Kaiser Foundation Hospital - Baldwin Park

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50515 Based on observation, interview and record review, the facility failed to provide personal privacy for one out of 30 sampled patients (Patient 24), when patient 24’s room door was not closed, nor curtains drawn, to ensure Patient 24’s privacy during a medical procedure, in accordance with the facility’s policy and procedure regarding Patient rights. This deficient practice resulted in Patient 24’s personal privacy being exposed to the general public within the care area, which could have negatively affected Patient 24’s right to dignity and privacy. Findings: During a review of Patient 24’s “Face Sheet (a document containing a patient’s medical and demographic information),” undated, the face sheet indicated Patient 24 was admitted to the facility on 5/15/2024 at 11:25 p.m., with a medical diagnosis of vertebral fracture (broken back). During an observation on 5/28/2024 at 3:30 p.m. on the fifth-floor unit, the door to isolation room 5050 was noticed to be wide open. A staff member (Phlebotomist, (PL) - a medical professional trained to perform blood collection) was inside the patient room, collecting blood from Patient 24 with no curtains drawn nor the door closed. During a concurrent observation and interview on 5/28/2024 at 3:32 p.m. with the Director of Risk Management and Patient Safety (DRM) on the fifth-floor unit, in front of isolation room 5050, the DRM stated the door or curtains should be closed to protect patient privacy. The DRM stated Patient 24 was in isolation, so no curtains were available for the room, but the patient’s room door should have been closed. During a concurrent observation and interview on 5/28/2024 at 3:34 p.m., with the PL in front of room 5050, the PL was questioned regarding patient right and privacy. The PL stated he was aware the room door should be closed, or the curtains drawn closed when doing a procedure with a patient. The PL stated, he closed the door for Patient 24’s procedure in room 5050, but someone else came in the room and left the door open. The PL stated he should have asked them to close the door while the procedure was still being completed for Patient 24. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” revised April 2023, the P&P indicated, “The patient has the following rights to: have personal privacy respected ...have privacy curtains used in semi-private rooms.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 42976 Based on observation, interview and record review, the facility failed to obtain a physician’s order for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for one of 30 sampled patients (Patient 14) when all four side rails of Patient 14’s bed were raised, in accordance with the facility’s policy and procedure regarding restraints use. This deficient practice resulted in Patient 14 being restrained without a physician’s order and had the potential to compromise patient safety with complications such Patient 14 attempting to get out of the bed and falling to the ground or strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc. Findings: During a concurrent observation and interview on 5/29/2024 at 10:39 a.m., at Patient 14’s room, with Director of Nursing Operations (DNO) 1, Patient 14 was observed awake with all 4 side rails of her (Patient 14) bed up. DNO 1 stated the following: All 4 side rails for Patient 14 should not be up. It is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when 4 side rails are up. Does not know why all 4 side rails are up for Patient 14 at this time. During an interview on 5/29/2024 at 10:43 a.m., at Patient 14’s room, with Registered Nurse (RN) 4. RN 4 stated the following: 4 side rails up for Patient 14 is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). There are other alternatives to used beside a restraint to prevent Patient 14 from falling. RN 4 said he (RN 4) will drop the one of the side rail for Patient 14 at this time. There is no order for restraint for Patient 14. During a review of Patient 14’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/2024, the H&P indicated Patient 14 was admitted to the hospital on 5/05/2024 with pain and weakness. The H&P also indicated Patient 14’s mental status was alert and oriented with no acute distress but appears very tired. During a concurrent interview and record review on 5/29/2024 at 12:26 p.m. with the Manager of Hospital Operations (MHO) 1, Patient 14’s “RN Flow Sheet Assessment (RFSA),” dated 5/2024 was reviewed. The RFSA indicated, on 5/22/2024 to 5/29/2024, there was no assessment documented for restraints use on Patient 14. MHO 1 stated the following: Confirmed no physician order for restraint use in Patient 14’s medical record. There should be an order for restraint use for Patient 14. During an interview on 5/30/2024 at 10:20 a.m. with Director of Nursing Operations (DNO) 1, DNO 1 stated the following: Confirmed there needs to be a physician order for restraint use. Should not have all 4 side rails up for Patient 14 because it a form of restraint. Potential for Patient 14 to injure self when trying to get out of bed. We will re-educate the staff with the policy of Restraint. During a review of the facility’s policy and procedure (P&P) titled “Restraint Use,” dated 2022, the “P&P” indicated “All patients have the right to be free from restraint or seclusion (involuntary confinement of patient alone in a room or an area from which the patient is physically prevented from leaving), of any form ... A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Under this definition, commonly used devices and other practices could meet the definition of a restraint, such as: Using four side rails to prevent a patient from voluntarily getting out of bed. The responsible physician must be notified as soon as possible from the initiation of the restraint, and the physician will provide a telephone or written order for the restraint.””

