Garfield 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: 33922 Based on interview and record review, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by: 1. The facility failed to post required EMTALA signage in a conspicuous place in the Emergency Department (ED). (Refer to Tag 2402). 2. The facility failed to ensure an adequate roster of on- call orthopedic physicians (specialty of medicine related to injuries or deformities of the musculoskeletal system- muscles and bones) was maintained and posted in the Emergency Department (ED). Orthopedic physicians were selectively on-call for patients of a medical group with [specific insurance]. The hospital did not ensure on-call orthopedic services were available for patients who did not have [specific insurance]. (Refer to Tag 2404). 3. The facility failed to provide an adequate Medical Screening Exam (MSE) for one of 20 sampled patients (Patient 1). (Refer to Tag 2406). 4. The facility failed to provide ongoing stabilizing treatment for 1 of 20 sampled patients (Patient 1). (Refer to Tag 2407). 5. The facility failed to ensure stabilizing treatment was not delayed when 1 of 20 sampled patients (Patient 11), who required orthopedic services to stabilize her Emergency Medical Condition, was not provided orthopedic services at the hospital based on her insurance status even though the hospital had the capabilities and capacity to treat Patient 11. (Refer to Tag 2408). These failures potentially resulted in delays to patients receiving necessary medical screening, needed treatments, stabilization, and potential delays in treatment which could result in harm to patients’ health and safety, up to and including death.”

“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: 35626 Based on observation, interview, and record review the facility failed to post signs in the emergency department (ED), visible to all who entered the ED, that specified the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC) and women in labor, in the following areas: 1. The ED waiting room 2. The ED treatment and exam rooms 3. One of three registration stations (station 3) In addition, the sign in registration station 1 was obscured by a suggestion box. This failure had the potential for patients and their families to be uninformed of their rights under EMTALA (Emergency Medical Treatment and labor Act). Findings: During a concurrent observation and interview with the Emergency Department Manager (EDM 1) on 12/5/23 at 10:30 AM, a sign which addressed patient rights related to EMTALA was observed at registration station 1 in the ED. The sign was partially obscured by a suggestion box so that the entire sign could not be read. EDM 1 confirmed the whole sign could not be read behind the suggestion box. In addition, there were no signs to address patient rights related to EMTALA in the ED waiting room, treatment rooms, or exam rooms. A review of the facility policy and procedure (P&P) titled, “Guidelines for Emergency Medical Screening Examinations, Triage, Treatments & Transfers”, dated 3/22, the P&P indicated, “The hospital will post in places likely to be noticed by all individuals entering the Emergency/Labor and Delivery Department, as well as those individuals waiting for examination and treatment, signs in clear and simple terms... the rights of individuals, under the law with respect to examination and treatment for emergency medical conditions ...””

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 33922 Based on observation, interview and record review, the facility failed to ensure an adequate roster of on- call orthopedic physicians (specialty of medicine related to injuries or deformities of the musculoskeletal system- muscles and bones) was maintained and posted in the Emergency Department (ED). Orthopedic physicians were selectively on-call for patients of a medical group with [specific insurance]. The hospital did not ensure on-call orthopedic services were available for patients who did not have [specific insurance] when: 1. One of 20 sampled patients (Patient 11), waited in the ED almost 30 hours before being transferred to another hospital for orthopedic treatment when the hospital’s orthopedic physician declined to treat Patient 11. This failure had the potential to result in extended pain, delayed healing and further medical complications for Patient 11 and all other patients seeking treatment of orthopedic emergencies as they waited for transfer to another facility. Findings: During an observation and concurrent interview with the Emergency Department Director (EDD) on 12/4/2023 at 10 a.m., in the Emergency Department (ED), the on-call white board was observed near the central station, with specialties listed and physician names/numbers next to each for the physician on call. Missing from the board were phone numbers for “Ortho” (orthopedics). The EDD stated the “Ortho” specialty was offered in the hospital but was limited to patients in a medical group