Piedmont Augusta Hospital

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47717 Based on review of medical records, facility policies and procedures, and staff interviews, it was determined that facility staff failed to turn one patient (P) (P1) of four patients reviewed every two hours. Findings included: A review the flowsheets revealed that P1 had sacral and right hip pressure injuries on admission. Review of P1’s progress notes dated 04/03/2026 through 04/08/2026, failed to reveal that P1 was turned and repositioned every two hours for ten of 36 staffing shifts (12-hour) reviewed . A review of the facility’s policy titled “Skin Assessment and Care,” number 15581456, last revised 04/05/2024, revealed if patient had a wound or skin breakdown noted and no orders for treatment are present, consult Wound Care Team, via EMR and follow approved nurse treatment protocols per Skin Breakdown Prevention Procedures. For patients with Braden Score of 18 or less, document prevention interventions on the Skin Injury Prevention flowsheet. A review of the facility’s “Nursing Skill Preventing Pressure Injuries in Adults,” revealed steps to prevent pressure injuries involve assessment of the patient’s risk of pressure injury development, frequent patient repositioning, nutritional supplementation, promotion of good hygiene, mobility as tolerated , use of pressure-redistributing devices/equipment, and avoidance of mechanical forces that contribute to pressure injury development. If patient cannot independently turn in bed, reposition every 1-2 hours per facility protocol, as ordered, or as tolerated by patient’s condition. An interview was conducted with RN FF on 05/12/2026 at 10:05 AM in the conference room. RN FF stated that her expectation was that staff turn patients every two hours unless patient is independent. RN FF stated Patient Care Technicians (PCT) can turn and chart on patients. RN FF stated she has informed the staff to make sure patients were turned every two hours and if they are unable to do so then they should ask for help. An interview was conducted with RN GG via telephone on 05/12/2026 at 12:35 PM. RN GG stated she did not remember P1. RN GG stated staff are supposed to turn patients every two hours if they cannot turn themselves. RN GG stated her goal was to always turn the patient but sometimes it just does not happen. RN GG stated turning is supposed to be charted under the daily part of the flowsheet.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47717 Based on review of medical records, facility policies, and staff interviews, the facility’s staff failed to provide appropriate nursing care. Specifically, the facility failed to turn one patient (P) P1 of four patients reviewed every two hours on 56 of 72 patient days. Findings included: A review of the facility’s Inpatient Admission Log revealed that P1 was admitted to the facility on 02/21/2026. A review of P1’s medical record revealed that he had multiple comorbidities and was admitted from a nursing home. A review of P1’s Wound Care Team progress notes revealed on admission P1 had pressure wounds to right hip, sacrum (Stage IV), left great toe, left heel, left second toe, and right ear. On 03/17/2026 P1 had two new pressure wounds on the left and right Ischial Tuberosity (pair of bony prominences at the base of the pelvis that support body weight when seated) unstageable and on 04/29/2026 scalp pressure wound unstageable. A review of Physical Therapy (PT) progress notes revealed that PT saw P1 three times a week for the first week of admission and then two times a week thereafter. Dressings were changed by PT, Wound Care Team and nursing services. A review of the Plan of Care revealed P1 was to be turned every two hours using wedges and elevating heels off bed with pressure relief boots. A Specialty Mattress and nutritional consult was ordered. P1’s Braden score (evidence-based assessment tool developed to predict a patient’s risk of developing pressure injuries (sores) ranged from 8-12 during the admission. A review of nurses notes and daily care flowsheets for 2/21/2026 through 05/03/2026 failed to reveal documentation that P1 was turned at least every two hours on 56 of 72 days A review of care management notes on 04/29/2026 revealed that P1’s spouse refused to have P1 discharged to a Skilled Nursing Facility (SNF) and requested transfer to a Long Term Acute Care (LTAC). P1 had been declined by multiple facilities. Care management staff will continue search for placement options. A review of the facility Complaint and Grievance Log revealed that P1’s spouse reported a complaint related to discharge planning on 03/25/2026 and a complaint related to wounds and P1 not being turned on 04/27/2026. No other grievances or complaints were reported by P1’s spouse from 02/21/2026 - 05/04/2026. A review of the facility’s policy titled “Skin Assessment and Care,” number 15581456, last revised 04/05/2024, revealed if patient had a wound or skin breakdown noted and no orders for treatment are present, consult Wound Care Team, via EMR and follow approved nurse treatment protocols per Skin Breakdown Prevention Procedures. For patients with Braden Score of 18 or less, document prevention interventions on the Skin Injury Prevention flowsheet. A review of the facility’s Nursing Skill “Preventing Pressure Injuries in Adults,” revealed steps to prevent pressure injuries involve assessment of the patient’s risk of pressure injury development, frequent patient repositioning, nutritional supplementation, promotion of good hygiene, mobility as tolerated , use of pressure-redistributing devices/equipment, and avoidance of mechanical forces that contribute to pressure injury development. If patient cannot independently turn in bed, reposition every 1-2 hours per facility protocol, as ordered, or as tolerated by patient’s condition. An interview was conducted with Registered Nurse (RN) CC on 05/04/2026 at 2:18 PM in the conference room. RN CC stated