Northeast Georgia Medical Center, Inc.

“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, medical records, and interviews with staff it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate transfer; specifically, the facility failed to provide medical treatment that was within its capacity to minimize the risks to the P#1’s health by transferring P#1 to another facility because their insurance was out-of-network. Additionally, the facility delayed treatment to P#1; specifically, the facility failed to provide treatment to P#1 once the provider was notified that P#1’s insurance was not in network with the facility. Findings Included: Cross refer to A-2408, as it relates to the facility’s failure to provide treatment to P#1 following notification that P#1’s insurance was out-of-network with the facility. Cross refer to A-2409 as it relates to the facility’s failure to provide P#1 with an appropriate transfer.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 49398 Based on a review of policy and procedures, facility documents, medical records, and interviews with staff it was determined that the facility delayed treatment to one patient (P) #1 out of 20 patients sampled. Specifically, P#1 was diagnosed with a hip fracture and when the provider was notified by facility staff that P#1’s insurance was not in network, the provider stopped treatment measures and facilitated P#1’s transfer to another facility. Findings Included: A review of the facility policy titled “EMTALA/COBRA Policy”, no number, last approved 1/26/22, revealed that the purpose of this policy was to delineate the policies and procedures for the screening, stabilization, and transfer of individuals with an Emergency Medical Condition (EMC) presenting to the facility. III. Statement of Policy 1. It is the Policy of the Medical Center to provide a Medical Screening Examination by a Qualified Medical Person to any individual who comes to the Medical Center’s dedicated emergency department or the campus of the facility and seeks an examination or medical treatment to determine if the individual has an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay; and if it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of the Medical Center, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below. This policy shall further apply to all individuals in any ambulance owned and operated by the Medical Center, subject to the policies and procedures of the local Emergency Medical Services (EMS) authority, or any ambulance not owned and not operated by the Medical Center that is on Medical Center property, even if instructed not to come to the Medical Center. 2. It is further the Policy of the Medical Center that it shall not delay the provision of a Medical Screening Examination, stabilizing treatment, or appropriate transfer in order to inquire about the individual’s method of payment of insurance status; or request, or allow a health plan to require prior authorization for services before the individual has received a Medical Screening Examination and stabilizing treatment; or condition the provision of emergency services and care upon an individual’s race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition, physical or mental disability, insurance status, economic status or ability to pay for medical services, except to the extent that a circumstance such as age, sex, pre-existing medical condition, or physical or mental disability is medically significant to the provision of appropriate medical care to the individual. 5. Individuals Who Have an Emergency Medical Condition. When it is determined that the individual has an Emergency Medical Condition, the Medical Center shall: 1) within the capability of the Medical Center stabilize the individual to the point where the individual is either “Stable for Discharge” or “Stable for Transfer,”; A review of the facility’s EMTALA training 2024 titled “EMTALA Duties & Challenges”, revealed that the facility would provide an MSE for every person who came to the facility’s dedicated ED or the campus of the hospital and requested an examination or treatment for a medical condition or had such a request made on his or her behalf. There were three basic EMTALA Requirements: 4. Appropriate Medical Screening 5. Stabilization of an EMC 6. Transfer to Another Facility If the MSE revealed the existence of an EMC, EMTALA required the patient to be stabilized and or transferred. A patient was considered to be stabilized when: 2. Sufficient medical treatment of the EMC was provided as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition was likely to result from or occur during the discharge/transfer of the individual from the facility. The facility may transfer or discharge a patient with an EMC when: 1. The patient was fully informed of the facility’s EMTALA obligation and risk of transfer. 2. The request was obtained in writing. 3. The request must not be coerced- even implicitly. Delay of the transfer caused by questioning an individual’s ability to pay for care was strictly prohibited. A review of P#1’s medical record (MR) revealed that P#1 was a 58-year-old female who was brought to facility #1’s ED by Emergency Medical Services (EMS) on 4/2/24 at 8:17 p.m. with left-sided hip pain associated with a ground-level fall. P#1 had a past medical history of diabetes mellitus (DM) (a metabolic disease, involving inappropriately elevated blood glucose levels). A review of a “Provider Note” dated, 4/3/24 at 12:13 a.m., revealed that upon exam P#1 had pain with internal and external rotation of the left hip. Further review revealed that an order for an x-ray (used to generate images of tissues and structures inside the body) of the left hip was ordered. Continued review revealed that the X-ray result was inconclusive for a fracture and a computerized tomography scan (CT) (imaging that uses X-ray techniques to create detailed images of the body) was ordered. Further review revealed that the CT result showed P#1 had a nondisplaced intertrochanteric fracture (hip fracture or broken hip. Hips that break between the bone bumps at the top of the thigh bone are said to have broken in the intertrochanteric area of the femur or hip) with adjacent soft tissue swelling. It is additionally noted that P#1’s insurance was out of network (OON) so staff were working on finding a facility with orthopedics where they could transfer P#1. Continued review of “Provider Note”, medical decision-making, dated 4/3/24, revealed that Medical Doctor Resident (MDR) JJ noted, “I considered need for additional hospitalization/observation and further care including: Patient will need orthopedic consult as her left hip CT showed nondisplaced intertrochanteric fracture with adjacent soft tissue swelling. Patient insurance was out of network so working on finding a facility with orthopedics that we can transfer her to. If not, we will consult our orthopedic group for inpatient medicine. The patient has uncontrolled type 2 DM.” A review of “Case Management Clinical Note”, dated 4/2/24 at 3:20 a.m., revealed that social worker (SW) WW was contacted by an ED provider to seek assistance with facilitating P#1’s transfer. It was noted that P#1 was OON with her insurance but planned to stay at facility #1 and that OON benefits would be provided unless P#1 decided otherwise. Continued review revealed that SW WW instructed staff that P#1 would need to sign an OON form (confirming that she understood that she would be responsible for the bill and hospital payments) to stay or begin the in-network process where the MD would call where she would want to go to secure an accepting MD at one of the facilities she could choose from. A review of “Flowsheets”, dated 4/3/24 at 1:08 a.m., revealed that the risks and benefits of transfer were discussed with P#1. The reason for the transfer was noted as “specialized treatment or services.” A review of “ED Timeline”, dated 4/3/24 at 3:11 a.m., revealed that EMS arrived, received report, and transported P#1 to facility #2. A review of P#1’s MR from facility #2 revealed that P#1 was transferred from facility #1 and arrived at facility #2 on 4/3/24 at 4:01 a.m. P#1 was diagnosed with a nondisplaced intertrochanteric fracture of the left femur. Further review revealed that upon arrival at the ED, an orthopedic surgeon was consulted, and P#1 