Banner-University Medical Center South Campus

“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: 52995 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: Hospital policy titled: “EMTALA - Medical Screening Examination and Stabilization” revealed” ...Purpose: Banner Health ...”The MSE is an ongoing process requiring continuing monitoring based upon the Patient ’ s needs and must continue until the EMC is stabilized or the patient is admitted or appropriately transferred.6. An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals Refusal of Examination/Treatment or Transfer. 1. If an individual or his/her Representative has refused examination/treatment or Transfer, the following will occur: a. The individual will be informed of the Hospital ’ s obligations under the EMTALA law, and the willingness of the Hospital to provide a MSE and render Stabilizing Treatment. b. The risks and benefits of refusing Stabilizing Treatment are explained by the physician or QMP. c. The Refusal of Treatment or Transfer form is signed, indicating what aspects of care are refused, the risks of refusal and the reasons for the refusal. If the individual/Representative refuses to sign, documentation relative to the above is noted in the medical record along with the steps taken to try to secure the written informed refusal. Record Keeping Requirements. The Hospital is required by law to maintain all forms, records, and other documentation required under this Policy for a minimum of five (5) years, including, but not limited to: a. On-Call Physician Lists, maintained by the Hospital and reflecting the specialties routinely available at the Hospital; b. All Refusal of Examination, Treatment or Transfer forms and Certification of Transfer forms, completed as appropriate ....”; Request was made for PO Oral Fluid Challenge Policy/Protocol/Guidelines. None was provided by the hospital. Review of hospital document Standing Order for Nurses titled “SO ED Pediatric Nausea/Vomiting” revealed “...if lethargy, POCT by Nursing Glucose ....” Review of patient #15 medical record revealed no documentation for physician orders for diagnostic exams, no physician documentation of consults with other disciplines, such as pediatric specialists. Review of Medical record of patient #15 revealed there was no documentation of glucose check on patient #15 who was described as “...lethargic ....” Further review of patient #15 medical record revealed no documented refusal of the Medical Screening exam by parent/guardian and no documented refusal of treatment by parent/guardian. Parent/Guardian of patient #15 confirmed that no Physician during the ED visit recommended labs, xrays or treatment other than the zofran ....” Review of medical records of 19 additional Emergency Department patients randomly selected from ED logs February 2025 through April 2025 was conducted. Review of 6 patients of 20 ED records (#6, #10, #13,#15,#16,#20). Review of Medical record for patient #6, #10, #13,#15,#16,#20, revealed patients with chief complaint of Nause/Vomiting /Diarrhea, no IV fluids provided, patients given a “PO challenge” prior to discharge. Patient charts revealed no Oral Intake or urinary Output documented during ED treatment prior to discharge. During an interview with employee #3 and employee #4 patient with signs and symptoms of Nause/Vomiting/Diarrhea are often given a “PO challenge” Employee #3 and Employee #4 describe a “PO challenge” as providing the patient with an antiemetic and a period of time for observation that the patient is tolerating PO fluids prior to discharge”. Employee #3 and Employee #4 confirmed that there is “...no policy or procedure for “PO challenge” No prescribed amount of intake and no prescribed amount of time to observe patients “tolerating fluids” ....” Review of Hospital document “Banner University Medical Center South Campus Medical Staff Bylaws” (last reviewed 2025) revealed “...3.3 BASIC OBLIGATIONS OF INDIVIDUAL STAFF MEMBERSHIP Each staff member, regardless of assigned staff category, and each practitioner exercising temporary privileges under these Bylaws, shall: Abide by the Banner Health Bylaws, these Bylaws, department rules and regulations, and all other standards and policies of the Board, the Medical Staff and Medical Center; Request was made for hospital policy regarding EMTALA training for medical staff and hospital staff. None was provided. Evidence of EMTALA training for medical providers was requested during credential review. Review of Eight (8) medical provider credential files revealed no current EMTALA training in file for employees ,#7,#20, #21,#22, #23,#24,#25,and #26 for the time period of February 2025, March 2025 or April 2025. The last documented EMTALA training was in 2023. An interview with Employee #5 confirmed that the facility does require medical providers to have current/annual EMTALA training. Employee #5 confirmed that no current EMTALA training was on file for medical providers employees #7, #20,#21,#22, #23,#24,#25 and #26 during the time period of February 2025, March 2025 and April 2025, L previous EMTALA training documented was in 2023.”