“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: 42976 Based on interview and record review, the facility failed to ensure hospital staff followed their Informed Consent Policy for one of 30 sampled patients (Patient 13) when staff who consented Patient 13 for a procedure did not accurately complete Patient 13’s consent form in accordance with the facility’s policy and procedure. This deficient practice had the potential for Patient 13 to have an incorrect procedure done. Findings: During an interview on 5/29/2024 at 10:24 a.m., with Registered Nurse (RN) 2, RN 2 stated the following: Patient 13’s preferred language is Spanish. A translator is used to obtain consent for procedures ordered for Patient 13 whose preferred language is Spanish. During a review of Patient 13’s “Face Sheet (FS, a document that gives a patient’s information at a quick glance and includes the patient’s name, date of birth, address, etc.,),” dated 5/2024, the FS indicated Patient 13 was admitted to the facility unit on 5/15/2024 for Severe Sepsis (a condition that happens when the body’s response to an infection damages vital organs and, often, causes death). The FS also indicated Patient 13’s spoken language and written language was Spanish. During a review of Patient 13’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/2024, the H&P indicated Patient 13 was admitted to the hospital on 5/15/2024 for generalized body pain. During a review of Patient 13’s “Consent Form,” dated 5/2024, the CF indicated Patient 13 was consented for the procedure “Right Thigh Biopsy,” on 5/16/2024 in Spanish. The title of the procedure was written in Spanish as “Biopsia muscular del quadriceps derecho.” The CF indicated the signature and date by an Allied Health Practitioner (AHP) of the hospital. During a review of Patient 13’s “Operative Note,” dated 5/2024, the Operative Note indicated Patient 13 had a right thigh muscle biopsy procedure done on 5/17/2024. During a review of Patient 13’s “Physician’s Orders,” dated 5/2024, the Physician’s Orders indicated Patient 13 had order on 5/16/2024 for right quadriceps muscle biopsy for purpose to study muscle on right leg. During a concurrent interview and record review on 5/30/2024 at 10:35 a.m. with the Director of Nursing Operations (DNO) 1, Patient 13’s “ Consent Form (CF),” dated 5/2024, was reviewed. The CF indicated title of the procedure was written in Spanish “Biopsia muscular del quadriceps derecho.” DNO 1 stated the following: The title of the procedure in the consent form should be written in English so that the staff can understand it during their time out meeting prior to starting the procedure. During a concurrent interview and record review on 5/30/2024 at 10:57 a.m. with the Director of Perioperative Services (DPS) 1, Patient 13’s “ Consent Form (CF),” dated 5/2024, was reviewed. The CF indicated title of the procedure was written in Spanish “Biopsia muscular del quadriceps derecho.” DPS 1 stated the following: DPS 1 confirmed Patient 13 was consented by a physician assistant of the hospital. If the consent form is not accurate, the staff will have to contact the physician to redo the consent. Confirmed consent is not correct due to physician who consented Patient 13 wrote the title of the procedure in Spanish instead of English. During a review of the facility’s policy and procedure (P&P) titled “Informed Consent, Written Consent and Refusal of Consent” dated 2023, the “P&P” indicated, “ informed consent is required for complex treatments and procedures. The patient’s physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining patient’s informed consent or informed refusal for the recommended treatment procedure. Physicians and Allied Health Practitioner (AHPs, for the purpose of obtaining informed consent for the procedure or treatment AHPs are practitioners such as physician assistant nurse practitioner or certified nurse midwife) must accurately document informed consent and refusal discussions. During a review of the facility’s policy and procedure (P&P) titled “Qualified Interpreter Services for Limited English Proficient Person,” dated 2024, the “P&P” indicated, “ Standards for Qualified Interpreter Services: Qualified Bilingual Staff (QBS): Those designated as QBS 1 or 2 are not authorized to provide language assistance services beyond the scope of their qualifications. During a review of the facility’s policy and procedure (P&P) titled “Comprehensive Linguistics Program: Qualified Bilingual Staff (QBS) Program Guide,” dated 3/2024, the “P&P” indicated, “ The Qualified Bilingual Staff (QBS) program allows Kaiser Permanente to further provide culturally and linguistically appropriate services by qualifying and recognizing bilingual staff that use their linguistic skills to provide language assistance services. The QBS employee should be able to use their language of service to directly communicate or interpret for another individual as appropriate for either level one or level 2 scope of practice. QBS employees cannot translate as they have not been qualified to do so. Translation is converting written text from one language to another written language.”

“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: 36206 Based on interview and record review, the facility failed to provide an appropriate Medical Screening Exam (MSE, the process required to within reasonable clinical confidence whether an emergency medical condition exist) for two of 20 sampled patients (Patients 1 and 20) in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma), when the MSE was delayed for approximately one (1) hour, after it was determined that Patient 1 and 20 required immediate aggressive interventions. This deficient practice resulted in a delay in treatment for Patient 1 and Patient 20 and resulted in Patient 1’s death. Findings: 1. During a review of Patient 1’s “Patient Care Timeline,” dated 5/24/2023, the Timeline indicated the following: At 7:10 p.m., Patient 1 arrived to the Emergency Department (ED). At 7: 11 p.m., The registered nurse (RN 1) checked Patient 1 into the ED for diarrhea and weakness and assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...). At 7:27 p.m., Patient 1 was triaged (a process to determine order in which patients will be provided a medical screening examination by a physician ...) by RN 2. History of present illness: Patient 1 complained of diarrhea, dizziness for three (3) days, generalized weakness ...Associated symptoms: Patient 1 complained of shortness of breath, appears pale. RN 2 assigned Patient 1 an ESI level of 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...). At 7:29 p.m., Patient 1’s Vital signs were taken. Respiratory rate (RR) was 22 (high, Normal is between 12 to 16), oxygen saturation (percentage of oxygen in the blood) was 85 % (low, normal is between 95 to 100 %), Blood Pressure (BP) was 88/43 (low, normal is 120/80), heart rate (HR) was 46 (low, normal is between 60 to 100), and pain was 5/10 (0 means no pain, 10 means worse pain), the location of the pain was not documented. At 7:33 p.m., RN 2 placed Patient 1 on oxygen via nasal cannula, oxygen saturation was 94 %. RN 2 re-assigned Patient 1 an ESI Level 2. At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions). At 7:40 p.m., an electrocardiogram (EKG, a recording of the heart ’ s electrical activity) was done and given to the Physician (MD 1), per RN 4 ’ s note. At 7:57 p.m., Charge nurse (CN) 1 documented that Patient 1 was awake, alert, and oriented ...expressed marked relief of shortness of breath with oxygen, in NAD (no apparent distress). Patient 1 will be roomed as soon as bed available. Otherwise, Patient 1 is on oxygen and IV (intravenous- vein access) started with labs (laboratory tests) drawn. EKG done. Patient 1 withing eyesight of triage. At 8:33 p.m., Patient 1 was roomed (placed in a ED room). At 8:35 p.m., Physician (MD 2) was assigned to Patient 1 At 8:39 p.m., “ED Provider (MD 2) Started.” At 8:41 p.m., MD 2 placed orders for a chest x-ray, atropine (treat heart rhythm problems) ... At 9:03 p.m., “ED Notes,” by RN 5 indicated the following: Received Patient 1 from Bed K, MD 2 at bedside, Patient 1 placed on cardiac pacer (a small device that prevents the heart from beating too slowly) ...responsive, awake, alert, + weakness, continue on cardiac and pulse monitoring ...hypotensive 78/38 (low blood pressure), MAP (mean arterial pressure, pressure within the arteries) is 43 (low, below 60 indicates not enough pressure to perfuse vital organs, normal is between 70 and 