that nurses were expected to turn patients every two hours as well as document in the patient’s medical record every two hours. An interview was conducted with RN FF on 05/05/2026 at 10:30 AM in the conference room. RN FF was on the Wound Care Team. RN FF explained that patients with wound care consults were evaluated and remained on the wound care teams patient list throughout the duration of the admission. RN FF explained that the wound care team assessed patients weekly if staffing was adequate. When the wound care team recommended debridement, either physical therapy (PT) or general surgery was consulted. RN FF explained that she had evaluated P1 and observed that his wounds looked better. An interview with PT Manager (PTM) GG took place on 05/05/2026 at10:39 AM in the conference room. PTM GG explained that PT was consulted to assess patient’s wounds and wound debridement if necessary. Nursing staff performed dressing changes in between PT visits. PTM GG recalled that PT consulted on P1 three times a week for the first week of his admission. After the first week, P1’s wounds were improved that the frequency of PT visits decreased to twice a week. An interview was conducted with Accreditation and International Standards of Organization (ISO) Manager (AM) AA on 05/05/2026 at 10:55 AM. AM AA explained that nursing was expected to turn patients every two hours when patients were unable to turn themselves. Staff were to document turns in the flowsheet or the nurses notes. A phone interview was conducted with Medical Doctor (MD) BB on 05/05/2026 at 12:02 PM. MD BB stated P1 had been in the hospital for about 75 days. MD BB recalled that he evaluated P1 last week and there was no change in his condition since admission. MD BB recalled that P1 had existing decubiti in various places, was on tube feeds, emaciated and contracted on admission. MD BB’s opinion was that P1 was getting good wound care. MD BB further explained that P1 was nonverbal and did not respond to verbal cues. MD BB explained that P1 was being cared for as good as possible but his prognosis was not positive. MD BB reported that the family has been kept updated on his condition and care. P1 remained hospitalized because finding placement was difficult. An interview was conducted with RN EE on 05/05/2026 at 1:31 PM in the conference room. RN EE stated he was a traveling nurse and assigned to the float pool where he is occasionally assigned as the charge nurse on various med/surgery units. RN EE stated he remembers P1. RN EE stated P1’s medical history was complex and he was in critical condition. RN EE stated P1 had a trach and had significant wounds that were being treated. RN EE stated he did not remember a time when he did not have a patient care aide to assist him with patient care. RN EE stated he did understand that patients who cannot turn themselves should be turned every two hours by a nurse or patient care aide. RN EE stated this care should be documented in the daily care flowsheets and/or in the nurse’s notes.”

“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: 49398 Based on a review of policy and procedures, facility surveillance video, police body camera video, medical records, and interviews with staff it was determined that (P#1) was not provided an appropriate medical screening examination (MSE) when he presented to the hospital’s Emergency department, with Law Enforcement acting on his behalf and requested a mental evaluation. As this resulted in patient #1 not receiving an appropriate medical screening examination that was within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition existed. 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: 49398 2405 Based on a review of policy and procedures, central log, facility Incident Report, facility surveillance video, police body camera video, and interviews with staff it was determined that the facility failed to maintain a central log when one (P#1) of 20 sampled patient was brought to the ED accompanied by law enforcement seeking medical assistance for a medical condition, and was not entered into the central log. P#1 presented to the facility’s Emergency Department (ED) on 5/2/24 accompanied by law enforcement for a psychiatric evaluation. Findings Included: A review of the facility’s policy titled “Transfer Activities in Accordance with EMTALA Requirements Policy,” policy# 11101630, last revised 1/27/22, revealed the following definitions: Record Keeping: j. A central log on each individual who “comes to the Emergency Department” seeking assistance. Such log should include whether the patient.” “ Refused treatment. “ Was refused treatment. “ Transferred to another facility. “ Was admitted and treated. “ Was stabilized and transferred. “ Was discharged. A review of the facility’s policy titled “Patients in Custody of Law Enforcement Agencies: Admission Hospital Safety and Dismissal (Guarded and Unguarded),” policy# 14644533, last revised 10/1/23, revealed the following: The policy revealed in part, 1. Admission/Registration ...access management will register the patient at that site.” A review of the facility’s Central Log dated 11/1/23 through 5/14/24 failed to reveal that Patient (P) #1 was registered as a patient on 5/2/24 at 4:12 a.m. A review of the facility’s Incident Report dated 11/1/23 through 5/14/24 for the ED failed to reveal an entry related to P#1. A review of the facility video recording time stamped 4/2/24 revealed: 11:47 a.m.: P#1 observed accompanied by a female police officer (PO JJ) and approached the ED registration desk. Despite Patient #1 being brought to the ED registration Desk by PO JJ, the facility failed to ensure the patient was entered in the central log as stated in their policy. 