Centura Health-St Anthony Hospital

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47959 Based on interviews and document reviews, the facility failed to ensure staff assessed an implantable port (a device placed under the skin of the chest used to deliver medications into the vein) according to facility policy and deaccessed (removed) the port connection prior to a patient’s discharge in one of one patient reviewed with an implantable port. (Patient #2) Findings include: Facility policy: The Intravenous and Central Venous Catheters policy read, central venous catheters (CVCs) (implantable ports) will be assessed at insertion, at least once per shift, with each use, with site care and dressing change, with discontinuation, and PRN (as needed) for signs and symptoms of infection and other complications. Documentation includes the date, time, and flush (injecting a solution to prevent clotting into the port) at the time of deaccessing the port. 1. The facility failed to ensure staff assessed an implantable port according to facility policy, and deaccessed the implantable port prior to a patient’s discharge. a. Medical record review revealed Patient #2 was admitted on 2/16/26 with altered mental status. Patient #2 had an implantable port placed in their right internal jugular (neck) vein for chemotherapy treatment (medication used to stop the growth of cancer cells) prior to admission. A physician order set was entered on 2/19/26 at 1:27 p.m. to access the port, to flush the port with heparin (medication to prevent blood clotting) before the port was deaccessed, and to deaccess the port. Patient #2’s implantable port was accessed by staff on 2/19/26 at 4:00 p.m., without evidence of a port assessment for the day shift or night shift. Additionally, the medical record failed to reveal port site assessments on the day shifts of 2/21/26 or 2/22/26. Patient #2 was discharged home on 2/22/26 at 3:00 p.m., however, the medical record failed to reveal evidence staff had flushed or deaccessed Patient #2’s port prior to discharge. This was in contrast to the provider’s orders on 2/19/26 at 1:27 p.m., which instructed staff to flush the port with heparin before the port was deaccessed, and for staff to deaccess the port. This was also in contrast to the Intravenous and Central Venous Catheters policy which read, the CVC should have been assessed at least once per shift. b. On 5/5/26 at 8:41 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated staff should have assessed the implantable port site at least every shift and as needed. RN #1 stated staff could not access or deaccess implantable ports without training. RN #1 stated trained staff from the oncology unit were called to assist with ports when the nurse did not have training to manage the port. RN #1 stated they deaccessed ports when the port was no longer needed or at the time of discharge. RN #1 stated patients were at risk for infection or injury when staff did not assess the port or ensure it was deaccessed prior to discharge. c. On 5/5/26 at 9:27 a.m., an interview was conducted with nurse manager (Manager) #2. Manager #2 stated staff were assigned online competencies for CVC management, which included implantable ports. Manager #2 stated not all nurses had received the training, and charge nurses who made staff assignments did not know which nurses had completed the training. Manager #2 stated the RN who discharged Patient #2 had not received the CVC training, and was unaware of the process to ask a trained oncology nurse to assist with the port management. Manager #2 stated patients with ports were rarely admitted to the unit and most of the staff on the unit were unaware of the process to seek the help of trained oncology nurses for port management. Manager #2 stated patients were at risk for infection or injury when staff did not know how to deaccess ports prior to discharge.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. 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, §482.23 NURSING SERVICES, was out of compliance. A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document reviews, the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient. Specifically, the facility failed to ensure nursing staff conducted assessments, reassessments, and vital signs monitoring in accordance with facility policy. This failure was identified in seven of twenty patients who received care in the emergency department (ED) (Patients #1, #8, #9, #10, #11, #12, and #13). Additionally, the facility failed to ensure alterations to patients’ skin integrity were appropriately assessed and documented in two of six inpatient medical records reviewed (Patient #1 and Patient #6). Furthermore, the facility failed to ensure a patient who was at-risk for pressure injuries received interventions to prevent skin breakdown in one of six inpatient medical records reviewed. (Patient #6)”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 52761 Based on interviews and document reviews, the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient. Specifically, the facility failed to ensure nursing staff conducted assessments, reassessments, and vital signs monitoring in accordance with facility policy. This failure was identified in seven of twenty patients who received care in the emergency department (ED) (Patients #1, #8, #9, #10, #11, #12, and #13). Additionally, the facility failed to ensure alterations to patients’ skin integrity were appropriately assessed and documented in two of six inpatient medical records reviewed (Patient #1 and Patient #6). Furthermore, the facility failed to ensure a patient who was at-risk for pressure injuries received interventions to prevent skin breakdown in one of six inpatient medical records reviewed. (Patient #6) Findings include: Facility policies: The Nursing Standards of Practice - Emergency Department policy read, the emergency registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. “Develops a plan” starts with documenting the chief complaint, history, vital signs and clinical presentations. This continues with the patient assessments and reassessments. These standards of practice do not replace clinical judgment but represent minimal, safe standards. All ED patients will have a focused assessment appropriate to the reason for visit. All patients in the ED are reassessed as warranted by Emergency Severity Index (ESI) acuity and presentation, including a complete set of vital signs and pain assessment. The Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy read, the purpose is to outline the standards of care for assessment, reassessment, vital signs and procedures to document and maintain an accurate record of the patients’ assessments, progress, treatments, medications, and condition. Reassessment of the hospitalized patient is a continuous, ongoing process. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes as determined by the caregiver. For ESI Level 1 - Life Threatening patients, an initial physical assessment is completed within 30 minutes and vitals are taken every 5-15 minutes based on patient condition, minimum every hour times four, then every two if clinically stable. For ESI Level 2 - Emergency patients, an initial physical assessment is completed within 30 minutes and ongoing vital signs are completed at minimum every hour times four, then every two hours if clinically stable. For ESI Level 3 - Urgent patients, an initial assessment will be completed within one hour and ongoing vital signs will be completed as follows: patients with normal vital signs at minimum every four hours. Patients with abnormal vital signs at minimum every two hours times four, then every four hours if clinically stable. For ESI Level 4 - Nonurgent patients, ongoing vital signs are completed at minimum every 4 hours & as needed (PRN) based on patient condition 1 hour prior to transfer or discharge from the unit. The Pain Management policy read, the provision and documentation of pain assessment and reassessment is driven by the scope of care, treatment, services provided and is based on individual patient assessment and interventions. Assess pain upon admission, during and after any known pain producing event, with each new pain producing event, and per unit protocol. Pain reassessment timeframe and/or interval is based on patient assessment and knowledge of the onset and peak effect of the intervention provided. Documentation of reassessment will be within 2 hours of pain interventions. Monitor for side effects of opioid medications including constipation, nausea, vomiting, and pruritus. Monitor for adverse effects of opioid medication including sedation and respiratory depression. According to the Hospital-Acquired Pressure Injury (HAPI) Prevention, Assessment and Documentation policy, the Braden Scale for Predicting Pressure Injury Risk was a validated and reliable tool that assessed the patient’s level of risk for skin breakdown based on the following six categories: sensory perception, skin exposure to moisture, activity level, mobility, nutritional intake, and exposure