Adventist Health Tulare

“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: 51540 Based on observation, interview, and record review the hospital failed to follow its policy and procedure (P&P) titled, “Consent and Informed Consent (Consent, a process where an individual gives voluntary agreement to a procedure, treatment, or action after receiving and understanding adequate information about its potential risks, benefits, and alternatives)”-California,” for seven of 24 patients (Patient 4, Patient 2, Patient 3, Patient 20, Patient 24, Patient 25 and Patient 30) when: 1. A Consent for a nephrostomy tube (a tube placed in the kidney to drain urine) placement was not completed and in the medical record for one of 24 Patients (Patient 4). 2. A Consent was incomplete when the procedure, anesthesia and doctor performing the the procedure were left blank on the consent form for one of 24 Patients (Patient 2). 3. A Consent indicated a different procedure than the procedure ordered by the medical doctor for one of 24 Patients (Patient 3). 4. Computed Tomography (CT-medical imaging technique) Consents with contrast (a substance given to a patient to improve visibility during a imaging test) were not witnessed (verifys the person signing the consent is the patient or responsible person) for 4 of 24 Patients (Patient 20, Patient 24, Patient 25 and Patient 30). These failures resulted in inaccurate and incomplete consents and had the potential for patients to have wrong site procedures. Findings: 1. During a review of Patient 4’s “History & Physical (H&P),” dated 6/3/25 at 6:29 p.m., the “H&P” indicated, “Pt [patient] BIBA [brought in by ambulance] for c/ [complaints of] left clogged nephrostomy tube ...Assessment/Plan ...IR [Interventional Radiology - specialized field that uses medical imaging to guide instruments for diagnosis and treatment] consulted, they will place nephrostomy tube tomorrow ...” During a review of Patient 4’s “Order Requisition (OR),” dated 6/3/25, the “OR” indicated, “CT Perc [percutaneous- through the skin] Nephrostomy Tube Plmnt [placement] ...Priority: Routine. Reason for Exam ...Obstructed Kidney ...” During a review of Patient 4’s “Moderate Sedation/Deep Sedation Form (MSDSF),” dated 6/3/25, the “MSDSF” indicated, “Date: 6/3/25. Planned Procedure: Nephrostomy Tube Insert ...Informed consent documented: Yes ...” During a review of Patient 4’s “CT Perc Nephrostomy Final Report (CTPNFR),” dated 6/4/25, the “CTPNFR” indicated, “Result Title: CT Perc Nephrostomy Tube Plmnt ...Impression: CT-guided percutaneous nephrostomy catheter [a small tube inserted into the body to drain fluids] placement ...” During a review of Patient 4’s “Progress Note (PN),” dated 6/4/25, the “PN” indicated, “ ...Patient had a nephrostomy tube placement 6/4 ...” During a concurrent interview and record review on 9/9/25 at 11:29 a.m. with Information Technologist Educator Registered Nurse (ITRN), Patient 4’s “Medical Record (MR),” undated was reviewed. The “MR” indicated there was no consent for the Nephrostomy Tube Placement. ITRN stated there was not a consent completed for the nephrology tube placement for Patient 4. During an interview on 9/9/25 at 11:33 a.m. with Director of Nursing (DON), the DON stated there was no consent noted in the chart but there should be one. During a review of the facility’s process for “Nephrostomy Tube,” undated: “ ...4. Verification & Documentation ...Confirm the consent form is signed by the patient (or authorized representative) and witnessed by the RN ...5. MD Documentation- Must Be Completed Pre-Procedure. Ensure the physician has completed and signed: the H&P, Informed Consent ...” 2. During a review of Patient 2’s “H&P,” dated 6/18/25, the H&P indicated, “ ...brought to ER [Emergency Room] for dizziness and ground-level fall ...Patient was transferred intensive care [specialty unit provides highest level of medical care to adults] for further monitoring and care ...” During a review of Patient 2’s General Surgery Consultation (GSC),” dated 6/19/25, the “GSC” indicated, “ ...CT scan of the abdomen and pelvis showed fluid around the gallbladder ...recommend IR cholecystostomy tube [tube placed in the gallbladder to drain fluid and reduce infection] as gallbladder does appear diseased ...” During a review of Patient 2’s “OR,” dated 6/19/25, the OR indicated, “Procedure: CT Drain Peritoneal Abscess [a collection of pus and infected fluid in the abdominal area] ...Reason for Exam: Abscess. Special Instructions: gall bladder drain ...” During a concurrent interview and record review on 9/9/25 at 10:00 a.m. with DON, Patient 2’s “Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures (ACSSDTP),” dated 6/19/25 was reviewed. The “ACSSDTP” indicated, “1. Your physicians and surgeons have recommended the following operation or procedure” was blank. The ACSSDTP indicated, “...the following type of anesthesia [medication given before surgical operations to lessen awareness and/or pain]” was blank. The ACSSDTP indicated, “...2. Name of the practitioner who is performing the procedure or administering the medical treatment,” was blank. The DON stated the consent was completely blank including procedure name, anesthesia and name of doctor performing. DON stated these should have been completed. DON stated the consent was incomplete. During a review of the facility’s Process for “CT-guided biopsy, drain,” undated: “Description: CT-guided biopsy and drain placement are minimally invasive procedures performed under computed tomography (CT) imaging to precisely target areas of concern within the body ...Work Standard Summary ...5. Pre-Procedure Requirements (MD to complete) ...informed consent ...” 