11:53 a.m. P#1 observed speaking to Patient Access Representative (PAR) EE. 12:29 p.m. PO JJ observed speaking with Patient Care Technician (PCT) DD. PO JJ remained at PAR EE’s window. At 4:12:19 a.m. a male officer (PO KK) was seen approaching PCT DD’s window and appeared to speak with PCT DD while PO JJ remained with P#1 at PAR EE’s window. Further review revealed that at 4:12:33 a.m., PO KK moved to RN AA’s window and began speaking with her. At 4:12:47 a.m. PO JJ and P#1 observed moving closer to PCT DD’s window. P#1 observed speaking to PCT DD. At 4:12:51 a.m., P#1 abruptly turned around and left the facility ED while both officers (PO JJ, and PO KK) remained at the registration window speaking to RN AA. At 4:13:16 a.m., PO JJ was seen leaving the facility ED, while the PO KK remained speaking to RN AA until 4:13:30 a.m. when he was additionally observed leaving the ED area. A review of officer body camera video (BCV) #1, timestamped 4:10:34 - 4:10:39, revealed that PO JJ approached PAR EE’s window and said, “Hello, here for an eval, where do we go for that?” Continued review of BCV #1, timestamped 4:10:40 - 4:11:23, revealed that PCT DD asked PO JJ, “What agency are y’all?” to which PO JJ replied, “Agency name. He requested to come here.” P#1 interjected and asked, “Who? No, y’all brought me here. I didn’t want to come to the hospital at first. I know you have to have a warrant to get people off to a property and y’all didn’t give me no warrant. So, you know arrest them and take them in behind a locked door.” PO JJ replied to P#1, “You’re not under arrest though.” P#1 responded, “But I’m saying a warrant is something that will put a person in a car.” PO JJ explained, “No, a warrant is for an arrest.” P#1 quickly interjected, “That’s what I’m saying, you didn’t give me a warrant. It was the first time you saw me on that property.” Continued review BCV #1, timestamped 4:11:24 - 4:11:36 PO JJ was seen moving closer to PCT DD’s window during which time PAR EE asked P#1, “Are you checking in?” P#1 replied, “Naw, I don’t wanna check in.” PCT DD looked over to P#1 and said, “You’re free to go.” P#1 responded, “Okay.’ and was seen walking out of the facility. A review of BCV #2, timestamped 4:11:10 - 4:11:20, revealed that PO KK approached PCT DD and asked PCT DD, “Who do I need to speak to about this?” PCT DD then gestured with his finger, pointing, to RN AA. Continued review of BCV #2, timestamped 4:11:21 - 4:11:45, revealed that PO KK approached RN AA and explained, “So, we found him lying down, face down over here by the old Sears building across from McDonald’s.” RN AA replied, “He said he didn’t want to come here.” Continued review of BCV #2, timestamped 4:11:50 - 4:12:10 revealed that PO KK explained to RN AA, “Well, the reason we brought him over here is that he was saying that people were trying to rape him, like the police, you know, was raping him. Talking out of his mind.” RN AA replied, “Did y’all assist him, or did y’all just decide to bring him here?” PO KK explained, “No, he said he wanted to come to Piedmont. We asked him if he wanted to go to (name of another hospital) and he specifically told us Piedmont and now he’s changed his mind.” RN AA replied, “Okay”. PO KK was seen exiting the area. During an interview on 5/14/24 at 4:25 p.m. in a board room with the Emergency Department Director (EDD) CC, EDD CC stated that she took the role of EDD CC on March 24. EDD CC said that she expects the check-in staff to enter all patients that enter the ED into the central log. She said that the former EDD did not require staff to enter patients under certain circumstances into the central log and that has created some confusion amongst the ED staff regarding the central log. During an interview on 5/14/24 at 4:36 p.m. with Director of Patient Access (DPA) MM in a board room, DPA MM stated that her expectations of the patient access representatives (PAR) that work in the ED are to greet patients, enter the patient’s information in the system, find out why they need to be seen and obtain consent signatures. She said everyone who comes into the ED to be evaluated should be evaluated. DPA MM added that she expects PAR to make every attempt possible to get the patients’ information. When this surveyor asked about the facility’s policy on the central log, DPA MM stated she did not know the facility’s policy regarding record keeping in the central log. A telephone interview was conducted on 5/14/24 at 9:15 p.m. with PAR EE. PAR EE stated that she remembered P#1 being brought in by a couple of AUPD (Augusta University Police Department) officers. She recalled asking P#1 to enter his social security number and P#1 responded by saying he did not want to check in. PAR EE said she did not have to enter P#1 into the central log because P#1 didn’t want to provide his information. She said she would enter a patient as “Jane” or “John Doe” if the patient was unable to give their information. During an interview on 5/15/24 at 10:12 a.m. with RN AA in a board room, RN AA stated that she recalled P#1 being brought into the ED by two officers. She added that if a patient does not give staff their information and they leave, nothing will be entered into the central log because staff would not know what information to add. During an interview on 5/15/24 at 2:00 p.m. with CN LL in a board room, CN LL stated that she has been an ED Nurse for seven years and a relief ED Charge Nurse for one and a half years. CN LL said that she was working as the Charge Nurse in the ED on 5/2/24. CN LL did not recall being called or notified by staff that P#1 was brought in for an evaluation and left. She added that if she had been notified, she would have encouraged P#1 to go to a room with her to be evaluated by a provider. Additionally, she would have had PAR enter him as a “John Doe” in the central log if he had not provided his information. CN LL further added that she feels like there needs to be more employee education regarding EMTALA regulations and policies. The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to maintain a central log on Patient #1 on 5/2/2024 who came to the emergency department seeking medical 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.”

