Washington County Regional Medical Center

“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: 49318 Based on review of facility’s policies and procedures, Medical Staff Bylaws, and staff interviews, it was determined that the facility failed to develop, adopt, implement, approve and enforce policies to assure compliance with the requirements of 42 CFR §489.24 . Findings Include: The facility’s Policy titled “Emergency Transports” , ( no policy number, no origination date, no revised date, and no reviewed and approved date). The revealed in part, “Emergency Transport will be handled by (Name) EMS (emergency medical services). These transports require: 1. Demographic sheet with patients SS# (social security number), and a printed quick report. 2. Transfer form stating where the patient is being transferred to, and what is the transferring diagnosis. What services are not available at WCRMC (Washington County Regional Medical Center). Patients condition (Stable-Unstable) and treatments required during transport. 3. If the transfer has been requested by the patient or parties responsible for the patient (Name) EMS can not perform these due to the readiness for true emergencies.” The Emergency Transport policy failed to state the requirements of an appropriate transfer under: “These requirements are found in 42 §CFR 489 (e) (2): §489.24 (2)(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; §489.24(e)(2)(ii), the receiving facility has agreed to accept the patient, has space and qualified personnel available for the treatment; §489.24(e)(2)(iii), the transferring hospital sends to the receiving facility all medical records related to the emergency medical condition which are available at the time of transfer and; §489.24(e)(2)(iv), the transfer is affected through qualified personnel and transportation equipment. (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;” The facility’s Medical Staff Bylaws adopted by the Medical Staff Executive Committee on 02/13/2024 and approved by the Governing Body on 02/27/2014 was reviewed. The Medical Staff Bylaws failed to reveal individuals who were determined qualified by Hospital Bylaws as qualified to conduct medical screening examinations. An interview was conducted with the Quality Manager (QM) AA on 04/13/2026 at 1:15 PM in the conference room. QM AA stated that the facility did not have a policy specifically on Medical Screening (MSE) and there was no information in the Medical Staff Bylaws stating who was qualified to perform an MSE. QM AA stated that she was unsure why there was no policy related to transfers. QM AA stated that the facility has a transfer form, but no written policy regarding transfers. QM AA further stated that she was aware that there was a transfer policy regarding pediatrics. An interview was conducted with the Chief Executive Officer (CEO) on 04/14/2026 at 2:40 PM in the conference room. The CEO stated that the facility previously provided services to the obstetric population within the community and there was verbiage in the Medical Staff Bylaws that identified who was allowed to perform a Medical Screening Examination (MSE). The CEO further stated that when obstetric services were no longer provided at the facility, she thinks the MSE documentation may have been inadvertently removed from the Medical Staff Bylaws. During the exit conference on 4/14/26 at 2:45 PM, the QM AA and CEO, stated “The facility follows EMTALA requirements related to physician on-call coverage, required signage, and maintenance of the ED log; however , a review revealed that did not have a written policy or procedures to support these practices.” The facility failed to provide written documented evidence of the providers agreement of 42 CFR §489.20(l) requiring that hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of § 42 CFR 489.24.”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 45841 Based on interview and facility document review, the facility failed to ensure services provided under contract were evaluated for safety and effectiveness. This deficient practice had the potential to affect all patients. Findings included: A facility contract document listed 135 contracted services. A facility document titled, “Hospital Authority of [Named] County Bylaws,” dated 04/29/2015, in the section “Article X: Administrator” revealed, “B. Authority and Duties - The Authority and duties of the chief administrative officer shall include the responsibility for the following,” and “7. “Cooperation with the Medical-Dental Staff and with all those concerned with the rendering of professional service, to the end that appropriate care may be rendered to the patients in Authority facilities or who are receiving Authority Services.” During an interview on 02/24/2026 at 5:55 PM, the Chief Executive Officer (CEO) stated that performance expectations were a part of the contract services or addendums attached to the contracts. The CEO stated the Administrative Assistant (AA) was responsible for evaluating the services to see if the performance expectations had been met. The CEO stated if expectations had not been met it was reported to her, and if there were no issues with performance expectations she did not see the evaluations. The CEO stated they did “not have a good process” to ensure the performance expectations had been reviewed. The CEO stated the expectation was that reviews were done on a continual basis, that a report of the reviews would go to management, and management would take the report and their recommendations to the Governing Board. The CEO stated she was unable to find any evidence that the 2025 contracts were evaluated, and she did not know why they were not getting done. The CEO stated that upon further review the list of provided contracted services also contained purchase agreements that were not contracts. During an interview on 02/24/2026 at 6:20 PM, AA #9 stated the CEO had spoken with her approximately six months prior and had asked her to look over the contracted services and update them with the required service expectation addendums. AA #9 stated she was not evaluating the contracts for performance expectations.