3. During a review of Patient 3’s “H&P,” dated 7/2/25, the H&P indicated, “ ...presented to the emergency department on [name of hospital] for one week of diffuse abdominal pain ...” During a review of Patient 3’s “GSC,” dated 7/2/25, the GSC indicated, “Patient c/o [complains of] increased pain and swelling to RUQ [right upper quadrant] abdomen at gallbladder drain site ...Patient has a liver abscess on CT scan of the abdomen ...Patient needs to proceed with an IR guided drain placement of the liver abscess ...” During a review of Patient 3’s “OR,” dated 7/5/25, the OR indicated, “Procedure: CT Cath [catheter] Drainage Perc Peri [around]/Retro [behind] Cavity ...Reason for Exam: Abscess ...” During a concurrent interview and record review on 9/9/25 at 2:21 p.m. with ITRN, Patient 3’s “ACSSDTP” was reviewed. The ACSSDTP indicated, “1. Your physicians and surgeons have recommended the following operation or procedure: CT guided Liver drain placement ...” The ITRN stated the order and consent do not match. ITRN stated it looks like two different procedures were completed. During a review of Patient 3’s “CT Cath Drainage Perc Peri/Retro Cavity Final Report (CCDFR),” dated 7/5/25 the “CCDFR” indicated, “Reason for Exam: Abscess. Report: CT-guided abscess drainage of peritoneal abscess ...Impression: CT-guided drainage of abscess as described area ...” During an interview on 9/9/25 at 2:35 p.m. with DON, DON stated the consent and order do not match. DON stated two different orders were put in place for one procedure and the previous order was not canceled. DON stated the nursing staff should have also seen there were two orders in place and before completing the consent should have contacted the surgeon for clarification. DON stated the consent should have matched the order. DON stated this is an incomplete consent because it has the wrong procedure listed. 39356 4. During an observation on 9/8/25 at 1:45 p.m. in the CT modular, Computed Tomography Technician (CT) 1 completed a CT angio (angiography - medical imaging techniques that uses contrast dye to visualize blood vessels and blood flow) of the head and neck with contrast on Patient 20. During a concurrent interview and record review on 9/8/25 at 2:20 p.m. with Manager of Radiology (MR), Patient 20’s “Consent For/And Explanation of Intravenous Contrast Study (CFICS)” undated was reviewed. The “CFICS” indicated there was no witness signature. MR stated a witness signature was only required if the consent was signed by someone other than the patient. During a review of Patient 24’s “CFICS”, undated, the CFICS indicated there was no witness signature. During a review of Patient 25’s “CFICS”, dated 5/31/25, the CFICS indicated there was no witness signature. During a review of Patient 30’s “CFICS”, undated, the CFICS indicated there was no witness signature. During an interview on 9/9/25 at 11:12 a.m. with DON, DON stated all consents are required to have a witness signature. DON stated the witness signature confirms who signed the consent. During a review of the facility’s P&P titled “Medical Staff Rules and Regulations,” dated 6/15/2022, the P&P indicated “ ...B. INFORMED CONSENT FOR TREATMENT. An informed consent must be obtained for all surgical, therapeutic, and invasive procedures and for the administration of anesthesia and blood and blood products. Therapies which require informed consent include injection of contrast media or other hazardous agents. It is the treating practitioner’s exclusive responsibility to obtain and document and informed consent. Informed consent must include the name of the licensed independent practitioner and any assistants, medical information regarding the nature of the treatment, its expected benefits or effects, its possible risks and complications, and any alternatives to the proposed treatment and their possible risks and complications. The treating practitioner’s must document in the patient’s medical record that a discussion of the planned procedure and anesthesia was held with the patient and that informed consent was obtained. Evidence of informed consent (copy of signed surgery permit from physician’s office, documented in pre-operative history & physical, or documented by handwritten note in the patient’s medical record) will be required before commencing with the intervention ...” During a review of the facility’s P&P titled, “Consent and Informed Consent-California,” dated 3/6/2025, the P&P indicated, “ ...E. Treatments/Procedures That Require an Informed Consent: ...a. Informed consent must be obtained for treatments/procedures that are “complex” in that they involve material risks that are not commonly understood ...c. Typically informed consent must be obtained for: ...ii. Invasive radiology or cardiology procedures. Iii. Procedures involving contrast ...v. The administration of anesthesia or sedation medication designated in the formulary ...4. Responsibility: a. The practitioner who ordered the procedure is responsible for providing the patient or patient’s legal representatives with the information that is necessary to allow an “informed decision” to be made and obtaining the informed consent or refusal. The informed consent or refusal must be obtained and documented prior to performance of the procedure ...d. The role of the health care facility in the informed consent process is to verify that the practitioner(s) obtained the patient’s informed consent before the practitioner(s) is/are permitted to perform the procedure/tests ...2. Consent to Surgery or Special Procedure Form: a. The consent for should include: i. The name of the patient, and when appropriate the patient’s legal representative. ii. The medical terminology for the procedure (without abbreviation) and the type of anesthesia to be used if applicable. iii. Name or names of practitioners who will perform important parts of the procedure/treatment/service. iv. Signature of witness ...vi. Ensure where signature is applicable that it is accompanied with a date and time ...4. The nursing staff shall be responsible for verifying that the documentation has been included in the chart prior to the surgery/procedure and checking this off the surgical checklist. If these conditions are not met, the practitioner performing the procedure must be contacted to obtain the required documentation. Non-emergency procedures will be delayed or canceled until the informed consent process has been completed and fully documented ...J. Witnessing: 1. The role of the witness: a. The role of the person asked to serve as the signature witness is limited to the attestation of the signatures. The witnessing person should not answer questions relating to the informed consent the patient may have about the proposed surgery or procedure and should refer all such questions back to the practitioner ...””