“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: 49398 Based on a review of policy and procedures, facility surveillance video, police body camera video, medical records, and interviews with staff it was determined that (P#1) was not provided an appropriate medical screening examination (MSE) when he presented to the hospital’s Emergency department, with Law Enforcement acting on his behalf and requested a mental evaluation. As this resulted in patient #1 not receiving an appropriate medical screening examination that was within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition existed. Findings Included: A review of the facility’s policy titled “Transfer Activities in Accordance with EMTALA Requirements Policy,” policy# 11101630, last revised 1/27/22, revealed in part, “ ...Definitions: Capacity was the ability of the receiving facility to accommodate an individual who had been referred for transfer from another facility and encompassed such things as numbers and availability of qualified staff, beds, and equipment and the hospital’s past practices of accommodating additional patients in excess of its occupancy limits. Comes to the Emergency Department- with respect to an individual requesting examination or treatment for an emergency medical condition (EMC) that the individual was on the facility’s property, at or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways. Emergency Medical Condition -was a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to psychic disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could be expected to result in either: a. 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 b. Serious impairment to bodily functions. c. Serious dysfunction of any bodily organ or part: or d. With respect to a pregnant woman who is having contractions: That there is adequate time to effect a safe transfer to another hospital before delivery; or that the transfer may pose a threat to the health or safety of the woman or her unborn child. Involuntary Status- applied equally to patients with psychiatric, drug, or alcohol-related conditions. Such patients who presented to the ED would receive a medical screening examination (MSE) and if they were found to have an EMC, they would receive stabilizing treatment within the capabilities and capacity of the facility. If their condition remained unstable an EMTALA appropriate transfer would be arranged for them. The appropriate involuntary transfer forms (1013;2013) for a general psychiatric referral or for a drug or alcohol referral, must be utilized and completed in addition to the hospital transfer forms. No consent to transfer the patient was required. A review of the facility video recording time stamped 4/2/24 revealed: 11:47 a.m.: P#1 observed accompanied by a female police officer (PO JJ) and approached the ED registration desk. 11:53 a.m. P#1 observed speaking to Patient Access Representative (PAR) EE. 12:29 p.m. PO JJ observed speaking with Patient Care Technician (PCT) DD. PO JJ remained at PAR EE’s window. At 4:12:19 a.m. a male officer (PO KK) was seen approaching PCT DD’s window and appeared to speak with PCT DD while PO JJ remained with P#1 at PAR EE’s window. Further review revealed that at 4:12:33 a.m., PO KK moved to RN AA’s window and began speaking with her. At 4:12:47 a.m. PO JJ and P#1 observed moving closer to PCT DD’s window. P#1 observed speaking to PCT DD. At 4:12:51 a.m., P#1 abruptly turned around and left the facility ED while both officers (PO JJ, and PO KK) remained at the registration window speaking to RN AA. A review of officer body camera video (BCV) #1, timestamped 4:10:34 - 4:10:39, revealed that PO JJ approached PAR EE’s window and said, “Hello, here for an eval, where do we go for that?” Continued review of BCV #1, timestamped 4:10:40 - 4:11:23, revealed that PCT DD asked PO JJ, “What agency are y’all?” to which PO JJ replied, “Agency name. He requested to come here.” P#1 interjected and asked, “Who? No, y’all brought me here. I didn’t want to come to the hospital at first. I know you have to have a warrant to get people off to a property and y’all didn’t give me no warrant. So, you know arrest them and take them in behind a locked door.” PO JJ replied to P#1, “You’re not under arrest though.” P#1 responded, “But I’m saying a warrant is something that will put a person in a car.” PO JJ explained, “No, a warrant is for an arrest.” P#1 quickly interjected, “That’s what I’m saying, you didn’t give me a warrant. It was the first time you saw me on that property.” Continued review BCV #1, timestamped 4:11:24 - 4:11:36 PO JJ was seen moving closer to PCT DD’s window during which time PAR EE asked P#1, “Are you checking in?” P#1 replied, “Naw, I don’t wanna check in.” PCT DD looked over to P#1 and said, “You’re free to go.” P#1 responded, “Okay.’ and was seen walking out of the facility. The form titled, “Health Augusta Exam (MSE) Offer Report dated 5/2/2024 at 3:53 P.M. for patient #1 was reviewed. The questions asked on the form, “Was this individual offered medical treatment /Screening (MSE) Exam (examination), and “Was Medical/Treatment/Screening (MMSE) refused” and both boxes “yes was checked off. Further review revealed in part, “Specifics of Situation: ... Law enforcement not medical ...request Piedmont for Mental Eval (evaluation) once at Piedmont he said he did not want to be treated.” Patient #1 reported to the hospital’s emergency department by Law Enforcement, (acting on the patient’s behalf) and requested a mental evaluation due the patient having altered mental status, and felt the patient needed be medically evaluated. The facility failed to ensure that their policy was followed as evidenced by failing to provide an appropriate medical screening examination was provided on 5/2/2024 when patient #1 presented to the hospital and a request was made by Law enforcement for a mental evaluation. The