Adventist Health Castle

“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: 39853 Based on interviews, policy review, document review, medical record review and observation, the hospital failed to meet the provider’s agreement and comply with 42-CFR 489.24 requirements of EMTALA. There was deficient practice in FA-2406, Medical Screening Exam related to ACTs #11635. Due to the nature and extent of the noncompliance, an immediate jeopardy for failure to provide a medical screening exam (MSE) for one patient (P)1, of a sample size of one. P1 was a minor, whose mother made the request for treatment on his behalf when she brought him to the Hospital for emergency exam and treatment. As a result of this deficient practice, she drove P1, whose behavior was unstable to another hospital for care, which put her and the occupants of the car, as well as others on the road, at high risk for serious harm or death. Findings Include: A federal EMTALA survey (Y17B11) which included ACTs #11451, was conducted in conjuction with this survey 04/09/2025 through 04/11/2025 and 04/14/2025, after authorization by The Centers of Medicare and Medicaid Services (CMS) San Francisco Regional Office. That investigation revealed an Immediate Jeopardy (IJ) with deficient practice in A-2406 Medical Screening Exam, but no deficient practice related to ACTs #11554, due to the fact the complaint included minimal information and the patient could not be identified. Further investigation post survey identified the patient (P)1, a minor, who was brought to the Hospital (H)1 Emergency Department (ED) by his mother for treatment on 03/09/2025 . At that time, ACTs #11635 was initiated and the OHCA received authorization by CMS for a second EMTALA investigation (3BDS11). Cross Reference F-A-2406- Medical Screening Examination On 03/09/2025, a mother took her minor son, P1, to the Emergency Department by to be treated for mental health/ behavioral issues. On arrival to the hospital, the minor left the car, the mother entered the ED registration area alone, and requested that her son be seen in the ED. After the minor returned to the car, with the mother, there was a discussion with hospital staff in the parking lot, that the hospital did not have adolescent behavioral health services. The mother then drove her son to another facility (H2) that had inpatient adolescent behavioral health, for emergency treatment.”

“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: 39853 Based on interviews, medical record/document review and observations, the facility failed to comply with the EMTALA obligation to provide a medical screening examination (MSE-determines the presence or absence of an emergency medical condition and must be done in accordance with policy and medical standards) for one (P)1, a minor, brought to the Hospital (H)1 by his mother seeking examination and treatment on his behalf, due to change of behavior. Although the mother informed ED registration she would like her son to be seen, and he was on the Hospital property in the parking lot, he did not receive a MSE. Instead, she drove approximately 10 miles for treatment to H2, which placed everyone in the car and on the road at high risk of serious harm or death due to P1’s unstable and unpredictable behavior. Findings include: 1 ) P1 was a 14-year-old male with past psychiatric history significant for ADHD (attention-deficit disorder/hyperactivity, a mental health disorder that includes problems, such as paying attention, hyperactivity and impulsive behavior). On 03/09/2025, his mother brought him to H1 to be seen in the ED for increased erratic behavior, but did not receive a MSE. She was informed H1 did not have an adolescent psychiatric unit and her son would likely be transferred to H2 for care. The mother drove P1 to H2 for treatment. On arrival to H2, P1 received a MSE by the ED provider and was admitted to the adolescent behavioral health unit for further care. P1 was discharged home on 03/13/2025. 2) Reviewed the ED Provider Notes from H2, dated 03/09/2025 at 05:09 PM. The notes included: “14-year-old male with ADHD, possible oppositional defiant disorder, now presenting with behavioral changes. ...Got into argument with mom today, more aggressive with mom, punched mom in the arm. Also more aggressive behavior towards younger sister. Was making statements of self-harm like “I do not want to live anymore. ...Patient presents with behavior change and escalation at home with concern for self-harm as well as harm of those around him including mom and younger sister. ... Discussed case with psychiatry who felt that inpatient admission was safe for this time to stabilize and ensure safety. ...” Reviewed P1’s History and Physical by the Psychiatrist (MD1) at H2 dated 03/10/2025 at 08:33 AM. The record included: “He (P1) states he was brought to the hospital after getting into an argument with his mother. ...Patient clarified that he was with his mother and little sister in the car on the way to his karate class yesterday when the argument started... Patient’s mother ended up driving patient to the H1 parking lot, where the argument became physical after patient threw a cup of water at his family and then punched his mother “on the arm.” Per patient, H1 staff/security came up to their car upon hearing the commotion and recommended that the patient be brought to the H2 instead, as patient was a minor and would likely get admitted to the adolescent psychiatric ward if admitted. Patient proceeded to run out of the car into the roadway, but was able to be de-escalated by police officers who happened to be passing by and patient eventually agreed to go back to his mother’s car and come to H2 for treatment of his depression.” On 04/22/2025 at 02:00 PM, conducted a telephone interview with P1’s mother. She said on 03/09/2025, she drove her son to H1, with the intent to have him seen in the emergency room because of his behavior. She said they were parked in the parking lot in front of the emergency room, when he punched her in the forearm, got out of the car and ran down the road. She said she thought “staff must of seen the commotion outside, and that I was stressed out, because two males in their mid 30’s came out, and were saying they (H1) were not the right facility for people that age (14), and that H2 had a unit for kids.” The mother said she did express to them she did not feel safe driving to the other hospital in the car. Inquired why, and she said on the way to H1, she and her son were arguing, when he jumped out of the car, and then he did it again when they got to H1. She described her son’s behavior as “unstable and irate.” The mother stated her young daughter was with them in the car, and on the way to H2, P1 was “screaming and crying, unbuckled his seat belt, jumped from the back seat to the front seat, and threw the phone out.” On 04/23/2025 at approximately 01:15 PM, interviewed H2’s Registered Nurse (RN), in the conference room at H2. She said she recently encountered a child brought in by his mother, who said they went to another hospital, and “they wouldn’t see him.” The RN said when they arrived, “Security (H2) helped watch the child because he was agitated, while the mom parked the car.” The RN said “the mom was very concerned and upset,” but did not share specific details of what occurred at the other hospital. She remembered the mom being “very distraught,”and said her son had been aggressive toward his sibling and her. The RN stated again, the mom took him to H1 and they said they wouldn’t see him. She said she tried to check in, and they refused to allow her to check him in. The RN confirmed this occurred on the day shift 03/09/2025, sometime in the afternoon. On 04/23/2025 at 03:30 PM, conducted a phone interview with the MD1, who cared for P1 at H2. He said from his understanding the mom and son were arguing and fighting in the parking lot on the windward side hospital parking lot, and staff saw and approached them. The mother told them her son was having behavioral issues, and wanted to bring him to the hospital. Someone told her they didn’t have a child psychiatric unit there, and sometimes have to wait in the emergency room a long time. MD1 was not clear on who it was they talked to. When asked if he had heard this directly from the the patient, he said yes, but also heard it separately from the mom, and the stories were consistent. He said they were in H1’s parking lot and redirected here (H2). The mom said from what she understood, H1 didn’t have the kind of ward for her son, and would have to hold him in the ER (ED) until sent to H2. 