Southern Inyo Hospital

“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: 47394 Based on interview and record review, the facility failed to implement and maintain its Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), when: 1. One of 31 sampled patients (Patient 31) when Patient 31, who came to the facility after five bee stings, was refused treatment at the facility, and was not documented or logged (Refer to Tag C2405). 2. One of 31 sampled patients when Patient 31, who presented to the Emergency Department (ED) after a bee sting, did not received Medical Screening Examination (MSE-an examination performed by a qualified medical provider to determine if a patient has an emergency condition) (Refer to Tag C2406). The cumulative effects of these failures resulted in one of 31 sampled patients who came to the ED seeking emergency medical care did not receive the MSE, which could delay treatment for critical medical conditions and potentially cause harm to the patient.”

“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: 51269 Based on interview and record review, the facility failed to maintain a centralized log for the Emergency Department (ED) per it’s Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P) for one of 31 sampled patients (Patient 31) when Patient 31, who came to the facility after five bee stings, was refused treatment at the facility, and was not documented or logged. This failure resulted in Patient 31 leaving the hospital without receiving medical treatment which could negatively affect Patient 31’s health and safety from delayed treatment of allergic reaction that could lead to severe allergic reaction and cause actual health damage. Findings: An unannounced visit was conducted on July 28, 2025, through July 30, 2025, to investigate a possible EMTALA violation. During an interview on July 25, 2025, at 2:24 PM, with Patient 31, Patient 31 stated he had gone to the facility ED on July 23, 2025, at midnight and was refused care by a Registered Nurse (RN 1). Patient 31 further stated that RN 1 instructed Patient 31 to go to the store to buy over-the-counter allergy medication. Patient 31 stated that RN 1 did not ask for his name or register him. During an interview on July 29, 2025, at 8:59 AM, with the Chief Nursing Officer (CNO), the CNO stated that RN1 notified him on July 28, 2025, over the phone that Patient 31 showed up to the emergency room around midnight, asking what could be done for a bee sting. The CNO further stated “unsure of the date the patient came in, it was sometime last week.” During a concurrent interview and record review on July 29, 2025, at 9:00 AM, with the CNO, the facility’s document titled, “ED logbook” (A book that keeps a record of all the patients who show up to the emergency department), dated January 2025, through July 2025, was reviewed. The ED logbook showed no evidence to indicate that Patient 31 was registered at the facility nor was there any documentation indicating Patient 31 received a medical screening examination (MSE) to rule out if an emergency medical condition existed or that the patient was medically stabilized. The CNO stated that the expectation is for all the patients who presented to the ED get logged. The CNO confirmed that Patient 31 did not get logged in and the facility was not able to provide any information about the Patient 31. During a telephone interview on July 29, 2025, at 11:00 AM, with RN1, RN1 stated Patient 31 came to the facility after being stung by a bee. RN1 was not able to recall the exact date. RN 1 stated Patient 31 did not see a provider and that the patient was not logged into the book. RN 1 further stated, the patient should have been logged into the book even if RN1 did not know the patient’s name as part of the facility’s P&P. During a concurrent interview and record review on July 30, 2025, at 8:32 AM, with the CNO, and the Interim Chief Executive Officer (CEO), the facility’s P&P titled, “Compliance with Emergency Medical treatment and active labor act (EMTALA),” dated May 20, 2025, was reviewed. The P&P indicated, “ ...Central log. Each dedicated emergency department of the hospital will maintain a central log recording the names of individuals who came to the emergency department. The central log will record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by the hospital ...” The CNO and CEO stated the policy was not followed, and confirmed Patient 31 was not documented into the ED log. During a concurrent interview and record review on July 30, 2025, at 8:34 AM, with the CNO, and CEO, the facility’s P&P titled, “Emergency Department Patient/ Central Log,” dated July 10, 2025, was reviewed. The P&P indicated, “ ...a patient log shall be maintained on each individual who come to the Emergency Department (ED) ... c. The log shall contain the following information (At a minimum) 1. Date admitted 2. Time of arrival 3. Patient name ...12. disposition of care (ex. Home, transfer AMA [Against medical advice- leaving the facility against medical advice after risk and benefits are explained], elopement [a patient leaving a facility unsupervised] ...” The CNO and CEO stated that the policy was not followed and should have been. The CNO stated that it is important to log any patient that comes to the ED because it keeps a record and for patient safety.