Colusa Medical Center

“SYSTEM QAPI POLICIES AND PROCEDURES CFR(s): The unified and integrated QAPI program establishes and implements policies and procedures to ensure that the needs and concerns of each of its separately certified hospitals, regardless of practice or location, are given due consideration, and that the unified and integrated QAPI program has mechanisms in place to ensure that issues localized to particular hospitals are duly considered and addressed. This Standard is not met as evidenced by: 41567 Based on interview, and record review, the facility failed to implement its policy, Quality Assurance Performance Improvement Plan (QAPI), dated 8/1/25, a comprehensive policy charging the Governing Board, Medical staff, and Administrative Leadership with the responsibility of overseeing the development and implementation of the Quality Plan to promote the highest quality patient care and services. This policy requires quarterly Quality Improvement Committee (QIC) meetings to be conducted; the last meeting held was on 11/21/25, a period of over 6 months in which two quarterly meetings should have been conducted and were not. This failure had the potential to undervalue the importance of the Quality Plan, and minimize the priority of patient safety and performance improvement which could lead to negative clinical outcomes. Findings: A review, of the facility’s policy titled, “Quality Assurance Performance Improvement Plan (QAPI)”, dated 8/1/25, indicated that the organization’s Board of Directors, Medical staff, and Administrative Leadership are dedicated to patient safety, and performance improvement, and are charged with the responsibility of overseeing the development and implementation of a quality plan consistent with the organization’s mission, vision, values and strategic initiatives. This policy defines the purpose of the Quality Improvement Committee: “facilitates the implementation of the strategic quality direction; oversee ongoing measurement, assessment, and improvement of current performance initiatives; receive reports of each facility’s patient safety adverse events; prioritize improvement activities; receive reports and coordinate accreditation efforts,” and, “review and revise the annual plan; complete an annual review of quality performance; serve as a resource for learning and applying new quality techniques.” The committee shall receive performance improvement information and provide oversight for the annual performance improvement and safety plan, and reports to senior leadership and the Governing Board with monthly board reports. This policy further stipulates quarterly QIC meetings are required. A review, was made of the most recent Quality Committee meeting minutes on 5/28/26; the date of that meeting was held was 11/21/25. A calculation made of time elapsed between these dates indicated that it had been 186 days, or just over 6 months, since a Quality Committee meeting had been held at the facility, indicating the last two required quarterly meetings had been missed. During an interview, on 5/28/26 at 10:47 am, the Quality & Risk Coordinator (QRC) was asked if any QIC meetings had been held since 11/21/25. QRC confirmed, that meetings had been planned but canceled due to surveys, and other related activities. When asked when the quarterly meetings are scheduled, she stated I’m still planning that. When asked if there was a meeting planned for the near future, she stated, “not yet.” QRC confirmed, that she knew meetings were to be held quarterly, and that two quarterly meetings had not been missed. During a concurrent interview, and record review, on 5/28/26 at 5 pm, the Chief Administrative Officer (CAO) was asked why the facility had not had a quarterly Quality Committee meeting since 11/21/25. CAO stated, that the facility had been very busy with surveys, and plans of correction and had had to cancel the Quality Committee meetings. When it was pointed out that the facility had missed the last two quarterly meetings, the CAO corrected, stating they had missed one meeting. Again it was pointed out that the last quality committee meeting had been on 11/21/25, which was, as of 5/28/26, 186 days or just over six months which would make it two quarters of missed meetings. CAO considered, and stated I totally understand and we’re definitely going to schedule the QAPI meeting very soon. When asked if the Governing Board was aware, that there had been no Quality Committee meetings since 11/21/25, CAO stated that the Board was aware.”

“DIRECTOR OF REHABILITATION SERVICES CFR(s): 482.56(a)(1) The director of the services must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services. This Standard is not met as evidenced by: 41567 Based on interview, and record review, the facility failed to ensure that rehabilitation services were accountable to a Director of Rehabilitation with the necessary qualifications to oversee and administer the service. This failure left patients potentially vulnerable to inadequate oversight of the program during a period in which the Rehabilitation Supervisor was on a leave of absence, and there was no Director of Rehabilitation to provide organizational leadership, to develop and implement effective planning processes, or to provide the framework to ensure the timely and safe delivery of patient care which could lead to negative clinical outcomes. Findings: A review, of the facility’s Administrative policy titled, “Organizational Decisions - Corporate Level,” dated. 6/25, indicated that the purpose of the policy was to establish the organizational structure, decision-making authority, and lines of accountability for the facility, and to ensure compliance with applicable federal, state, and accreditation requirements. This policy applies to all departments and services, to personnel and contracted staff, and indicates that all department directors and managers are responsible for operational decisions within their respective areas, consistent with board-approved policies, budgets, and strategic objectives. A review, of the facility’s policy titled, “Plan for Provision of Services,” dated 2/26, indicated that patient care departments and services, including inpatient rehabilitation, shall be provided through an organized and systemic process designed to ensure the delivery of safe, effective and timely care and treatment and that the provision of patient care delivery requires specialized knowledge, judgment and skill derived from the principles of physical, biological, behavioral, psychosocial, and medical sciences. Organizational leadership, defined as the Governing Board, the Chief Executive Officer, Administrative staff, departmental leaders and Medical staff, are responsible for providing the framework for planning health care services provided by the organization based on its mission, and for developing and implementing an effective planning process. A record review, was made of two facility’s job descriptions, as follows: Physical Therapist, dated 7/16 - the title page of this job description designates that the employee reports to the “Director of Rehabilitation Services/Rehab Supervisor.” Rehab Supervisor/Physical Therapist, undated - the title page of this job description designates that the employee reports to the “Director of Rehab Services.” During an interview, on 5/27/26 at 1:03 pm, the Quality and Risk Coordinator (QRC) responded to a request for the position description for the Director of the Department of Rehabilitation Services, and stated the facility did not have a Director of Rehabilitation of inpatient services, that they only had a Supervisor. A request was made to interview the Supervisor; QRC stated the Supervisor was out on a leave of absence, and that Physical Therapist (PT) A was covering the supervisory role. During an interview, on 5/27/26 at 2:02 pm, Physical Therapist A stated, that he had been assisting in the Rehabilitation Supervisor role as the Supervisor was on leave. When asked how long the facility had been without a Supervisor, he stated since March of 2026. When asked what duties he was covering, PT A stated, that he was supervising Physical Therapy, Occupational Therapy, and Speech Therapy. When asked, he confirmed that there had been no training at the facility for the position, but he did have prior supervisory experience at another facility. When asked if he was continuing with a case load of rehabilitation patients while acting as Supervisor, he indicated he was. When asked to expand on the duties he covered as temporary supervisor he stated, the difference between supervisory responsibilities, and practicing PT is quite vast. PT A stated, the supervisory role is demanding and involves supervising day-to-day operations, solving problems, relaying concerns/issues within the facility, and that Rehabilitation is involved in significant decisions tied into discharge planning. He confirmed, that there was no Director of Rehabilitation and when asked if the lack of a Director effected the service he stated, a Rehab Director is an important role to have because of the issues that come up on any given day. During a concurrent interview, and record review, on 5/28/26 at 5 pm, the Chief Administrative Officer (CAO) was asked why the facility did not have a Director of Rehabilitation. CAO stated, we have a supervisor that oversees all the rehabilitation operational and staffing needs. The CAO was shown the job descriptions, Physical Therapist, and Rehab Supervisor/Physical Therapist, with the title pages designating that the employees report to a Director of Rehabilitation Services. The CAO stated, that she would have the job descriptions updated. It was pointed out that federal law requires a Director overseeing the program; the CAO stated that rural hospitals are not required to have a Director of Rehabilitation, and the facility did not fulfill that position because they are in a rural hospital area, but if this was incorrect, the facility would comply with regulatory requirements, and will fill the position.”

