Providence St Joseph Hospital

“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: 37689 Based on interview and record review, the hospital failed to meet the regulatory requirements under Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by: 1. The hospital failed to ensure all obstetric patients presenting to the dedicated emergency department (DED) or the DED Labor and Delivery (L&D) Department, also known as the Childbirth Center (CBC), seeking a medical screening examination (MSE) for a potential emergency medical condition (EMC) were maintained or referenced on the ED central log for the timeframe of October 2023 through October 2024. (Cross reference to A-2405)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 37588 Based on document review, policy review, and interview, the facility failed to ensure all obstetric patient presenting to the dedicated emergency department (DED) or the DED Labor and Delivery (L&D) Department, also know as the Childbirth Center (CBC), seeking a medical screening exam (MSE) for a potential emergency medical condition (EMC) were maintained or referenced on the ED central log for the timeframe of October 2023 through October 2024. Findings include: Review of the document entitled “OB Outpatient Log,” paper logs for the timeframe of October 2023 through October 2024 showed all OB (obstetrics) patients, including scheduled OB appointment for patients coming from physician offices, but failed to show which OB patients were presenting to the ED or L&D/CBC Department seeking a MSE for a potential EMC. Review of the ED EMTALA electronic central logs for the timeframe of October 2023 through October 2024 failed to document all OB patients presenting to the ED or L&D/CBC Department for a MSE for a potential EMC. On 10/08/24 at 9:45 AM, while on tour of the ED, the Director of Childbirth Center (DCBC), also known as the L&D Department, stated, “ED OB patients are not documented on the ED EMTALA central log once they go to OB.” During an interview on 10/08/24 at 11:04 AM, the DCBC confirmed the OB Outpatient Log did not indicate which OB patients presented to the DED L&D/CBC Department or the DED ED seeking a MSE for a potential EMC. During an interview on 10/08/24 at 1:57 PM, the Childbirth Center Manager (CBCM) confirmed the L&D/CBC Department is a DED ED. The CBCM also confirmed that OB patients that circumvent the ED are not documented as OB ED patients seeking an MSE for a potential EMC on the OB Outpatient Log. The DCBC stated, “We are not keeping a log of OB ED patients.” Review of the policy titled, “EMTALA - Screening, Stabilization And Transfer Of Individuals With Emergency Medical Conditions, “ revised 02/07/2022 showed, “Section I: Policy & Purpose ...C. This Policy and Procedures apply to 1. Any individual who presents at any Dedicated Emergency Department (“DED”) of the Hospital, as defined in section II and requests and examination or treatment of a medical condition ...Section II. Definitions ...D. “Central Log” refers to the log maintained by the Hospital that documents each patient that comes to a Dedicated Emergency Department seeking assistance and documents such patient’s disposition. E. “Dedicated Emergency Department” (“DED”) means any department or facility of the Hospital, regardless of whether it is located on or off the main Hospital campus that meets at least one of the following requirements: ... 4. Presently, the Hospital’s DEDs are the main emergency department and the labor and delivery department ...G. “Emergency Medical Conditions” (“EMC”) means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; or 2. With respect to a pregnant woman who is having contractions: a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or b. That transfer may pose a threat to the health or safety of the woman or her unborn child. 2. With respect to a pregnant woman who is having contractions: ...Medical Screening Examination” (“MSE”) means the screening process performed by a physician or another QMP [Qualified Medical Provider] required to determine with reasonable clinical confidence whether an EMC does or does not exist. Section III. Procedures ...H. Recordkeeping. The Hospital, whether transferring or receiving patients must maintain the following: ...b. Logs that are maintained in other departments that perform Medical Screening Examinations shall be incorporated into the Central Log by reference. i. Such ancillary patient logs shall be maintained in accordance with the requirement for Central Log and are considered a part of the Central Log.””