with [specific insurance], and any patient who did not have [specific insurance] would be transferred to another hospital. The EDD stated the orthopedic physicians would provide consults and admit patients from the ED depending on the patients’ insurance coverage. During an interview with the Chief of Staff (MD 6) on 12/5/23 at 1:45 p.m., MD 6 stated, individual physicians were not required to take emergency call; however, the hospital required certain specialties to be on call for the ED. MD 6 stated, the orthopedic physicians no longer provided on-call coverage for the ED. MD 6 confirmed the Medical Executive Committee was aware of this lack of orthopedic on-call coverage and the plan was to transfer ED patients with orthopedic emergencies to another hospital unless they had [specific insurance]. MD 6 confirmed the hospital provided orthopedic services and had several orthopedic physicians on the medical staff. During an interview with the Emergency Department Medical Director (MD 1) on 12/5/23 at 2:25 p.m., MD 1 stated, “On call panel at the hospital is voluntary. No one wants to take call.” MD 1 stated the orthopedics service was on call 24/7 for the ED until a few months ago. MD1 stated, currently the orthopedics service will only cover for patients in a medical group with [specific insurance]. MD 1 stated, “Sometimes we call them anyway [orthopedic physician] to see if they can see the patient or admit the patient; but they will only see them based on [specific insurance]”. MD 1 stated, for patients with orthopedic emergencies, which cannot be stabilized by the ED physician and do not have [specific insurance], he “starts cold calling” other hospitals for placement. During an interview with the Orthopedic Physician (MD 4) on 12/5/23 at 3:52 p.m., MD 4 stated, as of March 2023, the hospital removed the orthopedic physicians from the Emergency On- Call list without asking them. MD 4 stated, “For many years we were on call for the ED 24/7; but they kicked us off.” MD 4 stated the orthopedic physicians provided consults for ED patients on a case-by-case basis based on insurance. 1. A review of Patient 11’s medical record indicated Patient 11 arrived at the ED on 9/4/23 at 4:39 p.m. and was diagnosed by the ED physician with a proximal displaced femur fracture (thigh bone with a break close to the hip which has bone fragments on each side of the break which are not aligned). The ED physician documented he called the orthopedic physician for consult and possible admission and the orthopedic physician declined to treat the patient. During a review of the facility’s “Emergency On-Call Calendars”, from 1/1/23-11/30/23, the “Emergency On- Call Calendars” indicated the orthopedic services maintained 24/7 on call coverage for the ED from 1/1/23-3/31/23. The orthopedic service was removed from the Emergency On-Call Calendar after 3/31/23. During a review of an email provided by the COO, dated 3/31/23, the email indicated, there was no longer orthopedic service coverage for the ED, “until further notice”. The email was sent to facility department heads including MD 1 and the CEO. During a review of the “Medial Staff Roster”, current at the time of the survey, the “Medical Staff Roster” listed a total of 12 orthopedic physicians with privileges at the hospital who were included on the “Emergency On-Call Calendar” prior to 3/31/23. During a review of the facility’s “Medical Staff General Rules and Regulations (R&R)”, dated 10/16/23, the R&R indicated, “On Call Panels: An adequate roster of staff physicians must be maintained at all times for backup call and admissions, and is posted in the emergency care areas ... The appropriate clinical department shall appoint panel members ...the governing body shall approve establishment of an on-call panel ... panel members will accept all calls regardless of the economic status of the patient ... Individual department chairmen, or the emergency service director may request modification of the criteria in order to assure adequate emergency room coverage in a particular specialty.” During a review of the facility’s Policy and Procedure (P&P) titled, “Guidelines for Emergency Medical Screening Examinations, Triage, Treatments & Transfers”, dated 3/22, the P&P indicated, “On-call physician services and ancillary services routinely available to the Emergency Department will be made available to individuals who come to the hospital seeking examination or treatment of an emergency medical condition.” During a review of facility policy and procedures (P & P) titled, “Hospital Policies & Procedures, Transfer Agreements, etc.” dated 11/20/2022 the P & P indicated, “If in the judgment of the emergency department physician, a patient requires admission or consultation and does not have a personal physician, or his personal physician is not available, the emergency department physician shall contact the staff physician on call for the area of medicine appropriate to the patient’s condition.””