“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: 49418 Based on observation, interview, and record review, the facility failed to meet the regulatory requirements for Code of Federal Regulations 489.24, the regulatory foundation of the Emergency Medical Treatment and Active Labor Act (EMTALA), as evidenced by: 1. The facility failed to post required EMTALA signage in a conspicuous place in the Emergency Department in a language (English) understandable to the population served by the facility. (Refer to Tag A-2402). 2. The facility did not establish or maintain a list and/or policy and procedure (P&P) detailing the names of on-call specialty consultants qualified to support the ED in addressing the needs of patients presenting with emergency medical conditions. (Refer to Tag A-2404). 3. The facility failed to document in the ED Central Log the name, date of birth, treatment received or refused, discussions with staff, and patient disposition - admitted, stabilized, transferred, or discharged - for one of 24 sampled patients (Patient 0) who presented to the ED seeking treatment. (Refer to Tag A-2405). 4. The facility failed to provide a medical screening examination for one of 24 sampled patients (Patient 0), a 35-weeks pregnant woman who came to the Emergency Department (ED) requesting to see a physician because she had not felt movement of her unborn baby for several hours. (Refer to Tag A-2406). 5. The facility failed to ensure licensed nursing staff performed ongoing patient assessments in the ED in accordance with facility P&Ps for two of 23 sampled patients (Patients 1 and 16) who were determined to have emergency medical conditions when: A. Patient 1’s Triage level was not changed from Emergency Severity Index (ESI - a five-level nursing triage tool) Level 4 (low, stable) to ESI Level 2 (high, critical/emergent) after it was determined he had pneumonia, sepsis (a life-threatening complication of infection, potentially leading to organ malfunction, shock, and/or death), and a non-ST-elevation myocardial infarction (NSTEMI - a heart attack caused by blockage of a coronary artery, resulting in decreased blood flow and heart muscle damage). (Refer to Tag A-2407, Finding 1A). B. Patient 1’s temperature was not reassessed and documented in accordance with facility P&Ps. (Refer to Tag A-2407, Finding 1B). C. Patient 16 was not reassessed per facility P&P by nursing staff during the night shift. (Refer to Tag A-2407, Finding 2). 6. The facility failed to complete and maintain transfer documents for two of two sampled patients (Patients 1 and 16) who were transferred by the facility to another hospital when: A. Patient 16’s transfer paperwork was not complete (Refer to Tag A-2409, Finding 1). B. The facility failed to maintain copies of completed and signed transfer forms to include Physician Authorization to Transfer, Patient Transfer Acceptance or Refusal, and Physician Certification Medically [Stable] for Transfer per facility P&P. (Refer to Tag A-2409, Finding 2). The cumulative effect of these systemic failures resulted in (a) the hospital’s inability to ensure the provision of quality healthcare in compliance with EMTALA regulations, and (b) placed patients at undue risk related to delayed medical interventions to minimize emergency medical conditions that posed a threat to health and life.”

“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: 41567 Based on observation, interview, and record review, the facility failed to post signage in compliance with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements, specifically, in a language understandable by the population served by the facility. This failure had the potential for patients arriving to the Emergency Department (ED) to be remain unaware of their rights to examination and treatment which could lead to negative clinical outcomes. Findings: A review, of facility’s policy titled “EMTALA Guidelines for Emergency Department Services,” rev. 3/25, indicated that the facility must post a sign in a conspicuous area of the Emergency Department specifying the rights of individuals, including women in labor, to examination and treatment of medical conditions. During a concurrent observation, and interview, with the Regional Emergency Director (EDD) in the facility’s ED lobby on 3/11/26 at 2:12 pm, there were no EMTALA signs in English noted. There was an 8 x 11-inch paper posted in Spanish that may have been an EMTALA sign, although there were no words in the common English language on the document to inform English readers of the sign’s purpose. When this was pointed out, EDD stated that she thought the EMTALA signs had been removed when the lobby was painted, and confirmed that there should also be an EMTALA sign posted in English. During a follow-up concurrent observation, and interview, in the ED lobby on 3/11/26 at 2:35 pm, EDD stated, that that the aforementioned posted document in Spanish was an EMTALA sign for Spanish-speaking populations. EDD stated staff found the EMTALA sign in English, and posted it next to the Spanish-only sign in the ED lobby.”

