National Park 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: 44854 Based on medical record review, policy review, interview and video recording review it was deteremined that the facility failed to provide a Medical Screening Exam for 1 of 25 patients seen in the Emergency Department. The failed practice did not ensure the patient had an emergency medical condition or not. The failed practice had the likelihood of affecting all patients seen in the Emergency Department. See tag 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: 44854 Based on clinical record review, policy review, and interview, the facility failed to ensure one of one (#1) patient received an appropriate medical screening exam (MSE) before Patient # 1 was the discharged. The failed practice did not ensure Patient #1 was examined to determine if an emergency medical condition existed. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department (ED). Findings follow: A. Review of the Policy and Procedure titled “EMTALA-Medical Screening and Treatment of Emergency Medical Conditions” reviewed date of 10/2025, showed the following: 1. The policy process was required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an EMC existed. 2. The hospital must provide an appropriate MSE (Medical Screening Examination) conducted by a physician or other QMP (Qualified Medical Professional, including to the extent necessary ancillary services within the Hospital’s capabilities and on-call physicians services, to determine whether or not an EMC existed. B. Review of the Policy and Procedure titled “Medication Management” reviewed date of 05/2025, showed the following: 1. The effects of medications on patients are monitored to assess the effectiveness of medication therapy and to minmize the occurence of adverse events 2. Monitoring will include the patient’s response to the prescribed medication and actual or potential medication related problems. 3.The patient care provider will monitor and assess the effects of medications on the patient. C. Review of Patient #1 Registered Nurse (RN) triage assessment dated 07/03/2025 at 3:28 AM showed, “ Pt. (patient) via EMS for post op bleeding. Pt reports he had surgery earlier today on his right foot. Pt. is very argumentative and yelling at EMS and ER (Emergency Room) staff upon arrival.” D. Review of Patient #1 Registered Nurse notes dated 07/03/2025 at 3:30 AM showed no evidence of medication follow up for Geodon effectiveness. E. Review of Patient #1 Physician documentation dated 07/03/2025 at 3:28 AM showed no evidence of the following: 1. Completed mental status examination and psychiatric examination. 2. Metabolic lab workup to rule out infection and intoxicants. 3. Medication reaction follow up for Geodon. F. During an interview on 08/12/2025 at 12:00 PM, the Emergency Room Director confirmed A-E. G. During an interview on 07/22/2025 at 10:30 AM, the Patient stated, “He had surgery and when he got home, he had a psychotic breakdown. The police took the patient to National Park Medical center, and he was not triaged or have a medical screen. This was after the EMT took him to SVI Hot Springs where they would not see him.” H. During an interview on 08/13/2025 at 9:00 AM, with the ED Medical Director, when asked to describe the process followed for patients who are verbally and/ or physically threatening facility staff. The medical director stated, “The initial step is for a provider to step in to evaluate the patient and attempt to screen them. Seeing the doctor will usually calm them down enough for us to at least complete the medical screening and some minimal treatment. We do everything we can to get them to allow us to care for them.” I. During an interview on 08/13/2025 at 11:00 AM, with the ED RN #1, when asked to describe the steps for triage and screening of a potentially violent patient. She stated, “if a patient appears to be agitated, they try to triage them quickly and get them in a room with a physician. The physicians can usually calm them down enough to do the screening. If we need to, we will call security. The security staff is really good at talking people down and getting them to cooperate. We have all had de-escalation training.” J. During an interview on 09/23/25 at 9:30 AM, with MD #1, when asked the process for performing MSE on a patient with psychosis, she stated, “When the patient presents, we ask the usual questions of orientation, such as their name, date of birth, where are they, what happened, etc. A CT(Computed Tomography)of the head would be ordered if needed based on physical exam as well as blood and urine labs including drug screen.” When asked for the follow up to his psychosis, she stated, “ I could and should of did a much better job of documentation.” When asked about the follow-up for the medication Geodon that was given for the patient’s psychosis, she stated, “Again, I should have documented better.” K. During an interview on 09/24/25 at 7:15 AM with RN #2, when asked for the protocol for a patient presenting with psychosis, she stated, “The patient is placed in a room, and the MD will attempt to deescalate the patient. There was no evidence that the patient medication had been reassessed. RN #2 confirmed she did not document the effects of the medication or change in the patient’s presenting symptoms.”