Iowa Specialty Hospital - Belmond

“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: 47335 Based on document review, hospital policy review, and interviews, the hospital (Hospital A) failed to ensure the Emergency Department (ED) staff followed hospital policy which resulted in 1 of 20 sampled patients (patient #6) not being registered in the ED log or receiving an appropriate medical screening exam (MSE) after presenting to the ED with medical care requested on their behalf. Failure to maintain a complete log may result in the hospital’s inability to track the care provided to each individual who comes to the ED and may also create an expectation among hospital staff that some individuals who come to the ED may not need to be provided an appropriate MSE. Failure to provide an appropriate MSE placed patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions (EMC) and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur. Findings include: 1. Review of the policy “ EMTALA Guidelines,” Last Revised 05/3/24, revealed in part: a. “ ...All patients presenting to Iowa Specialty Hospital Emergency ... Departments and seeking care ... must be accepted and evaluated...” b. “ ...All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis ...” c. “ ...The Emergency Department shall maintain a central log documenting the following information: Each individual presenting to the ED for assistance, if the individual refused treatment, if the individual was refused treatment, if the individual was transferred, admitted and treated, stabilized and transferred or discharged.” d. “ ...MSEs shall include at a minimum the following: ED Log entry, including disposition of patient, patient’s triage record, vital signs, history, physical exam of affected systems and potentially affected system, exam of known chronic conditions, necessary testing to rule out emergency medical conditions, notification and use of on-call staff to complete previously mentioned guidelines, notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary, vital signs upon discharge or transfer, and complete documentation of the medical screening exam ...” 2. Review of the policy “Emergency Services,” Last Revised 1/16/19, revealed in part: a. “...(the hospital) will offer reasonable care within the medical capabilities of the facility. Emergency services will be integrated with the other departments of the facility. This coordination includes communication between the emergency room and other departments of the facility ...” b. “ ...Emergency services are under the direction of a qualified member of the medical staff. The appropriateness of procedures, treatments, and care provided in the emergency room are determined by the medical staff ...” c. “ ...(the hospital) will determine whether an emergency exists, will render care appropriate to the facility ... make appropriate referrals to a facility that is capable of providing needed services. Emergency services will be available 24 hours a day with a practitioner trained in emergency care on call and available by telephone or radio 24 hours per day. The emergency care will include the provision of the appropriate equipment and qualified personnel necessary to furnish all services offered in a safe manner in accordance with acceptable standards of practice.” d. “ ...A log, containing the following information will be kept for a minimum of 5 years: patient name, admission time, discharge time, age, mode of arrival, provider, presenting complaint, final diagnosis, disposition and transfer facility. 3. Review of the policy “ Sexual Assault-Examination of Suspected or Alleged Abuse Victims,” Last Revised 1/28/22, revealed in part: a. “To provide guidance for the care and treatment of patients reporting sexual assault and/or abuse to include the following five essential elements: Care of physical injuries, sexually transmitted disease/sexually transmitted infection (STD/STI) prevention, pregnancy testing and prevention, evidence collection, crisis intervention and supportive counseling...” b. “ ...The hospital has an obligation to treat the medical and psychological needs of individuals presenting in the emergency room for treatment ...” c. “ ...Minors 14 and under presenting with and/or reporting concerns of sexual assault or abuse shall be provided with a medical screening to treat acute medical concerns. All assessment and evaluation of sexual assault or abuse will be referred to a Child Protection Center (CPC). Law enforcement and the Department of Human Services will assist with referral processes. Sexual Assault Response Team (SART) Advocate will be notified immediately upon presentation ...” d. “ ...Complete Nursing Assessment: Assessment will include chief complaints, emotional, psychosocial, physical state, vital signs, complaints, level of consciousness (LOC), and signs and symptoms presenting. Record all pertinent dates, times and persons present ...” e. “ ...Contact the following people: On-call provider or Sexual Assault Nurse Examiner (SANE) RN, authorities as directed by the provider or SANE (if not already present), lab personnel to draw blood and provide slides/materials for specimen collection if provider orders, Sexual Assault Advocate ...” 