“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: 49418 Based on interview and record review, the facility failed to create and maintain a policy and procedure (P&P) with names of on-call, back-up, specialty consultants capable of assisting in meeting the needs of individuals presenting to the Emergency Department (ED) as required by Emergency Medical Treatment and Active Labor Act (EMTALA - a 1986 federal law requiring Medicare-participating hospitals to provide emergency medical screening and stabilizing treatment) regulations. This deficient practice: 1. Had the potential to delay care for all patients requiring specialty consultations, and 2. Delayed the care of Patient 0, a 35-week pregnant female who came to the facility seeking care from an Obstetrician (OB - provides reproductive health and maternal care in pregnancy) because she had not felt her baby move in several hours. Patient 0 stated that facility staff reported they did not have an OB provider at the facility, and she then called 911 “because I didn’t have a ride” to another facility with an OB. Patient 0 stated that she was “concerned and stressed” because she “needed to go” elsewhere for obstetrical care. Findings: Review of facility P&P titled “EMTALA Guidelines for Emergency Department (ED) Services,” dated 3/2025, indicated the hospital shall provide an on-call physician specialty list to include all specialties privileged at the facility. The list was to be openly posted in the ED, and a record of all on-call lists was to be maintained for five years. Review of facility P&P titled “Obstetric Triage EMTALA,” dated 3/2025, indicated that patients presenting to the ED with potential medical, surgical, or obstetric emergencies shall receive a medical screening exam by the ED physician with obstetrical consultation with an on-call OB. Review of document titled “Delineation of ED Privileges” for Medical Doctor (MD) A, dated 4/24/24, indicated that MD A was an active staff member whose primary specialty was Emergency Medicine. MD A had ED privileges, including but not limited to the mandatory skills of admitting patients, performing history and physical exams, evaluation and initial management of all ED patients, pelvic exams, and emergency delivery of babies. The document indicated that in addition to assigned privileges, Medical Staff were authorized in an emergency to do anything necessary to save the life of any patient in immediate danger when any delay in administering treatment would increase the danger of acute worsening of the patient’s condition or of the likelihood of his[/her] death. During an interview with MD A on 3/13/26 at 12:08 pm, MD A stated that Registered Nurse (RN) A requested his assistance with Patient 0, a pregnant woman who came in because she had not felt her baby move in several hours. MD A stated that he informed Patient 0 he would be happy to do blood tests, an ultrasound, and check the baby’s size, which would confirm if the baby was alive. MD A stated he informed the patient that testing was typically done in a Labor & Delivery Unit, “but we don’t have that department here.” MD A stated that he did not perform an exam, or obtain an OB consultation for Patient 0. MD A stated that they used to have two OB providers at the facility, “but now we don’t have any OB doctors we call, as far as consults.” MD A stated that he has needed an OB consultation for ED patients in the past, noting, “Sometimes I’ll call the other local hospital and coordinate with the Transfer Center (coordinates patient movement between departments or facility-to-facility). They can put an OB on to talk to me.” MD A stated, “I just remember finding out who was on call and calling the other local hospital.” During an interview with Interim ED Leadership Support (IELS) on 3/13/26 at 3:05 pm, this surveyor requested the P&P listing on-call specialty physicians. IELS stated he would look for one but was not sure it listed specific providers’ names. This surveyor informed IELS that MD A stated he has had to call the other local hospital or Transfer Center when he had an obstetric emergency in the past. IELS stated that was “standard practice,” but he was not sure that was in a policy. During an interview with IELS on 3/13/26 at 3:20 pm, IELS acknowledged that the facility did not have an on-call list of specialty consultants or an on-call policy.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, this facility (Hospital A) failed to document Patient 0’s arrival and departure date and time, name and date of birth, treatment received or refused, discussions with staff, and if she was admitted, stabilized, transferred, or discharged from a visit to the Emergency Department (ED) on 2/13/26. Patient 0 was a 35-week pregnant, Punjabi-speaking female who came to the ED seeking care because she had not felt her unborn child move for several hours. This deficient practice prevented Hospital A, a Medicare-participating facility, from ensuring accurate patient identification of Patient 0, from creating necessary historical data in the electronic health record as required by state and federal regulations, and from facilitating a transfer for Patient 0, potentially jeopardizing the health and safety of Patient 0 and her unborn child. Findings: The Emergency Medical Treatment and Active Labor Act (EMTALA) is a 1986 Federal Law requiring Medicare-participating hospitals to provide emergency medical screening and stabilizing treatment, despite an individual’s ability to pay. EMTALA prevents “patient dumping” (transferring an uninsured individual) and requires transfer of the individual only if the hospital lacks capacity. Review of facility policy and procedure (P&P) titled “EMTALA Guidelines for Emergency Department Services,” dated 3/2025, indicated that the ED shall maintain a central log documenting each individual presenting to the ED for assistance, if the individual refused treatment, was denied treatment, was transferred, was admitted and treated, or stabilized and transferred or discharged. On 2/20/26 at 8:03 am, the California Department of Public Health (State Agency) received an anonymous complaint indicating an ambulance call was received on 2/13/26 from an unknown female patient (Patient 0) “requiring assistance” in this hospital’s parking lot (Hospital A). The complaint indicated Patient 0 was taken by ambulance to another facility (Hospital B). Review of document obtained from an outside ambulance company titled “Transfer of Care/Interim Patient (PT.) Care Report,” dated 2/13/26, indicated Emergency Medical Services (EMS) personnel picked up Patient 0 at Hospital A on 2/13/26. Patient 0 was a 31-year-old female, 35 weeks pregnant, complaining of no fetal movement after 9 am that day, with no change after she ate breakfast. The document indicated blood pressure was elevated at 150/104 and 145/106 (normal range 120/80 or below), with pulse in the 90s. The document indicated Patient 0 was scheduled for a Cesarean section on 3/16/26. On 3/11/26 at 1:50 pm, observed Hospital A’s security camera footage from 2/13/26 of the ED’s ambulance bay and surrounding parking lot in which a fire truck and an ambulance could be seen arriving separately at 11:30 am, and 11:32 am, respectively, without lights and sirens. The fire truck drove out of the camera’s view, but the back half of the ambulance remained in view. At 11:34 am, the back door of the ambulance was opened by a female who appeared to be EMS personnel. At 11:39 am, the back door was closed and the ambulance pulled away without lights and sirens. Patient 0 could not be seen at any point from the time of ambulance arrival to departure. During an interview with Registered Nurse (RN) A on 3/11/26 at 2:39 pm, RN A acknowledged working on 2/13/26 and remembered an encounter with a pregnant female (Patient 0). RN A stated she was called back to Triage (area for preliminary assessment to determine the urgency of patient’s need for treatment) where she found Patient 0 sitting with her hands on her belly. RN A stated that her conversation with Patient 0 was witnessed by Admitting Clerk (AC) A. Patient 0 informed RN A that she wanted to speak with a doctor because she had not felt her baby move since 9 am that morning. RN A stated she went to the providers’ lounge and asked Medical Doctor (MD) A to see Patient 0, who offered treatment options including an ultrasound. RN A stated that Patient 0 asked MD A if they had an Obstetrics and Gynecology (OB/GYN - treats women’s reproductive health and pregnancy) provider; MD A informed the patient, “No, but I’m here.” RN A stated that Patient 0 got on her cell phone, did not indicate whether she wanted to stay or go, then “walked out of the emergency room while talking on the phone.” RN A stated that the ED received a call shortly thereafter from 911 indicating emergency response vehicles were in the parking lot caring for Patient 0. During an interview with Patient 0 on 3/13/26 at 9:48 am (using Punjabi interpretation services at the patient’s request due to her limited English), Patient 0 stated she rode a bus to Hospital A on 2/13/26 because her husband was working. Patient 0 stated she went to Hospital A because she had not felt her baby move for five hours that morning. Patient 0 stated she spoke with several staff members on arrival, but they did not offer to register her. Patient 0 stated they told her they didn’t have an OB physician at the facility, so she called 911 “because I didn’t have a ride.” Patient 0 stated she was “concerned and stressed” because she “needed to go” elsewhere for care. During an interview with AC A on 3/13/26 at 11 am, AC A stated that she normally registered approximately 90 percent of patients coming to the ED before they were seen by a provider. AC A stated approximately 10 percent of the time, she would ask another staff member first before registering a patient if AC A was “not sure it’s something we can do” [treat]. AC A stated she remembered the encounter with a pregnant woman (Patient 0) on 2/13/26 but did not remember her name. AC A stated, “I don’t believe I actually registered her because I didn’t know what was going on.” AC A stated she had Patient 0 sit in Triage when she arrived, and she witnessed Patient 0 being attended to by at least two staff members - one nurse and one physician - prior to her departure. AC A stated, “Her biggest concern was a ride... I think she was panicking.” Review of the facility’s Emergency Department Log dated 2/13/26 indicated there was no documentation of Patient 0 being seen at the facility.”