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 47394 Based on interview and record review, the facility failed to ensure its policy and procedures (P&P) for the Emergency Medical Treatment and Active Labor Act (EMTALA) was appropriately followed for one of 31 sampled patients when Patient 31, who presented to the Emergency Department (ED) after a bee sting, did not received Medical Screening Examination (MSE). This failure resulted in Patient 31 not being appropriately triaged (process of assessing to know the severity of condition for the patient) or received MSE to determine if an emergency medical condition (EMC) existed and provided with appropriate treatment which could result in Patient 31 develop severe allergic reaction that led to death. Findings: During an interview on July 25, 2025, at 2:24 PM, with Patient 31, Patient 31 stated he had gone to the facility ED on July 23, 2025, at midnight and was refused care by a Registered Nurse (RN 1). Patient 31 further stated that RN 1 instructed Patient 31 to go to the store to buy over-the-counter allergy medication. Patient 31 stated that RN 1 did not ask for his name or register him. A review of the facility’s document titled, “ED logs book” (A book that keeps a record of all the patients who show up to the emergency department), dated January 2025, through July 2025, there was no documented evidence to indicate Patient 31 was registered nor received MSE to rule out if an EMC existed. During an interview on July 28, 2025, at 3:05 PM, with Physician 1 (P 1), P1 stated, he works as an on-call physician in the facility, and he was scheduled as on call physician on July 23, 2025. P1 further stated, he was not called by the staff for the last weeks which started on July 23, 2025, through July 29, 2025. During an interview on July 29, 2025, at 11:00 AM, with Registered Nurse 1 (RN1), RN1 stated, Patient 31 came to the ED around 12 AM or 1 AM with the complaint of “bee sting” and RN1 was not able to recall the exact date. RN 1 further stated, he did not log Patient 31 in ED log as Patient 31 left without triage. RN1 acknowledged that staff is expected to log every patient, triage and notify physician. During an interview on July 30, 2025, at 8:30 AM, with the Chief Nursing Officer (CNO), the CNO stated that he came to know about the incident from RN1 when California Department of Public Health (CDPH) officials came to the facility on July 28, 2025. The CNO further stated, staff is expected to log every patient who came to the ED in the ED log. During a concurrent interview and record review on July 30, 2025, at 8:40 AM, with the CNO, the facility’s P&P titled, “COMPLIANCE WITH EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA),” dated May 20, 2025, was reviewed. The P&P indicated, “PURPOSE: To describe and comply with EMTALA and to define policies and procedures for compliance with EMT ALA obligations. SCOPE OF EMT ALA: EMT ALA is applicable to any individual who comes to the emergency department. A medical screening examination will be offered to any individual who comes to the emergency department. The medical screening examination must be provided within the capability of the dedicated emergency department, including ancillary services routinely available to the dedicated emergency department (including the availability of the on-call physicians). The medical screening examination must be the same appropriate examination that the Hospital would perform on any individual with similar signs and symptoms, regardless of the individual’s ability to pay for medical care.” The CNO stated that the expectation is for all the patients who presented to the ED get logged. The CNO confirmed that Patient 31 did not get logged in and the facility was not able to provide any information about the Patient 31. The CNO further stated that all patients should have MSE done.”

“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: 51269 Based on interview and record review, the facility failed to implement and maintain its Emergency Medical Treatment and Active Labor Act (EMTALA), policy and procedures (P&Ps), by not ensuring the following: 1. One patient (Patient 29), who had just given birth was seeking medical attention, was refused treatment at the facility, and was not documented or logged. (Refer to Tag A- 2405) 2. Five of 29 sampled patients (Patients 7, 15, 25, 26, and 27) were presented to the Emergency Department with an emergency medical condition and were not provided with timely triage. (Refer to Tag A-2406) These failures resulted in the six of 29 sampled patients receiving delay of treatment for critical medical conditions and potentially cause complications, worsening of the condition, deterioration, or death to the patients.”