“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: 40516 Based on observation, interview, and record review, the hospital failed to post signs in the main registration area, which specified the rights of individuals under the Emergency Medical Treatment and Active Labor Act (EMTALA), regarding examination and treatment for emergency medical conditions and women in labor (having uterine contractions). This failure had the potential for patients and families to be unaware of their rights under EMTALA. Findings: During a concurrent observation and interview on 2/14/24 at 8:50 a.m. with Obstetrics Nurse Manager (OBNM) and Director of Emergency Department (DOE), in the Main Registration area, no signage for EMTALA patient rights was found. OBNM stated, there was no EMTALA signage. During a review of the hospital’s policy and procedure (P&P) titled, “EMTALA - Compliance With EMTALA” dated 6/5/19, the P&P indicated, “B. General Policies. 1. Signage. The Hospital will post signs in the locations and form required by CMS [Centers for Medicare and Medicaid Services- federal agency that provides health coverage] that specifies the following: a. The rights of individuals, including women in labor, to examination and treatment for Emergency Medical Conditions; and b. The Hospital participates in the Medicaid Program.””

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 39650 Based on interview and record review, the hospital failed to ensure two of two sampled patients (Patient 11 and Patient 12)’s leaving against medical advise forms were complete. This failure had the potential for Patient 11 and Patient 12 to make uninformed medical decisions. Findings: During a concurrent interview and record review on 2/14/24 at 9:25 a.m. with Director of Risk (DOR), Patient 12’s “Consent/Refusal/Request/Release. . .LEAVING HOSPITAL AGAINST MEDICAL ADVISE [AMA] form dated 7/5/23 was reviewed. The “AMA” indicated, “I am voluntarily leaving the hospital against the advice of [physician name]” left blank. No witness of Patient 12’s signature documented on AMA form. DOR stated, Patient 12’s signature should have been witnessed and signed by the staff. During a concurrent interview and record review on 2/14/24 at 9:30 a.m. with Director of Emergency (DOE), Patient 11’s “AMA” form dated 7/5/23 was reviewed. The “AMA” indicated, “I am voluntarily leaving the hospital against the advise of [physician name]”. No witness, date or time of Patient 11’s signature documented. DOE stated, Patient 11’s signature should be witnessed and the staff is to ensure the form is complete with dates and times. During a review of the facility’s policy and procedure review (P&P) titled, “EMTALA-Patient LWBS [left without being seen], ELOPEMENT, AMA [against medical advise], LABS [left after being seen],” dated 12/12/23, was reviewed. The P&P indicated, “Patient wishes to leave against medical advise after receiving an initial Medical Screening Examination or during the course of follow-up examination and Stabilizing treatment. . . The AMA form will be completed to document the patient’s refusal. . .Documentation: Staff will document all interventions and discussions with the patient, by time, in patient’s record. As appropriate the Treating physician will document: The risks and benefit, including alternatives discussed with the patient or his/her representative.””

“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: 40516 Based on interview and record review, the hospital failed to ensure: 1. A Medical Screening Exam (MSE) was completed on one sampled patient (Patient X) being brought to the hospital by ambulance before diverting the ambulance to another hospital. 2. A Standardized Procedure (legal mechanism for registered nurses [RN] to perform functions which would otherwise be considered the practice of medicine) was developed to determine RN qualifications to perform an Obstetric (OB- related to pregnancy, labor, or delivery) MSE within the California Board of Registered Nursing guidelines. 3. OB MSEs were performed by qualified RNs who met the competency standards outlined in a Standardized Procedure for OB MSEs, for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) in the Labor and Delivery (L&D) triage unit. 4. A Maternal Fetal Triage Index (MFTI- standardized approach to assessing and assigning acuity [general level of patient illness] of pregnant women who present to the hospital for care) score was assigned during the OB triage process for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). These failures had the potential for an OB emergency medical condition to not be recognized, OB MSEs to be performed by unqualified nursing staff, and for an emergency medical condition to not be reported timely to a physician. Findings: 1. During an interview on 2/13/24 at 9:25 a.m. OB Nurse Manager (OBNM), OBNM stated on 2/4/24 at 4:32 p.m. the Emergency Department (ED) at Hospital 2 received a call from an ambulance dispatch center. OBNM stated Physician 1 answered the phone and was told Patient X, who was 33 weeks pregnant (40 weeks is considered full term) and her cervix was 7 centimeters (cm- unit of measure) dilated (10 cm is considered fully dilated and ready to deliver the baby) had been admitted at a neighboring hospital (Hospital 1). OBNM stated the dispatch center told