“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: 41567 Based on observation, interview, and record review, the facility (Hospital A) failed to comply with Federal Emergency Medical Treatment and Active Labor Act (EMTALA) requirements to provide a medical screening examination for Patient 0, a 35-weeks pregnant woman who came to the Emergency Department (ED) requesting to see a physician because she had not felt movement of her unborn baby for several hours. This deficient practice resulted in Hospital A, a Medicare-participating facility, potentially jeopardizing the health and safety of both Patient 0 and her unborn baby by failing to determine if an emergency medical condition existed when the facility had capability with both a qualified provider and necessary equipment. This resulted in Patient 0 resorting to calling 911 emergency medical services from the parking lot, where she was found to have an elevated blood pressure, and Patient 0 was transported to Hospital B for evaluation. Findings: The Emergency Medical Treatment and Active Labor Act (EMTALA) is a 1986 Federal law requiring Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment. EMTALA obligates hospitals to provide stabilizing treatment if an emergency medical condition (EMC) exists, or, if unable to stabilize a patient within its capability, or if the patient requests, to implement an appropriate transfer to another facility. A review, of the facility’s policy titled “Federal Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” dated 2/26, indicated that an EMTALA obligation is triggered when an individual comes to a dedicated emergency department and requests an examination or treatment for a medical condition, or if a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs an examination or treatment of a medical condition. The hospital must provide an appropriate medical screening evaluation within the capability of the hospital’s ED to determine whether or not an emergency medical condition exists. The extent of an MSE varies by presenting symptoms; an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that involves performing ancillary studies and procedures. A review, of a webpage created by the Office on Women’s Health (OWH), U.S. Department of Health and Human Services, indicated OWH specifically addressed maternal health and blood pressures (a measurement of the pressure of blood against artery vessels) as follows: “During pregnancy, normal blood pressure is 120/80 millimeters of mercury (mm Hg, a unit of measure) or lower. If blood pressure is 140/90 mm Hg or higher at two separate times after 20 weeks of pregnancy, it’s considered high,” and, “High blood pressure during pregnancy can lead to complications for both the mother and the baby before or during birth that are dangerous or even life-threatening.” On 2/20/26 at 8:03 am, the California Department of Public Health (State Agency) received an anonymous complaint indicating an ambulance call was received on 2/13/26, from an unknown female requiring assistance in this hospital’s parking lot (Hospital A). The complaint indicated the woman was taken by ambulance to another facility (Hospital B). A review, of Hospital A’s ED logs for all (22 in total) patients registered on 2/13/26 in the ED indicated no pregnant patients were registered, evaluated, or treated in Hospital A’s ED. Patient 0 was not found among the records reviewed. A review, of a document obtained from an outside ambulance company, titled “Transfer Of Care/Interim Patient (PT.) Care Report,” dated 2/13/26 (untimed), indicated responding Emergency Medical Services (EMS) picked up Patient 0 at Hospital A on 2/13/26. Patient 0 was a 31-year-old, 35-weeks pregnant female complaining of no fetal movement since 9 am of that day. EMS documented blood pressures of 150/104 and 154/106, and Patient 0 was scheduled for an up-coming Cesarean section (C-section, a procedure to deliver a baby through a surgical incision through a woman’s abdomen and uterus in anticipation of a complicated or risky vaginal delivery). A review, of a document obtained from the outside ambulance company, titled “Fire Department Patient Care Report and Medical Emergency Field Notes,” dated 2/13/26 (untimed), indicated responding fire department personnel documented Patient 0’s blood pressure at 158/110. Observation was made on 3/11/26 at 1:50 pm, of Hospital A’s security camera recordings from 2/13/26 of the ambulance bay and surrounding parking lot. A fire truck and an ambulance could be seen arriving separately at 11:30 am, and 11:32 am, respectively, without lights and sirens. The fire truck was driven out of camera view; the back half of the ambulance remained in view. At 11:34 am, the back door of the ambulance was opened by a female who appeared to be EMS personnel. At 11:39 am, the back door was closed and the ambulance pulled away without lights and sirens. Patient 0 could not be seen within camera view at any point from the time of EMS arrival to departure. During an interview, with Hospital B’s Quality Performance Specialist (HB QPS) on 3/11/26 at 2:30 pm, HB QPS confirmed that Patient 0 was brought to Hospital B by ambulance on 2/13 26 at 12:24 pm, and sent to Labor & Delivery, where she was examined and monitored before being discharged. HB QPS provided supporting documentation from Hospital B. A review, was made of Hospital B’s medical records for Patient 0, dated 2/13/26, as follows: - Patient 0 was registered at 12:21 pm, with an initial diagnosis of decreased fetal movement (DFM - when a pregnant patient perceives a reduction in the frequency or strength of the unborn baby’s activity, a critical indicator of potential fetal distress, risk of stillbirth, and other complications to mother and/or baby). - Patient 0’s Flowsheet indicated she arrived to the Labor & Delivery unit at 12:24; interventions included examination, continuous Doppler ultrasound (a method of tracking the unborn baby’s heart rate and rhythm); tocodynamometer (a method of measuring frequency and duration of uterine [womb] contractions); repeated measurements of Patient 0’s vital signs (basic measurements of one’s bodily functions such as heart rate and blood pressure); diagnostic blood work; and a history of health data pertinent to pregnancy. - A clinical note at 12:30 pm indicated Hospital B Registered Nurse (RN) E documented that Patient 0 arrived by ambulance for decreased fetal movement, and electronic fetal monitoring was initiated. - A clinical note at 1:04 pm indicated RN E documented notifying Hospital B Medical Doctor (MD) B: “Status of patient given” and that MD B ordered “PIH labs” (PIH - Pregnancy-Induced Hypertension [high blood pressure during/caused by pregnancy] labs, a panel of blood and urine tests used to diagnose and monitor for preeclampsia [a potentially life-threatening blood pressure disorder occurring during pregnancy diagnosed by a blood pressure over 140/90 and other signs/symptoms] and other serious complications of pregnancy). - A clinical note at 2:42 pm indicated RN E documented notifying MD B of Patient 0’s blood pressure trends and lab results and that MD B would review Patient 0’s results and call back. - A clinical note at 2:47 pm indicated RN E documented MD B had called and discharged Patient 0. During an interview, with Registered Nurse (RN) A on 3/11/26 at 2:39 pm, RN A acknowledged working on 2/13/26 (at Hospital A) and remembered an encounter with Patient 0. RN A stated she was called to the front/triage room (the facility’s designated area where patients are registered, vital signs are taken, and patients are triaged - a process in which patients are sorted and/or classified according to type and urgency of their medical condition) to see a 35-weeks pregnant woman. RN A recalled Patient 0 told her she had not felt movement from the baby since the morning, she was unsure what she wanted to do, and she wanted to talk with the doctor. When asked why Patient 0 had not been registered, RN A stated it was because Patient 0 wasn’t sure she needed to be seen or not. RN A confirmed this conversation took place with a witness, Admitting Clerk (AC) A. RN A stated she asked Medical Doctor (MD) A to see Patient 0 in the front/triage room. When asked what she recalled of that encounter, RN A stated MD A offered to do an ultrasound. RN A stated Patient 0 asked MD A if they had an Obstetrics and Gynecology (OB/GYN, a medical specialty treating women’s reproductive health and pregnancy) provider; RN A stated MD A informed the patient, “No, but I’m here.” RN A stated Patient 0 got on her cell