“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: 33922 Based on interview and record review, the facility failed to ensure an adequate Medical Screening Examination (MSE- an examination performed to determine if an emergency medical condition exits) was provided for one of 20 sampled patients (Patient 1). As a result of this failure Patient 1 did not receive adequate diagnostic treatments necessary to direct appropriate stabilizing care. Findings: During a review of Patient 1’s medical record, the record indicated, Patient 1 was a 23-week premature infant (baby born approximately 4 months early) who was born in the hospital’s Labor and Delivery (L&D) Triage Department (Emergency department in the L&D Unit) on 9/30/23 at 1:16 a.m. During a review of Patient 1’s “Delivery Record”, dated 9/30/23 at 5:18 a.m., the “Delivery Record” indicated, Patient 1 was born at 1:16 a.m. and had an Apgar Score (measures heart rate, respiratory effort, muscle tone, reflexes, and color. A score of 7-10 is an indication that a newborn is in good health) of 1 at 1 minute of life, 2 at 5 minutes of life, and 2 at 10 minutes of life. There was no physician present to assume care of Patient 1. During a review of the “OB Tracevue Flowsheet”, dated 9/30/23 at 1:50 a.m., the “OB Tracevue Flowsheet” indicated, the Emergency Department (ED) physician arrived to L&D to assess Patient 1 (34 minutes after Patient 1 was born). A review of Patient 1’s entire medical record, indicated there was no documentation of a Medical Screening Examination (MSE), no physician orders, no physician progress notes and no documentation which indicated a physician accepted responsibility for providing care to Patient 1. During a review of the “Neonatal Resuscitation Record”, dated 9/30/23, the “Neonatal Resuscitation Record” contained an untimed and unsigned note which indicated, “[Patient 1] was cyanotic (blue), no respirations, no grimace, heart rate 89. Placed on warmer, dried, stimulated, positioned airway, suctioned secretions (mucus), placed on pulse oximeter (used to monitor oxygen level). O2 sat 86% (normal is 90-93%). ETT (tube inserted into the windpipe to provide oxygen during an emergency) ...O2 sat increased to 90-92%, heart rate 117-118 (normal is 110-160).” During a review of the “Neonatal Resuscitation Record”, dated 9/30/23, the “Neonatal Resuscitation Record” indicated: 9/30/23 at 1:21 a.m., Patient 1 was intubated (procedure where a tube is inserted into the windpipe to provide oxygen during an emergency); there was no ventilation (breathing) rate documented. Patient 1’s heart rate was 118 and his body was pink. 9/30/23 at 1:31 a.m., There was no ventilation rate documented. Patient 1’s heart rate was 117 and his body was pink. 9/30/23 at 1:41 a.m., There was no ventilation rate documented. Patient 1’s heart rate was 117 and his body was pink. There was no documentation in the medical record of Patient 1’s status between 1:41 a.m. and 2:30 a.m. 9/30/23 at 2:30 a.m., “UVC by [MD 2]”. There was no documentation which indicated the size or length of the catheter and no assessment of Patient 1 documented before, during or after the procedure. There was no documentation in the medical record of Patient 1’s status between 2:30 a.m. and 3:50 a.m. 9/30/23 at 3:50 a.m., Patient 1 did not have a heart rate and chest compressions were started. Epinephrine (medication given in an emergency to increase heart rate) was given. 9/30/23 at 3:51 a.m., Patient 1 did not have a heart rate and ventilations were provided at 40 breaths per minute. During a review of the “Progress Record” from Hospital B’s neonatal transport team (specialized team from an outside hospital capable of providing care for premature newborns), dated 9/30/23 at 4:10 a.m., the “Progress Record” indicated, Hospital B’s neonatal transport team physician (MD 5) documented, “Arrived to find extremely premature infant ... intubated on a vent ... lung sounds on right greater than left. ETT (breathing tube in windpipe) checked and found to be at 8 cm (which indicated the tube is too far inserted) and pulled back to 6 cm ... no heart rate... chest compressions started ... CPR stopped after 5 minutes ... given extreme prematurity, no pulses and heart rate of 70-80 for greater than 1 hour prior to arrival ... finished code at 3:55 a.m...” During an interview with the ED Physician (MD 2) on 12/5/23 at 4 p.m., MD 2 stated, on 9/30/23, he responded to a “Code White” (emergency for a patient under the age of 13) in L&D and when he arrived, Patient 1 was already intubated, and Patient 1 had vital signs. MD 2 stated he spoke with Hospital B’s transport team physician, who advised