Gundersen Palmer Lutheran Hospital and Clinics

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility failed to test their emergency preparedness plan in accordance with the Code of Federal Regulations (CFR) at §483.73(d)(2). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 11. Findings include: Record review and interview on 02/04/25 at 10:45 a.m., revealed the facility failed to provide documentation for a second full scale community or facility based exercise or conduct a tabletop exercise that challenges the facility ‘s emergency preparedness plan. The Maintenance Director verified this observation at the time of the survey process.”

“42 CFR 485.623(d) Gundersen Palmer Lutheran Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 Edition. Gundersen Palmer Lutheran Hospital is a two (2) story building that was built in 1949 with an additions 1963, 1980, and 2006. The building is composed of Type II(000) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors and the spaces open to the corridors. The facility has 25 certified beds. At the time of the survey, the census was 11. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 11. Findings include: Record review and interview on 02/04/25 at 10:10 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure. The Maintenance Director verified this observation at the time of the survey process.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 17359 Based on observation and interview, the facility failed to maintain smoke barrier doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.7.8(1), 2012 Edition. This deficient practice affects approximately 10 residents, staff, and visitors in 2 of 11 smoke zones. This facility has a capacity of 25 and a census of 11. Findings include: Record review and interview on 02/04/25 at 11:10 a.m., revealed that the 1963 hallway east west doors failed to fully close when initiated. The Maintenance Supervisor verified this observation at the time of the survey process.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 17359 Based on observation and interview, the facility failed to maintain access and working space around electrical panels in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code (Section-110.26), 2011 Edition. This deficient practice affects approximately 1 staff in 1 of 11 smoke zones. This facility has a capacity of 25 and a census of 11. Findings include: Observation and interview on 02/04/25 at 10:45 a.m., revealed numerous items being stored directly around and up to the electrical panels in the downstairs server room. The Maintenance Director verified this observation at the time of the survey process.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility is not conducting fire drills at unexpected times under varying conditions at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 11. Findings include: Record review and interview on 02/04/25 at 09:45 a.m., revealed that the facility was conducting fire drills quarterly on each shift however all drills were conducted within 60 minutes of all other drills in the past 12 months. First shift drills were commonly conducted at 1000 or 1030 while second shift drills were commonly conducted at 1500. The Maintenance Supervisor verified this observation at the time of the survey process.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 17359 Based on record review and interview, the facility failed to inspect and exercise main and feeder circuit breakers for their emergency generator in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.4.4.1.2.1), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 11. Findings include: Record review and interview on 02/04/25 at 11:30 a.m., revealed that the facility was unable to provide documentation for annual inspection and exercising of the main and feeder circuit breakers for their emergency generator. The Maintenance Supervisor verified this observation at the time of the survey process.”

“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: 49848 Based on review of policies, medical record review, and staff interviews, the Critical Access Hospital ’ s administrative staff failed to ensure the Emergency Department (ED) staff at the Hospital provided, with the hospital ’ s capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed from 8/1/23 to 2/1/23 (Patient #18). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care placed them at risk for undetected emergency medical conditions. Failure to provide the appropriate MSE and stabilizing treatment per hospital policy placed patients at risk for deterioration of health and potential risk of death. Findings include: Hospital Capabilities: 1. The CAH hospital ED was a level 4 Trauma Center staffed by physicians 24/7. X-ray and Lab were available after hours on call. The ED had the capability to care for the OB patient with Fetal Monitoring and Doppler Fetal heart tones as well as on-call ultrasound. OB nurses were available to float to the ED from the OB unit if needed. The CAH hospital ED had no specialty on-call staff, but had the availability to do phone consultations and patients were transferred from