phone, did not indicate whether she wanted to stay or go, then walked out of the ED while talking on the phone. RN A stated the ED received a call shortly thereafter from 911 indicating emergency response vehicles were in the facility parking lot. RN A stated she went out to see Patient 0 standing next to a gurney with an ambulance and EMS crew in the parking lot. During an interview, with Patient 0 on 3/13/26 at 9:48 am using Punjabi interpretation services at the patient’s request due to her limited English, Patient 0 stated she rode a bus to Hospital A on 2/13/26, because she had not felt her baby move for more than five hours that morning. When asked if any nurse or provider had examined her or taken her blood pressure, she stated, “No, they didn’t do anything. They just told me they didn’t have an OB here.” When asked if she was distressed when she came into Facility A, she stated, “For five hours I didn’t feel the baby move, so that’s why I went to the hospital.” Patient 0 also stated she was concerned and stressed when leaving because she needed to go to another hospital, and she called 911. During an interview, with Admitting Clerk (AC) A on 3/13/26 at 11 am, AC A recalled an encounter with Patient 0 on 2/13/36, when Patient 0 arrived at Hospital A’s ED. AC A stated she did not think Patient 0 spoke very good English, but she hadn’t felt the baby move in a long time. AC A stated Patient 0 was “scared, wasn’t sure about the baby.” AC A then stated, “Maybe not scared, but she didn’t look like she felt well.” AC A stated she wanted to get Patient 0 help because she “seemed upset.” AC A stated, “I got someone to talk to her.” AC A stated she had Patient 0 sit in the triage chair and noted, “There were several people there, I’m pretty sure they were taking vital signs.” AC A stated she had a nurse come out right after she said she hadn’t felt the baby move. AC A recalled MD A also came to see Patient 0. AC A recalled MD A telling Patient 0 we could see her but that we do not have an OB provider, and she might go elsewhere that has the ability to see if it’s baby-related. When asked if AC A registered Patient 0 for services, AC A stated, “Sometimes I wait to register them if the physician is going to recommend they go somewhere else.” When asked if she recalled Patient 0 having an examination, AC A stated, “I don’t think so” because Patient 0 never left triage, but she again noted Patient 0 she was on the phone talking to someone. AC A stated she knew Patient 0 called an ambulance because the facility received a call back (a call from EMS). AC A stated, “I think she was panicking. I told EMS we didn’t know she called.” AC A stated she did not know if it was Patient 0’s choice, not leaving triage. AC A stated, “She just disappeared. I didn’t see her leave” but acknowledged she gets up to go to the bathroom or go on break sometimes. AC A stated, “I don’t believe I actually registered her because I didn’t know what was going on.” AC A stated she never heard Patient 0 decline or refuse treatment. AC A stated approximately 10% of the time, she would ask another staff member first before registering a patient if AC A was “not sure it’s something we can do” (treatment). AC A stated, “I register the ones who are going to be seen.” During an interview, with MD A on 3/13/26 at 12:08 pm, MD A was asked how he determined an emergency medical condition (EMC) existed. MD A stated sometimes he would look at a patient if the nurse asked. MD A stated, rather than waiting for a room, MD A would talk to them in triage, especially if the nurse had a concern. When asked if an exam was required to determine an EMC, MD A replied, “It depends on the chief complaint and how the patient is doing.” MD A stated sometimes he would do an exam in the room, but not so in triage. MD A stated he determined EMC existed by talking with the patient most of the time, but “most of the time they’re in a room when I speak with them.” MD A stated, “It’s not super common to see them in triage.” When asked his usual practice for a pregnant female coming to the ED, MD A stated he would ask about pain, vaginal bleeding, and discuss getting a urine sample. MD A stated he would get an ultrasound (a comprehensive service of the Radiology Imaging Department requiring a specialized technician who uses a computer-integrated diagnostic tool and techniques to create images of the inside of the body) if ultrasound was available. MD A stated they had ultrasound services available usually Monday through Friday, but that it was not an option after 5pm and on the weekends. When asked if bedside Doppler ultrasound (a small, portable device used at bedside by nurses and physicians, designed for ease of use and immediate feedback, the use of which can confirm fetal heart tones/beats in pregnancy, in addition to other emergent conditions; a standard technology used in EDs) was available in the ED, MD A indicated it was and stated it could be used to get a fetal heartbeat. MD A affirmed he recalled the encounter with Patient 0 on 2/13/26 and stated he came to the front/triage room to talk with Patient 0 at the request of the RN, who informed him Patient 0 hadn’t felt fetal movement. According to MD A, he communicated with Patient 0 through the RN as a Punjabi translator and stated he would be happy to do some testing, blood tests, ultrasound, check size. MD A stated he informed Patient 0 that a blood test may help determine if there’s been a miscarriage... “That will tell you the baby is alive, but there is additional testing that may be done for other issues.” MD A informed the patient that was typically done on Labor & Deliver, but “we don’t have that department here, but we can get an ultrasound and blood tests,” ultimately, to tell you if baby is alive or not. When asked, MD A stated he did not offer bedside Doppler to check fetal heart tones. When asked if ultrasound services were available that day, MD A stated he thought there was an ultrasound tech still there. MD A acknowledged that in the past he had had trouble getting 2nd and 3rd trimester ultrasounds. MD A stated he “hadn’t really thought about getting an ultrasound when I was talking to her.” MD A stated he’d ordered 2nd and 3rd trimester ultrasounds before, but he’d been told they couldn’t do that. For this patient, if I can’t get an ultrasound, I would tell her I can do blood tests, but that doesn’t tell us a lot. When asked if he would check for fetal heart tones, MD A stated, “I could at the bedside, but my impression was that if there was a heartbeat, that’s not all the information she wanted.” MD A stated Patient 0 was insistent that she wanted to be reassured and not worried about it. When asked under what conditions would a person with an EMC be transferred to another facility, MD A replied, “If they require a higher level of care or we can’t provide service, we’ll set up a transfer for those processes.” When asked if a transfer for Patient 0 was a consideration, MD A stated it depends; sometimes people would go where they’ll deliver (the baby). MD A stated Patient 0 indicated she did not have a ride. MD A stated he informed Patient 0 sometimes an ambulance was able to take patients to the hospital if they didn’t have a ride. When asked if MD A provided Patient 0 a physical examination, MD A replied, “I didn’t listen to heart sounds or do a doppler.” MD A did not recall if there were vital signs taken. MD A stated he had no physical contact with her. MD stated he explained the tests they could do, but there was other testing that could be done at another hospital. MD A stated Patient 0 decided to go elsewhere after he spoke with her, “at least that was my understanding.” When asked how he determined if there was an EMC without performing an exam, MD A stated, as far as pregnant patients were concerned, if they were having bleeding or pain, he found that to be more concerning, “more of an emergency.” MD A was asked if a lack of fetal movement and concern whether the unborn baby was alive or not was a possible medical emergency from a physician’s point of view. MD A replied, “It could be a problem, but to me it’s not a medical emergency. She’s not going to die in the immediate future. I would look at pain and bleeding as more symptoms that are serious.” During an interview, with the Regional ED Director (EDD) on 3/13/26 at 12:45 pm, the EDD was asked her expectation of her ED staff in EMTALA compliance. EDD replied, “The answer is that we register them, we get a medical evaluation, then transfer them where they need to go or let them sign out against medical advice.””