him to place a UVC (UVC- catheter inserted through a large vein in the umbilical cord used to deliver medications or fluid) which was a rare procedure for an ED physician to perform. MD 2 stated he successfully placed the UVC and he gave a verbal order to obtain an x-ray (test to determine if the ETT and UVC were placed correctly) and to intubate Patient 1. MD 2 stated he left to return to the ED and confirmed Hospital B’s transport team had not arrived when he left. MD 2 stated it was the responsibility of L&D staff to conduct an MSE for Patient 1. During an interview with the Emergency Department Medical Director (MD 1) on 12/5/23 at 2:25 p.m., MD 1 stated every patient presenting to an ED area of the hospital should have a MSE and it should be documented in the patient’s record. During a review of the facility’s Policy and Procedure (P&P) titled, “Guidelines for Emergency Medical Screening Examinations, Triage, Treatments & Transfers”, dated 3/22, the P&P indicated, “Medical Examinations: The hospital will provide a medical screening examination by a Qualified Medical Person to any individual who comes to a Dedicated Emergency Department seeking an examination or medical treatment to determine if the individual has an emergency medical condition .... It will be documented in the [patient record] and include: date and time of screening, chief complaint, age, sex, vital signs, level of distress, other pertinent information ...” During a review of the facility’s Policy and Procedure (P&P) titled, “Guidelines for Emergency Medical Screening Examinations, Triage, Treatments & Transfers”, dated 3/22, the P&P indicated, “Those professionals who have been identified by the hospital’s governing body as qualified to administer a MSE ... will include the ED Physician ...Labor and Delivery Registered Nurse (for patients presenting in labor).””

“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: 33922 On 12/6/23 at 11:31 a.m., the survey team called an Immediate Jeopardy (IJ - a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death of a patient) in the presence of the facility’s Chief Operating Officer (COO), Interim Chief Nursing Officer (CNO), and Emergency Department Director (EDD). The Immediate Jeopardy situation began on 9/30/23 concerning the provision of a Medical Screening Examination (MSE) and ongoing stabilizing treatment for one of 20 sampled patients (Patient 1), who was born at the hospital. On 12/6/23 at 5:01 p.m., the CNO and COO provided the survey team with an IJ Removal Plan as follows: 1. The Labor and Delivery (L&D) Registered Nurse (RN) who identifies a high-risk patient (defined in policy) will contact the physician immediately for transfer orders. 2. The L&D RN will contact the outside hospital neonatal transport team (specialized team capable of providing care for premature newborns) to initiate a transfer or attend to the delivery when the high-risk mother cannot be transferred. 3. The newborn high-risk pediatrician (physician who specializes in the care of children) will be assigned as the accepting physician for all high-risk newborns. 4.During a Code White (emergency for a patient under the age of 13), the Anesthesiologist (physician who specializes in airway management and lifesaving procedures) or Emergency Department (ED) provider will be responsible to support the RN and Respiratory Therapist (RT). 5. The Anesthesiologist/ED physician will provide orders to nursing staff as appropriate. 6. The Anesthesiologist or high-risk pediatrician will remain with the patient until the outside hospital neonatal transport team arrives. 7. The high-risk pediatrician will be the admitting physician and will document doctor to doctor handoff to the outside hospital neonatal transport team. 8. Education on this procedure will be provided to all obstetricians (physicians who specialize in the care of pregnant women), pediatricians, ED providers, Anesthesiologists, Neonatal Intensive Care Unit RNs, Respiratory Therapists, Maternal Child Health Center staff, and the House Supervisor. 9. A log was created to document all physician and transport team notifications and response times and will be monitored daily by the L&D RN and reported to the Director of Maternal Child Health weekly. 