100) ... at 9:16 p.m., BP noted 72/38, Patient 1 remains calm, awake, oriented, denied any discomfort ...MD 2 at bedside for close monitoring. At 9:40 p.m., Patient 1 started vomiting ...MD 2 aware ... At 9:19 p.m., Troponin (collected on 5/24/2024 at 7:59 p.m.) final result at 9:19 p.m., was 16,986 (high, may indicate heart attack), Critical Result called to MD 1. At 9:38 p.m., Dopamine (helps support blood pressure) was given. At 9:48 p.m., Magnesium Sulfate (treats abnormal heart rhythms) ordered by MD 2. At 9:48 p.m., “ED Notes, Addendum,” indicated: At 9:46 p.m., Patient 1 is gagging, becoming altered ...At 9:48 p.m., Code (Code Blue, an adult is having a medical emergency, usually cardiac or respiratory arrest) started. MD 2 witnessed cardiac rhythm of Vfib (Ventricular fibrillation, a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), Heart Rate (HR) 241 (high, normal is 60 to 100). Patient woke up after defib (the delivery of electrical shocks across the chest), opens eyes, started gagging, vomited ...Given Zofran (ondansetron, treats nausea and vomiting) ... Magnesium ...started. At 9:49 p.m., HR is 232 (high) ...MD 2 remained at bedside. Patient 1 is becoming more confused, gagging, became unresponsive. MD 2 ordered defib ... HR is 163 ...BP is 129/87 (high), MAP is 93 (high) ...Dopamine discontinued. At 9:52 p.m., started Amiodarone (treats heart rhythm problems) ... Patient 1 becoming altered ...defib given ... At 9:54 p.m., “Code Documentation, Addendum,” At 9:54 p.m., 3rd and 4th defib ...9:55 p.m., compressions start, Bag valve mask (BVM, airway management technique allows for oxygenation and ventilation of patients), Epi (epinephrine, a medication used to restore cardiac rhythms) given ...At 9:59 p.m., no pulse, PEA (a condition where the heart stops because the electrical activity in the heart is too weak to make the heart beat), intubated (a tube is inserted through the mouth or nose, then down into the airway, to allow air to get through) started. Compression continued ...At 10:14 p.m., Death pronounced by MD 2 ... During a review of Patient 1’s “EKG,” dated 5/24/2024 at 7:40 p.m., the EKG indicated Sinus tachycardia (regular cardiac rhythm in which the heart beats faster than normal) with complete heart block (or third degree heart block is considered a medical emergency, there is a complete loss of communication from the atria [upper chamber of heart] to the ventricles [lower heart chamber]) ...Abnormal ECC (EKG). There were no initials on the EKG that indicated the EKG resulted were reviewed by a physician or emergency room provider. During a review of Patient 1’s “ED Provider (MD 2) Notes,” dated 5/24/2024 at 8:41 p.m., the ED Provider Noted indicated the following: Patient 1 presents with weakness, diarrhea ...Patient 1 ...presenting with complaints of two (2) days of generalized weakness and fatigue with diarrhea x four (4) episodes without melena (dark tarry stool or visible blood) ...Denies fevers ...nausea/vomiting, chest pain ...On presentation EKG showing new complete heart block, patient hypotensive (low blood pressure) and hypoxic (absence of enough oxygen in the tissues to sustain body functions). Delay in evaluation secondary to bed availability, Patient 1 placed on nasal cannula (a device used to deliver supplemental oxygen) and labs ordered by nursing triage prior to patient being roomed ... Physical Exam: Vitals: BP: 88/43 (low), pulse: 46 (low), oxygen saturation: 85 % (low) ...Patient pale, clammy ...bradycardic (low heart rate or pulse) ... Assessment: 1. AV (Atrio-Ventricular- the heart ’ s upper and lower chambers) Block, Complete. 2. Acute Respiratory Failure (an inability to maintain adequate oxygenation for tissues) ... 4. Ventricular Tachycardia (when the lower chambers of the heart, beat very quickly) sustained ...5. Cardiac Arrest (sudden, unexpected loss of heart function, breathing, and consciousness) due to unspecified cause 6. Acute Non-ST Elevation Myocardial Infarction (NSTEMI, a type of heart attack that usually happens when the heart ’ s need for oxygen cannot be met, it does not have an easily identifiable electrical pattern, like other heart attacks) ... Re-assess at 9:19 p.m., Cardiology on call contacted ...Patient 1 with pacemaker capturing and BP not improving, recommend patient be placed on dopamine ...Patient started to have nausea ... Patient then found to go into Vtach (Ventricular Tachycardia), Dopamine stopped. Patient 1 given Magnesium ...Patient 1 awake, alert, continued to deny chest pain, troponin 16,986. Heparin drip with bolus ordered but not started before patient altered mental status with loss of consciousness in between patient neuro infarct. After 2nd episode decision to intubate patient for airway protection ... while preparing to intubate patient lost pulses, ACLS protocol started ...Multiple rounds of epinephrine given without ROSC (Return of Spontaneous Circulation, restart of a sustained heart rhythm) ...Time of death called at 10:14 p.m. During a review of Patient 1’s “Progress Note,” dated 5/24/2024 at 9:42 p.m., by a Cardiac Physician (MD 3), the Progress Note indicated the following: “I (MD 3) was called with report that pt (Patient 1) is hypotensive and bradycardic with CHB (complete heart block) and he is hypoxic ...In terms of acute cardiac treatment, would support BP (blood pressure) and HR (heart rate) with pressors (medications that raise blood pressure and increase cardiac output) ...Heparin ...recommended for NSEMTI ...His (Patient 1) shock (the body ’ s response to a sudden drop in blood pressure) certainly could be MI (myocardial infarction, heart attack, blockage of blood flow to the heart) related and I did recommend transfer to an outside hospital ’ s cath lab (catheterization laboratory, where test and procedures can be carried out) tonight emergently if this the primary etiology thought to be occurring ... During a concurrent interview and record review, on 5/14/2024 at 10:35 a.m., with Assistant Clinical Directors (ACD) 2 & 3, ACD 3 reviewed Patient 1 ’ s Triage notes and Medical Screening Exam dated 5/24/2023 and stated the following: Patient 1 walked into the ED on 5/24/2024 at 7:11 p.m., for diarrhea and weakness. At 7:11 p.m., the Intake or Check-In Nurse (RN 1) assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...). At 7:27 p.m., Registered Nurse (RN) 2 triaged Patient 1. Patient 1 ’ s blood pressure was 88/43 (low, normal is 120/80), heart rate was 46 (low, normal is 60 - 100), oxygen saturation (percentage of oxygen in the blood) was 85 %, (low, normal is 95 % to 100%)and assigned Patient 1 an ESI Level 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...). An EKG was performed for Patient 1 at 7:40 p.m. and shown a physician (MD 1). ACD 3 verified that the EKG did not have MD 1 ’ s initials, acknowledging that the EKG had been interpreted, nor that MD 1 wrote any progress notes relating to Patient 1. At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions). ACD 3 stated that Patient 1 should have been placed in a room at 7:37 p.m., for immediate care, if no beds were available the nurse should have created a bed to place Patient 1 at 7:57 p.m., instead, Charge Nurse (CN) administered oxygen to Patient 1 and placed him (Patient 1) in front of the waiting room, within eyesight of triage area. Patient 1 was placed in a room at 8:35 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m. MD 2 started evaluating Patient 1 at 8:41 p.m., approximately an hour after Patient 1 was assigned an ESI Level of 1, at 7:37 p.m. ACD 3 stated Patient 1 should have been assigned a bed and a physician should have been notified to examine Patient 1 at 7:37 p.m., to assess Patient 1 and provide care. During an interview on 5/15/2024 at 7:42 a.m. with Registered Nurse (RN) 3, RN 3 stated the following: On 5/24/2023 at 7 p.m., he (RN 3) worked in the ED, as the Emergency Flow Coordinator (EFC) which included duties such as “traffic coordinator” for patients who have been triaged. RN 3 has no patient contact, but looks at the computer screen, checks patient ESI levels, vital signs and decides who should be placed in a room. Patient 1 arrived to the ED at 7:10 p.m. for weakness and diarrhea, an ESI Level of 3 was assessed by RN 1 (Intake /Check-In Nurse). At 7:27 p.m., RN 2 (triage nurse) triaged Patient 1, now complaining of shortness of breath and appeared pale. At 7:29 p.m., Patient 1 ’ s BP was 88/43 (low), HR was 46 (low), and oxygen saturation was 85 % (low). Pain was 5 of 10, the location was not documented. At 7:37 p.m., He (RN 