facility failed to ensure that Patient #1 was placed on an Involuntary Status due to the patient presenting to the hospital’s ED with psychiatric condition, would receive a medical screening examination within the capabilities and capacity of the hospital as stated in the hospital’s policy and procedure. On 5/21/24 patient #1 presenting to the ED with Law Enforcement (acting on Patient #1’s behalf) requesting a mental evaluation because they found the patient experiencing altered mental status (a change in mental function), and no medical screening examination was provided by a Qualified Medical Personnel. During a telephone interview on 5/14/24 at 3:15 p.m. with Police Captain (PC) BB, PC BB stated that he was made aware of the situation involving his offers and P#1. PC BB said that his officers conducted a building check on their property when they discovered P#1 lying face down in the grass. He said that the officers asked for P#1’s name but were unable to verify it because their computer systems were down. PC BB stated that officers said that P#1 appeared to have an altered mental status, and they felt strongly that he needed to be medically evaluated. When officers spoke to P#1 about being screened, P#1 insisted on being brought to the facility. PC BB said that upon arrival at the facility registration area, P#1 told the patient care access representative that he did not want to be evaluated and declared that if he was not under arrest, he was leaving and then proceeded to walk out of the ED. Officers spoke to the ED nurse at registration and tried to explain that P#1 was not mentally stable. PC BB stated that an ED staff member said P#1 seemed of sound mind and could make his own decisions. He added that his officers filed an EMTALA form because that is what they are trained to do anytime they bring a patient to the facility needing a medical screening. During an interview on 5/14/24 at 4:25 p.m. in a board room with the Emergency Department Director (EDD) CC, EDD CC stated that she took the role of EDD CC on March 24. She said that any patient that comes into the ED is supposed to receive an MSE and that if a patient refuses treatment the Charge Nurse should be notified, and they would have a qualified staff member try to speak with the patient and conduct an MSE. EDD CC said that neither a Patient Care Technician (PCT) nor a Registered Nurse (RN) are qualified to determine a patient’s competency. She added that if a patient presents to the ED with an altered mental status a provider would need to declare the patient competent to make their own decisions. During an interview on 5/14/24 at 4:36 p.m. with Director of Patient Access (DPA) MM in a board room, DPA MM stated that her expectations of the patient access representatives (PAR) that work in the ED are to greet patients, enter the patient’s information in the system, find out why they need to be seen and obtain consent signatures. She said everyone who comes into the ED to be evaluated should be evaluated. DPA MM added that she expects PAR to make every attempt possible to get the patients’ information. A telephone interview was conducted on 5/14/24 at 9:15 p.m. with PAR EE. PAR EE stated that she has been a night shift PAR for the facility for seven years. PAR EE said that she remembered P#1 being brought in by a couple of PO’s. She recalled asking P#1 to enter his social security number and P#1 responded by saying he did not want to check in. PAR EE added that she could recall either the PCT DD or RN AA going back and forth with the officers and that the officers told them that the patient requested to come to that facility. She further added that P#1 stated that he did not ask to go there and that if he was not under arrest he was leaving. PAR EE said that after P#1 made that statement he turned around and walked out. PAR EE stated that when a patient leaves the ED for any reason, she should let the charge nurse know. PAR EE could not recall if she let the Charge Nurse know that P#1 walked out. She added that it seemed to her that P#1 was the facility across the streets issue, and they just wanted to get rid of him, so they brought him to their facility. PAR EE further added that she receives annual EMTALA training During an interview on 5/15/24 at 8:00 a.m. with Patient Care Technician (PCT) DD in a conference room, PCT DD stated that he has been a Certified Nurse’s Assistant (CNA) for 14 years and a PCT for the facility for two years and four months. He added that his duties in the ED include taking patients from registration to a room, assisting patients from their vehicles, patient sitting, and assisting the nurses with anything they may need. PCT DD said the morning P#1 came in he was working at the check-in desk with PAR EE and RN AA. He recalled P#1 being accompanied into the ED by police officers. He additionally recalled hearing police officers (PO) say they found P#1 on an adjacent property, and then he heard P#1 say he did not want to be at the facility. PCT DD said that police officers should not have brought P#1 through that entrance. He added that patients accompanied by law enforcement are supposed to use a different entrance. He further added that he did not speak to the PO’s or P#1 as the officers spoke to RN AA. PCT DD said that they have had three patients from another facility be brought in by PO’s within one week, and P#1 was one of them. He said two were seen in the ED and one (P#1) was not seen. He added that staff are supposed to notify the Charge Nurse if a patient walks out and leaves. PCT DD recalled learning in EMTALA training that all patients seeking treatment in the ED should get an MSE at the bare minimum. He added that he receives EMTALA training annually. During an interview on 5/15/24 at 10:12 a.m. with RN AA in a board room, RN AA stated that she recalled P#1 being brought into the ED by two PO’s. She recalled