4. During an interview on 7/31/24 at 1:20 PM, Staff A, Hospital A ED RN, recalled Patient #6, a pediatric patient under the age of 14, presented to the Hospital A’s ED on the night of 1/29/24 with a police officer and asked if the hospital did sexual assault examinations on pediatric patients under age 14 years of age. RN A recalled telling the police officer Patient #6 could be seen in the ED if needed, but the ED staff could not complete a sexual assault examination. Staff A, Hospital A ED RN, acknowledged they did not register Patient #6 on the ED log. 5. During an interview on 8/1/24 at 2:15 PM, CNO Hospital A acknowledged Patient #6 was not registered or placed on the ED log when they presented to the ED on the night of 1/29/24. CNO acknowledged Patient #6 should have been registered on the log and checked in as an ED patient, and taken back to an ED room to be medically screened by the ED provider. 6. During an interview on 8/5/24 at 7:35 AM, Officer R recalled presenting to the Hospital A’s ED on the night of 1/29/24 with Patient #6 and their mother, and requested a sexual assault examination. Officer R reported the RN told Officer R the hospital didn’t do sexual assault exams for children. Officer R recalled the RN on duty didn’t see or assess Patient #6, and didn’t offer to have Patient #6 seen in the ED by a provider. 7. The Hospital A’s ED central log, dated 1/28/24 through 1/30/24, lacked documentation of patient #6’s name and reason for coming to the ED. The hospital failed to provide an appropriate medical screening examination, or any type of testing or evaluation within the Hospital A’s capability to rule out a potential emergency medical conditions, such as, but not limited to, physical injuries, sexually transmitted diseases or infections, and/or psychological crisis intervention or need for supportive counseling. ED staff failed to conduct the evaluation required by hospital policy, including consultation with an on-call provider on patient #6’s condition. Please refer to C-2405 and C-2406 for additional information.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 47335 Based on document review, hospital policy review, and interviews, Hospital A’s administrative staff failed to ensure hospital ED staff maintained a complete emergency department (ED) log for at least one individual who came to the ED (patient #6) seeking medical care. Failure to maintain a complete log may result in the hospital’s inability to track the care provided to each individual who comes to the ED seeking care for a potential emergency medical condition (EMC). Findings include: 1. Review of the policy “Emergency Services,” Last Revised 1/16/19, revealed in part: “ ...A log, containing the following information will be kept for a minimum of 5 years: patient name, admission time, discharge time, age, mode of arrival, provider, presenting complaint, final diagnosis, disposition and transfer facility. 2. During an interview on 7/31/24 at 1:20 PM, Staff A, Hospital A ED RN, recalled Patient #6, a pediatric patient under the age of 14, presented to the CAH’s ED on the night of 1/29/24 with a police officer and asked if the hospital did sexual assault examinations on pediatric patients under age 14 years of age. Staff A, Hospital A ED RN, recalled telling the police officer Patient #6 could be seen in the ED if needed, but the ED staff could not complete a sexual assault examination. Staff A, Hospital A ED RN, acknowledged they did not register Patient #6 on the ED log. 3. During an interview on 8/1/24 at 2:15 PM, CNO Hospital A acknowledged Patient #6 was not registered or placed on the ED log when they presented to the ED on the night of 1/29/24. CNO acknowledged Patient #6 should have been registered on the log and checked in as an ED patient, and taken back to an ED room to be medically screened by the ED provider. 4. During an interview on 8/5/24 at 7:35 AM, Officer R recalled presenting to the Hospital A’s ED on the night of 1/29/24 with Patient #6 and their mother, described the situation with Patient #6 to the hospital RN on duty, and requested a sexual assault examination. 5. The Hospital A’s ED central log, dated 1/28/24 through 1/30/24, lacked documentation of patient #6’s name and reason for coming to the ED.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 47335 Based on medical record review, staff and patient interviews, the hospital failed to provide 1 of 20 patients (Patient #6), selected for review, an appropriate medical screening examination (MSE) within the hospital’s capabilities (including the ancillary services routinely available to the emergency department) to determine whether an emergency medical condition (EMC) existed. Patient #6, a pediatric patient under the age of 14, presented to the hospital’s dedicated ED (Hospital A) with law enforcement requesting examination on their behalf. Hospital staff failed to provide an MSE to Patient #6 in accordance with it’s own policies (See C2400). Failure to provide an appropriate MSE placed current and future patients at immediate risk for deterioration of their health and wellbeing as a result of unidentified and/or untreated emergency medical conditions and creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur. Findings include: 1. Review of the police report pertaining to Patient #6’s alleged sexual assault revealed: a. On 1/29/24 at 7:22 PM, Officer R was dispatched to Patient #6’s residence for a report of sexual assault of Patient #6 sometime between the night of 1/27/24 