Kern Valley Healthcare District

“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: 32946 Based on interview and record review the facility failed to ensure a Medical Screening Exam (MSE) was performed on one of 20 sampled patients (Patient 1), who presented to the hospital. This failure resulted in Patient 1 being turned away, transported to another hospital, and at risk for harm. Findings: During a review of Patient 1’s “[Local Ambulance company] Incident Status: Draft,” date of service 1/30/2025 at 02:39 (2:39 a.m.), indicated, “Rescue one was dispatchment for a seizure. EMS (emergency medical services) was already on scene of the call. The Patient [Patient 1] was just transported to Emergency room by this crew. The patient [Patient 1] was turned away from the emergency room and told to call 911 (emergency services) for tran (sic) Patient [Patient 1] was assisted onto the ambulance gurney and transported to [Hospital 2] (sic) was contacted enroute. Patient [Patient 1] was registered and taken to his assigned bed upon arrival to Hospital 2. Handoff report was given to the nurse receiving care of the patient [Patient 1] . . . Incident: [Hospital 1] Destination [Hospital 2] . . . At Patient: [Arrived Hospital 1] 01/30/2025 00:03:14 (12:03 a.m.) Depart [Hospital 1]: 01/30/2025 00:28 (12:28 a.m.) Arrived Dest [destination Hospital 2]: 01/30/2025 01:29 (1:29 a.m.) . . . “ During a record review of Patient 1’s “Physician Face Sheet,” for Hospital 2, dated 1/2025, indicated, “Admit Date time 01/30/2025 (1:39 a.m.). During an interview on 2/13/25 at 1:22 p.m. with Emergency Medical Technician (EMT) 1, EMT 1 stated, the date of the event was on 1/30/2025 at 3:24 a.m., with Patient 1. EMT 1 and crew were dispatched to Patient 1’s home for 911 call. Patient 1 was transported to Hospital 1. EMT 1 stated, “We showed up at Hospital 1 and the nurse and the doctor stated they would not be seeing the patient (Patient 1).” Medical Doctor (MD) informed him [Patient 1] needed to call 911 and leave the hospital [Hospital 1] again. EMT 1 stated, “We were inside the ER (emergency room), the patient was taken off the EMS gurney and placed on a hospital gurney. The Doctor (MD) and Registered Nurse (RN) 3 were present. EMT 1 stated, “That’s when MD said informing the patient [Patient 1] he would need to contact 911 himself to be transported to another hospital.” EMT 1 stated, “The patient did what the doctor [MD] said informing the patient [Patient 1] he would need to travel “X” many yards off the hospital [Hospital 1] property.” During an interview on 2/18/25 at 11:12 a.m. with EMT 2, EMT 2 stated, they were trying to exit the emergency room after dropping off a patient. The crew [EMT 1] had come in with him [Patient 1] on the gurney. RN 3 and MD were in the triage entrance (ambulance entrance into emergency room) with EMT 1. RN 3 stopped them [EMT 1] and asked why the patient [Patient 1] was not taken to Bakersfield. EMT 1 informed RN 3 the patient [Patient 1] had requested (sic). RN 3 directed EMT 1 to place Patient 1 in room one A. MD stated, “They were not going to check Patient 1 into the ED (Emergency Department), Patient 1 was supposed to go to Bakersfield because they had previously taken care of everything for him [Patient 1] that day.” EMT 2 stated, we could not leave the hospital because of the incident going on in front of us. EM T 2 stated Patient 1 remained on the ambulance gurney. MD informed Patient 1 that when he [Patient 1] calls 911, to request one of three hospitals. EMT 2 stated she saw MD hand Patient 1 a sticky note with Hospital 2, Hospital 3, and Hospital 4 names written down. EMT 2 returned to the ambulance, and Patient 1 was walking out of the ED ambulatory entrance. EMT 2 stated, 10 to 15 minutes later she heard the call 10:15 (code to transport patient) to hospital. During a review of the facility documentation titled “Physician Schedule,” dated January 2025, indicated, “Thursday 30th [2025] ER pm [MD]. MD scheduled to work on 1/30/25 in the emergency room at Hospital 1. During an interview on 2/19/25 at 12:22 p.m. with MD, MD stated, “He (Patient 1) came in on 1/30/25 for possible Seizure and was discharged. Patient 1 returned later. MD stated Patient 1 might have been given a list of all hospital he could go if he wanted to. 29618 During an interview on 2/19/25 at 11:29 a.m. with Registered Nurse (RN) 1, RN 1 stated she heard about a patient being turned away twice. RN 1 stated she was told that Medical Doctor (MD) stopped the patient at the ER (emergency room) door, and told the patient to call 911 to go to Bakersfield. RN 1 stated she was told the patient was one of the hospitals “frequent flyers.” During an interview on 2/19/25 at 11:50 a.m. with RN 2, RN 2 stated “At times the assessment is done before triage, and the patient is told to go to Bakersfield.” RN 2 stated “MD is good for sending people away at the door.” RN 2 stated he (MD) will make staff call EMS (Emergency Medical Services) to tell them not to come. During a review of the facility’s policy and procedure (P&P) titled, Emergency Medical Treatment and Active Labor (EMTALA),” dated 11/2/16, indicated, “The admitting clerk will notify the appropriate triage nurse of all complaints and document. . . 2. Ambulance patient arrivals: a. Patients will be assessed by an ER/triage nurse and placed in an appropriate treatment area. The triage category will be assigned. B. The admitting clerk will come to the bedside and complete the demographic information excluding insurance information. 3. A patient’s insurance information will be requested with the MSE (Medical Screening Examination) is completed and order is flagged authorizing the information. B. Triage: 1. The admitting clerk will be notified of the location of all patients after the triage is completed. C. Medical Screening Exam: The hospital will provide a Medical Screening Exam (MSE) for every person who some to the Emergency Department and requests medical treatment. Within the capability of the Emergency Department, the screening examination will determine whether or not an Emergency Medical Condition (EMC) exists.””