“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: 39792 Based on staff interviews, clinical record review, and Emergency Department’s (ED) policy and procedures review, the hospital failed to comply with 42 CFR § 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Medical Treatment and Active Labor Act (EMTALA). Findings: The facility failed to follow its policy and procedure for transferring patients to a higher level of care (a hospital capable of providing diagnostic, intervention or care beyond the capacity of the hospital from which a patient originates) and did not have a current contract for emergent air transfer (air ambulance) of patients with the air ambulance company (AA 6). In practice, AA 6 assumed responsibility (including medical management and Physician Orders) of Hospital 2’s patients during transportation to a higher level of care, but facility policy indicated Hospital 2 was responsible for its patients during transport until arrival at the receiving facility. This failure could potentially contribute to unsafe patient transfers when medical responsibility for a patient’s care during transport was not clearly identified between Hospital 2 and the transportation company.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 39792 Based on staff interviews, clinical record review, and policy and procedure review, Hospital 2 did not follow its policy and procedure for transferring patients to a higher level of care (a hospital capable of providing diagnostic, intervention or care beyond the capacity of the hospital from which a patient originates) and did not have a current contract for emergent air transfer (air ambulance) of patients with the air ambulance company (AA 6). In practice, AA 6 assumed responsibility (including medical management and Physician Orders) of Hospital 2’s patients during transportation to a higher level of care, but facility policy indicated Hospital 2 was responsible for its patients during transport until arrival at the receiving facility. This deficiency could potentially contribute to unsafe patient transfers when medical responsibility for a patient’s care during transport was not clearly identified between Hospital 2 and the transportation company. Findings: During a concurrent interview and emergency medical record review on 9/19/24 at 3:50 p.m.., the Emergency Department (ED) Director stated P9 arrived in the ED on 4/2/24 at 3:01 a.m., with complaints of shortness of breath. A review of P9’s Provider Notes, dated, “4/2/24,” indicated (P9) was a 3 year-old male with a history of trisomy 21 (a genetic disorder that occurs when a person has a extra copy of chromosome 21) and atrioventricular canal defect (occurs when there are holes between the chambers of the right and left side of the heart) which had been repaired. Despite maximal medication therapy, P9 continued to decline and was intubated (a medical procedure that involves inserting a tube into the wind pipe to keep the airway open) at 5:01 a.m. on 4/2/24. Hospital 4 accepted transfer of P9 at 7:02 a.m., was transferred to Hospital 4 by airplane (air ambulance; AA 6) out of Hospital 2 at 7:37 a.m. on 4/2/24. The ED Director was asked about Hospital 2’s Physician Orders to manage P9 safely during the transport to the accepting facility and stated Hospital 2 did not manage the patients while they are being transported with AA 6, since the company had a medical provider who managed the patients during transport and coordinated with the receiving facility. The ED Director stated the Physicians at Hospital 2 coordinated with the receiving facility but when AA 6 transported the patient, the company assumed care of the patient because of a contract between AA 6 and Hospital 2 so Hospital 2 would not write orders or further care management of the patients during transport. The ED Director stated the contract between AA 6 and Hospital 2 had actually expired but there was a meeting scheduled for some time soon (date unknown) to work on the contract. During a concurrent interview and emergency medical record review on 9/19/24 at 4 p.m., the ED Director stated Patient 10 arrived in the ED on 4/25/24 at 12:07 a.m., with complaints of right ear pain. A review of P10’s Provider Notes, dated, “4/25/24,” indicated (P10) was a 6 year-old female with complaints of right ear pain. P10 was diagnosed with external otitis (an inflammation of the ear canal that can be caused by infection) and Otomastoiditis (inflammation of the mastoid and middle ear) and accepted at Hospital 4 at 8:40 p.m. on 4/25/24. AA 6 transported P10 on 4/25/24 at 6:50 a.m. due to weather, it was not safe to fly or or transport P10 until that timeframe. During a review of the emergency record, P23 arrived in the ED on 8/3/24 at 10:43 a.m., with complaints of burns on her face. P23 was accepted to Hospital 5 (burn unit) and transported on 8/3/24 at 1:45 p.m., by AA 6. During an interview on 9/19/24 at 4 p.m., the Area Manager of Accreditation Regulatory and Licensing (AR&L) stated there was no contract with AA 6 since it had expired about two years ago and could not explain why there was not a new contract in place. During a concurrent interview on 9/19/24 at 4:42 p.m., the Chief Nursing Officer (CNO) stated