the facility if a higher level of care was needed. Example: Neurology, Cardiology, Substance abuse, Psychiatric care. 2. Review of patient #18’s Medical Record revealed: a. Patient #18, presented to the Emergency Department (ED) on 1/14/24 at 7:55 PM via ambulance. Patient was mandated to the Residential Care Facility (RCF) by a County Court. Patient arrived at the ED unaccompanied by staff from the RCF. Patient #18 complained of facial and ankle pain after a confrontation with one or two fellow residents. Patient reported being punched on the side of the head leaving a contusion to the right lateral frontal cheekbone. Patient also reported being kicked in the leg and ankle. Patient denied strikes to the abdomen, and denied abdominal or chest pain.General palpation of the abdomen was performed by a physician. No doppler heartbeat check performed, no ultrasound ordered, no fetal heart tone monitoring, no labs drawn to further assess the health status of the unborn child and the health and safety of the mother. b. On 1/14/2024 at 7:55 PM Staff D ED Registered Nurse, documented ED notes: Patient #18 arrived per Ambulance with complaint of “bump on my head” from a fight and being struck by a hand during an altercation with a male resident. Patient reports that they were pushed against a cabinet, choked and punched several times in the right cheek at least 4 times and kicked in the leg, there is an abrasion on the ankle. Patient stated they were”12 weeks pregnant”, and concerned about the baby. Triage Vital Signs: Blood Pressure (BP) 124/72, Respiratory Rate (RR) 18 breaths per min, Heart Rate (HR) 97 beats per minute, Oxygen saturation (O2 Sat) 98% on room air, Temperature 98.4 degrees Fahrenheit. Patient denied any substance abuse or alcohol use. Patient had a Broset Violence and Columbia suicide screening scoring zero on both. c. On 1/14/2024 at 8:07 PM Staff A ED physician, documented, Patient #18, arrived by ambulance and law enforcement. Law enforcement did not stay after rooming the patient. Patient was on a mandated short stay at RCF. The patient may have instigated a confrontation with one or two fellow residents at the RCF. One of the residents punched the patient in the side of the head leaving a contusion on their right lateral and frontal cheekbone also on the left anterior ankle. Patient was approximately 12 weeks pregnant, was struck in the thigh and left side, but not struck in the abdomen, the patient was not having abdominal or chest pain. Physical exam revealed no acute distress, normal weight, normal systems, abdomen soft, non-tender per palpation, bowel sounds present, pupils equal and reactive to light. Abrasion/contusion to anterior ankle and cheek. Medical decision making was straightforward, injuries were minor, no imaging or lab were ordered. Psychiatric examination revealed a normal mood. Mental status alert and oriented to person, place and time. Neurological exam revealed no focal deficit present. 3. During an interview on 8/12/24 at 2:45 PM Staff A ED physician, recalled Patient #18 came to the ED by ambulance with chief complaint of being assaulted, with injuries sustained to the face after being struck by a male resident at the RCF, but not struck in the abdomen. Patient appeared upset and by the time the patient left the ED they were in a more settled mood. Staff A, recalled patient stated they were 12 weeks pregnant, Patient denied any abdominal or chest pain when asked. Patient complained of pain to face and ankle, denied abdominal pain or chest pain. Situation did not warrant any additional lab or x-rays based on presenting symptoms and medical evaluation. Abdomen was soft and nontender to palpation. Staff A ED Physician reported they saw the patient in room 4 and did an examination. Staff informed me that the patient had left the ED after I examined her and could not be located. Patient was returned to the ED a short time later by law enforcement and refused to be reexamined and signed out AMA. Due to the minor injuries “I did not feel pregnancy testing or listening for fetal heart tones was warranted in this situation.” The hospital had the capabilities to screen the OB patient for fetal heart tones and ultrasound; ED Physician A expressed that additional tests were not warranted. 4. During an interview 8/15/24 at 2:30 PM with Staff C ED Registered Nurse/Manager, recalled, Patient #18 had no indications that they were suicidal and was in the ED for assault. Columbia suicide and Brofet screening was negative for violence or suicide. Per Mental Health Policy 1:1 sitter was not indicated per violent and suicide score. “There was a mandate for the RCF where the patient was residing, not for the hospital.” Staff C stated “The RCF had the responsibility to notify us if the patient had a mandate and any concerns of mental health issues when sending them to the ED.” ED had the capability of providing 1:1 sitter at any time. Would call staff down from the floor or ambulance personnel to sit with the patient. “Do what we can within our capabilities to have a sitter for the patient. Even if that means calling in additional staff to cover the 1:1 sitter.””