“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: 51269 Based on interview and record review, the facility failed to maintain a centralized log for the Emergency Department (ED) per it’s Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure (P&P) for one of 29 sampled patient (Patient 29) when Patient 29, who had just given birth and was seeking medical attention, was refused treatment at the facility, and was not documented or logged in the ED log. This failure resulted in Patient 29 leaving in her own vehicle instead of getting medical treatment which could jeopardize the health and safety of the patient and her newborn baby. Findings: An unannounced visit was conducted on May 5, 2025, through May 6, 2025, to investigate a possible EMTALA violation. During an interview on May 5, 2025, at 2:36 PM, with the Acting Chief Executive Officer (ACEO), the ACEO stated that every patient requesting care should have been logged. The ACEO further stated that she was not sure if Patient 29 was logged. During a concurrent interview and record review, on May 5, 2025, at 3:15 PM, with the Chief Nursing Officer (CNO), the facility’s document titled, “Ed Admission Report w/ [with] the CNO Disposition of Care” (ED Report), dated Nov 2024 to May 2025, was review. There was no documented evidence to indicate Patient 29 was registered on the Facility’s ED log, nor was there documentation indicating Patient 29 received a medical screening examination (MSE) to rule out if an emergency medical condition existed or that the patient was medically stabilized. The CNO stated that the expectation is for all the patients to get logged. The CNO confirmed that Patient 29 did not get logged in and the facility was not able to provide any information about Patient 29. During an interview on May 6, 2025, at 8:28 AM, with the Emergency Medical Technician Captain (EMTC), the EMTC stated she was able to recall Patient 29. The EMTC stated that when she responded to the call, Patient 29 and the newborn baby seemed to be in good condition. The EMTC further stated, the newborn baby still had the placenta (a temporary organ that develops in the uterus during pregnancy. It acts as a vital connection between the mother and the growing fetus, providing essential nutrients, oxygen, and removing waste products) attached and in a grocery bag for transport. The EMTC stated that she called the facility and spoke to Register Nurse 1 (RN 1) to notify him that the transport team was bringing Patient 29 with the newborn baby. The EMTC further stated that when the transport team arrived at the ambulance bay of the facility, the Chief Executive Officer (CEO) informed the transport team through the window stating, “you’re not coming into the hospital, we do not accept OB [OB-obstetrics, a branch of medicine that focuses on the care of women during pregnancy, childbirth, and the postpartum period].” The EMTC stated they backed out of the ambulance bay and assisted Patient 29 into her private vehicle with the baby and the placenta still attached. During a telephone interview on May 6, 2025, at 11:55 AM, with Medical Doctor 1 (MD 1), MD 1 stated, he remembered receiving a call from RN 1 stating the facility would be receiving Patient 29 with the newborn baby. MD 1 stated, any patient who comes into the ED, the facility is obligated to assess, stabilize and treat within its limitations and capacity the facility has. MD 1 further stated, “ ...if the patient was told that she could not be seen it would be a huge violation of EMTALA ...”. MD 1 stated “an EMTALA violation is morally and ethically inappropriate.” During a telephone interview on May 6, 2025, at 12:20 PM, with RN 1, RN 1 stated that he remembered Patient 29 page over the radio of a home birth. RN 1 stated that typically during the day when a patient comes in registration, the facility staff will register and directly log patient’s name into the ED log. RN 1 further stated, he received a call from the EMTC stating the transport team was on the way and would give a report when the transport team arrived. RN 1 stated, he started preparing all the supplies needed, got hold of the doctor and waited for Patient 29 and the newborn baby. RN1 stated, Patient 29 arrived at the ambulance bay but did not come into the facility. RN1 further stated that the CEO told the facility staff that Patient 29 left AMA from the ambulance. During a telephone interview on May 6, 2025, at 2:00 PM, with the Fire Captain (FC), the FC stated he remembered Patient 29. The FC stated they received a call and brought Patient 29 to the facility. The FC stated, when the team was in the ambulance bay, the CEO impeded the process by stating that