Kaiser Foundation Hospital Fontana/Ontario

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47360 Based on interview and record review, the Governing Body (GB-a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure a safe and effective quality of care for a universe of 32 sampled patients admitted on December 16, 2025, when the GB did not ensure an effective quality improvement program and provide effective oversight of medication administration, incomplete patient assessments, missing hand-off report between patient care units and inadequate safety procedure in the Magnetic Resonance Imaging (MRI -a detailed scan that uses a powerful magnet, radio waves, and a computer to create clear pictures of your body’s insides, like organs, soft tissues, and bones, helping doctors diagnose problems without X-rays or radiation ) department. (Refer to A0049) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47360 Based on interview and record review the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 32 patients admitted on December 16, 2025, QAPI failed to monitor, collect and analyze quality data related to Magnetic Resonance Imaging (MRI - a detailed scan that uses a powerful magnet, radio waves, and a computer to create clear pictures of your body’s insides, like organs, soft tissues (brain, muscles, ligaments) patient safety and “unusual occurrence reporting” (a formal report anything unexpected or out-of-the-ordinary that happens in a hospital or clinic, especially if it could hurt a patient, visitor, or staff, like a patient falling, wrong medicine given, equipment breaking, or even a fire, so the facility can figure out what went wrong and stop it from happening again), medication administration, nursing assessments and hand-off report between patient care areas. (Refer to Tag A-0273). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas and ensure the provision of quality health care and nursing services in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health) which collaboratively contributed to Patient 32 suffering a full thickness burn (a serve burn damaging all layers of a patient skin) during an MRI examination and the potential for inadequate quality of care that may jeopardize the health and safety of other patients undergo the MRI examination.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47360 Based on interview and record review, the facility failed to maintain an organized Nursing Services to two of 32 sampled patients (Patient 22 and 32), as evidenced by: 1. For Patient 22, acetaminophen (Tylenol-a medication used for pain) was not administered according to the physician’s order.(Refer to tag A0398) 2. For Patient 32, there was no documented “hand-off” (one healthcare provider tells another provider all the important, up-to-date info about a patient) communication between patient care unit s ( Emergency department (ED- unit in the hospital where the patients come to receive care in case of an emergency) to pediatric unit (Peds- unit specialized for pediatric patients) and Peds to Magnetic Resonance Imaging ( MRI- a medical examination performed using a magnetic resonance imaging).(Refer to tag A0398) 3. For Patient 32, there was no documented skin assessment upon admission to the pediatric unit or by the Post Anesthesia Care Unit (PACU) after completion of the MRI..(Refer to tag A0398) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of safe and quality nursing care in a safe environment.”

“RADIOLOGIC SERVICES CFR(s): 482.26 The hospital must maintain, or have available, diagnostic radiological services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. This Condition is not met as evidenced by: 47360 Based on interview and record review, the facility failed to ensure Magnetic Resonance Imaging (MRI- a detailed scan that uses a powerful magnet, radio waves, and a computer to create clear pictures of your body’s insides, like organs, soft tissues (brain, muscles, ligaments), and bones, helping doctors diagnose problems without X-rays or radiation) Safety Procedures were followed for one of 32 sampled patients (Patient 32) when: 1. For Patient 32, the MRI Safety policy and procedure (P&P) was not followed and non-compatible (contains metal that will be dangerously pulled, heated, or damaged by the MRI’s powerful magnet) MRI monitoring leads (tiny electrical sensors that stick to your skin to read your body’s natural electrical signals to monitor your heart beat) were left on patient’s back and chest when in MRI room Zone IV (the MRI scan room containing the powerful MRI magnet; the highest risk area where only cleared, screened individuals and MR-safe equipment are allowed, supervised by personnel).(Refer to tag A0535) 2. For Patient 32, MRI and radiology personnel did not complete an “unusual occurrence report” (a formal report anything unexpected or out-of-the-ordinary that happens in a hospital or clinic, especially if it could hurt a patient, visitor, or staff, like a patient falling, wrong medicine given, equipment breaking, or even a fire, so the facility can figure out what went wrong and stop it from happening again) system.(Refer to tag A0535) 3. For Patient 32, the facility did not follow P&P regarding patient monitoring between MRI scans.(Refer to tag A0535) The cumulative effect of these failures resulted in a full-thickness burn (severe burn injury that affects both layers of skin) to Patient 32’s back after receiving a diagnostic MRI.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47360 Based on interview and record review, the Governing Body (GB- a group of people responsible for the overall direction and management of an organization) failed to identify and ensure patient safety and provide quality of care for two of 32 sampled patients when the GB did not maintain an effective oversight on medication administration, incomplete assessments, missing hand-off report between patient care units and inadequate safety procedure in the Magnetic Resonance Imaging (MRI a detailed scan that uses a powerful magnet, radio waves, and a computer to create clear pictures of your body’s insides, like organs, soft tissues, and bones, helping doctors diagnose problems without X-rays or radiation ) department. These failures resulted in the facility’s failure to identify the problem prone areas and deliver care with the GB oversight and to provide safe patient care environment with adequate supervision, which could jeopardize the health and safety of the patients. Findings: During a review of the facility document titled, “Executive Committee” (EC) dated November 11, 2025, the document indicated quality of care outcomes and identified safety concerns are discussed at monthly meetings per department reporting to the executive committee. There was no MRI safety documentation, and Pediatric Patient Safety only covered notifying the pediatric transport team for critical transport. During an interview on December 18, 2025, at 4:45 PM, in the conference room, with the members of the Executive Committee (Governing board), the survey team’s following findings were discussed: - For Patient 32, the MRI Safety policy and procedure (P&P) was not followed and non-compatible (contains metal that will be dangerously pulled, heated, or damaged by the MRI’s powerful magnet) MRI monitoring leads (tiny electrical sensors that stick to your skin to read your body’s natural electrical signals to monitor your heart beat) were left on patient’s body when in MRI room Zone IV (the MRI scan room containing the powerful MRI magnet; the highest risk area where only cleared, screened individuals and MR-safe equipment are allowed, supervised by personnel) resulted in full thickness burns (burn through all layers of skin) to Patient 32’s back post MRI. Additionally, there was no documented hand-off communication between patient care units and initial skin assessment upon admission to the pediatric unit or post MRI in the Post Anesthesia Care Unit (PACU - recovery room). - For Patient 22, acetaminophen (Tylenol-a medication used for pain) was not administered according to the physician’s order. The Assistant Hospital Administrator (AHA) stated, skin assessments and reassessments