer.” Review of the EMR did not reveal the triage evaluation included an assessment of P5’s pain or vital signs. Review of the EMR did not identify when P5 reported pain or a pain assessment was conducted to determine the level and intensity of P5’s pain. Review of the EMR did not contain evidence that hospital staff, who had knowledge of P5 wanting to leave the ED, discussed risks and benefits of refusing the examination or treatment During an interview on 05/11/26 at 3:40 PM, RN1 stated the EMR did not include documentation that vital signs were obtained on arrival or during the triage process. RN1 stated information is relayed to providers by nursing through a secure chat or face to face. If there is no response from the provider through secure chat after two attempts, nurses should contact another provider on call. RN1 stated the nurse assigned to the desk, Licensed Practical Nurse (LPN)1, received the critical report and was responsible to notify the triage nurse and the provider. RN1 stated the EMR did not include any documentation the provider was notified of the abnormal x-ray results. RN1 stated P5’s EMR did not identify vital signs and that pain assessments were conducted per the hospital’s policy. During an interview on 05/12/26 at 10:40 AM, LPN1 stated he/she was the desk nurse in the ED and is responsible to take calls from the laboratory, radiology, patients and answers lights. LPN1 stated when a critical or abnormal report is received, he/she is responsible to notify the provider and nurse. Notification of the provider and nurse is documented in the patients’ medical record to include the date, time and who was notified. The information is documented under the Note section of the medical record. LPN1 stated he/she did not recall whether the provider was notified of P5’s abnormal chest x-ray report. During an interview on 05/12/26 at 11:15 AM, ED Med Dir stated the providers assign themselves to patients who are displayed on the track board. The ED Med Dir stated he/she assigned P5 to himself/herself at 6:33 PM. The ED Med Dir stated that the typical wait time for a patient to see a provider after being assigned is less than 30 minutes and it is unusual if it is one hour. But in practice can be longer. The ED Med Dir did not recall being notified of P5’s rib fracture and small pneumothorax but stated the desk nurse is the point of contact for abnormal results. The desk nurse can call the providers on the secure chat to notify of abnormal results. The ED Med Dir stated he/she did not recall what was going on that day or why the patient was not seen. The patient was called two times after leaving to provide notification of the x-ray results, but the patient did not respond. The ED Med Dir stated there are always two physicians in the ED and it is not uncommon during peak hours for nursing to go to another provider. The ED also has an “On-Call” list that can be used when necessary. The ED Med Dir stated he/she was not aware of the patient’s severe pain level but does not order verbal controlled medications because the patient should be seen to determine any contraindications for a specific medication. 2. Review of P8’s “Visit Information” located in the EMR navigated by RN1 revealed P8 arrived at the hospital ED on 02/19/26 at 11:28 AM via personal car. Review of the “Reason for Visit” located in P8’s EMR revealed the arrival complaint was vaginal bleeding. Review of the “Triage” note dated 02/19/26 at 11:50 AM located in the EMR revealed, “ ...Triage Acuity- ESI 3 Urgent: Vaginal Bleeding. Pt arrived at the ED via POV from home with c/o-vaginal bleeding x 1 week, abdominal cramping, and lower back pain. Pt has tested positive for pregnancy- States her hCG level is rising but slowly and she was seen at [another hospital] yesterday but feels like they should have done something instead of sending her home- Pt had labs and US there yesterday.” Review of the “Vital Signs” located in the EMR dated 02/19/26 at 11:50 AM recorded: temperature 98.3 degrees F, pulse 83, B/P 109/75, respiration 18, and SpO2 99% on room air. Assessment identified a pain score of 7 of 10 (indicative of severe pain) with identified location in the back and abdominal area. Review of the “Orders” dated 02/19/26 at 11:52 AM, located in the EMR revealed orders for CBC with differential, CMP, quantitative