3) noticed Patient 1 ’ s low blood pressure, pulse and oxygen saturation, and changed Patient 1 ’ s ESI level of 2 to ESI Level 1 and notified the Charge Nurse (CN 1) and RN 4 of the ESI level change and inform them to find a room for Patient 1. RN 3 stated that in his (RN 3) opinion Patient 1 should have been assigned an ESI Level 1 at 7:29 p.m. RN 3 stated Patient 1 had an EKG done at 7:40 p.m. RN 3 reviewed the nursing “ED Notes,” at 7:57 p.m., and stated CN 1 placed Patient 1 on oxygen and placed within view of triage, but could not say where Patient 1 was placed, could only say that Patient 1 was not in a room. Patient 1 was placed in a room at 8:33 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m., and MD 2 started examining Patient 1 at 8:39 p.m. Patient 1 was moved to a bigger room at 8:57 p.m. RN 3 stated that eventually Patient 1 coded and passed away. During an interview on 5/15/2024 at 2 p.m. with Emergency Room Physician (MD 1), MD 1 stated the following: He (MD 1) worked in the ED on 5/24/2023 and was the two-star (**) physician between 6 p.m. to 8 p.m. that night. The two-star physicians were required to interpret all EKGs and receive critical labs values for those 2-hours. MD 1 stated he (MD 1) remembers an Emergency Room Assistant (ERA 1) showed him (MD 1) an EKG (for Patient 1) that he (MD 1) interpreted as a Third-degree Heart Block. MD 1 stated he (MD 1) told ERA 1 that Patient 1 needed to be brought to the “back (in a room)” immediately. MD 1 assumed Patient 1 was placed in a room, but he (MD 1) did not follow up with Patient 1. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Department Patient Flow,” dated 4/2021, the P&P indicated the following: All patients requesting treatment or emergency care to the ED will have a medical screening examination ...to determine if an emergency medical condition exist ....Triage ...a process to determine order in which individuals will be provided a medical screening examination by a physician ...Emergency Severity Index (ESI) - a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent to 5 (least urgent) based on acuity and resource needs ...All patients presenting to the ED will be initially interviewed by the Intake Registered Nurse (RN). The Intake RN will determine via the interview assessment and process, the presenting complaint of each patient and will assign a triage activity following the ESI ....The Level 1 and Level 2 triage activity patients will be immediately escorted to the treatment area by the ED personnel, and the nurse shall immediately notify an ED physician or the RN staff of any patients that present with a life-threatening emergency ...All other patients will be seen by the triage nurse and have a secondary assessment completed ... Emergency Severity Index (ESI) Level 1 = Resuscitation conditions - conditions that are threats to life or limb (or imminent deterioration) requiring immediate aggressive interventions. Level 2 = Emergent conditions - conditions that multiple resources are a potential threat to life, limb or function, requiring rapid medical interventions or delegated task. Leve 3 = Urgent conditions - conditions that could potentially progress to a serious problem requiring emergency intervention given chief complaint or injury will determine number of resources needed to determine diagnosis ... Assessment by RN: Initial assessments will be done an RN. This secondary assessment shall include: ...presenting information ...The triage RN shall transport any patients with a life-threatening emergency directly to the ED treatment area and endorse the care of the patient to the assigned RN. Attachment A: Emergency Severity Index Algorithm: A - requires immediate life-saving intervention, arrow point to 1 (Level 1). A. Immediate life-saving intervention required: airway, emergency medications, or other hemodynamic (how blood flows through the blood vessels) intervention ...; and/or any of the following clinical conditions: intubated, apneic (when breathing temporarily stops), pulseless (without a pulse), severe respiratory distress, SPO2 (oxygen saturation) less than 90%, acute mental status changes, or unresponsiveness. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 1/08/2023 indicated the following: Emergency Medical Condition (EMC) - A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and / or symptoms of substance abuse, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual ...in serious jeopardy, serious impairment to bodily functions; or serious dysfunction of any bodily organ or part ... Medical Screening Examination (MSE) - The process required to determine within reasonable clinical confidence whether an emergency medical condition exist. It is an ongoing process, including monitoring of an individual until the individual is either stabilized or transferred. 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. Medical Screening Examinations (MSE). All hospitals...will provide an appropriate MSE to any individual who comes to the ED to determine if an EMC exist. A MSE will be provided: ...The scope of the MSE is tailed to the presenting symptoms and medical history of the individual ...The extent of the necessary examination to determine whether an EMC exists is within the judgment and discretion of the physician ... 2. During a review of Patient 20’s Emergency Department Note (ED note, patient assessment, diagnoses and interventions completed by ED physician), dated 6/24/2023, the ED note indicated Patient 20 came to the facility ’ s ED with complaint of left sided non radiating chest discomfort. MD 6 evaluated Patient 20 ’ s EKG and identified Patient 20 had STEMI. MD 6 ordered to transfer Patient 20 to another facility for higher level of care for cardiac catheterization. During an interview on 5/15/2024 at 10:27 a.m. with the ED Assistant Clinical Director (ACD) 1, ACD 1 stated facility has STEMI protocol in place for patients who come in with chest pain. ACD 1 stated per STEMI protocol, chest pain patients would receive EKG within 10 minutes from door entry. ACD 1 stated the EKG is then interpreted by a 2-star physician (ED physician assigned to perform EKG interpretation) immediately to screen for STEMI. ACD also stated if STEMI is identified, the facility will transfer patient to STEMI center (hospital specialized in handling STEMI patients) for cardiac catheterization. During a concurrent interview and record review on 5/15/2024 at 10:43 a.m. with ACD 1, Patient 20’s “Patient Care Time Line (ED timeline, document shows the assessment and care flow patients received in ED),” from 6/23/2024 to 6/24/2024 was reviewed. The “ED timeline” indicated the following: At 11:30 p.m. Patient 20 arrived in ED At 11:32 p.m. Patient 20’s chief complaint was blood pressure problem and chest discomfort. Patient 20 was triaged (sorting of and allocation of treatment to patients) with Emergency Severity Index (ESI, ED triage algorithm that sorts patients into 5 groups from level 1 [most urgent] to level 5 [least urgent]) level 2. At 11:33 p.m. EKG ordered At 12:07 a.m. EKG completed At 12:15 a.m. Vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level): Temperature 98 degrees Fahrenheit (F, unit of measure), blood pressure 158/85 millimeter of mercury (mmHg, unit of measure), heart rate 40 beats per minute (bpm, unit of measures), respiration 20 breath per minute, Pain level 3 out of 10 (pain scale from 0 to 10 with 0 means no pain while 10 means most severe pain) at left chest At 12:39 a.m. MD 6 completed Medical Screening Examination At 12:58 a.m. Patient 20 was discharged to another facility ACD 1 stated Patient 20’s EKG was not done within 10 to 12 minutes from door entry and there was no interpretation documented by MD 5 which resulted in delay in MSE and STEMI identification. During a concurrent interview and record review on 5/15/2024 at 11:25 a.m. with ACD 1, Patient 20’s ED note, dated 6/24/2023, the ED note indicated MD 6 interpreted EKG at 12:39 a.m. ACD 1 stated Patient 20’s EKG should have been read by MD 5 immediately after when EKG was completed at 12:07 a.m. ACD 1 stated delay EKG interpretation could delay care and treatment. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 4/2023, the P&P indicated, “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 hospitals operated by [the facility] will provide an appropriate MSE to any individual who comes to the ED to determine if an Emergency Medical Condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity requires immediate medical attention) exists.”