the facility could not provide care for Patient 29 and the newborn baby. During an interview on May 6, 2025, at 2:42 PM, with Emergency Room technician (ERT), ERT stated, she was notified of Patient 29. ERT stated that she was waiting for about 15 minutes inside the ED, but Patient 29 never came in. ERT stated that the CEO stated that Patient 29 was not going to come to the facility and were going to a different facility. ERT stated that the expectation is to care for the patient regardless of insurance or way of paying and that it was not provided for this patient and should have. During a concurrent interview and record review on May 6, 2025, at 5:09 PM, with the ACEO, CNO, and Assistant Director of Nursing (ADON), the facility’s P&P titled “EMTALA GUIDLELINE FOR EMERGENCY DEPARTMENT SERVICES,” dated February 2016 , was reviewed. The P&P indicated, “ ...Medical Screening Exams should include at a minimum the following: Emergency Department Log entry including disposition of patient ...” The ACEO, CNO, and ADON stated the policy was not followed, and confirmed Patient 29 was refused treatment at the facility and was not documented into the ED log.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 51269 Based on interview and record review, the facility did not follow their policy and procedures (P&P) of the Emergency Medical Treatment and Labor Act (EMTALA) for five of 29 sampled patients (Patients 7, 15, 25, 26, and 27) when: 1. For three patients (Patient 7, 25, and 27), the nursing staff did not triage (the process of sorting patients into groups based on their need for care) patients after Patient 7, 25, and 27 registered to the Emergency Department (ED) prior to them leaving against medical advice (AMA-a patient’s decision to leave a hospital against the recommendation of their physician). 2. For one patient (Patient15), the nursing staff did not triage Patient 15 after Patient 15 registered into the ED prior to Patient 15 being discharged home. 3. For one patient (Patient 26), the nursing staff did not triage Patient 26 after Patient 26 registered into the ED prior to Patient 26 being transferred to another facility. These failures resulted in Patient 7, 15, 25, 26, and 27 not being provided appropriate triage to address the acuity (severity of illness) level of the patients’ needs which could negatively affect patients’ health from delaying treatment that can lead to complications, worsening of the condition, deterioration, or death. Findings: During an interview on May 5, 2025, at 3:15 PM, with the Chief Nursing Officer (CNO), the CNO stated, when patients come in by ambulance the nurse staff is responsible for putting them in a room and triaging them appropriately. The CNO further stated that if patients walk in, the admitting staff will register them and notify the nurse staff that patients are in the facility. The CNO stated the nurse is responsible for completing patients’ assessment. During an interview on May 5, 2025, at 3:55 PM, with Registered Nurse 2 (RN 2), RN 2 stated that when patients walk in through the door, they would stop at registration desk to check in and the nursing staff would triage them at bedside. RN 2 further stated, every patient would need to be triaged or assessed since it would help the nursing staff to determine the urgency of patients’ need. 1a. During a review of the facility’s document titled, “Ed Admission Report w/ [with] the CNO Disposition of Care” (ED Report), dated Nov 2024, through May 5th, 2025, the ED Report indicated, Patient 7 was admitted to the facility on December 31, 2024, at 11:00 PM, and left AMA on December 31, 2024, at 11:30 PM. During a concurrent interview and record review on May 6, 2025, at 10:00 AM, with the CNO, Patient 7’s “Emergency Department” (ED) document, dated December 31, 2024, was reviewed. The ED document indicated, Patient 7 was being “ ... evaluated status post accidental overdose ...” The CNO stated Patient 7 was not properly triage and assigned to the appropriate acuity level. During a review of Patient 7’s “Against Medical Advice” (AMA) form, undated, the AMA form indicated that Patient 7 signed on December 31, 2024, at 11:50 PM. 1b. During a review of the facility’s document titled, ED Report, dated Nov 2024, through May 5th, 2025, the ED Report indicated, Patient 25 was admitted to the facility on March 22, 2025, at 8:04 PM, and left AMA on March 22, 2025, at 8:15 PM. During a concurrent interview and record review on May 6, 2025, at 10:32 AM, with the Medical Record Manager (MDM), Patient 25’s ED document, dated March 22, 2025, was reviewed. The ED document indicated, Patient 25 came to the facility with the “chief complaint: right testicular pain”. The MDM stated Patient 25 was not assigned to the appropriate acuity level. During a review of Patient 25’s AMA form, dated March 22, 2025, the AMA form indicated that Patient 25’s parent signed on March 22, 2025, at 8:15 PM. 1c. During a review of the facility’s document titled, ED Report, dated Nov 2024, through May 5th, 2025, the ED Report indicated, Patient 27 was admitted to the facility on February 14, 2025, at 1:26 PM and left AMA on February 24, 2025, at 4:57 PM. During a concurrent interview and record review on May 6, 2025, at 10:40 AM with the MDM, Patient 27’s ED document, dated February 14, 2025, was reviewed. The ED document indicated, Patient 27 came to the facility with the “chief complaint: left foot swelling and numbness”. The MDM stated Patient 27 was not assigned to the appropriate acuity level. During a review of Patient 27’s AMA form, dated February 14, 2025, the AMA form indicated Patient 27 signed on February 14, 2025, at 4:57 PM. 2. During a review of the facility’s document titled, ED Report, dated Nov 2024, through May 5th, 2025, the ED Report indicated Patient 15 was admitted to the facility on January 30, 2025, at 3:07 PM and discharged home on January 30, 2025, at 6:30 PM. During a concurrent interview and record review on May 6, 2025, at 10:43 AM, with the CNO, Patient 15’s ED document, dated January 30, 2025, was reviewed. The ED document indicated, Patient 15 came to the facility with “Assessment/ Diagnoses: 1) Second-degree [damages the outer layer of skin and the underlying layer] partial thickness burn to the palmar aspect of the hand, 2) First degree [a minor burn that only affects the outermost layer of skin] burn to the anterior [front] aspect of the left thigh, 3) first in mild second-degree burn to the dorsal [relating to the back or posterior of a structure] aspect of the right thigh, 4) Left infraorbital ecchymosis [blue or purple discoloration of the upper and lower eyelids, which is a frequent symptom after traumatic injuries to the head and neck] ...” The ED document indicated Patient 15 was discharged to a local hotel. The CNO stated that Patient 15 was not properly triaged and assigned to the appropriate acuity level. During a review of the facility’s document titled, ED Report, dated Nov 2024, through May 5th, 2025, the ED Report indicated Patient 15 was readmitted to the facility on February 12, 2025, at 4:19 PM, and transferred to a mental health facility on February 12, 2025, at 7:00 PM. During a concurrent interview and record review on May 6, 2025, at 10:44 AM, with the MDM, Patient 15’s ED document, dated February 12, 2025, was reviewed. The ED document indicated, Patient 15 came to the facility with “Chief Complaint: agitation, alcohol intoxication” and was brought in by police officers. During a review of Patient 15’s “Discharge Instructions” (DC), dated February 12, 2025, the DC indicated, Patient 15 was “discharge to [Facility Name] Mental Health Facility”. 3. During a review of the facility’s document titled, ED Report, dated Nov 2024, through May 5th, 2025, the ED Report indicated Patient 26 was admitted to the facility on February 20, 2025, at 6:22 PM and was transferred to another facility on February 20, 2025, at 9:40 PM. During a concurrent interview and record review on May 6, 2025, at 10:36 AM, with the MDM, Patient 26’s ED document, dated February 20, 2025, was reviewed. The ED document indicated, Patient 26 came to the facility with “chief complaint: right inguinal hernia [a condition where part of the intestine or other abdominal tissue protrudes through a weak spot in the lower abdominal wall, known as the inguinal canal]”. The MDM stated Patient 26 was not assigned to the appropriate acuity level. During a review of the facility’s document titled, “interfacility Transfer Record and Physical,” dated February 20, 2025, Patient 26 was transferred to another facility at 9:40 PM. During a concurrent interview and record review, on May 6, 2025, at 5:09 PM, with the Acting CEO (ACEO), CNO, and Assistant Director of Nursing (ADON), the facility’s P&P titled “Triage- Patient Assessment,” dated October 3,2022, was reviewed. The P&P indicated, “ ...Patient’s shall be triaged upon entrance into the Emergency Department to determine the care treatment and serviced needed ...Patient shall be taken into the emergency department for treatment according to their acuity level ...” The ACEO, CNO, and ADON stated that the policy was not followed and should have been. The CNO stated, it is important to give a triage class because “it determines any emergent condition and if higher level of care is needed the triage class will help identify.””