3) On 04/25/2025 at 08:30 AM, toured the premises of H1, and observed the parking lot, ED entrance and registration area. It was noted there were surveillance cameras outside the entrance. The waiting room area had windows with views of the parking lot entrance, ED entrance and part of the parking lot. When sitting at the Registration desk, staff are able to see someone approaching the entrance and a portion of the parking lot. On 04/25/2025 at 10:33 AM, concurrent observation and interview was conducted with Security Manager (SM) in his office. At that time, the recorded surveillance video from Emergency Department (ED) entrance camera on 03/09/2025 between 12:00 PM to 03:00 PM was viewed with the SM. Upon reviewing recorded images/video, observed two male staff running toward the entrance of the ED heading outside, between 02:15 PM and 02:40 PM. They were later identified as the Security Supervisor, and ER Technician (seen wearing scrubs and putting on gloves). There was a third staff, a female nurse was in the waiting room area, a short distance from the ED entrance walking away from the door toward the waiting area. When asked the SM if he could pause the video and identify the staff, he was able to identify all three. Observed no recorded images between 01:00 PM and 02:20 PM. When SM was asked, he stated sometimes that happens when no activities are detected. On 04/25/2025 at 01:15 PM, concurrent observation and interview was conducted with SM and Risk Manager (RM) in the security office. SM and RM agreed the staff were responding to something that was going on outside the ED, by the parking lot. 4 ) On 04/25/2025 at 11:50 AM, conducted a phone interview with the assigned ED Charge RN on 03/09/2025. When inquired if she was aware of any unusual incident that occurred in the parking lot that day, she said she had a vague memory of something happening, and heard there was some kind of commotion, but had no direct involvement, or interaction with the patient or the mom. On 04/25/2025 at 12:35 PM, interviewed the Patient Access Representative (PAR) that was scheduled on 03/09/2025, in the conference room. She said there was a mother that came in by herself, and wanted to “check in her son.” The PAR stated the mother was “flustered” and apparently the son got combative. When the PAR asked where the son was, she pointed outside. The PAR said she could remember, because he had a red shirt on and could see him walking away toward the road. The PAR stated she let the mother know she couldn’t check him in until he was there. She asked the mother if she wanted to be seen, and her response was “no, I want my son to be seen.” The PAR said the mom was at the desk when she said she had to go get him and went outside. On 04/25/2025 at 01:21 PM, conducted a telephone interview with the Security Supervisor (SS), identified in the video. He said he saw a male teenager walking down the road and appeared upset and restless. SS stopped the teenager and asked if he was ok. SS said he observed the teenager walk back to his mother’s vehicle parked nearby, and that he (SS) proceeded to talk to them. He said he noticed another female child was inside the vehicle. He went on to say the mother wanted to check-in son to ER for “mental health” issues. SS explained that he did not remember if mother went inside to get some assistance. SS stated he mostly spoke with the son to calm him, while the ER tech spoke with the mother. He confirmed the vehicle was parked in the first row in front of the Emergency Room. On 04/25/2025, the Registered Nurse and ER tech seen in the video, were interviewed prior to being identified in the video, and both said they did not recall any unusual incident involving a mother bringing her teenage son to the ED for behavioral issues, or any incident occurring in the parking lot. 4) Reviewed the HI’s Systemwide Model Policy number 12117 titled “EMTALA-Medical Screening Examination (MSE) and Stabilization, last review date 03/18/2025. The policy included: Policy Intent: “A. To ensure that all individuals who Come to the Hospital (as defined in the Compliance with EMTALA policy) seeking or in need of Emergency Services and Care receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment in accordance with applicable laws and hospital policies.” Policy Compliance: “A. ...The Dedicated Emergency Department , must provide for an appropriate Medical Screening Examination within the Capability of the Dedicated Emergency Department, ...to determine whether or not an individual has an Emergency Medical Condition. ...” “1. In the Dedicated Emergency Department. The individual has presented at the Hospital’s Dedicated Emergency Department and requests or has a request made for his/her behalf for examination or treatment for a medical condition, or a prudent layperson observer would believe, based on the individuals appearance or behavior, that the individual needs examination or treatment for a medical condition;” “2. On Hospital Property. The individual has presented on Hospital Property other than a Dedicated Emergency Department, and request made on his/her behalf for examination or treatment for what may be an Emergency Medical Condition who or a prudent layperson observer would believe, based on the individuals appearance or behavior, that the individual needs emergency examination or treatment. ...” “H ...2. Psychiatric Condition: A Psychiatric Emergency Medical Condition is considered Stabilized when the Treating Physician has determined, within reasonable clinical confidence, that the individual is protected from injuring or harming himself/herself or others.””

“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: 39853 Based on interviews, policy review, document review, and medical record review, the hospital failed to meet the provider’s agreement and comply with 42-CFR 489.24 requirements of EMTALA. There was deficient practice in A-2406, Medical Screening Exam, with an immediate jeopardy for failure to provide a medical screening exam (MSE) that was appropriate for the condition of two individuals that presented to the Emergency Department for treatment of a sample size of 20. In addition, the hospital (H)1 was not able to provide a reason why two hospital’s requests to transfer patients for specialized services were denied when the hospital had capability and capacity. As a result of these deficient practices, patients did not receive the standard medical screening examinations that should have been provided, which had the potential to result in adverse outcomes. If the hospital denies transfers for specialized services, there is delay to obtain the services needed, which may result in adverse outcomes or death. Findings Include: 1) Cross Reference A-2406- Medical Screening Examination Two individuals (P1 and P2) out of a sample size of 20 that came to the Emergency Department for treatment were sent (moved) to the Women’s Center (WC (another department located within the hospital, that includes labor and delivery)) for the MSE by a Registered Nurse (RN), and were not evaluated by a physician. The WC RNs are approved by the hospital board and medical staff to provide a labor screening exam (MSE), but are not approved to provide the MSE on patients presenting to the ED with other conditions. 2) Cross Reference A-2411- Recipient Hospital Responsibilities The hospital was not able to provide sufficient evidence why one patient (P)3 transfer request, of a sample size of 12 for specialized services was denied, when the hospital had the capacity and capability to care for him.. The referral hospital was seeking neurosurgical services, which they did not provide.”

