Wellstar Douglas Medical Center

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 40979 Based on review of medical records, review of the Emergency Department (ED) Central Log, interviews with staff, an interview with Patient (P)1, and a review of the facility’s policies and procedures, it was determined that the facility failed to maintain a Central Log, for one (P1) of 20 sampled patients when P1 presented to the ED 06/06/2026, 06/21/2026, and 06/23/2026 seeking and evaluation and/or treatment. Findings: A review of Patient (P)1’s medical record revealed that on 06/06/2026 at 1:50 PM, she arrived in the emergency department (ED) with persistent nausea and vomiting for seven days, resulting in significant dehydration and an 18-pound weight loss. A review of Patient (P)1’s medical record revealed that on 06/21/2026 at 9:14 PM she arrived in the emergency department (ED) with complaints of pregnancy problems and emesis (vomiting). A review of Patient (P)1’s medical record revealed that on 06/23/2026 at 12:51 AM she arrived via emergency medical services (EMS) with complaints of emesis (vomiting). A review of the facility’s Central Log dated January 2026 through June 2026 revealed that P1 was not registered as a patient on 06/06/2026, 06/21/2026, and 06/23/2026. An interview was conducted with Nurse Manager (NM) HH on 06/29/2026 at 10:30 AM during the tour of the Emergency Department (ED). NM HH stated that all patients who come to the hospital to seek care and treatment are entered on a central log. She continued to explain specifically when patients arrive to the ED whether through the front door of the hospital, through the ambulance bay or the doors of the ED they are entered on the central log. NM HH stated the registered nurse (RN) who receives the patient either at the front desk or through the ambulance bay is responsible for entering the patient’s information. During a telephone interview with Patient (P)1 on 6/29/2026 at 3:10 PM she stated that she was nine weeks pregnant when she went to the Emergency Department (ED) and that she was extremely sick at the time. P1 confirmed that she had visited the facility’s ED on 06/06/2026, 06/21/2026, and 06/23/2026. She continued to explain that on her last visit, 06/23/2026, she arrived via ambulance. A follow-up interview was conducted with Nurse Manager (NM) HH on 07/01/2026 at 12:30 PM in the conference room. NM HH confirmed the process for entering patients who seek emergency care and treatment at the hospital. She explained that the registered nurse (RN) who is assigned to the front desk or at the ambulance bay is responsible for entering the patient in the system which will log them in as a patient for the day, no matter the disposition (discharge destination). NM HH confirmed that P1 was not listed for the three visits (06/06/2026, 06/21/2026, and 06/23/2026) on the ED log that was provided to this surveyor. A review of the facility’s “Emergency Medical Treatment and Labor Act (EMTALA)” policy, policy #LD-108, last reviewed 09/20/2022, revealed Step Three. 3.1 Central Log. The Hospital must maintain a central log of individuals who “Come to the Emergency Department” (and any other department the qualifies as an ED like Labor and Delivery) and include in such log whether such individuals refused treatment, left without being seen, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or other transferred or were discharged. The log must register all patients who present for an examination or treatment, even if they leave prior to triage or MSE. The facility failed to follow their policy and procedure as evidenced by failing to maintain a Central Log for Patient #1, on 06/6/2026, 6/21/2026 and 06/23/2026 , when she presented to the hospital’s ED seeking an evaluation and/or treatment as stated in the facility’s policy.”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 40979 Based on review of medical records, facility documents, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that radiographic services were available for one patient (P) (P#1) of four sampled patients when a STAT (as soon as possible) MRI was ordered for P#1 on 10/17/24 at 5:44 p.m. and was not completed until 10/19/24 at approximately 3:30 p.m. Findings include: A review of P#1’s medical record revealed P#1 was admitted to the facility on 10/17/24 by EMS (emergency medical services) through the ED (emergency department) with a diagnosis of seizures (a burst of uncontrolled electrical activity between brain cells). Review of ED Initial Assessment note dated 10/17/24 at 4:56 p.m. revealed that there was no CT (CAT Scan) evidence of ICH (intracerebral hemorrhage) (bleeding in the brain). An MRI of the brain had not been done. A review of the ED Care Timeline revealed a physician order dated 10/17/24 at 5:44 p.m. for an MRI Brain without IV Contrast. The order was acknowledged at 6:04 p.m. Further review revealed that the order was modified to MRI brain without IV contrast on 10/17/24 at 6:21 p.m. A review of the ED Patient Care Timeline dated 10/17/24 at 6:21 p.m. revealed Orders Discontinued - MRI Brain without IV Contrast. A review STAT Imaging note dated 10/17/24 at 6:22 p.m. revealed that the order was discontinued on 10/17/24 at 8:22 p.m. A review of a physician note dated 10/18/24 at 11:42 a.m. revealed that an MRI brain was pending. Continued review of physician notes dated 10/18/24 at3:04 p.m. revealed awaiting EEG, MRI, and formal neuro consult. A physician note dated 10/19/24 at 9:16 a.m. revealed that an MRI of the brain was pending. A review of a physician assessment and plan dated 10/19/24 at 10:53 a.m. revealed that an MRI of the brain was pending. A review of an imaging screening form dated 10/19/24 at 3:10 p.m. revealed a procedure for MRI of the brain with