Physician 1, Patient X left Hospital 1 “against medical advice” because of childcare issues on 2/3/24. OBNM stated the dispatch center told Physician 1, Patient X called for an ambulance on 2/4/24 “midday” and requested to be taken to Hospital 2. Physician 1 instructed the dispatch to bring Patient X to Hospital 2. OBNM stated Physician 1 then called the the Labor and Delivery (L&D) unit to give the nurse report on Patient X and her expected arrival. OBNM stated the two L&D nurses on duty discussed Patient X coming to the hospital between themselves and decided it would be better for Patient X to go to Hospital 3 which is in a different city about 20 minutes further north than Hospital 2. OBNM stated RN 2 called the ED, got the ambulance dispatch center’s phone number. OBNM stated Physician 1 told RN 2 that calling the dispatch center to divert the ambulance to Hospital 3 would be an “EMTALA” (Emergency Medical Treatment and Labor Act- Federal law requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition) situation. OBNM stated despite the discussion with Physician 1, RN 2 called the dispatch center and diverted the ambulance to Hospital 3. OBNM stated OB nurses are not allowed to divert ambulances. During an interview on 2/13/24 at 9:40 a.m. with Pre-hospital Liaison Nurse (PHLN), PHLN stated, there were justified reasons for the hospital to divert ambulances, but a process had to be followed. During an interview on 2/13/24 at 10:06 a.m. with RN 1, RN 1 stated on 2/3/24 she was scheduled to work in L&D with RN 2. RN 1 stated RN 2 received a phone call from Physician 1 in the ED and was told Patient X was coming to the hospital and Patient X was 33 weeks pregnant and 7 cm dilated. RN 1 stated she called the Respiratory Therapist and gave report on Patient X’s expected arrival. RN 1 stated she then began to set up a room to prepare for Patient X. RN 1 stated when she came out of the room, RN 2 told her Patient X was not going to come to the hospital any longer, she was going to Hospital 3. RN 1 stated RN 2 told her she called the ambulance dispatch center initially to get an estimated time of arrival (ETA), but then told the dispatch center to take Patient X to Hospital 3. During an interview on 2/14/24 at 11:10 a.m. with RN 2, RN 2 stated on 2/4/24 she received a call from the ED saying a pre-term pregnant patient (Patient X) was 7 cm dilated and coming in by ambulance. RN 2 stated “a good deal of time passed” without seeing an ambulance arriving in the ED so she consulted with her “colleague” (RN 1) and decided to call the dispatch service to find out an ETA. RN 2 stated while speaking with the dispatch center, she asked if Patient X could be taken to Hospital 3 instead. RN 2 stated she was placed on hold and when the dispatch staff came back on the line, she was told the ambulance would be diverted to Hospital 3. RN 2 stated she had never contacted the ambulance dispatch center for an inbound patient prior to this call. During a review of Patient X’s “Emergency Medical Services Base Hospital Run Report” (RR) dated 2/4/23 at 4:32 p.m. the RR indicated when dispatch called Hospital 2’s ED, the ambulance was 12 minutes away from the Hospital 2 and by the time the RR was filled out the ETA was 10 minutes. 2. During an interview on 2/13/24 at 10 a.m. with OBNM, OBNM stated she was unable to find a standardized procedure for OB MSEs. During an interview on 2/23/24 at 10:06 a.m. with RN 1, RN 1 stated she performed OB MSEs, but did not remember getting education on a standardized procedure to perform OB MSEs. During an interview on 2/13/24 at 10 a.m. with OBNM, OBNM stated L&D nurses had been performing OB MSEs without a written standardized procedure. 3. During a concurrent interview and record review on 2/14/24 at 9:15 a.m. with OBNM and Regulatory Nurse (RRN), Patient 1’s medical record (MR) was reviewed. The Antepartum Triage, dated 2/12/24, indicated Patient 1 presented to the hospital’s L&D at 7:18 a.m. for a scheduled induction of labor (medication given to start the labor process). OBNM stated RN 3 completed Patient 1’s OB MSE. During a concurrent interview and record review on 2/14/24 at 9:27 a.m. with OBNM and RRN, Patient 2’s MR was reviewed. The Antepartum Triage, dated 2/13/24, indicated Patient 2 presented to the hospital’s L&D at 12:44 a.m. for abdominal pressure. OBNM stated RN 4 completed Patient 2 ‘s OB MSE. During a concurrent interview and record review on 2/14/24 at 9:41 a.m. with OBNM and RRN, Patient 3’s MR was reviewed. The Antepartum Triage, dated 2/2/24, indicated Patient 3 presented to the hospital’s L&D at 10:26 a.m. for decreased fetal movement. OBNM stated RN 5 completed Patient 3’s OB MSE. During a concurrent interview and record review on 2/14/24 at 9:48 a.m. with OBNM and RRN, Patient 4’s MR was reviewed. The Antepartum Triage dated 2/10/24 indicated Patient 4 presented to the hospital’s L&D at 7:49 p.m. for vaginal bleeding. OBNM stated RN 4 completedPatient 4’s OB MSE. During a concurrent interview and record review on 2/14/24 at 10:05 a.m. with OBNM and RRN, Patient 5’s MR was reviewed. The Antepartum Triage dated 2/13/24 indicated Patient 5 presented to the hospital’s L&D at 11:19 a.m. for leaking amniotic fluid (fluid surrounding a fetus in the womb). OBNM stated RN 1 completed the Patient 5’s OB MSE. During a concurrent