are being tracked as part of the hospital acquired pressure injury (HAPI - skin damage from staying in one position too long, cutting off blood flow, ranging from red, unbroken skin (Stage 1) to deep wounds down to bone (Stage 4) focus and are regularly reported to EC, but are not continuously monitored for every patient or pertaining particularly to pediatrics, unless there is a risk for or development of a HAPI. The AHA stated, documentation of hand-off (including patient assessment and patient plan), was not a focus by EC currently. The AHA stated, the EC will review the MRI safety procedure case after the radiology safety committee reviews and then will present it to the EC. The AHA stated, the EC has overall accountability and responsibility of patient care and safety in the hospital. The AHA stated, when opportunities are identified, it was the responsibility of the EC to provide oversight of corrective actions and ensure trends are moving in the right direction. During a review of the facility’s document titled, “Hospital Quality and Patient Safety Program Description Annual Work Plan and Evaluation” dated May 2, 2025, the document indicated, “ ...The Board of Directors of [Name of Hospital], the governing body, through its Quality and Health Improvement Committee (“QHIC”) oversees each hospital’s Quality and Patient Safety Program (“Program”) ... The Board of Directors’ QHIC has set an expectation that the hospital administrator in partnership with the Chief of Staff will identify, prioritize and remedy quality and safe patient care issues as they occur, consistent with the parameter of the quality plan ...”. During a review of the facility document titled, “Professional Staff Bylaws Rules & Regulations [Name of Hospital]”, dated 2023, the document indicated, “ ...The purpose of this organization shall be: a. To foster, promote and oversee the quality of healthcare, toward the objective that all persons admitted to the Hospital or treated in the Emergency Department shall receive appropriate, cost-effective care of a quality consistent with acceptable standards of hospital and professional practice. B. To promote and foster continuing education and maintain acceptable educational standards ...c. acceptable standards of performance of the medical administrative responsibilities of the Professional Staff ...d ...acceptable professional, technical and ethical standards ... Section E-16 Quality and Performance Improvement Leadership Committee ...The committee shall evaluate the quality and safety the quality and safety of patient care through ongoing monitoring and analysis of data and performance improvement activities. Committee function shall include, but need not be limited to , coordinating departmental quality improvement and risk management activities for all practitioners, collection of appropriate data required for quality improvement decision making function, identifying problem areas in healthcare or clinical performance, monitoring the programs designed to evaluate the quality and appropriateness of care, monitoring and evaluating the effectiveness of corrective actions taken and identifying opportunities to improve health care ...”.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 47360 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for two of 32 sampled patients (Patient 22 and 32), QAPI did not monitor, collect and analyze quality data related to MRI patient safety and unusual occurrence reporting, medication administration, nursing assessments and hand-off report between patient care areas. This failure resulted in the hospital’s inability to identify problem prone areas and ensure the provision of quality health care and nursing services in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health) which collaboratively contributed to Patient 32 suffering a full thickness burn during an MRI examination and the potential for inadequate quality of care that may jeopardize the health and safety of other patients undergo the MRI examination. Findings: During a review of the facility document titled, “[Name of Hospital] Area Radiation Safety Committee” dated September 19, 2025, the document indicated, the radiology department monitored radiation safety and dosimetry (the science of measuring radiation exposure and ensuring staff do not exceed set limits). The document further indicated, there was documented focus for specific to MRI. During a review of the facility document titled, “Patient Safety Leadership Committee ...Meeting Minutes” dated November 21, 2025, the document indicated, patient assessment, reassessment, and hand-off report between patient care areas were not identified as focus areas. During an interview on December 19, 2025, at 4:06 PM, with the representatives (seven members) for the Quality and Health Improvement Committee (QHIC) , the following findings were reviewed: radiology staff failed to follow the facility’s MRI safety policy and procedure (P&P) and “near misses” not being reported in MRI; nursing services failed to perform medication administration per orders, assessments and reassessments per P&P, and failed to provide hand-off report in-between patient care departments. - For Patient 32, the MRI Safety policy and procedure (P&P) was not followed and non-compatible (contains metal that will be dangerously pulled, heated, or damaged by the MRI’s powerful magnet) MRI monitoring leads (tiny electrical sensors that stick to your skin to read your body’s natural electrical signals to monitor your heart beat) were left on patient’s body when in MRI room Zone IV (the MRI scan room containing the powerful MRI magnet; the highest risk area where only cleared, screened individuals and MR-safe equipment are allowed, supervised by personnel) resulted in full thickness burns (burn through all layers of skin) to Patient 32’s back post MRI. Additionally, there was no documented hand-off communication between patient care units and initial skin assessment upon admission to the pediatric unit or post MRI in the Post Anesthesia Care Unit (PACU - recovery room). - For Patient 22, acetaminophen (Tylenol-a medication used for pain) was not administered according to the physician’s order. The Assistant Hospital Administrator (AHA) stated, radiology safety committee metrics are tracked and reviewed quarterly and focus on radiation exposure, shielding and patient care issues. The AHA stated, the incident involving Patient 32 suffering a burn during MRI had been investigated, but the findings had not been discussed in the Radiation Safety Committee meeting. The AHA stated, the meeting was to be held today December 19, 2025, at which time this incident was to be discussed, but had to be moved to January 2026 because of the survey. The AHA stated, the facility did not identify and analyze quality concerns related to MRI safety practices including failure to remove non-compatible equipment, failure to report a near-miss event, and lack of documented monitoring between scans prior to Patient 32 suffering the burn. The AHA stated, pediatric assessments, reassessments and hand-off reports have not been a focus item in quality reporting. The Chief Operating Officer (COO) stated managers track their own data on each unit and there is a number of patient care metric being tracked each month. The COO stated, any incident that involves patient harm is investigated and an action plan is put into place immediately. The COO stated this incident is not reflected in committee meeting minutes because it will rise to the respective committees and then escalate to quality and governing body. During a review of the facility’s document titled, “Hospital Quality and Patient Safety Program Description Annual Work Plan and Evaluation” dated May 2, 2025, the document indicated, “ ...The Quality and Patient Safety Program structure and oversight ensures that consistent and systematic efforts are maintained to continually measure, assess, and improve processes and outcomes related to services provided ... establishing structures and processes that focus on safety and quality, improving the health care safety of patients and reducing preventable adverse patient events ...”.”

