Northwest 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: 52757 Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by: Policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy” revealed: “... Introduction ... The purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA), the regulations and rules promulgated thereunder, and the State Operations Manual interpretive guidelines. This Emergency Medical Treatment and Patient Transfer policy is based on federal law relating to the obligations of hospitals to provide screening and emergency medical treatment and the appropriate transfer of individuals between hospitals. The treatment and transfer of an individual shall not be predicated upon arbitrary, capricious, or discrimination based upon race, color, religion, national origin, age, sex, sexual orientation or identification, diagnosis, physical condition, economic status, payor source, ability to pay, or other protected category. (Individual Hospitals should determine whether their state laws and regulations have any additional or different requirements than those set forth herein and ensure the Hospital ’ s emergency medical treatment and patient transfer policy and procedures are in compliance with all applicable laws ... I. GENERAL EMTALA OBLIGATIONS; CENTRAL LOG ... A. EMTALA Requirements: As further detailed in this EMTALA Policy, 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 requesting medical services (including via ambulance), or having someone request medical services on their behalf, the hospital must:... Provide an appropriate medical screening examination by a qualified medical professional, within the capability of the hospital’s emergency department, to determine whether or not an emergency medical condition exists, and ... (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, or an appropriate transfer ... 2. Documentation When Patient Leaves Without Being Seen, Against Medical Advice, Without Notifying Hospital Staff ... If a patient informs the ED Registration staff that s/he is leaving prior to receiving an MSE, ED staff should obtain the patient ’ s signature, date and time, on an “AMA” or “Refusal of Care” form, indicating that they have been informed of the risks of leaving the ED prior to receiving and MSE or prior to receiving stabilizing treatment for and EMC. If the patient refuses to sign the form, staff should document the circumstances of the refusal ....” Policy titled, “Refusal for Treatment - AMA Policy - NWC” revealed: “... PURPOSE: To identify the process whereby a competent adult refuses medical treatment which could result in an adverse outcome ... DEFINITIONS: 1. Against Medical Advise (AMA): patient refuses medical treatment or leaves against medical advice after receiving screening, diagnosis, and possibly some treatment ... INSTRUCTIONS: 1. SIGNING OUT AMA: a. Inform the patient (family or personal representative if appropriate) of the risks and potential medical consequences in signing out AMA ... b. Whenever feasible, contact the physician and have the physician discuss the risks with the patient or the patient ’ s personal representative directly ... c. Attempt to have the patient sign a Leaving facility against advise (RM1720) form. If the patient refuses to sign the form, have this refusal witnessed and document the refusal in the patient ’ s medical record ... e. If the physician “discharges” the patient against medical advice or better judgment, an attempt should be made to have the patient sign the refusal form ... i. The medical record must contain complete details of the refusal and instructions given ....” Review of Patient #1 ED medical record dated 01/15/2026 revealed a note titled “ED Documents Physician” revealed: “... Time seen: Date & Time 01/15/2026 01:30:00 ... History of Present Illness ... Patient #1 is a 41-year-old {female} with a past medical history significant for cauda equina, neurogenic bladder, and chronic left foot droop presenting to the emergency department for evaluation of back pain. Patient states that for the past few months, {she} has been experiencing worsening back pain. {She} states that {she} does have a history of cauda equina and has had multiple procedures with hardware in place. {She} states that {her} last surgery fo cauda equina was in 2022. Patient states {She} has not noticed any changes in urine. {She} reports that {she} does self cath approximately 6 times a day at baseline and has had no changes in this. {She} denies any numbness, weakness, or tingling in extremities, or further symptoms ... Medical Decision Making: Rationale: Patient is a 41-year-old {woman} with history of cauda equina who presents with worsening back pain. Patient reports history of left-sided foot droop, chronic neurogenic bladder requiring straight caths. Reports {her} back pain is worsened today despite home medication. Neurologic exam is unchanged from baseline on arrival. Given history, will get MRI. Will give analgesia while in the emergency department. Patient denied any dysuria, do not think urinary analysis indicated. Will reassess after clinical interventions ... Reexamination/Reevaluation ... 01/15/2026 05:10:19 MST - Called to bedside as I was informed patient wanted to leave AGAINST MEDICAL ADVICE. Patient did receive pain medication already including Dilaudid and Tylenol. I was informed the patient requested more pain medication so oxycodone and lidocaine patch were ordered. Prior to receiving this patient informed the nurse that {she} wanted to leave. So I went to bedside and discussed with patient that we have not completed emergency part evaluation. That we have not gotten MRI yet, that it is the middle of the night so it has been taking longer to acquire this imaging and if {she} would leave now I would not be able to diagnose worsening of {her} chronic cauda equina which would be an emergent diagnosis. Patient able to read my concerns but reports {she} wants to leave regardless. I discussed with the patient {she} can return anytime, that I was trying to make {her} comfortable and rule out life-threatening illness. Patient reported {she} wants to go home. DUring discussion {she} is already calling over on {her} phone, and did not want to stay. Will have the patient sign out AGAINST MEDICAL ADVICE ... The patient refused further medical evaluation and treatment and requested to leave against medical advice. The patient was AAOx4 and no obvious cognitive impairment or evidence of intoxication was noted. The patient was deemed to have appropriate decision making capacity and clearly articulated a safe discharge plan. We made reasonable attempt to persuade the patient to stay without success. This provider explained the plan of care and alternatives. We informed the patient of any risks that may be associated with the refusal of care and leaving against medical advice, including but not limited to worsening of the patient ’ s medical condition, delay in diagnosis and treatment, permanent disability, and/or death. Discussed specifically concerns _ with potential acute