Lee Memorial Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 25618 Based on review of Emergency Medical Services (EMS) Patient Care Record, staff interviews and review of hospital policies, the hospital failed to ensure that an appropriate medical screening was provided 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 existed for 1 (Patient #1) of 20 patients reviewed seeking emergency services for care. Refer to findings in Tag A-2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 25618 Based on Emergency Medical Services (EMS) patient care record review, interviews, and review of hospital policies, the hospital failed to maintain a Central Log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged for 1 (Patient #1) of 20 patients reviewed. The findings include: Policy review revealed on 1/24/24, the Central Log, Policy #118 last approved on 1/6/2023, stated the purpose was to track the care provided to each individual who came to the hospital seeking care for a medical condition. The hospital offering emergency services will maintain a computerized central log on each individual who “comes to the emergency department” seeking assistance for a medical condition, which included individual presenting to OB/triage. Procedure: A. The Central Log must contain: 1) The name, age, and sex of the individual seeking assistance; 2) Date, time and means of arrival; 3) Nature of complaint; 4) The disposition including whether or not he or she: a. refused treatment, b. was transferred, c. was admitted and treated, d. was stabilized and transferred, e. was discharged; 5) The Central Log will include all Withdrawal of Request for Services forms that are completed when patients leave the Emergency Department (ED) after refusing exam and treatment; 6) ... Staff should strongly encourage the patient to be seen or if needed seek the help of the Supervisor/Charge Registered Nurse (RN). If patient still refuses to be seen, the visit should be documented in the electronic health record (HER) with all elements A, 1-3 (patient name, age, and sex of the individual seeking assistance, date, time and means of arrival, and nature of complaint). The ED staff will mark the patient as “left without being seen” (LWOT). The Triage RN or Supervisor would write a narrative note in the HER about the person’s request. If A, 1-3 (the patient’s personal information) was not given by the person, registration will record as “unknown” with a description of the person. On 1/24/24 a review of Emergency Medical Services (EMS) patient care record dated 1/07/24, stated EMS was notified of an 80-year-old female (Patient #1) complaining of abdominal pain and diarrhea with a duration of 7 hours. EMS assessed the patient and determined to transport Patient #1 to the Emergency Room for further treatment. The EMS crew notified the Emergency Room/Department prior to their arrival to the ED, Patient #1’s chief complaint was abdominal pain and diarrhea, and that Patient #1 had fleas covering the patient’s chest, and upper and lower extremities. The EMS patient care record for Patient #1 stated, “Upon arrival to the ED ... the charge nurse came outside and spoke with Patient #1 about the procedure to decontaminate the patient outside in a warm shower prior to coming inside the ED. Patient #1 was removed from the ambulance via stretcher, but once out of the ambulance patient refused to shower or change clothes prior to entering the emergency room. The charge nurse explained that it was required for Patient #1 to be decontaminated prior to being brought inside the ED. The ER physician agreed she must be decontaminated first. The patient continued to refuse and asked if the ambulance could just drive her home. The ambulance crew explained to Patient #1 they could not take her home, so she asked the ED staff to call her a taxi and send her home. Patient #1 was placed in a wheelchair by ED staff and taken to the front of the ED to wait for a taxi. Patient #1 was never fully registered at the ED prior to leaving.” Review of the Central Log revealed no entry and/or documentation of the EMS crew bringing Patient #1 to the hospital as required by their Central Log policy #118. On 1/24/24 at 12:32 during an interview, Staff A said she was the charge nurse working in the ED on 1/7/24 and remembers EMS bringing them a patient complaining of abdominal pain and diarrhea. She said she was told by the EMS crew prior to their arrival at the ED that Patient #1 had fleas to her chest and upper and lower extremities. She determined Patient #1 needed to be decontaminated prior to entering the ED for the safety of the patient, staff, and other patients currently in the ED. She said Patient #1 refused to be decontaminated prior to entering the ED and stated she wanted to go home. Patient #1 called a taxi to pick her up at the ED front entrance. Staff A said an ED staff assisted Patient #1 in a wheelchair to the front entrance of the ED to wait for the taxi. Staff A said because Patient #1 was not decontaminated prior