was prepped for the operating room (OR). A telephone interview was conducted on 5/21/24 at 4:10 p.m. with Orthopedic Surgeon (OS) DD. OS DD stated that he has been an on-call Orthopedic Surgeon with facility #1 for two years. He explained that facility #1’s orthopedics group specializes in hip fracture surgeries and non-complicated pelvic injuries. He added that major pelvic injuries, complicated hip fractures, and acetabular surgeries would be transferred to facility #1’s flagship campus. OS DD stated that hip fractures are considered a higher acuity level that typically requires surgical intervention within 24-48 hours. He added that the only instance a patient with a hip fracture would be transferred out of facility #1 would be due to potential complications in which case the patient would be transferred to the flagship campus. OS DD said that he never looks at or considers what insurance a patient has and that he would be shocked if facility #1 transferred a patient with a hip fracture to another facility due to insurance. The only way he could see that happening was if a patient had a low acuity injury, but high acuity patients need to be treated right away. A telephone interview was conducted on 5/22/24 at 7:45 a.m. with a Doctor of Osteopathic Medicine (DO) II, DO II stated that he is a nightshift ED physician for facility #1. He said that he assumed care of P#1 on 5/2/24 when he came on shift. DO II recalled P#1 presented at the ED for hip pain and was ultimately diagnosed with a hip fracture. He said P#1 was offered the choice to be admitted to facility #1 for treatment or to be transferred to a facility that was within her insurance network. He recalled P#1 and P#1’s family expressing with great desire to be transferred to facility #2 for treatment because facility #2 was in-network with P#1’s insurance. DO II said that he did not speak directly with P#1 or P#1’s family but that the nurses would relay information to him. He explained that registration is responsible for telling patients if their insurance is in-network or out-of-network. DO II considers hip fractures to be emergent injuries that require emergent admission. DO II explained that there are times when registration will add “OON” next to a patient’s name on the patient tracker. He said it is a nonofficial way to communicate and has zero bearing on patient disposition. During an interview on 5/22/24 at 9:30 a.m. with Patient Access Representative Manager (PARM) PP in a conference room, PARM PP stated that she has worked in patient access for 15 years and began working for facility #1 in 2016. PARM PP said that once the provider has performed the MSE it will be notated on the patient tracker board. A patient access representative (PAR) will run the patient’s insurance through a program called, “real-time eligibility” (RTE) to determine the patient’s benefits. A PAR will go over the insurance benefits with the patient and collect a copay or deposit for self-pay customers if applicable. If the patient is OON, they will have them sign a “Beneficiary Notification Letter” and discuss the “Surprise Billing Letter” with them. The PAR will add “OON” next to the patient’s name on the patient tracker board to alert case management (CM). PARM PP said that “OON” is not added to alert all of the ED staff, but it is there to let case management know because that patient is going to be an inpatient admission. She added if it is a Keiser patient, they will add “Keiser” next to the patient’s name on the patient tracker board, so it is known the patient is OON. She explained that management encourages admission versus transfer when it is after hours, and case management is unavailable. During an interview on 5/22/24 at 9:55 a.m. with Emergency Department Medical Director (EDMD) OO in a conference room, EDMD OO stated that he has been the EDMD at facility #1 for five years. EDMD OO said that when someone presents to the ED with a hip fracture they would be checked in, undergo a work-up, and have blood work done for pre-op because hip fractures usually require surgical treatment. He added that he would have someone from internal medicine or orthopedics do a consultation with the patient to formulate a treatment plan for the patient. EDMD OO said he does not usually know if a patient is OON or not. He added that registration will sometimes send “e-chats” to let the team know that a patient is OON. When this surveyor asked why it would be necessary or pertinent for registration to let providers know in an “e-chat” if a patient is OON? EDMD OO said the information is not pertinent to the doctors and he does not know why registration tells them. He speculated that maybe it is so doctors will know case management is going to be involved. He added that it is his expectation of ED staff to initiate care regardless of payment. During an interview on 5/22/24 at 10:30 a.m. with Case Management Manager (CMM) QQ, in a conference room, CMM QQ stated that she has been a CMM for facility #1 since 2019. CMM QQ said that CM will collaborate with the providers when a patient is OON. She said that there is a CM column on the ED patient tracker board where registration will add “OON” so case management can identify which patients are OON. CMM QQ said she is unsure whether that information is visible to all ED staff or if it is visible only to members of the CM team. She added that CM will approach a patient about being OON once they are stabilized. CMM QQ said that registration will review the “Surprise Billing Letter” with OON patients, but she is not sure what specific verbiage registration uses. A telephone interview was conducted on 5/22/24 at 11:05 a.m. with Resident Medical Doctor (RMD) JJ, MDR JJ said that he joined facility #1’s resident program in July 2023. MDR JJ stated that P#1 was brought in by EMS for hip pain associated with a ground-level fall. He stated that he ordered a CT scan and the results revealed that P#1 had a nondisplaced intertrochanteric left hip fracture. MDR JJ said that upon getting the CT results his next step was going to be to ask for an orthopedic consultation. He explained that before he was able to contact the on-call orthopedic provider, a staff member notified him that P#1 was OON and needed to be sent somewhere for treatment that was within P#1’s insurance network. MDR JJ could not recall who gave him those instructions, but he thought it was someone from registration. He added that hip fractures are considered emergent and that he was unable to follow up with P#1’s transfer and outcome as his shift had ended and DO II assumed P#1’s care. Cross Refer to 2409.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49398 Based on a review of policy and procedures, facility documents, medical records, and interviews with staff it was determined that the facility inappropriately transferred P (#1) to Facility #2, when the sending hospital had the capability and capacity to provide stabilizing treatment for P#1’s Emergency Medical Condition (EMC), for one of 20 sampled patients. P#1 presented to the Emergency Department (ED) on 4/2/24 and was diagnosed with a hip fracture. Orthopedic services, including an on-call Orthopedic Surgeon, were available to ED staff on 4/2/24. When the provider was notified that P#1’s insurance was out-of-network the facility transferred P#1 to another facility for treatment. Findings Included: A review of the facility policy titled “EMTALA/COBRA Policy”, no number, last approved 1/26/22, revealed that the purpose of this policy was to delineate the policies and procedures for the screening, stabilization, and transfer of individuals with an Emergency Medical Condition (EMC) presenting to the facility. III. Statement of Policy 1. It is the Policy of the Medical Center to provide a Medical Screening Examination by a Qualified Medical Person to any individual who comes to the Medical Center’s dedicated emergency department or the campus of the facility and seeks an examination or medical treatment to determine if the individual has an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay; and if it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of the Medical Center, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below. This policy shall further apply to all individuals in any ambulance owned and operated by the Medical Center, subject to the policies and procedures of the local Emergency Medical Services (EMS) authority, or any ambulance not owned and not operated by the Medical Center that is on Medical Center property, even if instructed not to come to the Medical Center. 