decompensation and death (sic). The patient verbalized understanding he risks. The patient was invited to return to the ED at any time for worsening or changing symptoms. Written discharge instructions provided. The patient signed the AMA form. The patient left against medical advice in stable condition ....” Review of Patient #1 ED medical record dated 01/15/2026 revealed a form titled “Leaving Against Medical Advice (AMA)” which did not reveal Patient #1 ’ s signature. Review of Patient #1 ED medical record dated 01/15/2026 revealed a form titled “Leaving Against Medical Advice (AMA)” which revealed two (2) nurse signatures. A review of 19 additional medical records dated December 2025 through February 2026 was conducted. Two (2) of those records, Patient #5 and Patient #6, did not contain a “Leaving Against Medical Advice (AMA)” although their final disposition was left against medical advice. One (1) of those records, Patient #21, did not contain a witness signature on the “Leaving Against Medical Advice (AMA)” although their final disposition was left against medical advice. Employee #1 confirmed during an interview conducted on 02/19/2026 that two (2) nurse signatures indicate the patient refused to sign. Employee #7 confirmed during an interview conducted on 02/19/2026 that the provider ’ s note states Patient #1 signed the AMA form. Employee #7 confirmed that there is not a signature in the recipient or authorized representative spot on the leaving against medical advice form.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 45167 Based on observation and interview, the facility failed to provide testing for the operating room’s emergency lighting and document the battery backup emergency lighting testing. Failure of these units during a power outage could cause harm to the patients by allowing the operating rooms to go dark during a surgery. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 “Emergency lighting shall be provided in accordance with Section 7.9”. Section 7.9.3 “ Periodic Testing of Emergency Lighting Equipment” “ Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.” Findings include: During observation while on tour conducted on February 25, 2025 in Operating Rooms 1, 2, 3, 4, 5, 6, 7, 8 and 9, no designated emergency lighting could be identified. In an interview conducted on February 26, 2025, Employee #14 was asked if there was emergency lighting in the operating rooms and if so, where the emergency lighting could be found. Employee #14 stated that he/she was unaware of the location of emergency lighting but stated the lights do stay on when the generator is exercised. Employee’s #10 and #14 confirmed during the exit interview that there was not any emergency lights in the ORs”

“Laboratories CFR(s): NFPA 101 Laboratories Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected by 1-hour fire resistance-rated separation, automatic sprinkler system, and are in accordance with 8.7 and with NFPA 99. Laboratories not considered a severe hazard are protected as hazardous areas (see K321). Laboratories using chemicals are in accordance with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Gas appliances are of appropriate design and installed in accordance with NFPA 54. Shutoff valves are marked to identify material they control. Devices requiring medical grade oxygen from the piped distribution system meet the requirements under 11.4.2.2 (NFPA 99). 19.3.2.2, 8.7, 8.7.4.1 (LSC) 9.3.1.2, 11.4.3.2, 15.4 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour, interview, and review of facility documentation, it has been determined the facility has failed to ensure the laboratory has utilized chemicals in compliance with NFPA 45 by ensuring laboratory hood maintenance and safety. Failure to comply with NFPA 45 guidelines can result in unnecessary chemical exposure to staff and fire hazard in the laboratory. NFPA 45 (2011), Section 7.14.2 indicated: “...When installed or modified and at least annually thereafter, chemical fume hoods, ductless fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested as applicable, as follows...Visual inspection of the physical condition of the hood interior, sash, and ductwork....” Findings include: During observation while on tour conducted on February 25, 2025, three (3) laboratory hoods were observed within the laboratory bearing PM (preventative maintenance) stickers with a test date of February 15, 2024. A rubber gasket on the right side of one of these hoods intended to enclose power cords was worn out and could no longer enclose the cords on the laboratory hood. A current PM for the laboratory hoods was requested but could not be provided. Employee #10 acknowledged the deficiency while on tour on February 25, 2025. During an exit interview conducted on February 26, 2025, members of administration staff acknowledged the deficient practice.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, the hospital failed to ensure cooking equipment that collects grease were being cleaned on a regular basis. Failing to inspect and clean cooking equipment that collects oil and grease buildup can result in a kitchen fire, increasing the likelihood of harm to patients and/or staff. NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, “Cooking Facilities.” “Cooking facilities shall be protected in accordance with 9.2.3.” Section 9.2.3, “Commercial Cooking Equipment” “Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.7.2 Cooking Equipment Maintenance indicated: “...Cooking equipment that collects grease below the surface, behind the equipment, or in the cooking equipment flue gas exhaust, such as griddles or char broilers, shall be inspected and, if found with grease accumulation, cleaned by a properly trained, qualified and certified person acceptable to the authority having jurisdiction....” Findings include: Observations made while on tour on February 25, 2025, revealed the following; Multiple appliances including, but not limited to, the deep fat fryer, and the commercial range, had buildup of grease, food, and in the case of what appeared to be a commercial kettle, also a soiled cloth, on and around the appliances, including the outlets the equipment was plugged in to. Employee #10, who accompanied Compliance Officers on tour, acknowledged the presence of the grease and debris. In an exit interview conducted on February 26, 2025, members of administrative staff acknowledged the deficient practice.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 45167 Based on observation and interview, it has been determined that the facility failed to install fire extinguishers near the generators and failed to maintain access to fire extinguishers in the operating rooms. Failure to provide and maintain access to fire extinguishers in key areas of the hospital can result in the likelihood of the spread of a fire in the event of a fire due to lack of fire prevention options, leading to increased possibility of harm to patients and to staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 “Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1” Section 9.7.4.1 “Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers.” 