“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: 36206 Based on observation, interview, and record review, the facility failed to post written notice or signage informing patients of their right to receive a medical screening examination, stabilizing treatment and an appropriate transfer, regardless of their ability to pay, in a conspicuous (attracts notice or attention) way in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma). This deficient practice had the potential for patients in the ED not knowing their rights when they visit the ED seeking treatment for a medical condition, which may negatively impact the patients ’ ability to take an active role in their treatment plan. Findings: During an observation on 5/13/2024 beginning at 1:35 p.m., in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma), a sign informing patients of their right to a medical screening, stabilizing treatment ...regardless of their ability to pay, was posted on a wall behind the Check-In window, and behind the nurse who checks patients into the ED. No other signs were observed in the entrance of the ED, ED waiting rooms or ED treatment areas. Concurrently, during an interview, on 5/13/2024 at 1:46 p.m., the Assistant Administrator for Quality (AAQ) stated there was no signage posted in the waiting room. The sign should be posted in an area where the public can see it (referring to the sign regarding Patient Rights). During an interview on 5/13/2024 at 1:47 p.m. with Assistant Clinical Director (ACD) 3, ACD 3 stated the sign behind the Check-In window was not accessible to the patients in the waiting room. The sign should be posted in an area that was accessible to the patients, so patients can see and read the notice and be informed of their rights. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 1/08/2023, the P&P indicated the following: Signage: Conspicuous signs will be posted at hospital entrances and in places likely to be noticed by all individuals who entered the Emergency Department (ED) (e.g., parking garage, entrance, admitting area, waiting room, treatment area). Signage will specify the rights of individuals to examination and treatment for emergency medical conditions regardless of the ability to pay, and the rights of women in labor for health care services, and whether the hospital participates in the Medicaid (a government program that provides health insurance for adults and children with limited income and resources) program ...”

“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: 36206 Based on interview and record review, the facility failed to provide an appropriate Medical Screening Exam (MSE, the process required to within reasonable clinical confidence whether an emergency medical condition exist) for two of 20 sampled patients (Patients 1 and 20) in the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma), when the MSE was delayed for approximately one (1) hour, after it was determined that Patient 1 and 20 required immediate aggressive interventions. This deficient practice resulted in a delay in treatment for Patient 1 and Patient 20 and resulted in Patient 1’s death. Findings: 1. During a review of Patient 1 ’ s “Patient Care Timeline,” dated 5/24/2023, the Timeline indicated the following: At 7:10 p.m., Patient 1 arrived to the Emergency Department (ED). At 7: 11 p.m., The registered nurse (RN 1) checked Patient 1 into the ED for diarrhea and weakness and assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...). At 7:27 p.m., Patient 1 was triaged (a process to determine order in which patients will be provided a medical screening examination by a physician ...) by RN 2. History of present illness: Patient 1 complained of diarrhea, dizziness for three (3) days, generalized weakness ...Associated symptoms: Patient 1 complained of shortness of breath, appears pale. RN 2 assigned Patient 1 an ESI level of 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...). At 7:29 p.m., Patient 1 ’ s Vital signs were taken. Respiratory rate (RR) was 22 (high, Normal is between 12 to 16), oxygen saturation (percentage of oxygen in the blood) was 85 % (low, normal is between 95 to 100 %), Blood Pressure (BP) was 88/43 (low, normal is 120/80), heart rate (HR) was 46 (low, normal is between 60 to 100), and pain was 5/10 (0 means no pain, 10 means worse pain), the location of the pain was not documented. At 7:33 p.m., RN 2 placed Patient 1 on oxygen via nasal cannula, oxygen saturation was 94 %. RN 2 re-assigned Patient 1 an ESI Level 2. At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions). At 7:40 p.m., an electrocardiogram (EKG, a recording of the heart ’ s electrical activity) was done and given to the Physician (MD 1), per RN 4 ’ s note. At 7:57 p.m., Charge nurse (CN) 1 documented that Patient 1 was awake, alert, and oriented ...expressed marked relief of shortness of breath with oxygen, in NAD (no apparent distress). Patient 1 will be roomed as soon as bed available. Otherwise, Patient 1 is on oxygen and IV (intravenous- vein access) started with labs (laboratory tests) drawn. EKG done. Patient 1 withing eyesight of triage. At 8:33 p.m., Patient 1 was roomed (placed in a ED room). At 8:35 p.m., Physician (MD 2) was assigned to Patient 1 At 8:39 p.m., “ED Provider (MD 2) Started.” At 8:41 p.m., MD 2 placed orders for a chest x-ray, atropine (treat heart rhythm problems) ... At 9:03 p.m., “ED Notes,” by RN 5 indicated the following: Received Patient 1 from Bed K, MD 2 at bedside, Patient 1 placed on cardiac pacer (a small device that prevents the heart from beating too slowly) ...responsive, awake, alert, + weakness, continue on cardiac and pulse monitoring ...hypotensive 78/38 (low blood pressure), MAP (mean arterial pressure, pressure within the arteries) is 43 (low, below 60 indicates not enough pressure to perfuse vital organs, normal is between 70 and 100) ... at 9:16 p.m., BP noted 72/38, Patient 1 remains calm, awake, oriented, denied any discomfort ...MD 2 at bedside for close monitoring. At 9:40 p.m., Patient 1 started vomiting ...MD 2 aware ... At 9:19 p.m., Troponin (collected on 5/24/2024 at 7:59 p.m.) final result at 9:19 p.m., was 16,986 (high, may indicate heart attack), Critical Result called to MD 1. At 9:38 p.m., Dopamine (helps support blood pressure) was given. At 9:48 p.m., Magnesium Sulfate (treats abnormal heart rhythms) ordered by MD 2. At 9:48 p.m., “ED Notes, Addendum,” indicated: At 9:46 p.m., Patient 1 is gagging, becoming altered ...At 9:48 p.m., Code (Code Blue, an adult is having a medical emergency, usually cardiac or respiratory arrest) started. MD 2 witnessed cardiac rhythm of Vfib (Ventricular fibrillation, a life-threatening heart rhythm that results in a rapid, inadequate heartbeat), Heart Rate (HR) 241 (high, normal is 60 to 100). Patient