Providence Queen of the Valley 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: 35598 Based on observation, interview, and record review, the facility failed to meet the regulatory requirements under Emergency Medical Treatment and labor Act (EMTALA) as evidenced by: 1. The facility failed to conspicuously post signage specifying the rights of individuals with respect to the EMTALA in locations likely to be noticed by all individuals entering the Emergency Department (ED), as well as individuals waiting for examination and treatment including the entrance and waiting areas of the ED. (Refer to A-2402) 2. The facility failed to ensure stabilizing treatment and continuous monitoring relevant to the emergency medical condition to one out of 31 sampled patients (Patient 1) and ensure no material deterioration of the condition would likely occur when Patient 1, on a 5150 hold (a 72-hour involuntary psychiatric detention, triggered when a mental health professional or law enforcement determines an individual poses a danger to themselves or others, or is gravely disabled, due to a mental illness), left the ED to wander the streets and was returned to the ED by the local police department 5.5 hours later. (Refer to A-2407) 3. The facility failed to show evidence of required transfer documentation for 5 of 31 sampled patients (Patients 11, 19, 23, 24, and 25) when the facility did not fill out required “Patient Transfer” forms for patients transferring from the ED to higher level of care for Patients 23, 24, and 25, and the facility failed to fully complete “Patient Transfer” forms by not obtaining Patient 11 and Patient 19’s signature indicating understanding of the risks, benefits, and process for transfer. (Refer to A-2409)”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 42291 Based on observation, interview, and facility policy review, the facility failed to conspicuously post signage specifying the rights of individuals with respect to the Emergency Medical Treatment and Labor Act (EMTALA) in locations likely to be noticed by all individuals entering the Emergency Department (ED), as well as individuals waiting for examination and treatment including the entrance and waiting areas of the ED. This failure resulted in the potential for patients to not know their rights to receive a medical screening examination or treatment for their emergent medical condition, including active labor. Findings: On 6/9/25 at 9:30 a.m., a tour was conducted of the hospital ED. No postings or signage related to patient rights to examination, treatment, or Medicaid participation were observed in the outside ED ambulance entrance, the patient check-in area, or the triage and patient waiting area. One EMTALA sign posted in English and Spanish was observed in the walk-in entrance of the ED with multiple other signs. During the tour conducted on 6/9/25 at 9:30 a.m., the ED Manager (EDM) indicated, the EMTALA sign posted in the patient walk-in entrance was the only EMTALA sign posted in the ED. During a review of the facility’s policy and procedure (P&P) titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions,” the P&P indicated, ...”Signage means that the facility is required to post signs in the DED (“Dedicated Emergency Department” 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: ... It is held out to the public by name, posted signs, advertising, or other means) as a place that provides care for EMC’s [Emergency Medical Condition] on an urgent basis without requiring a previously scheduled appointment ... Further review of the facility’s policy and procedure (P&P) titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions,” the P&P indicated, ...”The hospital shall conspicuously post signs ... Such signage shall be posted in all pertinent languages that are spoken by patient populations using Hospital Services. ...Such signage shall specify the rights of individuals under the law with respect to examination and treatment for EMCs ...and are in areas where patients might present seeking emergency medical treatment and in all areas where patients wait prior to examination and treatment. ...these signs shall be posted in the emergency department, and in other DEDs. ...Signage must be readable in the area where it is posted and from a distance of at least 20 feet ...””