and without IV contrast. A nursing note dated 10/19/24 at 3:24 p.m. revealed that the physician authorized that P#1 could be transported to MRI without a monitor. A review of P#1’s Incident #410487 dated 10/17/24 revealed reporter spoke to CC (critical care) PA (physician assistant) and House Supervisor. STAT MRI ordered and house supervisor was notified. Per house supervisor, MRI screening form was to be faxed asap (as soon as possible) and prior to 7:00 p.m. The MRI form was completed and signed by family and faxed to MRI. MRI called and asked timeframe for decisions of transport to ICU from ED. MRI stated they would do the MRI tomorrow. Reporter explained that it was a STAT order and MRI staff replied that the patient could be done tomorrow because he has a MD appointment at 7:30 p.m. this date. The House supervisor was notified of delay in imaging and CC NP to be advised. Safer entered per request of delay. A review of P#1’s Incident #410615 dated 10/17/24 revealed patient had a stat MRI of brain with/without contrast ordered on 10/17/24 8:23 p.m. MRI staff were not in house at that time. MRI staff were in house on 10/18/24 and left at 5:00 p.m. without completing the MRI. Reporter called and spoke with someone (unknown name) who stated that they ‘would get to it’. MRI was never done. A review of Chief Technologist (CT) EE’s tech notes dated 10/17/24, 10/18/24, and 10/19/24 revealed communication attempts to ICU (intensive care unit) to coordinate: 10/17/24 08:22:43 p.m . NP (Nurse Practitioner) enters order 10/18/24 07:49:56 a.m. CT not answering 10/18/24 03:17:16 p.m. CT still not answering 10/18/24 03:18:30 p.m. CT still not answering, called charge RN, she’s not answering 10/19/24 03:07:07 p.m. P#1 appointment scheduled 10/19/24 03:07:12 p.m. P#1 arrived for study 10/19/24 03:55:52 p.m. MRI Imaging begins 10/19/24 04:08:05 p.m. MRI Imaging ends A review of the facility’s Medical Imaging Department Description dated 2024 revealed II. Description. Medical Imaging services are located on the first floor. All patient types and ages are served. Portable equipment allows radiographs to be obtained in surgery, trauma/emergency, medica/surgical and intensive care units. Services provided include Diagnostic Radiology, Ultrasound, CT Scanning, Nuclear Medicine, MRI, Mammography, Bone Density, Intervention Radiology, Transportation support, clerical support. Additional outpatient services are at the (facility imaging center) a service of (Hospital). III. Organization. The Director and Manager manage the operations of the services. IV. Staffing. B. Daily Staffing Pattern. MRI. Minimum one MRI registered radiological technologist plus on-call (hospital). Radiologist. Hospital 8:00 am - 4:00 pm. Monday to Friday. (Radiology facility) covers remotely all other hours to provide 24 hour/7 day a week coverage for hospital. A review of the facility’s policy titled “Inpatient MRI Procedure Delay,” Policy #MRI125, last revised 9/1/22 revealed it is (facility) policy MRI department will communicate with nursing staff and physician if there is a delay of more than 24 hours to completing a patients MRI scan. The purpose is to define a process to inform the nursing team members of any delays for MRI. Exceptions. Emergency Department patients take priority. A review of the facility’s policy titled “Emergency Call for MRI Exams,” Policy #MRI128, last revised 9/1/22 revealed it is (facility) policy to provide overnight emergent care for sites that do not have 24/7 coverage or when staff is out on overnights. Purpose is to define a process for after-hours emergency MRI exam. On Call Procedure. Step One. 1.1 (Hospital) MRI department will provide ON CALL coverage for MRI exams that meet the emergency criteria set forth in this policy. All hospitals have either 24/7 service or ON CALL service. 1.2 Service will be provided for (facility) in-patients or Emergency Department patients only. 1.3 Exams deemed an emergency by the ordering physician and approved by the radiologist. 1.5 A screening form must be filled out prior to the technologist being called in. If the patient has something that is contraindicated for an MEI, the ordering physician will be informed, and the study cancelled. The patients nurse will complete the screening form with the patient. An interview was conducted with Director of Diagnostic Services (DDS) AA on 12/10/24 at 12:00 p.m. in the administration conference room. DDS AA stated that she became aware of the delay with P#1’s MRI when this surveyor entered the facility on 12/9/24. She continued to explain that she reviewed P#1’s chart this morning and determined that P#1 was seen in the ED (emergency department) on 10/17/24 and when the STAT (immediate) MRI order was placed there were limited radiology staff available to perform the test. She continued to explain that the radiologist on staff on 10/17/24 was scheduled to get off at 5:00 p.m. and therefore no one was available to complete the MRI and there was no coverage available on 10/17/24 . DDS AA continued to explain that P#1 was then scheduled to have the STAT MRI on the next day, 10/18/24. DDS AA stated she was not sure why or what happened, but P#1 did not have the STAT ordered MRI on 10/18/24 either. She continued to explain that she did not have the MRI completed until 10/19/24, two days after the order was given. DDS AA stated that the facility does not have a policy on the timeframe STAT orders should be completed however, the expectation is within 24 hours from the date and time of the order. DDS AA stated that she is unsure as to why there was a delay in testing for P#1. An interview was conducted with Registered Nurse (RN) BB on 12/10/24 at 12:30 p.m. in the administration conference room. RN BB stated that after review of his safer