Montrose Regional Health

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52761 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0115 The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure patients were assessed according to facility policy. This failure was identified in two of two emergency department (ED) patients’ medical records reviewed. (Patient #1 and #2)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 52761 Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure patients were assessed according to facility policy. This failure was identified in two of two emergency department (ED) patients’ medical records reviewed. (Patient #1 and #2) Findings include: Facility policies: The Assessment and Reassessment of Patients While in the Emergency Room policy read, focused assessments shall be performed at transfer of care, with change in patient condition, and at a minimum every two hours for patients with an emergency severity index (ESI) (tool used to categorize patients based on their severity) of 3 (urgent). Additionally, reassessments shall be performed following medication administration to assess the patient’s response. The Fall Prevention Outpatient policy read, neurological assessments (assesses the brain, spinal cord, and nerves) shall be performed immediately after a patient falls, then every 15 minutes for one hour, and then every hour for four hours or until the patient is discharged or transferred. 1. The facility failed to ensure ED patients were assessed according to facility policy. A. Document Review i. Review of Patient #1’s medical record revealed Patient #1 presented to the facility on 10/25/25 at 11:18 a.m. with injuries to their right leg and hip after a fall at home. A triage assessment at 11:20 a.m. revealed Patient #1 was assigned an ESI of 3 (urgent). At 11:25 a.m., the registered nurse’s (RN) assessment revealed Patient #1 had bruises and abrasions on the back of their arms, skin tears on their toes, a wound on their right hip, and a swollen and externally rotated right leg (indicates fracture near the hip and upper thigh). Between 1:15 p.m. and 1:21 p.m., x-rays of Patient #1’s pelvis, right hip, and right femur (thigh bone) were completed and revealed Patient #1 had a right comminuted intertrochanteric fracture (a severe fracture where the upper thigh bone shatters into three or more pieces, rather than snapping in two). A note from the RN revealed Patient #1 fell when staff attempted to transfer them from the stretcher to the x-ray table. At 3:06 p.m., the RN documented an assessment of Patient #1’s Glasgow Coma Scale (tool used during a neurological assessment to assess a patient’s level of consciousness based on the patient’s ability to open their eyes, speak, and move). At 3:09 p.m., Patient #1 was transferred to an outside facility for continued care. The medical record failed to reveal further assessments of Patient #1’s neurological status (pupillary reaction to light and size and shape of pupils), or ongoing assessments of Patient #1’s musculoskeletal system (joint swelling, tenderness, and pain, and limb movement) or wounds after the initial assessment at 11:25 a.m. This was in contrast to the Assessment and Reassessment of Patients While in the Emergency Room policy, which revealed focused assessments should have been performed at transfer of care, with change in patient condition, and at a minimum of every two hours for patients with an ESI of 3. This was also in contrast to the Fall Prevention Outpatient policy, which revealed neurological assessments were to be performed immediately after a patient fell, every 15 minutes for one hour, and then every hour for four hours or until the patient was discharged or transferred. Further review of Patient #1’s medical record revealed Patient #1’s pain level at 12:00 p.m. was 10/10 (severe). At 12:22 p.m., Patient #1 received 15 mg of intravenous (IV) ketorolac (pain medication). Patient #1 received 0.5 mg of IV dilaudid (pain medication) at 1:49 p.m. and 2:22 p.m. The medical record failed to reveal assessments of Patient #1’s pain following the administrations of ketorolac or dilaudid. This was in contrast to the Assessment and Reassessment of Patients While in the Emergency Room policy, which revealed reassessments were to be performed following medication administration to assess the patient’s response. ii. Review of Patient #2’s medical record revealed Patient #2 presented to the facility on 10/14/25 at 12:35 p.m. with an infected foot wound. Patient #2 had a right toe amputation on 7/23/25 due to osteomyelitis (bacterial infection of the bones). A triage assessment at 1:36 p.m. revealed Patient #2 was assigned an ESI of 3. At 2:05 p.m., the RN’s assessment revealed Patient #2 had redness surrounding a wound on their right foot. At 5:49 p.m., Patient #2 was admitted to the hospital due to concerns for cellulitis (bacterial skin infection). The medical record failed to reveal ongoing assessments of Patient #2’s wound during their five hours and 14 minutes in the ED, and prior to their transfer to the inpatient unit. This was in contrast to the Assessment and Reassessment of Patients While in the Emergency Room policy, which revealed focused assessments were to be performed at transfer of care and at a minimum of every two hours for patients with an ESI of 3. B. Interviews i. On 2/24/26 at 11:29 a.m., an interview was conducted with RN #2. RN #2 stated pain was reassessed 30 minutes after a patient received IV pain medication. This was in contrast to review of Patient #1’s medical record, which failed to reveal reassessments of Patient #1’s pain following the administration of IV ketorolac and dilaudid. ii. On 2/25/26 at 2:11 p.m., an interview was conducted with RN #3. RN #3 stated it was important to reassess a patient’s pain following the administration of pain medication