to entering the facility she never was entered into the Central Log system as coming to the hospital on 1/7/24 seeking assistance with her abdominal pain and diarrhea. She said because Patient #1 was never entered into their computer system, an electronic health record was never created with the required information related to the patient’s name, age and sex, the date, time and means of arrival, the nature of the complaint, the patient disposition, and the time of their departure. On 1/25/24 at 9:00 a.m. in an interview, the Manager of Patient Access (MPA) said for a patient to be entered into the Central Log, they had to be registered into the hospital computer system to create an electronic health record (HER) for that hospital visit. The MPA confirmed the facility’s Central Log chapter S22-02 Policy #118 stated if a patient refused to be seen and left the ED, registration was required to record the patient as “unknown” in the computer with a description of the person. He confirmed this was not done for Patient #1, which is why she was not found in the ED Central Log as required. On 1/25/26 at 9:30 a.m. during an interview with the System Director of RM (SDRM), Healthcare Risk Manager (HRM), Director of Emergency Services (DES), Program Manager of Accreditation and Quality Assurance (PMAQA), and Director of Patient Access (DPA), they confirmed Patient #1 arrive at the ED via EMS with a chief complaint of abdominal pain and diarrhea as per the EMS patient care record dated 1/7/24. They said the ED staff and registration did not enter Patient #1 as “unknown” into their computer system per their policy causing Patient #1 to not be entered on the Central log as required. The facility failed to ensure that their policy titled “Central Log Policy #118” was followed as evidenced by facility to enter Patient #1 on the ED log on 1/7/2024, when presented to the facility via ambulance seeking medical assistance for complaint of abdominal pain and diarrhea.”

“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: 25618 Based on review of Emergency Medical Services (EMS) Patient Care Record, staff interviews and review of hospital policies, the hospital failed to ensure that an appropriate medical screening was provided 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 existed for 1 (Patient #1) of 20 patients reviewed seeking emergency services for care. The findings include: Review of the Policy on 1/24/24, “Medical Screening Examination (MSE)”, Policy #561, last approved 4/6/22, revealed in part, “An Individual who ‘comes to the emergency department “requesting emergency services or has presented on hospital property ...shall receive an appropriate medical screening examination with 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 Policy on 1/24/24, “Triage of Patients in the Emergency Department (ED) Guidelines For” Policy #884, last approved 7/26/23 was reviewed. The policy revealed in part, “Triage is the process of sorting patients quickly to identify patients with life- threatening conditions or a high-risk situation from patients who can safely wait. The triage process may be a multi-tiered, may by-pass the traditional location, or may be conducted in a team approach. The goal of the triage process is to address emergent needs immediately.” Policy review revealed on 1/24/24, the Refusal of Treatment or Transfer Policy #762, last approved 1/11/2023, stated: Purpose - To outline the procedure for individuals who refused examination, care, treatment, or transfer for an emergency medical condition. Policy - Every competent adult had the fundamental right of self-determination regarding decisions pertaining to his or her own health, including the right to choose or refuse medical care and treatment. In the event an individual refused medical examination, care, treatment or transfer for an emergency medical condition, such refusal should be documented in accordance with this procedure. Procedure - A) When a patient refused examination, care, treatment, or transfer for an emergency medical condition: 1. Inform the individual of their right to examination, care, treatment and/or proposed transfer for an emergency medical condition; and 2. Inform the individual of the risk and benefits of such examination, care, treatment and/or proposed transfer. B) Reasonable steps should be taken to obtain the individual written informed refusal. The written documentation includes the fact the individual had been informed of the risks and benefits of the examination, care, treatment and/or proposed transfer. C) Document in the patient’s electronic health record or on the Withdrawal of Request for Services form (FM#2148), as appropriate: 1. A description of the examination, care, treatment, and/or proposed transfer that was refused; 2. The reason given by the patient for the refusal; 3. If the patient has a medical record, an objective description of behavior relating to their refusal, such as prohibiting a nurse from obtaining vital signs or other types of examination, care, or