“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: 52995 Based on review of policies and procedures, hospital documents and staff interviews, it was determined that the hospital failed to provide a complete Medical Screening Examination to a pediatric patient who presented to the ED for examination and treatment (Patient #15) with a 1 week history of Nausea/Vomiting/Diarrhea. Findings Include: Hospital policy titled: “EMTALA - Medical Screening Examination and Stabilization” revealed “...The policy titled “EMTALA - Medical Screening Examination and Stabilization (03/28/2024)” revealed “...5. An MSE will be conducted to determine whether the patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the patient’s needs and must continue until the EMC is stabilized or the patient is admitted or appropriately transferred...8. When an individual comes to the Hospital ’ s Dedicated Emergency Department and requests services for a medical condition that is not of an emergency nature, the Hospital will perform such screening as would be appropriate to determine that the individual does not have an EMC. After such determination is made, the person may be directed elsewhere for services...12. The MSE includes ancillary services routinely available to the Hospital along with available personnel, which includes on-call physicians, in determining whether an EMC exists. Review of hospital document, Nursing Standing Order titled “SO ED Pediatric Nausea/Vomiting” revealed “...if lethargy, POCT by Nursing Glucose....” Review of medical record of patient #15 revealed that patient #15 was registered in the Emergency Department (ED) on 03/19/2025 at 0759 with chief complaint of one (1) week history of nausea,vomiting and diarrhea. A triage note by a Registered Nurse, employee #16, on 03/19/2025 at 0806 revealed “ ...vital signs (in flow charting) HR 170, RR-24,SPO2 94%, room air, unable to obtain BP...skin pallor, dry, cool...general appearance agitated...diarrhea...alert...temp 36.5C....” Further review of patient #15 medical record revealed a medical screening exam (MSE) was initiated on 03/19/2025 at 0821. Further review of the medical record revealed a Resident Provider Note by employee #26, revealed “...Chief complaint POV N/V/D, irritability, decreased activity, & loss of appetite x 1 wk, given “bacterial medicine” in ER yesterday & zofran that pt will not take. Hx autism, non verbal baseline. Decreased amount of wet diapers. Unable to obtain BP d/t pt movement...Hx of Present Illness Patient is 4 y/o..with past medical history of developmental delay secondary to autism spectrum disorder following with developmental pediatrics, presenting today for nausea, vomiting and diarrhea. The patient was reportedly seen in the emergency department on 3/18 and was prescribed an “bacterial medication” as well as Zofran dissolvable tablets. Began experiencing severe diarrhea last Thursday (3/13) which worsened by Friday, leading to her/him being sent home from school. Despite having five siblings, including one in the same classroom, none of them are currently sick. She/he has experienced gastrointestinal disturbances in the past, but not to this extent of rapid weight loss as seen now. Initially she/he was able to eat and drink, but as of yesterday, she/he stopped eating altogether ,although she/he continued to drink from her bottle last night. She/he wears diapers, and there was only one wet diaper yesterday , though the exact number is hard to recall due to the caregiver ’ s responsibilities with five children, including two with autism. There has been no fever reported. Vomiting occurred, with the last episode being yesterday morning. He/ She has been irritable, which is believed to be due to hunger. The caregiver estimates his/her weight before falling ill was approximately 30 pounds. There is noticeable weight loss, as evidenced by more pronounced ribs, sunken eyes and cheekbones....lips appear chapped ...clings to mom ...ED course ...Based on Mom ’ s preillness estimated weight lost approximately 2 pounds ...Vitals notable tachycardia,likely in the setting of acute stress in new environment ......Physical exam technically difficult due to patient’s affect, however, abdominal exam did appear to produce pain or suggest tenderness to palpation, and no masses were appreciated....” Further review of patient #15 medical record revealed a documented weight on 11/26/2024 as 16.12 kg(35.46 lbs), on 