Contra Costa Regional 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: 50146 This Standard is not met as evidenced by: Based on interview and record review, the hospital failed to provide necessary stabilizing treatment when, for four of five sampled patients (Patients 8, 11, 13, and 14), the hospital did not perform any interventions for multiple complaints of significant pain. The failure of the hospital to perform interventions for patients’ pain placed all patients receiving care at the hospital at risk of experiencing further untreated pain. (Refer to A-2407.) Findings: A review of the “Vital Signs” records for Patients 8, 11, 13, and 14 indicated that Patients 8, 11, 13 and 14 all did not receive adequate intervention for significant complaints of pain. Refer to A-2407.”

“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: 50146 Based on interview and record review, the hospital failed to provide necessary treatment when, for four of five sampled patients (Patients 8, 11, 13, and 14), the hospital did not perform any interventions for multiple complaints of significant pain. The failure of the hospital to perform interventions for patients’ pain placed all patients receiving care at the hospital at risk of experiencing further untreated pain. Findings: During a review of the untitled hospital facesheet (a document used to communicate the most pertinent information about a patient), undated, for Patient 8, the facesheet indicated Patient 8 was admitted to the facility in July 2025. During a review of the “[Hospital] ED [Emergency Department] Note” for Patient 8, dated 7/26/25, the “ED Note” indicated Patient 8 came to the ED in July 2025 with a chief complaint of bleeding during pregnancy. During a concurrent interview and record review on 4/27/26 at 1:00 p.m. with the Registered Nurse (RN), the “Vital Signs” flowsheet for Patient 8, dated 7/26/25, was reviewed. The flowsheet indicated Patient 8 reported a pain score of six out of ten (indicating moderate-to-severe pain) on 7/26/25 at 3:58 p.m., and no intervention was performed to alleviate Patient 8’s pain. RN confirmed no interventions were documented as performed for Patient 8’s report of pain. During a review of the untitled hospital facesheet, undated, for Patient 11, the facesheet indicated Patient 11 was admitted to the hospital’s emergency department in March 2025. During a review of the “[Hospital] ED Note” for Patient 11, dated 3/1/2025, the “ED Note” indicated Patient 11 came to the ED in March 2025 with a chief complaint of bleeding during pregnancy with lower abdominal pain. During a concurrent interview and record review on 4/27/26 at 1:27 p.m. with RN, the “Vital Signs” flowsheet for Patient 11, dated 3/1/25, was reviewed. The flowsheet indicated Patient 11 reported a pain score of six out of ten on 3/1/25 at 7:11 p.m., and reported a second pain score of six out of ten on 3/1/25 at 10:06 p.m., and no intervention was performed to alleviate Patient 11’s pain either time. RN confirmed no interventions were documented as performed for Patient 11’s reports of pain. During a review of the untitled hospital facesheet, undated, for Patient 13, the facesheet indicated Patient 13 was admitted to the hospital’s emergency department in January 2026. During a review of the “ED Provider Notes” for Patient 13, dated 1/29/26, the “ED Provider Notes” indicated Patient 13 came to the ED in January 2026 with a chief complaint of bleeding during pregnancy with right-sided lower pelvic pain. During a concurrent interview and record review on 4/27/26 at 1:27 p.m. with RN, the “Vital Signs” flowsheet for Patient 13, dated 1/29/26, was reviewed. The flowsheet indicated Patient 13 reported a pain score of six out of ten on 1/29/26 at 1:38 p.m., and a second reported pain score of five out of ten (indicating moderate pain) on 1/29/26 at 5:47 p.m.. No interventions were performed to alleviate Patient 13’s pain in either case. RN confirmed no interventions were documented as performed for Patient 13’s reports of pain. During a review of the untitled hospital facesheet, undated, for Patient 14, the facesheet indicated Patient 14 was admitted to the hospital’s emergency department in March 2026. During a review of the “[Hospital] ED Note” for Patient 14, dated 3/9/26, the “ED Note” indicated Patient 14 came to the ED in March 2026 with a chief complaint of lower pelvic pain. During a concurrent interview and record review on 4/27/26 at 1:27 p.m. with RN, the “Vital Signs” flowsheet for Patient 14, dated 3/9/26, was reviewed. The flowsheet indicated Patient 14 reported a pain score of seven out of ten (indicating severe pain) on 3/9/26 at 7:16 p.m., and a second reported pain score of six out of ten on 3/9/26 at 11:27 p.m.. No interventions were performed to alleviate Patient 14’s pain in either case. RN confirmed no interventions were documented as performed for Patient 14’s reports of pain. During an interview on 4/27/26 at 2:37 p.m. with RN, RN stated when patients complain of pain, the staff assigned to the patients will let the doctors know and advocate for pain control methods. RN stated the risks of untreated pain include further pain, infection, and dissatisfaction with the care provided. During a review of the hospital’s policy and procedure (P&P) titled “Policy for Pain Management”, dated 3/04 and last reviewed 11/22, the P&P indicated, “Interventions to treat and manage the patient’s pain will be provided ...””