“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: 39853 Based on interviews, medical record and document review, the facility failed to comply with the EMTALA obligation to provide an appropriate medical screening examination (MSE (determines the presence or absence of an emergency medical condition and must be done in accordance with policy and medical standards)) to two patients (P)1 and P2), of a sample size of 20, that presented to the Emergency Department (ED) for treatment. P1 and P2 were sent (moved) to the Womens Center (WC), but did not receive a medical screening exam by a qualified individual to rule out an emergency medical condition. The nature and extent of this noncompliance created the likelihood there would be a serious adverse outcome of harm or death if not corrected, and resulted in immediate jeopardy. Findings include: 1) P1 was a 30 year old female who presented to the ED on 03/23/2025 at approximately 07:45 PM for treatment after a motor vehicle accident (MVA). She was approximately 33 weeks pregnant, and reported she was wearing a seatbelt at the time of the accident. On arrival to the ED, she was moved to the WC, where she was assessed by a Registered Nurse (RN), and placed on a fetal heart monitor to measure the heart rate and rhythm of the fetus (baby), to see how the baby was doing. P1 did not see a physician, and was discharged after monitoring on 03/24/2025 at approximately 00:04 AM. Review of P1’s report titled “OB Admission Screen,” confirmed there was no face to face MSEI (Medical Screening Examination Initiated) by a Provider. The record included “Chief Complaint: s/p (status after an event) MVA. The “Assessment/Plan,” documented by the RN, was “dc (discharge) home. pt (P1) instructed on importance of kick counts, pt given s/s (signs/symptoms) of PTL (preterm labor). pt verbalized understanding. pt to follow up with OB (obstetrician) on April 1st.” The written discharge instructions were for preterm labor. Review of P1’s “Obstetrics Procedure” report included the indication for a non stress test (monitoring) “patient was rear ended at a stop light by a car going 10-20 mph (miles per hour); seat belt below gravid (pregnant) abdomen and NO airbag deployed.” Review of the “Nursing Documentation Flowsheet,” revealed the following entries: - “Pain or contractions present ...back pain when walking.” - “Arrived From Emergency Department.” - Obstetrician was notified by phone of P1’s arrival and again with results. There were no ED medical records or triage documentation for P1. She did not see a physician and did not have a standard medical screening examination by an approved qualified individual for a pregnant woman post MVA, which is a high risk event. 2) P2 was a 35 year old female who presented to the ED with complaint of elevated blood pressure (BP) and headache on 04/02/2025 at approximately 05:55 PM. She was five days postpartum. On arrival to the ED, she was moved to the WC for MSE, where she was assessed and monitored by a RN. The RN contacted P2’s Obstetrician (OB), who ordered labs. When the lab results returned, the RN contacted the Provider again, and P2 was discharged home at 07:50 PM. She did not see a physician and did not have a standard medical screening examination by an approved qualified individual for this type of complaint. Review of P2’s “Nursing Documention Flowsheet” revealed the following entries: - Arrival to unit: 04/02/2025 at 05:55 PM - Pain location: head - Pain: 4 (scale of 1-10 with 10 being the worst) - OB notified at 06:14 PM. Orders received for preeclampsia labs (Comprehensive Metabolic Panel, CBC (complete blood count), and urinalysis. - OB notified at 07:25 PM. Orders received for discharge home with pre-eclampsia precautions. There were no ED medical records, triage notes, or documentation of a BP taken on arrival to the ED. On 04/03/2025, at approximately 09:33 PM, P2 presented to the ED again. This encounter, P2 was seen by the ED physician, who completed the MSE to rule out an emergency medical condition. Reviewed the ED Physician notes dated 04/03/2025, which included, “... presents to ED for elevated blood pressure at home of 162/104. ...Today states her blood pressure was even higher than yesterday. ...” The ED physician ordered additional lab tests, a chest xray, and electrocardiogram to rule out an emergency medical condition, consulted an Obstetrician, and discharged her home. 3) Reviewed the ED policy/procedure titled “Pregnant Patients Presenting to the Emergency Department” last revision date 04/07/2025, which included the following: - Policy Intent: “To establish guidelines for triaging patients to the Emergency Department or the Birth Center (WC).” - Policy: Compliance: “A. Any pregnant woman presenting to the Emergency Department for care will have a triage assessment. ...C. Any pregnant woman presenting with symptoms suggestive of non-pregnancy related illness or extensive bleeding will be evaluated in the Emergency Department. D. The “Triage of Pregnant Patient > 20 Weeks” form is part of the medical record and should be sent to the Department of Health Information to scan into the patient record.” - Procedure: D. All pregnant women presenting at greater than 20 weeks gestation with isolated pregnancy-related complaints will be assessed by the Emergency Department triage RN by utilizing the “Triage of Pregnant Patient > 20 Weeks” form... 2. If the triage nurse deems the complaint is not pregnancy related, the patient will be evaluated in the Emergency Department. 3. If the triage nurse deems a pregnancy related complaint, the patient will get a medical screening/assessment in the Birth Center. ...4. If upon evaluation at the Birth Center, it is determined that the patient does not have a pregnancy related problem and needs to be seen in the Emergency Department, the patient will be returned to the Emergency Department for final disposition.” 5. If the Emergency Department Physician requests fetal monitoring on a pregnant patient with symptoms of non-pregnancy related illness, the patient remains in the Emergency Department patient until results of fetal monitoring are obtained. a. Birth Center staff will do fetal monitoring in the Emergency Department, or b. Patient is transported to the Birth Center for monitoring. ...d. If upon evaluation at the Birth Center, it is determined that the patient does not have a pregnancy related problem, the patient will be returned to the Emergency Department for final disposition. 4) Reviewed the Systemwide Model Policy number 12119, titled “EMTALA-Medical Screening Exams Labor and Delivery,” last review date of 05/17/2024. The policy included:, - Policy Intent: “A. To ensure that all individuals who Come to the hospital (as defined in the Compliance with EMTALA policy) seeking or in need of Emergency Services and Care, including Labor and Delivery (L&D), receive a appropriate Medical Screening Examination and further examination and Stabilizing treatment in accordance with applicable laws and Hospital policies. B. The Medical Screening Examination will be performed by individuals qualified to perform the Examination to determine if the individual has an Emergency Medical Condition, the Hospital will provide further examination and treatment necessary to Stabilize the Emergency Medical Condition.” - Policy: Compliance: “...b. Provide a Medical Screening Examination by a physician, clinical nurse midwife or a registered nurse authorized to provide a Medical Screening Examination to any pregnant woman who comes to Labor and Delivery (WC) seeking examination or treatment.” - Procedure: “2a. A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an individual is, or is not, experiencing Labor or another Emergency Medical Condition. ...c. The Hospital and Medical Staff will determine the categories of Qualified Medical Persons who may perform the Medical Screening Examinations. The Medical Staff bylaws or rules and regulations, as approved by the Hospital governing body, will designate the categories of Qualified Medical Persons in L&D who are authorized to perform the Medical Screening Examination. A Qualified Medical Person who is authorized to perform a Medical Screening Examination in L&D must: i. Practice within the scope of his/her license issued by the state in which the Hospital is located; ii. Demonstrate his/her current competence in performance of Medical Screening Examinations, within the authorized scope of his/her health profession; and iii. As applicable, perform the Medical Screening Examination in accordance with protocols standardized procedures or other policies as may be required by law or approved by the Hospital governing body and the Medical Staff. ...”4. Non -Labor Related Condition. If it is determined that the patient is not in labor, but has a presenting complaint, signs or symptoms (such as abdominal pain) that is beyond the scope of the nurses license or authorized practice in the Hospital, or of a Qualified Medical Person treating the patient, the nurse or Qualified Medical Person will arrange for the completion of the Medical Screening Examination by requesting a physician to come to L&D in a timely manner to examine the patient, or arrange to have the patient taken to the Emergency Department.” 