Southeast Georgia Health System- Brunswick Campus

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 42305 Based on facility documents, record reviews, and staff interviews, it was determined that The facility failed to maintain radiologic services according to the needs of patients when timely results of radiology studies were not provided for three patients (P) (P8, P12, P16) out of 13 Emergency Department (ED) patients who had radiological testing while at the ED. Review of the “Radiology Services Independent Contractor Agreement,” March 9, 2020, revealed that Group contracts to be on-call and immediately available to provide specialty services in the specialty of radiology, specifically preliminary services as requested by the Group for patients in need of such services. During the time when Physician is scheduled to provide tele-radiology services, he shall be available by telephone. Physicians will produce reports for preliminary interpretations for routine cases within an average of 30 minutes, and 45 minutes for non-routine cases, of the Radiologist receipt of the patient’s entire radiologic examination. Exhibit A, coverage hours for the facility were from 8:00 PM to 8:00 AM, 365 days. Medical record review revealed the following: 1. P8 - came to the ED on 03/23/2026 at 10:09 PM with complaints of right lower quadrant (abdominal) pain and nausea. P8 was triaged at 10:32 PM. Review of the ED Physician Note revealed that P8 was seen by Medical Doctor (MD) KK on 03/24/26 at 00:07. Review of Orders revealed that a CT (computed tomography) (rotating x-ray machine) of the Abdomen and Pelvis with contrast was ordered Stat (urgent) by MD KK at 00:06 AM. “Radiology” revealed that a CT of the Abdomen/Pelvis with contrast was initiated on 03/24/2026 at 02:18. The on-call radiologist, MD BB, discussed the findings with MD KK at 3:25 AM, and the final report was dictated by MD BB on 03/24/2026 3:25 AM. P8 was transferred to a higher level of care on 03/24/2026 at 5:31 AM. 2. P12 - came to the ED on 03/24/2026 at 2:26 AM with complaints of a fall with neck pain. P12 was triaged at 2:51 AM and seen by MD KK at 3:16 AM. Stat CTs of head, cervical spine, and lumbar spine were ordered by MD KK at 3:16 AM. The CT head was completed at 3:24 AM. The final report was dictated at 4:45 AM by MD NN. The CT cervical spine was completed at 3:29 AM. The results were verbally communicated by MD NN to MD KK at 05:09. The final report was dictated by MD NN at 5:19 AM. The CT lumbar spine was completed at 3:49 AM and the final report was dictated by MD NN at 5:31 AM. 3. P16 - came to the ED on 04/8/2026 at 2:28 AM. P16 was triaged at 03:01 AM and complained of being slapped in the face, knocked unconscious, with left side head/face pain. P16 was seen by MD LL at 4:08 AM. CTs of the head, cervical spine, and facial bones were ordered Stat at 4:08 AM. The exams were completed at 4:44 AM. Results of the CTs were signed by the radiologist (MD) RR from 8:49 AM to 8:50 AM. The final reads by MD RR were from 8:51 AM to 8:52 AM. The ED Physician Note by MD LL, signed at 6:41 AM, stated that the radiology report had been reviewed with no evidence of fractures. An interview took place with the Senior Picture Archive Communication Systems (PACS) Administrator (PA) AA on 04/7/2026 at 1:31 PM in the conference room. PA AA said he was called on 3/24/2026 at 1:20 AM because the emergency department ultrasound and CT were having issues getting images to the outside vendor. PA AA further said that on 3/24/2026, the on-call radiologists were called and started reading the studies. They read all STATs (urgent) studies. The outside vendors read the queued studies anyway and put their read over the hospital’s read. PA said the on-call radiologist (MD) BB wanted reassurance from PA AA that her studies would not be double read. PA AA said the on-call radiologists did not want to read all night when they had to read all the next day. PA AA also said radiology studies were read promptly, but reconciling the studies was difficult. An interview took place with the Executive Director of Cardiovascular and Imaging studies (EDCI) on 04/7/2206 at 2:00 PM in the conference room. EDCI said there had been some issues with tele-radiology. There was a company that provided services after hours from 5:00 PM to 8:00 AM. There were issues that led to delays in getting results back, but it had not been one thing consistently. EDCI said the outside company would normally give preliminary results then a final read. Sometimes there was a delay in getting the final read. A telephone interview took place with the Radiologist (MD) BB on 04/7/2026 at 2:33 PM. MD BB said 03/24/2026 was the second time the server went down; it went down a week prior. MD BB logged into the computer and read the studies. MD BB called PA AA and said she did not want to read the studies since there were double reports after the system came back up. MD BB got a call from ED techs with seven CTs and they were about to do another one. PA AA told MD BB not to worry about the studies, because the server had just come back. MD BB said all the studies were STAT (urgent). MD BB said she expected the ED