hearing PO KK say that they found P#1 asleep on their property. She said P#1 told the staff at the window that he did not ask to come to the facility. RN AA said protocol, when a patient is brought in by law enforcement, is for PAR to get the patient’s information, such as name and birthdate, while police give the RN a report on the patient. She added that if a patient is in custody, then the patient has no choice but to stay and P#1 told the staff that he was not in custody. Additionally, she said that P#1 did not appear to be in any distress, in her opinion, but that she did not speak to him directly. She explained that she is expected to call the charge nurse if a patient walks out of the ED without being evaluated. RN AA could not remember if she called the charge nurse when P#1 left the facility. RN AA said that per EMTALA regulations, the facility cannot refuse treatment to anyone who comes through the ED door. RN AA stated that she receives annual EMTALA training. During an interview on 5/15/24 at 2:00 p.m. with CN LL in a board room, CN LL stated that she has been an ED Nurse for seven years and a relief ED Charge Nurse for one and a half years. CN LL said that she was working as the Charge Nurse in the ED on 5/2/24. She said she frequently works at the check-in desk triaging patients as they come into the ED. CN LL stated that when a patient with an altered mental status comes into the ED she has them assessed first by an ED provider and if the patient is unable to provide their information, she enters them into the central log as “Jane” or “John Doe” regardless of what their disposition ends up being. CN LL added that if a patient wants to leave or tries to leave the facility the Charge Nurse should be notified immediately so they can speak to the patient and try to encourage the patient to stay and discuss the risks and benefits of leaving. CN LL did not recall being called or notified that P#1 was brought in for an evaluation and left. She added that if she had been notified, she would have encouraged P#1 to go to a room with her to be evaluated by a provider. CN LL further added that she feels like there needs to be more employee education regarding EMTALA regulations and policies. CN LL said she receives annual EMTALA training.”

“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, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) 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 for one (P#1) of 20 sampled patients when she was transported to the ED on 11/24/23. Family members requested that P#1 be evaluated for behavioral health symptoms. 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: 42305 Based on review of the Emergency Department Log, video surveillance, facility policies and staff interviews, it was determined the facility failed to maintain a central log on P#1 who came to the emergency department seeking medical assistance, when she was transported to the ED on 11/24/23 by family members for evaluation of behavioral health symptoms. The findings included: A review of the facility’s Emergency Department log failed to reveal an entry for P#1 on 11/24/23. Video surveillance was requested concerning Patient (P) #1. A review of the video surveillance provided took place in the security office with Public Safety Officer (PSO) AA on 12/4/23 at 4:30 p.m. The following timeline was observed from 11/24/23: 8:28:43 - A white sport-utility vehicle (SUV) with darkly tinted windows pulled into the ambulance bay. 8:33: 12 - The driver’s side rear window was lowered, and it was observed that a person was flailing her arms outside the window. 8:33: 57 - Staff identified as RN CC and Patient Care Technician (PCT) DD were observed coming out of the ED. 8:34:58 - RN CC was observed at the rear window of the vehicle. PSO AA said RN CC was talking to the female in the back seat of the vehicle. 8:36:34 - The individual in the back seat was observed hanging out of the window. 8:38:48 - The male family member got out of the car and forced the female in the back seat back into the car. 8:39:10 - The vehicle pulled away from the ED. A review of the facility’s policy titled “Transfer Activities in Accordance with EMTALA Requirements Policy” #11101630, last revised 1/27/22 revealed that with respect to an individual requesting examination or treatment for an emergency medical condition (EMC), the individual “came to the Emergency Department” when the individual was on hospital property or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways. The ED would maintain a central log on everyone who came to the emergency department seeking assistance, which would include whether the patient refused treatment, was refused treatment, transferred to another facility, was admitted and treated, was stabilized and transferred, or was discharged. An interview took place with the Public Safety Officer (PSO) AA on 12/4/23 at 3:55 p.m. in the Conference Room. PSO AA said a car pulled into the ambulance bay, and he and PSO BB walked outside to the vehicle. A man got out of the vehicle and was speaking to the Registered Nurse (RN) CC, saying his daughter was having a breakdown and was out of control. The rear window of the car was lowered, and RN CC asked the patient’s name, date, and if she knew where she was. A telephone interview took place with the Registered Nurse (RN) CC on 12/4/23 at 4:44 p.m. RN CC said she did not get P#1’s name because P#1 never came into the ED. The policy was that patient’s had to be present at the desk to be put on the log. RN CC said she asked P#1 orientation questions, but information was never put into the system. The facility failed to ensure that their Policy and procedure was followed as evidenced by failing to ensure that when Patient #1 came to the hospital’s ED, the hospital failed to maintain a central log on patient #1 seeking medical assistance for a medical condition.”

