Saline Memorial Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50014 Based on review of an educational brochure, emails, and interviews, it was determined that the facility failed to provide the patient a safe environment of care with respect and comfort. By not ensuring that the patient receives care in a manner that upheld the patients dignity and emotional health when needed, the patient left discouraged and melancholy. Patients with stillborn babies coming to the Emergency Room or Labor and Delivery, had the likelihood of experiencing an unsafe environment of care. Findings follow: A.Review of the “Your guide to Postpartum and Newborn Care” brochure on 05/27/26 at 9:44 AM, showed several pictures of a newborn baby with their mother and a newborn baby alone. B. Review of email dated 02/17/26 at 10:10 AM, showed interaction with the CEO and the patients mother regarding the original complaint. The email shows the original complaint and on 10:18 AM she also sent “And then the discharge paperwork - the folder was full of how to take care of your baby. Maybe consider that bereaving mothers do not want to see that. Maybe there needs to be a separate folder specific for bereaving mothers with information about infant loss and grief and how to take care of themselves. Again, dealing with life and death especially on Labor and Delivery unit you should always have stuff for both. Not everyone gets to leave with their baby.” 11:07 AM from CEO showed “ ...Thank you for taking the time, in the middle of your own pain, to share such specific and thoughtful feedback. Please know that your concerns are being taken seriously. We will be reviewing the triage process, communication around infant remains, and the entire experience of bereaved parents, including discharge procedures and environment. ...” 11:56 AM from Risk Manager showed “Thank you very much for sharing your experience and loss. I am so very sorry. I want to let you know that as soon as I heard of this, I met with the Director to schedule a debrief of how we ensure that experience never happens again. As the CEO states, we would love for you to connect to our Risks Manager to discuss all of your experiences and suggestions. ...” C. In an interview with Patient #1 on 04/07/26 at 9:31 AM, she stated “The day I was being discharged, they handed me brochure with new baby instructions and postpartum care. I gave it to my husband and then gave it back to the nurse. It was too hard after seeing my dead baby.” D. In an interview with Patient #2 husband on 05/27/26 at 8:30 AM, he stated “When the nurses gave us the brochure with the newborn pictures on the front page, I looked at it and gave it back to them. I could not believe they were handing us a guide to newborn care when our baby had died.” E. In an interview with the CEO on 04/07/26 at 11:30 AM, she was asked if she had developed an action plan from the findings in the complaint. She explained that they had meetings specific to the complainants issues. Nothing had been developed as of the survey day. She verified the findings in B, C, and D. F. In an email with the CEO on 05/27/26 at 9:44 AM, she verified findings in A and E.”

“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: 40282 Based on review of policy, clinical record review, observation, and interview, it was determined the facility failed to comply with 42.CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to place patients presenting to the Emergency Department and Labor and Delivery on the log and failed to provide a timely medical screening exam for 1 (1) of 20 patients reviewed. See tag 2405 and 2406.”

“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: 40282 Based on policy review, record review and interview it was determined the facility failed to maintain an accurate central log of individuals who presented to the Emergency Department for 1 (Patient #1) of 20 emergency department records and incomplete Labor and Delivery Department log. The failed practice had the likelihood of affecting all patients presenting to the Emergency Department and the Labor and Delivery Department and did not ensure the facility’s ability to track, monitor, and provide appropriate care. Findings included: A. Review of facility policy titled “EMTALA - Central Log” approval date 02/2026 showed the following: 1. Policy: The Emergency Department (ED) must maintain a central log to include individuals who come to the hospital property or premises requesting treatment including patients present to Labor and Delivery (LD), the ED, or any other area where patients may have emergency medical conditions. 2. Procedure: 5. The log must contain: name, if refused treatment, transferred, admitted and treated, stabilized and transferred or discharged. B. Review of the facility ED log dated February 2026 did not show Patient #1 listed on the log. C. Review of the Facility LD log dated January 14, 2026, to February 13 , 2026 showed the log was incomplete in that there were blanks of missing information. For example: 1. On 01/16 /26, Patient #26 was missing the time of arrival, EMTALA -Exempt, EGA (Estimated Gestational Age), origin of patient, complaint, services rendered, discharge time, MSE (Medical Screening Exam) provider, and disposition. 2. On 02/02/26, Patient #27 was missing date of birth, EGA origin of patient, attending physician, diagnosis, services rendered, discharge time, MSE provider, and disposition. 3. On 02/11/26, Patient #28 was missing services rendered, discharge time, MSE provider, and disposition. D. During interview on 04/07/26 at 2:30 PM, the Director of Woman & Infants confirmed the findings in B. E. During interview on 04/08/26 at 1:00 PM, the Director of Women and Infants confirmed the findings in A.1, and C.”