10. The hospital NICU reopened on 11/3/23 with 24/7 Neonatologist (physician who specializes in the care of premature and critically ill infants). The Neonatologist will perform a MSE, evaluate diagnose, treat, and provide stabilizing treatment to newborns with complex and life-threatening conditions. In the case of a transfer to a higher level of care, the Neonatologist will call the facility who provides specialty care and speak with the accepting physician, document the accepting hospital information, and certify the transfer. The Neonatologist will round daily at the hospital, provide on call coverage 24/7 and will respond to phone calls within 20 minutes and will report to the hospital within 30 minutes when needed. On 12/7/23 at 10:45 a.m., while onsite after confirming the implementation of the IJ Removal Plan through observations, interviews, and record reviews, the survey team removed the IJ in the presence of the COO. Based on interview and record review, the facility failed to provide necessary stabilizing treatment within the capabilities of the staff and services provided at the hospital for 1 of 20 sampled patients (Patient 1). The facility failed to provide a physician to accept responsibility for the care and ongoing stabilizing treatment for Patient 1, who died at the facility approximately three hours after birth. Findings: During a review of Patient 1’s medical record, the record indicated, Patient 1 was a 23-week premature infant (baby born approximately 4 months early) who was born in the hospital’s Labor and Delivery (L&D) Triage Department (Emergency Department in the L&D Unit) on 9/30/23 at 1:16 a.m. During a review of Patient 1’s “Delivery Record” dated 9/30/23 at 5:18 a.m., the “Delivery Record” indicated, Patient 1 was born at 1:16 a.m. and had an Apgar Score (measures heart rate, respiratory effort, muscle tone, reflexes, and color. A score of 7-10 is an indication that a newborn is in good health) of 1 at 1 minute of life, 2 at 5 minutes of life, and 2 at 10 minutes of life. There was no physician present to assume care of Patient 1. During a review of the “OB Tracevue Flowsheet” dated 9/30/23 at 1:50 a.m., the “OB Tracevue Flowsheet” indicated, the Emergency Department (ED) physician arrived in the L&D Triage Department to assess Patient 1 (34 minutes after Patient 1 was born). During a review of Patient 1’s entire medical record, the record indicated there was no documentation of a medical screening examination (MSE), no physician orders, no physician progress notes and no documentation which indicated a physician accepted responsibility for providing care to Patient 1. During a review of the “Neonatal Resuscitation Record” dated 9/30/23, the “Neonatal Resuscitation Record” contained an untimed and unsigned note which indicated, “[Patient 1] was cyanotic (blue), no respirations, no grimace, heart rate 89. Placed on warmer, dried, stimulated, positioned airway, suctioned secretions (mucus), placed on pulse oximeter (used to monitor oxygen level). O2 sat 86% (normal is 90-93%). ETT (tube inserted into the windpipe to provide oxygen during an emergency) ...O2 sat increased to 90-92%, heart rate 117-118 (normal is 110-160).” During a review of the “Neonatal Resuscitation Record” dated 9/30/23, the “Neonatal Resuscitation Record” indicated: 9/30/23 at 1:21 a.m., Patient 1 was intubated (procedure where a tube inserted into the windpipe to provide oxygen during an emergency); there was no ventilation (breathing) rate documented. Patient 1’s heart rate was 118 and his body was pink. 9/30/23 at 1:31 a.m., There was no ventilation rate documented. Patient 1’s heart rate was 117 and his body was pink. 9/30/23 at 1:41 a.m., There was no ventilation rate documented. Patient 1’s heart rate was 117 and his body was pink. There was no documentation in the medical record of Patient 1’s status between 1:41 a.m. and 2:30 a.m. 9/30/23 at 2:30 a.m., “UVC by [MD 2]”. There was no documentation which indicated the size or length of the catheter and no assessment of Patient 1 documented before, during or after the procedure. There was no documentation in the medical record of Patient 1’s status between 2:30 a.m. and 3:50 a.m. 9/30/23 at 3:50 a.m., Patient 1 did not have a heart rate and chest compressions were started. Epinephrine (medication given in an emergency to increase heart rate) was given. 