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards...Type of Hazard...Basic Minimum Extinguisher Rating...Maximum Travel Distance to Extinguishers...(moderate)...20-B...50 ft....” NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility. Findings include: Observations made while on tour on February 25, 2025, revealed the following: There was not a fire extinguisher installed within 50 feet of the generator. Fire extinguishers with obstructed access were found in the following areas: 1) One extinguisher in the laboratory 2) One extinguisher in OR 1 3) One extinguisher in OR 3 4) One extinguisher in OR 4 5) One extinguisher in OR 6 6) One extinguisher in sterile storage in the operating room area While on tour, Employee #1 confirmed there was no fire extinguisher within 50 feet of the generators and Employees #10 and 14 acknowledged the extinguishers were obstructed in the operating rooms.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 45167 Based on observation, interview and review of facility documentation, it has been determined the facility has failed to maintain HVAC equipment. Failure to maintain HVAC equipment can result in aggravation to patients’ medical conditions and discomfort for patients and staff. NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, “Heating Ventilating and Air Conditioning.” Section 19.5.2.1 “Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture’s specifications” Section 9.2.1 “ Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment.” Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 91. NFPA 91 Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, Chapter 10, Maintenance Program, Section 10.6.1 indicated, “....All system components shall be maintained in good operating condition....” Section 10.6.5 indicated: “...Serious deficiencies shall require immediate attention....” Findings include: Based on observation while on tour, review of facility documentation and interview, the Department has determined the Administrator failed to ensure that the hospital HVAC systems were maintained in working order. Failure to ensure that the HVAC system is maintained in working order can result in discomfort for staff and patients and can result in adverse outcomes for patients. Findings include: Air Handler Unit 4/VFD (Variable Frequency Drive) Document titled, “ ...Event Report ....” revealed: “ ...Occurrence Date ...01/06/2025 ...Report Date ...01/16/2025 ...Nature of Service Failure ...Temperature of Environment ...Description of event ...01-26-2025 Sorry computer crashed ...It was freezing cold ...had one blanket but wanted another blanket ...Patient was on the floor in the ED with only one blanket ...Offer our sincere apologize [sic] ...Investigation findings ...02-03-2025 ED was on Red level surge and staffing issues, we attempt to do our best ...02-05-2025 ...Thanks for your review ....” “ ...Northwest Medical Center Request ....” documents revealed: Dated 09/25/2024: “ ...Temp controller broken ...ED 9 ...Room is not warming up; thermostat hissing and not adjusting ...comments ...replaced t-stat ....” Dated 10/31/2024: “ ...Check damper, thermostat not working blows cold air ...ED offices ...comments ...opened damper ....” Dated 10/31/2024: “ ...ED Ancillary very cold ...comments ...opened damper ....” Dated 01/20/2025: “ ...Cold offices in ED Admin hall. Check all t-stats. See floor plan ...Raised ahu temp ....” Dated 01/31/2025: “ ...ER rooms 9, 10 and 15 are too cold ...comments ...Raised AHU temp ....” A tour was conducted of the Emergency Department on 02/20/2025 beginning at 10:33 a.m. The majority of staff observed in the Emergency Department while on tour were wearing jackets. Patients were observed to be lying in gurneys inside the ambulance entrance which registered the lowest temperature reading of 62.7°F. At this time, the outdoor temperature was 61°F. A total of 24 environmental temperatures were taken in the Emergency Department with the highest and the lowest temperatures removed.: 1. BH1-BH6 65.4 2. BH1-BH6 behind nurse’s station 66.9 3. Outpatient entrance 67.6 4. Waiting room between outpatient and ER 66.3 5. Small waiting room, outpatient 65.8 6. Registration 66.2 7. Emergency room desk 64.7 8. Ancillary bed 3 65.6 9. Ancillary bed 9 65.8 10. 67.2 Hallway clean utility (ER) 11. Triage bed 2 66.0 12. Triage behind the ED desk 65.6 13. Exam Room 1 doorway 65.3 14. ER nurse’s station 71.0 15. Ambulance entrance 62.7 16. ER Room 10 63.6 17. Room 14 65.3 18. Nurse’s station by room 18 63.5 19. Room 19 64.2 20. Room 23 64.2 21. Room 27 64.2 22. Room 28 63.3 23. Room 30 64.2 24. Check-out desk 69.9 The average of 22 temperatures taken in the Emergency Department was 65.2°F. The lowest and the highest temperatures were removed prior to temperatures being averaged. Upon return to Northwest Medical Center on February 26, 2025, Employees #1 and #10 indicated a desire to utilize their own temperature gun. A side-by-side test was conducted throughout the hospital which indicated the calibrated gun utilized by Northwest Medical Center staff monitored temperature at about 2 degrees higher. Had this temperature gun been utilized, it is possible the average temperature would have instead registered at 67.2°. An interview was conducted with Employee #1. Employee #1 stated that the VFD (Variable Frequency Drive) had died and it had taken six weeks to get a needed part. Employee #1 stated they had wanted to initiate the repair but a “cold snap” had occurred and because the repair would have required the VFD to be non-operational for four (4) hours, Employee #1 deferred the repair for when the weather improved. Employee #1 stated that until then the VFD was put at a constant fan speed. Compliance Officer asked, wouldn’t a constant fan speed have made the environment colder? Employee #1 explained that it was better to have the VFD on than off and the temperature could still be controlled. Employee #1 stated that the central computer, known as the Building Automation System (BAS) monitored the temperature; however, the temperature was set by the staff. Employee #5 stated he/she set the temperature in the 50s “because we are in Arizona.” Employee #1 stated that the temperature was checked daily and adjustments could be made manually. Compliance Officer asked if these daily temperatures were logged, and initially Employee #1 stated they were logged and could be provided but later Compliance Officer was informed there was no historical data available. Compliance Officer asked what was being done when work orders were being received and/or complaints regarding the temperature being too cold. Employee #1 stated an employee would be sent to see if there was an actual temperature issue and if there was, the first line of defense was to check the thermostats to see if there was a thermostat not functioning properly. If not, other adjustments could be made. A subsequent interview was conducted on