“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: 49418 Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff performed ongoing patient assessments in the Emergency Department (ED) in accordance with the facility’s policies and procedures (P&Ps) for two of 23 sampled patients (Patients 1 and 16) who were determined to have emergency medical conditions (EMC) as evidenced by: 1A. Patient 1’s triage level (severity of patient’s illness and the intensity of nursing care required) was not changed from Emergency Severity Index (ESI - a five-level nursing triage tool) Level 4 (low, stable) to ESI Level 2 (high, critical/emergent) after it was determined the patient had pneumonia, sepsis (a life-threatening complication of infection, potentially leading to organ malfunction, shock, and/or death), and a possible new-onset non-ST-elevation myocardial infarction (NSTEMI - a heart attack caused by blockage of a coronary artery, resulting in decreased blood flow and heart muscle damage). 1B. Patient 1’s temperature was not reassessed and documented in accordance with facility P&Ps. 2. Patient 16 was not reassessed by nursing staff during the night shift. These failures created the potential for any deterioration in the patients’ health to go unrecognized, leading to a delay in treatment and negative clinical outcomes. Findings: A review of the facility’s P&P titled “Triage-Patient Assessment,” dated 4/2025, indicated that the registered nurse (RN) will evaluate and categorize each ED patient on arrival using the five-level ESI system as follows: A. Level 1 (resuscitative): Immediate care, life-threatening conditions. B. Level 2 (emergency - major injury or illness, but stable): Treatment and reassessment should occur within five to 15 minutes. C. Level 3 (urgent): Treatment and reassessment should occur within 15 to 45 minutes. D. Level 4 (semi-urgent): Treatment and reassessment should occur within one to two hours. E. Level 5 (routine): Treatment and reassessment should occur within four hours. Note: The P&P indicated that the ESI level may require a change if worsening conditions are noted after reassessment. Review of facility P&P titled “Assessment and Reassessment Emergency Department,” dated 4/2025, indicated that ED RNs shall initiate accurate and ongoing assessment of physical and psychosocial (relationship of social factors and individual thought and behavior) needs of patients within the ED using the ESI system. Reassessment of patients shall be done on a regular basis to determine the patient’s response to treatment and to note significant changes in the patient’s condition and/or diagnosis. The following were to be documented for all patients coming to the ED: A. Initial vital signs (VS - blood pressure, heart rate, respiratory rate, oxygen levels, temperature, and pain level), with additional VS taken depending on the patient’s condition: (1) critical patients every five to 15 minutes, as needed, (2) intermediate every one to two hours or as needed, and (3) all other patients every four hours or at the time of discharge if less than four hours since triage. B. Response to medications administered. Review of facility P&P titled “Emergency Medical Treatment and Labor Act (EMTALA - a 1986 Federal law requiring Medicare-participating hospitals to provide emergency medical screening and stabilizing treatment) Policy,” dated 2/2026, indicated that qualified medical staff must determine the scope of the Medical Screening Examination (MSE) for anyone presenting to the ED: A. An MSE must be performed to assess for an emergency medical condition (EMC); triage is not equivalent to an MSE. B. The MSE is an ongoing process with continuous patient monitoring until the EMC is stabilized or the patient is admitted or transferred. C. The medical record must document all patient monitoring before the MSE is completed and until discharge or transfer. D. The extent of the MSE depends on presenting symptoms and may range from a brief assessment to comprehensive diagnostics including lab tests, imaging, and other procedures. 1A. Patient 1’s medical record was reviewed. Review of document titled “ED Nursing Triage,” dated 2/13/26, indicated Patient 1 arrived to the Emergency Department (ED) on 2/13/26 at 7:15 am with a cough, ear pain, and sore throat. Patient 1 was assigned ESI Triage Level 4 at 7:40 am by RN D. Review of Patient 1’s electrocardiogram (ECG - measures the heart’s electrical activity, evaluates rhythm and function) performed 2/13/26 at 9:08 am indicated elevated heart rate, nonspecific T-wave abnormality (slight rhythm change that may indicate heart damage), and “abnormal rhythm ECG.” Review of Patient 1’s “ED Nursing Documentation,” dated 2/13/26, indicated that the physician decided to admit Patient 1 at 11 am, and Patient 1 was transferred to the Medical-Surgical Department at 11:25 am. Review of Patient 1’s “Portable Chest X-ray,” dated 2/13/26 at 11:33 am, indicated concerns for right upper lung pneumonia. Review of Patient 1’s “ED Provider Documentation Report,” dated 2/13/26, indicated that Patient 1’s lab testing at 12:26 pm showed an elevated troponin (protein in heart muscle; higher levels indicate severe heart muscle injury) at 18,196.5 picograms per milliliter (pg/mL - a unit of measure). The document indicated low troponin levels were less than 5 pg/mL, and high troponin levels were greater than 81.3 pg/mL. Review of Patient 1’s “ED Progress Note,” dated 2/13/26, indicated Medical Doctor (MD) A decided to transfer Patient 1 to a higher level of care as the patient would require cardiology evaluation for NSTEMI not available at the facility. The facility contacted the Transfer Center at 1:45 pm; no beds were available at that time. While calls were made to other hospitals, Patient 1 was returned to the ED until transfer was possible. Patient 1’s Diagnostic Impression was NSTEMI (heart attack) and sepsis secondary to right upper lobe pneumonia. Review of Patient 1’s “ED Nursing Documentation,” dated 2/13/26, indicated the following: - At 2 pm, Patient 1 was brought back from the Medical-Surgical Department due to critical troponin level of 18,196.5 pg/mL. - At 2:15 pm, heparin (medication used to treat NSTEMI to prevent further blood clot formation) drip (medication given continuously into a vein) was started per protocol. MD to start transfer process. - At 2:45 pm, Patient 1’s pain reduced in head and throat. - At 4:30 pm, administered additional Tylenol for rising fever and headache. - At 7:10 pm, Lab called [second] critical troponin level of 43,929.2 pg/mL. MD notified. Review of document titled “Sepsis Alert,” dated 2/13/26, indicated Patient 1 met sepsis criteria as evidenced by a temperature on admission greater than 100.4 degrees F, respiratory rate greater than 20, heart rate greater than 90, and lab testing indicating white blood cell level (primary sign of infection if elevated) greater than 12,000 (normal 4,000 to 11,000) cubic millimeters (mm³ - a unit of measure). The document directed nursing staff to place Patient 1 on a cardiac monitor with every five to 15 minute re-check VS. Review of Patient 1’s “Patient Progress Notes,” dated 2/13/26, indicated the following: A. VS were assessed and documented by ED nursing staff on admission at 7:22 am, after return to the ED at 2:13 pm, 2:42 pm, 3:04 pm, 3:44 pm, 5:24 pm, 6:47 pm, 9:43 pm, and at 10:48 pm (shortly before transfer). B. Pain was documented as elevated at 8 out of 10 (0 being no pain, 