03/19/2025 documented weight was 13.1 kg (28.82 lbs), estimated weight loss in that time period (approximately 4 months) is 3.02 kg (6.64lbs). Further review of patient #15 medical record revealed no documentation for physician orders for diagnostic exams, no physician documentation of consults with other disciplines. Further review of patient #15 medical record revealed no documentation that parent/guardian was presented with information regarding diagnostic exams such as laboratory exams, imaging, or potential treatment with Intravenous Fluids (IV) for hydration. Further review of the medical record of patient #15 revealed there was no documentation of glucose check on patient #15 who was described by parent/guardian as “...lethargic ....” Further review of patient #15 medical record revealed no documented refusal of the Medical Screening exam by parent/guardian and no documented refusal of treatment by parent/guardian. Review of Patient #15 medical record from Hospital #2 revealed an Emergency Department provider note dated 03/21/2025 which revealed: “...presenting by EMS for concern of unresponsiveness in the setting of 10 days of nausea, vomiting, diarrhea. Patient was evaluated on 03/18 and 03/19 for symptoms of vomiting and diarrhea. Symptoms started 03/13...{She} has also had some weight loss. Mother states appetite was initially suppressed, however patient has not eaten anything in the last 48 hours.{She} is still drinking milk. Mother states patient is still having wet diapers...Mother laid {her} down this morning around 9:30...Patient then napped and did not wake up. When mother found {her} to wake {her}, {she} was unresponsive...Glucose enroute for EMS of 130’s...Vital signs: T(37.5), HR 162, RR 31 Oxygen flow rate 15 liters per non rebreather mask, Pulse ox 100%, BP 112/74...General: Unresponsive...Neurologic: No spontaneous eye movements, pupils 4 and nonreactive, no clonus, intermittently responds to pain, nonverbal at baseline...Due to patient’s clinical circumstances, we elected to intubate the patient for low GCS and need for airway protection...Differential diagnosis: Ischemic stroke, hemorrhagic stroke, sinus venous thrombosis, seizure, hyponatremia, dehydration, hydrocephalus, hypoglycemia, electrolyte abnormality, viral illness, menigitis, encephalitis, traumatic injury, intracranial mass...Patient was given a 20cc/kg lactated ringers bolus. Initial weight that we were using was 21 kg. Nursing reweighed patient and patient was found to be 13 kg...Basic lab workup initiated...Stat VBG with electrolytes was ordered which was concerning for hypernatremia with a sodium of 163. CMP showed serum sodium of 164. Patient alos had hypercholremia with a chloride of 130. CO2 of 14, and anion gap of 18...Patient had trace thrombocytosis with platelets of 451...Stat CT head imaging was obtained which showed extensive edema of left temporal lobe and right cerebellum with acute infarcts and subarachnoid hemorrhage along the temporal lobe on the left and bilateral cerebellar regions...Chest imaging showed pulmonary embolism...Repeat serum sodium shoed sodium of 158, will hold on any fluid resuscitation at this time...Given concern for hypercoagulability we did elect to add on PT, INR, PTT, DIC panel which are all pending at time of admission...Patient transferred to PICU in critical condition....” Review of Patient #15 medical record from Hospital #2 History and Physical dated 03/21/2025 revealed: “...Chief complaint: BIBA (brought in by ambulance). Pts mom went to check on pt during nap and found pt unresponsive around 1300. LKW (last known well) 0930...Pt responsive to pain only...Hx autism and nonverbal at baseline, + posturing, HR 118-180 bpm, febrile with EMS...Parents report that 10 days ago {she} started to have emesis and diarrhea...They thought it was a stomach bug. Because {she} was not eating or drinking, they brought {her} to the ED for evaluation where {she was prescribed zofran on 03/18. They report {she} continued with emesis, diarrhea, and inability to tolerate PO, so they returned to the ED the next day where {she} was again given a script for zofran. Since then, {she} lost weight and {her} eyes appeared sunken...mom reports this aftenoon after nap became limp and unresponsive...Assessment/Plan: Neuro: Acute infarcts of temporal lobe, right cerebellum, right pons, subarachnoid hemorrhage, concern for increased ICP/herniation...Heme/Onc: multiple