“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, policy and procedures, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) 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 for one (P#1) of 20 sampled patients when she was transported to the ED on 11/24/23. Family members requested that P#1 be evaluated for behavioral health symptoms. The findings included: A review of the Medical Staff Rules and Regulations, Section 5, Medical Screening Exam for Emergency Department (ED), revealed that any patient who requested examination or treatment would receive an appropriate medical screening examination within the capacity of the emergency department to determine whether an emergency existed. A review of the facility’s “Transfer Activities in Accordance with EMTALA Requirements Policy” #11101630, last revised 1/27/22, revealed that it was the policy of the facility to provide an appropriate medical screening examination (MSE), stabilizing treatment, and/or an appropriate transfer. With respect to an individual requesting examination or treatment for an emergency medical condition (EMC), the individual “came to the Emergency Department” when the individual was on hospital property or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways. Continued review of the policy revealed that an emergency medical condition was a condition manifesting itself by acute symptoms of such severity, including pain, psychic disturbances, or symptoms of substance abuse, that the absence of immediate medical attention could reasonably be expected to place the health of the individual in serious jeopardy. The policy revealed that Involuntary Status applied equally to patients with psychiatric or drug/alcohol related conditions. Such patients who presented to the ED would receive a medical screening examination and stabilizing treatment. If their condition remained unstable, an appropriate transfer would be arranged. The appropriate involuntary transfer forms (1013,2013) were required to be utilized and completed in addition to the hospital transfer forms. No consent for transfer from the patient was required. Video surveillance was requested concerning Patient (P) #1. A review of the video surveillance provided took place in the security office with the Public Safety Officer (PSO) AA on 12/4/23 at 4:30 p.m. The following timeline was observed from 11/24/23: 8:28:43 - A white sport-utility vehicle (SUV) with darkly tinted windows pulled into the ambulance bay. 8:33: 12 - The driver’s side rear window was lowered, and it was observed that a person was flailing her arms outside the car window. 8:33: 57 - Staff identified by PSO AA as RN CC and Patient Care Technician (PCT) DD were observed coming out of the ED. 8:34:58 - RN CC was observed at the rear window of the vehicle. PSO AA said RN CC was talking to the female in the back seat of the vehicle. 8:36:34 - The individual in the back seat was observed hanging out of the window. PSO AA said the individual was screaming. The deputy and the father were observed standing behind the vehicle. PSO AA said the deputy and father were talking, but he could not hear the conversation. 8:37:10 - CD EE and the father were observed walking to the rear passenger door. PSO AA said the dad pushed the girl back into the vehicle. 8:38:01 - The father got into the car. The individual was still hanging out of the window. 8:38:48 - The father got out of the car and forced her back into the car. 8:39:10 - The vehicle pulled away from the ED. Further review revealed that Patient #1 was taken to another hospital by her parents. Review of the medical record revealed that patient #1 arrived at the other hospital on 11/24/2023 at 8: 52 P.M. The reason for the hospital visit was listed as “MENTAL HLTH (Health).” Further review revealed in part, “History and Present Illness ... female with history of panic attacks, meth (methamphetamine recreational drug) and THC (Marijuana) abuse presents to ER (emergency room) intoxicated and appearing manic, received Haldol (drug used to treat symptoms of agitation, irritability and delirium) 5mg/Versed (drug used to treat anxiety and tension) 5 mg IM (intramuscular) on arrival for acute agitation. UDS (Urine Drug Screen) + (positive) meth & THC. Patient was observed by ER team overnight and reassessed after some metabolization of substance, however, on reassessment still appeared pressured speech in speech, agitated, and delusional so psychiatry consulted ...She states has anxiety and PTSD (Post Traumatic Distress Disorder-an anxiety disorder that develops after experiencing or witnessing a terrifying event) but marijuana is only this that makes it better.” Review of the medical record titled “Discharged.” Patient #1’s Discharge Diagnosis was listed as “Methamphetamine use (other stimulates abuse, uncomplicated).” Further review revealed in part, “Hospital Course ... In reassessment on 11/26/2023, patient denies SI (suicidal ideation)/HI (Homicidal Ideation)/AVH (Audio visual hallucinations) ...Agreeable to take Zyprexa 2.5 mg PO (by mouth) QHS (every night) and follow-up with outpatient psychiatry..” The patient was discharged from the hospital on 11/26/2023. An interview took place with the Public Safety Officer (PSO) AA on 12/4/23 at 3:55 p.m. in the Conference Room. PSO AA said a car pulled into the ambulance bay, and he and PSO BB walked outside to the vehicle. A man got out of the vehicle and was speaking to the Registered Nurse (RN) CC, saying his daughter was having a breakdown and was out of control. The rear window of the car was lowered, and RN CC asked the patient’s name, date, and if she knew where she was. RN CC then asked the patient if she wanted to be treated, and the patient said no. The patient’s mother demanded the nurse remove the patient from the vehicle and treat her, but if the patient was declining treatment, she could not be forced. The patient started throwing shoes out the window and screaming obscenities. When the nurse said she would not pull the patient out of the car, the father said to get someone else. The nurse went into the Emergency Department (ED). RN CC came back and said the doctor would not come out. The patient would have to enter the ED to be seen. The patient said she was not going in and did not want to be treated. PSO AA heard the patient say she should just go kill herself, and that