hCG, and urinalysis. Review of the “hCG blood work” dated 02/19/26 identified a result of 114 mIU/ml. Review of the “ED nurse note” dated 02/19/26 at 3:40 PM revealed, “Pt came to triage desk to ask to have vitals retaken because [his/her] back pain is worse ...” Review of the “ED Timeline” located in the EMR identified vital signs were obtained on 02/19/26 at 3:40 PM revealed pulse 74, BP 115/74, respiration 18, and SpO2 98 % on room air. Review of the EMR did not reveal a nursing conducted a pain assessment when P8 reported worsening back pain at 3:40 PM. Review of the “Discharge Information” located in the EMR dated 02/19/26 at 6:07 PM revealed the patient Left Without Being Seen (LWBS) before assigned or evaluated by a provider. Review of the EMR did not identify P8 was assigned to a physician or was seen by a provider on 02/19/26 from 11:28 AM to 6:07 PM. Review of the EMR did not identify P8 was treated for the severe pain documented on triage or at 3:40 PM after reporting an increase in pain. Review of the EMR did not contain evidence that hospital staff, who had knowledge of P8 wanting to leave the ED, discussed risks and benefits of refusing the examination or treatment. 3. Review of P12’s electronic medical record (EMR) under the “ED Triage Navigator” tab, navigated by Nursing Manager (NM1), indicated P12 arrived at the ED on 02/20/26 at 3:12 PM by private vehicle with a chief complaint of medical clearance/suicidal Review of P12’s “ED Care Timeline,” located under the “ED Triage Navigator” tab, indicated the Medical Doctor (MD1) was assigned as the attending physician at on 02/20/26 at 4:01 PM, and Registered Nurse (RN2) was assigned as the RN on 02/20/26 at 4:07 PM. Review of P12’s “ED Care Timeline” dated 02/20/26 indicated MD1 ordered a behavioral health intake evaluation at 4:57 PM. There was no documentation a MSE was performed by MD1 to determine if an EMC existed. Review of documentation dated 02/20/26 at 6:46 PM by RN2 indicated, “Attempted to start work up for possible inpatient placement, patient refusing and walked out. . .” There was no documentation RN2 informed P12 of the risks of leaving without a MSE and the benefits of an MSE and and/or stabilizing treatment. During interview on 05/11/26 at 2:40 PM, RN1 stated the EMR did not include documentation a pain re-assessment was conducted when P8 went to the reception desk and reported increased back pain at 3:40 PM. RN1 stated the EMR did include documentation the provider was notified of the patient’s severe pain (score of 7 of 10) when triaged per the hospital policy. RN1 stated the EMR did not include documentation pain medication was ordered for P8. During an interview on 05/11/26 at 2:30 PM, the ED Director of Nursing (ED DON) stated the hospital policy does not direct specific times to conduct vital signs and reassessments of a patient after the initial triage. The frequency of subsequent vital signs and reassessments of patients are based on the patient’s condition. If a patient condition changes then more frequent monitoring is conducted. During an interview on 05/12/26 at 2:25 PM with MD1 and ED Medical Director (ED Med Dir) present, MD1 confirmed he/she did not perform an MSE. MD1 stated P12 was triaged by a nurse, and the first thing the triage nurse tries to do is get an order for a mental health evaluation. MD1 stated he/she couldn’t specifically say what happened, but he/she probably was tied up and couldn’t get to the patient timely. MD1 stated by the time he/she could get back to P12, P12 had left the hospital. During an interview on 05/13/26 at 9:41 AM, the Emergency Department Medical Director (ED Med Dir) stated he/she feels the hospital gives very good care, but patients have to wait too long. The ED Med Dir stated. “with an 8 hour wait, it’s not systematically that the patient would be monitored for bleeding, pain, etc.” The ED Med Dir stated anyone they would pull to check conduct more monitoring would be someone pulled who was needed more in the ED. The ED Med Dir stated the hospital has triage protocols for assessments, but he/she does not know if there is one for pain. The ED Med Dir stated, “that’s tricky because they haven’t actually assessed the patent to know if there’s a contraindication to certain meds, even Tylenol and [he/she] doesn’t know that they [nursing] are systematically calling patients back for reassessments of patients waiting for a room.” Review of the facility’s policy titled, “FTSM [Fort Smith] ED Nursing Assessment and VS Documentation Policy” dated 03/02/26 revealed, “ ...Complete vital signs (VS) should be taken at appropriate intervals based on the patient’s condition. a) Time begins with the triage time and or first patient contact. b) Triage staff may need to repeat v/s in the waiting room due to a delay in the patient being taken to the patient exam area. c) This does not replace monitoring of unstable, trauma, critical or sedated patients. Discharge vital signs are not required on patients that meet ALL of the following criteria: a) Do not have abnormal vital signs recorded on the medical record. b) Do not receive intervention during their ED visit that could affect their vital signs. c) Length of stay is <1 hour. For all other patients seen in the ED an appropriate set of vital signs are repeated prior to discharge ...Patient Assessment: On initial contact with a patient, a chief complaint will be recorded in the patients Electronic Medical Record. A primary assessment and specific detailed assessment must also be completed by an RN ...Reassessment: Assessment is an ongoing process. Patients should be reassessed at appropriate intervals based on the patient’s condition and VS.” Review of the hospital’s policy titled, “MW [hospital name ministry] Nursing Pain Assessment and Reassessment Policy” dated 05/04/26 revealed, “ ...Nursing staff will assess and reassess pain using standardized tools and timeframes to promote optimal patient comfort and safety. Pain management interventions, including medication administration, will be implemented in accordance with licensed independent practitioner (LlP) orders and evidence-based practice .... Pain Assessment and Management interventions: 1. Pain shall be assessed on admission, per nursing shift, and whenever clinically indicated. 2. Pain will be assessed and reassessed throughout the continuum of care using a validated tool appropriate for the patient’s age, cognitive ability, and condition. 3. Analgesic medication will be administered based on the patient’s reported pain rating and in accordance with the provider’s ordered pain regimen. 4. To prevent duplicate or conflicting analgesic orders, providers will identify primary and secondary line pain medications in the medication administration instructions. Nurses will administer the appropriate medication consistent with these designations and within the ordered parameters. 5. Nurses shall not exceed the dosage, frequency, or pain-level thresholds specified in the provider order. Escalation: lf pain remains uncontrolled after interventions or if pain intensity increases unexpectedly, the nurse must promptly notify the provider. Immediate communication is required for any severe, rapidly worsening, or clinically concerning pain.” Review of the hospital’s policy titled “MW [hospital name ministry] COMPL [complete] EMTALA Requirements Policy approved 08/27/25 indicated, “. . . “MSE is a process required in determining with reasonable clinical confidence whether an EMC exists. The screening must be completed within the Capabilities of the hospital, must determine what if any further medical examinations and/or treatments may be required to Stabilize the patient, or to determine that the patient needs to be transferred to a different facility once the patient is Stabilized per the Capabilities of the transferring facility. . . shall not discharge a Covered Person without having completed an MSE unless the Covered Person or his/her legal representative refuses to consent to the MSE, and the refusal is documented on a [name of hospital] approved Patient Consent/Refusal of Treatment Form. If a Covered Person (or legally responsible person) chooses to withdraw his or her request for examination or treatment, and if the staff is aware that the patient intends to leave prior to completion of the MSE or Stabilizing Treatment, the following steps should be taken: 1. Offer the Covered Person an MSE and treatment as may be required to identify and stabilize an EMC; and 2. Inform the Covered Person of the benefits of an MSE and and/or Stabilizing Treatment, and of the risks of leaving prior to receiving an MSE and