to friction and shear. The lower the score, the higher the risk for skin breakdown. The subscales measured functional capabilities of the patient that contributed to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A Braden Score of less than or equal to 18 indicated a risk for pressure injury development. Pressure injury prevention strategies were implemented for adult patients with a Braden Scale score of less than or equal to 18, or a subscale component less than or equal to two. All Registered Nurses (RNs) on inpatient nursing units initiated the HAPI protocol and requested a consult for wound care for any patient with a Braden Score less than or equal to 18. A pressure injury was localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury could be present as intact skin or an open ulcer and may be painful. The injury occurred as a result of intense and/or prolonged pressure combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. The RN assessed risk factors for development of pressure injuries and performed the Braden Scale and a head-to-toe skin assessment within four hours of admission, within four hours of the start of each shift, upon transfer from another unit or department, upon discovery of a suspected pressure injury, and with a change in patient condition. Integumentary assessment included color, temperature, texture/turgor, integrity, moisture, and edema. The RN implemented prevention strategies for patients identified to be at risk for pressure injury development based on risk factors and the risk assessment tool. Prevention strategies included skin care to maintain skin integrity, such as the application of moisture barrier products and the use of silicone multi-layer foam dressings on areas of high risk (e.g., sacrum, heels and other bony prominences). If Braden mobility subscale score less than or equal to two, the RN repositioned the patient at least every four hours or more frequently based on patient risk factors (e.g., skin and tissue tolerance, medical condition, comfort and pain), level of activity, and ability to independently reposition. The RN completed documentation to include a Braden Scale risk assessment and head-to-toe skin assessment. Photography, which included visible patient identifiers (e.g., medical record number, identification number, name), measurement device, and date captured for each photograph of a pressure injury or wound, was to be included in documentation upon discovery of a pressure injury or wound, weekly, with any change in patient or wound status, and prior to discharge. According to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy, nursing staff in the intensive care unit (ICU) performed a focus reassessment of systems every four hours and as needed per patient condition. 1. The facility failed to ensure nursing staff performed assessments, reassessments, and monitored vital signs for ED patients. A. Document Review i. A review of Patient #1’s medical record revealed Patient #1 presented to the ED on 4/15/25 at 10:19 a.m. with a chief complaint of a fall. Nursing staff triaged Patient #1 as an ESI Level 4. The provider’s note filed on 4/15/25 at 1:23 p.m. revealed Patient #1 took the medication Eliquis (used to reduce the risk of forming a blood clot, which increases a patient’s risk for bleeding). In the ED, Patient #1 was diagnosed with multiple left-sided rib fractures (broken bones) and a hemothorax (a condition where blood collects between the chest wall and the lungs and can cause respiratory failure). The ED Care Timeline revealed nursing staff assessed Patient #1’s vital signs on 4/15/25 at 10:28 a.m., as part of the triage process. Patient #1’s vital signs were not re-assessed until 3:50 p.m., five hours and twenty-two minutes later. This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, vital signs should have been assessed at a minimum of every four hours and PRN, based on patient condition. The ED Care Timeline also revealed Patient #1 rated their pain level in triage as an eight out of 10. Tylenol 650 milligrams (mg) was administered at 12:07 p.m. Nursing staff did not reevaluate Patient #1’s pain level in the ED after pain medication had been administered. Patient #1 was transferred to the Med Surg Trauma unit at 4:24 p.m. This was in contrast to the Pain Management policy which read, documentation of reassessment should have been within 2 hours of pain interventions. ii. A review of Patient #8’s medical record revealed Patient #8 presented to the ED on 7/9/25 at 7:57 p.m. with a chief complaint of left sided facial numbness and weakness. Nursing staff triaged Patient #8 as an ESI level 2 (emergency). At 8:16 p.m., the provider ordered vital signs to be assessed every 15 minutes for one hour, and then every hour once stable, with continuous pulse oximetry monitoring, continuous cardiac monitoring, and neurological assessments every 30 minutes for one hour, and then hourly. Patient #8 was diagnosed with a transient ischemic attack (a temporary blockage of blood flow to the brain). The ED Care Timeline revealed nursing staff performed a neurological assessment and an assessment with the National Institutes of Health (NIH) stroke scale (a tool to determine neurological deficits) on 7/9/25 at 8:06 p.m. There were no further neurological assessments completed in the ED until 7/10/25 5:15 a.m., nine hours and nine minutes later. This was in contrast to the provider’s order which instructed staff to perform neurological assessments every 30 minutes for one hour, and then hourly. The ED Care Timeline revealed nursing staff assessed Patient #8’s vital signs on 7/9/25 at 8:30 p.m., 9:00 p.m.,10:50 p.m., and 11:00 p.m. There were no additional vital signs assessed until 7/10/25 at 3:00 a.m., four hours later. There was no evidence in the ED Care Timeline of continuous pulse oximetry and cardiac monitoring for Patient #8. This was in contrast to the provider’s order for vital signs to be assessed every 15 minutes for one hour, and then every hour once stable, with continuous pulse oximetry monitoring, and continuous cardiac monitoring. This was also in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 2 - Emergency patients ongoing vital signs should have been completed at a minimum of every hour times four, and then every two hours if clinically stable. iii. A review of Patient #9’s medical record revealed Patient #9 presented to the ED on 6/13/25 at 3:00 a.m. with a chief complaint of vomiting blood and syncope (a temporary loss of consciousness that follows a drop in blood flow to the brain). The provider’s note revealed Patient #9 had vomited an estimated two units of blood prior to arrival. Patient #9 had a history of esophageal varices (swollen veins in the esophagus that can rupture and cause massive bleeding) and portal hypertension (high blood pressure in the portal vein that runs through the liver). Nursing staff assessed Patient #9’s heart rate of 88 (normal is 60-100) beats per minute at 3:06 a.m., and assessed Patient #9’s blood pressure of 77/55 (normal is 120/80) at 3:10 a.m. Nursing staff triaged Patient #9 as an ESI level 1 (life threatening) at 3:11 a.m. No additional vital signs were assessed until 4:00 a.m., 50 minutes later. At 3:53 a.m. nursing staff administered 500 milliliters (ml) of packed red blood cells via Massive Transfusion Protocol (a rapid blood administration protocol used in cases of massive bleeding). Nursing staff assessed vital signs every five to 10 minutes from 4:00 a.m. until 4:50 a.m. At 4:50 a.m., Patient #9’s blood pressure reading was 83/54. Vital signs were next assessed at 5:30 a.m., 40 minutes later. At 5:30 a.m., Patient #9’s blood pressure was 74/52. From 5:30 a.m. to 6:51 a.m., when Patient #9 was transferred to the intensive care unit (ICU), there was a period of one hour and 21 minutes with no additional vital signs assessed in the ED. These gaps in vital signs assessments were in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 1 patients, vital signs should have been assessed every 5-15 minutes. iv. A review of Patient #10’s medical record revealed Patient #10 presented to the ED on 6/21/25 at 3:12 a.m. with a chief complaint of a gunshot wound to the right shoulder. The provider diagnosed Patient #10 with a fracture of the right humerus (the upper arm bone). Nursing staff triaged Patient #10 as an ESI level 1. The ED Care Timeline revealed Patient #10’s vital signs were assessed at 3:19 a.m., 3:20 a.m. and 3:25 a.m. No additional vital signs were assessed until 5:35 a.m., two hours and five minutes later. This gap in vital signs monitoring was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 1 patients, vital signs should have been assessed every 5-15 minutes based on patient condition, and if clinically stable, at minimum every hour times four. At 3:38 a.m., nursing staff administered 4mg of Morphine (an opioid medicine used for severe pain) intravenously (IV). Nursing staff administered a second dose of 4mg of Morphine IV at 6:03 a.m. There were no nursing assessments for pain prior to administrations of Morphine, or