“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: 32946 Based on interview and record review the facility failed to ensure three of three staff (Registered Nurse (RN) 3, RN 4, and Respiratory Therapist [RT]) and Emergency Department Physicians were provided Emergency Medical Treatment and Labor Act (EMTALA - emergency room regulations) training. This failure resulted in staff not being provided EMTALA training. Findings: During a concurrent interview and record review 2/18/25 at 3:38 p.m. with, Health Information Management (HIM) 1, HIM 1 provided the Education transcripts for RN 3. No EMTALA education training documentation was found in the training to indicated RN 3 had been provided training. During a concurrent interview and record review 2/18/25 at 3:40 p.m. with HIM 1, HIM 1 provided the Education transcripts for RN 4. No EMTALA education training documentation was found in the training to indicated RN 4 had been provided training. During a concurrent interview and record review 2/18/25 at 3:42 p.m. with HIM 1, HIM 1 provided the Education transcripts for RT. No EMTALA education training documentation was found in the training to indicated RT had been provided training to indicated staff had been provided training. During an interview on 2/19/2025 at 11:59 a.m. with Chief Nursing Officer (CNO), CNO stated, “EMTALA [training] has not been required, but were going to start.” 29618 During an interview on 2/19/25 at 12:07 p.m. with Learning Management System (LMS), LMS stated the ED (Emergency Department) Physicians have not had EMTALA training. “We don’t have record of any EMTALA training for our Physicians.””

“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: 29618 Based on interview and record review, the hospital failed to ensure the Physician Certification Statement for Ambulance Services (PCSAS) was completed for one of three sampled patients (Patient 14) was completed. This failure had the potential to result in inaccurate information. Findings: During a concurrent interview and record review on 2/19/25 at 9:00 a.m. with Health Information Management Manager (HIMM), Patient 14’s Electronic Medical Record (EMR) for date of service 10/4/24 was reviewed. The EMR indicated Patient 14 was transferred to another hospital on 10/4/24. The PCSAS was not completely filled out, and was missing the following information on the form: Section I - Receiving Physician NPI (National Provider Identifier) Section II - #2 Describe the Medical Condition. . . (section was blank), #4 Can this patient safely be transported. . . Yes or No (not marked) The page with heading “Please fill in all appropriate information and check off each section before transferring patient.” was missing the following information: Is PCS filled in accurately and signed by an authorized individual? Y or N (not marked) Form completed by: (section was blank) During an interview on 2/19/25 at 9:02 a.m. with HIMM, HIMM stated “We have the provider hospital, but we don’t have the number.” HIMM confirmed the PCSAS form was incomplete. A Policy and Procedure for Physician Certification was requested, and not provided.”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 42148 Based on interview and record review, the facility failed to ensure confidential patient information was safeguarded for two of two sampled patients (Patient 1 and Patient 2) when Patient 1 was treated under Patient 2’s name. This failure resulted in Patient 1 receiving the wrong physical therapy treatment and Patient 2 having her confidential information provided to another patient. Findings: During an interview on 10/28/24 at 12:55 p.m. with Privacy Officer (PO), PO stated on 6/17/24, Rehab Care Coordinator (RCC 1) took a 3-way call from Patient 1’s insurance company and Family Member (FM) 1 to schedule a physical therapy session. PO stated Patient 2’s information was used to book an appointment for Patient 1 on 6/18/24. PO stated, on 6/18/24, FM 1 showed up at the appointment with Patient 1. RCC 1 presented paperwork to FM 1 with Patient 2’s name on it and FM 1 signed it. Staff did not talk to Patient 1 to verify the name and date of birth (DOB). PO stated the Physical Therapy Assistant (PTA) 1 that did Patient 1’s physical therapy also did not verify Patient 1’s name and DOB. PO stated “It wasn’t until further investigation the next day that they [the facility] realized they had given physical therapy to a patient [Patient 1] with the wrong name [Patient 2].” PO stated “We are the