5. Individuals Who Have an Emergency Medical Condition. When it is determined that the individual has an Emergency Medical Condition, the Medical Center shall: 1) within the capability of the Medical Center stabilize the individual to the point where the individual is either “Stable for Discharge” or “Stable for Transfer,”; or 2) provide for an appropriate transfer of the non-stabilized individual to another medical facility in accordance with these procedures. If an individual has an Emergency Medical Condition that has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth below. The individual may be transferred: a) On Patient Request. The individual may be transferred if the individual or the legally responsible person acting on the individual’s behalf is first fully informed of the risks of the transfer, the alternatives (if any) to the transfer, and of the Medical Center’s obligations to provide further examination and treatment sufficient to stabilize the individual’s Emergency Medical Condition, and to provide for an appropriate transfer. The transfer may then occur if the individual or legally responsible person: (i) makes a written request for transfer to another medical facility, stating the reasons for the request; and (ii) acknowledges his request and understanding of the risks and benefits of the transfer, by signing the Patient Transfer to Other Facility Form. 7. On-Call Physicians. The Medical Center shall maintain an on-call list of physicians, including specialists and sub-specialists who are available for duty to screen, examine, and treat patients with potential Emergency Medical Conditions. On-call physicians shall respond to the Medical Center calls for emergency coverage within a reasonable time after receiving communication indicating that their attendance is required. If an on-call specialist or sub-specialist is not available, the emergency department physician or his or her designee shall attempt to obtain the services of another appropriate specialist or sub-specialist from the Medical Center’s medical staff as defined by the medical staff bylaws. If the necessary on-call services remain unavailable despite these efforts, such that the patient requires a transfer in order to obtain the necessary services at another medical facility, the emergency department physician or his or her designee shall note the name and address of the on-call physician who refused or failed to appear, in the C-3 Form. A review of the facility’s EMTALA training 2024 titled “EMTALA Duties & Challenges”, revealed that the facility would provide an MSE for every person who came to the facility’s dedicated ED or the campus of the hospital and requested an examination or treatment for a medical condition or had such a request made on his or her behalf. There were three basic EMTALA Requirements: 1. Appropriate Medical Screening 2. Stabilization of an EMC 3. Transfer to Another Facility If the MSE revealed the existence of an EMC, EMTALA required the patient to be stabilized and or transferred. A patient was considered to be stabilized when: 1. Sufficient medical treatment of the EMC was provided as may be necessary to ensure, within reasonable medical probability, that no material deterioration of the condition was likely to result from or occur during the discharge/transfer of the individual from the facility. The facility may transfer or discharge a patient with an EMC when: 1. The patient was fully informed of the facility’s EMTALA obligation and risk of transfer. 2. The request was obtained in writing. 3. The request must not be coerced- even implicitly. Conversations with patients regarding the need for potential transfer should occur after the MSE had been conducted- even if the transfer may be needed for additional testing. Transfer certification (EMTALA form) was to be completed and records were made available to the receiving facility. Transfer of the patient required written certification that the expected medical benefits of the transfer outweighed the risk. The transfer must be medically indicated and should not be for the convenience of the on-call schedule. Delay of the transfer caused by questioning an individual’s ability to pay for care was strictly prohibited. A review of P#1’s medical record (MR) revealed that P#1 was a 58-year-old female who was brought to facility #1’s ED by Emergency Medical Services (EMS) on 4/2/24 at 8:17 p.m. with left-sided hip pain associated with a ground-level fall. P#1 had a past medical history of diabetes mellitus (DM) (a metabolic disease, involving inappropriately elevated blood glucose levels). A review of a “Provider Note” dated, 4/3/24 at 12:13 a.m., revealed that upon exam P#1 had pain with internal and external rotation of the left hip. Further review revealed that an order for an x-ray (used to generate images of tissues and structures inside the body) of the left hip was ordered. Continued review revealed that the X-ray result was inconclusive for a fracture and a computerized tomography scan (CT) (imaging that uses X-ray techniques to create detailed images of the body) was ordered. Further review revealed that the CT result showed P#1 had a nondisplaced intertrochanteric fracture (hip fracture or broken hip. Hips that break between the bone bumps at the top of the thigh bone are said to have broken in the intertrochanteric area of the femur or hip) with adjacent soft tissue swelling. It is additionally noted that P#1’s insurance was out of network (OON) so staff were working on finding a facility with orthopedics where they could transfer P#1. Continued review of “Provider Note”, medical decision-making, dated 4/3/24, revealed that Medical Doctor Resident (MDR) JJ noted, “I considered need for additional hospitalization/observation and further care including: Patient will need orthopedic consult as her left hip CT showed nondisplaced intertrochanteric fracture with adjacent soft tissue swelling. Patient insurance was out of network so working on finding a facility with orthopedics that we can transfer her to. If not, we will consult our orthopedic group for inpatient medicine. The patient has uncontrolled type 2 DM.” A review of “Case Management Clinical Note”, dated 4/2/24 at 3:20 a.m., revealed that social worker (SW) WW was contacted by an ED provider to seek assistance with facilitating P#1’s transfer. It was noted that P#1 was OON with her insurance but planned to stay at facility #1 and that OON benefits would be provided unless P#1 decided otherwise. Continued review revealed that SW WW instructed staff that P#1 would need to sign an OON form (confirming that she understood that she would be responsible for the bill and hospital payments) to stay or begin the in-network process where the MD would call where she would want to go to secure an accepting MD at one of the facilities she could choose from. A review of “Flowsheets”, dated 4/3/24 at 1:08 a.m., revealed that the risks and benefits of transfer were discussed with P#1. The reason for transfer was noted as “specialized treatment or services.” A review of “ED Timeline”, dated 5/3/24 at 3:11 a.m., revealed that EMS arrived, received report, and transported P#1 to facility #2. A review of P#1’s MR from facility #2 revealed that P#1 was transferred from facility #1 and arrived at facility #2 on 4/3/24 at 4:01 a.m. P#1 was diagnosed with a nondisplaced intertrochanteric fracture of the left femur. Further review revealed that upon arrival at the ED, an orthopedic surgeon was consulted, and P#1 was prepped for the operating room (OR). During an interview on 5/21/24 at 3:30 p.m. in a conference room with Registered Nurse (RN) NN, RN NN stated that she has been an ED Nurse for the facility since 2/23. RN NN was unable to recall caring for P#1 during her admission because the ED treats quite a few patients with hip fractures. She said that her primary focus is caring for the patients and not what insurance patients have. She said that out-of-network (OON) patients are identified with “OON” next to the patient’s name on the ED patient tracker board. RN NN is unsure who is responsible for