“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: 47360 Based on interview and record review the facility failed to ensure the nursing staff adhered to the policy and procedure (P&P) for two of 32 sampled patients (Patient 22 and 32) when: 1. For Patient 22, acetaminophen (Tylenol-a medication used for pain) was not administered according to the physician’s order. This failure had the potential to cause adverse health outcomes such as ineffective pain management and unrelieved pain which could negatively affect Patient 22’s health and safety by unable to participate in treatment plan due to unrelieved pain with unsafe medication administration and could prolong hospitalization of Patient 22. 2. For Patient 32, there was no documented “hand-off” (one healthcare provider tells another provider all the important, up-to-date info about a patient) communication between patient care units Emergency department (ED-unit in the hospital where the patients come to receive care in case of an emergency) to pediatric unit (PEDS- unit specialized for pediatric patients) and PEDS to Magnetic Resonance Imaging ( MRI- a medical examination performed using a magnetic resonance imaging). 3. For Patient 32, there was no documented skin assessment upon admission to the pediatric unit or by the Post Anesthesia Care Unit (PACU) after completion of the MRI. These failures had resulted in miscommunication between the healthcare team and improper nursing skin assessment which had contributed to Patient 32’s skin burnt from the cardiac monitoring leads (devices placed on the skin that connect to wires, sending the heart’s signals to a monitor) and had the potential to increase the risk of undetected skin integrity issues and interrupt in patient care. Findings: 1. During a review of Patient 22’s “face sheet” (demographic data), the “face sheet” indicated, Patient 22 was admitted to the facility on December 15, 2025, with the diagnosis of syncope (a condition in which a person temporary loss of consciousness and posture due to brief drop in blood flow to brain). During an interview on December 19, 2025, at 1:10 PM, with Registered Nurse 1 (RN 1), RN1 stated, nurses are expected to administer pain medications based on the pain scale (a tool used to assess patient’s pain, ranging from zero as no pain to 10 as the worst pain) and as per the physician order. RN 1 further stated, if medication was not given according to the physician order for pain scale, nurses should obtain a new order or notify a physician. During a concurrent interview and record review on December 19, 2025, at 1:30 PM, with the Assistant Hospital Administrator (AHA), Patient 22’s “Physician order”, dated from December 15, 2025, through December 19, 2025, was reviewed. The “Physician order” indicated, Patient 22 was ordered to have Tylenol 650 milligram (mg-a unit of measurement) for pain scale of 1 to 3 (mild pain) and Oxycodone IR (an immediate release pain medication for the short-term management of moderate to severe pain) 5 mg for a pain scale of 4 to 6 (moderate pain). The AHA acknowledged the physician order for pain medication in accordance with pain scale. During a concurrent interview and record review on December 19, 2025, at 1:31 PM, with the AHA, Patient 22’s “Medication Administration Record” (MAR), dated from December 15, 2025, through December 17, 2025, was reviewed. The MAR indicated, on December 16, 2025, at 1:00 PM, Patient 22 received Tylenol 650 mg for pain scale of 6. The AHA stated that Tylenol 650 mg was ordered for mild pain with a pain scale of 1 to 3. The AHA acknowledged that that medication was not given as ordered. During a concurrent interview and record review on December 19, 2025, at 1:35 PM, with the AHA, the facility’s P&P titled, “Medication Administration”, dated January 1, 2025, was reviewed. The P&P indicated, “ ...81.0 Purpose to Ensure accurate and safe medication administration and documentation and to delineate those staff members who are authorized to administer medications ... 4.10 License personnels are responsible for the following related to medication administration: 4.10.8 verifying the medication is being administered at the proper time, at the prescribed dose, and by the correct route ...” The AHA verified and stated that the policy was not followed. The AHA further stated that the nurses should have followed the prescribed order or notified a physician to request a change of medication order. 2. During a review of Patient 32’s “History and Physical” (H&P - a document including patient’s medical history, physical exam, and treatment plan), dated September 13, 2025, the H&P indicated Patient 32 had a growing sacral (the sturdy, triangular bone at the very bottom of your spine, just above your tailbone (coccyx), that connects your spine to your pelvis and hips) mass (any abnormal lump, swelling, or collection of tissue that’s larger than normal, detected by touch or scans), that was progressively becoming more painful and altering Patient 32’s ability to walk. The H&P indicated, Patient 32 was admitted to the pediatric unit with a plan to perform a sedated MRI scan. During a review of Patient 32’s “Events,” dated September 13, 2025, the “Events” indicated Patient 32 was admitted to observation at 10:53 AM, and a bed was requested on the pediatric unit and Patient 32 was transferred to the pediatric unit at 12:08 PM. During a concurrent interview and record review on December 17, 2025, at 10:00 AM, with the Manager of Pediatrics and Pediatric Intensive Care U nit (MPP), Patient 32’s “Flowsheet,” dated September 13, 2025, was reviewed. There was no documented evidence of report being given from the ED nurse and the receiving nurse in the pediatric unit. The MPP stated, he looked at Patient 32’s notes around the time of admission and the Nurse Knowledge Exchange (NKE), and there was no documented evidence of a report between the two patient departments. The MPP stated that the importance of a hand off report is to communicate patient medical background, vital sign (measure the basic functions of your body, including your body temperature, blood pressure, pulse and breathing rate) trends, reason for transfer or admission and patient plan. During an interview on December 18, 2025, at 1:30 PM, with RN 2, RN 2 stated, she did not exactly recall receiving report from the ED regarding Patient 32. RN 2 stated, she does recall the patient being brought to the unit by transport and accompanied by family. RN 2 stated, it is important to receive reports to communicate information pertinent to the patient admission. RN 2 stated, generally the person giving report, document that the report was given. During a review of Patient 32’s “Audit Information,” dated September 13, 2025, the “Audit Information” indicated Patient 32’s MRI Screening Questionnaire Form (questions about metal in your body and medical history to ensure safety, because the strong magnet can pull on metal, making the scan dangerous