and the morning of 1/28/24. Officer R asked Patient #6 and their mother if they would want a sexual assault examination done at the CAH, and they agreed. Officer R transported Patient #6 and their mother to Hospital A’s ED. Officer R had Patient #6 and their mother waited in the waiting area of the ED while Officer R went inside the ED and talked with nursing staff. Officer R asked the Hospital A’s nursing staff if they could do a sexual assault kit on Patient #6, a pediatric patient under the age of 14, and Officer R was informed Hospital A’s ED staff couldn’t do the examination on people under the age of 15. The ED nursing staff made some phone calls and then informed Officer R that the closest place for a sexual assault examination was Hospital B. b. On 1/30/24, unknown time, Chief/Officer K contacted Child Protective Center (CPC) at Hospital B and scheduled at time for Patient #6 with CPC for an interview and medical examination. 2. During an interview on 8/5/24 at 7:35 AM, Officer R recalled presenting to Hospital A’s ED on the night of 1/29/24 with Patient #6 and their mother, described the situation with Patient #6 to the hospital RN on duty, and requested a sexual assault examination. Officer R reported the RN made some phone calls, and when the RN returned, they told Officer R the hospital didn’t do sexual assault exams for children of Patient #6’s age. Officer R recalled the RN on duty didn’t see or assess Patient #6, and didn’t offer to have Patient #6 seen in the ED by a provider. 4. During an interview on 7/31/24 at 1:20 PM, Staff A, Hospital A ED RN, recalled Patient #6 presented to the CAH’s ED on the night of 1/29/24 with a police officer and asked if the hospital did sexual assault examinations on pediatric patients under age 14 years of age. RN A recalled telling the police officer Patient #6 could be seen in the ED if needed, but the ED staff could not complete a sexual assault examination. Staff A, Hospital A ED RN, reported the police officer had Patient #6 and their mother wait in the waiting area of the ED, and Patient #6 never entered the ED. Staff A, Hospital A ED RN, acknowledged they did not register Patient #6 in the ED log. Staff A, Hospital A ED RN, acknowledged they did not assess or talk to Patient #6 or Patient #6’s mother. 5. During an interview on 7/31/24 at 2:10 PM, Staff C, Hospital A Advanced Registered Nurse Practitioner (ARNP), reported they were covering as the hospitalist on duty on 1/29/24, they were not covering the ED, and were not notified of Patient #6 presentation to the ED on the night of 1/29/24. Staff C, ARNP Hospital A, reported they are a Sexual Assault Nurse Examiner (SANE) provider and could do sexual assault examinations on patients age 12 and older. Staff C, ARNP Hospital A, reported being “on the clock,” and “would have been local” on the night of 1/29/24 when Patient #6 presented to the ED. Staff C, ARNP Hospital A, reported they could have completed a sexual assault examination on Patient #6. 6. During an interview on 8/1/24 at 12:35 PM, Staff P, Hospital A ED/SANE RN, recalled being contacted on the night of 1/29/24 by Staff A, Hospital A ED RN, with report of a pediatric patient under the age of 14 that presented to the ED for a sexual assault examination. Staff P, Hospital A ED/SANE RN, reported they weren’t trained to do pediatric sexual assault examination and could only do the examinations for patients 14 years and older. 7. During an interview on 8/1/24 at 2:15 PM, CNO Hospital A acknowledged Patient #6 was not registered or placed on the ED log when they presented to the ED on the night of 1/29/24. CNO Hospital A acknowledged Patient #6 should have been registered on the log and checked in as an ED patient, and taken back to an ED room to be medically screened by the ED provider. 8. Hospital A ED staff failed to complete any form of an assessment or an appropriate medical screening examination, including use of ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed, such as, but not limited to, physical injuries, sexually transmitted diseases or infections, and/or psychological crisis or need for supportive counseling. ED staff failed to consult with an on-call provider on patient #6’s condition. 9. On 1/30/23 at approximately 1:30 PM, Patient #6 presented to Child Protective Center (CPC) at Hospital B with Chief/Officer K for a forensic interview and medical evaluation following a reported sexual assault. 10. Review of an incident report completed by Hospital B staff, dated 2/7/24, revealed CPC Staff Q documented Patient #6 met criteria to have a SANE done the evening of 1/29/24 when Patient #6 presented to the Hospital A’s ED. CPC Staff Q also documented refusal to see Patient #6 could have resulted in a missed opportunity to collect evidence. 11. During an interview on 8/1/24 at 2:15 PM, CPC staff Q recalled Patient #6 presented to their CPC office on 1/30/24 for a sexual assault examination, the day after presenting to Hospital A’s ED. CPC staff Q reported CPC staff were on call 24 hours a day, seven days a week, and that Patient #6 met criteria for an emergent sexual assault examination at the time they presented to Hospital A’s ED, and that a staff person with CPC would have come in to the CPC location to evaluate Patient #6, if they would have been contacted by the Hospital A’s staff about Patient #6 on the night of 1/29/24.”