interview and record review on 2/14/24 at 10:10 a.m. with OBNM and RRN, Patient 6’s MR was reviewed. The Antepartum Triage dated 1/11/24 indicated Patient 6 presented to the hospital’s L&D at 3:54 p.m. for leaking amniotic fluid. OBNM stated RN 2 completed Patient 6’s OB MSE. During a concurrent interview and record review on 2/14/24 at 10:17 a.m. with OBNM and RRN, Patient 7’s MR was reviewed. The Antepartum Triage dated 2/8/24 indicated Patient 7 presented to the hospital’s L&D at 10:28 p.m. for lower back pain. OBNM stated RN 8 completed Patient 7’s OB MSE. During a concurrent interview and record review on 2/14/24 at 10:40 a.m. with OBNM and RRN, Patient 8’s MR was reviewed. The Antepartum Triage dated 2/5/24 indicated Patient 8 presented to the hospital’s L&D at 5:51 a.m. for abdominal pain and blurred vision. OBNM stated RN 9 completed Patient 8’s OB MSE. During a concurrent interview and record review on 2/14/24 at 10:49 a.m. with OBNM and RRN, Patient 9’s MR was reviewed. The Antepartum Triage dated 10/2/23 indicated Patient 9 presented to the hospital’s L&D at 8:21 p.m. for uterine contractions and leaking fluid. OBNM stated RN 10 completed Patient 9’s OB MSE. 4. During an interview on 2/13/24 at 10:06 a.m. with RN 1, RN 1 stated during the OB triage process, no MFTI scores are being assigned to patients being triaged in L&D. During an interview on 2/13/24 at 10:55 a.m. with OBNM, OBNM stated the electronic documentation system the hospital was using did not have a built-in method to administer a MFTI score to patients being triaged in L&D. OBNM stated nurses were not giving an MFTI or any triage score to patients being triaged in L&D. During a concurrent interview and record review on 2/14/24 at 9:15 a.m. with OBNM and Regulatory Nurse (RRN), Patient 1’s “Antepartum Triage” (AT-process of evaluating a pregnant or in labor patient for the timeliness or level of care needed), dated 2/12/24 was reviewed. The AT indicated Patient 1 presented to the hospital’s L&D at 7:18 a.m. for a scheduled induction of labor. OBNM stated no MFTI score was given for Patient 1. During a concurrent interview and record review on 2/14/24 at 9:27 a.m. with OBNM and RRN, Patient 2’s AT, dated 2/13/24, was reviewed. The AT indicated Patient 2 presented to the hospital’s L&D at 12:44 a.m. for abdominal pressure. OBNM stated no MFTI score was given for Patient 2. During a concurrent interview and record review on 2/14/24 at 9:41 a.m. with OBNM and RRN, Patient 3’s AT, dated 2/2/24, was reviewed. The AT indicated Patient 3 presented to the hospital’s L&D at 10:26 a.m. for decreased fetal movement. OBNM stated no MFTI score was given for Patient 3. During a concurrent interview and record review on 2/14/24 at 9:48 a.m. with OBNM and RRN, Patient 4’s AT , dated 2/10/24, was reviewed. The AT indicated Patient 4 presented to the hospital’s L&D at 7:49 p.m. for vaginal bleeding. OBNM stated no MFTI score was given for Patient 4. During a concurrent interview and record review on 2/14/24 at 10:05 a.m. with OBNM and RRN, Patient 5’s AT, dated 2/13/24, was reviewed. The AT indicated Patient 5 presented to the hospital’s L&D at 11:19 a.m. for leaking amniotic fluid (fluid surrounding a fetus in the womb). OBNM stated no MFTI score was given for Patient 5. During a concurrent interview and record review on 2/14/24 at 10:10 a.m. with OBNM and RRN, Patient 6’s AT, dated 1/11/24, was reviewed. The AT indicated Patient 6 presented to the hospital’s L&D at 3:54 p.m. for leaking amniotic fluid. OBNM stated no MFTI score was given for Patient 6. During a concurrent interview and record review on 2/14/24 at 10:17 a.m. with OBNM and RRN, Patient 7’s AT, dated 2/8/24, was reviewed. The AT indicated Patient 7 presented to the hospital’s L&D at 10:28 p.m. for lower back pain. OBNM stated no MFTI score was given for Patient 7. During a concurrent interview and record review on 2/14/24 at 10:40 a.m. with OBNM and RRN, Patient 8’s AT, dated 2/5/24, was reviewed. The AT indicated Patient 8 presented to the hospital’s L&D at 5:51 a.m. for abdominal pain and blurred vision. OBNM stated no MFTI score was given for Patient 8. During a concurrent interview and record review on 2/14/24 at 10:49 a.m. with OBNM and RRN, Patient 9’s AT, dated 10/2/23, was reviewed. The AT indicated Patient 9 presented to the hospital’s L&D at 8:21 p.m. for uterine contractions and leaking fluid. OBNM stated no MFTI score was given for Patient 9. During a review of the hospital’s policy and procedure (P&P) titled, “EMTALA - Medical Screening Exams Labor and Delivery” dated 6/5/19, the P&P indicated, “Policy Summary/Intent: A. To ensure that all individuals who come to the hospital. . . seeking or in need of Emergency Services and Care, including Labor & Delivery (L&D), receive an appropriate Medical Screening Exam and further examination and Stabilizing treatment in accordance with applicable laws and Hospital policies. B. The Medical Screening Exam will be performed by individuals qualified to perform the Examination to determine if the individual has an Emergency Medical Condition. If an individual has an Emergency Medical Condition, the Hospital will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition. . . A. 1. In accordance with EMTALA and Hospital policies, Labor & Delivery (L&D) will: a. Maintain a Central