if metal is present in or around patient) was completed at 3:12 PM, and Patient 32’s MRI exam began at 5:06 PM. During a concurrent interview, and record review on December 17, 2025, at 10:00 AM, with the MPP, Patient 32’s “Flowsheet” dated September 13, 2025, was reviewed. There was no documented evidence of report being given from the pediatric nurse and the receiving MRI technician prior to Patient 32’s MRI examination in Patient 32’s notes or NKE. During an interview on December 18, 2025, at 1:30 PM, with RN 2, RN 2 stated, Patient 32’s MRI Questionnaire was completed in the pediatric unit with the assistance of Patient 32’s family. RN 2 stated, because Patient 32 required sedation, the MRI was coordinated between the MRI tech and the anesthesia (specialty that provides medication that decreases level of consciousness and pain during procedures) department. RN 2 stated, MRI would call when ready to perform the exam and send transport. RN 2 stated, cardiac monitoring leads were not removed from Patient 32 prior to transport because Patient 32 was fussy and she could not recall if that was communicated to the MRI technician. RN 2 stated she was not certain if or who she gave report to in MRI prior to Patient 32’s MRI exam, but reported it is not a common practice to give report to imaging or a department that is not nursing to a nursing unit. During a record review of Patient 32’s “Multi-Discipline Progress Note” dated September 14, 2025, indicated “ ...Report from PACU was obtained around [9:00 PM] and the patient was brought up to PEDS unit around [9:15 PM]. Upon initial assessment, patient was fussy and irritable. When assessing patient’s sacral mass, skin assessment was performed, and a wound was noted on the patient’s back ...Both parents and family stated that the wound was not there prior to admission or prior to MRI. Pictures of the wound were taken ...The wound was measured to be approximately 2cm [centimeter-cm-unit of measurement] x 2cm ...”. During a record review of Patient 32’s “Wound Consult” dated September 14, 2025, the “Wound Consult” indicated, “ ...Noted injury to her mid back with grayish black base and clear outline. Per pts nurse it is believed that the injury is a burn caused by a lead that was left on [patients] back. It is presumed that it must heave heated up during MRI causing burn. Injury appears as a full thickness burn, base is soft grayish/black tissue with well defined borders that are in the same shape as suspected device that caused injury ...”. During a review of the facility’s P&P titled, “Warm Hand Off Communication,” dated November 2022, the P&P indicated, “ ...PURPOSE: 1. Improve the effectiveness of communication among caregivers to ensure the safety and continuity of patient care. 2. To provide accurate, clear, and complete information using interactive communication about patient’s care, treatment, services, current condition, and any recent or anticipated changes. DEFINITIONS: 1. In addition to shift change there are many other patient care/ caregiver transitions. Each time there is patient care/caregiver transition there is a hand off ...PROVISIONS/PROCEDURE ...2. Nursing will verify that Nurse Knowledge Exchange (NKE) has been completed at the bedside by both nurses, by documenting in [Name of Hospital electronic charting system].” 3. During a concurrent interview, and record review on December 17, 2025, at 10:00 AM, with the MPP, Patient 32’s “Flowsheet,” dated September 13, 2025, at 1:00 PM, was reviewed. There was no documented evidence of skin assessment upon Patient 32’s admission to the Pediatric Unit. The MPP stated, a skin assessment is a component of the admission assessment and should have been documented by the nurse. During a concurrent interview and record review on December 18, 2025, at 1:30 PM, with RN 2, Patient 32’s “Flowsheet,” dated September 13, 2025, at 1:00 PM, was reviewed. The “Flowsheet” indicated Patient 32’s admission assessment but did not include a skin assessment. RN 2 stated the admission assessment is a head-to-toe assessment that includes a skin assessment. RN 2 stated, Patient 32’s skin was assessed and there were no wounds noted. RN 2 stated, she does not recall why she did not document the skin assessment but recalls performing the assessment. RN stated, the importance of a skin assessment is to address any skin issues. During a concurrent interview, and record review on December 17, 2025, at 10:00 AM, with the MPP, Patient 32’s “Flowsheet,” dated September 13, 2025, at 7:56 PM, was reviewed. There was no documented evidence of skin assessment for Patient 32 by the Post-Anesthesia Care Unit (PACU- where a patient is recovered after anesthesia) nurse after Patient 32’s MRI scan was complete. The MPP stated, that the PACU nurse performed an assessment but did not include a complete skin assessment after Patient 32’s MRI examination. During a record review of Patient 32’s “Multi-Discipline Progress Note” dated September 14, 2025, indicated “ ...Report from PACU was obtained around [9:00 PM] and the patient was brought up to PEDS unit around [9:15 PM]. Upon initial assessment, patient was fussy and irritable. When assessing patient’s sacral mass, skin assessment was performed and a wound was noted on the patient’s back ...Both parents and family stated that the wound was not there prior to admission or prior to MRI. Pictures of the wound were taken ...The wound was measured to be approximately 2cm x 2cm ...”. During a record review of Patient 32’s “Wound Consult” dated September 14, 2025, the “Wound Consult” indicated, “ ...Noted injury to her mid back with grayish black base and clear outline. Per pts nurse it is believed that the injury is a burn caused by a lead that was left on [patients] back. It is presumed that it must heave heated up during MRI causing burn. Injury appears as a full thickness burn, base is soft grayish/black tissue with well defined borders that are in the same shape as suspected device that caused injury ...”. During an interview on December 19, 2025, at 11:00 AM, with RN3, RN 3 stated a PACU nurse is responsible for recovering patients after receiving anesthesia for surgical procedures and sometimes exams. RN 3 stated, when a PACU nurse receives the patient from anesthesia the expectation for monitoring is every 15-minute vital signs and a head-to-toe assessment, which includes a full skin assessment, even if the patient is coming from a radiology (a branch of medicine that uses imaging technology to look inside the body and diagnose diseases or injuries) exam. During a review of the facility’s P&P titled, “Patient Assessment,” dated August 2023, the P&P indicated, “ ...Each patient will be assessed and documented upon admission and at appropriate intervals thereafter to determine his/her needs for care ...Assessments will consider, as appropriate, the patient’s biophysical needs ...Each patient’s need for nursing care will be assessed by a Registered Nurse ...”.”