to call with batches. MD BB did not read the studies because she was told not to worry about them. MD BB said this issue was happening more frequently; it happened to her twice and her colleagues twice in the past month. MD BB said the on-call radiologist (MD) EE was up all night on 4/6/2026, and the tele-radiology system never came back up that night. A telephone interview took place with MD EE on 04/7/2026 at 3:02 PM. MD EE said the tele-radiology system failed on 4/6/2026 at around 1:30 AM and never came back on. The system was down from 1:30 AM to 6:00 AM. MD EE was the back-up radiologist and was reading the STATs (urgent studies). MD EE said the CT techs would call when they had a few studies to be read. MD EE said this issue was happening more frequently; twice to him personally. MD EE read studies from 1:40 AM to 2:00 AM, then 3:00 AM to 3:30 AM. The last batch was from 5:50 AM to 6:00 AM. Non-STATs were read the next morning. An interview took place with the nursing director (RN) FF of the Emergency Care Center (ED) on 04/7/2026 at 3:47 PM in the conference room. RN FF said over the past two months, there had been extreme delays in reading to the extent that multiple patients left AMA (against medical advice) or eloped without the final read being back. There had been some discrepancies in the preliminary reads versus the radiologist on site who may have read the studies the next morning. There was a patient who left AMA that evening who had a long delay. She was tired of waiting for the read. The patient had signed an AMA (against medical advice) form and was aware of the risks of leaving. The ED made a follow-up call that the patient needed a C-collar (neck brace) and to follow up with neurosurgery; she had a C5 (neck) fracture. RN FF said the length-of-stay had increased due to waiting on final reports. RN FF said on 04/6/2026, the nurse and radiology technician notified the physician around 1:30 AM. RN FF said at 5:30 AM, the radiologist on call said he was not reading anything else until 8:00 AM. STAT reads sat there and patients were still in the ED when RN FF got there in the morning. A telephone interview took place with the ED Director (MD) HH on 04/7/2026 at 4:27 PM. MD HH said the tele-radiologist never held to the standard when it came to getting reads back. Sometimes, there was a preliminary read, then half a day later a final read would pop up in the ED. One patient’s preliminary read was normal, then a final read came back as a pulmonary embolism. At night, the ER doctors were relied on to read the CTs and MRIs to look for anything bad. Sometimes a consultant would be involved in looking at the pictures. A telephone interview took place with the ED Clinical Leader (RN II) on 04/8/2026 at 4:05 PM. RN II said there had been a delay in reading for sure. The studies were done, but the reads were awful. People left before the physicians could talk to them. There were some callbacks. The physicians were the ones who called patients concerning radiology reads. The biggest complaints in the ER were wait times; hours for reads, especially on the weekends. There was a patient who left recently who needed neurosurgery for a c-collar (neck brace). The physician tried to call the patient all day, and the RN was finally able to reach her. The patient left AMA because of the wait times. RN II said it was much worse now as far as wait times; at least over the past year and a half. The problem was with tele-radiology. There was nothing to fix the problem. A telephone interview took place with the ED Registered Nurse (RN) JJ on 04/8/2026 at 7:06 PM. RN JJ said there was an issue with the tele-radiology system all night. The ED was waiting three to four hours for radiology readings. Patients left because it took too long to get back the reads. A patient came into the ED with shortness of breath, and the ED was stuck waiting for a read to rule out a pulmonary embolism. The patient was tired of waiting and had been there entirely too long. There was a traffic jam in the ED (patients waiting in exam rooms for results while other patients needed to be seen), especially when the wait was that long. RN JJ said nothing was getting read the night of 04/6/2026. It was common to intermittently wait for CT reads, but there was an extensive amount of time where patients were waiting five to six hours for reads. A telephone interview took place with the ED Doctor of Osteopathy (DO) KK on 04/8/2026 at 4:32 PM. DO KK said there was trouble with tele-radiology at night. The reads took 1.5 to two hours to come back. DO KK had to discharge patients then call them back, or there were calls with different results than the preliminary reads. STAT results took longer than two hours. A telephone interview took place with MD LL on 04/9/2206 at 12:38 PM. MD LL said CTs and MRIs were sent to tele-radiology. There was sometimes a preliminary read, then a final. The final read usually took 30 to 90 minutes. MD LL said there was a radiologist on call. If MD LL was struggling, he could always send the scan to tele-radiology. Sometimes, the reads could take a couple hours. MD LL would act on some CTs before getting the results back.”

