St Lukes Regional Medical Center

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49842 Based on medical record review, policy review, and staff interviews, the Acute Care Hospital (ACH)’s administrative staff failed to ensure hospital staff adhered to physician orders for one-to-one (1:1) monitoring for 1 of 10 sampled patients (Patient #8). Failure to provide appropriate monitoring and supervision, in accordance with the orders prescribed by the provider, could result in an increased risk of harm to the patient, including injury, disability, deterioration in the patient’s condition, or other serious adverse health outcomes. Findings include: 1. Review of the hospital’s 04/2025 policy, “Documentation: Nursing Care,” revealed in part: a. Purpose: “To outline the role of the nursing staff in provision of evidence-based, individualized care driven by the patient goals and outcomes.” b. “If the orders prescribed by the provider are not carried out, based on the nurse’s professional judgment, accountability shall include but not be limited to the following. Documentation of notification to the provider who entered the orders and the reasons the orders were not executed.” 2. Review of Patient #8 (P8)’s 1/28/26 medical record revealed the following: a. On 1/28/26 at 11:46 AM, staff admitted P8, a patient with intellectual disability and high impulsivity who presented with a right proximal femur periprosthetic fracture after sustaining a fall, which required surgical repair of the femur fracture. The patient had a medical history significant for congestive heart failure (CHF), coronary artery disease (CAD), and hypertension (HTN). At the time of admission, Staff A (Physician) entered a physician order for 1:1 monitoring of the patient at all times due to safety concerns related to the patient’s intellectual disability and impulsivity. b. On 1/28/26 at 12:05 PM, Staff M (Nurse Practitioner) documented a consultation request by Staff A (Medical Provider) to evaluate the patient’s rehabilitation needs during their admission to the Acute Inpatient Rehabilitation unit. A Patient Safety Attendant (PSA) remained at the patient’s bedside for 1:1 monitoring at this time. c. On 1/28/26 at 9:00 PM, Staff C (Registered Nurse (RN)) noted a PSA was not available to provide 1:1 monitoring of the patient at this time. d. On 1/29/26 at 7:00 AM, Staff C (RN) documented no PSAs were available to provide 1:1 monitoring of the patient at this time. e. On 1/29/26 at 6:54 PM, Staff N (RN) documented no PSAs were available to provide 1:1 monitoring of the patient at this time. f. On 1/30/26 at 7:00 AM, Staff P (RN) documented no PSAs were available to provide 1:1 monitoring of the patient at this time. g. On 2/1/26 at 12:45 PM, Staff Q (RN) documented that 1:1 monitoring of the patient was not medically indicated at this time. h. On 2/2/26 at 7:23 PM, Staff Q (RN) documented that 1:1 monitoring of the patient was not medically indicated at this time. i. On 2/4/26 at 7:28 PM, Staff Q (RN) documented that 1:1 monitoring of the patient was not medically indicated at this time. j. The medical record did not include evidence of staff providing 1:1 monitoring of the patient, in accordance with the physician’s orders, on 2/5/26. Staff did not document that said monitoring was no longer medically indicated, nor did staff document that a PSA was not available on this date. k. The medical record did not include evidence of staff providing 1:1 monitoring of the patient, in accordance with the physician’s orders, on 2/6/26. Staff did not document that said monitoring was no longer medically indicated, nor did staff document that a PSA was not available on this date. l. The medical record did not include evidence of staff providing 1:1 monitoring of the patient, in accordance with the physician’s orders, on 2/7/26. Staff did not document that said monitoring was no longer medically indicated, nor did staff document that a PSA was not available on this date. m. The medical record did not include evidence of staff providing 1:1 monitoring of the patient, in accordance with the physician’s orders, on 2/8/26. Staff did not document that said monitoring was no longer medically indicated, nor did staff document that a PSA was not available on this date. n. The medical record did not include evidence of staff providing 1:1 monitoring of the patient, in accordance with the physician’s orders, on 2/9/26. Staff did not document that said monitoring was no longer medically indicated, nor did staff document that a PSA was not available on this date. o. The medical record did not include evidence of staff providing 1:1 monitoring of the patient, in accordance with the physician’s orders, on 2/10/26. Staff did not document that said monitoring was no longer medically indicated, nor did staff document that a PSA was not available on this date. p. On 2/12/26, staff discharged P8 from the hospital and discontinued the order for 1:1 monitoring following the patient’s discharge. 3. During an interview on 3/25/26 at 8:30 AM, Staff J (Unit Manager / RN) acknowledged nursing staff failed to provide 1:1 monitoring of P8, as ordered by the patient’s provider. Staff J indicated the patient’s condition and cognition improved during the admission, and the patient may no longer have required the 1:1 monitor; however, nursing staff did not notify the provider of a change in the patient’s condition or request discontinuation of the order for 1:1 monitoring, which Staff J acknowledged was not discontinued until the patient’s discharge. Staff J reported that a PSA had not been available to provide 1:1 monitoring of the patient during a significant portion of the patient’s admission.”