woke up after defib (the delivery of electrical shocks across the chest), opens eyes, started gagging, vomited ...Given Zofran (ondansetron, treats nausea and vomiting) ... Magnesium ...started. At 9:49 p.m., HR is 232 (high) ...MD 2 remained at bedside. Patient 1 is becoming more confused, gagging, became unresponsive. MD 2 ordered defib ... HR is 163 ...BP is 129/87 (high), MAP is 93 (high) ...Dopamine discontinued. At 9:52 p.m., started Amiodarone (treats heart rhythm problems) ... Patient 1 becoming altered ...defib given ... At 9:54 p.m., “Code Documentation, Addendum,” At 9:54 p.m., 3rd and 4th defib ...9:55 p.m., compressions start, Bag valve mask (BVM, airway management technique allows for oxygenation and ventilation of patients), Epi (epinephrine, a medication used to restore cardiac rhythms) given ...At 9:59 p.m., no pulse, PEA (a condition where the heart stops because the electrical activity in the heart is too weak to make the heart beat), intubated (a tube is inserted through the mouth or nose, then down into the airway, to allow air to get through) started. Compression continued ...At 10:14 p.m., Death pronounced by MD 2 ... During a review of Patient 1 ’ s “EKG,” dated 5/24/2024 at 7:40 p.m., the EKG indicated Sinus tachycardia (regular cardiac rhythm in which the heart beats faster than normal) with complete heart block (or third degree heart block is considered a medical emergency, there is a complete loss of communication from the atria [upper chamber of heart] to the ventricles [lower heart chamber]) ...Abnormal ECC (EKG). There were no initials on the EKG that indicated the EKG resulted were reviewed by a physician or emergency room provider. During a review of Patient 1 ’ s “ED Provider (MD 2) Notes,” dated 5/24/2024 at 8:41 p.m., the ED Provider Noted indicated the following: Patient 1 presents with weakness, diarrhea ...Patient 1 ...presenting with complaints of two (2) days of generalized weakness and fatigue with diarrhea x four (4) episodes without melena (dark tarry stool or visible blood) ...Denies fevers ...nausea/vomiting, chest pain ...On presentation EKG showing new complete heart block, patient hypotensive (low blood pressure) and hypoxic (absence of enough oxygen in the tissues to sustain body functions). Delay in evaluation secondary to bed availability, Patient 1 placed on nasal cannula (a device used to deliver supplemental oxygen) and labs ordered by nursing triage prior to patient being roomed ... Physical Exam: Vitals: BP: 88/43 (low), pulse: 46 (low), oxygen saturation: 85 % (low) ...Patient pale, clammy ...bradycardic (low heart rate or pulse) ... Assessment: 1. AV (Atrio-Ventricular- the heart ’ s upper and lower chambers) Block, Complete. 2. Acute Respiratory Failure (an inability to maintain adequate oxygenation for tissues) ... 4. Ventricular Tachycardia (when the lower chambers of the heart, beat very quickly) sustained ...5. Cardiac Arrest (sudden, unexpected loss of heart function, breathing, and consciousness) due to unspecified cause 6. Acute Non-ST Elevation Myocardial Infarction (NSTEMI, a type of heart attack that usually happens when the heart ’ s need for oxygen cannot be met, it does not have an easily identifiable electrical pattern, like other heart attacks) ... Re-assess at 9:19 p.m., Cardiology on call contacted ...Patient 1 with pacemaker capturing and BP not improving, recommend patient be placed on dopamine ...Patient started to have nausea ... Patient then found to go into Vtach (Ventricular Tachycardia), Dopamine stopped. Patient 1 given Magnesium ...Patient 1 awake, alert, continued to deny chest pain, troponin 16,986. Heparin drip with bolus ordered but not started before patient altered mental status with loss of consciousness in between patient neuro infarct. After 2nd episode decision to intubate patient for airway protection ... while preparing to intubate patient lost pulses, ACLS protocol started ...Multiple rounds of epinephrine given without ROSC (Return of Spontaneous Circulation, restart of a sustained heart rhythm) ...Time of death called at 10:14 p.m. During a review of Patient 1 ’ s “Progress Note,” dated 5/24/2024 at 9:42 p.m., by a Cardiac Physician (MD 3), the Progress Note indicated the following: “I (MD 3) was called with report that pt (Patient 1) is hypotensive and bradycardic with CHB (complete heart block) and he is hypoxic ...In terms of acute cardiac treatment, would support BP (blood pressure) and HR (heart rate) with pressors (medications that raise blood pressure and increase cardiac output) ...Heparin ...recommended for NSEMTI ...His (Patient 1) shock (the body ’ s response to a sudden drop in blood pressure) certainly could be MI (myocardial infarction, heart attack, blockage of blood flow to the heart) related and I did recommend transfer to an outside hospital ’ s cath lab (catheterization laboratory, where test and procedures can be carried out) tonight emergently if this the primary etiology thought to be occurring ... During a concurrent interview and record review, on 5/14/2024 at 10:35 a.m., with Assistant Clinical Directors (ACD) 2 & 3, ACD 3 reviewed Patient 1 ’ s Triage notes and Medical Screening Exam dated 5/24/2023 and stated the following: Patient 1 walked into the ED on 5/24/2024 at 7:11 p.m., for diarrhea and weakness. At 7:11 p.m., the Intake or Check-In Nurse (RN 1) assigned Patient 1 an ESI (Emergency Severity Index, a five -level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) Level 3 (urgent condition, could potentially progress to a serious problem ...). At 7:27 p.m., Registered Nurse (RN) 2 triaged Patient 1. Patient 1 ’ s blood pressure was 88/43 (low, normal is 120/80), heart rate was 46 (low, normal is 60 - 100), oxygen saturation (percentage of oxygen in the blood) was 85 %, (low, normal is 95 % to 100%)and assigned Patient 1 an ESI Level 2 (Emergent conditions - conditions that multiple resources are a potential threat to life, limb, or function, requiring rapid medical interventions ...). An EKG was performed for Patient 1 at 7:40 p.m. and shown a physician (MD 1). ACD 3 verified that the EKG did not have MD 1 ’ s initials, acknowledging that the EKG had been interpreted, nor that MD 1 wrote any progress notes relating to Patient 1. At 7:37 p.m., RN 3 assigned Patient 1 an ESI Level 1 (Resuscitation conditions - are threats to life or limb [or imminent risk of deterioration] requiring immediate aggressive interventions). ACD 3 stated that Patient 1 should have been placed in a room at 7:37 p.m., for immediate care, if no beds were available the nurse should have created a bed to place Patient 1 at 7:57 p.m., instead, Charge Nurse (CN) administered oxygen to Patient 1 and placed him (Patient 1) in front of the waiting room, within eyesight of triage area. Patient 1 was placed