it was not the policy for Hospital 2 to manage the care of patients being transported by AA 6; the company had a medical provider who managed the patients and coordinated with the receiving facility regarding the care of the patients. The CNO stated she was unaware of the policy, and stated AA 6 managed the patients, they had a medical director who took over the care, and there were protocols their staff would follow and there were transfer agreements between Hospital 2 and AA 6. A review of facility policy titled, “RECIPROCAL TRANSFER AGREEMENT,” dated 8/31/21, indicated, “2.3 The Transferring Facility ... *** shall assume responsibility for the patient’s care and safety during transport ....Receiving Facility shall not be responsible for the patient until arrival at Receiving Facility.” The policy further indicated......”The Transferring Facility shall arrange and coordinate the method of the transportation of the patient to the Receiving Facility and shall assume responsibility for the patient’s care and safety during transport ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 41175 Based on interview and record review, the facility failed to implement its policies and procedures when: 1. One of 30 sampled patients (Patient 1) was not given pain medications after reporting pain; and, 2. One staff member did not perform proper hand hygiene after exiting an Isolation Room. These failures had the potential to result in unrelieved pain and unnecessary suffering to Patient 1, and poor hand hygiene increased the risk of transmitting harmful microorganisms to patients which may lead to serious infections and even death. Findings: 1. During an interview on 8/7/24 at 4:10 p.m., Nurse C stated a patient’s pain level was assessed at least every shift, and pain scales were often used to determine the pain level. Nurse C stated pain scales used numbers from 0 to 10, with 0 meaning no pain, and 10 meaning the worst possible pain. Nurse C stated pain medications were given depending on the patient’s pain level, and the pain level was reassessed about an hour after giving oral pain medications, and about 30 minutes after giving intravenous (IV) pain medications. Nurse C stated the goal was to keep the patient’s pain at at an acceptable level and to maintain comfort. During a concurrent interview and record review with Nurse Manager D on 8/8/24 at 10:39 a.m., Patient 1’s, “Pain Flowsheet,” was reviewed. Patient 1’s, “Pain Flowsheet,” indicated a pain level of, “5” at 1540 (3:40 p.m.) on 7/4/24, and pain levels of, “6” on 7/5/24 at 0610 (6:10 a.m.), 1200 (12 p.m.), and 1710 (5:10 p.m.). Patient 1’s, “Pain Flowsheet,” indicated an, “Acceptable Comfort Level: 3.” Nurse Manager D confirmed there was no documentation that Patient 1 received any pain medication, or any other interventions, for his reported pain on 7/4/24 and 7/5/24. A review of the facility policy titled, “Pain Management,” dated, “6/8/2022,” indicated, “Patients have the right to pain management. It is the policy of the hospital to do the following: ... C. Assess the patient’s response to care, treatment, and service implemented to address pain. D. Treat the patient’s pain or refer the patient for treatment... C. INTERVENTIONS: 1. Initiate intervention whenever patient’s current pain score exceeds their goal... 3. Use adjunctive interventions when appropriate that may include: positioning, relaxation, massage, guided imagery, humor, music, and application of heat/cold...” 38322 2. During an observation and concurrent interview on 8/5/24 at 2:40 p.m., Nurse Aide A exited a patient room which had a sign on the door indicating, “Enhanced Droplet Precautions” (required for patients diagnosed with or suspected of having infectious microorganisms transmitted by both the Droplet and Contact routes), wearing a N95 respirator (personal protective equipment (PPE) that is used to protect the wearer from potentially infectious particles). Nurse Aide A removed her N95 respirator, threw the respirator in the trash, and sat down at the nurses’ station to make a phone call. Nurse Aide A did not perform hand hygiene. When queried, Nurse Aide A verified she did not perform hand hygiene after touching the respirator. Nurse Aide A stated she should have performed hand hygiene after removing the respirator and verified she had received training on hand hygiene. When asked the reason hand hygiene should be performed after removing PPE, Nurse Aide A stated, “Germs.” During an interview on 8/8/24 at 11 a.m., Nurse Manager B stated it was her expectation staff perform hand hygiene after removing a N95 respirator and before making a phone call. When asked the reason hand hygiene should be performed after removing PPE, Nurse Manager B stated, “Infection control.” Review of hospital policy, “[Hospital Name] Specific Hand Hygiene Policy,” last revised 4/25/23, indicated, “Purpose: To provide evidence-based guidelines for effective and safe hand hygiene in the healthcare setting and: . . . To reduce the transmission of pathogenic microorganisms and the incidence of healthcare associated infections caused by these organisms . . . Hand hygiene will be performed before or after the following activities: . . . After removing PPE . . . .””