placing the identifier and she does not know whether or not the facility transfers OON patients regularly. She added that her role in preparing patients for transfer as an RN is to prepare the transfer form, ask the patient if they have any questions, and provide the patient with an ETA. RN NN said that occasionally she will ask her Charge Nurse why a patient is being transferred but she doesn’t make it standard practice to ask because the decision doesn’t involve her. A telephone interview was conducted on 5/21/24 at 4:10 p.m. with Orthopedic Surgeon (OS) DD. OS DD stated that he has been an on-call Orthopedic Surgeon with facility #1 for two years. He explained that facility #1’s orthopedics group specializes in hip fracture surgeries and non-complicated pelvic injuries. He added that major pelvic injuries, complicated hip fractures, and acetabular surgeries would be transferred to facility #1’s flagship campus. OS DD stated that hip fractures are considered a higher acuity level that typically requires surgical intervention within 24-48 hours. He added that the only instance a patient with a hip fracture would be transferred out of facility #1 would be due to potential complications in which case the patient would be transferred to the flagship campus. OS DD said that he never looks at or considers what insurance a patient has and that he would be shocked if facility #1 transferred a patient with a hip fracture to another facility due to insurance. The only way he could see that happening was if a patient had a low acuity injury, but high acuity patients need to be treated right away. A telephone interview was conducted on 5/22/24 at 7:45 a.m. with a Doctor of Osteopathic Medicine (DO) II, DO II stated that he is a nightshift ED physician for facility #1. He said that he assumed care of P#1 on 5/2/24 when he came on shift. DO II recalled P#1 presented at the ED for hip pain and was ultimately diagnosed with a hip fracture. He said P#1 was offered the choice to be admitted to facility #1 for treatment or to be transferred to a facility that was within her insurance network. He recalled P#1 and P#1’s family expressing with great desire to be transferred to facility #2 for treatment because facility #2 was in-network with P#1’s insurance. DO II said that he did not speak directly with P#1 or P#1’s family but that the nurses would relay information to him. He explained that registration is responsible for telling patients if their insurance is in-network or out-of-network. DO II considers hip fractures to be emergent injuries that require emergent admission. DO II explained that there are times when registration will add “OON” next to a patient’s name on the patient tracker. He said it is a nonofficial way to communicate and has zero bearing on patient disposition. During an interview on 5/22/24 at 9:30 a.m. with Patient Access Representative Manager (PARM) PP in a conference room, PARM PP stated that she has worked in patient access for 15 years and began working for facility #1 in 2016. PARM PP said that once the provider has performed the MSE it will be notated on the patient tracker board. A patient access representative (PAR) will run the patient’s insurance through a program called, “real-time eligibility” (RTE) to determine the patient’s benefits. A PAR will go over the insurance benefits with the patient and collect a copay or deposit for self-pay customers if applicable. If the patient is OON, they will have them sign a “Beneficiary Notification Letter” and discuss the “Surprise Billing Letter” with them. The PAR will add “OON” next to the patient’s name on the patient tracker board to alert case management (CM). PARM PP said that “OON” is not added to alert all of the ED staff, but it is there to let case management know because that patient is going to be an inpatient admission. She added if it is a Keiser patient, they will add “Keiser” next to the patient’s name on the patient tracker board, so it is known the patient is OON. She explained that management encourages admission versus transfer when it is after hours, and case management is unavailable. During an interview on 5/22/24 at 9:55 a.m. with Emergency Department Medical Director (EDMD) OO in a conference room, EDMD OO stated that he has been the EDMD at facility #1 for five years. EDMD OO said that when someone presents to the ED with a hip fracture they would be checked in, undergo a work-up, and have blood work done for pre-op because hip fractures usually require surgical treatment. He added that he would have someone from internal medicine or orthopedics do a consultation with the patient to formulate a treatment plan for the patient. EDMD OO said he does not usually know if a patient is OON or not. He added that registration will sometimes send “e-chats” to let the team know that a patient is OON. When this surveyor asked why it would be necessary or pertinent for registration to let providers know in an “e-chat” if a patient is OON? EDMD OO said the information is not pertinent to the doctors and he does not know why registration tells them. He speculated that maybe it is so doctors will know case management is going to be involved. He added that it is his expectation of ED staff to initiate care regardless of payment. During an interview on 5/22/24 at 10:30 a.m. with Case Management Manager (CMM) QQ, in a conference room, CMM QQ stated that she has been a CMM for facility #1 since 2019. CMM QQ said that CM will collaborate with the providers when a patient is OON. She said that there is a CM column on the ED patient tracker board where registration will add “OON” so case management can identify which patients are OON. CMM QQ said she is unsure whether that information is visible to all ED staff or if it is visible only to members of the CM team. She added that CM will approach a patient about being OON once they are stabilized. CMM QQ said that registration will review the “Surprise Billing Letter” with OON patients, but she is not sure what specific verbiage registration uses. During an interview on 5/22/24 at 5:00 p.m. with RN HH in a conference room, RN HH stated that she has been an ED nurse for facility #1 for two years. She said that facility #1 does not typically transfer patients with a hip fracture to another facility but sometimes it happens. She said that facility #1 will keep OON patients and provide treatment if the receiving hospital refuses the transfer, which occasionally occurs. RN HH said that when a patient is out-of-network with their insurance and going to be admitted someone will add “OON” next to the patient’s name on the patient tracker board. RN HH said that registration will collaborate with the doctors on deciding whether ONN patients will be transferred to another facility. She said that patients with hip fractures are considered to be of a high acuity level. She added that if a patient were dyslexic, she would make sure she verbally explained the consent information to the patient. RN HH said her understanding of EMATALA is that if a patient needs emergent care and treatment, treatment should not be delayed due to insurance. She further said that she receives EMTALA training annually. A telephone interview was conducted on 5/23/24 at 9:50 a.m. with the ED Flow Coordinator (FC) LL for Facility #2. FC LL stated that she remembered taking the patient report from an RN at facility #1 because she was told P#1 was being transferred to their facility for an orthopedic service. FC LL recalled a provider in facility #2’s ED inquiring about why facility #1 was transferring a patient for orthopedics when facility #1 had orthopedic services. She further recalled that the nurse explained to her that P#1’s insurance was OON with their facility and the patient wanted to be transferred to a facility that is within her insurance network. FC LL said that ED staff at facility #2 began looking up EMTALA regulations because they didn’t feel like the transfer was entirely appropriate and were trying to discern appropriateness based off EMTALA regulations. During a telephone interview on 5/23/24 at 12:55 p.m. with OS RR, OS RR stated that he works as an on-call OS for facility #2 and could recall everything about P#1’s case because of the circumstances surrounding her transfer. OS RR said that he received a call from facility #2’s ED to let him know he