verifiers, not the patient.” PO stated Patient 1 had not been a patient at the facility before, but Patient 2 had. During an interview on 10/28/24 at 1:10 p.m. with RCC 1, RCC 1 stated On 6/18/24, she provided FM 1 with Patient 2’s information when they arrived for their physical therapy appointment and FM 1 signed it. RCC 1 stated staff never spoke to Patient 1 to verify name or DOB. RCC 1 stated she also scheduled Patient 1 another follow-up appointment using Patient 2’s name and gave the information to FM 1. RCC 1 stated she should have spoken to Patient 1 directly and verified identification, name, and DOB. RCC 1 stated, “we should have done better.” During an interview on 10/28/24 at 1:20 p.m. with PTA 1, PTA 1 stated she did physical therapy with Patient 1 on 6/18/24. PTA 1 stated the patient chart she got from the front desk had Patient 2’s information and physical therapy evaluation order (PTE). PTA 1 stated she did not ask Patient 1 her name and DOB. PTA 1 stated the PTE was for leg and back pain. PTA 1 stated FM 1 seemed confused and told her “she [Patient 1] is here to do exercises, why aren’t you doing that?” PTA 1 stated she thought it was confusing. PTA 1 stated Patient 1 did not speak during the session and “I never check DOB or name, that is up to the front desk staff.” During an interview on 10/28/24 at 2:38 p.m. with Physical Therapy Manager (PTM), PTM stated she was called to the physical therapy department on 6/18/24. PTM stated when she got to the department, she was told the patient was Patient 2. PTM stated FM 1 told her that Patient 1 was just seen in the emergency room (ER). PTM stated that didn’t make sense to her because Patient 2’s chart did not reflect a recent ER visit. PTM stated it wasn’t until the next day that the staff realized they had the wrong chart, and that the real patient was Patient 1 NOT Patient 2. PTM stated “I understand we didn’t do our part.” PTM stated Patient 1 consented for FM 1 to review her PTE. PTM stated FM 1 was concerned about the date of the evaluation because Patient 1 was admitted in the hospital at that time and didn’t have a PTE. PTM stated FM 1 “looked at the evaluation and stated it was incorrect because [Patient 1] was never made to walk and that the evaluation was [made up].” PTM stated she looked in the system and couldn’t find that Patient 1 was in the hospital recently. PTA stated after investigating further, it was discovered that the evaluation they were looking at and gave to FM 1 was for Patient 2 not Patient 1. FM 1 then confirmed the wrong name. PTM stated that Patient 1 had never had PT before, and FM 1 was given the wrong evaluation. PTM stated FM 1 went home with Patient 2’s paperwork and the facility had to call him and ask him to return the documents. During a concurrent interview and record review on 10/28/24 at 2:50 p.m. with PO, The PTM, PTA, and RCC 1’s, “Statement of Confidentiality/Computer and Information Usage Agreement (SCCIA),” was reviewed. The SCCIA indicated, “[Name of Facility] considers maintaining the security and confidentiality of protected health information a matter of its highest priority. All aspects involving the collection, review, and evaluation of patient/resident care information are confidential. Each person accessing data and resources holds a position of trust relative to this information and must recognize the responsibilities entrusted in preserving the security and confidentiality of this information.” The SCCIA was signed by PTM on 5/31/24, PTA 1 on 8/3/20, and RCC 1 on 3/6/18. PO stated that by signing this agreement PTM, PTA 1 and RCC 1 should of not allowed this incident to happen. During a review of the hospital’s policy and procedure (P&P) titled, “Confidential Information,” dated 11/29/2011, the P&P indicated, “all information of medical or business nature concerning patients, residents, families, doctors or employees, retained either electronically or on paper, is considered strictly confidential and personal. Under no circumstances will such information be discussed with unauthorized persons either inside or outside [name of hospital]. . . Any unauthorized release of disclosure of confidential information will result in corrective action according to hospital policy and procedure. . . A. Because confidentiality of patient, residents and employee information is so important, it is covered in both the new employee orientation and in yearly re-orientation completed during the employees annual evaluation. . .””