report #410615 dated 10/18/24 he did recall P#1 and the delay in her MRI while in the ED (emergency department). He continued to explain that after P#1 completed her CT Scan it was determined that the scan did not give the results needed and the physician ordered a STAT (immediate) MRI. He continued to say that once the order was given, he was told to complete the MRI form send it over and call to advise there is a patient in the ED with a STAT MRI order. RN BB stated that he followed the order, and he spoke to someone in radiology, but did not get their name, who stated that a radiologist was on site and could get to it. RN BB stated that he never received a call to bring the patient to radiology to have the MRI completed. He continued to explain that he notified House Supervisor (HS) CC of the delay and stated that P#1 could have the test done the next day, 10/18/24 however, it was not completed the next day either and then P#1 was transferred to ICU. RN BB stated that he did not know what happened or caused the delay in testing. A telephone interview was conducted with House Supervisor (HS) CC on 12/10/24 at 1:00 p.m. HS CC stated that he did recall the incident involving P#1 who did not receive the STAT MRI as ordered when RN BB called on the day it was ordered. He continued to say that from what he could recall he thinks that there was no coverage on the evening P#1 was seen in the ED (emergency department) and that the radiologist on duty could not stay past his shift and there were no on-call radiologist available. He continued to explain that he discussed the situation with RN BB that if the order was STAT-treatment dependent than we would look into having her transferred to another facility with radiology techs on duty or if the STAT order was more information gathering than P#1 could have the test completed the next day. HS CC stated that he could not recall if he was scheduled to work the next day, therefore could not determine what happened the next day. He continued to explain that if P#1 was not transferred to another facility than she should have had the MRI on the next day. HS CC stated that if P#1 did not have the MRI the next day than there should be a reason for the delay. HS CC stated that for all STAT orders the expectation is to have the order completed within 24 hours of the order. An interview was conducted with Medical Imaging Manager (MIM) DD on 12/10/24 at 2:00 p.m. in the administration conference room. MIM DD stated that she became aware of the incident involving P#1 on the day this surveyor entered the facility. She continued to explain that she reviewed P#1’s chart on 12/9/24 with DDS AA to determine where the missed opportunity originated from. She stated that P#1 was seen in the ED on 10/17/24 but was unsure of what time the order was made. MIM DD continued to explain that once the order was made it was determined that the radiology tech on duty would not be able to stay past his shift at 7:30 p.m. and therefore P#1 would not be able to have the MRI completed. She continued to explain that the radiology department has overnight staff coverage on Wednesday, Thursday, and Friday however, there was no coverage on 10/17/24, a Thursday evening. She continued to explain that for the evenings there is no coverage the medical staff will need to determine if STAT orders need to be transferred out to another facility for imaging. MIM DD stated that the radiology staffing and coverage is communicated out through the leadership huddle. She continued to explain that it is announced to the leadership when coverage will end for us and that they will be responsible for determining if their STAT patient can wait for the next day or should be sent out for their imaging test. MIM DD stated that P#1 was not sent out but could not determine what happened the next day and did not know why P#1 did not have the STAT MRI done the next day. She stated it is the responsibility of the nursing staff from the unit and from the radiology department to coordinate a time to bring the patient and the coordination did not happen the next day on the 18th, but P#1 had her imaging test done on Saturday afternoon. MIM DD stated that it is the expectation to complete STAT orders within 24 hours. An interview was conducted with MRI Chief Technologist (CT) EE on 10/10/24 at 3:30 p.m. in the administration conference room. CT EE stated that she did recall P#1, and the incident related to her missed MRI on 10/18/24. She stated that in order for a patient who is vented to be brought to the radiology department the MRI screening summary form must be completed, and a nurse must accompany the patient to monitor at all times. She stated that she could not speak to what happened on 10/17/24 other than it could have been a staffing issue because the technician who works Thursdays, his shift ends at 7:00 p.m. and he may not have been able to stay. CT EE stated that she did see the order for P#1 on 10/18/24. She stated that by this time P#1 was transferred from the ED (emergency department) to ICU (intensive care unit). She continued to explain that she began calling the nurses station in the ICU early the morning of 10/18/24 to begin coordinating a time for P#1 to be brought to the imaging unit with a nurse. CT EE stated she called several times throughout the day on 10/18/24 and no one answered the phone. She stated usually if she has additional coverage, or another tech on duty with her she would have walked over to ICU to speak with the charge nurse and coordinate a time for her study, but she was unable to do so because she was short staffed. CT EE stated that she was not able to get in touch with anyone all day on 10/18/24 and therefore P#1 did not have her MRI test done until Saturday, the next day, on 10/19/24.”