“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: 50212 Based on medical record review, patient/family interviews and staff interviews, hospital emergency department (ED) staff failed to provide, within the hospital’s capabilities, an appropriate medical screening examination (MSE) and the appropriate stabilizing treatment for 1 of 20 sampled patients (Patient #5) per the hospital’s policies. Failure to provide appropriate ED services resulted in hospital staff discharging Patient #5-a patient with severe pain, pneumonia (an infection of the lungs), difficulty breathing, and pulmonary edema (a potentially life-threatening accumulation of fluid in the lungs) without the patient receiving the appropriate stabilizing treatment for the severe pain reported by the patient or for the pulmonary edema identified by the ED provider. Failure to provide the appropriate stabilizing treatment for severe pain could have resulted in worsened, chronic pain and masking of other underlying conditions (i.e., delayed diagnosis and treatment of other emergency medical conditions). Additionally, failure to facilitate a safe discharge resulted in a patient leaving the facility with neither appropriate transportation arrangements nor appropriate discharge instructions, given the presence of an emergency medical condition and the absence of stabilizing treatment of such. Instead, the cognitively impaired patient left the facility and attempted to walk home in frigid weather while inappropriately clothed, enfeebled, and with an empty oxygen tank. See A-2407 and A-2409 for additional information.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and interviews with patients, family, and staff, the hospital’s administrative staff failed to ensure Emergency Department (ED) staff provided the appropriate stabilizing treatment to 1 of 20 patients (Patient #5) who presented to the ED seeking medical care from 4/8/24 to 8/19/24. Failure to provide appropriate ED services resulted in hospital staff discharging Patient #5-a patient with severe pain, pneumonia (an infection of the lungs), difficulty breathing, and pulmonary edema (a potentially life-threatening accumulation of fluid in the lungs) without the patient receiving the appropriate stabilizing treatment for the severe pain reported by the patient or for the pulmonary edema identified by the ED provider. Failure to provide the appropriate stabilizing treatment for severe pain could have resulted in worsened, chronic pain and masking of other underlying conditions (i.e., delayed diagnosis and treatment of other emergency medical conditions). Findings include: 1. Review of the medical record for Patient #5 revealed the following: a. On 4/9/24 at 2:24 AM, Patient #5 presented to the ED via ground ambulance with complaints of generalized weakness, intermittent fever, sore throat, worsening chest pain and cough, and severe pain, including arthralgia (joint pain), which the patient scored 8 out of 10 in severity (10 being the highest). The patient’s medical history included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), shortness of breath (SOB), asthma, diabetes mellitus (DM), memory loss, and epilepsy. b. Physical examination of the patient revealed the presence of wheezing (abnormal lung sounds associated with a number of respiratory conditions) and tachycardia (elevated heart rate). Record review revealed recent diagnoses of streptococcal pharyngitis (infection of the throat and tonsils) and walking pneumonia (infection of the lungs), for which the patient received broad-spectrum antibiotic therapy. Chest x-ray (CXR) imaging revealed the presence of pulmonary edema/vascular congestion (a potentially life-threatening accumulation of fluid in the lungs), for which the patient received diuretic medication (used to reduce fluid retention) c. However, the medical record did not include documentation of reassessment or treatment of the severe pain reported by the patient, nor did the record include reassessment of the patient ’ s pulmonary status or respiratory effort after diuresis to determine the appropriateness of outpatient follow-up versus inpatient admission for further work-up and treatment. 2. During an interview on 8/22/24 at 1:44 PM, Patient #5’s significant other (SO) reported contacting 911 on 4/9/24 to request emergency medical services (EMS) after the patient experienced a fall and possible seizure. The SO reported the patient had a concurrent diagnosis of pneumonia and exhibited weakness, lethargy, and disorientation. The SO indicated the patient returned from the hospital with worsened SOB and disorientation. The SO voiced concerns that ED staff discharged the patient without appropriately treating the patient ’ s condition. 3. During an interview on 8/20/24 at 11:17 AM, Patient #5 reported experiencing chest pain and suffering a fall on 4/9/24, prompting the patient ’ s family to contact EMS. The patient reported notifying hospital staff of worsening pain and disorientation upon arrival at the ED. The patient voiced concerns that ED staff did not adequately treat their condition prior to discharge, citing continued disorientation and impaired mentation (ability to think and reason) at the time of discharge. 