5) Reviewed the Hospital Rules and Regulations, which included: P/14.000, “Medical Screening Examinations shall be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. The Medical Executive Committee designated who is qualified to perform medical screening examinations. Currently: Physician members of the medical staff with privileges in the Emergency Department. A qualified labor and delivery nurse shall provide a labor screening exam to any patient assigned to a medical staff member with obstetrical privileges. Disposition of the patient shall be determined by the attending physician. The obstetrics on-call physician will provide a labor screening exam to any woman who is not a patient of our medical staff with obstetric privileges. The Hospital Rules and Regulations approve WC RN’s to do Medical Screening Exams for labor only, when present to the ED for treatment. 6) On 04/11/2025 at 10:00 AM, interviewed one of the WC Nurses (RN)1, who said the WC works closely with the ED, and recently participated in their skills fair to share information on “OB emergencies.” She said the WC created a reference binder for the ED nursing staff, which included information on post partum hemorrhage and hypertension. Inquired if there had been any updates to policies regarding triaging or moving patients that present to the ED with post partum high BP, or after a MVA, she replied no. RN1 said the WC RNs have competencies for screening for labor. When inquired if they had competencies to conduct MSE for post partum preeclampsia, or other nonrelated pregnancy conditions, she replied no. RN1 said she took the call from the ED RN the day P2 came for treatment of a headache and high blood pressure. She recalled the ED RN mentioned the ED skills fair education and asked if they were able to take this patient, rather than go through the ED, and she told the RN they could bring the patient to the WC. On 4/11/2025 at 11:30 AM, conducted an interview in the conference room with the WC Nurse Manager (NM). She said the Hospital had been preparing for new CMS regulations on “OB emergency readiness (initiative to prepare to respond to emergencies that my cause or contribute to maternal mortality),” and the WC recently had a station at the ED skills fair, where they shared information and resources including an algorithm to identify OB emergencies. The UM went on to say if someone came to the ED and had already delivered, they usually go through the ED. She said the process for triage and moving patients to WC had not changed. The UM said the ED should do their MSE, and then consult the OB provider if needed. She said the WC MSE was focused on labor, and if someone had been sent to WC, and found to have a nonpregancy related condition, she would expect the staff to contact the hospitalist to examine the patient, or send the patient to the ED. On 04/11/2025 at 12:00 PM, conducted an interview in the conference room with the Obstetrics Nurse Educator (NE). She said she was not familiar with the ED specific policies, but if a patient presents in active labor, or to rule out active labor, the ED would send the patient to WC. The NE said she would expect all others to get a MSE in the ED, and consult the OB provider as needed. The NE went on to say the WC had a station at the ED skills fair about OB emergencies that the ED might see, and that she created a reference binder for them. The NE said the focus was on early recognition of OB emergencies and early OB consult. She acknowledged anyone presenting to the ED post partum with headache and concerns about high blood pressure should be triaged in the ED, have vitals taken immediately, and be seen by the ED physician. On 04/11/2025 at 12:45 PM, conducted an interview with the Director of Education and Workforce Development (DE) and the ED Clinical Nurse Educator in the conference room. The DE confirmed the WC station at the skills fair and that there were no policy changes. She said it was “informative education for staff,” but no process change. On 04/11/2025 at 01:12 PM, had a phone interview with the ED Medical Director. He said patients that present with pregnancy related complaint, would be sent to L&D for MSE. If not pregnancy related, they would stay in the ED. At that time reviewed the scenario of P1 and P2, who presented to the ED for treatment and moved to WC. The MD said a headache postpartum, is “kind of a grey zone if associated with pregnancy or not, and would be reasonable to triage, and could send to OB in nature, but currently there had not been any policy changes.” He went on to say a MVA in pregnant women (P1) is at increased risk due to the pregnancy, and should be triaged into the ED for the MSE. On 4/14/25 at 07:30 AM, conducted a telephone interview with WC RN2, who cared for P1. Her recall was that the ED called saying they had a pregnant lady from a car accident and were sending her over for monitoring. RN2 said she “did not know if P1 had been seen in the ED by a physician or not.””

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 39853 Based on interviews, medical records and document review, the hospital (H)1 was not able to provide sufficient evidence why one patient (P)3 transfer request of a sample size of 12 was denied for neurosurgical specialized services, when the receiving hospital had the capacity and capability to care for them. As a result of this deficiency, P3 did not receive the specialized services timely. After his conditioned deteriorated, several days later, he was accepted for transfer by H4. If patients do not receive the specialized services needed in a timely manner, there is a high probability of serious adverse outcomes. Findings include: 1) The Office of Healthcare Assurance received notice of approval to investigate an anonymous complaint that H1 refused to accept a transfer of a patient that needed specialty neurosurgical services from an outer island hospital (H2) that does not provide that service. During the investigation, reviewed the log, titled “Med/Surg Patient Transfer Requests,” for the period of October 1, 2024, through March 31,2025, which is maintained by the House Supervisors (HS). The log revealed a request for transfer from H2 for neurosurgical services for P3. The log indicated H1 had the capability and capacity at the time the request for transfer was made. Review of the On-call schedule provided by Medical Staff Office revealed a neurosurgeon (NMD) was scheduled on call at the time of the request. 2) On 01/28/2025 H2 requested to transfer P3 to H1 for neurosurgical services they did not provide. Reviewed the form the House Supervisor (HS) at H1 initiated on 01/28/2025 at 06:50 PM, that documented the transfer request. The form included: “Patient Diagnosis: Septic knee/possible spinal epidural abscess.” “Specialty Need: Neuro surg/ID (infectious disease).” Type of bed request: “Med/Surg (medical/surgical).” Part II: “Criteria to determine whether the request is for an EMTALA or non-EMTALA transfer.” “1. Is the patient in an emergency department or labor & delivery?” The box was checked “Yes.” “2. Has there been a determination that the patient has an “emergency medical condition?” The Box was checked “Yes.” “3. Has there been a determination as to whether the emergency medical condition is “stabilized” or not?” The box marked said “stabilized.” “4. What are the reasons for transfer?” The box marked was “Specialized care.” “5. Does the sending facility have the present capability & capacity to provide the services needed?” The box was checked “No.” Part III: “Determine hospital capability and capacity to accept the transfer.” “1. Does AHCS (H1) have an appropriately staffed bed that is expected to be available at the time of the patient’s arrival; ...” The box was marked “Yes.” “2. Is the Emergency Department expected to have the capacity to examine, treat & monitor the patient pending assignment ...?” The box was marked “Yes.” “3. Does AHCS expect to have service capacity at the time of this patient’s arrival or within clinically required timeframes) to provide the level of care required for the patient?” The box was marked “Yes.” “4. Is there an appropriate medical staff physician who will accept responsibility for the patient?” The HS wrote “NO” next to the box, “Does patient need specialty services not provided at AHC?” The HS also wrote “No,” next to the box “Is there accepting coverage for any specialty services?” Part IV: “Time requesting physician called specialist: 19:50 PM (07:50 PM).” “Part V. Documentation if Transfer Not Accepted.” This section has eight reasons that can be checked to explain the reason for denial. These included: Not an emergency medical condition, Emergency medical condition stabilized, Patient does not require specialized services at AHCS, AHCS does not have a bed, services or emergency department capacity (document the reasons below), On-call physician is not available to accept the patient (document the reasons) below, Transfer is for insurance reasons, Transfer is a lateral transfer (level of care available at transferring hospital at time of transfer), and Other (document below). The box “On-call physician is not available to accept the patient (document the reason below)” was checked. “Other information/Issues with Transfer:” The HS wrote “NMD declined the request, doesn’t meet spine admission criteria.” Reviewed P3’s “ED Provider (EDMD) notes” from H2, dated 01/28/2025, which included the following: Medical Decision Making: “This 67-year-old male PMH (pertinent medical history) of HTN (hypertension) and DM (Diabetes) presents to the ED for left shoulder pain, right knee pain and continued back pain. ...His knee shows a large effusion without erythema (redness). Mild warmth ...Although the knee does not appear septic, will obtain synovial fluid (in joint cavity) to evaluate for septic arthritis. MRI (Magnetic Resonance Imaging) ...to evaluate for possible spinal epidural abscess (infection that can cause rapidly deteriorating neurological functioning due to compression). 