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45841 Based on interview, facility document and policy reviews, it was determined that the facility failed to thoroughly investigate an allegation of sexual abuse for 1 (Patient #1) of 1 allegation of sexual abuse reviewed. Specifically, the facility failed to conduct interviews with all staff who worked on Patient #1’s floor during the shift of the alleged abuse. Additionally, the facility failed to ensure documentation of an interview with the alleged victim. Findings included: A facility policy titled, “Abuse and Neglect,” reviewed 12/2022, indicated, “Policy - Health care personnel having reasonable cause to believe a patient is a victim of abuse, neglect, or exploitation will immediately investigate, document findings and make referral to appropriate personnel and or agency.” A facility policy titled, “Patient Rights and Responsibilities,” revised 02/2023, indicated, “All patients have the following rights,” and revealed “1. Safe and Respectful Care: The right to considerate, respectful care given by competent personnel in a safe environment free from all forms of abuse, neglect or mistreatment, and in a manner that optimizes the patient’s comfort and dignity.” A facility document titled, “Required Hospital Self Reports to the Department Form,” dated 01/28/2026 at 5:00 PM, included an incident of an unconfirmed rape that occurred in the hospital. The report indicated the time the incident occurred was unknown. The incident report indicated the facility was made aware of the incident on 01/28/2026 at 11:45 AM when Patient #1 stated the real reason they left the hospital was because they were raped. The incident report revealed Patient #1 stated they had fallen asleep while their phone was running a video chat application, and their spouse saw the rape over the video chat. The incident report indicated security camera footage was reviewed for burgundy scrubs. The incident report indicated Patient #1 signed out of the hospital Against Medical Advice (AMA) on 01/28/2026 at 6:00 AM. A police department’s “Persons Crime Report,” dated 01/28/2026 at 2:50 PM, revealed a detective reviewed the video footage of the hallway outside Patient #1’s room of the timeframe from 01/27/2026 at 7:00 PM through 01/28/2026 at 7:00 AM. The Persons Crime Report indicated the video revealed that Respiratory Therapist (RT) #7 entered and exited Patient #1’s room on 01/27/2026 at 8:01 PM. The Persons Crime Report indicated the video revealed that on 01/27/2026 at 8:11 PM RT #7 entered Patient #1’s room, and on 01/27/2026 at 8:12 PM RT #7 exited Patient #1’s room. The Persons Crime Report indicated the video revealed that on 01/28/2026 at 5:30 AM a phlebotomist entered Patient #1’s room and then exited the room on 01/28/2026 at 5:44 AM. A facility document titled “Staff Interviews,” dated 01/28/2026, revealed staff interviews conducted by the Quality Coordinator (QC) and the Interim Director of Nursing (IDON) did not include an interview with a phlebotomist or RT #7. During an interview on 02/24/2026 at 2:09 PM, the QC stated she and the IDON were responsible for interviewing the staff about this incident. The QC stated they tried to interview any of the staff that had been on the floor that night and interacted with the patient. The QC stated she thought RT #7 was interviewed later by the police. The QC stated she did not interview a phlebotomist. During an interview on 02/24/2026 at 2:42 PM, the IDON stated when they called Patient #1 the patient’s spouse stated the perpetrator wore a maroon or burgundy shirt. The IDON stated that housekeeping staff wore burgundy as a part of their uniform, housekeeping staff had been working on Patient #1’s unit the night of the alleged incident, but housekeeping staff had not been interviewed about the incident. The IDON stated they did not interview RT #7. The IDON stated they did not interview the phlebotomist who went into Patient #1’s room during the time of the incident because she was over nursing and that was out of her jurisdiction. The IDON stated, if the phlebotomist needed to be interviewed, that was the responsibility the phlebotomist’s manager. The IDON stated they should have interviewed the individuals at the facility that wore burgundy, but they were more focused on nursing. During an interview on 02/24/2026 at 4:36 PM, the Chief Clinical Officer (CCO) stated they tried to interview the staff that participated in Patient #1’s care. The CCO stated they tried to call RT #7, but they were unable to reach him, and she did not know why they had been unable to contact RT #7 since the incident. The CCO stated she did not know if they had spoken with the phlebotomist that had been in Patient #1’s room, she did not know why they would not, and she did not think the phlebotomist was off limits to interview. During an interview on 02/24/2026 at 5:23 PM, the Chief Executive Officer (CEO) stated that none of the staff members were off limits for an interview as a part of the investigative process, and any member of the leadership staff was able to interview any member of the staff. The CEO stated when she was informed of the incident on the morning of 01/28/2026 by the IDON they spoke with Patient #1 over the phone. The CEO revealed Patient #1 stated the incident occurred sometime between midnight and that morning by someone in burgundy scrubs. The CEO revealed Patient #1 stated the incident occurred when the patient “was out [insensible]” after taking medication, and Patient #1 stated their spouse saw the incident over a video chat application. The CEO stated it was determined that all the staff who had worked that night on the floor were to be interviewed. The CEO stated she did not document the phone call she and the IDON made with Patient #1, and there was no record of the call.”