infarcts, pulmonary embolism, subarachnoid bleed, microlytic anemia: Unclear cause of coagulopathy at this time...CV: Hypotension, FEN/GI Hypernatremia, dehydration, hypernatremia likely 2/2 dehydration....” Review of Patient #15 Discharge Summary from Hospital #2 dated 03/23/2025 revealed: “...PICU Death Note/Discharge Summary: Admission/Discharge Diagnoses: Ischemic Stroke (Cerebral infarctation), Cerbral cenous sinus thrombosis, Subarachnoid hemorrhage, Pulmonary Emboli, Unresponsive...Admission HPI: 4 year old {female} wiht autism spectrum-nonverbal and iron deficiency anemia who presented via MES afer being found unresponsive by parents following 10 days of emesis and diarrhea...Hospital course by system: 1. Neuro: Multiple acute infarcts...Subarachnoid hemorrhage...Dural sinus thromboses...Concern for increased ICP/herniation...Patient’s sedation was stopped yesterday 03/21 at 2100 and the pateint was not demonstrating any spontaneous breathing, absent brain stem reflexes...They approached the medical team to discuss comfort care measures, which we discussed in full. They opted to change to DNR, stop meds except pain medication and extubate, favoring comfort care measures only. {She} was extubated at 23:45 and placed in mother’s arms. Time of death was called at 0003....” Review of Patient #15 Autopsy Final Report from Hospital #2 dated 04/25/2025 revealed: “...Final Diagnosis: 1. Hypercoagulation in the setting of gastroenteritis( See Comment)...A. Cerebral venous sinus thrombosis, wein of Galen, straight sinus, left transverse sinus..B. Pulmonary embolism, right and left lungs, segmental and subsegmental arteries...C. Thrombus, right common and external iliac veins...D. Dehydration, per medical record: 1. Hypernatremia per medical record, 2. Hyperchloremia, per medical record...E.Dilatation of descending colon...F. Prolongation of activated partial thromboplastin tiume...G. Prolongation of dilute Russell biper venom time...Comment: The present clinical, laboratory, and postmortem examination findings are consistent with an acquired ot otherwise unmasked prothrombic disorder such as antiphospholipid antibody syndrome. Such antibody-driven prothrombotic disorders may manifest following viral infection, and may be exacerbated by dehydration with resultant hemoconcentration...Case Information: A complete autopsy was performed on 03/24/2025 at 1000....” Review of medical records of 19 additional Emergency Department patients randomly selected from ED logs February 2025 through April 2025 was conducted. Review of 20 ED records revealed 6 pediatric patients (#6, #10, #13,#15,#16,#20) with chief complaint of Nausea/Vomiting /Diarrhea, received antiemetic medication and given Per Oral (PO) fluids prior to discharge. Review of medical records for Patient #6,#10,#13,#15,#16,#20 revealed no oral Intake or urinary Output documented during ED treatment prior to discharge. During a tour of the Emergency Department (ED) on 03/10/2026, a triage Registered Nurse (RN) employee # 10 interviewed, stated that “...for a patient with chief complaint of Nause/Vomiting/Diarrhea x 1 week, the nurse could anticipate medical provider to order diagnostics such as Vital Signs, labs and potential treatment of IV fluids for dehydration ...of course each patient is different ....” A telephone interview with Employee #7 (Attending Medical Provider) was conducted on 03/10/2026. During the telephone interview, Employee #7 stated “...kid looked ill, the doctor (resident, Employee #26) offered labs, IV fluids, the parent said ’ no and to just try more oral medication ’ ... the resident tried to coach the parent to do diagnostics, ultimately the parent decided not to ....” A telephone interview with the parent/guardian of patient #15 was conducted on 03/09/2026. During the telephone interview the parent/guardian confirmed: “...I took him/her to Banner South for another opinion and more care because we had been at Sells ED the day before. I thought they (Banner South) could do more. When we came to ED she/he (patient #15) was lethargic, had no energy ,wouldn’t walk, would lay on bed or lay on floor, skin under eyes was black, eyes sunken in, cheeks sunken in ....” Additionally, the parent/guardian of patient #15 confirmed during the telephone interview on 03/09/2026 that Patient #15 was seen by only one (1) physician during the ED visit. Patient #15 parent/guardian confirmed during the interview that