Mena Regional Health System

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 51070 Based on review of Medical Staff Bylaws, policies, clinical record review and interview, it was determined the Governing Board failed to ensure the Medical Staff bylaws identified who may serve as qualified medical personnel (QMP), including any criteria or training requirements, for those responsible for performing medical screening exams (MSE) on patients presenting with an emergency medical condition (EMC) to the Emergency Department (ED) and/or Labor and Delivery (L&D) Department for five (#1, #24-#27) of 27 (#1-#27) patients reviewed. The failed practice did not ensure a QMP performed MSEs thereby increasing the potential an EMC would go undiagnosed and/or untreated. The failed practice had the likelihood of affecting all patients presenting to the ED or L&D with an EMC. See C0962 for details.”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 51070 Based on review of policy, clinical records, and interview it was determined the facility failed to ensure now, one time, and as needed (PRN) medication orders included the indication for which the drug was being prescribed, and that clinical staff performed a follow-up assessment to ensure the drug achieved the prescribed indicated effectsfor 9 (#10-#12, #14, #16, #19-#22) of 27 (#1-#27) patients reviewed. The failed practice did not ensure the medication met the needs of the patients or allow for any adjustments or additional dosing that may be needed to reach the desired effects. The failed practice had the likelihood of affecting all patients receiving medication in the Emergency Department (ED). Findings follow: A. A review of policy titled “Medication Administration” no date, showed medication orders “must” include “indication for use” which include “orders for PRN administration and/or multiple uses for the same medication”. Additionally, “the licensed nurse will monitor the effectiveness within one hour of the administration”. B. Review of Patient #10-#12, #14, #16, #19-#22’s records showed a one time and/or PRN medication order. None of the orders reviewed showed the indication for use (i.e. nausea, pain, blood pressure, etc.). Additionally, none of the orders reviewed showed a follow-up nursing assessment had been performed within one hour of administration to ensure the medication effectively met the patient’s needs. C. During an interview with the Emergency Department Director on 05/13/25 at 1:45 PM and the Chief Nursing Officer on 05/14/25 at 10:30 AM, the findings in A-B were confirmed.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 51070 Based on review of Medical Staff Bylaws, policies, clincial record review and interview, it was determined the Governing Board failed to ensure the facility identified who may serve as qualified medical personnel (QMP), including any criteria or training requirements, for those responsible for performing medical screening exams (MSE) on patients presenting with an emergency medical condition (EMC) to the Emergency Department (ED) and/or Labor and Delivery (L&D) Department for five (#1, #24-#27) of 27 (#1-#27) patients reviewed. The failed practice did not ensure a QMP performed MSEs thereby increasing the potential an EMC would go undiagnosed and/or untreated. The failed practice had the likelihood of affecting all patients presenting to the ED or L&D with an EMC. Findings follow: A. Review of the bylaws dated 01/30/25 no time, showed no evidence of who may serve as the QMP who performs a MSE on patients who present to the ED or L&D with and EMC. B. Review of policy titled “EMTALA Guidelines for Emergency Department Services” dated 01/30/25, showed the healthcare practitioners “who may certify false labor include physicians, certified nurse-midwifes, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and state law.” C. A list of QMPs including the training requirements and/or criteria to perform MSEs was requested on 05/12/25 at 11:25 AM, none was provided. D. Review of Patient #1’s record showed the following: 1) Patient #1 presented to L&D triage (gravida 8, para 5) on 04/04/25 at 10:45 PM with the following signs and symptoms. a) Patient reported uterine contractions 1-2 minutes apart and that she had taken castor oil earlier in the day to induce labor. b) Assessment by a Registered Nurse (RN) at 10:45 PM showed the patients cervix dilated to 4.0 cm, 60% effaced, station -2, membranes intact. c) Nursing assessment at 11:42 PM showed patient had uterine contractions every 1-3 minutes lasting 50-60 seconds, cervix was dilated 4.5 cm, 60% effaced, station at -2. d) The clinical record showed the Obstetrician Gynecologist (OBGYN) was paged at 11:45 PM and updated on findings. The record showed verbal instructions were received to “keep patient an additional hour and recheck her cervix. If no progress, discharge patient home.” e) Nursing assessment showed on 04/05/25 at 12:30 AM, “patient on hands and knees at this time, difficulty tracking fetal heart tones (FHT).” f) Nursing assessment on 04/05/25 at 12:36 AM showed “no changes”. Note showed at 12:40 AM, OBGYN was notified and a verbal order was received to discharge Patient #1 home. g) Nursing note dated 04/05/25 at 12:44 AM, showed patient #1 was informed of discharge and “patient refused to sign discharge paperwork and ambulated from unit angry and stated she will go to Hot Springs”. h) Review of a triage note dated 04/05/25 at 2:05 AM, showed Patient #1 arrived via ambulance and reported the urge to push uncontrollably. i) Nursing note showed OBGYN was notified on 04/05/25 at 2:08 AM that Patient #1 was “complete and pushing”. j) Nursing note showed on 04/05/25 at 2:09 AM, a “viable male newborn delivered by spontaneous vaginal delivery (SVD) with loose nuchal x1 around neck”. OBGYN was noted to “be in room” at 2:23 AM. E. Additional review of Patients #24-#27 showed they presented to the facility greater than 20 weeks pregnant. No evidence was provided that showed Patients #24-#27 received a MSE by a QMP prior to discharge. F. During an interview with Director of Womens Services on 05/13/25 at 10:30 AM, she confirmed the nurses in L&D perform an exam and then call physician to discuss findings when a women presents to the emergency department and are greater than 20 weeks pregnant.”

“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: 50014 Based on review of policy and the Emergency Departments (ED) central log and interview, it was determined the facility failed to maintain a complete log of patients who presented to the ED. The failed practice did not allow the facility to track each patient, their condition, treatment, or disposition. The failed practice had the likelihood of affecting all patients presenting to the ED requesting care. Findings follow: A. Review of policy titled “EMTALA Guidelines for Emergency Department Services” dated 01/30/25, showed the ED would maintain a central log documenting the name of the patient, if they refused treatment or were refused treatment, if the patient was admitted, transferred, stabilized and transferred, or discharged. B. Review of two ED central logs books on 05/12/25 at 1:30 PM, showed missing information throughout each log. Missing information included the time patients presented, the nature of their injury, what services were rendered, and the disposition of care. C. During an interview with the Director of the ED on 05/12/25 at 2:30 PM, she confirmed the findings in A and B.”