February 26, 2025 with Employee #13 who stated, “We didn’t ignore the problem.” Employee #13 confirmed that adjustments were made in response to employee complaints. Employee #13 indicated he/she had noted some of these temperature adjustments and provided a copy of handwritten notes indicating temperature adjustments made to the CT (computed tomography) room, twice on 11/20/24, once on 11/22/24, once on 12/2/24, once on 12/3/24 and once on 12/5/24; however, the CT room is in a separate area than the Emergency Room and Outpatient and the complaints verbalized by the staff of CT was that the temperature was too warm. Two additional temperature adjustments were noted by Employee #13 on 12/4/24 and 01/09/25, but the location of these temperature adjustments were not logged. Email communications regarding the VFD repairs revealed the following: From third-party service to Employee #1 dated 12/30/2024: “ ...See below for the dates we have available for the installation for the VFD on AHU 4 ...1/9 ...1/10 ...Or any day between 1/14-1/16 ...This will be approx ...4-hour shutdown ....” From Employee #5 to third-party service dated 12/31/2024: “ ...We will need to put HEPA filters and fans in the space during the shut down ....” On February 5, 2025 at 8:55 a.m., Employee #5 contacted third-party service regarding a different repair. Third-party service responded at 9:28 a.m. with this question: “ ...Hate to keep asking but when do you want to do the VFD on AHU3. Everything is on site waiting for a shutdown ....” Employee #5 9:31 a.m. response: “ ...AHU3-Is this 3 (Cath lab) or 4 (ED)?....” Third-party service 9:33 a.m. response: “ ...Women’s center AHU4 ....” Employee #5 9:37 a.m. response ...How long do you need to do the repair?....” Third-party service 9:38 a.m. response: “ ...4 hrs ....” Employee #5 9:52 a.m. response: “ ...My team is telling me this should be AHU for the ED. We do not have VFD issues at the WC. How much notice do you need? The weather is much warmer this week ....” Third-party service 11:40 a.m. response: “ ...This was an old job that we’ve been trying to get closed out but wasn’t being allowed to do the work. See attached ....” Employee #5 12:04 p.m. response: “ ...So what POs do we still have open? Do we need to regroup?...AHU4-ED needs new VFD ....” Third-party service response: “ ...We probably need to sit down and go over open items. We can set something up later this week or next week ....” Heat Exchanger/Hot Water Pump In the interview with Employee #1, Employee #1 further explained that the hospital heating hot water system also required repair but had not yet been repaired because Employee #1 was waiting for parts from third-party service. Employee #5 expected the repair to be executed on Tuesday, February 25. Employee #1 provided a summary which indicated: “ ...Background ...The heating system runs on steam and hot water. The steam is generated in the boilers and sent to a heat exchanger. This heat exchanger is where the steam transfers its heat to the heating water system. The heating water is then pumped out to the floors to fan oil units and air handlers to keep occupants warm. This system consists of one heat exchanger and two pumps ...Assessment ...The tubes that separate the steam from the water inside the heat exchanger are corroded. We know this because we are getting steam in our heating water system. This overheating and steam in the wrong pipes cause system and pump failure. Pump #1 has been damaged by the excessive heat and needs to be replaced. We are currently only running on Pump #2 ....” “ ...TDI Industries ....” Scope of Work dated October 22, 2024 revealed: “ ...NWMC-CP1 Replace HWP-2 & Seal Replacement for HWP-1 ....” Scope of Work dated October 10, 2024 revealed: “ ...NWMC CP1, West HX Repairs ....” Scope of Work dated October 10, 2024 revealed: “ ...NWMC Replace HX-1 Tube Bundles with gaskets ....” Email from third-party service to Employee #5 dated 02/18/2025 indicated: “ ...This is scheduled for next Tuesday for the installation of the heat changer ....” An attempt was made to repair the heat changer on February 25, 2025, but the HX-1 tube bundle arrived damaged and could not be installed. Boiler #2 On September 29, 2022, Factory Mutual Insurance Company conducted an inspection and indicated in a report dated October 1, 2022 that Boiler #2 had leaking and warped tubes. On November 7, 2022, Employee #1 sent an email to Employee #15 to discuss repairs that needed to be made to the hospital. Employee #1 stated: “ ...Also, we just found out, and are waiting for the official report, that boiler #2 needs to be replaced and cannot be rebuilt ...We have been told verbally that ...recommendation is for full replacement ....” Employee #15 responded on November 8, 2022: “ ...I have to get this finalized and submitted, so we must make some tough decisions. I think starting on the elevators and the boiler is the priority. A big part of our dilemma is that we have projects rolling over into 2023. In your case, there is currently $468,748 still waiting to be spent on Chiller 4. Essentially, I am having to pull this amount out of the ‘22 and ‘23 budgets! If you add that rollover amount to our proposed ‘23 budget, it means I am putting close to $1.5M into NMC Tucson which we really can’t afford to do ....What is the absolute priority that can affect patient care and keeps you up at night?....” On November 9, 2022, Employee #1 responded: “ ...See details below. As we delay these projects we are creating a bottleneck of funds for future years to come. As we slowly tackle these big dollars issues more will arise just pushing the state of the aging and soon to be obsolete infrastructure down the road. ...I will take every dime you can send my way to help avoid, and improve,t he current state we are in at Northwest Medical ...McCcok [sic] has recommended that we replace boiler #2 for reasons stating in other emails ...The verbal estimate today is 600k ...Lead times are a couple of months and should be ready for install over the summer of 2023. Note-boiler #1 is the same age as boiler #2 ....” Employee #15 responded on November 11, 2022 “ ...Thanks ...You didn’t answer my questions on how you want to prioritize. I am putting down the boiler #2 ....” A Contractor Authorization to Proceed was issued on February 15, 2023. The boiler was installed December 27, 2023.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour, it has been determined the facility failed to appropriately label medical gas piping. Failure to appropriately label medical gas piping can result in confusion or error. NFPA NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 5, Section 5.1.11.1 Pipe Labeling indicated: “...Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, or the vacuum system and include the following...Name of the gas or vacuum system or the chemical symbol per Table 5.1.11...Gas or vacuum system color code per Table 5.1.11...the operating pressure...Pipe labels shall be located as follows...At intervals of not more than 6.1m (20ft)....” 