pain reassessments after Morphine had been administered. Nursing staff administered a third dose of 4mg of Morphine IV at 6:47 a.m., and documented Patient #10’s pain was an eight out of 10 at the time of medication administration. ED nurses discharged Patient #10 from the facility at 6:59 a.m. and did not reassess Patient #10’s pain prior to discharge. This lack of pain assessment and reassessment was in contrast to the Pain Management policy which read, the pain reassessment timeframe and/or interval should have been based on the knowledge of the onset and peak effect of the intervention provided. Documentation of reassessment should have been within 2 hours of pain interventions. Staff should have monitored for adverse effects of opioid medication including sedation and respiratory depression. The lack of pain assessment and reassessment was also in contrast to the Nursing Standards of Practice - Emergency Department policy which read, the emergency registered nurse should have developed a plan that prescribed strategies to attain expected, measurable outcomes. This should have continued with patient assessments and reassessments. All patients in the ED should have been reassessed, including a complete set of vital signs and pain assessment. v. A review of Patient #11’s medical record revealed Patient #11 presented to the ED on 5/7/25 at 9:24 p.m. with a chief complaint of a seizure. The ED Care Timeline revealed nursing staff triaged Patient #11 as an ESI level 2. The provider diagnosed Patient #11 with a breakthrough seizure. Nursing staff assessed Patient #11’s vital signs at 9:30 p.m. No additional vital signs were taken until 11:45 p.m., two hours and 15 minutes later. This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 2 - Emergency patients ongoing vital signs should have been completed at minimum every hour times four, and then every two hours if clinically stable. vi. A review of Patient #12’s medical record revealed Patient #12 presented to the ED on 6/21/25 at 2:10 p.m. with a chief complaint of a sore throat after sinus surgery. Nursing staff triaged Patient #12 as an ESI level 3 (urgent). Patient #12 complained of difficulty breathing, talking, and swallowing. The provider’s note revealed Patient #12 appeared to be in distress with difficulty speaking. The provider diagnosed Patient #12 with a retropharyngeal abscess (a severe infection that can pose a threat to life by obstructing the airway) and tracheal perforation (tear or break in the windpipe that affects the airway). The ED Care Timeline revealed nurses assessed Patient #12’s vital signs at 2:26 p.m. in triage and they were within the normal range. No additional vital signs were obtained in the emergency department. Patient #12 was admitted to the operating room at 7:16 p.m for intubation (a lifesaving medical procedure that uses a tube to keep the airway open). The gap in vital signs from triage to Patient #12’s transfer to the operating room was a period of four hours and 50 minutes. This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read for ESI Level 3 - Urgent patients, vital signs should have been completed at a minimum of every four hours. vii. A review of Patient #13’s medical record revealed Patient #13 presented to the ED by ambulance on 5/9/25 at 11:16 p.m. with a chief complaint of left sided facial paralysis and facial drooping. Nursing staff triaged Patient #13 as an ESI level 2 on arrival and completed a stroke assessment using the NIH Stroke Scale. At 11:19 p.m., the provider placed a nursing order for neurological assessments to be performed every 30 minutes for one hour, and then hourly. Nursing staff did not perform a primary assessment or any neuro assessments while Patient #13 was in the ED. This was in contrast to the provider’s order for neurological assessments to be performed every 30 minutes for one hour, and then hourly. This was also in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, for ESI Level 2 - Emergency patients, an initial physical assessment should have been completed within 30 minutes. B. Interviews i. An interview was conducted on 7/14/25 at 9:30 a.m. with registered nurse (RN) #8. RN #8 stated patients who were classified as a lower ESI were considered high acuity (the severity of an illness or medical condition) patients. RN #8 stated it was important for ED nurses to assess and reassess patients in the emergency department. RN #8 stated at minimum, nurses should have conducted a primary assessment and a focused assessment based on the chief complaint of the patient. This was in contrast to Patient #13’s medical record review which revealed nurses did not perform a primary or neurological assessment of Patient #13 while they were in the ED. RN #8 also stated at minimum, vital signs should have been assessed every two hours on all patients. RN #8 stated if a patient had abnormal vital signs, vital signs should have been assessed at a minimum of every hour. This was in contrast to Patient #1’s medical record review which revealed a gap of five hours and twenty-two minutes in the assessment of vital signs. ii. An interview was conducted on 7/16/25 at 9:26 a.m. with RN #7. RN #7 stated ED nurses were expected to document an assessment and a focused assessment addressing the patient’s chief complaint. RN #7 stated reassessments of patients were completed based on length of stay in the ED, any medications they received, and if any changes in condition occurred. RN #7 reassessments should have been conducted if pain medication was given. RN #7 stated ED providers relied on nurses to observe and report changes in patient condition. RN #7 stated ED patient’s vital signs were checked more frequently based on their ESI level. A patient who was assigned an ESI level 2 should have had vital signs assessed every 15 minutes to every 30 minutes depending on the chief complaint. This was in contrast to Patient #11’s medical record review which revealed they were scored as an ESI level 2 and had a two hour and 15 minute gap in the assessment of vital signs. RN #7 also stated a patient who was evaluated in the ED for stroke-like symptoms should have had a neurological assessment and vital signs at a minimum of every hour to determine if there were any neurological status changes. RN #7 stated the risk of not reassessing a patient with stroke-like symptoms included a worsening neurological status and abnormal vital signs. This was in contrast to Patient #8’s medical record review which revealed a neurological reassessment did not occur, and vital signs were not assessed every hour while they were in the ED. This was also in contrast to Patient #13’s medical record review which revealed nurses did not perform a neurological assessment when the patient presented with left sided facial paralysis and facial drooping. Additionally, RN #7 stated a patient with a retropharyngeal abscess with tracheal perforation should have been monitored closely and assessed frequently for airway status and changes in vital signs. RN #7 stated vital signs should have been documented every five minutes for a patient with retropharyngeal abscess with tracheal perforation. RN #7 stated the risk of not reassessing a patient with retropharyngeal abscess with tracheal perforation included a loss of airway and death. This was in contrast to Patient #12’s medical record review which revealed nurses did not assess Patient #12’s vital signs for four hours and 50 minutes. RN #7 stated a patient with a chief complaint of vomiting blood and syncopal episodes should have been reassessed frequently for changes in vital signs, cardiac monitoring, mental status, labs, and airway. RN #7 stated a blood pressure in the 70s/50s was dangerously low, required frequent monitoring, and provider notification. This was in contrast to Patient #9’s medical record review which revealed multiple gaps in vital signs assessments, which included gaps of 50 minutes, 40 minutes, and one hour and 21 minutes. Additionally, nursing staff documented multiple episodes of low blood pressure readings and there was no evidence of provider notification regarding the abnormal vital signs. Furthermore, RN #7 stated patients who received IV Morphine should have been monitored for blood pressure, pain control, and vomiting for at least one hour after administration. RN #7 stated it was important to reassess blood pressure because pain medication, such as Morphine, had a risk of lowering blood pressure to a dangerous level. RN #7 stated it was important to reassess a patient’s pain level after administering any pain medication to determine if the pain medication had effectively reduced a patient’s pain level. This was in contrast to Patient #10’s medical record review which revealed nurses administered two doses of Morphine without completing a pain assessment, and no pain reassessments were performed. Additionally, Patient #10 was discharged from the ED twelve minutes after a third dose of IV Morphine had been administered. This was also in contrast to the medical record review for Patient #1 which revealed a pain