Stabilizing Treatment; and 3. Take all reasonable steps to obtain the covered Person’s written informed refusal of the MSE and Stabilizing Treatment on a [name of hospital]-approved Patient Consent/Refusal of Treatment Form. Include documentation of the risks and benefits discussed with the patient in the patient’s medical record. . .” Review of the hospital’s policy titled, “MW [hospital name ministry] Nursing Pain Assessment and Reassessment Policy” dated 05/04/26 revealed, “ ...Nursing staff will assess and reassess pain using standardized tools and timeframes to promote optimal patient comfort and safety. Pain management interventions, including medication administration, will be implemented in accordance with licensed independent practitioner (LlP) orders and evidence-based practice .... Pain Assessment and Management interventions: 1. Pain shall be assessed on admission, per nursing shift, and whenever clinically indicated. 2. Pain will be assessed and reassessed throughout the continuum of care using a validated tool appropriate for the patient’s age, cognitive ability, and condition. 3. Analgesic medication will be administered based on the patient’s reported pain rating and in accordance with the provider’s ordered pain regimen. 4. To prevent duplicate or conflicting analgesic orders, providers will identify primary and secondary line pain medications in the medication administration instructions. Nurses will administer the appropriate medication consistent with these designations and within the ordered parameters. 5. Nurses shall not exceed the dosage, frequency, or pain-level thresholds specified in the provider order. Escalation: if pain remains uncontrolled after interventions or if pain intensity increases unexpectedly, the nurse must promptly notify the provider. Immediate communication is required for any severe, rapidly worsening, or clinically concerning pain.” Review of the facility’s policy titled, “FTSM [Fort Smith] ED Nursing Assessment and VS [vital Signs] Documentation Policy” dated 03/02/26 revealed, “ ...Complete vital signs should be taken at appropriate intervals based on the patient’s condition. a) Time begins with the triage time and or first patient contact. b) Triage staff may need to repeat v/s in the waiting room due to a delay in the patient being taken to the patient exam area. c) This does not replace monitoring of unstable, trauma, critical or sedated patients ...Patient Assessment: On initial contact with a patient, a chief complaint will be recorded in the patients Electronic Medical Record. A primary assessment and specific detailed assessment must also be completed by an RN. The Adult Pediatric navigator will be completed by the RN at the time of the Primary Assessment. Other nursing observations should be made and documented. Subsequent RN assessments may be brief but pertinent to the patient’s condition or status. Reassessment: Assessment is an ongoing process. Patients should be reassessed at appropriate intervals based on the patient’s condition and VS.””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 17281 Based on record review, policy review, and interviews, the hospital failed to ensure the provision of stabilizing treatment within the hospital’s capabilities for one of 20 (Patient (P)12. Specifically, P12, who presented the ED for screening, failed to have an adequate reassessment or continued evaluation performed to determine whether the EMC was stabilized prior to discharge. The hospital’s failure to provide stabilizing treatment had the potential to place all patients who present to the ED at risk of harm. Findings include: 1. Review of P12’s electronic medical record (EMR) under the “ED Triage Navigator” tab, navigated by Nursing Manager (NM1), indicated P12 arrived at the ED on 02/20/26 at 3:12 PM by private vehicle with a chief complaint of medical clearance/suicidal. Review of P12’s “ED Care Timeline,” located under the “ED Triage Navigator” tab, indicated at 3:50pm, the initial Columbia-Suicide Severity Rating Scale screening was completed and P12 score was high for suicide risk. Review of P12’s “ED Care Timeline,” located under the “ED Triage Navigator” tab, indicated the Medical Doctor (MD1) was assigned as the attending physician at on 02/20/26 at 4:01 PM, and Registered Nurse (RN2) was assigned as the RN