the physician had not recommended labs, xrays or treatment with IV fluids. During an interview on 03/10/2026 with employee #3 and employee #4 it was confirmed that a patient with signs and symptoms of Nausea/Vomiting/Diarrhea are often given a “PO challenge” Employee #3 and Employee #4 describe a “PO challenge” as “...providing the patient with antiemetic and oral fluids and then a period of time for observation that the patient is tolerating PO fluids prior to discharge ....” Employee #3 and Employee #4 confirmed that there is “...no policy or procedure for the PO challenge and no prescribed amount of oral intake and there is no prescribed amount of time to observe patients “tolerating fluids” ....””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 52995 Based on review of policies and procedures, hospital documents and staff interviews, it was determined that the hospital failed to provide stabilizing treatment to a pediatric patient. FIndings Include Hospital Policy titled “EMTALA - Medical Screening Examination and Stabilization” revealed “...Emergency Medical Condition or EMC: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part ...5. An MSE will be conducted to determine whether the patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ’ s needs and must continue until the EMC is stabilized or the The patient is admitted or appropriately transferred. 6. An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay. Medical screening and stabilizing treatment will not be delayed to obtain payment or insurance information. Reasonable registration processes, including insurance information, may be followed as as long as individuals are not unduly discouraged from remaining for further evaluation ...15. An MSE and Stabilizing Treatment will be provided to all individuals with an EMC regardless of managed care/payor requirements. Managed care plans/payors may be notified of the individual ’ s presentation and asked to identify an attending physician, but no request for authorization will be sought until the individual has been examined and treatment has been initiated to stabilize an EMC.1. If the MSE demonstrates that an EMC exists, the Hospital will provide Stabilizing Treatment within the Hospital ’ s Capabilities, even if the Hospital must transfer the Patient. An on-call physician is expected to present to the Hospital to stabilize and treat a Patient when requested by a physician or a QMP. 2. A Patient with an EMC is stabilized when the physician/QMP determines that: a. The Patient is Stable for Discharge (i.e., when, within reasonable clinical confidence, the physician or QMP determines that the Patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient)... Review of medical record of patient #15 revealed a medical providers note dated 03/19/2025 noting potential signs and symptoms of dehydration and malnutrition “...severe diarrhea since last thursday (7 days)...rapid weight loss as seen now ...as of yesterday she/he stopped eating and drinking altogether ...she/he wears diapers, and there was only wet diaper yesterday ...vomiting occurred with last episode being last yesterday morning she has been irritable, which is believed to be due to hunger. The caregiver estimates her weight before falling ill was approximately 30 pounds there is noticeable weight loss, as evidenced by more pronounced ribs, sunken eyes,and cheekbones ....” Further review of patient #15 medical record revealed no ordered documented for IV fluids, no order documented for oral fluid intake, no order documented for “...PO challenge ....”. Review of medical provider order on 03/19/2025 at 0840 “...Ondasteron 1.3 mg oral ,1.63ml,oral once. Further review of patient #15 medical record revealed RN documented “...on 03/19/2026 at 0953, Completed- Ondasteron 1.3 mg, 1.63 ml, oral once ....” Medical record of patient #15 revealed patient was discharged on 03/19/2025 at 1030 ....” Review of medical record revealed Patient #15 was observed for approximately 37 minutes after given antiemetic medication and PO fluids prior to discharge on 03/19/2025 at 1030. Further review of Patient #15 medical record revealed no documented oral intake or urinary output for the ED visit. Further review of Patient #15 medical record revealed the ED length of stay was 2 hours and 30 minutes. Further review of patient #15 medical record revealed a note by medical provider employee #26 “...tolerating PO intake prior to discharge....” Patient #15 was discharged to home on 03/19/2025 at approximately 1030 with a paper prescription for “... zofran oral liquid....”