reassessment had not been completed by nursing staff after Tylenol 650mg had been administered for a pain level of eight out of 10. iii. An interview was conducted on 7/16/25 at 1:57 p.m. with the ED director (Director) #6. Director #6 stated the requirement varied for nursing assessments and rounding on patients based on patient acuity. Director #6 stated it was important to assess patients in the ED because medical conditions and acuity levels could change. Director #6 stated all ED patients should have received a primary assessment by nursing staff, and a focused assessment based on their chief complaint. Director #6 stated nurses should have re-assessed patients after interventions, or with any patient changes in patients’ conditions. Director #6 stated nurses would have identified changes in patient condition by being present in the patient’s room, talking with patients, administering medication, and assessing vital signs. Director #6 also stated pain levels should have been reassessed after pain medications were administered in the ED. Director #6 stated abnormal vital signs should have been reassessed more frequently. Director #6 stated it was important to reassess patients with neurological complaints because if a neurological condition, such as a stroke, was not quickly treated, irreversible damage to brain tissue could have occurred. Director #6 stated assessment was the only way to determine if a patient’s condition had worsened. Additionally, Director #6 stated the risk of not monitoring a patient who had received a rapid blood transfusion could have been a blood transfusion reaction. Director #6 stated it was important for nurses to communicate abnormal blood pressure readings, including low blood pressure, to providers. Director #6 stated it was concerning if patients had gaps of several hours in vital signs monitoring or assessments. Director #6 stated patients were at risk for deterioration if they were not assessed, reassessed, or if their vitals signs were not monitored. 2. The facility failed to ensure alterations to patients’ skin integrity were appropriately assessed and documented. A. Document Review i. A review of Patient #1’s medical record revealed Patient #1 presented to the hospital on 4/15/25 after an unwitnessed fall at home which resulted in left rib cage bruising and tenderness, pain with passive movement of the left arm, and shallow breathing. The patient was diagnosed with multiple rib fractures and a hemothorax (collection of blood in the space between the chest wall and the lung). Patient #1 arrived to the inpatient unit on 4/15/25 at 4:24 p.m. On 4/15/25 at 4:30 p.m., Patient #1’s initial Braden Scale score was 16. The initial skin assessment, documented on 4/15/25 at 8:30 p.m., revealed the patient’s skin to be intact. Subsequent nursing assessments revealed Patient #1 had bruising to the left posterior hip. However, the record failed to reveal documentation of a wound care consult or images of the wound uploaded into the patient’s chart. This was in contrast to the HAPI Prevention, Assessment and Documentation policy which read, nurses on all inpatient units were to document photographs of pressure injuries or wounds upon discovery. A Braden Scale score of less than 18 indicated a risk for pressure injury development, and the RN should have requested a wound care consult. ii. A review of Patient #6’s medical record revealed Patient #6 presented to the facility on 6/8/25 with necrotizing fasciitis (a bacterial infection that rapidly destroys tissue under the skin) which required emergent surgery. The patient’s hospitalization was complicated by duodenal perforations (a life-threatening condition where there are holes or tears in the wall of part of the small intestine), which required multiple surgeries, and an acute kidney injury requiring continuous renal replacement therapy (continuous dialysis treatment that helps filter waste and excess fluid from the bloodstream). Patient #6 was transferred to the ICU on 6/13/25 at 1:13 a.m. The initial skin assessment, documented on 6/13/25 at 3:53 a.m., revealed disruptions in skin integrity to include surgical incisions to the abdomen and right lower extremity, and bruising to an unspecified location; no pressure injury was identified at that time. Five days later, on 6/18/25 at 11:28 a.m., a skin assessment revealed the presence of a pressure injury. Documentation thereafter revealed the wound bed to be unapproximated (the edges of the wound were separated), until 6/22/25 at 4:00 p.m., at which point documentation revealed the wound bed to be pink and friable. This was in contrast to the wound care RN’s assessment on 6/25/25 at 2:30 p.m. which revealed the wound bed to be black and purple with areas of necrosis (dead or dying tissue). The record failed to reveal images of the pressure injury uploaded into the patient’s chart by the primary nurses until the wound care RN’s assessment, seven days after the wound was discovered. The record also failed to reveal consults for wound care regarding the newly acquired pressure injury. This was in contrast to the HAPI Prevention, Assessment and Documentation policy which read, nurses on all inpatient units were supposed to document photographs of pressure injuries upon discovery, weekly, and with any change in patient or wound status. Additionally, the medical record review revealed lapses between skin assessments, which included a 12 hour gap between assessments from 6/24/25 at 8:00 p.m. until 6/25/25 at 8:00 a.m. An eight hour gap was identified between assessments from 6/20/25 at 12:00 p.m. until 8:00 p.m. Additionally, a seven hour gap was identified between assessments from 6/14/25 at 4:00 p.m. until 11:00 p.m. This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, focused reassessments were to be performed by ICU nursing staff every four hours. Furthermore, skin assessments in Patient #6’s medical record lacked key characteristics including skin color, temperature, texture/turgor, and integrity. At least two out of six characteristics were absent from skin assessments on 6/15/25 at 8:00 p.m., 6/16/25 at 12:00 a.m. and 4:00 a.m., and 6/19/25 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. This was in contrast to the HAPI Prevention, Assessment and Documentation policy which read, integumentary assessments should have included documentation of skin color, temperature, texture/turgor and integrity, moisture, and edema. B. Interviews i. On 7/14/25 at 9:35 a.m., an interview was conducted with ICU RN #1. ICU RN #1 stated two nurses performed an assessment of patients’ skin upon admission to the ICU. If skin breakdown was noted, the RN should take a photograph of the breakdown and consult the wound care nurse for further evaluation and care recommendations. RN #1 also stated skin assessments should be performed every four hours. This was in contrast to the medical record review for Patient #6, which failed to reveal skin assessments performed every four hours. ii. On 7/14/25 at 10:32 a.m., an interview was conducted with the medical/surgical clinical coordinator (Clinical Coordinator) #2. Clinical Coordinator #2 stated RNs should obtain a photograph of wounds upon discovery and consult the wound care team. Clinical Coordinator #2 also stated a bruise may be differentiated from a deep tissue injury or pressure injury based on whether or not it was near a bony prominence or pressure point. If there was any uncertainty regarding whether or not discoloration was a bruise or injury, then the RN should have uploaded a photograph into the medical record and consulted wound care. iii. On 7/15/25 at 3:11 p.m., an interview was conducted with RN #3. RN #3 stated the primary RN should have consulted wound care any time there was skin discoloration noted on assessment in order to distinguish between pressure injury, deep tissue injury, and bruising. iv. On 7/16/25 at 3:11 p.m., an interview was conducted with wound care RN #4. RN #4 stated the primary RN should take a photograph of patients’ wounds upon discovery and consult the wound care nurse for further evaluation. These interviews were in contrast to the medical record review, which failed to reveal images of Patient #1’s wound at any point during their hospitalization. These interviews were also in contrast to the medical record review, which failed to reveal images of Patient #6’s wound captured by the primary RNs in the seven days between initial discovery and assessment by the wound care RN. Furthermore, these interviews were in contrast to the medical record reviews, which failed to reveal consultation to the wound care RN upon discovery of the wounds for both Patient #1 and Patient #6. 