Log in accordance with the Central Log Policy to record the names and disposition of individuals presenting to the Dedicated Emergency Department (including Labor & Delivery) seeking or in need of examination or treatment for a possible Emergency Medical Condition. b. Provide a Medical Screening exam by a physician, clinical nurse midwife or a registered nurse authorized to provide a Medical Screening Examination to any pregnant women who comes to Labor & Delivery seeking examination or treatment. c. If it is determined that a woman is in Labor or an Emergency Medical Condition exists, provide the woman with further medical examination and treatment as required to Stabilize her condition; and d. If Transfer of the woman to another hospital is appropriate, carry out the Transfer in accordance with the Patient Transfer policy.” During a review of the hospital’s P&P titled, “EMTALA - Medical Screening Examination (MSE) and Stabilization” dated 6/5/19, the P&P indicated, “B. Triage. 1. Triage is a sorting process to determine the order in which individuals will be provided a Medical Screening Examination by a physician or Qualified Medical Person. Triage is not the equivalent of a Medical Screening Examination and does not determine the presence or absence of an Emergency Medical Condition. 2. The triage assessment and classification of prioritization for the Medical Screening Examination will be performed in accordance with hospital policies and procedures. 3. Documentation. The Triage nurse will record the findings of the Triage examination in the patient medical record in accordance with Hospital policies and procedures.” During a review of the hospital’s “Medical Staff Rules & Regulations 2019” (MSRR) dated 6/5/19, the MSRR indicated, “J. STANDARDIZED PROCEDURE The means designated to authorize performance of a medical function (changes in treatment regimen after observing signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determining that these exhibit abnormal characteristics; these activities may overlap the practice of medicine when it is the registered nurse who determines that they are to be undertaken). A standardized procedure developed through collaboration among registered nurses, physicians, and administrators in the health care system in which it is to be used and approved by . . . committee. . . M. MEDICAL SCREENING EXAMS 1. Emergency services and care shall be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care. . . 2. Medical Screening Examinations, within the capability of this hospital, will be performed on all individuals who come to the hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable hospital policies and procedures are defined as. . . b. Labor and Delivery Department i. Members of the medical staff with privileges in obstetrics. ii. Certified nurse midwives who have scope of practice in the labor and delivery department. iii. Registered nurses who have completed the labor and delivery departmental orientation/competency program may perform an appropriate medical screening in accordance with labor and delivery policies and procedures.” During a review of the California Board of Registered Nursing’s guideline titled, “Standardized Procedure Guidelines,” dated 1/11, the “Standardized Procedure Guidelines” indicated, “1470. Purpose The Board of Registered Nursing in conjunction with the Division of Allied Health Professions of the Board of Medical Quality Assurance (see the regulations of the Board of Medical Quality Assurance, Article 9.5, Chapter 13, Title 16 of the California Code of Regulations) intends, by adopting the regulations contained in the article, to jointly promulgate guidelines for the development of standardized procedures to be used in organized health care systems which are subject to this rule. The purpose of these guidelines is: (a) To protect consumers by providing evidence that the nurse meets all requirements to practice safely. (b) To provide uniformity in development of standardized procedures. 1474. . . Standardized Procedure Guidelines: Following are the standardized procedure guidelines jointly promulgated by the Division of Allied Health Professions of the Board of Medical Quality Assurance and by the Board of Registered Nursing: (a) Standardized procedures shall include a written description of the method used in developing and approving them and any revision thereof. (b) Each standardized procedure shall: (1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it. (2) Specify which standardized procedure functions registered nurses may perform and under what circumstances. (3) State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions. (4) Specify any experience, training, and/or education requirements for performance of standardized procedure functions. (5) Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions. (6) Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions. (7) Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician. (8) Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient’s physician concerning the patient’s condition. (9) State the limitations on settings, if any, in which standardized procedure functions may be performed. (10) Specify patient record keeping requirements. (11) Provide for a method of periodic review of the standardized procedures.””