4. During an interview on 8/27/24 at 11:16 AM, Staff O (Paramedic) reported responding to the EMS request on 4/9/24, which pertained to an unconscious/fainting individual (Patient #5). Staff O reported, upon arrival, the patient appeared confused, forgetful, and generally weak. 5. During an interview on 8/22/24 at 5:00 PM, Staff F (ED Physician) noted-given the patient ’ s ongoing respiratory infection, history of epilepsy, and comorbidities-the patient remained at an elevated risk of potential adverse health outcomes. Staff F cited the potential for breakthrough seizures due to the lower seizure threshold associated with infection as one such example. 6. During an interview on 8/22/24 at 9:40 AM, Staff E (ED NP) reported performing an assessment of the patient on 4/9/24 and recalled the patient indicated their condition had not improved since their recent Pulmonology appointment, and they still felt tightness in their chest and a burning sensation in their lungs. Staff E acknowledged appropriate treatment for a patient with a similar presentation to Patient #5 likely would have required inpatient admission-rather than overnight observation or discharge-and indicated that patient-reported pain scores of 8 out of 10 generally warrant pain intervention. Furthermore, Staff E acknowledged hospital policy required intervention for this severity of pain. 7. During an interview on 8/27/24 at 1:14 PM, Staff R (ED Manager) confirmed the patient reported a pain score of 8 out of 10 and acknowledged, per hospital policy, a pain score of 4 out of 10 and above necessitated medical intervention and subsequent reassessment. Upon review of the medical record, Staff R acknowledged ED staff failed to perform and document treatment and reassessment of the patient ’ s pain in accordance with hospital policies and acceptable standards of practice. 8. Review of the hospital ’ s 10/10/2023 policy “ Transfer & Emergency Examination-EMTALA “ revealed in part: a. “ Purpose: To establish a procedure for the examination, stabilization, and transfer of individuals coming to [the hospital] emergency department and a request has been made for examination or treatment for a medical condition . . . This policy is also intended to assure appropriate treatment and transfer protocol in compliance with EMTALA (the Emergency Medical Treatment and Labor Act). “ b. “ Definitions: A. Emergency Medical Condition. 1. Medical/Psychiatric - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual . . . in serious jeopardy, b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part. “ c. “ B. Stabilizing Treatment: To provide such medical treatment of the condition as may be necessary to assure that no material deterioration of the condition is likely, within reasonable medical probability . . . If a hospital is unable to stabilize an individual within its capability, appropriate transfer should be implemented. “ d. “ C. Stabilized: The treating physician or [Qualified Medical Professional] attending to the individual in the emergency department/hospital has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved. To be considered stable the emergency medical condition that caused the individual to seek care in the dedicated ED must be resolved, although the underlying medical condition may persist. “ e. “ General Procedures . . . B. Further Steps When Emergency Medical Condition is Found: If the individual has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition. “ f. “ E. Discharge: Prior to discharging an individual seeking emergency medical services . . . the examining health care practitioner shall document in the individual ’ s medical record that (i) the individual is not in an emergency medical condition, or (ii) the individual ’ s emergency medical condition is stabilized. “ 9. Review of the hospital’s 12/2023 policy “ Process Standards for Emergency Department “ revealed in part: a. “ 1. The assessment will be completed as indicated by the patient ’ s chief complaint using focused assessments upon presentation and as condition change warrants. “ b. “ i) Assessment of physical pain will be documented in the initial assessment of all patients. If pain is present, intensity (using a 0-10 scale), location, quality, aggravating/alleviating factors, duration and frequency will be assessed. “ c. “ Planning: . . . F. Pain Management, both pharmacologic and non-pharmacologic will be included in the plan as appropriate. “ d. “ III. Implementation: A. Documentation will include: . . . 5. Pain, if present at a level of 4 or greater, will be reassessed at intervals appropriate for the patient ’ s condition and a pain reassessment will be completed within 60 minutes of any intervention. Pharmacologic and non-pharmacologic interventions will be documented. “ e. “ IV. Evaluation: A. Responses to interventions will be documented where a response is expected to be observable during the emergency department stay. “”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and interviews with patients, family, and staff, the hospital’s administrative staff failed to ensure Emergency Department (ED) staff provided for a safe and appropriate discharge for 1 of 20 patients who presented to the ED seeking medical care from 4/8/24 to 8/19/24. Failure to facilitate a safe discharge resulted in Patient #5 leaving the facility with neither appropriate transportation arrangements nor appropriate discharge instructions, given the presence of an emergency medical condition and the absence of stabilizing treatment of such. Instead, the cognitively impaired patient left the facility and attempted to walk home in frigid weather while inappropriately clothed, enfeebled, and with