3. The facility failed to ensure a patient who was at-risk for pressure injuries received interventions to prevent skin breakdown. a. Medical record review revealed Patient #6’s Braden Scale score upon arrival to the ICU on 6/13/25 at 1:31 a.m. was 12 (high risk). Patient #6’s mobility subscale score was two (very limited mobility); their mobility subscale score ranged from one (completely immobile) to two for the duration of their hospitalization. Patient #6’s pressure injury was discovered on 6/18/25 at 11:28 a.m. However, the medical record failed to reveal the application of a bordered foam dressing until 6/24/25, six days after initial discovery of the pressure injury. Barrier cream had not been applied to Patient #6’s sacral wound until 6/26/25, eight days after initial discovery. This was in contrast to a provider’s order placed on 6/13/25 at 8:54 a.m., which instructed nursing staff to apply barrier cream to Patient #6’s sacrum. This was also in contrast to a provider’s order placed on 6/14/25 at 9:34 a.m., which instructed nursing staff to place a large bordered foam dressing on Patient #6’s sacrum if a pressure injury developed. Patient #6’s medical record also revealed gaps in patient repositioning. Examples included an eight hour gap from 6/19/25 at 8:00 p.m. until 6/20/25 at 4:00 a.m., during which the patient was repositioned once. A 10 hour gap was also identified from 6/17/25 at 8:00 a.m. until 6:00 p.m., during which the patient had not been repositioned. The failure to reposition Patient #6 was in contrast to the HAPI protocol, ordered by Patient #6’s provider on 6/13/25 at 7:37 a.m., which instructed nursing staff to turn the patient every two hours. Furthermore, this was in contrast to the HAPI Prevention, Assessment and Documentation policy, which read patients with a Braden mobility subscale score less than or equal to two should have been repositioned at least every four hours or more frequently. b. On 7/14/25 at 8:45 a.m., an interview was conducted with the ICU charge RN (RN) #5. RN #5 stated patients with Braden Scale scores of less than or equal to 14 were at risk for skin breakdown. RN #5 explained patients with Braden Scale Scores less than or equal to 14 should have been repositioned every two hours, had barrier cream applied with episodes of incontinence, and had foam bordered dressings applied to bony prominences. c. On 7/14/25 at 10:32 a.m., an interview was conducted with the medical/surgical clinical coordinator (Clinical Coordinator) #2. Clinical Coordinator #2 stated if a patient had a Braden Scale score of less than 18, the RN should have shifted the patient’s weight every two hours and minimized moisture around the patient’s skin. These interviews were in contrast to the medical record review, which failed to reveal the application of a bordered foam dressing until six days after the initial discovery of Patient #6’s wound, or application of barrier cream until eight days after the initial discovery of the wound. These interviews were also in contrast to the medical record review, which revealed Patient #6 had not been turned every two hours as ordered by their provider.”

“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: 50313 Based on interviews and document review, 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 2409: Restricting Transfer Until the Individual Is Stabilized §489.24(e) (2) A transfer to another medical facility will be appropriate only in those cases in which - (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. Based on interviews, and document reviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure patients were transported to an acute healthcare facility by qualified personnel with access to emergency equipment during transfer. This failure was identified in one of two records reviewed for patients who presented to the emergency department for medical care and were transferred to another facility. (Patient #4)”

“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: 50313 Based on interviews and document reviews, the facility failed to ensure patients were transported to an acute healthcare facility by qualified personnel with access to emergency equipment during transfer. This failure was identified in one of two records reviewed for patients who presented to the emergency department for medical care and were transferred to another facility. (Patient #4) Findings include: Facility policy: The Emergency Medical Treatment & Active Labor Act (EMTALA) policy read, the purpose of the policy is to describe the policies and procedures for the treatment and transfer of individuals in need of emergency medical services. The transfer will be accomplished through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. If the individual does not consent to transfer: If the hospital offers an appropriate transfer and informs the individual or the person acting on the individual’s behalf of the risks and benefits to the individual of the transfer, but the individual or the person acting on the individual’s behalf does not consent to the transfer, the hospital will take all reasonable steps to have the individual or person acting on the individual’s behalf sign the Transfer Refusal portion of the EMTALA Transfer Form. In addition to completing the Transfer Refusal document, the medical record will contain a description of the proposed transfer that was refused by or on behalf of the individual. 1. The facility failed to ensure patients were transported to an acute healthcare facility by qualified personnel with access to emergency equipment during transfer. A. Document Review i. A review of Patient #4’s medical record revealed Patient #4 presented to the emergency department (ED) on 5/10/25 at 1:06 a.m. with a chief complaint of seizures. Patient #4 was 25 weeks pregnant, and a family member reported Patient #4 had a four-minute tonic clonic seizure (a type of seizure that involves a loss of consciousness and violent muscle contractions) prior to arrival. Patient #4 had a history of one prior seizure during pregnancy. Nursing documentation on 5/10/25 at 2:41 a.m. revealed Patient #4 was on seizure precautions (a room set-up that typically includes padded side rails, suction equipment, supplemental oxygen, and cardiac monitoring) in the ED. The ED provider’s note revealed Provider #2 consulted with obstetrics at another facility who recommended the patient be transferred for ongoing fetal monitoring. The transfer form revealed the patient was being transferred for a higher or specialized level of care in obstetrics at the receiving facility. The risks of transfer were deterioration and death. The ED provider’s note and transfer form revealed the patient would go by private vehicle. On 5/10/25 at 3:39 a.m., nursing notes revealed Patient #4 was transferred to another facility by private vehicle. There was no documentation that Patient #4 had been offered or refused transfer by ambulance. This record review was in contrast to the EMTALA policy which read, transfer would have been accomplished through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. B. Interviews i. An interview was conducted on 7/16/25 at 9:26 a.m. with registered nurse (RN) #1. RN #1 stated it was necessary to monitor patients who presented to the ED for seizures. RN #1 stated it was necessary to monitor a patient’s airway, breathing, circulation, and neurological status following a seizure. RN #1 stated it was important to have emergency equipment, such as suction, supplemental oxygen, cardiac monitoring, pulse oximetry, and seizure pads, available in case a patient had another seizure. RN #1 stated it would not have been appropriate to transfer a 25-week pregnant patient who presented to the facility for seizures by private vehicle. Additionally, RN #1 stated the risk of transferring a pregnant patient who recently had a seizure without medical personnel or emergency equipment available included deterioration in condition, harm to the baby, and another seizure. ii. An interview was conducted on 7/16/25 at 2:30 p.m. with ED provider (Provider) #2. Provider #2 stated the decision regarding the method of transportation for a patient to another facility was dependent on many factors including the acuity of the patient, concern for potential decompensation, and if medication was required or anticipated. Provider #2 stated a patient who was 25 weeks pregnant with a medical history of seizure prior to arrival to the ED should not have been transferred by private vehicle. Provider #2 stated Patient #4 met the facility’s eclampsia (a condition in which one or more convulsions occur in a pregnant woman often followed by coma and posing a threat to the health of mother and baby) criteria and it was inappropriate to transfer by private vehicle without medical personnel and emergency equipment available. Provider #2 stated the risk of transferring Patient #4 by private vehicle was decompensation and further seizure activity while in a private vehicle without medical personnel or emergency equipment available. Provider #2 stated transfer by private vehicle was only appropriate if Patient #2 had refused transfer by ambulance, however, Provider #2 stated they would have documented the refusal and a conversation with Patient #4 about the risks of transportation by private vehicle in the medical record. This was in contrast to Patient #4’s medical record review which revealed no evidence Patient #4 had refused to be transferred by ambulance.”