9/30/23 at 3:51 a.m., Patient 1 did not have a heart rate and ventilations were provided at 40 breaths per minute. During a review of the “Progress Record” from Hospital B’s neonatal transport team (specialized team from an outside hospital capable of providing care for premature newborns), dated 9/30/23 at 4:10 a.m., the “Progress Record” indicated, Hospital B’s neonatal transport team physician (MD 5) documented, “Arrived to find extremely premature infant ... intubated on a vent ... lung sounds on right greater than left. ETT (breathing tube in windpipe) checked and found to be at 8 cm (which indicated the tube is too far inserted) and pulled back to 6 cm ... no heart rate... chest compressions started ... CPR stopped after 5 minutes ... given extreme prematurity, no pulses and heart rate of 70-80 for greater than 1 hour prior to arrival ... finished code at 3:55 a.m...” During an interview with the ED Physician (MD 2) on 12/5/23 at 4 p.m., MD 2 stated, on 9/30/23, he responded to a “Code White” (emergency for a patient under the age of 13) in L&D Triage and when he arrived, Patient 1 was already intubated (a tube was placed in the windpipe to assist in breathing) and Patient 1 had vital signs (signs of life). MD 2 stated he spoke with Hospital B’s transport team’s physician by phone, who advised him to place a UVC (UVC- catheter inserted through a large vein in the umbilical cord used to deliver medications or fluid) which was a rare procedure for an ED physician to perform. MD 2 stated he successfully placed the UVC and he gave a verbal order to obtain an x-ray (test to determine if the ETT and UVC were placed correctly) and to intubate Patient 1. MD 2 stated he left to return to the ED and confirmed Hospital B’s transport team had not arrived when he left. During an interview with Registered Nurse (RN 2) on 12/5/23 at 4:35 p.m., RN 2 stated, on 9/30/23 at approximately 1:16 a.m., she and the Respiratory Therapist (RT 1) were called to L&D when Patient 1 was born. RN 2 stated Patient 1 had a heartbeat but was not breathing, was blue, and floppy. RN 2 stated there was no physician present at the delivery to care for Patient 1. RN 2 stated a code white was called at that time. RN 2 stated, she placed Patient 1 on a warmer and RT 1 intubated the patient and provided oxygen. RN 2 stated, 20-30 minutes later, the Emergency Department Physician (MD 2) arrived. RN 2 stated she left to call Hospital B’s neonatal transport team and RN 3 arrived to help. RN 2 stated, MD 2 placed a UVC and MD 2 returned to the ED shortly after placing the UVC. RN 2 stated, RN 3 and RT 1 continued to care for Patient 1 without a physician present and without physician orders. RN 2 confirmed, no medications were ordered or given by hospital staff, no labs were ordered or collected, no x rays were ordered or performed, and no fluid boluses (large amount of fluid to increase blood pressure) were ordered or administered to Patient 1. RN 2 stated, Hospital B’s neonatal transport team arrived around 3:50 a.m. (almost 3 hours after Patient 1 was born) and, at that time, Patient 1’s heart stopped. RN 2 stated Hospital B’s neonatal transport team administered CPR (Cardiopulmonary Resuscitation -an emergency lifesaving procedure performed when the heart stops beating); but Patient 1 died. During an interview with the Respiratory Therapist (RT 1) on 12/5/23 at 5 pm, RT 1 stated, on 9/30/23, she was called to the L&D Triage Department for a delivery. RT 1 stated Patient 1 was born with a heart rate of greater than 100 beats per minute (bpm- greater than 100 is an acceptable range immediately after birth) but was not breathing effectively. RT 1 stated she intubated Patient 1 and provided breaths. RT 1 stated MD 2 arrived as staff were moving Patient 1 and the ETT slipped out. RT 1 stated she then re-intubated Patient 1 and MD 2 assisted in securing the ETT and then left to make phone calls. RT 1 stated, MD 2 returned and placed a UVC and then returned to the ED. RT 1 confirmed Patient 1 did not receive an X-ray to confirm ETT or UVC placement. RT 1 stated, when Hospital B’s transport team arrived, Patient 1 did not have a heart rate and they started CPR, but Patient 1 died. During a review of the facility’s Policy and Procedure (P&P) titled, “Guidelines for Emergency Medical Screening Examinations, Triage, Treatments& Transfers”, dated 3/22, the P&P indicated, “D. “Comes to the Dedicated Emergency Department” means: Individual who presents on hospital property ... for what a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs emergency examination or treatment ... L. The hospital will provide the individual, within the capabilities of the hospital, with such further medical examination and treatment, as required, to stabilize the medical condition ...The record will identify the tests and procedures performed to evaluate the individual’s chief complaint and, if necessary, stabilize the individual’s emergency medical condition.” During a review of the facility’s “Medical Staff General Rules and Regulations”, dated 10/16/23, the rules and regulations indicated, “The emergency room physician shall immediately see and treat all patients. The emergency room physician is responsible for the admission, transfer, discharge, and triage process in the emergency room and for appropriately documenting the same ...””