had a patient with a fractured hip coming in as a transfer from facility #1. He said he was immediately concerned because he knew that facility #1 had the capability of providing orthopedic services to P#1 so he wondered why they were transferring a patient over. He recalled P#1 explaining to him that facility #2 had told her that her insurance was not in-network with them and that she would be stuck with the bill if she did not transfer to a facility for treatment that was within her insurance network. OS RR said that P#1 seemed very confused about the insurance and transfer issue when he spoke with her. He added that she seemed as if she was coerced into the transfer. He further added that P#1’s fracture was straightforward and could have been treated by any OS on-call and there was no reason why it couldn’t have been done at facility #1. OS RR recalled telling P#1 that what facility #1 did was an EMTALA because she did not elect to break her hip, it was an emergent admission, and as long as facility #1 had the capabilities to treat her injury, they were obligated to treat her regardless of whether her insurance was in-network or OON. OS RR said that he reported the situation to facility #2’s Chief Medical Officer (CMO). He followed up with the CMO who explained that he listened to facility #2’s phone recording and felt there was not much he could do because the RN from facility #1 made it sound like P#1 requested the transfer. During a telephone interview on 5/24/24 at 10:30 a.m. with EDMD VV, EDMD VV stated that he has worked for facility #2 for 20 years. He said he did not physically see P#1 when she arrived at the ED, but he had been notified about the details regarding P#1’s transfer. EDMD VV said over the last few years facility #1 has transferred quite a few patients to them due to the patient being OON. He said facility #1 will say the patient requested it. He added that facility #2 will not deny the transfers because they are obligated to accept the transfers and treat the patients. Cross Refer to 2408.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45841 Based on record review, interview, and facility document and policy review, the facility failed to ensure that restraints were implemented appropriately in accordance with hospital policy for 1 (Patient #4) of 1 sampled patient reviewed for restraints. Findings included: A review of a facility policy titled “Patient Rights and Responsibilities,” dated 03/25/2022, revealed, “As a patient, guardian or other designated legal representative, you have the right:” to “Be free from restraints of any form that are not medically necessary.” A review of a facility policy titled “Restraints - Patient Care,” dated 11/17/2021, revealed, “4: Orders:” included “c) An order for restraint use is not written as a standing for PRN [pro re nata; as needed] order.” The policy revealed, “8) Assessment, monitoring, and documentation of the patient in restraints or seclusion: a) For all types of restraints or seclusion an RN [registered nurse] assesses the patient immediately after application and every two hours.” The policy continued to reveal, “The assessment will include: i) Signs of injury associated with restraint ii) Respiratory and circulatory status iii) Psychological status including level of distress or agitation, mental status, and cognitive functioning [sic] iv) Need for range of motion, exercise of limbs, and systematic release of restrained limbs v) Hydration/nutritional needs vi) Hygiene, toileting/elimination needs are being met vii) Type of restraint used.” Further review of the policy revealed, “9) Discontinuation:” “b) When an RN determines that the patient meets criteria for release in the restraint order, restraints are discontinued by staff with demonstrated competence. Once restraints are discontinued, a new order for restraint is required to reapply restraints.” A review of Patient #4’s medical record revealed the patient was admitted to the facility on 09/03/2022 with a diagnosis of acute cerebellar stroke. A review of Patient #4’s medical record revealed an order for non-violent or non-self-destructive restraints dated 09/04/2022 at 5:26 PM with a discontinuation date of 09/05/2022 at 11:05 PM. A review of Patient #4’s “Restraint Monitoring Every 2 Hours” flowsheet revealed that the last documented restraint monitoring for this order was on 09/05/2022 at 6:35 AM for right and left soft wrist restraints and revealed the restraints were “continued.” Upon further review of Patient #4’s medical record, there was no documentation of further assessments or an RN’s determination that the patient met the criteria for restraint discontinuation for this order. A review of Patient #4’s medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 12:55 AM with a discontinuation date of 09/07/2022 at 5:25 AM. Further review of the medical record revealed there was no documentation that the restraints were used during this time. A review of Patient #4’s medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 10:18 AM with a renewal date of 09/08/2022 at 9:37 AM and a discontinuation date of 09/09/2022 at 9:33 AM. A review of Patient #4’s “Restraint Monitoring Every 2 Hours” flowsheet revealed that on 09/07/2022, the use of right and left soft wrist restraints started at 11:03 PM. A review of the medical record revealed no documentation that the restraints were used prior to 09/07/2022 at 11:03 PM for this order. During a review of Patient #4’s medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed there were missing assessments and there was an order dated 09/07/2022 at 12:55 AM that was placed and not used until being discontinued approximately five hours later on 09/07/2022 at 5:25 AM. RN #5 confirmed that an order was placed on 09/07/2022 at 10:18 AM and was not used until approximately 11 hours later on 09/07/2022 at 11:03 PM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45841 Based on record review, interviews, and facility document and policy review, the facility failed to ensure that restraints were used in accordance with the physician’s order for 1 (Patient #4) of 1 sampled patient reviewed for restraints. Findings included: A review of a facility policy titled “Patient Rights and Responsibilities,” dated 03/25/2022, revealed, “As a patient, guardian or other designated legal representative, you have the right:” to “Be free from restraints of any form that are not medically necessary.” A review of a facility policy titled “Restraints - Patient Care,” dated 11/17/2021, revealed, “4: Orders:” included “c) An order for restraint use is not written as a standing for PRN [pro re nata; as needed] order.” A review of Patient #4’s medical record revealed the patient was admitted to the facility on 09/03/2022 with a diagnosis of acute cerebellar stroke. A review of Patient #4’s medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 12:55 AM with a discontinuation date of 09/07/2022 at 5:25 AM. A review of the medical record revealed no documentation that the restraints were used during this time. A review of Patient #4’s medical record revealed an order for non-violent or non-self-destructive restraints dated 09/07/2022 at 10:18 AM with a renewal date of 09/08/2022 at 9:37 AM and a discontinuation date of 09/09/2022 at 9:33 AM. A review of Patient #4’s “Restraint Monitoring Every 2 Hours” flowsheet revealed that on 09/07/2022, the use of right and left soft wrist restraints started at 11:03 PM. A review of the medical record revealed no documentation that the restraints were used prior to 09/07/2022 at 11:03 PM for this order. During a review of Patient #4’s medical record with Registered Nurse (RN) #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed that there was an order dated 09/07/2022 at 12:55 AM that was placed and not used until being discontinued approximately five hours later on 09/07/2022 at 5:25 AM. RN #5 confirmed that an order was placed on 09/07/2022 at 10:18 AM and was not used until approximately 11 hours later on 09/07/2022 at 11:03 PM. During an interview on 12/29/2023 at 9:45 AM, RN #14 stated he has been in charge of restraint oversight since 2020. RN #14 stated there is an audit that is meant to be done each shift by the charge nurse of any patient in restraints. RN #14 stated looking at Patient #4 and the issues identified with the record