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 47360 Based on interview and record review, the facility failed to ensure Magnetic Resonance Imaging (MRI a detailed scan that uses a powerful magnet, radio waves, and a computer to create clear pictures of your body’s insides, like organs, soft tissues (brain, muscles, ligaments), and bones, helping doctors diagnose problems without X-rays or radiation) Safety Procedures were followed for one of 32 sampled patients (Patient 32) when: 1. For Patient 32, the MRI Safety policy and procedure (P&P) was not followed and non-compatible (contains metal that will be dangerously pulled, heated, or damaged by the MRI’s powerful magnet) MRI electrodes (tiny electrical sensors that stick to your skin to read your body’s natural electrical signals to monitor your heart beat) were left on patient when in MRI room Zone IV (the MRI scan room containing the powerful MRI magnet; the highest risk area where only cleared, screened individuals and MR-safe equipment are allowed, supervised by personnel). 2. For Patient 32, MRI and radiology personnel did not complete an “unusual occurrence report” (a formal report anything unexpected or out-of-the-ordinary that happens in a hospital or clinic, especially if it could hurt a patient, visitor, or staff, like a patient falling, wrong medicine given, equipment breaking, or even a fire, so the facility can figure out what went wrong and stop it from happening again) system. 3. For Patient 32, the facility did not follow P&P regarding patient monitoring between MRI scans. These failures resulted in a full-thickness burn (severe burn injury that affects both layers of skin) to Patient 32’s back, pain and distress, that caused further emotional distress and feeling of helplessness for Patient 32’s parents and family. Additionally, these failures had the potential for further inability to identify process issues that could lead to inadequate patient safety and quality of care in MRI. Findings: 1. During a review of Patient 32’s “History and Physical” (H&P - a document including patient’s medical history, physical exam, and treatment plan), dated September 13, 2025, indicated Patient 32 was a 21 month old with an growing sacral (the sturdy, triangular bone at the very bottom of your spine, just above your tailbone (coccyx), that connects your spine to your pelvis and hips) mass (any abnormal lump, swelling, or collection of tissue that’s larger than normal, detected by touch or scans), that was progressively becoming more painful and altering Patient 32’s ability to walk. The “H&P” indicated, Patient 32 was admitted to the pediatric unit with a plan to perform a sedated MRI scan later that day. During a review of Patient 32’s “Flowsheet” dated September 13, 2025, at 5:2 7 AM, the “Flowsheet” indicated Patient 32’s skin was warm, dry and intact (free from any wounds or scratches). During an interview on December 17, 2025, at 10:00 AM, with the Manager of Pediatrics and Pediatric Intensive Care Unit (MPP), the MPP stated leads are used to measure vital signs (heart rate and breathing rate) for admitted patients on the pediatric unit. The MPP stated, he recalled Patient 32 was very active and was pulling at the leads, she then had leads placed on her back to prevent Patient 32 from pulling them off. The MPP stated, Patient 32 did not require cardiac monitoring (record the heart’s electrical activity), the leads were placed only to monitor vital signs. During a phone interview on December 18, 2025, at 8:18 AM, with Anesthesiologist Physician (AP), AP stated, he recalled Patient 32 and stated he was observing the patient as Certified Registered Nurse Anesthetist (CRNA) prepared Patient 32 for MRI in Zone IV. AP stated, CRNA 1 was carrying (holding) Patient 32 in the MRI room zone IV. AP stated, he and Radiology Technician 1 (RT 1) observed wires from monitoring leads hanging out of Patient 32’s gown. AP stated, he then entered MRI Zone IV and removed three leads from Patient 32’s back and four adult leads from Patient 32’s chest. AP stated that he did not check Patient 32’s gown specifically for monitoring leads. AP stated, Patient 32 should not have had leads on when being brought into Zone IV. AP stated, he thought this incident was a “near-miss” until Patient 32 was found to have a burn on the back after MRI. During a concurrent interview and record review on December 19, 2025, at 1:35 PM, with RT 1, Patient 32’s “MRI Screening Questionnaire” (questions about metal in your body and medical history to ensure safety, because the strong magnet can pull on metal, making the scan dangerous if metal is present in or around patient) completed by RT 1 on September 13, 2025 at 4:25 PM, was reviewed. The “MRI Screening Questionnaire” indicated, Patient 32 was screened by RT 1 with a ferromagnetic detector (wand - sensitive sensor to find strong magnetic metal and alarms if someone does have metal in or on their person, preventing dangerous accidents with the powerful MRI magnet) and cleared to proceed with the MRI scan. RT 1 stated, the process is to review the MRI Questionnaire with the patient and then wand the patient to identify if there is any ferromagnetic metal (magnetic) on or within the patient. RT 1 stated, he did not use the wand per P&P on Patient 32 prior to Patient 32 entering MRI Zone IV and performing MRI scan. RT 1 stated, monitoring leads were noted to be on patient in MRI Zone IV RT 1 stated, a total of seven leads were removed from Patient 32 in Zone IV. RT 1 stated, the purpose of using the wand to scan the patient prior to entering Zone IV MRI is to ensure there are no magnetic metals on a patient that can cause injury. During a record review of Patient 32’s “Multi-Discipline Progress Note” dated September 14, 2025, indicated “ ...Report from Post Anesthesia Care Unit (PACU) was obtained around [9:00 PM] and the patient was brought up to [pediatric] unit around [9:15 PM]. Upon initial assessment, patient was fussy and irritable. When assessing patient’s sacral mass, skin assessment was performed, and a wound was noted on the patient’s back ...Both parents and family stated that the wound was not there prior to admission or prior to MRI. Pictures of the wound were taken ...The wound was measured to be approximately 2cm [centimeter-cm-unit of measurement] x 2cm ...”. During a record review of Patient 32’s “Wound Consult” dated September 14, 2025, the “Wound Consult” indicated, “ ...Noted injury to her mid back with grayish black base and clear outline . Per pts [patient’s] nurse it is believed that the injury is a burn caused by a lead that was left on [patients] back. It is presumed that it must have heated up during MRI causing burn. Injury appears as a full thickness burn, base is soft grayish/black tissue with well defined borders that are in the same shape as suspected device that caused injury ...”. During a record review of Patient 32’s “Pediatric Discharge Summary Note” dated September 19, 2025, the “Pediatric Discharge Summary Note” indicated, “ ...Hospital course was complicated by full thickness wound on back after a cardiac lead was accidentally left in place at time of MRI scan. Plastic surgery and wound care consulted ...”