“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: 42291 Based on interview, record review, and hospital policy review, the hospital failed to ensure stabilizing treatment and continuous monitoring relevant to the emergency medical condition (EMC) to one out of 31 sampled patients (Patient 1) and ensure no material deterioration of the condition would likely occur, when; Patient 1 on a 5150 hold (a 72-hour involuntary psychiatric detention, triggered when a mental health professional or law enforcement determines an individual poses a danger to themselves or others, or is gravely disabled, due to a mental illness) was allowed to leave the emergency department, found wandering the streets and returned to the ED by the local Police Department (PD), 5.5 hours later. This failure caused Patient 1 on a 5150 hold (gravely disabled -being unable to provide for basic needs like: food, clothing, shelter, personal care and medical care needs) to elope and be at risk for injury and/or harming self. Findings: During a concurrent interview and record review on 6/9/25 at 10:30 a.m. with Emergency Department Manager (EDM), the following records were reviewed: Patient 1’s History and Physical (H&P) dated 4/27/25 at 3:20 a.m., indicated, Patient 1 presented to the ED on 4/27/25 for a Medical Clearance (a medical assessment performed to ensure a person’s psychiatric symptoms are not caused by a medical condition). The H&P further indicated Patient 1 was placed on a 5150 for concerns of grave disability. Patient 1’s home medication included escitalopram (a drug used to treat depression and anxiety). The “Psychiatric Exam”, indicated, “Patient with slightly pressured speech, redirectable, but with occasional anxious pacing behaviors.” Patient 1’s “ED Provider Notes (EPN)”, dated 4/27/25 at 11:32 a.m., indicated Patient 1 presented to the ED with the PD on a 5150 after eloping from the ED. The EPN further indicated, Patient 1 was given lorazepam (used to reduce anxiety) tablet 1 mg (milligram - unit of measure) orally at 11:12 a.m. and olanzapine 5 mg orally at 12:15 p.m. Patient 1 was transferred to a Crisis Center at 4:40 p.m. Patient 1’s Nursing Notes (NN) dated 4/27/25 at 1:00 a.m., indicated, “Pt [patient] hyperactive, giggling repeatedly, incoherent thoughts. Sitter at bedside. Needs frequent redirection.” Patient 1’s NN dated 4/27/25 at 3:47 a.m., indicated, “Pt [patient - Patient 1] becoming increasingly agitated. Repeatedly tries to walk past sitter and stating wants to leave. Provider aware. Pt [patient -Patient 1] reeducated that PD [Police Department] would have to become involved if pt leaves.” The EDM acknowledged no MD orders or assessment was documented. Patient 1’s NN dated 4/27/25, at 4:22 a.m., indicated “Pt [patient] remains restless and hyperactive. Needs frequent redirection ...” Patient 1’s NN dated 4/27/25, at 5:31 a.m., indicated, “Pt [patient] still exhibiting incoherent thoughts. Hyperactive, questioning authority of sitter/staff. Pacing around room.” Patient 1’s NN dated 4/27/25 at 05:57 a.m., indicated, “Pt [patient - Patient 1] pushed past sitter and walked out of ambulance bay. Security notified. PD notified. MD aware.” During a concurrent interview and Patient 1’s record review on 6/10/25 at 10:44 a.m., with EDM, EDM stated no provider orders documented on 4/27/25 at 3:38 a.m., which was unusual since the patient was pacing and escalating. EDM further stated that on 4/27/25 at 4:22 a.m., Patient 1 was a flight risk and physician should have been notified. During a joint interview on 6/10/25 at 12:35 p.m., with Medical Doctor (MD) 1, Patient 1’s treating provider at the time of the event, and Medical ED Director (MEDD) MD, MD 1 indicated he had not had EMTALA training since 2019 and no specific EMTALA training requirements for providers. MEDD indicated EMTALA training was the facility’s EMTALA policies and procedures. Further interview on 6/10/25 at 12:35 p.m., with MD 1, MD 1 indicated, Patient 1 was on a 5150 hold who was being seen for medical clearance. Patient 1 was drinking water, had a sitter and easily redirected. MD 1 indicated, Patient 1 had no medical indications for restraints or medication interventions. MD 1 stated, “the decision making provided to Patient 1 was appropriate”. MD 1 indicated, he had written Patient 1’s initial assessment (4/27/25 at 03:38 a.m.), and did not write any additional documentation. MD 1 indicated, the ED does not have Security personnel, if a patient wants to physically leave, including a patient on a 5150 Hold, the ED staff does not attempt to stop them and the PD is notified. During an interview on 6/11/25 at 7:28 a.m., with RN 1, RN 1 indicated, she was the nurse taking care of Patient 1 on 4/27/25. RN 1 indicated, Patient 1 came to the ED on a 5150 for gravely disabled, family sent him for not drinking or eating. RN 1 stated, “[Patient 1] followed commands at times, his behavior was childlike, giggling, laughing, hyperactive, big movement pacing in the room and required to be re-directed.” RN 1 