treatment, should be documented as a nursing note in the electronic health record (EHR); 4. If applicable, that the individual refused to sign the written informed refusal. On 1/24/24 a review of Emergency Medical Services (EMS) patient care record dated 1/07/24 stated they were notified of an 80-year-old female (Patient #1) complaining of abdominal pain and diarrhea with a duration of 7 hours. The EMS assessed the patient and determined to transport Patient #1 to the Emergency Room for further treatment. The EMS crew notified the Emergency Room/Department prior to their arrival to the ED, Patient #1’s chief complaint was abdominal pain and diarrhea for the past 7 hours and that Patient #1 had fleas covering the patient’s chest, upper and lower extremities. The EMS patient care record for Patient #1 stated upon arrival to the ED the charge nurse came outside and spoke with Patient #1 about the procedure to be decontaminated outside in a warm shower prior to coming inside the ED. The charge nurse explained that it was required for Patient #1 to be decontaminated prior to being brought inside the ED. Patient #1 refused and asked if the ambulance could drive her home. The ambulance crew explained to Patient #1 they could not take her home and she asked the ED staff to call her a taxi and send her home. Patient #1 was placed in a wheelchair by ED staff and taken to the front of the ED to wait for a taxi. Patient #1 was never fully registered at the ED prior to leaving. On 1/24/24 at 12:32 p.m., during an interview, Staff A said she was the charge nurse working in the ED on 1/7/24 and remembered when EMS brought them a patient complaining of abdominal pain and diarrhea for the past 7 hours. She said she was told by the EMS crew prior to their arrival at the ED that Patient #1 had fleas covering her chest and upper and lower extremities. She determined Patient #1 needed to be decontaminated prior to entering the ED for the safety of the patient, staff, and other patients currently in the ED. She said Patient #1 refused to be decontaminated prior to entering the ED and stated she wanted to go home. Staff A stated Patient #1 called a taxi to pick her up at the ED front entrance. Staff A said ED staff assisted Patient #1 in a wheelchair to the front entrance of the ED to wait for the taxi. Staff A said because Patient #1 was not decontaminated prior to entering the facility she was never entered into the Central Log system as coming to the hospital via EMS on 1/7/24 seeking assistance with her abdominal pain and diarrhea. She said because Patient #1 was never entered into their computer system an electronic health record was never created with the required information related to the patient’s name, age and sex, the date, time and means of arrival, the nature of the complaint, the patient disposition, and the time of their departure. Staff A further said because the EHR was never initiated for Patient #1, she had no documentation she had initiated a triage assessment to determine the severity of Patient #1’s complaint of abdominal pain and diarrhea. She said she had no documentation she had the Withdrawal of Request for Services form (FM#2148) as required per their policy with a description of the examination/triage she had performed to evaluate Patient #1 abdominal pain and document the reason given by Patient #1 for the refusal of treatment, and if the patient had a medical record, an objective description of behavior relating to their refusal. On 1/25/26 at 9:30 a.m. in an interview. the System Director of RM (SDRM), Healthcare Risk Manager (HRM), Director of Emergency Services (DES), Program Manager of Accreditation and Quality Assurance (PMAQA), and Director of Patient Access (DPA), all confirmed Patient #1 arrived at the ED via EMS with a complaint of abdominal pain and diarrhea as per the EMS patient care record dated 1/7/24. They confirmed an EHR was not created for Patient #1 when she arrived via EMS to the ED related to abdominal pain and diarrhea, and there was no documentation the ED staff had initiated triage or completed the Withdrawal of Request for Services form to include a description of the examination, care, treatment and/or proposed transfer that was refused as per their policy. On 1/25/24 at 10:15 a.m. during an interview, Patient #1 said she had called EMS because she had abdominal pain and diarrhea which was a lot better by the time she arrived at the ED. She confirmed the ED staff had asked her to take a shower outside of the ED because they thought she had fleas. She said she refused to take a shower outside because it was cold, and she did not want to take off her clothing. She said since she was feeling better, she decided to call a taxi and go home. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that an appropriate MSE was provided within the capability of the hospital’s emergency department, including ancillary services to determine whether or not an emergency medical condition existed for patient #1 on January 7, 2024.”