03:10 PM: Knee arthrocentesis (fluid drawn from joint) performed. 06:15 PM: “...Pending orthopedic consultation and MRI read (results).” 06:30 PM: “...MRI shows ...collection along the posterior aspect of the right L4/5 (lumbar) facet joint. This potentially represents abscess formation. This extends into the spinal canal along the posterior aspect of the canal. The patient has ...septic arthritis (infection of one or more joints) and possible abscess draining into his spinal canal. ... Additional liter of fluids (intravenous) ordered as the patient is slightly tachycardic (increased heart rate). He was placed on 2 L (liters) of oxygen due to mild hypoxia (low oxygen level) ...” 06:37 PM: “Call placed to H4 but they are over capacity and cannot accept at this time.” 06:39 PM: “Called H5, pending call back.” 06:40 PM: “Call placed to H1. Requested MRI images beamed (to be sent) first.” 07:21 PM: “Pt (P3) declined from H5” 07:25 PM: “I (ED physician) spoke with NMD (H1 spine) who felt that the patient’s lumbar MRI findings were more consistent with a synovial cyst.” Clinical Impression included bacteremia (bacteria in the blood stream)..., pyrogenic (infection) arthritis of right knee joint and infection of lumbar spine. EDMD Provider notes dated 01/28/2025 at 09:23 PM: “Patient signed out to me by previous provider for follow-up on disposition. NMD at H1 does not think that this is infectious, he states that he thinks that this is a synovial cyst and can be treated outpatient however will consult if patient transferred per previous provider. patient [sic] does show signs of infectious etiology particularly the knee, however, is very possible that patient is bacteremic and has also seeded his spine (rare condition called a spinal cord abscess). When discussed with NMD again he still declines transfer. ...” 01/29/2025: “ADDENDUM: MRI cervical spine and lumbar spine overread this morning: ...T2 (thoracic area) hyperintense lesion dorsal epidural space at the L4-5 level, concerning for phlegmon (localized inflammation or infection)/developing abscess (well defined pocket filled with pus). ...Radiologist discussed with MD2 who is attempting to obtain additional Neurosurgery consultation.” P3 was admitted at H2 for IV antibiotic therapy and monitoring. He had progressive decline in clinical status including worsening weakness in his left upper extremity and bilateral lower extremities. He was accepted for transfer to H4 on 02/04/2025 where he had surgery 02/06/2025. Reviewed P3’s H4 “Operative Report” dated 02/06/2025, which included the following: Postoperative Diagnosis: 1. Incomplete quadriplegia due to cervical discitis and epidural abscess, C5-C6 and C6-C7. 2. Cervical spinal stenosis, C5-T1. 3. L4-:5 spinal stenosis (narrowing of spinal canal) likely due to epidural abscess. The initial Web anonymous complaint, included that H1’s NMD, “refusal to transfer for neurosurgery evaluation but stated multiple times if the pt was already on oahu [sic] and at their hospital they would consult. ...” 3) On 04/14/2024 at 10:15 AM, interviewed the Medical Staff Officer (MSO) in the administrative conference room. He said he reviews the quality data on transfer requests monthly, to identify trends and opportunities. The MSO said he will sometimes discuss a case with the specialist, for additional information regarding the reason for denial. Brought to MSO’s attention that the reason for denial of transfer for P3 was “doesn’t meet spine admission criteria.” When asked what the facility spine admission criteria was, he said they did not have any specific spine criteria. The MSO said he had a discussion with NMD about the denial, and recalled NMD told him after he looked at the x-rays, he felt the issue was a septic knee, and needed orthopedic consult. On 04/15/2025 at 03:30 PM had a telephone interview with NMD. Inquired if he recalled the request from H2 to transfer P3. He said when he spoke with the ED doctor and with the information he had at that time, he felt the priority would be to have an orthopedic specialist assess the patient for the obvious knee infection, and that he recommended further workup to differentiate the spinal involvement and diagnosis. NMD said he felt the spinal issue could have been a synovial cyst or septic arthritis, rather than an epidural abscess, needing immediate neurosurgical consult/treatment. He went on to say the “ER physician was exacerbated” with him and was not open to the recommendation of further workup at H2 with additional consult after receiving results. NMD said he felt he left it open for the ER doctor to call him back if needed after further work up. 4) Reviewed H1’s policy/procedure number 1200, titled “Model Policy: EMTALA - Acceptance of Emergency Transfers,” with last review date of 01/22/2024. The policy included the following: 1. Acceptance of Transfers. a. A hospital with specialized capabilities or facilities will accept the Transfer of an individual with an Unstabilized Emergency Medical Condition if the individual requires the specialized services of facilities of the Hospital ... “ b. If another hospital requests acceptance of Transfer of an individual who does not have an Emergency Medical Condition, or Emergency Medical Condition is Stabilized, the Transfer will be reviewed for medical necessity, the level of acuity, the capability of the Hospital to manage the patient’s condition, the availability of staff, beds and other resources, an accepting physician and other factors, ...” 2. Hospital Process for the Acceptance Transfers. a. Responsibility for the Acceptance of Transfer requests. ...ii. If a member of the medical staff, including an On-call specialist, is contacted directly by the transferring hospital or physician to accept a Transfer, the physician should notify staff assisted to handle Transfers, and provide pertinent information as to the patient, his/her clinical status and needs and other information to the requested transfer,” g. Refusal to Accept Transfer. - i. Except where the Hospital is required to accept a Transfer under applicable state law or its contractual obligations (including Transfer agreements and health plan contracts), the Hospital may refuse to accept a Transfer of an individual with an Unstabilized Emergency Medical Condition of anyone if the following conditions exist I. The individual does not require the specialized capabilities and facilities of the Hospital at the time of the Transfer; II. The Hospital does not have the Capacity at the time of the Transfer to provide the specialized services required for the individual; III. The transferring facility had the present Capability and Capacity to provide the specialized services required for the individual; or IV. The transferring facility provides the same level of specialized services that are present at the Hospital at the time of the Transfer. Lateral Transfers between facilities of comparable resources are not required by EMTALA because they do not offer enhanced care benefits to the individual except where there is a mechanical failure of equipment, no beds or staff available at the transferring hospital, or similar circumstances. - ii Reporting of Denial of Transfer Request if the Receiving Physician declines a Transfer, he/she will immediately report the denial of the Transfer to the house nursing supervisor on duty. If the Receiving Physician declines a transfer, he/she will submit a written report to [click here and insert name] within 24 hours. The written report will include the name of the patient’s condition and need for care, the reason given for the Transfer and the reason that the physician or house nursing supervisor declined the Transfer. The model policy provided was not revised to include the name of individual to submit written report of a transfer that was declined,and that process was not in place.