indicated, Patient 1 had a sitter, after a couple of hours in the ED, Patient 1 started questioning authority and expressed he (Patient 1) was going to leave. Patient 1 pushed passed the sitter and was allowed to leave the facility. The PD was notified. RN 1 stated that Patient 1’s family was not notified of the elopement. Continue interview on 6/11/25 at 07:28 a.m., with RN 1, RN 1 indicated, she had communicated with MD 1 Patient 1’s behavior. RN 1 indicated, Patient 1 was not medicated for his behavior and could not remember MD 1’s rational for saying no to the medication request. During an interview on 6/11/25 at 09:45 a.m., with Security Officer (SO), SO indicated, for a 5150 patient Security can use reasonable force to keep the patient in the ED. SO further explained that reasonable force would be positioning SO’s body at least 6 feet from the patient with hands down, open and talking to the patient. During a review of the facility’s policy and procedure (P&P) titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions,” dated 5/24, the P&P indicated, ... “If it is determined that the individual has an EMC (Emergency Medical Condition), to provide the individual with such further medical examination and necessary treatment as required to stabilize the EMC within the capability of the Hospital ... EMC means: ... A medical condition manifesting itself by acute symptoms of sufficient severity (including ..., psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to result in: ... Placing the health of the individual ... in serious jeopardy; or ...With respect to individuals with psychiatric symptoms: That the individual is determined to be a danger to self or others.” Further review of the facility’s P&P titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions,” dated 5/24, the P&P indicated, ... “Stabilize or to stabilize means: with respect to a psychiatric condition, the patient is no longer considered a harm to himself/ ... or to others.” Further review of the facility’s P&P titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions,” dated 5/24, the P&P indicated, ... “The Hospital’s EMTALA obligation ends when a physician or QMP (Qualified Medical Person) has decided: ... “That an EMC exists, and the individual is appropriately transferred to another facility ...”. During a review of the facility’s “Security Post Orders (SCO),” dated July 2024, the SCO indicated, ... “5150 Leaving AMA, 5150 patients can not leave AMA until the time at which the 5150 hold is lifted. ... If a 5150 patient attempts to leave AMA security must use reasonable force to stop them ... If security officers are unable to stop a 5150 patient from leaving ... law enforcement should be summoned immediately.” During a review of the facility’s P&P titled, “AMA - Leaving Against Medical Advice and/or Elopement, and/or Patient Refusal of Medical Care (AMALAMA/E/PRoMC),” dated 8/2022, the P&P indicated, ... “After a patient elopes and a physician has determined that the patient lacks capacity for decision making then, the physician, nursing staff ... a. determines the next steps regarding patient treatment ... b. contact the patient’s legal surrogate or guardian ...””

“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: 50619 Based on interview medical record review, and hospital Policy and Procedure (P&P) review, the hospital failed to show evidence of required transfer documentation for 5 of 31 sampled patients (Patients 11, 19, 23, 24, and 25) when: 1. The facility did not fill out required “Patient Transfer” forms for patients transferring from Emergency Department (ED) to higher level of care for Patients 23, 24, and 25, and 2. The facility failed to fully complete “Patient Transfer” forms by not obtaining Patient 11 and Patient 19’s signature indicating understanding of the risks, benefits, and process for transfer. These failures had the potential for Patients 11, 19, 23, 24, and 25 to not be informed of their transfer risks, benefits, process for transfer, and reason for transfer and the inability to make informed decisions regarding their care. Findings: 1. During a concurrent interview and record review on 6/10/25 at 9:50 a.m. with Emergency Department Nurse Educator (EDNE), Patient 23’s “History and Physical (H&P),” dated 5/27/25, revealed Patient 23 was brought to the ED by ambulance with a self-inflicted laceration (cut) to the wrist. Further review of Patient 23’s H&P revealed Patient 23 was medically cleared and transferred to an acute psychiatric hospital for psychiatric care. During a concurrent interview and record review on 6/10/25 at 9:50 a.m. with EDNE, Patient 23’s ED “Nursing Notes (NN),” dated 5/27/25 at 6:26 a.m., the NN indicated that the county Mobile Response Team (a team of mental health professionals that provide community-based interventions for those experiencing a mental health crisis) came to Patient 23’s bedside in the ED and placed Patient 23 on a 5150 hold (72-hour involuntary hold placed on a person with a mental health disorder after that person