.Patient discharge instructions were provided. Vital signs of patient #15 on 03/19/2025 at 1026 revealed “...HR 166, Respirations 30, Pox 99 on room air, unable to obtain BP, skin- pallor, warm, dry general appearance- agitated, alert....” Review of Patient #15 medical record from Hospital #2 revealed an Emergency Department provider note dated 03/21/2025 which revealed: “...presenting by EMS for concern of unresponsiveness in the setting of 10 days of nausea, vomiting, diarrhea. Patient was evaluated on 03/18 and 03/19 for symptoms of vomiting and diarrhea. Symptoms started 03/13...{She} has also had some weight loss. Mother states appetite was initially suppressed, however patient has not eaten anything in the last 48 hours.{She} is still drinking milk. Mother states patient is still having wet diapers...Mother laid {her} down this morning around 9:30...Patient then napped and did not wake up. When mother found {her} to wake {her}, {she} was unresponsive...Glucose enroute for EMS of 130’s...Vital signs: T(37.5), HR 162, RR 31 Oxygen flow rate 15 liters per non rebreather mask, Pulse ox 100%, BP 112/74...General: Unresponsive...Neurologic: No spontaneous eye movements, pupils 4 and nonreactive, no clonus, intermittently responds to pain, nonverbal at baseline...Due to patient’s clinical circumstances, we elected to intubate the patient for low GCS and need for airway protection...Differential diagnosis: Ischemic stroke, hemorrhagic stroke, sinus venous thrombosis, seizure, hyponatremia, dehydration, hydrocephalus, hypoglycemia, electrolyte abnormality, viral illness, menigitis, encephalitis, traumatic injury, intracranial mass...Patient was given a 20cc/kg lactated ringers bolus. Initial weight that we were using was 21 kg. Nursing reweighed patient and patient was found to be 13 kg...Basic lab workup initiated...Stat VBG with electrolytes was ordered which was concerning for hypernatremia with a sodium of 163. CMP showed serum sodium of 164. Patient alos had hypercholremia with a chloride of 130. CO2 of 14, and anion gap of 18...Patient had trace thrombocytosis with platelets of 451...Stat CT head imaging was obtained which showed extensive edema of left temporal lobe and right cerebellum with acute infarcts and subarachnoid hemorrhage along the temporal lobe on the left and bilateral cerebellar regions...Chest imaging showed pulmonary embolism...Repeat serum sodium shoed sodium of 158, will hold on any fluid resuscitation at this time...Given concern for hypercoagulability we did elect to add on PT, INR, PTT, DIC panel which are all pending at time of admission...Patient transferred to PICU in critical condition....” Review of Patient #15 medical record from Hospital #2 History and Physical dated 03/21/2025 revealed: “...Chief complaint: BIBA (brought in by ambulance). Pts mom went to check on pt during nap and found pt unresponsive around 1300. LKW (last known well) 0930...Pt responsive to pain only...Hx autism and nonverbal at baseline, + posturing, HR 118-180 bpm, febrile with EMS...Parents report that 10 days ago {she} started to have emesis and diarrhea...They thought it was a stomach bug. Because {she} was not eating or drinking, they brought {her} to the ED for evaluation where {she was prescribed zofran on 03/18. They report {she} continued with emesis, diarrhea, and inability to tolerate PO, so they returned to the ED the next day where {she} was again given a script for zofran. Since then, {she} lost weight and {her} eyes appeared sunken...mom reports this aftenoon after nap became limp and unresponsive...Assessment/Plan: Neuro: Acute infarcts of temporal lobe, right cerebellum, right pons, subarachnoid hemorrhage, concern for increased ICP/herniation...Heme/Onc: multiple infarcts, pulmonary embolism, subarachnoid bleed, microlytic anemia: Unclear cause of coagulopathy at this time...CV: Hypotension, FEN/GI Hypernatremia, dehydration, hypernatremia likely 2/2 dehydration....” Review of Patient #15 Discharge Summary from Hospital #2 dated 03/23/2025 revealed: “...PICU Death Note/Discharge Summary: Admission/Discharge Diagnoses: Ischemic Stroke (Cerebral infarctation), Cerbral cenous sinus thrombosis, Subarachnoid hemorrhage, Pulmonary Emboli, Unresponsive...Admission HPI: 4 year old {female} wiht autism