she was going to do a gang dance on all their faces. The patient was saying random things that did not make sense. PSO AA said he heard the deputy say the other hospital had a better facility and staff that could handle that. The patient was trying to get out of the vehicle and was screaming, cursing, and threatening. A telephone interview took place with the Registered Nurse (RN) CC on 12/4/23 at 4:44 p.m. RN CC said she did not get P#1’s name on a log, because P#1 never came into the ED. RN CC asked P#1 her name, date of birth, where she was, and what was going on. There was a lot of shouting on P#1’s part, because P#1 was upset that her parents brought her to the ED. RN CC asked P#1 several times if she wanted to be seen, and P#1 declined every time she was asked. The mom was pleading for them to get P#1 out of the vehicle and make her be seen. RN CC informed the mom that the Nurse Practitioner (NP) DD said if P#1 was willing to check in, the ED was more than willing to avail their services, but they could not force care upon her. A telephone interview took place with the off-duty, contracted deputy (CD) EE on 12/4/23 at 5:15 p.m. CD EE said he was sitting in a cubicle near the ED when somebody called to say they were bringing their daughter into the ED. When they pulled up, there was a girl in the back of the vehicle. The parents were asking for her to be seen. The doctor said they were not coming outside to evaluate the patient. CD EE told the dad that she could not be snatched out of the car against her will without a 1013 (involuntary transport order), because it would be kidnapping. All law enforcement hands were tied without a 1013. The individual was screaming and cursing. An interview took place with the Registered Nurse (RN) II while on a tour of the Emergency Department (ED) on 12/5/23 at 9:30 a.m. RN II said if a patient would not enter the ED, she would get the patient’s information and try to get a provider to come outside to screen them. An interview took place with the Nurse Practitioner (NP) JJ while on a tour of the ED on 12/5/23 at 9:30 a.m. NP JJ said he would go outside to evaluate a patient who was refusing to come into the ED. An interview took place with the ED Nurse Manager (RN) FF on 12/5/23 at 10:33 a.m. in the Conference Room. RN FF said it would have been normal for a doctor to go outside to see the patient. RN CC wanted to make sure the patient was alert, oriented and answered questions, but it still should have been the provider. RN FF further said the staff would ask the patient directly if she had thoughts of harming herself, and if so, she would be asked if there was a plan. An interview took place with the ED Medical Director (DO) GG on 12/5/23 at 10:37 a.m. in the Conference Room. DO GG said the staff could not drag people out of cars who refused care. Patients had the right to refuse treatment. If there was an imminent threat to life or limb that needed emergent evaluation, DO GG would expect the medical staff to be outside evaluating the patient. The doctor would not be expected to go out or security drag a patient in unless the situation needed emergent care. The nurse would say if she needed a clinician outside. DO GG further said the ED had an obligation to provide care to those who presented seeking care. An interview took place with the Public Safety Officer (PSO) HH on 12/5/23 at 11:18 a.m. in the Conference Room. PSO AA said that when he arrived on the scene, an individual was in the back of a car acting irate. A lady came out in blue scrubs and asked the individual her name, etc. The lady told the parents if the patient refused medical attention, there was nothing they could do. The doctor said to bring the patient in, but if she was refusing, they could not make her come in. The patient was saying she wanted to walk on their faces and all kinds of stuff. PSO HH said everybody in the vicinity, including RN CC, should have heard when P#1 said she wanted to kill herself. PSO HH said the way the patient was carrying on, she seemed like a threat to herself. RN CC asked the individual her name and where she was, and the individual answered. The individual threw her shoes out of the car and was kicking the window, so PSO HH backed away and did not hear everything that was said. A telephone interview took place with the Patient Care Technician (PCT) DD on 12/5/23 at 2:00 p.m. PCT DD said the nurse asked the patient what was going on and if she wanted to be seen. The patient said no. RN CC was asking orientation questions, which were answered appropriately. RN CC asked the patient if she wanted to get into a wheelchair and come into the ED, and the patient said no. The patient was yelling, stopped to answer the nurse’s questions, then continued to yell. The police officer spoke to the father, and then the patient and father drove away from the ED. PCT DD could not hear what was being discussed when the police officer spoke with the father. A telephone interview took place with the Nurse Practitioner (NP) HH on 12/5/23 at 2:15 p.m. NP HH said the nurse told him there was an adult female who was having mental health problems who did not want to get out of the car. NP HH said that based on the nurses’ report, it sounded like the patient had the capacity to make her own decisions and refused to get out of the car. If she wanted to come in to be evaluated, the ED would be more than happy to see her. NP HH said it was not routine to evaluate patients before they were registered, and it did not seem that the patient was in a state that it was imperative that she be evaluated. The facility failed to ensure that their own policies and procedures were followed as evidenced by failing to ensure that on 11/24/23 Patient #1 presented to the hospital’s property (ambulance bay) via family’s SUV manifesting symptoms of “psychic disturbances” that in absence of immediate medical attention could reasonably be expected to place the health of an individual in serious jeopardy. The patient presented to the ED indicating she wanted to kill herself. As Patient #1 required further evaluation and treatment to determine if the patient was an imminent harm to herself and others. The patient was not placed on an involuntary hold, and no measures were taken by the ED staff to bring Patient #1 into the ED to receive an appropriate medical screening examination.”