“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: 40282 Based on policy review, record review, observation, and interview, it was determined the Facility failed to provide an appropriate medical screening exam within a timely manner by qualified medical personnel for 1 (Patient #1) of 20 patients. The failed practice did not ensure a timely medial screening examination to determine the presence or absence of the need for emergent care and a risk for delay in treatment. This failed practice had the likelihood of affecting all patients who are pregnant and present to the Emergency Department. A. Review of facility policy titled “Medical Screening Exam for Labor Status by Qualified Medical Personal” (QMP)-last approved 04/2024 showed the following: 1. A physician or QMP will perform the medial screening examination of all patients who present to the L & D unit for emergent care. The obstetric RN with demonstrated competency can act as the QMP for labor status and rule out rupture of membranes in consult with a physician. 2. Unscheduled OB patient: any obstetric patient who presents to the hospital unannounced, unplanned, or unanticipated regardless of whether the patient has an attending physician or a pre-registration account or whether the physician has notice labor and delivery that the patient is coming to the hospital will provide a medical screening exam and any necessary stabilizing treatment. By registering the patient as an obstetric patient, the patient’s information will be written in the paper log in L and D. B. Review of facility policy titled “Obstetrical Triage in Emergency Department and Woman & Infants” approved 07/2025 showed the following: General Information: 1. Patients who present to the ED (Emergancy Department) with potential medical. Surgical or obstetric emergencies are assessed by the ED physician with obstetrician consultation in collaboration with the L & D (Labor & Delivery) nurse. 2. Patients presenting for an anticipated routine delivery are taken directly to L & D. 3.Non trauma patients more than 20 weeks gestational presenting with abdominal pain, vaginal bleeding or obvious labor are seen initially in Labor and Delivery. 4.Emergency Room guidelines for triaging obstetrical patients: 5.After initial ED assessment pregnant patients are transferred to L & D for further care: possible labor intermittent abdominal pain, vaginal bleeding, or leaking of fluid, stable trauma, pregnancy induced hypertension, temperature more than 100.4. C. Review of Patient #1’s clinical record dated 02/14/26 and interviews showed the following timeline of events: During interview Patient #1 said she arrived at Saline Memorial Hospital Emergency Department on 02/16/26 at approximately 1:30 PM and ED staff instructed her to go to LD. Per interview with ED staff they could not recall a time of arrival. Review of ED log showed no time of arrival for Patient #1. Review of Patient #1’s 2/14/26 clinical record showed the following: 1:45 PM: Labor and Delivery Bed Registration: (no date) Assigned to room: 312 1:45 PM: Consent form signed by Patient and RN #2 - 2:23 PM: RN #1 called to BS (bedside) to help with FHT (fetal heart tones). Called (Physician #1) MD (medical doctor) in route to BS. 2:45 PM: Physician #1 at bedside for ultrasound. 2:52 PM: Patient #1’s heart rate 71 & SpOP2 (pulse oxygenation) 98% 3:00 PM Nursing Intervention: other: taking over as primary RN. Pt c/o (complaint of) upper abd (abdomen) pain. MD aware. 3:05 PM: Patient #1’s Blood pressure 165/94 4:00 PM Nursing Interventions: prep for CS (cesarean section) Physician Order Set: LDRP (Labor Delivery Recovery Postpartum): 4:05 Admit to Inpatient, Priority: routine, Order Summary: Obstetrics 4:30 Consent form signed by Patient #1 for C S. 4:42 PM: Physician #1 note discussed bedside ultrasound confirmed no fetal heart tones and no fetal activity and discussed medical findings and treatment options with Patient #1. 5:00 PM: MD notified for delivery. 