“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: 47962 Based on interviews and document review, 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 2406: - 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. Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted two of 22 patients’ medical records reviewed.”

“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: 47962 Based on interviews and document review, the facility failed to ensure patients received a medical screening exam (MSE) according to facility policy. Specifically, the facility failed to ensure patients presenting to the facility with a potential emergency medical condition (EMC) were medically screened according to facility policy. This failure impacted two of 22 patients’ medical records reviewed. (Patients #2 and #9) Findings include: Facility policies: According to the Emergency Medical Treatment & Active Labor Act (EMTALA) policy, the facility will provide an appropriate MSE to determine whether an EMC exists for an individual who presents to the emergency department (ED), requesting or needing examination or treatment for a medical condition. If it is determined that the individual has an EMC, the facility will provide further medical examination and treatment as required to stabilize the emergency medical condition or arrange for the transfer of the individual to another medical facility. The MSE is an ongoing process. The medical record must reflect an ongoing assessment of the patient’s condition. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred. There should be evidence of this before discharge or transfer. Medical records should contain documentation such as medically indicated screenings, tests, mental status, impressions, and diagnoses. For individuals with psychiatric symptoms, the medical records should indicate an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. According to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy, the purpose is to outline the standards of care for assessment, reassessment, and vital signs. Reassessment of the patient is a continuous, ongoing process based upon specific assessment parameters as well as in response to changes in diagnosis, treatments, procedures, and the plan of care. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes. For patients with an Emergency Severity Index (ESI) of ESI 3, the initial vital signs are completed upon arrival. For patients with abnormal vital signs, the vital signs are assessed at a minimum of every two hours four times, then every four hours if stable. Patients will receive vital signs one hour before discharge. Reference: According to the provider order set titled “ED Alcohol Withdrawal,” an initial loading dose of Phenobarbital (causes relaxation or sleepiness) 10 milligram (mg) /kilogram (kg) can be administered intravenously (IV). Reassess Clinical Institute Withdrawal (a physiological response to stopping drugs or alcohol) Assessment for Alcohol (CIWA) one hour after medication administration. If the patient has a persistently elevated CIWA, recurrent IV dosing of Phenobarbital 5mg/kg can be administered 30 minutes after completion of the previous infusion. Assess vital signs every hour. Reassess CIWA one hour after medication administration. For initial dosing of benzodiazepines (central nervous system depressants which cause sleepiness and relaxation), physicians can choose IV Diazepam with an initial loading dose of five to 10 mg or Lorazepam with an initial loading dose of one to 3mg. Reassess CIWA one hour after medication administration. For recurrent dosing of benzodiazepines, when the CIWA score is under 11, administer Lorazepam 2mg tablets or Chlordiazepoxide 50mg capsules. Reassess CIWA one hour after medication administration. Assess vital signs every hour. When the CIWA is eight to 14, administer Diazepam 5mg intravenously every 30 minutes as needed for alcohol withdrawal or Lorazepam 1mg intravenously every hour. Reassess CIWA one hour after medication administration. Assess vital signs every hour. 1. The facility failed to ensure patients presenting to the facility for an EMC received appropriate and consistent MSEs per facility policy. A. Medical record review i. A review was conducted of Patient #2’s medical record which revealed Patient #2 had presented to the ED for acute alcohol intoxication (a temporary condition that affects the central nervous system causing impairment in judgment and behavior) on 3/5/24 at 7:51 p.m. During the encounter starting at 7:51 p.m., the triage registered nurse (RN) documented Patient #2’s history of alcoholism and current state of intoxication. This RN documented that Patient #2 was drowsy and confused. The RN performed a Columbia Suicide Severity Rating Scale (C-SSRS) which revealed the patient was at high risk of suicide and documented interventions that were to be implemented. The physical exam section of the initial provider note by Provider #1 revealed the patient was intoxicated, disheveled, and had slurred speech. Provider #1 documented clear lungs, regular heart rate and rhythm, and lack of edema (excess fluid) in the extremities (arms and legs). Provider #1 did not include any other assessments related to the physical examination of Patient #2 to rule out an EMC. Provider #1 did not request laboratory testing, imaging, or a psychiatry consult to rule out an EMC pertaining to the symptoms Patient #2 presented with, including potential severe malnutrition, acute liver disease, infection, overdose, or head injury. Provider #1’s note read Patient #2 stated their family “could probably” pick them up after discharge. The RN note at 9:45 p.m. read Provider #1 had ordered a “road test” to assess Patient #2’s ability to ambulate (walk), and as the patient was able to walk alone, they were to be discharged home in a ride-hailing service. In the discharge vitals note recorded on 3/5/24 at 10:07 p.m., although an RN documented Patient #2 was “oriented,” their level of orientation was not assessed. Provider #1 also failed to conduct a follow-up neurological assessment prior to discharge to ensure the patient was clinically sober and safe for discharge. The RN note documented nurses assisted the patient to the vehicle at the time of discharge. The record did not reveal any attempts to contact Patient #2’s family or friends to provide Patient #2 with transportation home. The ED provider note by physician (Provider) #1 written on 3/5/24 at 7:51 p.m. and filed at 9:05 p.m., revealed Provider #1 had not assessed Patient #2’s statement of wanting to “disappear” as indicative of suicidal ideas or plans and had therefore documented that Patient #2 would not be placed on a hold (an involuntary commitment for plans to harm oneself or others or due to a state of disability). An edited ED provider note written by Provider #1 on 3/5/24 and filed at 11:08 p.m., four minutes after the patient returned to the ED in an unresponsive state, read that Provider #1 had specifically asked Patient #2 about suicidal thoughts and Patient #2 had stated they were not suicidal. The lack of physical assessment, including a neurological and psychiatric exam, laboratory testing, imaging, and referral to psychiatry as well as the lack of consideration of other potential etiologies given Patient #2’s confusion and drowsiness revealed an inappropriate MSE. Provider #1’s failure to determine clinical sobriety by conducting a thorough clinical evaluation and/or blood alcohol screening prior to discharge contributed to the overall failure to provide an appropriate MSE which was in contrast to the EMTALA policy which read, the facility provided an appropriate MSE for individuals who presented to the ED, needing examination or treatment. The MSE condition continued until the patient was stabilized. ii. A review was conducted of Patient #9’s medical record which revealed Patient #9 had presented to the ED for alcohol intoxication on 4/1/24 at 5:18 p.m. The medical record revealed Patient #9 had a history of alcohol withdrawal seizures (abnormal electrical activity in the brain). The triage RN note at 5:33 p.m. revealed Patient #9’s blood pressure (BP) was 164/97 (normal was 120/80) and pulse rate (PR) was 105 (normal was 60-100). At 5:39 p.m., six minutes later, the record revealed the patient was given hydroxyzine (a medication used to help with relaxation) for anxiety. Laboratory testing revealed Patient #9’s blood alcohol level (BAL) was 352, indicating severe alcohol intoxication. At 5:40 p.m., the RN conducted a CIWA and the patient scored 11, which indicated moderate alcohol withdrawal. The record did not reveal any provider orders or additional interventions by the nursing staff after the CIWA was performed. In addition, there was no evidence of additional CIWA assessments conducted during the patient’s stay to determine if alcohol withdrawal symptoms were increasing, which could have indicated a higher risk for seizure. This was in contrast to an interview with physician assistant (Provider) #6 on 5/23/24 at 9:02 a.m., who stated a CIWA score of 11 required the CIWA to be performed again at regular intervals not more than an hour apart., Provider #6 also stated patients who scored a CIWA score of 11 were required to be on telemetry (heart and oxygen monitoring) and vital signs to be