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39853 Based on interviews, record review (RR) and document review, the facility failed to have consistent processes in place for the high-risk intervention of restraint to protect and promote each patient’s rights in the Behavioral Health Services Unit (BHU). The investigation identified several deficiencies at the Standard level. The lack of consistent processes and the cumulative effect of the deficiencies, decreases the protection of patient rights and increases the likelihood of harm and resulted in a Condition level deficiency in Patient Rights. Findings include: 1) The facility is an acute care hospital that is part of an integrated health system servicing the West Coast and Hawaii. The hospital operates an inpatient Behavioral Health Services Unit where patients receive services for full-range of psychiatric disorders. Reviewed the “Systemwide Standard Policy” titled “Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion) number 12579 last reviewed by individual entity, 06/2024. The policy summary included the statement “ To outline an organizational approach to restraints that protects the patient’s health and safety and preserves their dignity, rights and well being. This includes a description of patients basic rights, organizational intent to eliminate inappropriate and unnecessary use of restraint or seclusion and to manage restraint initiation, monitoring, discontinuation, staff education and reporting.” “J. Quality Assessment and Performance Improvement (QAPI) 1. The organization leadership is responsible for creating a culture that supports patient rights. Leadership ensures that the policy is followed as intended. Data will be collected on the use of restraint/seclusion. The use of restraint will be analyzed and measured for quality assurance/control, performance improvement, and identification of patterns, tends, and variations by the QAPI committee.” The investigation revealed a lack of effective administrative and clinical processes that led to areas of noncompliance at the standard level. Facility leadership was unaware of the issues of noncompliance and did not have an effective process in place to ensure their policy was followed. The cumulative effect of these deficiencies resulted in a Condition level deficiency in Patient Rights. 2) Cross Reference A-154 Patient Rights: Restraint The facility leadership failed to ensure there was an organized effective quality improvement process in place to assess, monitor and identify needs for improvement in the use of restraint/seclusion to support patient’s rights. The BHU audited restraint events, but did not identify noncompliance with regulations. In addition, the facility could not provide evidence restraint use was incorporated into the Quality Assurance Performance Improvement (QAPI) program. 3) Cross Reference A-168 Patient Rights: Restraint The facility failed to obtain an order immediately (within a few minutes) from a LIP (Licensed Independent Practitioner operates within the scope of his or her license, consistent with individually granted privileges) after an emergency application of restraint on two patients (P)1 and P4, of a sample size of four. 4) Cross Reference A-170 Patient Rights: Restraint There was lack of evidence that the LIP, responsible for the management and care of one patient (P)1 of a sample size of four, was made aware of an emergency restraint intervention. 5) Cross Reference A-178 Patient Rights: Restraint The facility failed to ensure a LIP provided the face-to-face evaluations within one hour after emergency restraints were applied on three patients (P)1, P2, and P3 of a sample size of four. In addition, the facility policy for Restraint Management, that included the 1-hour face-to-face evaluation, was a “Systemwide Standard Policy,” and did not specify what categories of practitioners (i.e. Registered nurses (RN), Advanced Practice Professionals) were authorized to conduct the evaluation at this facility. 6) Cross Reference A-179 Patient Rights: Restraint Documentation is a key practice in any clinical treatment, but especially important when a high-risk intervention like restraint is used. The facility failed to ensure the face-to-face evaluation (clinical and behavioral assessments) met regulatory standards. In three patient’s (P)1, P2, and P3 of a sample size of four, the 1-hour, face-to-face evaluations did not meet requirements because 1) the brief findings were documented by RN’s, rather than the LIP when the evaluation was conducted, 2) the times entered by the RN’s were the time the restraints were initiated. The actual tune the LIP conducted the evaluation is unknown, and 3) there was lack of documentation of a physical and behavioral assessment to rule out possible underlying causes or contributing factors to the patient’s behavior.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 39853 Based on interviews, Medical Record Review and document review, facility leadership failed to ensure there was an organized effective quality improvement process in place to assess, monitor and identify needs for improvement in the use of restraint/seclusion to evaluate and support patient’s rights. The Behavioral Health Services Unit (BHU) audited restraint events, but did not identify noncompliance with regulations. Specifically, there was trend on the evening/night shift the one-hour face-to-face did not include the actual time of the evaluations, were not completed tiennly, and the content of the assessments did not meet regulatory standards. In addition, the facility could not provide evidence restraint use throughout the facility was incorporated into the QAPI program. Findings include: 1) Reviewed the Facility Systemwide Standard Policy number 12579, titled “Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included: Definition: “G. Quality Assessment and Performance Improvement (QAPI): The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services ...; and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.” “J. Quality Assessment and Performance Improvement (QAPI) 1. The organization leadership is responsible for creating a culture that supports patient rights. Leadership ensures that the policy is followed as intended. Data will be collected on the use of restraint/seclusion. The use of restraint will be analyzed and measured for quality assurance/control, performance improvement, and identification of patterns, tends, and variations by the QAPI committee. Reviewed the Facility Behavioral Health Services Policy titled “Policy & Procedure: Suicide Prevention - Interventions in Behavioral Health Settings, Number CMBHPP060039, review date 06/17/2024. The policy included “G. Implementation and effectiveness of this policy shall be monitored via periodic validation audits with reporting of aggregate data to leadership and to the committee overseeing quality. 2) On 10/31/2024 at approximately 02:15PM, during an interview with the Director Quality (QD), she said the Manager of BHU recently left the position, and was unavailable for interview. She said the unit does a debriefing on all restraint events, and maintains a binder on the unit for chart audits. She went on to say, if anything was identified that needed referral for follow up, it would be reported to the Manager. Request was made for any documentation that the data was aggregated, reported and incorporated into the facility QAPI program. The QD said they would investigate and respond. On 11/05/2024, the following correspondence was received by email from the QD. “The Behavioral Health Unit (BHU) Manager conducts ongoing reviews of restraint debriefing forms to ensure completeness. Key components of this review include verifying physician orders for restraints, alignment with care plans, adherence to policy for vital sign monitoring, timely face-to-face evaluations of patients, and discontinuing restraints at the earliest appropriate moment. Additionally, any potential patient harm events are reviewed by Patient Safety Council. A gap was identified in the routine reporting of the data (i.e. the review by the BH manager) to the appropriate council. To address this, a structured process for reporting restraint data to the quality council was established on 11/04/2024 with the first report scheduled for 11/25/2024. The restraint data is now integrated into the Quality Assurance and Performance Improvement (QAPI) program and will be reported quarterly to monitor for process gaps and drive any necessary improvements.””

“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: 39853 Based on interviews, medical record review (RR) and document review, the facility failed to obtain an order immediately (within a few minutes) after an emergency application of restraint on two patients (P)1 and P4, of a sample size of four. As a result of this deficiency the use of these restraints were not used 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 by hospital policy. Findings include: 1) Reviewed the Facility Systemwide Standard Policy number 12579, titled “Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included: “Definitions: ... B. Emergency Situation: An immediate, urgent or critical situation of a temporary nature, regardless of its cause, which may seriously endanger or threaten the life, health, or safety of individuals.” “RN (Registered Nurse) may authorize/initiate mechanical or seclusion restraints (excluding chemical) in emergency situations without an order but must obtain an order from the LIP (licensed independent practitioner) during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint has been applied.” “ LIP or clinical psychologist is consulted, as soon as possible, if they did not order the restraint(s) or seclusion.” 2) On 10/31/2024 at 12:50 PM, during an interview with a Psychiatric Mental Health Nurse Practitioner (PMHNP)1, she said she was employed by the hospital and the BHU had on site coverage with a LIP (MD/OD/PMHNP) every day from 07:00 AM until 07:00 PM. After hours, one of the BHU LIP’s will be on call. She went on to say when emergency restraints are initiated during after hours, the nursing staff will usually notify the on call BHU provider for the restraint order, but will then notify the hospitalist (24/7 coverage) by pager, to come to the unit to do the face- to-face evaluation. 