“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: 39650 Based on interview and record review, the facility failed to follow its policy and procedure titled, “EMTALA - Patient Transfer” for nine of 20 sampled patients (Patient 14, Patient 16, Patient 20, Patient 1, Patient 8, Patient 10, Patient 17, Patient 18, and Patient 19) when risks, benefits, and alternatives (RBAs) to tranferring to another hospital and/or consent to transferring to another hospital were not documented as being done prior to the transfer. These failures had the potential for Patient 14, Patient 16, Patient 20, Patient 1, Patient 8, Patient 10, Patient 17, Patient 18, and Patient 19 to make medical decision without being fully informed of the potential risks versus benefits and alternatives to transferring to another hospital. Findings: During a concurrent interview and record review on 2/14/24 at 10:30 a.m. with Director of Risk (DOR), Patient 16’s “All Relationships [AR],” 10/26/23 was reviewed. Patient 16’s “AR” indicated, FM 1 relationship Father and telephone number. DOR stated, Patient 16 had FM 1 documented as his contact person. Patient 16’s “Patient/Facility Transfer form (Nursing)-auth (Verified) [TF]” dated 10/27/23 was reviewed. The “TF” indicated, “PATIENT ACKNOWLEDGEMENT: I understand that I have a right to receive have a right to receive medical screening, examination, and evaluation by a physician or other appropriate personnel . .prior to any transfer from this hospital and that I also have the right to be informed of the reasons for any transfer. I acknowledge that I have received medical screening, examination, and evaluation by a physician or other appropriate personnel, and that I have been informed of the reasons for my transfer, both orally and in writing.” Time 7:47 a.m. Date 10/27/23 Patient or legal Representative signed by two Registered Nurses and witnessed by (illegible). DOR stated, Patient 16’s “TF” should have been signed by FM 1 because Patient 16 was unable to sign for himself due to his medical condition. During a concurrent interview and record review on 2/14/24 at 11:05 a.m. with DOR, Patient 16’s medical record was reviewed. DOR stated, she was unable to provide a signed consent form for Patient 16’s transfer to another facility for higher level of care or documentation the RBAs were discussed with FM 1. DOR stated, FM 1 should have been contacted to obtain consent and he should have been provided RBAs of the transfer. During a concurrent interview and record review on 2/14/24 at 11:30 a.m. with DOR, Patient 14’s “Patient/Facility Transfer form (Nursing)-auth (Verified) [TF]” dated 11/2/23 was reviewed. The “TF” indicated, “PATIENT ACKNOWLEDGEMENT: I understand that I have a right to receive have a right to receive medical screening, examination, and evaluation by a physician or other appropriate personnel . . . prior to any transfer from this hospital and that I also have the right to be informed of the reasons for any transfer. I acknowledge that I have received medical screening, examination, and evaluation by a physician or other appropriate personnel, and that I have been informed of the reasons for my transfer, both orally and in writing.” Time 7:45 a.m. Date 11/2/23 Patient or legal Representative signed by Patient 14. DOR stated, Patient 14’s “TF” did not include a consent to transfer for a higher level of care or documentation RBA’s were discussed prior to transfer. DOR stated, Patient 14’s signature was not witnessed on the TF. During a concurrent interview and record review on 2/14/24 at 1:40 p.m. with DOR, Patient 20’s “Patient/Facility Transfer form (Nursing)-auth (Verified) [TF]” dated 11/15/23 was reviewed. The “TF” indicated, “PATIENT ACKNOWLEDGEMENT: I understand that I have a right to receive medical screening, examination, and evaluation by a physician or other appropriate personnel . . . prior to any transfer from this hospital and that I also have the right to be informed of the reasons for any transfer. I acknowledge that I have received medical screening, examination, and evaluation by a physician or other appropriate personnel, and that I have been informed of the reasons for my transfer, both orally and in writing.” Time 2:25 p.m. Date 11/15/23 Patient or legal Representative signed by Patient 20. DOR stated, Patient 20’s “TF” did not include a consent to transfer for a higher level of care or documentation RBA’s were discussed prior to transfer. During a concurrent interview and record review on 2/14/24, at 1:50 p.m. with Director of Emergency (DOE) and DOR, the facility’s policy and procedure review (P&P) (P&P) titled, “EMTALA-Patient Transfer,” dated 12/12/23, was reviewed. the P&P indicated, “B. Transfer of an Individual with an Emergency medical Condition is Unstabilized. . . B. 4.c. Medical Records. . .It is preferred to use the attached Transfer Form. If another form is used, it needs to have minimally the elements as outlined in the Transfer Form. . .C. Transfer of an Individual whose Emergency medical Condition is Stabilized. An individual who has an Emergency Medical Condition that has been Stabilized may be transferred in accordance with the following procedures. . .2. d. Medical Records. The Hospital will send the medical records to the receiving facility in accordance wit the same procedures for Transfer of patient with an Emergency Medical Condition that is not Stabilized. (B.4.c.).” The facility’s P&P titled, “EMTALA-Patient Transfer,” dated 12/12/23 was reviewed. The P&P indicated, “Patient Transfer Acknowledgment and Agreement. . . I understand that I have a right to receive medical screening, examination, and evaluation by a physician (or other appropriate personnel), . .prior to any transfer from this hospital. I also have the