in a room at 8:35 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m. MD 2 started evaluating Patient 1 at 8:41 p.m., approximately an hour after Patient 1 was assigned an ESI Level of 1, at 7:37 p.m. ACD 3 stated Patient 1 should have been assigned a bed and a physician should have been notified to examine Patient 1 at 7:37 p.m., to assess Patient 1 and provide care. During an interview on 5/15/2024 at 7:42 a.m. with Registered Nurse (RN) 3, RN 3 stated the following: On 5/24/2023 at 7 p.m., he (RN 3) worked in the ED, as the Emergency Flow Coordinator (EFC) which included duties such as “traffic coordinator” for patients who have been triaged. RN 3 has no patient contact, but looks at the computer screen, checks patient ESI levels, vital signs and decides who should be placed in a room. Patient 1 arrived to the ED at 7:10 p.m. for weakness and diarrhea, an ESI Level of 3 was assessed by RN 1 (Intake /Check-In Nurse). At 7:27 p.m., RN 2 (triage nurse) triaged Patient 1, now complaining of shortness of breath and appeared pale. At 7:29 p.m., Patient 1 ’ s BP was 88/43 (low), HR was 46 (low), and oxygen saturation was 85 % (low). Pain was 5 of 10, the location was not documented. At 7:37 p.m., He (RN 3) noticed Patient 1 ’ s low blood pressure, pulse and oxygen saturation, and changed Patient 1 ’ s ESI level of 2 to ESI Level 1 and notified the Charge Nurse (CN 1) and RN 4 of the ESI level change and inform them to find a room for Patient 1. RN 3 stated that in his (RN 3) opinion Patient 1 should have been assigned an ESI Level 1 at 7:29 p.m. RN 3 stated Patient 1 had an EKG done at 7:40 p.m. RN 3 reviewed the nursing “ED Notes,” at 7:57 p.m., and stated CN 1 placed Patient 1 on oxygen and placed within view of triage, but could not say where Patient 1 was placed, could only say that Patient 1 was not in a room. Patient 1 was placed in a room at 8:33 p.m. MD 2 was assigned to Patient 1 at 8:35 p.m., and MD 2 started examining Patient 1 at 8:39 p.m. Patient 1 was moved to a bigger room at 8:57 p.m. RN 3 stated that eventually Patient 1 coded and passed away. During an interview on 5/15/2024 at 2 p.m. with Emergency Room Physician (MD 1), MD 1 stated the following: He (MD 1) worked in the ED on 5/24/2023 and was the two-star (**) physician between 6 p.m. to 8 p.m. that night. The two-star physicians were required to interpret all EKGs and receive critical labs values for those 2-hours. MD 1 stated he (MD 1) remembers an Emergency Room Assistant (ERA 1) showed him (MD 1) an EKG (for Patient 1) that he (MD 1) interpreted as a Third-degree Heart Block. MD 1 stated he (MD 1) told ERA 1 that Patient 1 needed to be brought to the “back (in a room)” immediately. MD 1 assumed Patient 1 was placed in a room, but he (MD 1) did not follow up with Patient 1. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Department Patient Flow,” dated 4/2021, the P&P indicated the following: All patients requesting treatment or emergency care to the ED will have a medical screening examination ...to determine if an emergency medical condition exist ....Triage ...a process to determine order in which individuals will be provided a medical screening examination by a physician ...Emergency Severity Index (ESI) - a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent to 5 (least urgent) based on acuity and resource needs ...All patients presenting to the ED will be initially interviewed by the Intake Registered Nurse (RN). The Intake RN will determine via the interview assessment and process, the presenting complaint of each patient and will assign a triage activity following the ESI ....The Level 1 and Level 2 triage activity patients will be immediately escorted to the treatment area by the ED personnel, and the nurse shall immediately notify an ED physician or the RN staff of any patients that present with a life-threatening emergency ...All other patients will be seen by the triage nurse and have a secondary assessment completed ... Emergency Severity Index (ESI) Level 1 = Resuscitation conditions - conditions that are threats to life or limb (or imminent deterioration) requiring immediate aggressive interventions. Level 2 = Emergent conditions - conditions that multiple resources are a potential threat to life, limb or function, requiring rapid medical interventions or delegated task. Leve 3 = Urgent conditions - conditions that could potentially progress to a serious problem requiring emergency intervention given chief complaint or injury will determine number of resources needed to determine diagnosis ... Assessment by RN: Initial assessments will be done an RN. This secondary assessment shall include: ...presenting information ...The triage RN shall transport any patients with a life-threatening emergency directly to the ED treatment area and endorse the care of the patient to the assigned RN. Attachment A: Emergency Severity Index Algorithm: A - requires immediate life-saving intervention, arrow point to 1 (Level 1). A. Immediate life-saving intervention required: airway, emergency medications, or other hemodynamic (how blood flows through the blood vessels) intervention ...; and/or any of the following clinical conditions: intubated, apneic (when breathing temporarily stops), pulseless (without a pulse), severe respiratory distress, SPO2 (oxygen saturation) less than 90%, acute mental status changes, or unresponsiveness. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 1/08/2023 indicated the following: Emergency Medical Condition (EMC) - A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances and / or symptoms of substance abuse, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual ...in serious jeopardy, serious impairment to bodily functions; or serious dysfunction of any bodily organ or part ... Medical Screening Examination (MSE) - The process required to determine within reasonable clinical confidence whether an emergency medical condition exist. It is an ongoing process, including monitoring of an individual until the individual is either stabilized or transferred. 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. Medical Screening Examinations (MSE). All hospitals...will provide an appropriate MSE to any individual who comes to the ED to determine if an EMC exist. A MSE will be provided: ...The scope of the MSE is tailed to the presenting symptoms and medical history of the individual ...The extent of the necessary examination to determine whether an EMC exists is within the judgment and discretion of the physician ... 