to determine if the treatment was effective. Additionally, RN #3 stated patients were assessed upon arrival to the ED or with changes in their condition. This was in contrast to the Assessment and Reassessment of Patients While in the Emergency Room policy, which revealed focused assessments were also to be performed at transfer of care, and at a minimum of every two hours for patients with an ESI of 3. RN #3 stated patients were reassessed on an ongoing basis to monitor for changes in condition and to evaluate their response to treatments. RN #3 explained staff would not be able to recognize a patient’s deteriorating status if they had not performed ongoing assessments of the patient. Furthermore, RN #3 stated focused assessments of the patient’s wounds, musculoskeletal system, and neurological system were performed immediately after a fall to identify new injuries caused by the fall, and to determine if immediate medical intervention was required. RN #3 stated ongoing reassessments of the patient were performed because some injuries might not be apparent immediately, or could become more severe over time. This was in contrast to review of Patient #1’s medical record, which failed to reveal an assessment of Patient #1’s wounds, musculoskeletal system, or neurological system immediately after Patient #1’s fall, or on an ongoing basis prior to their transfer from the facility. iii. On 2/25/26 at 2:33 p.m., an interview was conducted with Director #4. Director #4 stated patients in the ED were reassessed at ongoing intervals based on their ESI score. Director #4 explained it was important to reassess patients to evaluate how they responded to treatments and to monitor their condition. Director #4 stated staff would not know if a patient’s condition was deteriorating if they did not perform focused reassessments. This was in contrast to review of Patient #1 and Patient #2’s medical records, which failed to reveal ongoing focused reassessments. Furthermore, Director #4 stated the RN reassessed patients following changes in condition. Specifically, Director #4 stated focused reassessments should have been performed at ongoing intervals after Patient #1’s fall to evaluate for new or worsened injuries, to ensure patient safety, and to determine if the patient required pain medication or other interventions. iv. On 2/26/26 at 3:49 p.m., an interview was conducted with Physician #5. Physician #5 stated it was important to frequently reassess a patient’s neurological status after a fall to monitor for intracranial hemorrhage (brain bleed), which could be fatal. Furthermore, Physician #5 stated repeat assessments were performed because complications like intracranial hemorrhage might not present immediately.”

“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: 46674 Based on observation, interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements. FINDINGS 1. The facility failed to meet the following requirements under the EMTALA regulations: Tag 2408: §489.24(d)(4),(5)(4) Delay in Examination or Treatment.(i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status.(ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual ’ s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.(iii) An emergency physician or non-physician practitioner is not precluded from contacting the individual ’ s physician at any time to seek advice regarding the individual ’ s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section.(iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. Based on observations, interviews, and document reviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment for a patient who sought emergency care. (Patient #5)”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 46674 Based on observations, interviews, and document reviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment for a patient who sought emergency care. (Patient #5) Findings include: Facility policies: The Obstetrics (OB) Patients Presenting to the emergency department (ED) policy read, patients who are presenting to the ED who are over 20 weeks gestation with OB complaints will register with ED admissions and will go straight up to the Family Center. The EMTALA Compliance policy read, reasonable registration processes may be implemented and may include asking whether the individual has insurance and the name of the insurer so long as these procedures do not delay the screening examination or necessary stabilizing treatment. Labor means the process of childbirth beginning with the latent or early phase and continuing through the delivery of the placenta. For purposes of this policy, a woman is in “true” labor unless a physician or qualified medical person certifies, after a reasonable period of observation, that she is in false labor. Reference: The Patient Access Representative job description read, the patient access representative is a non-clinical staff member. Required education, high school graduate or equivalent. 1. The facility failed to ensure the registration process did not delay examination and treatment for a pregnant patient who sought emergency care. a. Medical record review revealed Patient #5 was a 27 year old, 39 weeks and 6 days pregnant patient who presented to the facility on 8/22/24 at 9:48 a.m. Nursing documentation revealed Patient #5 presented to the family center (obstetrics department) at 10:00 a.m. and reported she had blood in the toilet with clots at 2:00 a.m. and was unsure if her water had broken. A fetal heart rate was not present and Patient #5 was diagnosed with suspected placental abruption (separation of the placenta from the wall of the uterus) and fetal demise (death). b. On 9/24/24 at 11:35 a.m., ED lobby video footage was reviewed and revealed Patient #5 approached the ED registration desk on 8/22/24 at 9:37 a.m. Patient #5 remained at the registration