10 being worst pain) at 7:40 am and 7:44 am. Reassessment of pain was not documented. Review of Patient 1’s ECG performed 2/13/26 at 7:37 pm indicated normal rhythm, moderate T-wave abnormality - consider anterior ischemia (insufficient oxygenated blood flow to the front wall of the heart causing tissue death), and abnormal ECG. During an interview with Interim ED Leadership Support (IELS) on 3/13/26 at 1:46 pm, IELS stated Patient 1 should have received a nursing reassessment by ED nursing staff upon return to the ED. IELS stated he would have expected VS to be taken every 15 minutes during heparin treatment as well as for critically elevated troponins. IELS stated he would have expected Patient 1 to have been changed from an ESI Triage Level 4 to Level 2 due to abnormal troponin levels, new-onset heart attack, and the heparin drip. IELS acknowledged that a nursing reassessment was not documented on Patient 1’s return to the ED, Patient 1’s Triage Level was not changed, and VS were not taken appropriately for a Triage Level 2 - with or without a heparin drip. 1B. Review of Patient 1’s “Patient Progress Notes,” dated 2/13/26, indicated Patient 1’s temperature was documented by nursing staff as follows: At 7:22 am, temperature indicated a fever of 101.3 degrees Fahrenheit (F - a unit of measure). The temperature was not reassessed. At 3:07 pm, temperature was documented as 98.5 degrees F. At 10:48 pm, temperature was documented as 98.9 degrees F. Review of Patient 1’s “ED Nursing Documentation,” dated 2/13/26 at 4:30 pm, indicated that RN D had documented administering additional Tylenol for rising fever and headache. Patient 1’s temperature and pain were not reassessed and documented after Tylenol administration. During an interview with IELS on 3/13/26 at 1:46 pm, IELS stated that any abnormal need to VS be reassessed and recorded until within normal limits. IELS acknowledged that Patient 1’s temperature was not reassessed and documented by nursing staff per policy. IELS stated the risks associated with not performing reassessments as directed included (a) not getting 100 percent of the information needed before giving a medication and (b) unknown effects following the administration of a medication that could affect VS. 41567 2. Patient 16’s medical record was reviewed. Patient 16’s medical records indicated, that he had been seen in the Emergency Department (ED) for urinary bleeding. Patient 16’s ED Progress Note, dated 2/13/26, indicated, that Medical Doctor (MD) A documented under Past Medical History diagnoses that included HFrEF 20% (severe heart failure), methamphetamine abuse (a substance abuse disorder), chronic obstructive pulmonary disease (COPD, a group of inflammatory lung conditions that obstruct airflow and make it hard to breathe, tobacco dependence (a compulsive need to use tobacco products), osteomyelitis (infection of bone and tissue), acute hepatitis (sudden, short-term inflammation of the liver), MRSA bacteremia (a serious bloodstream infection caused by Methicillin-resistant Staphylococcus aureus bacteria). Under History of the Present Illness, MD A documented a left ventricular thrombus (a blood clot in the main chamber of the heart) for which Patient 16 was undergoing anticoagulation (medications to dissolve clots). The record indicated Patient 16 developed persistent hematuria (ongoing bleeding through the urinary tract) due to the anticoagulation and required urology intervention (treatment by a provider specializing in conditions of the urinary tract) in order to continue with anticoagulation. MD A’s plan was to transfer Patient 16 to another facility for a higher level of care. Patient 16’s ED Nursing Triage, by Registered Nurse (RN) A, dated 2/13/26 at 4:50 pm, indicated that RN A assigned a triage or emergency severity level of “3” to Patient 16, and performed standard ED screenings. Patient 16’s ED Nursing Documentation, dated 2/13/26, indicated the following: At 5 pm, RN A entered a narrative note documenting interventions performed for Patient 16. RN A documented receiving Patient 16, taking vital signs, connecting to a cardiac monitor, the status of dressings and equipment that accompanied Patient 16, and performed wound care. At 5:30 pm, RN A documented that a transfer request was put in for Patient 16 and the facility was awaiting acceptance. At 5:45 pm, RN A performed a comprehensive systems assessment (a head-to-toe physical examination that evaluates the function of the body’s systems such as the nervous, heart, lungs, skin, urinary, and bowel systems in order to gather information on a patient’s status and identify specific needs). At 6:50 pm, RN A documented, “Report given to night shift RN’s.” From 2/13/26 at 6:50 pm until 2/14/26 at 4:42 am (when Patient 16 transferred out), there were no systems assessments of Patient 16 by RN C, who assumed Patient 16’s care. In the total of 9 hours and 52 minutes that Patient 16 remained in the ED, RN C documented brief narrative notes related to direct patient care as follows: At 8 pm, the presence of an intravenous line in Patient 16’s right arm. At 10 pm, Patient 16 urinated without bleeding. At 12 am midnight of 2/14/26, Patient 16 given sips of water and pudding. At 1 am, Patient 16 given a medication for agitation. At 3:05 am, Patient 16 given medication for pain. At 3:30 am, Patient 16 tolerated the pain medication and was comfortable. Other entries at 2:02 am, 3:34 am, 4:30 am, and 4:42 am related directly to transferring and not to direct patient care. A review, of Patient 16’s Order Chronology, dated 2/14/26 at 12:54 am, indicated MD A ordered Ativan (a sedating medication) 1 milligram (mg - a unit of measure) tablet by mouth (PO) times 1 (x1) STAT (without delay). At 2:46 am, MD A ordered Morphine (a controlled, potent narcotic pain reliever) 4 mg intravenous piggyback (IVP - to be injected into the vein). Patient 16’s Medication Administration Record, dated 2/14/26, indicated that RN C documented administering the ordered Ativan at 1:06 am, and the Morphine at 3:03 am. A review, of Patient 16’s vital signs (VS - basic measurements of one’s bodily functions including, among other measurements, temperature, heart rate, blood pressure [the force blood exerts against arterial blood vessel walls], Mean Arterial Pressure [an averaged pressure of the heart’s cycle], breaths per minute, a measurement of the oxygen the blood carries) indicated VS were taken on 2/13/26 at 4:55 pm, 5:25 pm, 5:59 pm, and 6:10 pm. There were no further VS entries for that date. On 2/14/26, Patient 16’s vital signs were entered once at 4:01 am. RN C did not document VS measurements to assess Patient 16’s status, nor indicators of potential dangers of the sedative and narcotic medications administered. During a concurrent interview, with Interim ED Leadership Support (IELS), and record review, on 3/13/26 at 1:46 pm, IELS was shown Patient 16’s Nursing Documentation and Vital Signs from 2/13/26 at 6:50 pm to 2/14/26 at 4:42 am. When it was pointed out that for the duration of that time, there were no documented assessments of systems, no vital signs until just before transfer, and that narcotics and sedatives were given without an assessment, IELS acknowledged an assessment was not completed during night shift. IELS stated, that he expected hourly vital signs for a patient with a triage acuity of 3 and expected a full systems assessment as well as an assessment for why the patient was getting medication.”