. During a concurrent interview and record review, on December 19, 2025, at 2:06 PM, with the MRI Supervisor (MRIS), the facility’s policy and procedure (P&P) titled, “Safety Precautions for Magnetic Resonance Environments”, dated February 2023, was reviewed. The “P&P” indicated, “ ...The MR technologist and trained MR personnel must ensure applicable safety precautions and considerations in the MR environment are always addressed ... The on-site MRI technologist scanning the patient is responsible for ensuring their patient’s safety from ferrous hazards, implanted devices ...All people entering MR Zone IV must be carefully screened for metallic objects in their bodies, on their bodies or attached to their bodies by MR personnel ...Final verification of the MR Screening Questionnaire must be performed by a MR technologist immediately prior to scan and before entering Zone IV ...The use of ferromagnetic detection systems (FMDSs) is recommended as an adjunct to thorough and conscientious screening of persons and devices prior to being permitted into Zone IV ...”. The MRIS stated, there should not be any non-approved MRI material in Zone IV and allowing monitoring leads that are not MRI compatible in Zone IV is a violation of the facility’s policy and procedure. The MRIS stated, the importance of removing all non-approved MRI devices is a patient safety issue, as items can become projectiles or cause burns. During a review of the facility document titled “Job Description: MRI Tech” (JD), dated April 18, 2024, the “JD” indicated, “ ...Essential Responsibilities ...Upholds [Name of Hospital Policies and Procedures ....Ensures patient and staff safety which includes explaining safety protocol, requesting removal of hazardous objects, an alerting staff of danger of carrying metal near magnet ...Performs all routine aspects of MRI procedures ...Interviews patients to obtain information that would manifest safety concerns ...Demonstrates an understanding of the cognitive, physical, emotional and chronological maturation process in delivery of services to patients of the age group served ...Observes all organizational, regional, medical service area and Diagnostic Imaging Department policies and procedures. Maintains standards of professional behavior established to enhance quality of service ...”. 2. During a review of Patient 32’s “History and Physical” (H&P - a document including patient’s medical history, physical exam, and treatment plan), dated September 13, 2025, indicated Patient 32 was a 21 month old with an growing sacral mass (any abnormal lump, swelling, or collection of tissue that’s larger than normal, detected by touch or scans), that was progressively becoming more painful and altering Patient 32’s ability to walk. The “H&P” indicated, Patient 32 was admitted to the pediatric unit with a plan to perform a sedated MRI scan for later that day. During a phone interview on December 18, 2025, at 8:18 AM, with Anesthesiologist Physician (AP), AP stated, he recalled Patient 32 and stated he was observing as CRNA prepared Patient 32 for MRI in Zone IV. AP stated, CRNA 1 was holding Patient 32 in the MRI room zone IV. AP stated, he and Radiology Technician 1 (RT 1) observed wires from monitoring leads hanging out of Patient 32’s gown, AP stated, he and RT 1 then entered MRI Zone IV and removed three leads from Patient 32’s back and four adult leads from Patient 32’s chest. AP stated, that he did not check Patient 32’s gown specifically for monitoring leads. AP stated, Patient 32 should not have had leads on when being brought into Zone IV. AP stated, he thought this incident was a “near-miss” until Patient 32 was found to have a burn on the back after MRI. During an interview on December 19, 2025, at 1:35 PM, with RT 1, RT 1 stated he did not document an “Unusual Occurrence Report” after the monitoring leads were found on Patient 32 in Zone IV. RT 1 stated, the MRI department has “near-misses” often and it is not common practice to report these situations as an “unusual occurrence”. During a concurrent interview and record review, on December 19, 2025, at 2:06 PM, with the MRI Supervisor (MRIS), the facility’s policy and procedure (P&P) titled, “Safety Precautions for Magnetic Resonance Environments”, dated February 2023, was reviewed. The “P&P” indicated, “ ...Reporting Adverse or Unusual Occurrences ...Adverse events including ...where ferromagnetic items entered Zone IV, injuries resulting from the presence of ferromagnetic items in Zone IV, and near misses must be reported immediately using the unusual occurrence reporting (UOR) system ...Additionally, the individual reporting the event shall also notify the MR Safety Officer, the MR Director and the Department Administrator or designee ...”. The MRIS stated, there was an “Unusual Occurrence Report” entered by nursing after the wound was found. The MRIS stated, RT 1 should have entered an Unusual Occurrence Report” related to the monitoring leads being found on Patient 32 in MRI Zone IV. The MRIS stated, the importance of reporting “near-misses” is to give the department opportunity to identify issues and breakdowns in the process prior to an injury. 3. During a review of Patient 32’s “History and Physical” (H&P - a document including patient’s medical history, physical exam, and treatment plan), dated September 13, 2025, indicated Patient 32 was a 21 month old with a growing sacral mass that was progressively becoming more painful and altering Patient 32’s ability to walk. The “H&P” indicated, Patient 32 was admitted to the pediatric unit with a plan to perform a sedated MRI scan for later that day. During a record review of Patient 32’s “Audit Information” dated September 13, 2025, the “Audit information” indicated, Patient 32 had an order for an MRI Exam for Sacrum and coccyx with and without contrast (a special dye used to make specific body parts stand out clearly against normal tissue, helping doctors see problems better. The “Audit Information” indicated, the MRI Exam started at 5:06 PM and ended at 7:29 PM. During an interview on December 19, 2025, at 10:06 AM, with Radiology Technician 2 (RT 2), RT 2 stated, it is not the practice of the radiology staff to move patient’s during the MRI scan. RT 2 stated there are other tools used such as foam padding and towels to protect the skin. RT 2 stated moving the patient would prolong and interrupt the scan. During an interview on December 19, 2025, at 1:35 PM, with Radiology Technician 1 (RT1), RT 1 stated, Patient 32 was visually checked by staff when giving contrast, but not moved or repositioned between scans. During a concurrent interview and record review, on December 19, 2025, at 2:06 PM, with the MRI Supervisor (MRIS), the facility’s policy and procedure (P&P) titled, “Safety Precautions for Magnetic Resonance Environments”, dated February 2023, was reviewed. The “P&P” indicated, “ ...Patients who are unconscious, sedated, or anesthetized shall be examined after each imaging sequence with potential repositioning of the EKG leads and any other electrically conductive material with which the patient is in contact ...”. The MRIS stated, she was not aware of this section in the “P&P”, but acknowledged it is part of the facility’s P&P. The MRIS stated, it is not common practice to reposition the patient during MRI, regardless of sedation or duration of MRI imaging.”