is determined to be a danger to themselves or others and/or gravely disabled). EDNE found an electronic “Patient Transfer” form in Patient 23’s record but stated it was not signed by the nurse, doctor, or patient. EDNE stated the electronic “Patient Transfer” form needed to be signed. During a concurrent interview and record review on 6/10/25 at 10:02 a.m. with EDNE, dated 6/5/25, Patient 25’s “H&P” was reviewed. The “H&P” indicated Patient 25 was brought to the ED on 6/5/25 by the local police department and placed on a 5150 hold for suicidal ideation (thoughts). Review of Patient 25’s H&P further indicated that Patient 25 was medically cleared and transferred to an acute psychiatric hospital for further care. EDNE reviewed Patient 25’s medical record and stated there were no completed “Patient Transfer” forms and transfer forms were not done. During a record review on 6/10/25 at 10:17 a.m. with EDNE, Patient 24’s “H&P” dated 6/5/25 was reviewed. The “H&P” indicated Patient 24 was brought to the ED by the Mobile Response Team and placed on a 5150 hold for suicidal ideation. Patient 24 was medically cleared and transferred to an acute psychiatric hospital. During an interview on 6/10/25 at 10:17 a.m. with EDNE, EDNE reviewed Patient 24’s medical record and stated there were no completed “Patient Transfer” forms for this transfer. EDNE stated that since this was a “designated a discharge and not a transfer”, there was no transfer paperwork. During an interview on 6/10/25 at 2:40 p.m., Emergency Department Manager (EDM) stated that when patients were transferred from the ED to acute psychiatric hospitals, she did consider these transfers, not discharges, and the ED staff were expected to complete the “Patient Transfer” forms. EDM verified that in the cases of Patients 23, 24, and 25 the “Patient Transfer” forms should have been completed. 2. During a review of Patient 11’s “H&P,” dated 3/2025, the H&P indicated Patient 11 was seen the ED in 3/2025 after a motor vehicle accident and obtained a severe ankle injury involving both bone fractures and significant soft tissue damage. Patient 11 was medically stabilized and transferred to another trauma center for further care. The “Patient Transfer” form was missing Patient 11’s signature. During a concurrent interview and record review on 6/9/25 at 1:45 p.m., with EDM, Patient 11’s facility “Patient Transfer” form was reviewed. EDM acknowledged “Patient Transfer” form was missing Patient 11’s signature. During a review of Patient 19’s “EMR”, dated 2/2025, the “EMR” indicated that Patient 19 was seen in the ED in February of 2025 for an acetaminophen (pain medication) overdose with a past medical history of psychiatric (mental health) issues. The patient was treated and medically cleared and then transferred to a psychiatric hospital. During a review of Patient 19’s electronic “Patient Transfer” form, dated 2/2025, the electronic “Patient Transfer” form was signed by the doctor and nurse, but not signed by Patient 19 and the box indicating, “Unable to Sign” was not checked. The hospital was unable to provide a paper copy of the “Patient Transfer” form with a patient signature. During an interview on 6/10/25 at 3:10 p.m. with EDM, EDM stated that the hospital is supposed to keep original “Patient Transfer” form with patient signature and then the form gets scanned into the system after discharge. EDM confirmed that Patient 19 did not have signed “Patient Transfer” form scanned into the chart and could not provide a paper copy of the signed form. During a review of the hospital’s P&P titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions” dated 5/2024, the P&P indicated, “2. B. The appropriate portions of the Patient Transfer Acknowledgement form (see exhibit A) shall be completed if the individual is transferred to another medical facility.” The Patient Transfer Acknowledgement Form “Exhibit A” indicated, “COPY OF FORM MUST BE SENT WITH PATIENT” and had a section titled, “PATIENT TRANSFER ACKNOWLEDGEMENT” that indicated, “I understand that I have a right to receive medical screening, examination, and evaluation by a physician, or other appropriate personnel without regard to my ability to pay, prior to any transfer from this hospital and that I have a right to be informed of the reasons for any transfer. I acknowledge that I have received medical screening, examination and evaluation by a physician, or other appropriate personnel at [Hospital named] and that I have been informed of the reason for my transfer.” Below that paragraph is a place to fill out date, time, patient or legal representative signature line, representative relationship, and witness signature line. A checkbox for patient unable to sign also on form. During a review of the hospital’s P&P titled, “EMTALA: Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions” dated 5/2024, the P&P indicated, ...” Documentation. All information regarding the individual’s transfer shall be part of the medical record ... The patient consents to the transfer.””