that was reviewed during the survey, he reported that looking at the orders to see if any restraints were ordered and not being used was not part of the audit. RN #14 stated the challenge with non-violent restraints is the timing of orders versus how long patients are in the restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45841 Based on record review, interview, and facility document and policy review, the facility failed to ensure the condition of a restrained patient was monitored by an interval determined by hospital policy for 1 (Patient #4) of 1 sampled patient reviewed for restraints. Findings included: A review of a facility policy titled “Patient Rights and Responsibilities,” dated 03/25/2022, revealed, “As a patient, guardian or other designated legal representative, you have the right:” to “Be free from restraints of any form that are not medically necessary.” A review of a facility policy titled “Restraints-Patient Care,” 11/17/2021, revealed, “8) Assessment, monitoring, and documentation of the patient in restraints or seclusion: a) For all types of restraints or seclusion an RN [registered nurse] assess the patient immediately after application and every two hours.” The policy continued to reveal, “The assessment will include: i) Signs of injury associated with restraint ii) Respiratory and circulatory status iii) Psychological status including level of distress or agitation, mental status, and cognitive functioning [sic] iv) Need for range of motion, exercise of limbs, and systematic release of restrained limbs v) Hydration/nutritional needs vi) Hygiene, toileting/elimination needs are being met vii) Type of restraint used.” A review of Patient #4’s medical record revealed the patient was admitted to the facility on 09/03/2022 with a diagnosis of acute cerebellar stroke. A review of Patient #4’s medical record revealed an order for non-violent or non-self-destructive restraints dated 09/04/2022 at 5:26 PM with a discontinuation date of 09/05/2022 at 11:05 PM. A review of Patient #4’s “Restraint Monitoring Every 2 Hours” flowsheet revealed that the last documented monitoring for this order was on 09/05/2022 at 6:35 AM for right and left soft wrist restraints and revealed the restraints were “continued.” During a review of Patient #4’s medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed there were missing restraint assessments/monitoring for Patient #4.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 45841 Based on record review, interviews, and facility document and policy review, the facility failed to assign nursing care in accordance with patient’s needs for 1 (Patient #3) of 2 sampled patients reviewed for pressure ulcers. Findings included: A review of a facility policy titled “Pressure Injury Prevention and Management,” dated 09/02/2020, revealed, “Patients assessed to be at a high risk (patients with a Braden [a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries] of <15) on admission or during shift assessments will require a WOC [wound, ostomy, and continence] nurse consult.” A review of a facility policy titled “Procedure: Pressure Injury Assessment and Management,” dated 08/12/2020, revealed that for a “Total Braden Score less than or equal to 15,” interventions directed staff to “Place timely consult to WOC nurse.” A review of Patient #3’s medical record revealed the patient was admitted to the facility on 06/28/2022 with diagnoses that included anoxic brain injury, respiratory failure, and renal failure. A review of Patient #3’s wound documentation flowsheet dated 06/29/2022 revealed the patient had stage one pressure injuries to the patient’s left inner thigh and lower sacrum that were present upon admission. A review of Patient #3’s wound documentation flowsheet dated 07/01/2022 revealed that pressure injuries to the left inner thigh and lower sacrum had progressed to stage two. A review of Patient #3’s “Braden Scale Score” flowsheets revealed documentation of Braden scores less or equal to 14 on 06/28/2022, 06/29/2022, and 06/30/2022. Further review of the medical record revealed no documentation that a WOC consult was placed until 07/01/2022. A review of Patient #3’s “Initial WOC - Wound” note dated 07/06/2022 revealed an order for a WOC consult was placed on 07/01/2022 at 3:33 PM for a stage two pressure ulcer to the patient’s sacrum. The note revealed Patient #3 had a stage two pressure ulcer to the gluteal cleft and coccyx. The note did not address the pressure injury to the patient’s inner left thigh. The note revealed the gluteal cleft and coccyx pressure ulcer measured 5.5 centimeters (cm) length x (by) 2 cm width x 0.2 cm depth. An interview was conducted on 12/28/2023 at 11:44 AM with Registered Nurse (RN) #9, a WOC nurse. RN #9 stated, when possible, they tried to see patients within 24 hours of a consult, not including weekends; sometimes, it was 48 hours. RN #9 stated staffing may play a role. RN #9 stated floor nurses were encouraged to use policies and procedures for prevention measures. RN #9 stated that Braden scale interventions could be implemented by any nurse; floor nurses did not need to wait for a WOC nurse to instruct them on what to do. During a review of Patient #3’s medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed that the WOC nurse was not consulted according to the facility policy.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45841 Based on record review, interviews, and facility document and policy review, the facility failed to adhere to policies and procedures for pressure injury prevention and wound consults for 2 (Patient #1 and Patient #3) of 2 sampled patients reviewed for pressure ulcers. Findings included: A review of a facility policy titled “Pressure Injury Prevention and Management,” dated 09/02/2020, revealed, “3) Pressure reduction interventions based on the patients Braden assessment [a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries] will be implemented by nursing and documented in the EHR [electronic health record].” The policy revealed, “Skin care interventions will be implemented when appropriate and documented in the EHR.” Further review revealed, “(v) Patients assessed to be at a high risk (patients with a Braden of <15) on admission or during shift assessments will require a WOC [wound, ostomy, and continence] nurse consult.” A review of a facility policy titled “Procedure: Pressure Injury Assessment and Management” dated 08/12/2020, revealed, “Total Braden Score less than or equal to 15” with interventions that directed staff to “Turn /reposition patient every 2 hours while in bed” “Order Low Air loss mattress for total Braden score less or equal to 14” “Keep head of bed at less than or equal to 30-degree angle.” The policy further revealed that for a “Total Braden Score less than or equal to 15,” interventions directed staff to “Place timely consult to WOC nurse.” A review of an undated facility policy titled “[Facility] Treatment Guide for Pressure Injuries” revealed for “Basic Care for all Pressure Injuries” “Reposition every 2 hours.” Further review revealed, “All patients with pressure injuries stage 2 or greater should have WOC consult placed in [electronic medical record].” 1. A review of Patient #1’s medical record revealed the facility admitted the patient on 01/12/2022 with diagnoses that included heart failure, end-stage renal disease (ESRD), a left closed femur fracture, and chronic anticoagulation. A review of Patient #1’s WOC note dated 01/25/2022 revealed that Patient #1’s left buttock had a full thickness unstageable pressure injury measuring approximately 10 centimeters (cm) length x (by) 7 cm width x 0.3 cm depth. Further review revealed, there was a nonblanchable deep tissue pressure injury to the left buttock measuring 14 cm length x 8 cm width of light purple intact skin, and the coccyx had a partial thickness opening that measured 2 cm length x 2 cm width x 0.2 cm depth. A review of Patient #1’s “Position” flowsheets for the timeframe from 01/17/2022 to 01/27/2022 revealed documentation that the patient was observed lying in the Semi Fowler’s position (a position in which the individual lies on their back on a bed with the head of the bed elevated at 30-45 degrees) on 01/17/2022, 01/18/2022, 01/23/2022, and 01/24/2022. Further review of the staff’s flowsheet documentation revealed that the staff did not ensure that the patient was turned and repositioned every two hours. During a review of Patient #1’s medical record with Registered Nurse (RN) #5 on 12/27/2023 from 1:00 PM to 3:30 PM, RN #5 confirmed turning and repositioning was not documented every two hours. 