“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: 41567 Based on interview, and record review, the facility failed to obtain consent for transfer to a higher level of care for two out of two sampled patients (Patient 16, and Patient 1) who were transferred out of the facility. This failure resulted in ambiguity whether Patient 16, and Patient 1 had been provided sufficient information to give informed and unequivocal consent prior to leaving the facility for treatment. Findings: A review, of facility’s policy titled “Transfer Of Patient To Another Facility,” rev. 4/25, indicated that the patient shall be transferred to an appropriate facility if the facility was unable to continue with care. Patients shall be informed of the reason for the transfer, and transfer documents shall be completed including the Patient Transfer Acceptance Or Refusal form. Attached to this policy was a document titled “Patient Transfer Acknowledgement,” with instruction to check the three appropriate sections. Sections included: 1. Acknowledgement (in which the patient acknowledged they had the right to be informed of the reason for a transfer, had received a medical screening and evaluation, and had been informed of the reason for the transfer). 2. Patient Request For Transfer Or Discharge (the consent to transfer, in which the patient was to acknowledge they had been informed of the potential risks and consequences involved in a transfer, the possible benefits of continuing treatment at this facility, and alternatives to the transfer). 3. Patient Refusal To Transfer (in which the patient acknowledged they had been offered a transfer for treatment and refused the transfer, had been informed of the risks and consequences involved in the refusal, the possible benefits of transfer to another facility, and alternatives to the decision to refuse the transfer). 1. Patient 16’s medical record was reviewed. Patient 16 was seen in the Emergency Department (ED) for urinary bleeding. A review, of Patient 16’s ED Progress Note, dated 2/13/26, indicated that Medical Doctor (MD) A documented under Past Medical History diagnoses that included HFrEF 20% (severe heart failure), methamphetamine abuse (a substance abuse disorder), chronic obstructive pulmonary disease (COPD, a group of inflammatory lung conditions that obstruct airflow and make it hard to breathe, tobacco dependence (a compulsive need to use tobacco products), osteomyelitis (infection of bone and tissue), acute hepatitis (sudden, short-term inflammation of the liver), MRSA bacteremia (a serious bloodstream infection caused by Methicillin-resistant Staphylococcus aureus bacteria). Under History of the Present Illness, MD A documented a left ventricular thrombus (a blood clot in the main chamber of the heart) for which Patient 16 was undergoing anticoagulation (medications to dissolve clots over time). The document indicated Patient 16 developed persistent hematuria (ongoing bleeding through the urinary tract) due to the anticoagulation and required urology intervention (treatment by a provider specializing in conditions of the urinary tract) in order to continue with anticoagulation. MD A’s plan was to transfer Patient 16 to another facility for a higher level of care. Under Disposition, MD A documented Patient 16 was agreeable with the discharge, proposed treatment and follow-up plans. Patient 16’s ED Nursing Documentation, dated 2/13/26 at 4:43 am, indicated that Registered Nurse (RN) C documented under Disposition, Medical Benefits of Transfer, that Patient 16 was transferred to obtain a level of care or service unavailable at this facility. Under Patient Consent to Transfer, RN C documented, “Yes, see consent form.” Patient 16’s Patient Transfer Acceptance Or Refusal Form, dated 2/13/26 at 2:04 am, indicated the section labeled Acknowledgement was checked, and Patient 16 signed his name under the Patient Signature near the bottom of the page. Patient Request For Transfer, Or Discharge and Patient Refusal To Transfer sections were not checked, leaving ambiguity whether Patient 16 consented to transferring from the facility. During a concurrent interview, and record review, with Interim ED Leadership Support (IELS) on 3/13/26 at 1:46 pm, IELS reviewed Patient 16’s incomplete Patient Transfer Acceptance Or Refusal form. When asked if he would say Patient 16 consented to the transfer, IELS stated, “Based on this form, that would be incomplete. However I would defer to the disposition by the nurse in her documentation.” IELS reviewed “ED Nursing Documentation,” dated 2/13/26 at 4:43 am. When asked if the disposition options auto populated, IELS stated no, that staff had to check a box for each. When it was pointed out that no risks or benefits of transfer were checked, IELS stated, “It seems this specific nurse did not check the boxes for risk of transfer, but she did check benefits of transfer. I would confirm with a provider note to see if they concur.” 49418 2. Review of Patient 1’s “Patient Transfer Checklist,” dated 2/13/26, which was provided by facility staff upon request of medical records for Patient 1, indicated the checklist “MUST be completed prior to patient transfer.” The checklist directed nursing staff to maintain the original form with the patient’s chart and send a copy to accompany the transfer packet. The following items were checked off as having been completed: -Patient Transfer Summary (diagnosis, physician/registered nurse signature, vital signs within 30 minutes of transfer). -Patient Transfer Acknowledgement (physician and patient signature) -All labs -Copy electrocardiogram (evaluates heart rhythm and function) -Printout of all Radiology images -Medication Reconciliation (medications patient takes at home) and most current medical administration record (medications received at the facility) -History and Physical Exam (all physician notes) -Nurses’ notes and triage Note: Copies of the completed forms were not provided. Review of document titled “Emergency Department (ED) Progress Note,” signed and dated by MD A on 2/13/26, indicated the diagnostic impression for Patient 1 was heart attack and sepsis (a life-threatening complication of infection, potentially leading to organ malfunction, shock, and death) secondary to right upper lobe pneumonia. The document indicated MD A discussed Patient 1’s case with [physician name] at the receiving facility, who agreed to accept Patient 1 for transfer. Review of document titled “ED Nursing Documentation,” dated 2/14/26 at 12:27 am, indicated “Patient Consent to Transfer: Yes, see consent form.” The document indicated the consent had been signed on 2/13/26 at 10 pm and that Patient 1 was transferred on 2/13/26 at 11:36 pm. During an interview with IELS and Regional ED Director (EDD) on 3/10/26 at 4:25 pm, IELS acknowledged Patient 1’s transfer packet checklist was present in the patient’s medical record and indicated it had been completed; however, IELS acknowledged the facility did not have a copy of the signed Consent to Transfer and the other forms listed on the checklist. IELS and EDD acknowledged all completed paperwork should be in Patient 1’s chart. During an interview with IELS on 3/13/26 at 1:46 pm, IELS stated that the facility had contacted the ambulance company, transfer center, and the receiving hospital and were unsuccessful at retaining those records.”