5.1.11.1.3 indicated: “...Medical gas piping shall not be painted....” Findings include: Observation while on tour conducted on February 25, 2025 in the medical vacuum/medical piping areas revealed medical gas piping that was painted pink, yellow, blue, white and green. Although the piping was observed to be labeled with stenciling indicating the purpose of the piping, this stenciling was not observed to occur every 20 feet. Employee # 10 conformed while on tour that the Med gas piping was painted and not labeled properly.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation during the tour and interview, the facility failed to maintain electrical receptacles in patient areas and offices throughout the facility. Failure to maintain receptacles could result in them not working or electrical problems. NFPA 101 Life Safety Code, 2012 Edition, Chapter 9, Section 9.1.2 “Electrical Systems. Electrical wiring and equipment shall be in accordance with NFAP 70, National Electrical Code, unless shch installations are approved existing installations, which shall be permitted to be continued in service.” NFPA 70, 2011, Chapter 4, Section 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess mounted receptacle shall effectiviely close the opening and seat against the mounting surface.” Findings include: Observation while on tour conducted on February 25, 2025, revealed: -Two receptacles with broken covers in room 475 -One receptacle hanging by wires in Telemetry area -One receptacle hanging by wires in Laboratory area -One junction box in Laboratory under a desk missing a face plate -One receptacle face plate missing in room near Operating Room 7 -Life safety receptacle installed over sink taped over with no explanation In an interview conducted with Employee #10 while on tour, Employee #10 confirmed the findings. During an exit interview conducted on February 26, 2025, the deficient items were acknowledged by administrative staff.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it was determined that the facility allowed the use of power strips but did not mount to the equipment in the operating rooms. Failure to properly use power strips and outlets could lead to electrical overload or fire, harming the patients and staff. NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 “Mandatory References” NFPA 99 “Standard for Health Care Facilities, “ 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , “All Patient Care Areas,” Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)” Minimum Number of Receptacles.” “The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. CMS S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as reference for healthcare surveyors as they survey physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation. If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity: o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1 o Power strips cannot be used for non-medical equipment If line-operated medical equipment is used in a patient care room/area, outside the patient care vicinity: o UL power strips could be used for medical & non-medical equipment with precautions as described in the memo o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1 o Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363 If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity: o UL power strips could be used with precautions Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363. In non-patient care areas/rooms, other UL strips could be used with the general precautions. Findings include: Observations conducted while on tour February 25, 2025 revealed that Operating Rooms 2, 3, 4, 6 and 9 had power strips that were not mounted to a rack, table, pedestal, or cart-mounted and tested medical equipment assembly. Employees # 10 and #14 confirmed the improper use of power strips by not having them permanently mounted to equipment in the operating rooms.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 45167 Based on observation while on tour and interview, it has been determined the facility failed to ensure that positive-pressure gases are properly and securely stored. Failure to securely and properly store positive-pressure gases can result in a fire, leading to potential harm to patients or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 “Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.” NFPA 99 2012 Edition Chapter 11, Section 11.2, Subsection 11.2.1 indicated, “...Cylinders and containers shall comply with 5.1.3.1....” Section 5.1.3.1, Subsection 5.1.3.3.2 Design and Construction indicated: “...Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:...(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits...New to the 2012 edition is this requirement for outdoor storage enclosures to have two entries/exits. This requirement is intended to address the situation where, if a person was in the enclosure and an event occurred taht prevented egress via the one opening, the person could exit via the other opening. The most common form in which this requirement will be implemented will be placing two gates in a chain-link fence surrounding a bulk system....” NFPA 99 Section 5.1.3.1 Subsection A.5.1.3.3.2(7) indicated: “...They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty...Paragraph 5.1.3.3.2 (7) is a change to the 2002 requirement for individual securing of the cylinders. In the 2005 edition, the standard returned to the more relaxed “secure all cylinders” which permits, for instance, the single chain around multiple cylinders, which was common practice prior to the 2002 edition...Exhibit 5.3 illustrates two arrangements: one in which the cylinders are secured properly, and one in which the cylinders are not secured properly....” Findings include: During observation while on tour on February 25, 2025, four outdoor medical gas enclosures were observed: one area where nine (9) CO2 canisters were connected to a regulator outdoors located next to the main hospital building, and three separate but connected enclosures behind the hospital building constructed out of chain-link fencing that contained: 1) Bulk oxygen; 2) Assorted positive-pressure canistered medical gases; 3) empty canisters of medical gas and medical gas cabinets. None of these enclosures had two entries and exits. The photo pictured in NFPA 99 Exhibit 5.3 of improperly secured cylinders depicts seventeen (17) cylinders secured behind a single chain. During observation while on tour conducted on February 26, 2025, within the outdoor medical gas enclosures, six (6) medical gas canisters were observed to be secured in a triangular formation by a single chain. Twenty-two (22) assorted medical gases were observed to be in a cluster formation and secured by a single chain. Two (2) canisters appeared to be unsecured. In an interview conducted with Employee #10, Employee #10 confirmed that the outdoor enclosures did not possess two separate entries or exits. In an exit interview conducted on February 26, 2025, the deficient practices were acknowledged by administration staff.”