2. A review of Patient #3’s medical record revealed the facility admitted the patient on 06/28/2022 with diagnoses that included anoxic brain injury, acute respiratory failure with hypoxia, and hypercapnia. A review of Patient #3’s wound documentation flowsheet dated 06/29/2022 revealed the patient had stage one pressure injuries to the patient’s left inner thigh and lower sacrum that were present upon admission. A review of Patient #3’s wound documentation flowsheet dated 07/01/2022 revealed that pressure injuries to the left inner thigh and lower sacrum had progressed to stage two. A review of Patient #3’s “Braden Scale Score” flowsheets for the timeframe from 06/28/2022 through 07/06/2022 revealed documented Braden scores of less or equal to 14 for each day during that timeframe. A review of Patient #3’s medical record revealed a WOC nurse consult was not placed until 07/01/2022. Further review revealed that a specialty mattress was not placed until 07/07/2022. A review of Patient #3’s “Position” flowsheet for the timeframe from 06/28/2022 through 07/06/2022 revealed documentation that the patient’s head of bed (HOB) was 30 degrees or higher daily from 06/29/2022 through 07/02/2022, and on 07/04/2022. The flowsheets revealed documentation that the patient was observed lying in the Semi Fowler’s position on 07/03/2022 and 07/06/2022. Further review of the staff’s flowsheet documentation revealed that the staff did not ensure that the patient was turned and repositioned every two hours. An interview was conducted on 12/28/2023 at 11:44 AM with RN #9, a WOC nurse. RN #9 stated, when possible, they tried to see patients within 24 hours of a consult, not including weekends; sometimes, it was 48 hours. RN #9 stated staffing may play a role. RN #9 stated floor nurses were encouraged to use policies and procedures for prevention measures. RN #9 stated that Braden scale interventions could be implemented by any nurse; floor nurses did not need to wait for a WOC nurse to instruct them on what to do. During a review of Patient #3’s medical record with RN #5 on 12/28/2023 from 9:15 AM to 10:50 AM, RN #5 confirmed that the WOC nurse was not consulted according to the facility policy. RN #5 confirmed that Patient #3’s HOB was documented at 30 degrees or higher when the facility policy stated less than or equal to. RN #5 confirmed that the flowsheet documentation revealed that staff did not ensure Patient #3 was turned and repositioned every two hours. Additionally, RN #5 confirmed that a specialty mattress was not placed according to the facility’s policy.”

“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: 42060 Based on a review of the facility’s central log, medical records, policies and procedures, and staff interviews, it was determined that the facility failed to conduct an appropriate medical screening examination (MSE) for one patient P (#1) out of 20 sampled patients. Specifically, P#1 presented to the facility’s ED accompanied by parents. The parents requested that the patient (P #1) be examined for a medical condition that had started earlier in the day. The facility failed to have a doctor examine the patient to determine whether a medical emergency existed. Findings were: Cross refer to A-2406, as it relates to the facility’s failure to provide P#1 with an appropriate Medical Screening Examination (MSE).”

“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: 42060 Based on a review of the facility’s central log, medical record, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE) within its capabilities. Specifically, on 12/8/23, P#1 was brought to the facility’s (ED) emergency department by her parents for examination. During the triage assessment, P#1’s mother announced that she intended to take the patient to a children’s hospital. The facility failed to have a doctor examine the patient to determine whether a medical emergency existed. The parents transported the patient to another ED (Facility #2). P#1 went into cardiac arrest shortly after arrival to Facility #2 and expired thereafter. Findings included: A review of the Emergency Department (ED) central log revealed that P #1 presented to the ED and was registered on 12/8/23 at 3:48 a.m. with an assigned medical record number. A review of the ‘Medical Staff Rules and Regulations’ last revised February 2022 revealed Article 2. Admissions, Assessments and Care Treatment and Services. 2.4 Availability and Alternate Coverage. (a) Physicians provided professional care for their patients in the Medical Center by being personally available or by making arrangements with an alternate member who had appropriate clinical privileges to care for their patients. Under Article 10. Emergency Services. 10.2. Medical Screening Examinations. (a) Medical screening examinations (MSE), within the capability of the Medical Center, were performed on all individuals who came to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who could perform medical screening examinations (MSE) within applicable Medical Center policies and procedures were defined as: (1) Emergency Department: members of the Medical Staff with clinical privileges in Emergency Medicine; other Active Staff members and appropriately credentialed advanced practice professionals (APP). (2) Labor and Delivery: members of the Medical Staff with OB/Gyn privileges; Certified Nurse Midwives with OB privileges and Registered Nurses who have achieved competency in Labor and Delivery and who have validated skills to provide fetal monitoring and labor assessment. Review of policy title “ED Triage” revealed the purpose of this policy was to outline the triage process in the Emergency Department. The policy delineated: 1) Triage was utilized to prioritize incoming patients and to identify those who could not wait to be seen. a) The triage RN performed a brief chief complaint assessment, a complete set of vital signs, pertinent screenings, and assigned the patient a triage acuity level, which was a proxy measure of how long an individual patient could safely wait for a medical screening examination and treatment. b) ESI (Emergency Severity Index) scoring was assigned to the patient after a rapid assessment of subjective and objective information. c) The RN entered complaint-based, approved protocol orders. 2) The ED placed patients in rooms prior to a full history/physical exam until all beds/rooms were filled. 3) The bedside RN completed primary assessment upon the patient’s arrival to the bed/room. A review of the facility’s “EMTALA/COBRA” policy, no policy number, no effective date, no revision date revealed it was the Policy of the Medical Center to provide a Medical Screening Examination by a Qualified Medical Person to any individual who came to the Medical Center’s dedicated emergency department or the Campus of the Hospital and sought an examination or medical treatment to determine if the individual had an Emergency Medical Condition, whether or not eligible for insurance benefits and regardless of ability to pay; and if it was determined that the individual had an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of the Medical Center, or to arrange for transfer of the individual to another medical facility in accordance with the procedure set forth below. Procedures: The policy stated that the Medical Center was to provide a Medical Screening Examination for every person who came to the Medical Center’s dedicated emergency department or the Campus of the Hospital and requested an examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual was considered to exist if a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needed examination or treatment for a medical condition. The policy defined Emergency Medical Condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either: 1.Placing the health of the individual (or in regards of a pregnant patient, the health of the women or unborn child) in serious jeopardy; or 2. Or serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part. Medical Screening Examination meant the Screening Process required