assessed every 30 minutes to one hour. The Provider note documented Patient #9 had anion gap metabolic acidosis (a buildup of acid in the body that could lead to shock or death) which they attributed to alcoholic ketoacidosis (increased acid due to breakdown of fats in the body). The laboratory testing failed to reveal additional workup to rule out other causes of the acidosis which if present, increased Patient #9’s seizure risk. Also, the lack of this additional workup indicated gaps in the MSE as the provider was not able to assess, treat, and stabilize other potential causes of the acidosis. At 6:51 p.m. (an hour and 18 minutes after the triage vitals), the RN assessed Patient #9’s PR at 98 but did not reassess BP, which had been elevated on admission, or perform another CIWA, which was also elevated on admission At 6:54 p.m., Patient #9 was discharged home. This discharge home without reassessment of an abnormal BP was in contrast to an interview with RN #7 on 5/23/24 at 7:35 a.m. who stated a blood pressure of around 160/90 was concerning as the risks to discharging a patient with these vitals included cardiovascular risk (negative impacts to the heart and blood vessels). Patient #9 was also discharged home without reassessing their CIWA score which was initially scored at 11. This lack of reassessment of an elevated blood pressure reading and elevated CIWA score was in contrast to an interview with Provider #6 on 5/23/24 at 9:02 a.m., which revealed they administered medications and conducted frequent patient assessments of patients with CIWA scores of 11, as hypertension (high blood pressure) and tachycardia (high heart rate) indicated more severe alcohol withdrawal with risks such as seizures, electrolyte (which help conduct electrical impulses necessary for sustaining life) imbalances, and dehydration. The lack of assessment including comprehensive laboratory testing to fully evaluate Patient #9’s acidosis, repeated CIWA scoring for an initially high score, and repeated vitals for an elevated blood pressure contributed to the provider’s failure to provide an appropriate MSE which was in contrast to the EMTALA policy which read, the facility provided an appropriate MSE needing examination or treatment. This assessment and monitoring continued until the patient was stabilized. This review of medical records for Patients #2 and #9 was in contrast to the EMTALA and Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policies which read, the facility provided an appropriate MSE to determine whether an EMC existed for individuals who presented to the ED, requesting or needing examination or treatment for a medical condition. The MSE was an ongoing process and this ongoing assessment and monitoring continued until the individual was stabilized. Assessment and reassessment of the patient occurred in response to changes in diagnosis, treatments, and the plan of care. Patient condition and ongoing changes in status warranted more frequent reassessment. Vital signs were assessed before discharge. B. Interviews i. On 5/21/24 at 10:16 a.m., an interview was conducted with ED case manager (CM) #3. CM #3 stated they assisted patients with discharge planning to facilitate safe discharges. They stated asking a family or friend to transport the patient home was always the first option once the patient was safe for discharge. CM #3 stated a safe discharge complemented the medical care to reduce the need for aftercare, future hospitalizations, and to ensure proper care after discharge. ii. On 5/22/24 at 2:47 p.m., an interview was conducted with RN #4. RN #4 stated patients who presented with alcohol intoxication were screened with a breathalyzer or serum alcohol test and a CIWA to assess their level of intoxication in order to help guide treatment and estimated time to sobriety. This was in contrast to the review of Patient #2’s medical record which showed no evidence that the patient received alcohol testing or a CIWA assessment. RN #4 stated staff treated the patients’ symptoms if the patients were assessed as being in alcohol withdrawal in order to keep the patients safe. RN #4 stated once patients were clinically sober, which they defined as walking steadily, talking in complete sentences, and able to safely arrive at their destination, and could pass the “road test,” which RN #4 described as observations of the patients walking down the hallway, steadily and without needing assistance, the patients were safe for discharge. RN #4 stated the “road test” was ordered by the provider to assess the patients’ abilities to safely arrive at their destinations. They stated patients with a higher tolerance for and more habitual use of alcohol, had better control of their movements when performing the road test, even if intoxicated. RN #4 stated patients were asked if someone was able to provide them with a ride home, but if not, patients were provided with a ride-hailing service or an ambulance ride. RN #4 stated the appropriate discharge process was important to ensure patients’ safety, for example, to ensure patients did not fall and hit their heads or accidentally cause harm to themselves as they were not able to safely care for themselves while on the way home. iii. On 5/22/24 at 1:46 p.m., an interview was conducted with RN #5. RN #5 stated they preferred family or friends to assist patients with discharging home and if a trusted family or friend could not provide transport, providers might hold patients until they were sober. RN #5 stated for a patient to be able to use public transport at discharge, they would need to be at “perfect zeros,” which RN #5 defined as functioning at baseline, which was in contrast to the review of Patient #2’s medical record. They stated the provider was ultimately responsible for determining a patient’s safety for discharge and the method of transport home. iv. On 5/23/24 at 7:35 a.m., an interview was conducted with RN #7. RN #7 stated their initial patient assessment included airway, breathing, and circulation (ABCs), a head-to-toe assessment, and then a focused assessment based on the patient’s chief complaint. RN #7 stated they performed a CIWA on patients who smelled like alcohol and may have been altered mentally to rule out alcohol withdrawal and then implemented various monitoring including cardiac (heart) and oxygen. They stated CIWAs were done on arrival and repeated every 30 minutes to an hour depending on the patient’s presentation which was in contrast to a review of Patient #9’s medical record. RN #7 stated the provider would order repeat CIWA assessments based on the severity of the CIWA score. They stated the provider would also order medications such as phenobarbital or lorazepam to manage the patient’s withdrawal symptoms, which included anxiety, nausea, dehydration, or seizures. RN #7 stated discharge vitals were important to assess changes in a patient’s condition and to ensure the patient was safe for discharge. They stated they specifically looked for high or low blood pressure, low oxygen saturation, and a high heart rate. This was in contrast to a review of Patient #9’s medical record which showed no evidence that the patient’s blood pressure was reassessed prior to discharge. RN #7 stated a blood pressure around 160/90 was concerning. They stated the risks of discharging a patient with abnormal vitals such as an elevated BP included cardiovascular risk, stroke, and death. RN #7 stated patients were assessed and reassessed to ensure patient safety. v. On 5/23/24 at 9:02 a.m. an interview was conducted with Provider #6. Provider #6 stated their MSE included vitals, a review of the presenting complaint, the past medical history, a head-to-toe assessment, and a physical exam. They stated this was modified depending on the patient’s complaint and vital signs. Provider #6 stated the MSE was important to diagnose a patient, assess the severity of their condition, and determine the patient’s disposition (placement) at discharge. Provider #6 stated the risk of not performing a thorough MSE was anything up to and including the death of the patient. Provider #6 stated they performed alcohol testing for patients presenting with alcohol intoxication to assess alterations of mental status, the level of intoxication, and the possibility of withdrawal symptoms. They stated they may or may not order other laboratory testing for patients with alcohol intoxication but would base this decision on vital signs and other patient complaints. Provider #6 stated the only situation in which they had not ordered a full panel of labs was for a patient who presented with acute alcohol intoxication and had no recent history of trauma or complaints of nausea or vomiting. Provider #6 stated for this patient, they had still assessed the patient’s alcohol level, ordered and administered intravenous (IV) fluids, obtained vital signs, and observed the patient over the course of several hours. Provider #6 stated the CIWA was an assessment that was performed when they were concerned for the health of a patient withdrawing from alcohol. They stated the CIWA gave a numerical score which dictated the chance for more severe withdrawal symptoms, such as seizures, and the need for preventative medications. Provider #6 stated a CIWA score of 11 required medications to be