“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: 42305 Based on review of medical records, Medical Staff Rules and Regulations, policy and procedures and interviews with staff it was determined that the facility failed to ensure that one patient (P) (P#1) of 20 sampled patients received a complete medical screening examination. Specifically, P#1 arrived at the Emergency Department (ED) by ambulance on 2/23/24 at 12:53 a.m. with complaints of difficulty breathing and pain. P#1 had been in a house fire and had been extracted through a window. The medical screening examination failed to include a musculoskeletal examination and failed to note a wound to P#1’s left foot and was therefore incomplete and inappropriate. Findings included: Cross refer to A2406 as it relates to the facility’s failure to ensure that a complete, appropriate medical screening examination was conducted for P#1.”

“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: 42305 Based on review of medical records, Medical Staff Rules and Regulations, and hospital policy and procedures, it was determined that the facility failed to ensure that one patient (P) (P#1) of 20 sampled patients received a complete medical screening examination within the capacity and capability of the facility. Specifically, P#1 arrived at the Emergency Department (ED) by ambulance on 2/23/24 at 12:53 a.m. with complaints of difficulty breathing and pain. P#1 had been in a house fire and had been extracted through a window. The medical screening examination failed to include a musculoskeletal examination and failed to note a wound to P#1’s left foot and was therefore incomplete and inappropriate. Findings included: A review of P#1’s medical record revealed that she was triaged at 12:59 a.m. Triage notes indicated that bleeding was noted from a surgical wound to the left foot. A Medical Screening Exam (MSE) was initiated at 1:16 a.m. The MSE did not include a musculoskeletal exam nor documentation of the wound to the left foot as noted in a nursing note. Review of an ED Assessment on 2/23/24 at 1:38 a.m. by RN CC revealed that P#1 was involved in a house fire with smoke inhalation. P#1 had a bleeding surgical wound on her left food from being pulled out of the window by a neighbor and an officer. P#1 complained of shortness of breath and pain overall. P#1 was alert and oriented. Review of an ED Progress Note by RN FF on 2/23/24 at 5:15 p.m. revealed that RN FF spoke to P#1’s daughter at the bedside and another family member on the phone. Review of an ED Progress Note by RN EE on 2/23/24 at 8:30 p.m. revealed that P#1 was moved to the Clinical Decision Unit (CDU) exam room 21 for the night at the request of the administrator on call, until resource management could become involved and find a resolution to the patient’s current living situation. Review of an ED Progress Note by the Registered Nurse (RN) DD on 2/24/24 at 10:36 a.m. revealed that family members approached the front desk and said P#1 had developed chest pain. P#1 would be moved back to the ED for reevaluation. Review of the Medical Staff Rules and Regulations, adopted by the health system on 2/26/20, revealed that a Medical Screening in the Emergency Department (ED) would be performed by qualified registered nurses, certified nurse practitioners, physician assistants, and physicians. If the screening was performed by a qualified registered nurse, certified nurse practitioner, or physician assistant, the screening would be performed according to established policy with the physician readily available for personal supervision except for life-threatening situations. Patients determined to have an emergency medical condition would be evaluated by an emergency medicine physician. Review of the “EMTALA - Medical Screening Examination and Stabilization Policy,” Version 1, reviewed 11/1/21, revealed it was the policy of the health system that when an individual came to the dedicated emergency department (DED) requesting examination or treatment for a medical condition, an appropriate medical screening examination (MSE) within the capabilities of the hospital’s DED would be performed by an individual qualified to perform such examination. The determination of whether an individual was stable or not was not based on the clinical outcome of the individual’s medical condition. An individual was considered stable when the physician determined that the condition that caused the individual to seek care in the ED was resolved although the underlying medical condition may have persisted.”