an empty oxygen tank. Failure to ensure the safety and appropriateness of discharge of patients with cognitive or memory impairments-or other identified vulnerabilities-could result in serious, evitable physical and emotional harm to patients. Findings include: 1. Review of Patient #5’s medical records revealed: The patient presented to the ED via ground ambulance on 4/9/24 at 2:24 AM with complaints of generalized weakness, worsening chest pain, and severe pain, including arthralgia (joint pain). The patient ’ s medical history included cognitive and memory deficits, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and shortness of breath (SOB). Diagnostic work-up of the patient revealed walking pneumonia (infection of the lungs) and pulmonary edema/vascular congestion (a potentially life-threatening accumulation of fluid in the lungs). Staff provided antibiotic and diuretic therapy (used to reduce fluid retention) and discharged the patient home for self-care at 6:09 AM. The medical record did not include documentation of staff discussing the patient ’ s transportation or other arrangements to ensure a safe discharge, given the patient ’ s known cognitive, memory, and mobility impairments. 2. During an interview on 8/22/24 at 1:44 PM, Patient #5 ’ s significant other (SO) reported the patient required emergency medical services (EMS) after experiencing a fall and possible seizure on 4/9/24 at approximately 2:00 AM. The SO reported-shortly thereafter-ED staff discharged the patient without transportation arrangements, in inappropriate clothing for the cold weather, and with an empty oxygen tank. The SO reported an acquaintance later located the patient on the side of a road with their shorts down, appearing visibly short of breath, confused, and disoriented while struggling to walk home by themselves in a soiled diaper and with an empty oxygen tank. The SO indicated the patient had reported requesting assistance with arranging for transportation from a staff member, but the unspecified staff member allegedly stated they were unable to help the patient with such. 3. During an interview on 8/20/24 at 11:17 AM, Patient #5 reported difficulty recalling certain aspects of the encounter due to memory impairment; however, the patient stated they did recall requesting help with arranging transportation from a nurse, who reportedly stated they were unable to do so. The patient indicated they were unable to reach their SO via phone at this time and, thus, decided to attempt to walk home in shorts and a short-sleeved t-shirt despite the 30-degree Fahrenheit temperature outside. The patient confirmed they experienced difficulty ambulating due to Parkinson ’ s disease and noted they could typically walk for only 10 to 15 minutes at a time. The patient reported, during the walk home, their shorts fell down-exposing the patient ’ s soiled diaper to others in public and causing significant embarrassment until an acquaintance happened to drive by the patient and offered them transportation. 4. During an interview on 8/21/24 at 2:30 PM, Staff C (ED Director) reported they expected ED staff to provide for safe discharge to all patients, which they noted would include verifying the patient had an appropriate mode of transportation when leaving the facility. Staff C reported they would not expect a patient to walk home from the hospital and noted the hospital routinely offered taxi vouchers for patients without means of transportation. Staff C underscored the importance of ensuring appropriate transportation arrangements for patients with confusion or limited mobility. 5. During an interview on 8/22/24 at 5:00 PM, Staff F (ED Physician) reported, given Patient #5 ’ s respiratory infection, history of epilepsy, and comorbidities, they would have recommended the patient be discharged with a family member or friend-rather than alone. Staff F noted the patient remained at an elevated risk of potential complications (e.g., breakthrough seizures due to the lower seizure threshold associated with infection). 6. During an interview on 8/27/24 at 1:14 PM, Staff R (ED Manager) acknowledged staff did not document treatment or reassessment of Patient #5 ’ s severe pain nor evaluation of their pulmonary status after treatment to determine the appropriateness of the discharge. 7. Review of the hospital’s 10/10/2023 policy “ Transfer & Emergency Examination-EMTALA “ revealed in part: a. “ Purpose: To establish a procedure for the examination, stabilization, and transfer of individuals coming to [the hospital] emergency department. “ b. “ Definitions: A. Emergency Medical Condition. 1. Medical/Psychiatric - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse). “ 8. Review of the hospital’s 12/2023 policy “ Process Standards for Emergency Department “ revealed in part: a. “ D. Psychosocial support is provided as well as consultations to other appropriate resources such as social services, chaplain or psychiatric services. These consultations should be documented in the medical record. “ b. “ E. Communication to patient and families will include plan of care, approximate time frame, goal of cares and unexpected delays in initiation of plan of care. “ c. “ V. Disposition: . . . D. Patients discharged to home. 1. Assure patient can care for self or sufficient support mechanisms are in place. “ d. “ D. Patients discharged to home. 1. Assure patient can care for self or sufficient support mechanisms are in place. “”