spectrum-nonverbal and iron deficiency anemia who presented via MES afer being found unresponsive by parents following 10 days of emesis and diarrhea...Hospital course by system: 1. Neuro: Multiple acute infarcts...Subarachnoid hemorrhage...Dural sinus thromboses...Concern for increased ICP/herniation...Patient’s sedation was stopped yesterday 03/21 at 2100 and the pateint was not demonstrating any spontaneous breathing, absent brain stem reflexes...They approached the medical team to discuss comfort care measures, which we discussed in full. They opted to change to DNR, stop meds except pain medication and extubate, favoring comfort care measures only. {She} was extubated at 23:45 and placed in mother’s arms. Time of death was called at 0003....” Review of Patient #15 Autopsy Final Report from Hospital #2 dated 04/25/2025 revealed: “...Final Diagnosis: 1. Hypercoagulation in the setting of gastroenteritis( See Comment)...A. Cerebral venous sinus thrombosis, wein of Galen, straight sinus, left transverse sinus..B. Pulmonary embolism, right and left lungs, segmental and subsegmental arteries...C. Thrombus, right common and external iliac veins...D. Dehydration, per medical record: 1. Hypernatremia per medical record, 2. Hyperchloremia, per medical record...E.Dilatation of descending colon...F. Prolongation of activated partial thromboplastin tiume...G. Prolongation of dilute Russell biper venom time...Comment: The present clinical, laboratory, and postmortem examination findings are consistent with an acquired ot otherwise unmasked prothrombic disorder such as antiphospholipid antibody syndrome. Such antibody-driven prothrombotic disorders may manifest following viral infection, and may be exacerbated by dehydration with resultant hemoconcentration...Case Information: A complete autopsy was performed on 03/24/2025 at 1000....” Review of medical records of 19 additional Emergency Department patients randomly selected from ED logs February 2025 through April 2025 was conducted. Review of 6 pediatric patients (#6, #10, #13,#15,#16,#20), revealed that 6 patients out of 20 patients with chief complaint of Nause/Vomiting /Diarrhea, received antiemetic medication and given Per Oral (PO) fluids prior to discharge. Review of medical records for Patient #6,#10,#13,#15,#16,#20 revealed no oral Intake or Urinary Output was documented during ED treatment prior to discharge. An interview with parent/guardian of patient #15 on 03/09/2026 revealed that no staff member evaluated amount of PO fluid taken or urinary output prior to discharge. Patient #15 parent/guardian confirmed: “...she/he took very little from his/her bottle before being discharged ....” During an interview with employee #3 and employee #4 patient with signs and symptoms of Nause/Vomiting/Diarrhea are often given a “PO challenge” Employee #3 and Employee #4 describe a “PO challenge” as providing the patient with an antiemetic and a period of time for observation that the patient is tolerating PO fluids prior to discharge”. Employee #3 and Employee #4 confirmed that there is “...no policy or procedure for “PO challenge” No prescribed amount of intake and no prescribed amount of time to observe patients “tolerating fluids” ....””

“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: 52392 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. Findings Include: Hospital Policy titled, “EMTALA- Medical Screening Examination and Stabilization Treatment”, revealed: “ ...appropriate MSE will be offered to individuals in the Hospital ’ s Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance behavior would cause a prudent layperson observer to believe that such individuals need examination or treatment for a medical condition...an EMS provider brings an individual to the Hospital with a Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms...An MSE will be conducted to determine whether the Patient has an Emergency Medical Condition [sic]EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ’ s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred...An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay. Medical screening and stabilizing treatment will not be delayed to obtain payment or insurance information....” The hospital failed to provided to medical screening exam for to 6 patients prior to the patients leaving. Employee #6 confirmed that medical screening exams were not provided to the patients that were not treated.”