3) P1 was a 45 year old female brought to the Emergency Department (ED) on October 8, 2024. She had no known previous psychiatric history, but had a past pertient medical history of hypertension. P1 was admitted to the BHU at 02:33 AM on 10/09/2024, where she became intrusive with other peers, did not respond to verbal redirections, and required sedation and emergency restraint. RR of P1’s “Restraint/Seclusion Progress Record (45BHCS) revealed the following: 10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair. RR of P1’s orders revealed the following: 10/09/2024 04:30 AM Restraint Order initiated (entered in electronic medical record) by Registered Nurse (RN)1 10/09/2024 04:30 AM Psychiatric Mental Health Nurse Practitioner (PMHNP)2 notified by phone. RN1 conducted readback (process to validate phone order). RR of “Nursing Documentation - Flowsheet, which included the following entries documented by RN1 : 10/09/2024 at 03:45 AM: Documented PMHNP2 notified by phone regarding restraint. For physician communication results, RN1 documented “No orders received” 10/09/2024 at 03:58 AM: Hospitalist (MD)1 notified of restraint by phone, pager. Although the nursing note documented the PMHNP2 was notified at 03:45 AM, there was no documentation of an order obtained or entered until 04:30 AM. 3) P4 was a 23 year old male admitted to the BHU due to suicidal and homicidal threats on 08/15/2024. On 08/16/2024, P4 had behaviors that required emergency restraint. RR of P4’s “Restraint/Seclusion Progress Record revealed the following: 08/16/2024 at 09:21 PM, emergency restraint applied using the restraint chair. RR of P4’s orders revealed the following: 08/16/2024 at 09:23 PM, order for “Restraint/Seclusion” entered by RN3. 08/16/2024 at 10:29 PM, “Communication Type: Phone w/ Readback” entered by RN3 Review of Nursing Documentation Flowsheet revealed the following entries: 08/16/2024 at 09:50 PM: Physician (MD) notified: “MD2” Notified by “phone” Notified of “Restraint/Seclusion” Physician communication results “Orders received” “Comments/Attempts to notify “ This documentation was followed by corrected results, “Date and time corrected from 8/16/2024 21:23 (09:23 PM (time order entered by RN)) HST (Hawaii Standard Time) on 8/16/2024 22:37 (10:37 PM),” entered by RN3. There was a delay in over an hour to obtain the order for emergency restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 39853 Based on interviews, record review (RR) and document review, there is lack of evidence that the attending physician, responsible for the management and care of one patient (P)1 of a sample size of four, was aware of an emergency restraint intervention. As a result of this deficiency, the attending may not have information that may have a significant impact on the subsequent course of treatment. Findings include: 1) P1 was a 45 year old female brought to the Emergency Department on October 8, 2024 by the police for psychiatric care after having religious preoccupation and delusion. She had no known previous psychiatric history, but had a past pertient medical history of hypertension. P1 was admitted to the Behavioral Health Services Unit (BHU) on a MH4 (involuntary 48 hour hold/ deemed to be at risk for harm to self or others). She was transported to the BHU at 02:33 AM. P1 became intrusive with other peers, and did not respond to verbal redirections, and required sedation and emergency restraint. RR of P1’s “Restraint/Seclusion Progress Record (45BHCS) revealed the following: 10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair. 10/09/2024 at 07:40 AM, restraint terminated. RR of P1’s medical records revealed on 10/09/2024 at 04:30 AM, the on call LIP (Psychiatric Mental Health Practioner (PMHP)2) gave a phone order for the restraints, and LIP (MD1), conducted the 1 hour face-to-face evaluation. . 2) On 10/31/2024 at 01:15 PM, interviewed Registered Nurse (RN)1, who cared for P1 the night of the restraint. Inquired who notified P1’s attending of the restraint, she said LIP1 doesn’t take phone calls after she leaves the hospital, so would “normally notify the Medical Director if needed, and he would probably be the one to notify LIP, likely on the day shift. On 10/31/2024 at 01:30 PM , interviewed RN2, a day shift charge, who said he wouldn’t rely on the hospitalist who did the face to face evaluation to notify the attending, and said it would usually be nursing that would notify the attending in the morning and should be documented in the electronic medical record under “physician communication.” He went on to say sometimes they use tiger text, to communicate, which would not be retrievable, or part of the medical record.. 3) P1’s attending was LIP1, the restraint was ordered by Psychiatric Mental Health Nurse Practitioner (PMHNP)2, and the 1 hour face-to-face was done by the Hospitalist (MD1). There is no documentation or evidence that the attending was made aware of the emergency restraint. RR of LIP’’s progress note dated 10/09/2024 at 11:39 AM, included “Per staff report, patient (P1) presents with bizarre behavior on the unit, intrusive with other peers, hugged roommate to “bless” her, did not respond to verbal redirections, requiring IM (intramuscularly) haldol, benadryl and ativan (sedatives) at 0309 and 1040. ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 39853 Based on interviews, medical record review (RR) and document review, the facility failed to provide evidence that a 1-hour face-to-face evaluations was conducted by a Licensed Independent Practitioner (LIP) after emergency restraints were applied on three patients (P)1, P2, and P3 of a sample size of four. As a result of these deficiencies, a prompt assessment was not done to evaluate the behavior that led to the intervention, and determine the continued need for the intervention. In addition, the facility policy for Restraint Management, that included the 1-hour face-to-face evaluation, was a “Systemwide Standard Policy,’” and did not specify what categories of practitioners (i.e. Registered nurses, Advanced Practice Professionals) were authorized to conduct the evaluation at this facility. Findings include: 1) Reviewed the Facility Systemwide Standard Policy number 12579, titled “Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included: Definitions: “C. Face-to-Face Assessment: In -person evaluation documented by a licensed independent practitioner (LIP), or their designee, or registered nurse who has been trained according to the current regulatory requirement.” “F. Restraint Considerations- Violent/self-destructive: 3. If the face-to-face evaluation is conducted by a trained RN or Physician assistant, that RN or physician assistant must consult the LIP responsible for the care of the patient as soon as possible after completion of the 1-hour face-to-face evaluation.” 2) On 10/30/2024, during an interview with the Quality Director (QD), inquired if the Registered Nurses (RN) were approved and to conduct the 1 hour face-to-face evaluation post emergency restraint. The QD, returned later and stated RN’s are not approved to the evaluation and it must be a physician (MD/DO) or facility employed Psychiatric-Mental Health Nurse Practitioner (PMHNP) 3) P1 was a 45 year old female brought to the Emergency Department (ED) on October 8, 2024 by the police for psychiatric care after having religious preoccupation and delusion. P1 was admitted to the Behavioral Health Services Unit (BHU). When P1 became intrusive with other peers, did not respond to verbal redirection, and required sedation, emergency restraints were applied. Review of P1’s Medical records revealed the following: - “Restraint/Seclusion Progress Record (45BHCS) revealed on 10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair. - “Nursing Documentation - Flowsheet” included the following entries documented by Registered Nurse (RN)1 : 10/09/2024 at 03:58 AM: Physician (MD)1 notified of restraint by phone, pager. 10/09/2024 at 04:09 AM: Physician Communication: “physician called back ... informed of restraints and asked if he can come and see patient. ...” 10/09/2024 at 05:17 AM, Clinical Nursing Note: “...At 0345 patient was placed in restraints, contact On call provider, contacted hospitalist (MD)1 (which we are still waiting for physician to see patient). contacted house supervisor. patient is currently in restraints at 0520 (05:20 AM) d/t (due to) not displaying safe behavior, still being verbally and physically aggressive to staff. ...” -“Evaluation of Patient in Restraint/Seclusion” form: The form used to document the 1 hour face-to-face evaluation did not document the time MD1 actually completed the evaluation, but the nursing note above indicated it had not yet been completed at 05:20 AM, and was beyond the one hour requirement. On 10/31/2024 at 01:15 PM, during a telephone interview with RN1, she confirmed she worked the night shift on 10/09/2024 and took care of P1 when the restraints were applied. She said she had a hard time tracking down the hospitalist to come do the evaluation that night. RN1 went on to say at night, they rely on the Hospitalist and it depends when they are able to come as they cover needs for the whole hospital. She confirmed she wrote in the time at the top of the evaluation, acknowledged it was the time the restraint was applied, and she did not know when MD1 actually did the evaluation. RN1 acknowledged there were “a few times they had a hard time getting the hospitalist to get up (to the BHU).” 