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 33922 Based on observation, interview and record review, the facility failed to prevent a delay in orthopedic (specialty of medicine related to injuries or deformities of the musculoskeletal system- muscles and bones) consultation and treatment for one of 10 sampled patients (Patient 11) when: orthopedic physicians on service at the facility refused to provide orthopedic consult or treatment within the capacity and capability of the facility as requested by the emergency room physicians, based on insurance coverage. This failure had the potential to result in prolonged pain/suffering, delayed healing and unforeseen medical complications for Patient 11, and all patients seeking emergency orthopedic treatment, as they were denied care in house and waited for transfer to another facility. Findings: During a concurrent observation and interview with the Emergency Department Director (EDD) on 12/4/23 at 10 a.m., in the Emergency Department (ED), the on-call white board was observed near the central station, with specialties listed and physician contact information. Missing from the board were phone numbers for “Ortho” (orthopedics). The EDD stated the “Ortho” specialty was offered in the hospital but was limited to patients in a medical group with [specific insurance], and any patient who did not have [specific insurance] would be transferred to another hospital. The EDD stated the orthopedic physicians would provide consults and admit patients from the ED depending on the patients’ insurance coverage. During an interview on 12/4/23 at 2:54 p.m., the ED Director stated there was a memo that showed the dates when the hospital no longer had on-call providers for orthopedics, except for those patients with [specific insurance]. A review of Patient 11’s medical record, indicated she was an 86 year-old female who presented to the ED on 09/4/23, at 10:47 p.m., with the presenting complaint of left leg pain after a fall. A review of the ED Physician’s Note dated 9/4/23 11 p.m., indicated, Patient 11 was diagnosed with a displaced left femur fracture (left broken thigh bone). The ED Physician Note indicated he attempted to obtain a consult with the in house orthopedic physician, for possible admission with orthopedic treatment, but the orthopedic physician declined the consult and admission, due to Patient 11’s insurance coverage. During a review of Patient 11’s medical record, on 12/5/23 at 9:40 a.m., the facility document, titled, “Interfacility Transfer/ Admission/ Insurance Verification Time Log” dated 9/5/23 at 4:34 a.m. indicated, “Spoke To: [orthopedic physician] ...ORTHO DOES NOT ACCEPTS CONSOLE”. A series of entries documented from 4:23 a.m. on 9/5/23 to 1:15 a.m. on 9/6/2023, indicated ED staff made multiple attempts to locate a hospital with an orthopedic physician to accept Patient 11 as a transfer. During this delay, the record indicated, Patient 11 waited in the ED bed for over 30 hours before she was transferred to another area hospital for orthopedic care. During an interview with the Chief of Staff (MD 6) on 12/5/23 at 1:45 p.m., MD 6 stated, the hospital planned to transfer ED patients with orthopedic emergencies to another hospital unless they had [specific insurance]. MD 6 confirmed the hospital provided orthopedic services and had a group of orthopedic physicians on the medical staff. During an interview with the Emergency Department Medical Director (MD 1) on 12/5/23 at 2:25 p.m. MD 1 stated, currently the orthopedics service will only cover for patients in a medical group with [specific insurance]. MD 1 stated, “Sometimes we call them anyway [orthopedic physician] to see if they can see the patient or admit the patient; but they will only see them based on [specific insurance]”. MD 1 stated, for patients with orthopedic issues which cannot be stabilized by the ED physician and do not have [specific insurance], he “starts cold calling” other hospitals for placement. During an interview with the Orthopedic Physician (MD 4) on 12/5/23 at 3:52 p.m., MD 4 stated the orthopedic physicians would consult and admit ED patients on a case-by-case basis based on insurance. During an interview with the EDD on 12/7/23 at 10:45 a.m., she stated, “If we have capability, meaning we have the bed, we have the ortho service, we have the staff, we still can’t admit because they [orthopedic physicians] won’t take the patient because of the insurance.” During review of facility Daily Census for September 4 - 6, 