“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: 52392 Based on review of documents and staff interview, it was determined the hospital failed to provide medical screening exam to 6 patients out of 20 patients prior to them leaving the Emergency department. (patient #1, Patient #3, Patient #5, Patient #6, Patient #9, and Patient #10). Findings Include: Hospital Policy titled, “EMTALA- Medical Screening Examination and Stabilization Treatment”, revealed: “ ...appropriate MSE will be offered to individuals in the Hospital ’ s Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance behavior would cause a prudent layperson observer to believe that such individuals need examination or treatment for a medical condition...an EMS provider brings an individual to the Hospital with a Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms...An MSE will be conducted to determine whether the Patient has an Emergency Medical Condition [sic]EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ’ s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred...An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay. Medical screening and stabilizing treatment will not be delayed to obtain payment or insurance information....” Review of six (6) out of twenty (20) patient emergency medical records randomly selected from the hospital emergency logs for the months of December 2024, January 2025 and February 2025 revealed there was over five (5) hour delays and patients Left without Triage/Treatment. Patient #1 Registered at 1617 on 12/01/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 10 hours and 37 minutes. Patient #3 Registered at 2018 on 12/02/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 4 hours and 57 minutes. Patient #5 Registered at 2009 on 12/06/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 7 hours and 02 minutes. Patient #6 Registered at 2009 on 12/014/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 9 hours and 22 minutes. Patient #9 Registered at 1921 on 12/21/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 6 hours and 02 minutes. Patient #10 Registered at 2132 on 12/23/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 5 hours and 18 minutes. Employee #5 stated the hospital and ED “have made changes in the ED, dramatic changes that has diminished the LWOT times drastically”. Employee #5 and #6 confirmed on 03/24/2025 the hospital had identified in February the long MSE times and implemented a new process on 2/26/2025.”

“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: 52392 Based on review of policies and procedures, clinical records, hospital documents, and staff interviews, it was determined the facility failed to provide a Medical Screening Examination (MSE) and treatment to six (6) out of (20) patients (Patients #1,3,5,6,9,and 10)who left without treatment (LWOT) and delayed an MSE and treatment for two (2) out of twenty (20) patients (Patients #7, #11). Findings include: Hospital Policy titled, “EMTALA- Medical Screening Examination and Stabilization Treatment”, revealed: “ ...appropriate MSE will be offered to individuals in the Hospital ’ s Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance behavior would cause a prudent layperson observer to believe that such individuals need examination or treatment for a medical condition...an EMS provider brings an individual to the Hospital with a Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms...An MSE will be conducted to determine whether the Patient has an Emergency Medical Condition [sic]EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ’ s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred...An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay. Medical screening and stabilizing treatment will not be delayed to obtain payment or insurance information....” Review of the medical records of 20 randomly selected patients from the ED logs revealed the following: The hospital failed to provide a medical screening exam to 6 of 20 patient s before the patients left without treatment. Patient #1 Registered at 1617 on 12/01/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 10 hours and 37 minutes. Patient #3 Registered at 2018 on 12/02/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 4 hours and 57 minutes. Patient #5 Registered at 2009 on 12/06/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 7 hours and 02 minutes. Patient #6 Registered at 2009 on 12/014/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 9 hours and 22 minutes. Patient #9 Registered at 1921 on 12/21/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 6 hours and 02 minutes. Patient #10 Registered at 2132 on 12/23/2024 and Left before medical screening Exam (MSE), with an MSE elapsed time of 5 hours and 18 minutes. Further review reviewed the hospital delayed an MSE and treatment for 2 of the 20 patients. Patient #7 Registered at 1040 on 12/16/2024 and had an MSE of 1 hour and 54 minutes. Patient #11 Registered at 1735 on 02/27/2025 and had an MSE of 3 hours and 23 minutes. Employee #5 confirmed the hospital had identified the long MSE times and implemented a new process on 2/26/2025.”