5:11 PM Labetalol given per (Physician #1) 5:30 PM: Taken to Operating Room (OR) Labor Summary Form dated 2/14/26 8:45 PM documented that the condtion of Patient #1 baby was stillborn with a date/time of death at 2/14/26 at 6:07 PM D. During observation/tour of facility ED and L&D on 04/08/26 at 10:15 AM the walk from the ED department to the LD was a distance of 266.91 yards (according to facility map) with no signage for directions or signs for LD noted in the halls or the elevators. E. During interview with Physician #1 on 04/07/26 at 1:15 PM, he stated “I was aware that there was a delay in paperwork and registration for Patient #1. I have heard the nurses say that they cannot place the patients on the monitors until after the registration process has occurred. I was contacted by one of the nurses regarding this patient. They told me that they were unable to find fetal heart tones on the patient. I brought the US (ultrasound) machine into Patient #1’s room. She informed me that she had some contractions, increased blood pressure, and pain.” F. During phone interview with Patient #1 on 04/08/26 at 9:31 AM, she stated “I was in the area with my high school students for a school outing. I am from east Arkansas, not familiar with the area. I have never been to Saline Memorial Hospital before. I began to have pain, so my coworker dropped me off at the ED entrance. As I approached the window, the registrar, who was a female, appeared to be on her personal phone, possibly on facetime. I told her I think I am in labor. She then turned around and spoke to a tall male that was wearing a white lab jacket, with dark hair and wearing glasses. He waved and said send her on to L & D. The Registrar then pointed to the elevator and told me to use that elevator. I got on the elevator, and it took me to the wrong floor. I was in the radiology area, so I went back down to the ER desk for further instructions. As I started back to LD, I ran into an off-duty RN, she told me where L & D was located. I was having contractions and pain in my abdomen. I did not know that L & D was as far as it was from the ED. G. In an interview with RN #1 on 04/09/26 at 10:00 AM, prior to any discussion she asked if she needed legal representation, after explaining the purpose of the interview she continued with the interview. Surveyor #1: What time did the Patient arrive to Labor and Delivery? RN #1: “Whatever is in the chart.” Surveyor #2: Do you recall registering Patient #1 or taking her to her room? RN #1: “ No I do not.” Surveyor #2: Your name is documented under the first nurse assessment in the patients LD chart, but there is no documentation of what interventions were performed. The documentation is blank. RN #1: “ Whatever is in the chart is what I did.” Surveyor #2: Do you remember any interventions you performed for Patient #1? RN #1: “Whatever is in the chart is what I did.” H. In an interview with RN #2 on 04/08/26 at 11:10 AM, she stated “I recall that I was assigned to the nursery on the day Patient #1 came into the hospital. We did not have any extra staff working that day, during the week a scrub technician is staffed, but it was just the nurses and we were very busy. I was not assigned Patient #1. “Surveyor #2: On Patient #1’s record you signed the consent form. Did you register Patient #1 or witness her sign the consents? RN #2: “No, however, when I see consents laying near the fax machine, I sign them regardless if I witnessed the consent or not because the faster we send the ER her paperwork the faster we can assess the patient. We cannot put anybody on the monitor until they are registered.” Surveyor #2: What is the process of registering Patients to LD for an assessment? RN #2: “On the weekends the nurses register the patients, we fill out the paperwork and consents, then we fax the information to the ER and the registrar in ER registers the patient. Surveyor #2: Did you provide any care for Patient #1? RN #2: “The L & D was very busy, and the MD sitting at the nurse’s station asked who was in room 312 with no monitor? I went into the room, and the patient was coming out of the bathroom. She was not registered so I could not take her blood pressure or put her on the monitor to find fetal heart tones. I went back into the room once the patient was in bed. I then attempted to find the fetal heart tones, but I could not hear them. We always have a second nurse check if we are unable to find heart tones, so I notified the other 2 nurses that I could not hear the heart tones and walked back to the nursery.” G. During a phone interview with the ED Registrar 04/08/26 at 10:30 AM, she said Patient #1 she was hurting and in labor, I then turned to a group of nurses standing behind me and they said, “send her on up to L & D”. I told her to go on up to LD. H. The findings in A & B were confirmed by the Director of Quality on 04/07/26 at 1:00 PM. I. The findings in C were confirmed on 04/09/26 at 9:30 AM by the Director of Woman and Infants.”