“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: 49848 Based on review of policies, medical record review, and staff interviews, the Critical Access Hospital ’ s administrative staff failed to ensure the Emergency Department (ED) staff at the Hospital provided, with the hospital ’ s capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed from 8/1/23 to 2/1/23 (Patient #18). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care placed them at risk for undetected emergency medical conditions. Findings: 1. Review of Policy, “Mental Health Patient Care and Observation,” last revised 7/24, revealed in part: “...Patients who enter the ED with a mental health concern are roomed in room 4 and equipment is removed for patient safety. If a patient is violent or has aggressive behavior then they should be placed under ordered direct 1:1 supervision by hospital staff, until the medical provider has deemed the patient not at risk to harm themselves or others ...” 2. Review of Policy, “EMTALA Medical Screening exam,” last revised 10/4/23, revealed in part: “... Section 1 of “Comes to the emergency department: has presented at a hospitals ’ dedicated emergency department, as defined in this section and requests examination or treatment for a medical condition ...” 3. Review of Policy, “Obstetrical Screening exam,” last revised 7/24, revealed in part: a. “...Definition section, Emergency Medical condition or “EMC” means a medical condition that manifests itself by acute symptoms of enough severity such that the absence of medical attention could reasonably be expected to result in one of the following: 1) placing the health of the individual (with respects to the pregnancy woman, the health of the unborn child) in serious jeopardy ...” b. “... Medical screening examination or “MSE” is the process required to reach with reasonable clinical confidence, the point at which can be determined whether a medical emergency does or does not exist. A MSE is an ongoing process. Depending on the patient’s condition, a MSE may involve: 1) a simple press such as a brief history of a medical exam; 2) a complex process such as a history and physical examination, followed by ancillary studies and procedures 3) anything in between ...” c “... regardless of gestational age, when trauma and/or emergency medical conditions are present in the pregnant patient, the patient will be assessed in the emergency department first, and the location of further assessment and treatment will be at the discretion of the emergency department provider. All patients presenting for evaluation will receive at a minimum the standard obstetric evaluation as indicated by the obstetrics evaluation form. A qualified evaluator will perform this. The results of any scoring indicate that a physical exam is required, or upon the request of the nurse evaluator, the patient must be seen by a physician without waiting for further interval scoring. The patient’s attending physician or the on-call physician will examine the patient for the purposes of completing the medical screening exam. The manager is responsible for ensuring that their staff are complying with this policy/ procedure ...” 4. Review of Patient #18’s medical record revealed the following: a. Patient #18, presented to the Emergency Department (ED) on 1/14/24 at 7:55 PM via ambulance. b. On 1/14/2024 at 7:55 PM Staff D ED Registered Nurse, documented the following ED notes: Patient #18 arrived per Ambulance with complaint of “bump on my head” from a fight and being struck by a hand during an altercation with a male resident. Patient reported that they were pushed against a cabinet, choked and punched several times in the right cheek at least 4 times and kicked in the leg, there was an abrasion on the ankle. Patient stated they were”12 weeks pregnant”, and concerned about the baby. Triage Vital Signs: Blood Pressure (BP) 124/72, Respiratory Rate (RR) 18 breaths per min, Heart Rate (HR) 97 beats per minute, Oxygen saturation (O2 Sat) 98% on room air, Temperature 98.4 degrees Fahrenheit. Patient denied any substance abuse or alcohol use. Patient had a Broset Violence and Columbia suicide screening scoring zero on both (indicating no concern with suicidal ideation or a concern with violent behavior). c. On 1/14/2024 at 8:07 PM Staff A ED Physician, documented, Patient #18, arrived by ambulance and law enforcement. Law enforcement did not stay after rooming the patient. Patient was on a mandated short stay at Residential Care Facility (RCF). The patient may have instigated a confrontation with one or two fellow residents at the facility. One of the residents punched the patient in the side of the head leaving a contusion on their right lateral and frontal cheekbone also on the left anterior ankle. Patient was approximately 12 weeks pregnant, was struck in the thigh and left side, but not struck in the abdomen, the patient was not having abdominal or chest pain. Physical exam revealed no acute distress, normal weight, normal systems, abdomen soft, non-tender per palpation, bowel sounds present, pupils equal and reactive to light. Abrasion/contusion to anterior ankle and cheek. Medical decision making was straightforward, injuries were minor, no imaging or lab were ordered. Psychiatric examination revealed a normal mood. Mental status alert and oriented to person, place and time. Neurological exam revealed no focal deficit present. 