“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: 25065 Based on policy review, patient medical record reviews, and interviews, the hospital failed to comply with § 489.24(d)(5) by failing to have documentation of the description of the proposed transfer, the risks and benefits of the transfer, and the reasons for the individual’s refusal for one (Patient (P) 19) of three patient records reviewed for appropriate transfer from a sample of 20 patient records. This deficient practice had the potential to affect all ED patients requiring transfer that could result in the patient experiencing a deterioration in his/her medical condition. (See findings in A2408).”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 25065 Based on policy review, review of patient medical records, and interviews, the hospital failed to have documentation of the description of the proposed transfer, the risks and benefits of the transfer, and the reasons for the individual’s refusal for one (Patient (P) 19) of three patient records reviewed for appropriate transfer from a sample of 20 patient records. This deficient practice had the potential to affect all ED patients requiring transfer that could result in the patient experiencing a deterioration in his/her medical condition. Findings include: Review of the hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” revised 07/14/22, indicated “. . . The purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA), the regulations and rules promulgated thereunder, and the State Operations Manual interpretive guidelines. . .. If a patient accepts the transfer but refuses the facility’s recommendation and offer of an appropriate means of transportation electing to travel by other means . . . then the risks associated with such a disposition must be thoroughly explained to the patient and documented. If the patient still insists on traveling by other means then the facility should take all reasonable steps to obtain the patient’s or the patient representative’s refusal and certification in writing using the Patient Transfer Form. The completed form must be filed in the patient’s medical record and the disposition of the patient may be indicated as Transferred, but should never be indicated as “discharged. . .” Review of the hospital’s “Patient Transfer Form” indicated Section C included “Refusal of Recommended Transport Medical Risks of Refusing Medical Transport: The risks of refusing transport as recommended have been explained to me by a member of the medical staff and I understand them to be as follows: [box to check before each of the following] Deterioration/worsening of my condition(s), Lack of life-saving equipment, Additional pain or suffering, Permanent disability/disfigurement/loss of limb, organ, or function, Death (self or unborn fetus), Delays in getting to the other hospital or failure to arrive at the other hospital due to traffic, motor vehicle accident, or inability to drive, Other (specific to patient’s emergency medical condition, e.g. [such as] heart attack, stroke, loss of oxygen, etc. [and so on]: Certification of Refusal and Release: This to certify that I refuse to go to the receiving hospital by the recommended transport. This is my choice and I understand this choice is against the medical advice/recommendation of the emergency physician. I accept personal responsibility for all harm or disability I may suffer from this refusal. . .” Review of P19’s medical record indicated P19 presented to the ED on 11/03/24 at 5:52 PM. Review of the P19’s ED record indicated he/she was a six-year-old brought in by his/her father who stated P19 was jumping on the bed, fell off, and landed on his/her left arm and was complaining of left elbow pain. Review of P19’s x-ray report indicated P19 had a “complex distracted supracondylar fracture dislocation injury of left elbow.” Review of Phys9’s documentation on 11/03/24 at 7:03 PM indicated “. . . Patient is neurovascular intact able to radially deviate the wrist extend the wrist there is no sensory deficits patient though will likely need urgent surgical intervention as such I have contacted TMC Hospital [name of physician] pediatric orthopedics who is agreeable to accept patient for transfer for surgical intervention. I have contacted the hospitalist [name of physician] is expecting patient for transfer and admission to the hospital for surgical intervention of significant supracondylar fracture patient neurovascularly intact splinted and transferred. Review of P19’s “Patient Transfer Form” indicated P19’s mother signed the “Certification of Refusal and Release” on 11/03/24. Review of the form indicated no boxes were checked in Section C indicating which medical risks for refusing emergency transport had been discussed with P19’s parents. There was no documentation indicating P19’s parent’s reasons for the refusal of transfer by ambulance, and the medical record did not contain a description of the risks and benefits of the proposed transfer that was refused on behalf of the patient. During an interview on 12/06/24 at 1:00 PM, NA Mgr. confirmed no risks were checked on P19’s “Patient Transfer Form,” and there was no documentation of the risks and benefits of the proposed transfer that were refused.”

“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: 48110 Based on record reviews and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases when a patient arrived at the hospital emergency department by ambulance for evaluation and treatment (Patient #1). Findings include: Hospital policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)”, revealed: “ ...Definitions ...Ambulance Parking occurs when hospital staff refuses to release EMS staff or equipment and prevents EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, thereby delaying the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS ....II. Medical Screening Examination. A. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....Patients will be asked to remain in waiting areas until they are called for the MSE ...B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay. Ambulance Parking is never appropriate and could result in an EMTALA violation ....” Review of Patient #1 medical record revealed Hospital #2 had accepted Patient #1 as an ED to ED transfer from Hospital #2. Further review of the medical record revealed the hospital failed to provide a Medical Screening Examination (MSE) to Patient #1 upon Emergency Department by ambulance. Employee #6 confirmed during an interview conducted on 03/06/2024 that Patient #1 was an accepted transfer from Hospital #2 with diagnosis of NSTEMI, arrived by ambulance, and triaged with acuity of 3. Employee #6 also confirmed Patient #1 waited for more than two hours for a bed. Employee #6 further confirmed Patient #1 medical screening examination was delayed.”