on 02/20/26 at 4:07 PM. Review of P12’s “ED Care Timeline,” located under the “ED Triage Navigator” tab, indicated at 4:18pm, P12 was triaged with an acuity of 2/emergent. Review of P12’s “ED Care Timeline,” located under the “ED Triage Navigator” tab, indicated at 4:20pm, the ED Behavioral Health Assessment notes the patient being suicidal Review of P12’s “ED Care Timeline” dated 02/20/26 indicated MD1 ordered a behavioral health intake evaluation at 4:57 PM. The evaluation recommened inpatient psychiatric admission. Review of documentation dated 02/20/26 at 6:46 PM by RN2 indicated, “Attempted to start work up for possible inpatient placement, patient refusing and walked out. . .” There was no documentation RN2 informed P12 of the risks of leaving without a MSE and the benefits of an MSE and and/or stabilizing treatment. There was no documentation in the EMR of ongoing monitoring in a safe environment by qualified hospital staff and measures to reduce the risk of elopement before P12 left the ED. During an interview on5/12/26 at 2:25pm with MD1 and ED Medical Director (ED Med Dir) present, MD1 stated by the time he/she could get to P12 they left. MD1 stated if the patient is refusing to be admitted, the ED staff would have to physically restrain or chemically restrain the patient, which they can do on rare occasion. MD1 also stated they could put in a clinical hold order, but it would have been challenging to enforce it. MD1 stated if there’s a patient that should be behaviorally admitted but is unwilling and leaves, their process is to notify the police, as a bare minimum. MD1 confirmed the ED nurse should have informed the patient of the risks of leaving while being assessed to need inpatient hospitalization. Review of the hospital’s policy titled “MW [hospital name ministry] COMPL [complete] EMTALA Requirements Policy approved 08/27/25 indicated, “. . . Mercy must provide Stabilizing Treatment within its Capacity and Capability or, if Mercy does not have the Capacity or Capability to provide Stabilizing Treatment, Mercy must provide a transfer to another hospital having such capabilities. ln addition, Mercy must effectuate a transfer for any Covered person who requests a transfer. Until a Covered Person is transferred, Mercy must provide treatment to the Covered Person within Mercy’s Capacity and Capability to minimize the risks to the person’s health. Stabilizing Treatment shall be provided by or under the direction of QMP........ C. Patient who refuses Stabilizing Treatment: lf a patient (or legally responsible person) does not consent or withdraws his or her consent for Stabilizing Treatment, and if the hospital personnel is aware that the patient intends to leave prior to being Stabilized, the following steps should be taken: 1. Offer the patient Stabilizing Treatment as may be required to Stabilize the EMC; and 2. lnform the Covered Person of the benefits of Stabilizing Treatment, and of the risks of leaving prior to Stabilizing Treatment; and 3. Take all reasonable steps to obtain the patient’s written informed refusal of Stabilizing Treatment on a Mercy approved Patient Consent/Refusal of Treatment Form. lnclude documentation of the risks and benefits discussed with the patient in the patient’s medical record. D. Patient who leaves without notice: lf a Covered Person leaves without notifying hospital personnel, hospital personnel is required to document that the patient had been at the hospital and the time it was discovered that the patient left. All triage notes and other records pertaining to the encounter must be retained in the patient’s medical record. D. Patient who leaves without notice: lf a Covered Person leaves without notifying hospital personnel, hospital personnel is required to document that the patient had been at the hospital and the time it was discovered that the patient left. All triage notes and other records pertaining to the encounter must be retained in the patient’s medical record.””