2023, the census indicated the facility had available beds for admission of orthopedic patients. During a review of an email provided by the COO, dated 3/31/23, the email indicated there was no longer orthopedic service coverage for the ED “until further notice”. The email was sent to facility department heads including MD 1 and the CEO. During a review of the “Medial Staff Roster”, current at the time of the survey, the “Medical Staff Roster” listed a total of 12 orthopedic physicians with privileges at the hospital. During a review of the facility’s Policy and Procedure (P&P) titled, “Guidelines for Emergency Medical Screening Examinations, Triage, Treatments& Transfers”, dated 3/222, the P&P indicated, “When it is determined that the individual has an emergency medical condition, the hospital will provide treatment to stabilize the individual within the capabilities of the hospital including admission to the hospital.” During a review of the facility’s “Medical Staff General Rules and Regulations”, dated 10/16/23, the rules and regulations indicated, “Emergency Room Physicians: D. Unless extenuating circumstances are documented in the patient’s record, no patient is arbitrarily transferred to another hospital if the hospital where the patient is initially seen has the means for providing adequate care.” During a review of facility policy and procedures (P & P) titled, “Hospital Policies & Procedures, Transfer Agreements, etc.” dated 11/20/2022 (last approval date), the P & P indicated, “Article III - Emergency Services, A. General Emergency Department Rules... 5. If in the judgment of the emergency department physician, a patient requires admission or consultation and does not have a personal physician, or his personal physician is not available, the emergency department physician shall contact the staff physician on call for the area of medicine appropriate to the patient’s condition. The appropriate on call staff physician shall answer calls from the emergency department physician in the event that the latter requests advice or assistance concerning the management and disposition of emergency department patients ...When the emergency department physician feels the patient requires admission or further consultation assessment, but the on-call physician disagrees or wants the patient transferred to another facility, it is the responsibility of the on-call staff physician to come in and personally see the patient before final disposition is made ...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40174 Based on interview and record review, the facility failed to ensure Patient 1 consented for hemodialysis (procedure for cleaning the blood of waste products) treatment prior to receiving hemodialysis treatment. This failure resulted in a violation of Patient 1’s right to make an informed decision regarding his or her care. Findings: During a review of Patient 1’s History and Physical, dated 10/9/23, indicated Patient 1 was admitted to the facility on 10/8/23, with diagnoses that included End Stage Renal Disease (ESRD, loss of kidney function, wherein the kidneys no longer work as they should to meet a person’s needs). During a review of Patient 1’s medical record indicated a Physician Order for hemodialysis, dated 10/10/23 at 8:13 AM. During a review of Patient 1’s Hemodialysis Record, dated 10/10/23 at 10:12 AM, indicated Patient 1 received hemodialysis treatment. During a concurrent interview and record review with Informatics Registered Nurse (RN 1) on 11/14/23 at 4:14 PM, RN 1 stated she was unable to locate documented evidence to show Patient 1 consented for hemodialysis treatment on 10/10/23. During an interview with the Chief Nursing Officer (CNO) on 11/15/23 at 9:27 AM, the CNO stated the physician should have discussed with Patient 1 or patient’s representative the risks and benefits of procedures/treatments, including hemodialysis treatments prior to the start of the treatment. The CNO reviewed Patient 1’s medical record and was unable to locate and provide documented evidence to show Patient 1’s verbal or written consent was obtained for the hemodialysis treatment completed on 10/10/23. During a review of the facility’s policy and procedure (P&P) titled, “Consents,” dated 3/22, the P&P indicated, “2.3.1 The hospital cannot permit any treatment, without the risk of liability, unless the patient, or a person, or a person legally authorized to act on his behalf, has consented thereto ... 2.7 Who May Give Consent ... 2.7.1 A competent adult patient.””