“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: 47360 Based on interview and record review, Facility A failed to implement and maintain it’s Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), when: 1. One of 29 sampled patients (Patient 29), who was 34 weeks pregnant, presented to Facility A seeking emergency medical care after sustaining a fall and was not logged or registered to the labor and delivery (L&D) unit. (Refer to Tag A- 2405) 2. Three of 29 sampled patients (Patients 20, 24 and 29) presented to the L&D unit with an emergency medical condition and were not provided a timely triage or Medical Screening Exam (MSE). (Refer to Tag A-2406) The cumulative effects of these failures resulted in three of 29 sampled patients, to leave without being seen (LBWS) after arriving to the L&D unit for emergency medical care which could delay treatment for critical medical conditions and potentially cause harm to the patient and fetus.”

“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: 47360 Based on interview and record review, Facility A failed to maintain a centralized log for the Labor and Delivery (L&D) unit per it’s Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P) for one of 29 sampled patients (Patient 29) when, Patient 29, who was 34 weeks pregnant, presented to Facility A seeking emergency medical care after sustaining a fall and was not logged. This failure resulted in emotional distress due to Patient 29’s uncertainty about the priority of care for her , and which could jeopardize the health and safety of the patient and her unborn baby. Findings: An unannounced visit was conducted on February 24, 2025, through February 26, 2025, to investigate a possible EMTALA violation. During a review of Facility A’s Emergency Deaprtment (ED) and obstetric (OB- specialty for pregnancy and childbirth) logs indicated, there was no documented evidence to indicate Patient 29 was registered on Facility A’s ED or OB logs, nor was there documentation indicating Patient 29 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized. During an audio/ visual call (Microsoft TEAMS) on February 24, 2025, at 5:30 PM, with Facility B’s Accrediting, Licensing and Regulatory Specialist (ALR 1), Facility B’s “Telephone Encounter OB Advice Call” dated November 5, 2024, at 10:03 PM, was reviewed. The” Telephone Encounter OB Advice Call” indicated, Patient 29 was 34 weeks pregnant and reported a fall, Patient 29 was directed to go to Facility A’s L&D department for evaluation because it was closer to her home. ALR 1 stated, Patient 29 was instructed to follow-up at Facility A because it was closer to her home. ALR 1 further stated, these documents were accessible by Facility A and could be provided to surveyor by them. On February 25, 2025, at 9:16 AM, Patient 29’s documents dated November 5, 2024, by Facility B were reviewed with Facility A’s Maternal Child Educator (MCE), and received the documents as requested. During an interview on February 25, 2025, at 9:32 AM, with Facility A’s Accrediting, Licensing and Regulatory Specialist (ALR 2), ALR 2 taken away the documents from the surveyor and stated, Facility A could not provide Facility B’s documents, even though they belong to same company and are accessible because they are not Facility A’s property. During an interview on February 25, 2025, at 11:08 AM, with Unit Secretary 1 (US1), US1 stated she was able to recall Patient 29. US1 stated, Patient 29 presented to the L&D waiting room and rang the doorbell for the department. US1 stated, Patient 29 had her child with her and US1 inquired if there was another adult with hem to sit with her child, which Patient 29 answered she did not. US 1 Stated, she then informed the triage nurses, who followed the chain of command and called the charge nurse. US1 stated, the charge nurse spoke with Patient 29 in the waiting room. US1 further stated, she was told by the charge nurse there was no need to register Patient 29 to the L&D unit because she had left. During an interview on February 25, 2025, at 3:00 PM, with Charge Nurse 1 (CN1), CN 1 stated she recalled Patient 29 presenting to the L&D Department. CN1 stated, one of the triage nurses informed her that Patient 29 was in the waiting room with a child. CN1 stated, Patient 29 was not originally brought into the department because she had a child. CN1 stated, she inquired if Patient 29 had someone to take care of her child in the event she had an emergency and needed to stay, but Patient 29 stated she did not have anybody. CN 1 sated, during this conversation in the waiting room, Patient 29 decided she was going to leave and go home. CN1 further stated, she did not know if Patient 29 was registered or logged to the unit. During an interview on February 26, 2025, at 10:05 AM, with the Director of the Maternal Child Department (DMC), the DMC stated, she was aware that Patient 29 had been to the unit to request medical care. The DMC stated she did not know why the normal workflow was not followed for Patient 29. The DMC stated, Patient 29 should have been invited into the hall and registered to the L&D unit per the normal workflow. The DMC further stated, Patient 29 should have not been left to stay in the waiting room and should have been registered before escalating to the charge nurse. The DMC stated, there was no policy against unaccompanied minors to be present during the initial assessment and a patient presenting with a child should not delay registration to the unit and medical evaluation. During an interview on February 26, 2025, at 10:35 AM, with Medical Doctor 1 (MD 1), MD 1 stated, when a patient presents with a minor and no other adult, initial patient work-up including registration, triage and a medical screening exam should occur in the same manner as patients presenting without a minor. During a review of the facility’s policy and procedure ( P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer” dated January 9, 2023, the P&P indicated, “It is the policy of [Name of Facility] to comply with the Emergency Medical Treatment and Labor ACT (EMTALA) obligations ...The hospital prohibits actions that would discourage an individual from seeking emergency medical services ...Central EMTALA Log ...Logs will be maintained by the emergency and labor and delivery departments on each person who comes to the hospital seeking medical care ...The log shall be maintained and shall contain at least information about whether the individual refused treatment, and individual’s disposition (e.g., admit, discharge, transfer, LWBS elopement, and leaving against advice) ...”. During a review a review of the facility’s document titled, “Job Description” (JD), dated November 1, 2021, the “JD” indicated, “ ...Domain: RN [Registered Nurse] ...Specialty: Hospital-Labor & Delivery ...Essential Responsibilities ...Leadership: Upholds [Name of Hospital] Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately, and demonstrate appropriate accountability ...Demonstrates professional, supportive behavior ...Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes ...Participates in problem identification and resolution ...Documentation reflects nursing process and interventions and evaluations taken ...”.”