“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: 53764 Based on review of policy, observation, clinical record review, and interview it was determined the facility failed to provide a medical screening exam (MSE) for two (#1-#2) of twenty-five (#1-#25) patient records reviewed. The failed practice did not allow the facility to determine if the patient had an emergency medical condition (EMC). The failed practice had the likelihood of affecting all patients presenting to the Emergency Department requesting treatment. Findings follow: A. Review of policy “MW COMPL EMTALA Requirements Policy” dated 08/27/25, showed “Mercy Qualified Medical Personnel (QMP) provide a Medical Screening Examination to each Covered Person who comes to the Emergency Department (ED)...” The policy also stated an MSE, “...is a process required in determine with reasonable clinical confidence whether and EMC exists” and “Mercy provides a MSE to each patient”. Patient who leave prior to receiving an MSE or before one is completed the following is required: Patients who “...expresses the intent to leave the hospital, either the QMP, triage nurse, or other nurse in charge is responsible to encourage the Covered Person to remain and explain to the patient the risks of leaving and the benefits of the MSE. If they leave without notice, “...hospital personnel is required to document the fact that the patient had been at the hospital and the time it was discovered that the patient left.” B. Review of Patient #1’s clinical record showed the following: a) Patient #1 presented to the Fort Smith Mercy Hospital’s, Emergency Department (ED) on 10/09/25 at 6:14 PM by way of Emergency Medical Services (EMS) with complaints of “Numbness.” b) Review of the ED timeline dated 10/09/25 at 7:13 PM, showed Pt #1 was triaged, vital signs were obtained and showed the chief complaint as “tightness and tingling in chest, and pain in left shoulder that radiates down left arm.” An Emergency Severity Index (ESI) score was assigned as “3 urgent”. c) A intravenous catheter (IV) was placed on 10/9/25 at 7:16 PM, followed by a labs collected at 7:51 PM, which included a Complete Blood Count (CBC), comprehensive metabolic panel (CMP), Troponin Baseline, Thyroid-Stimulating Hormone (TSH), and Urinalysis (UA) including drug screen . d) An Electrocardiogram (EKG) completed on 10/09/25 at 7:56 PM. e) A 1-view Chest x-ray was completed on 10/09/25 at 8:20 PM. f) Patient was put in Emergency Department room # 23 at 10:29 PM. h) The ED Timeline dated 10/09/25 at 10:48 PM, showed the Attending Physician was assigned to Pt #1 and that “Attending provider initial contact with patient”. k) ED timeline showed RN documented disposition on 10/10/25 at 1:55 AM as Against Medical Advice (AMA) followed by “patient removed IV and pressure dressing was applied” at 1:56 AM. l) Physician Discharge Disposition on 10/10/25 at 1:55 AM patient “Left Without Being Seen.” m) Evidence was requested on 01/06/26 at 3:00 PM which showed a Medical Screening Exam (MSE) had been completed and that an AMA form was signed by Pt #1 indicating they understood the risk of leaving the hospital before their medical condition had been stabilized. None was provided. C. Review of Patient #2’s clinical record showed the following: a) Patient #2 presented to the Emergency Department on 06/16/25 at 3:01 PM with complaints of “Vaginal Bleeding Pregnant, (patient arrives to the ED from home with c/o vaginal bleeding for the past week. 6 weeks pregnant. Reports she was seen here Thursday for same but bleeding more and blood clots present.)” b) Emergency Scoring Index (ESI), dated 06/16/25 at 4:50 PM, showed ESI score “3 urgent”. Review of the ED timeline showed, triage started at 4:50 PM and is documented as completed at 4:51 PM. c) Vital signs were documented at 4:52 PM and level of pain was documented at 8.5, location abdomen region, and constant. Evidence was requested on 01/06/26 at 2:15 PM, which showed Pt #2’s pain had been addressed, none was provided. d) A left anticubetal peripheral IV was placed at 4:58 PM, at which time a complete blood count (CBC), comprehensive metabolic panel (CMP), hCG quantitative blood, and magnesium level, was collected and sent to the laboratory. e) Evidence was requested on 01/06/26 at 3:00 PM which showed if Pt #2 was roomed or placed back in waiting area following IV start and lab collection. None was provided f) At 7:42 PM, ED RN documented “Patient roomed in ED: To room Checkout”. g) At 8:20 PM, ED LPN documented “AMA/LWBS Disposition Selected: ED Disposition as LWBS after Triage.” D. During an interview with the Director of Emergency services on 01/06/26 at 2:45 PM, the findings in A-C were confirmed.