right to be informed of the reasons for any transfer. I acknowledge that I have received medical screening, examination, and evaluation by a physician (or other appropriate Personnel), and that I have been informed of the risk and benefits of the transfer and of the reason(s) for my transfer which is/are indicated by the physician above. I agree to the transfer and permission for records to be released to _____medical facility. Signature of Patient/Family/Legal Representative:____Date:____Time:____ Relationship to the Patient:____Witness Signature RN [Registered Nurse]: ____.” DOE stated, the transfer form currently being used by staff for all transfer patients was not the same form as in the current P&. Patient 20’s “Patient/Facility Transfer form (Nursing)-auth (Verified) [TF]” dated 11/15/23 was reviewed. DOE stated, Patient 20’s “TF” does not include a facility transfer consent and documentation the patient received the RBAs. DOE stated, they will have to correct and update the form to include the transfer consent and discussion of the RBA by the physician. 40516 During a concurrent interview and record review on 2/14/24 at 9:15 a.m. with Obstetric Nurse Manager (OBNM) and Regulatory Nurse (RRN), Patient 1’s medical record (MR) was reviewed. The Antepartum Triage dated 2/12/24 indicated Patient 1 presented to the hospital’s L&D at 7:18 a.m. for a scheduled induction of labor (medication given to start the labor process). OBNM stated Patient 1 was transferred to another hospital for a higher level of care because Patient 1 had a previous cesarean section (surgical delivery of the fetus through the abdominal wall) and her induction of labor would require an OB doctor to be present in the hospital throughout the induction and delivery process but no MD was available to stay in the hospital. OBNM and RRN were unable to find documented RBAs or a signed consent to transfer. The MR indicated Patient 1 was transferred to another hospital on 2/12/24 at 12:02 p.m. During a record review on 2/14/24 at 10:40 a.m. with OBNM and RRN, Patient 8’s MR was reviewed. The Antepartum Triage dated 2/5/24 indicated Patient 8 presented to the hospital’s L&D at 5:51 a.m. for abdominal pain and blurred vision. The “Patient Transfer Form” dated 2/5/24 indicated Patient 8’s pregnancy was preterm at 32 6/7 weeks (40 week is full term) and she had pre-eclampsia with severe features (disorder of pregnancy with high blood pressure which can lead to liver and kidney dysfunction, the only cure is to deliver the fetus). The reason for the transfer was “higher neonatology [medical care of a newborn] unit.” OBNM and RRN were unable to find a signed consent to transfer. The MR indicated Patient 8 was transferred to another hospital on 2/5/24 at 9:35 a.m. During a record review on 2/14/24 at 11:20 a.m. with OBNM and RRN, Patient 10’s MR was reviewed. The “Emergency Department Reports” dated 7/1/23 indicated Patient 10 presented to the hospital’s ED at 2:03 p.m. for blood in stool for seven days. The “Patient Transfer Form” dated 7/2/23 at 2:36 a.m. indicated Patient 10 had a lower gastrointestinal bleed and cirrhosis (severe scarring of the liver). The reason for the transfer was “GI [Specialty services for patients with stomach, intestinal, or digestive problems]. OBNM and RRN were unable to find a signed consent to transfer to another hospital. The MR indicated Patient 10 was transferred to another hospital on 7/2/23 at 2:36 a.m. During a record review on 2/14/24 at 11:47 a.m. with OBNM and RRN, Patient 17’s MR was reviewed. The “Emergency Department Reports” dated 1/23/24 indicated Patient 17, a 14-year-old, presented to the hospital’s ED at 7:13 p.m. with his mother, for abdominal pain. The “Patient Transfer Form” dated 1/24/24 at 8:39 a.m. indicated Patient 17 had “acute appendicitis [appendix becomes inflamed and filled with pus, causing pain].” OBNM and RRN were unable to find a signed consent to transfer to another hospital. The MR indicated Patient 17 was transferred to another hospital on 1/24/24 at 8:40 a.m. During a record review on 2/14/24 at 11:50 a.m. with OBNM and RRN, Patient 18’s MR was reviewed. The “Emergency Department Reports” dated 10/1/23 indicated Patient 18 presented to the hospital’s ED at 3:16 p.m. with complaints of vomiting and blood in vomit and stool. The “Patient Transfer Form” dated 10/2/23 at 1:02 p.m. indicated Patient 18 had “gastroparesis [paralysis of the stomach which prevents proper emptying of stomach contents], DKA [diabetic keto acidosis- complication of diabetes in which acids build up in the blood to levels that can be life-threatening].” OBNM and RRN were unable to find a signed consent to transfer to another hospital. The MR indicated Patient 17 was transferred to another hospital on 10/2/24 at 5:20 p.m. During a record review on 2/14/24 at 11:24 a.m. with OBNM and RRN, Patient 19’s MR was reviewed. The “Emergency Department Reports” dated 1/4/24 indicated Patient 17, a 4-year-old, presented to the hospital’s ED at 4:24 p.m. with her mother and father, for “lethargy [lack of energy or enthusiasm] fever and not eating very well over the last 3 days.”. The “Patient Transfer Form” dated 1/4/24 at 8:35 p.m. indicated Patient 19 had “pneumonia [inflammation and fluid in the lungs caused by bacterial, viral, or fungal infection] and “influenza B [type of flu]. OBNM and RRN were unable to find a signed consent to transfer to another hospital. The MR indicated Patient 19 was transferred to another hospital on 1/4/24 at 7:21 p.m. During an interview on 2/14/24 at 1:25 p.m. with Director of Risk (DOR), DOR stated no consents for transfer to another hospital were signed for Patient 14, Patient 16, Patient 20, Patient 1, Patient 8, Patient 10, Patient 17, Patient 18, or Patient 19.”