to determine with reasonable clinical confidence whether an Emergency Medical Condition existed or did not. Qualified Medical Person was defined as a licensed physician, advanced health professional as defined by Northeast Georgia Medical Center Medical Staff Bylaws acting pursuant to those Bylaws, state law, and within applicable scope of practice or a qualified registered obstetrical nurse acting within scope of practice and law. During an interview with the Director of the Pediatric Unit/RN (AA) on 12/18/23 at 2:30 p.m. in the Pediatric Unit, Director AA said the pediatric unit operated 24/7 and was always equipped with nurses. Director AA said they received pediatric patients from the emergency room during late hours. Director AA said the ED physician saw pediatric patients in the emergency room and determined if the patients needed to be admitted. Director AA said the way the process worked was for the ED doctor to reach out to the Pediatrician on-call and discuss the case with the on-call pediatrician. Director AA said if the pediatrician on-call determined the facility had the capability to provide level of care the patient needed, then the on-call pediatrician was to accept and give the order to admit. Director AA explained once the child was admitted, then all communication about the patient, including treatment orders was between the unit nurse and the on-call pediatrician. Director AA explained that the facility did not offer high level of pediatric care such as respiratory, trauma and heart diseases among some other complex children’s illnesses. Director AA said when they were unable to provide the level highly specialized of care, the facility transferred the patient to another local facility that they worked closely with. Unit Director AA said she was not aware of any incident where a child came and was not treated in recent times. During an interview with the Manager of the Pediatric Unit/RN (BB) on 12/18/23 at 2:35 p.m. in the Pediatric Unit, Manager BB explained the way the process worked when it came to admitting pediatric patients. Manager BB said the unit received patients from private practice and from the ED at all times. Manager BB said they had Pediatrician on call at all times. Manager BB said when a patient went to the ED, the ED doctor saw the patient and after the patient was assessed, the ED doctor would determine if the child needed further treatment through admission. Manager BB said the ED doctor had the list of Pediatrician on-call and the ED doctor called the Pediatrician on-call to report the potential admission. Manager BB said the ED would call them upstairs until after the case had been discussed between the two doctors. Manager BB said once decision was made between the two doctors to admit the patient, the on-call pediatrician called the unit to place all orders. Manager BB said the facility did not see complex cases such as children with heart condition, and advanced trauma. Manager BB said they transferred all the complex cases to another facility that had more specialized doctors in children care. Manager BB said they never refused to admit a pediatric patient that was referred to the unit. Manager BB said she was not aware of any recent case where a pediatric patient did not get the care needed and was sent to another facility. During an interview with ED Manager/RN DD on 12/18/23 at 4:42 p.m. in a private office in the administration suite, Manager DD explained that she was made aware of the complaint around P #1. Manager DD stated that the Director asked her to call the Nurse (RN FF) that was in triage the night P #1 was brought in the ED. Manager DD said she contacted RN FF and told her to call ED Executive Director CC. Manager DD said she did not know anything about what was said nor the nature of the conversation. Manager DD said she received report that a baby came to the ED and was sent to another children’s hospital that they closely worked with. Manager DD said it was the ED policy for the nurses to assess all patients of all ages. Manager DD said that the next step was to get such patient in a room as soon as possible. Manager DD said the nurses had access to the on-call doctors and on the list, there was always a pediatrician (a doctor that treated children). Manager DD said the night P #1 came in it was busy as the facility’s ED tended to be busy anyway, especially now with the flu season, but she added it was not crazy in the ED. Manager DD said after the nurse triaged a patient with high acuity (very sick patient), the nurse ought to try to convince the patient to stay and to call the ED doctor to talk to the patient if necessary. Manager DD said she was not sure of the details about the case, but it was just the facility’s policy not to turn patients away. During an interview with ED Registrar (EE) on 12/19/23 at 2:00 p.m. in a private office in the Administration suite, Registrar EE said she remembered night the parents brought P #1 to the ED. Registrar EE explained that she registered the baby (P #1) and during check in, the parent stated that the baby was not well and that the baby had a heart condition. Registrar EE said she informed triage nurse (RN FF) about the baby’s heart condition. Registrar EE said she overheard conversation between the parent and RN FF and that the parent said she wanted to take the baby to another facility. Registrar EE said her job was to register all patients who came for treatment and the triage nurse was the first to assess the patients. Registrar EE said they tried to get patients in the back as fast as they could but that was always dependent on bed availability. Registrar EE said she was aware of the EMTALA law which required that the ED treated all patients in need of medical care. During a phone interview with Triage Nurse RN FF on 12/19/23 at 2:32 p.m., RN FF said she remembered the parent who brought P #1 in the ED. RN FF said she was the triage nurse the night the parent came in the ED with the baby. RN FF said the parent reported to her during intake interview that she was concerned about the child breathing and brought her to the ED. RN FF said she took the baby’s weight as part of her initial triage. RN FF said as she started triage, a patient that was unresponsive came in and she left the parent and the baby to briefly attend the unresponsive patient. RN FF said she then came back, and the baby’s parent asked her about how long they were going to wait before a doctor could see the baby (P #1); RN FF said she replied that she did not know. RN FF stated that the baby’s parent stated that she did not want to wait, and she made the decision to leave and to go another facility. The parent told her what facility she was going to. When asked if she asked the parent to sign anything as proof of refusal to get treatment, RN FF said she did not. RN FF did not say if she tried to convince the parent to stay either. During an interview with ED Executive Director CC on 12/20/23 at 3:25 p.m. in a private office in the administrative suite, Executive Director CC stated that she had interviewed RN FF after they had received a call from the other facility about possible EMTALA violation. Executive Director CC stated that RN FF said P #1’s parent asked her should she just go to the other facility after they discussed waiting time. Executive Director CC said she reviewed the ED video footage and put in place training with Director of Registration regarding patient cancelation on the system. Executive Director FF said the staff in registration should not have cancelled and allowed the RN to document her interaction with the baby’s parent. Executive Director CC said that RN FF told the baby’s parent that she had the option to go somewhere else if she wished, but they would treat the baby if she chose to stay. A review of a medical record obtained from Facility #2 revealed Patient #1 (P #1) was an eleven-month-old female who presented unresponsive to the Emergency Department (ED) on 12/8/23 at 5:00 a.m. accompanied by her parents. P#1 had a history of congenital heart disorders and heart surgery. The parents reported that P#1 had difficulty feeding the night before and had had bloody stools. Facility #2 staff started resuscitation efforts on arrival. P#1 was placed on a ventilator and transferred to the cardiac intensive care unit. P#1 later expired.”