“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: 47360 Based on interview and record review, the facility failed to ensure the policy and procedures (P&P’s) pertaining to the Emergency Medical Treatment and Labor Act (EMTALA) for a timely medical screening examination (MSE) to determine if an emergency medical condition existed and were implemented for three of 29 sampled patients (Patients 20, 24 and 29) when: 1. Patient 20 was registered to the labor and delivery unit (L&D), but there was no triage (the process of sorting patient into groups based on their need for care) by nursing or medical screening exam (MSE- an examination preformed by a qualified medical provider to determine if a patient has and emergency condition) provided prior to Patient 20 leaving without being seen (LWBS - leaving before patient was seen by the provider). 2. Patient 24 was registered to L&D, but there was no triage by nursing or MSE provided prior to Patient 24 leaving without being seen . 3. Patient 29 presented to the L&D unit for medical emergency and was not provided a triage, or MSE. These failures resulted in Patients 20, 24, and 29 not being provided an appropriate triage or MSE to address if these patients had an existing emergency medical condition and had the potential to severely impact the health and welfare of these patients and their fetus (unborn baby). Findings: 1. During a review of the “[Regional Hospital] L&D Admissions EMTALA” (L&D log) dated for January 2025, the (L&D log) indicated, Patient 20 was admitted to L&D on January 23, 2025, at 4:50 PM, for labor symptoms and LWBS on January 23, 2025, at 10:58 PM. During a concurrent interview and record review on February 24, 2025, at 3:10 PM with the Maternal Child Educator (MCE ), Patient 20’s “Encounter” for January 23, 2025, was reviewed. There was no other documentation noted in the Patient 20’s chart for this visit during the six hours Patient 20 was registered to the L&D unit. The MCE stated, there was no documented evidence of a nurse triage, a medical screening exam or the situation leading to Patient 20’s LWBS. The MCE further stated every patient is expected to be triaged by a nurse and the physician to be contacted regarding patient presentation. 2. During a review of the “[Regional Hospital] L&D Admissions EMTALA” (L&D log) dated for February 2025, the L&D log indicated, Patient 24 was admitted to L&D on February 10, 2025, at 3:44 PM, for labor symptoms and LWBS on February 10, 2025, at 7:00 PM. During a concurrent interview and record review on February 24, 2025, at 3:40 PM, with the MCE, Patient 24’s “Encounter” for February 10, 2025, was reviewed. Patient 24’s “Encounter” indicated, “3:51 PM ...Contractions .... RN: ABD [abdominal] Pain/Dizziness ...”. There was no other documentation noted in the Patient 24’s chart for this visit during the three hours Patient 24 was registered to the L&D unit. The MCE stated, the note entered was a “Quick Assessment” by the RN. There was no other documented evidence of a nurse triage, a medical screening exam or the situation leading to Patient 24’s LWBS. The MCE stated, there was no specific requirements regarding charting of a “Quick look” assessment or triage. The MCE further stated, facility had a tirage color system to classify patients that need to be medically screened by the provider immediately and patients that can wait, but there was no charting regarding this triage model in Patient 24’s chart. 3. During a review of Facility A’s Emergency Department (ED) or obstetric (OB- specialty for pregnancy and childbirth) logs indicated,there was no documented evidence to indicate Patient 29 was registered on Facility A’s ED or OB logs, nor was there documentation indicating Patient 29 received a medical screening examination to rule out if an emergency medical condition existed or that the patient was medically stabilized. During an interview on February 26, 2025, at 9:00 AM, with the Director of the Maternal Child Department (DMC), the DMC stated, she was aware Patient 29 had been to the unit to request medical care. The DMC stated she did not know why the normal workflow was not followed for Patient 29. The DMC stated, Patient 29 should have been invited into the hall and registered to the L&D unit per the normal workflow. The DMC further stated, Patient 29 should have not been left to stay in the waiting room and should have been registered before escalating to the charge nurse. During a concurrent interview and record review, on February 26, 2025, at 10:05 AM, with the Maternal Child Manager (MCM), the facility’s P&P titled “Labor and Delivery Triage” dated December 2023, was reviewed. The P&P indicated, “ ...It is the policy of [Name of Hospital] to maintain patient safety by providing consistent and timely care to women who present to Labor and Deliver[y] for triage ...Register patient as an outpatient in [name of electronic chart] ...For all patients presenting to Labor and Delivery Triage ...Initial interview and assessment will be done by an L&D RN ...The nurse shall perform a patient assessment including subjective and objective information to determine the appropriateness for initiating the Standing Orders prior to provider evaluation ...”. The MCMC stated, patients presenting to L&D are registered by the unit secretary and then a nurse will see the patient before they are sent to a waiting room. The MCM stated, the nurse asks for a chief complaint (reason for patient to present to the L&D unit) and any other signs or symptoms and will determine acuity of the patient and decide how quickly the patient needs to be seen. The MCM stated a Quick assessment is gathering information from the patient by asking questions and this depends on what the patient’s chief complaint. The MCM further stated, there was no policy on what is actually included in a triage assessment or “Quicklook” assessment, documentation of these assessments with priority to be seen or a timeline in which these assessments need to be completed. During an interview on February 26, 2025, at 10:32 AM, with Medical Doctor 1 (MD1), M D1 stated, the L&D unit was responsible for registering and triage of any maternal patient that steps foot in the hospital, seeking a medical examination and the L&D obligation does not end until all care is provided until the patient is stable or is appropriately transferred. MD 1 stated, an L&D triage includes mother’s vital signs (measure the basic functions of the body: temperature, heart rate, blood pressure, respiratory rate), fetal doppler (measuring of an unborn baby’s heartbeat), and interview questions tailored to the patient complaints. MD 1 stated, once the triage evaluation is done by the nurse then report is to be given to the provider. MD 1 further stated, if a patient is planning to leave, whether or not they have been evaluated by the provider, the goal is to address any of the patient’s issues before they leave. During a review of the facility’s policy and procedure ( P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer” dated January 9, 2023, the P&P indicated, “ ...It is the policy of [Name of Facility] to comply with the Emergency Medical Treatment and Labor ACT (EMTALA) obligations ...The hospital prohibits actions that would discourage an individual from seeking emergency medical services ...The hospital will provide a MSE by a QMP [Qualified Medical Professional - doctor, nurse practitioner, midwife] to any individual who comes to the hospital seeking emergency medical treatment ...to determine if the individual seeking care has an EMC {Emergency Medical Condition] ... The hospital prohibits actions that would discourage an individual from seeking emergency medical services ...Triage ...As soon as practical after arrival, all individuals who come to the emergency department or labor and delivery department for medical treatment will be triaged to determine the order in which they will receive an MSE ...All reasonable efforts should be made to conduct a MSE before the individual leaves, with documentation of the discussions and efforts made to prevent the individual from leaving ...Staff will attempt to obtain the individual’s signature on the form documenting the individual refused an MSE ...If the individual refuses to sign the form, a notation to such should be made by the [staff] ...”