given, the CIWA to be performed again at regular intervals, not more than an hour apart, the patient to be on telemetry (heart and oxygen monitoring), and monitoring of vital signs every 30 minutes to one hour, which was in contrast to a review of Patient #9’s medical record. Provider #6 stated obtaining vitals was important to assess heart rate and blood pressure especially as these values informed the provider of the patient’s level of withdrawal. They stated hypertension and tachycardia indicated a more severe withdrawal with risks such as seizures, electrolyte imbalances, and dehydration. Provider #6 stated it was important for nurses to assess discharge vitals to rule out tachycardia (fast heart rate), febrile (high body temperature) illness, and hypertension which carried higher risks of poor outcomes such as infection and dehydration. Provider #6 stated if any of the discharge vitals were out of range, they needed to be informed. Provider #6 stated there was a risk of missing a change in patient condition and a chance to treat the patient while at the facility if discharge vitals were not performed. vi. On 5/22/24 at 3:09 p.m., an interview was conducted with Provider #1. Provider #1 stated the MSE was used to determine if a patient had a medical emergency. They stated Patient #2 presented to the facility in an intoxicated state on 3/5/24 and they were this patient’s treating physician. They said Patient #2 had ambulated safely and talked in complete, coherent sentences so they felt comfortable discharging them home several hours after arrival. Provider #1 stated Patient #2 initially wanted their family to pick them up but then told the provider their family was not an option so Provider #1 instructed the RN to obtain a ride-hailing service. Provider #1 stated Patient #2 was a young person who was used to obtaining rides from the ride-hailing service and was without a medical condition which would have prevented them from getting home safely via this type of transport. Provider #1 stated they were still on shift when Patient #2 was returned to the ED an hour and four minutes after discharge. They stated they then edited the medical record as they had not specifically documented Patient #2’s denial of suicidal ideations or plans at the earlier visit. Provider #1 stated they rarely ordered laboratory testing for alcohol levels in patients who presented with alcohol intoxication as a patient’s alcohol tolerance was a more important factor than a lab value. Provider #1 also stated they had not performed any other workup for Patient #2 as the patient had been inpatient at another facility until earlier that day so they felt Patient #2’s lab values would not be concerning. Provider #1 also stated patients needed to want help and Patient #2 was brought to the ED in an intoxicated state by ambulance and only wanted to return home. Provider #1 stated Patient #2 did not have an emergency medical condition but rather suffered from chronic alcoholism which the patient had to be ready to address on their own timeline. Provider #1 stated they felt comfortable with their current process of screening and treating patients who presented with alcohol intoxication. They stated they would follow this same process for treating patients with alcohol intoxication in the future. This interview was in contrast to the EMTALA policy which read, the facility provided an appropriate MSE to determine whether an EMC existed for individuals who presented to the ED, requesting or needing examination or treatment for a medical condition. The MSE was an ongoing process and this ongoing assessment and monitoring of the patient’s condition continued until the individual was stabilized, appropriately admitted, or transferred.”

“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: 45020 Based on interviews and document review, 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 2406: - 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. Based on interviews and document review, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not an emergent psychiatric condition existed for one of nine medical records reviewed of patients who presented to the facility and requested emergency psychiatric services but were not admitted.”

“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: 45020 Based on interviews and document review, the facility failed to provide an appropriate medical screening examination (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulations. Specifically, the facility failed to determine whether or not an emergent psychiatric condition existed for one of nine medical records reviewed of patients who presented to the facility and requested emergency psychiatric services but were not admitted. (Patient #7) Facility findings: Facility policy: The EMTALA policy read, it is the hospital policy that when an individual comes to the Emergency Department (ED): The hospital will provide an appropriate medical screening exam (MSE), within the capability of the hospital’s dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. The MSE is an ongoing process. The medical record must reflect ongoing assessment of the patient’s condition. Monitoring must continue until the individual is stabilized, appropriately admitted or transferred. There should be evidence of this prior to discharge or transfer. According to the policy’s definitions: Emergency medical condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either (1) placing the health of the individual (Or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or (2) serious impairment to bodily functions or (3) serious dysfunction of any bodily organ or part. Medical screening exam (MSE): The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist. Initial triage is not considered a MSE. The MSE represents a spectrum ranging from a brief history and physical examination to complex processes that also involve performing ancillary studies and procedures. 1. The facility failed to ensure patients who presented to the facility for emergency psychiatric services received a MSE to determine if an emergency psychiatric condition existed for the patient. a. Review of Patient #7’s medical record, dated 6/15/23 at 1:10 a.m., revealed Patient #7 arrived at the ED with the chief complaint of danger to self or others. Medical record review revealed a Columbia-Suicide Severity Rating Scale (a suicide risk assessment tool that involves asking the patient a series of simple, plain-language questions) was performed on Patient #7 on 6/15/23 at 1:01 a.m., which determined Patient #7 was at a moderate suicide risk with the risk interventions recommended of continuous visual observation, remaining with the patient until monitoring was in place, notifying the provider and performing room safety checks. At 1:35 a.m., Patient #7’s medical record revealed he was discharged, 35 minutes after the patient was classified as a moderate risk for suicide, with the disposition of left without being seen (LWBS). Registered nurse (RN) #1 documented in Patient #7’s medical record that the patient approached the triage desk and threw a water bottle at a staff member, refused to calm down or answer questions, continued to be violent towards staff, and was subsequently escorted off hospital property by security. Further medical record review revealed no evidence that a provider evaluated Patient #7. b. On 11/7/23 at 2:29 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated if a patient presented with a psychiatric complaint they were to be evaluated by a provider. RN #1 stated if a patient scored as a moderate risk on the Columbia scale the patient was at risk of harming themselves or others and should not have been asked to leave. RN #1 stated it was important for all patients to receive a medical screening exam because there could have been a medical problem that needed to be addressed. c. On 11/8/23 at 7:59 a.m., an interview was conducted with medical provider (Physician) #2. Physician #2 stated all patients who presented to the emergency department were to receive a Columbia score per policy. Provider #2 stated if a patient were to throw a water bottle they would not be asked to leave. Provider #2 stated more questions would need to be asked to determine if the patient was a risk of self harm or of harm to others. Provider #2 stated everyone who presented to the ED was entitled to a medical screening even if they were disruptive. Provider #2 stated she was not aware of a specific risk if a medical screening was not performed. d. On 11/8/23 at 8:51 a.m., an interview was conducted with ED physician (Physician) #3. Physician #3 stated all patients who presented to the ED should have been provided a medical screening exam. Physician #3 stated it was important for patients to be seen so a medical condition could be assessed to minimize negative outcomes. Physician #3 stated there was a risk of any medical condition going unidentified if a medical screening was not performed. e. On 11/8/23 at 12:59 p.m., an interview was conducted with the director of emergency services (Director) #5. Director #5 stated it was important for patients to be seen by a provider for a medical screening evaluation because the evaluation could prevent a negative situation for the patient, including death.”