desk until she was escorted by staff out of camera view at 9:55 a.m.,18 minutes later. This was in contrast to the EMTALA Compliance policy which read, reasonable registration processes may be implemented as long as these procedures did not delay the screening examination or necessary stabilizing treatment. c. On 9/25/24 at 2:08 p.m., an interview was conducted with patient access representative (PAR) #1, who registered Patient #5. PAR #1 stated the registration process took 18 minutes because she was a new employee and was being trained. PAR #1 stated when patients greater than 20 weeks pregnant presented to ED registration for unscheduled care, they were registered as a clinical outpatient and a long registration was completed. PAR #1 stated the long registration included more steps than the short registration which was utilized for ED patients. d. On 9/25/24 at 8:00 a.m., observations were conducted in ED registration. Observations revealed patients who requested to be seen in the ED were registered using a short registration process. Patients were asked to verify their name, date of birth, preferred language, primary care provider, chief complaint, and a copy of their drivers licenses was obtained if it was not in the computer system. Observations of the PAR’s computer registration system revealed the long registration contained additional fields, which included guarantor, insurance, contact, provider, demographics, and employer information. e. On 9/25/24 at 1:15 p.m., an interview was conducted with PAR #2, who trained PAR #1 on 8/22/24 when Patient #5 presented to the facility for care. PAR #2 stated Patient #5 informed them her water had possibly broken and she denied having contractions. PAR #2 stated she thought they had collected Patient #5’s insurance card, but was not certain if this had occurred. PAR #2 stated the current process for when individuals greater than 20 weeks pregnant arrived was to register them as a clinical outpatient and their driver’s license and insurance information was collected and scanned into the computer before they were sent to the family center. PAR #2 stated this was the process they were trained to perform. PAR #2 stated the process to generate the OB assess clinical outpatient record took longer than the process to generate a record for an ED patient. PAR #2 stated they were not able to evaluate or assess patients because they were not clinical staff. PAR #2 stated insurance information was not collected for serious, laboring patients. PAR #2 stated laboring patients were sent to the family center to not delay their treatment. PAR #2 stated they asked patients if they felt like they needed to push and they could tell if patients were or were not in distress. This was in contrast to the PAR job description which read, the PAR was a non-clinical staff member. This was also in contrast to the EMTALA Compliance policy which read, reasonable registration processes may be implemented and may include asking whether the individual had insurance and the name of the insurer so long as these procedures did not delay the screening examination or necessary stabilizing treatment. A woman was in “true” labor unless a physician or qualified medical person certified, after a reasonable period of observation, that she was in false labor. f. On 9/30/24 at 1:09 p.m., an interview was conducted with director of patient access (Director) #3. Director #3 stated staff should register OB patients greater than 20 weeks the same way as ED patients. Director #3 stated due to the nature of the computer system, for OB patients, staff were required to tab through and not complete the fields of the long registration to register the patients faster. Director #3 stated staff should not have been accepting insurance information. Director #3 stated staff were trained to tab through the fields during their training phases, but stated the facility did not have the training documented. This was in contrast to the interview with PAR #2, who stated they were trained to complete the long registration fields and collect insurance information for all family center patients who were not in labor and sent directly to the family center. Additionally, Director #3 stated the expected time frame to register a late term patient with bleeding and blood clots should have been one to three minutes. Director #3 stated staff asked patients how far along their pregnancy was, their presenting complaint, if their water had broken, and if they were having contractions. Director #3 stated if a patient came to the facility pushing, they would be sent directly to the family center and a short registration would be completed. Furthermore, Director #3 stated they did not know why it was important not to delay treatment because they were not clinical staff. This was in contrast to the EMTALA Compliance policy which read, a woman was in “true” labor unless a physician or qualified medical person certified, after a reasonable period of observation, that she was in false labor. g. On 9/30/24 at 11:22 a.m., an interview was conducted with certified nurse midwife (CNM) #4. CNM #4 stated there were many medical emergencies other than labor which could occur in patients greater than 20 weeks pregnant. CNM #4 stated vaginal bleeding in patients greater than 20 weeks could have indicated labor, placental abruption, uterine rupture (a tear in the muscular wall of the uterus), or a placenta previa (a pregnancy complication that occurs when the placenta partially or completely covers the opening to the birth canal). CNM #4 stated no one other than a provider or an OB nurse could determine if these patients were experiencing a medical emergency. CNM #4 stated it was important not to delay treatment in these patients, as staff needed to act quickly to not compromise the health of the mother and the baby.”