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 53764 Based on review of policy, clinical record review, observation, and interview, it was determined the facility failed to provide stabilizing treatment for one (#3) of twenty-five (#1-#25) patients reviewed. The failed practice did not ensure each patient’s Emergency Medical Condition (EMC) was stabilized prior to leaving the facility. The failed practice has the likelihood of affecting all patients presenting with an EMC. Findings follow: A. Review of policy “MW COMPL EMTALA Policy” last review of 08/27/2025 showed a “Qualified Medical Personnel (QMP) will provide a Medical Screening Examination (MSE) to each Covered Person who comes to the Emergency Department...if the individual has an EMC, Mercy either; provides any necessary Stabilizing Treatment; (2) provides an appropriate transfer to another hospital; or (3) admits the individual as an inpatient.” Additionally the policy states “Mercy may not discharge a patient with an EMC until the patient is Stabilized or when the patient or his/her legal representative refuses to consent to Stabilizing Treatment, and the refusal is documented on a Mercy-approved Patient Consent/Refusal of Treatment Form. “If a patient (or legally responsible person) does not consent or withdraws his or her consent for Stabilizing Treatment, and if the hospital personnel is aware the patient intends to leave prior to being Stabilized, the following steps should be taken: a) Offer the patient Stabilizing Treatment as may be required to Stabilize the EMC; b) Inform the Covered Person of the benefits of Stabilizing Treatment, and the risks of leaving prior to Stabilizing Treatment; and c) Take all reasonable steps to obtain the patient’s written informed refusal of Stabilizing Treatment...include documentation of the risks and benefits discussed with the patient in the patient’s medical record.” B. Review of policy “72 Hour Behavioral Health Hold”, dated 06/19/25, showed “A Behavioral Health Hold dictates the legal obligation of a hospital that has a psychiatrist on staff to hold a patient who does not wish to remain in the hospital and who has harmed or threatened to harm himself, herself, or another ...” C. Review of Pt #3’s clinical record showed the following: a) Patient #3 arrived on 11/15/25 at 11:44 AM, via ambulance for “Intentional overdose of Klonopin, unknown how much. Received nasal Narcan by Police Department (PD).” b) ED timeline dated 11/15/25 at 11:47 AM, showed Pt #3 was roomed an RN noted “took 10-12, 2 milligram (mg) Klonopin ...Pt is awake, talking, and drowsy. c) Review of the “Columbia Suicide Severity Rating Scale (C-SSRS), dated 11/15/25 at 3:15 PM, showed “Suicidal intent with specific plan” and that Pt #3, responded “yes” to having thoughts of harming another person. d) Review of Behavioral Intake Assessment, dated 11/15/25 at 4:39 PM, showed a Psychiatric telehealth visit had occurred and under “Plan/Dispo as directed by provider; Staffed with (Named) provider and it has been determined that pt is to admit to a behavioral health facility due to the following: Imminent danger to self”. e) Review of ED Note dated 11/15/25 at 7:47 PM, showed “Pt stated someone needs to tell me the plan, I’m keeping myself calm right now. If they make me stay here that’s gonna be a different story.” f) Review of RN Note dated 11/15/25 at 8:52 PM, showed “Patient’s friend (Named) arrived to pick pt up. Fort Smith Police Department that was already on hospital grounds was notified of patient elopement.” g) Review of ED times line dated 11/15/25 at 8:00 PM, showed Physician set ED Disposition as “Elopement”. Another entry by a second Physician at 8:52 PM, showed disposition changed to “Against Medical Advice.” h) Evidence was requested on 01/07/26 at 1:15 PM, which showed Pt #3’s condition had been fully stabilized or that reassessment had occurred by the Psychiatric staff that had recommended inpatient behavioral health placement to ensure the patient was safe for discharge. None was provided. D. During an interview with the Director of Emergency services on 01/05/26 at 10:00 AM and again on 01/06/26 at 2:45 PM, she confirmed the hospital utilizes Psychiatric telehealth Physicians/Providers staffed by Mercy Hospital System and the findings in A-E were confirmed.”