5. During an interview on 8/12/24 at 2:45 PM Staff A ED Physician, recalled Patient #18 came to the ED by ambulance with chief complaint of being assaulted, with injuries sustained to the face after being struck by a male resident at the RCF, but not struck in the abdomen. Patient appeared upset and by the time the patient left the ED they were in a more settled mood. Staff A, recalled patient stated they were 12 weeks pregnant. Patient denied any abdominal or chest pain when asked. Patient complained of pain to face and ankle, denied abdominal pain or chest pain. Situation did not warrant any additional lab or x-rays based on presenting symptoms and medical evaluation. Abdomen was soft and nontender to palpation. Staff A ED Physician reported they saw the patient in room 4 and did an examination. “Staff informed me that the patient had left the ED after I examined her and could not be located. Patient was returned to the ED a short time later by law enforcement and refused to be reexamined and signed out AMA.” Due to the minor injuries “I did not feel pregnancy testing or listening for fetal heart tones was warranted in this situation.” 6. During an interview on 8/13/24 @4:47 PM Staff D ED Registered nurse, recalled Patient #18 was seen in the ED after an assault at the RCF by another resident. Patient was struck about the face and shoved into a cabinet per patient report. Patient was seen for facial contusion and ankle abrasion. Did disclose that they were 12 weeks pregnant. Staff D ED RN explained “Doppler fetal heart tones are generally completed at 20 weeks, anything earlier than that you may not get anything” and “up to the provider discretion to complete the screening.” Staff D ED RN reported the patient arrived by ambulance unaccompanied by staff from the RCF. Patient was on a court mandate to the RCF. Hospital did not receive any type of report from the RCF. Staff ED RN stated, “(Patient) was triaged and examined by the physician in the ED, and shortly after the exam, left the ED unwitnessed as I was in another room with a patient.” RCF and Law enforcement (LE) were notified of the missing patient after searching the ED and hospital. Staff ED RN stated, “When I called the RCF to report the elopement they stated that the patient does this often.” Patient #18 returned a short time later accompanied by LE with an orange soda in hand acting nicer. The patient refused reexamination, “(patient) just wanted their stuff and to leave.” Patient signed out AMA after risks and benefits were explained to them. The patient was transported back to RCF by LE. 7. During an interview 8/15/24 at 2:30 PM with Staff C ED Registered Nurse/Manager, recalled, Patient #18 had no indications that they were suicidal and was in the ED for assault. Columbia suicide and Broset screening were negative for violence or suicide. Per Mental Health Policy 1:1 sitter was not indicated per violent and suicide score. “There was a mandate for the RCF where the patient was residing, not for the hospital.” Staff C stated “The RCF had the responsibility to notify us if the patient had a mandate and any concerns of mental health issues when sending them to the ED.” ED had the capability of providing 1:1 sitter at any time. Would call staff down from the floor or ambulance personnel to sit with the patient. “We do what we can within our capabilities to have a sitter for the patient. Even if that means calling in additional staff to cover the 1:1 sitter.” 8. During an interview on 8/13/24@ 11:22 AM Program Manager at Residential Care Facility (RCF). Patient #18 had been a the facility for a couple of days; admitted on 1/8/2024. Patient #18 was admitted to the RCF here on a mandate from a County Court for mental health. The patient had a substance abuse history of Cannabis, Amphetamines and Methamphetamines. Active medical history of Psychoactive Substance dependence, unspecified psychosis and bipolar disorder. Patient was pregnant and delivered the child prior to June 24, 2024 at Hospital B (indicative that the patient was 12 weeks pregnant at the time of the ED visit on 1/14/24). 9. During an interview on 8/12/24 with Staff I ED Registered Nurse, Manager in Training, during ED tour was asked about the arrival of Obstetric (OB) patients and how triaged. OB patients were seen in the ED. If an OB patient was 20 weeks or greater they could have also been taken to the OB floor for examination. To ensure safety of the patient who arrived in the ED with a behavioral health diagnosis, they were assessed and assigned 1:1 direct observation by hospital staff if needed. Hospital would call additional staff in for assistance. Court ordered patients had a 1:1 sitter by either law enforcement or nursing staff. Elopements happened and patients could not be held against their will. Staff made all attempts to keep the patient. If a patient eloped, law enforcement was contacted to locate the patient and return them to the ED. If a patient chose to leave, staff would explain the risks and benefits and have them sign the AMA form. ED staff failed to perform a complete MSE on Patient #18. The ED Physician documented awareness of Patient #18’s court committal to the RCF. ED staff failed to maintain the safety of the patient, within the hospital’s capability, by preventing the patient from eloping from the ED. Patient #18 had been involved in a violent altercation prior to coming to the ED for medical treatment. Patient #18 expressed concern for the safety and well-being of their unborn child. ED staff failed to perform any type of testing to confirm the patient’s pregnancy and well-being of the fetus including, but not limited to, laboratory testing to further assess the health status of the unborn child and the health and safety of the mother, use of a Doppler to check the status of fetus’ heart rate and rhythm or the use of ultrasound imaging.”