“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: 48110 Based on record reviews and staff interviews, it was determined that the hospital failed to provide an appropriate Medical Screening Examination to (8) out of twenty (20) patients who presented to the ED for examination and treatment (Patients #1, #2, #4, #9, #10, #12, #14, #19). Findings include: Hospital policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)”, revealed: “ ...Definitions ...Ambulance Parking occurs when hospital staff refuses to release EMS staff or equipment and prevents EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, thereby delaying the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS ....II. Medical Screening Examination. A. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....Patients will be asked to remain in waiting areas until they are called for the MSE ...B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay. Ambulance Parking is never appropriate and could result in an EMTALA violation ....” Hospital policy titled, “Refusal for Treatment - AMA”, revealed: “ ...Definitions: ...3. Left With Out Treatment (LWOT): patient presents seeking care but leaves before being seen or treated by a physician ....Instructions: ...5. Left Without Treatment (LWOT) ...a. LWOTS include patients who leave before triage (LBT) and patients who leave prior to Medical Screening Exam (LPMSE) ...b. If a patient verbalizes they cannot wait to be seen either prior to triage or after triage but prior to the Medical Screening exam, if possible, an attempt is made for the UC/ED/OB nurse to talk with the patient prior to their departure ....” Hospital document titled, “ED Throughput Committee Meeting” dated 02/15/2024, revealed: “ ...I. Last Month Metrics: (January 1 - January 31) ...Door to Triage 10 min ...Door to provider (doctor) 138 min (PA) 90 min ...IV Current Topics: ...Concern for Flow: It seems as though providers are signing up for MSE’s but taking a very long time to see the patient and then later review the results and dispo the patients ....” Hospital document titled, “NW Tucson ER January Department Meeting” dated 01/2024, revealed: “ ...Current Metrics ...Average Arrival to Provider Exam Minutes ...Goal 20 mins ...6-Jan ...135 ...13-Jan ...109 ...20-Jan ...127 ...27-Jan ...97 ...MTD ...118 ....” Review of Patient #1’s medical record from Hospital #2 dated 01/23/2024 revealed: “ ...Date of Visit: 01/23/2024 15:28 ...Visit CC: Fall Injury ...IVPB Medication Administered: Heparin ...Dose: 570Units/Hr ...Rate: 15.7ml/hr ...Date/Time Stopped: Heparin infusing at stated rate at the time of transfer out of (Hospital #2) ED ...22:40 - Patient has been received by (Provider #1) at (Hospital #1) with ER to ER transfer ....24-Jan-2024 ...00:45 ...Patient is going direct to ED accepted by (Provider #1). Patient ETA to (Hospital #1) ED is 2.5 hrs from now ....Altered Labs: #1 Trop - 91.5 ...#2 Trop - 217.2 ...D-Dimer 1.97 ...Diagnosis (reason for transfer) NSTEMI, multiple recent falls ...Time Left 01:10 Date 01/24/24 ....” Review of Patient #1’s EMS Runsheet dated 01/24/2024 revealed: “ ...Narrative ...Troponin elevated at 91.5 with repeated Troponin level increased at 217.2 and a D-Dimer of 1.97. Pt was treated with 2 IV access points ...Heparin bolus 2800units at 2130hrs, and continued on Heparin drip of 570units/hr or rate of 15.7ml/hr - IV access site 20ga left A/C. 18ga Right A/C NS Lock. Pt referred to (Hospital #1) ED, accepting physician (Provider #1) for non-STEMI and multiple falls ....(Hospital #1) contacted at 0115hr with pt’s ETA ....Continued on Dx drip of 15.7ml/hr ....(Hospital #1) recontacted at 0232hrs with pt’s 15 min ETA. Upon arrival pt transported in on stretcher with Heparin IV pump and cardiac monitor. Pt registered with charge RN and was directed to wait in the hall. (Hospital #1) performed an initial 12-lead assessment approx. 30min after arrival. Awaited for a room till 0445hrs. Approx 2 hours and 50minutes wait time ....RN ...arrived and received report. Heparin drip clamped off and taken off IV pump. RN advised ....Arrive Dest: 01/24/2024 02:41 ...Signatures ...Printed Name: RN ...(Hospital #1) ED ...Signature Reason: Transfer of Patient Care ...Date/Time of Signature: 01/24/2024 04:52 ....” Review of Patient #1’s medical record from Hospital #1 dated 01/24/2024 revealed: “ ...ED Events Information ...Arrive ...02:56 ...Triage ...02:56 ...Bed Assign ...05:01 ...Quick Triage ...Chief Complaint ...Transfer from (Hospital #2) Presented to (Hospital #2) ER for multiple falls, dx with NSTEMI. On heparin gtt at 11.9u/kg/hr ...Mode of Arrival: Ambulance ...Systolic Blood Pressure: 162mmHg ...Diastolic Blood Pressure: 89 mmHg ...Time seen: ...05:44 ...History of Presenting Illness ...Patient’s [niece] reports [she] went to the restroom and could not get up and fell ...unaware if [she] lost consciousness but this is not the first time that this has happened before. Patient presenting without any chest pain, shortness of breath ...Medical Decision Making ...had a ground-level fall and was seen at an outside hospital. They did not identify any evidence of trauma, and were going to release [her], but [her] troponin came back elevated ...transferred here for evaluation by cardiology for an NSTEMI ...EKG was reassuring without evidence of ischemia. No evidence of STEMI at this time ....Pt arrived from outside hospital on a Heparin drip ....Cardiac Markers ...Troponin HS ...Collected Date/Time ...1/24/2024 05:30 ...Result ...399.9 ...Reference Range [0.0-54.0] ...Troponin HS ...Collected Date/Time ...1/24/2024 10:14 ...Result ...309.3 ...Reference Range [0.0-54.0] ....” A total of 20 ED medical records were randomly selected for review including patients who were transferred, admitted, discharged home, or left before medical screening examination (MSE). Review of 20 ED medical records revealed seven (7) patients did not receive a MSE. 1. Patient #2, arrived 02/01/2024 03:27, triaged 03:28, ESI 3, LWOT 04:25, Time elapsed: 58 minutes 2. Patient #4, arrived 02/05/2024 19:55, triaged 20:03, ESI 3, LWOT 22:31, Time elapsed: 2 hours 36 minutes 3. Patient #9, arrived 01/03/2024 15:11, triaged 15:46, ESI 4, LWOT 19:23, Time elapsed: 4 hours 12 minutes 4. Patient #10, arrived 01/04/2024 03:13, triaged 03:18, ESI 3, LWOT 08:05, Time