4) P2 is a 20 year old female admitted to BHU from the ED on 07/06/2024 for suicidal ideation. On 07/10/2024, P2 had emergency restraint (restraint chair) applied for self harm behaviors. -RR of P2’s “Restraint/Seclusion Progress Record” included the following: 07/10/2024 at 10:23 PM, emergency restraint applied using the restraint chair. 07/10/2024 at 11:30 PM “RN + Doctor examine pt, release L (left) ankle. This document revealed the face-to-face evaluation was completed by Provider (not identified on this form) over one hour from the time restraint was initiated. 5) P3 was a 36 year old female presented to the ED on 09/01/2024 with suicidal ideation and precipitated by multiple stressors. She was admitted to the BHU for psychiatric care where her behaviors required emergency restraint. Review of P3’s medical records revealed the following: -“Restraint/Seclusion Progress Record:” On 09/01/2024 at 08:30 PM, emergency restraint applied using the restraint chair. -“Evaluation of Patient in Restraint/Seclusion” form completed by the RN: The RN documented the time at the top of the form “2030 (08:30 PM),” which was the time P3’s restraint was initiated. MD3 (illegible) signed the form, but there was no time documented to indicate when the evaluation was actually conducted.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 39853 Based on interviews, document review and medical record review (RR), three patient’s (P)1, P2, and P3 of a sample size of four, did not have a documented 1-hour, face-to-face evaluation that met requirements. Specifically, 1) brief evaluation findings were documented by a Registered Nurse in preparation for the MD to sign, 2) the time documented on the form was the time the restraints were initiated, not the time of the qualified provider evaluation, and 3) the evaluation did not include a physical and behavioral assessment to rule out possible underlying causes or contributing factors to the patient’s behavior. Findings include: 1) Reviewed the Facility Systemwide Standard Policy number 12579, titled “Standard Policy: Restraint Management (Mechanical, Chemical, Seclusion), last reviewed 06/10/2024. The policy included: “After the initial intervention, patients will be seen face-to-face within 1 hour by a qualified LIP, registered nurse, or physician assistant who had reviewed education in accordance with requirements to evaluate: a. Patients immediate situation, b, Reaction to intervention, c. Medical and behavioral condition d. Need to continue or terminate the restraint (s),or seclusion.” standards, which includes both a physical and behavioral assessment. The Centers for Medicare & Medicaid Services (CMS) interpretation is that an evaluation of the patients medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient’s history, drugs and medications etc. The purpose of this evaluation is to complete a comprehensive review of the patient’s condition to determine of other factors, such as drug or medication interactions, electrolyte imbalance, hypoxia, sepsis, etc., are contributing to the patient’s violent or self destructive behavior. 2) Cross reference A-178 Patient Restraint The quality practitioners authorized by the facility to conduct the 1 hour face-to-face evaluation after emergency restraint, included the categories of licensed independent practitioners (LIP) of MD (medical doctors), DO (Doctors of Osteopathic Medicine), and PMHNP (Pyschiatric Mental Health Nurse Practitioners). Registered Nurses are not authorized. 3) On 10/31/2024 at 12:50 during an interview with PMHNP1, she said the Behavioral Health Services Unit (BHU) had coverage on site from 07:00 AM until 07:00 PM. After hours, one of the Providers, MD, or PMHNP will be on call. She went on to say when emergency restraints are initiated during those hours, the RN staff will usually notify the on call BHU provider for the order, but will then notify the hospitalist on duty by pager, to come to the unit to do the face-to-face evaluation. PMHNP1 said nursing has a packet that contains all the required forms for restraints, and it includes a form for the provider to document the 1 hour face-to-face evaluation. She confirmed it is the providers responsibility to complete the form at the time of their evaluation. 4) Reviewed the form titled “Evaluation of Patient for Restraint/Seclusion,” which had preprinted categories of Date, Time, Patient’s Immediate Situation, Patient’s reaction to the intervention, Patient’s medical condition, Patient’s behavioral condition, Continue or Terminate restraint or seclusion and Physician Signature. 5) P1 was a 45 year old female admitted to the Behavioral Health Services Unit (BHU) on October 8, 2024 for psychiatric care after having religious preoccupation and delusions. She had no known previous psychiatric history, but had a past pertient medical history of hypertension. P1 became intrusive with other peers, did not respond to verbal redirections, and required sedation and restraints. RR of P1’s “Restraint/Seclusion Progress Record revealed the following: 10/09/2024 at 03:45 AM, emergency restraint applied using the 5-pt (five point) restraint chair. “Described behavior that justified restraint/seclusion: “screaming, physically aggressive, increasingly agitated.” “Described behavior that justified restraint/seclusion (second page): “Disorganized, impulsive, hostile, restless/pressured.” 10/09/2024 at 07:40 AM, restraint terminated. Reviewed P1’s “Evaluation of Patient Restraint/Seclusion” form, completed by RN1. The form included: “Date: 10/9/2024” “Time: 0345” “Patient’s Immediate Situation: physically aggressive, lunged at staff, yelling, refusing to follow any direction.” “Patient’s reaction to the intervention: continues to yell, verbally hostile, swearing.” “Patient’s medical condition: stable” “Patient’s behavioral condition: currently still yelling, rocking in restraint chair, verbally hostile.” MD1 (illegible) signed the form, but there is no time noted. On 10/31/2024 at 01:15 PM during a phone interview with RN1, who initiated the emergency restraint for P1 on 10/09/2024 confirmed the hospitalists do the face-to-face evaluations after 07:00 PM. When inquired who completes the “Evaluation of Patient in Restraint/Seclusion” form, RN1 said “the nurses do.” She went on to say the Hospitalist signs the form when they come to the unit to see the patient. The 1 hour face-to-face evaluation was not documented by the Provider, and does not reflect both a physical and psychological assessment of the patient in order to rule out possible underlying causes or contributing factors to the patient’s behavior. . 6) P2 is a 20 year old female admitted to the BHU from the ED on 07/06/2024 for suicidal ideation. She had a past psychiatric history of schizophrenia and methamphetamine use. On 07/10/2024, P2 had emergency restraint (restraint chair) applied for self harm behaviors. RR of P2’s “Restraint/Seclusion Progress Record revealed the following: 07/10/2024 at 10:23 PM, emergency restraint applied using the restraint chair. “Described behavior that justified restraint/seclusion: Banging doors, yelling, kicking, hurting self” 07/10/2024 restraint terminated at 11:55 PM. Reviewed P2’s face-to-face evaluation form, completed by the RN as follows: “Date: 07/10/2024” “Time: 2223 (10:23 PM)” “Patient’s Immediate Situation: pt. (patient/P2) banging door, kicking wall 2 staff yelling creaming; agitated” “Patient’s reaction to the intervention: medication was already given.” “Patient’s medical condition: stable” “Patient’s behavioral condition: restless” MD2 (illegible) signed the form, but no time documented. The evaluation /assessment was not documented by the Provider, and does not reflect both a physical and psychological assessment of the patient in order to rule out possible underlying causes or contributing factors to the patient’s behavior. 7) P3 was a 36 year old female has a history of borderline personality disorder, post traumatic stress disorder, attention deficit hyperactivity disorder, depression and agoraphobia (avoiding places or situations that might cause panic). She presented to the ED on 09/01/2024 with suicidal ideation precipitated by multiple stressors and was admitted to BHU for psychiatric care, where her behaviors required emergency restraint. RR of P3’s “Restraint/Seclusion Progress Record revealed the following: 09/01/2024 at 08:30 PM, emergency restraint applied using the restraint chair. “Described behavior that justified restraint/seclusion: “Assaultiveness towards security and this writer upon admission, scratched writer on L (left) wrist; kicked at writer and security” 09/01/2024 restraint terminated at 10:00 PM. Reviewed P3’s face-to-face evaluation form, completed by the RN as follows: “Date: 09/01/2024” “Time: 2030 (08:30 PM)” “Patient’s Immediate Situation: aggressive, assaulted staff” “Patient’s reaction to the intervention: unwilling to process w/ (with) staff; wanting to leave or have a private room.” “Patient’s medical condition: none” “Patient’s behavioral condition: crying, but not willing to participate on education.” Continue restraint was checked. MD3 (illegible) signed the form, but no time documented. The evaluation /assessment was documented by the RN, not the physician, and does not reflect an appropriate physical and psychological assessment of the patient in order to rule out possible underlying causes or contributing factors to the patient’s behavior.”