2. During a review of Patient 20 ’ s Emergency Department Note (ED note, patient assessment, diagnoses and interventions completed by ED physician), dated 6/24/2023, the ED note indicated Patient 20 came to the facility ’ s ED with complaint of left sided non radiating chest discomfort. MD 6 evaluated Patient 20 ’ s EKG and identified Patient 20 had STEMI. MD 6 ordered to transfer Patient 20 to another facility for higher level of care for cardiac catheterization. During an interview on 5/15/2024 at 10:27 a.m. with the ED Assistant Clinical Director (ACD) 1, ACD 1 stated facility has STEMI protocol in place for patients who come in with chest pain. ACD 1 stated per STEMI protocol, chest pain patients would receive EKG within 10 minutes from door entry. ACD 1 stated the EKG is then interpreted by a 2-star physician (ED physician assigned to perform EKG interpretation) immediately to screen for STEMI. ACD also stated if STEMI is identified, the facility will transfer patient to STEMI center (hospital specialized in handling STEMI patients) for cardiac catheterization. During a concurrent interview and record review on 5/15/2024 at 10:43 a.m. with ACD 1, Patient 20 ’ s “Patient Care Time Line (ED timeline, document shows the assessment and care flow patients received in ED),” from 6/23/2024 to 6/24/2024 was reviewed. The “ED timeline” indicated the following: At 11:30 p.m. Patient 20 arrived in ED At 11:32 p.m. Patient 20 ’ s chief complaint was blood pressure problem and chest discomfort. Patient 20 was triaged (sorting of and allocation of treatment to patients) with Emergency Severity Index (ESI, ED triage algorithm that sorts patients into 5 groups from level 1 [most urgent] to level 5 [least urgent]) level 2. At 11:33 p.m. EKG ordered At 12:07 a.m. EKG completed At 12:15 a.m. Vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level): Temperature 98 degrees Fahrenheit (F, unit of measure), blood pressure 158/85 millimeter of mercury (mmHg, unit of measure), heart rate 40 beats per minute (bpm, unit of measures), respiration 20 breath per minute, Pain level 3 out of 10 (pain scale from 0 to 10 with 0 means no pain while 10 means most severe pain) at left chest At 12:39 a.m. MD 6 completed Medical Screening Examination At 12:58 a.m. Patient 20 was discharged to another facility ACD 1 stated Patient 20 ’ s EKG was not done within 10 to 12 minutes from door entry and there was no interpretation documented by MD 5 which resulted in delay in MSE and STEMI identification. During a concurrent interview and record review on 5/15/2024 at 11:25 a.m. with ACD 1, Patient 20 ’ s ED note, dated 6/24/2023, the ED note indicated MD 6 interpreted EKG at 12:39 a.m. ACD 1 stated Patient 20 ’ s EKG should have been read by MD 5 immediately after when EKG was completed at 12:07 a.m. ACD 1 stated delay EKG interpretation could delay care and treatment. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 4/2023, the P&P indicated, “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 hospitals operated by [the facility] will provide an appropriate MSE to any individual who comes to the ED to determine if an Emergency Medical Condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity requires immediate medical attention) exists.”

“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: 48212 Based on interview and record review, the facility failed to provide inter-hospital transfer summary (transfer form, document for transfer with information of reasons for transfer, including risk and benefits of the transfer, and receiving facility information) for one of 20 sampled patients (Patient 15) when Patient 15 was transferred from the facility ’ s emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) to an acute psychiatric facility (facility which is specialized in treatment patients with mental illnesses). This deficient practice had the potential to result in physician not evaluating Patient 15 ’ s medical condition and indicate the risk and benefits prior transferring Patient 15 to another facility. Findings: During a review of Patient 15 ’ s “Emergency Provider Notes (ED notes, a formal and complete assessment of the patient and the problem completed by the emergency department physician),” dated 6/20/2023, Patient 15 presented to the facility ’ s ED for ingestion of toxic substance. The ED note indicated Patient 15 presented in critical condition with suicidal ideal with immediate/ potential threat at the time of evaluation and had the potential for high morbidity/mortality requiring constant attention. During a review of Patient 15 ’ s “Sign -Out Note (ED physician hand off progress note),” dated 6/20/2023, the sign-out note indicated there was a bed secured at a psychiatric facility, Patient 15 pending transport. During an interview on 5/14/2024 at 4:03 p.m. with the ED Assistant Clinical Director (ACD) 2, ACD 2 stated physician and nursing staff would complete “Inter-hospital Transfer Summary (transfer form)” for all patients transferring to another facility from ED. ACD 2 stated physician and nursing staff need to complete all 5 sections on the form including: Section 1: Patient Information Section 2: Patient Transfer Acknowledgment Section 3: Physician Certification Section 4: Accepting Facility and Physician Transfer Information Section 5: Transfer Assessment ACD 2 stated the transferring physician would complete “Section 3: Physician Certification” to certify that he or she had examined the patient and determine either the patient was stable or unstable for transfer. ACD 2 stated the transferring physician would also indicate the risks and benefits of transfer in this section. During an interview on 5/14/2024 at 4:10 p.m. with ACD 2, ACD 2 stated there was no “Interhospital Transfer Summary” form in Patient 15 ’ s electronic medical record. ACD 2 stated the transfer form should be kept in Patient 15 ’ s electronic medical record. ACD 2 stated there was no other document to show the physician had completed the physician certification for Patient 15. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer,” dated 1/2023, the P&P indicated, “It is the policy of [the facility] to comply with the Emergency Medical Treatment and Labor Act (EMTALA) obligations application to hospital with a dedicated emergency department ... Physician Determination to Transfer: after providing a medical examination and treatment withing the capability and capacity of the hospital, the physician may determine that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual. The physician must follow the procedures set forth in section Transfer: Obligations of the sending facility ... Transfer: Obligations of the sending facility: the transferring physician will complete the transfer form certifying that: For unstable patients, the medical benefits of receiving treatment at another facility outweigh the risks to the individual (and, if pregnant, the unborn child) from effecting the transfer, or For stabilized patients, within reasonable medical probability, the transfer creates no medical hazards to the individual.””