elapsed: 4 hours 42 minutes 5. Patient #12, arrived 01/14/2024 19:17, triaged 19:32, ESI 4, LWOT 23:03, Time elapsed: 3 hours 46 minutes 6. Patient #14, arrived 01/24/2024 01:37, triaged 02:14, ESI 3, LWOT 04:20, Time elapsed: 2 hours 43 minutes 7. Patient #19, arrived 12/19/2024 12:24, triaged 12:36, ESI 3, LWOT 14:50, Time elapsed: 2 hours 26 minutes Employee #6 confirmed during an interview conducted on 03/06/2024 that Patient #1 was an accepted transfer from Hospital #2 with diagnosis of NSTEMI, arrived by ambulance, and triaged with acuity of 3. Employee #6 also confirmed Patient #1 waited for more than two hours for a bed. Employee #6 further confirmed Patient #1 waited 2 hours and 48 minutes for a medical screening examination. Employee #6 further confirmed Patient #1 medical screening examination was delayed. Employee #7 confirmed during an interview conducted on 03/06/2024 that the door to doctor time in the ED was 60.01 minutes two weeks ago, and 32.07 minutes one week ago. Employee #6 and Employee #7 also confirmed there was a long wait time to see a provider in the ED, and patients would leave before receiving a MSE.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for one (1) patient (Patient #1), who was an accepted transfer from another hospital, and presented to the Emergency Department via Emergency Medical Services (EMS) transport. Findings include: Hospital policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)”, revealed: “ ...Definitions ...Ambulance Parking occurs when hospital staff refuses to release EMS staff or equipment and prevents EMS staff from transferring patients from the ambulance stretcher to a hospital bed or gurney, thereby delaying the Medical Screening Examination or stabilizing treatment of a patient who arrives via EMS ....II. Medical Screening Examination. A. Triage and Registration of Patients Prior to Medical Screening Examination (MSE) ...The triage nurse takes and documents vital signs, along with any other relevant observations, and assigns the patient an acuity level (ESI) that dictates the order in which the patient will be seen ....Patients will be asked to remain in waiting areas until they are called for the MSE ...B. Medical Screening. When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED ...shall be provided to determine whether an emergency medical condition (EMC) exists ...The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay. Ambulance Parking is never appropriate and could result in an EMTALA violation ....” Review of Patient #1’s medical record from Hospital #2 dated 01/23/2024 revealed: “ ...Date of Visit: 01/23/2024 15:28 ...Visit CC: Fall Injury ...IVPB Medication Administered: Heparin ...Dose: 570Units/Hr ...Rate: 15.7ml/hr ...Date/Time Stopped: Heparin infusing at stated rate at the time of transfer out of (Hospital #2) ED ...22:40 - Patient has been received by (Provider #1) at (Hospital #1) with ER to ER transfer ....24-Jan-2024 ...00:45 ...Patient is going direct to ED accepted by (Provider #1). Patient ETA to (Hospital #1) ED is 2.5 hrs from now ....Altered Labs: #1 Trop - 91.5 ...#2 Trop - 217.2 ...D-Dimer 1.97 ...Diagnosis (reason for transfer) NSTEMI, multiple recent falls ...Time Left 01:10 Date 01/24/24 ....” Review of Patient #1’s EMS Runsheet dated 01/24/2024 revealed: “ ...Narrative ...Troponin elevated at 91.5 with repeated Troponin level increased at 217.2 and a D-Dimer of 1.97. Pt was treated with 2 IV access points ...Heparin bolus 2800units at 2130hrs, and continued on Heparin drip of 570units/hr or rate of 15.7ml/hr - IV access site 20ga left A/C. 18ga Right A/C NS Lock. Pt referred to (Hospital #1) ED, accepting physician (Provider #1) for non-STEMI and multiple falls ....(Hospital #1) contacted at 0115hr with pt’s ETA ....Continued on Dx drip of 15.7ml/hr ....(Hospital #1) recontacted at 0232hrs with pt’s 15 min ETA. Upon arrival pt transported in on stretcher with Heparin IV pump and cardiac monitor. Pt registered with charge RN and was directed to wait in the hall. (Hospital #1) performed an initial 12-lead assessment approx. 30min after arrival. Awaited for a room till 0445hrs. Approx 2 hours and 50minutes wait time ....RN ...arrived and received report. Heparin drip clamped off and taken off IV pump. RN advised ....Arrive Dest: 01/24/2024 02:41 ...Signatures ...Printed Name: RN ...(Hospital #1) ED ...Signature Reason: Transfer of Patient Care ...Date/Time of Signature: 01/24/2024 04:52 ....” Review of Patient #1’s medical record from Hospital #1 dated 01/24/2024 revealed: “ ...ED Events Information ...Arrive ...02:56 ...Triage ...02:56 ...Bed Assign ...05:01 ...Quick Triage ...Chief Complaint ...Transfer from (Hospital #2) Presented to (Hospital #2) ER for multiple falls, dx with NSTEMI. On heparin gtt at 11.9u/kg/hr ...Mode of Arrival: Ambulance ...Systolic Blood Pressure: 162mmHg ...Diastolic Blood Pressure: 89 mmHg ...Time seen: ...05:44 ...History of Presenting Illness ...Patient’s [niece] reports [she] went to the restroom and could not get up and fell ...unaware if [she] lost consciousness but this is not the first time that this has happened before. Patient presenting without any chest pain, shortness of breath ...Medical Decision Making ...had a ground-level fall and was seen at an outside hospital. They did not identify any evidence of trauma, and were going to release [her], but [her] troponin came back elevated ...transferred here for evaluation by cardiology for an NSTEMI ...EKG was reassuring without evidence of ischemia. No evidence of STEMI at this time ....Pt arrived from outside hospital on a Heparin drip ....Cardiac Markers ...Troponin HS ...Collected Date/Time ...1/24/2024 05:30 ...Result ...399.9 ...Reference Range [0.0-54.0] ...Troponin HS ...Collected Date/Time ...1/24/2024 10:14 ...Result ...309.3 ...Reference Range [0.0-54.0] ....” Employee #6 confirmed during an interview conducted on 03/06/2024 that Patient #1 was an accepted transfer from Hospital #2 with diagnosis of NSTEMI, arrived by ambulance, and triaged with acuity of 3. Employee #6 also confirmed Patient #1 waited for more than two hours for a bed. Employee #6 further confirmed Patient #1 waited 2 hours and 48 minutes for a medical screening examination. Employee #6 further confirmed Patient #1 medical screening examination was delayed.”