Mercy Medical Center-New Hampton

“42 CFR 485.623(d) Mercyone New Hampton Medical Center 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. Mercyone New Hampton Medical Center is a one story building that was built in 1949,1967,1973,1983,1996,2004, & 2017. The building is composed of Type II (111) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms, and the spaces open to the corridors. The facility has 18 certified beds. At the time of the survey, the census was 2. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 23031 Based on observation, interview, and testing, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2. 7), 2012 Edition. This deficient practice affects approximately 2 residents, staff, and visitors. This facility has a capacity of 18 and a census of 2. Findings include: Observation, interview, and testing on 09/23/25 at 1:00 p.m., revealed the 90 minute fire rated door to room #1609 failed to fully self-close and positively latch within the door frame when tested. The top of the door was bowed out approximately 1/2 inch. The Director of Ancillary Services verified this observation at the time of the survey process.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 23031 Based on observation and interview, the facility failed to provide fire alarm notification in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.3.5), 2012 Edition. This deficient practice affects all residents, staff, and visitors in the enclosed courtyard. This facility has a capacity of 18 and a census of 2. Findings include: Observation and interview on 09/23/25 at 12:22 p.m., revealed the Enclosed Courtyard did not contain an audible and visible notification device for the fire alarm system being activated. The Director of Ancillary Services verified this observation at the time of the survey process.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 23031 Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.1.1.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 18 and a census of 2. Findings include: Observation and interview on 09/23/25 at 12:53 p.m., revealed that 4 standard response sprinkler heads in the Kitchen contained excessive dirt and lint on the sprinkler bulb, arms and diffuser. The sprinklers were located on the ceiling around the hood system. The Director of Ancillary Services verified this observation at the time of the survey process.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 23031 Based on observation and interview, the facility failed to maintain the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-5.6.5.6), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 18 and a census of 2. Findings include: Observation and interview on 09/23/25 at 12:31 p.m., revealed the emergency generator for the facility was located outdoors. The facility failed to provide a remote manual stop station located outside the generator housing a safe distance away from the generator. The Director of Ancillary Services 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: 48530 Based on medical record review of Hospital K and Hospital L, Nursing Home S, patient and staff interviews, the critical access hospital’s administrative staff failed to ensure hospital emergency department (ED) staff provided the following within their capabilities for patients that presented to the ED seeking medical care from 7/1/23 to 1/9/24: 1) a complete ED log for 1 of 21 sampled patients (Patient #21) to track the care provided to each individual who comes to the hospital seeking care for a potential emergency medical condition (EMC); 2) an appropriate medical screening (MSE) for 1 of 21 sampled patients (Patient #21); 3) appropriate stabilizing treatment for 1 of 21 sample patients (Patient #21) that had a EMC; and, 4) an appropriate transfer for 1 of 21 sampled patients (Patient #21) that had an EMC and required a transfer. 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 hospital seeking care for a potential EMC. Failure to provide an appropriate MSE places patients at risk for an undiagnosed emergency medical condition resulting in a deterioration in health and at a potential risk for death. Failure to provide all patients with appropriate stabilizing treatment and appropriate transfer placed patients at risk for a worsening EMC and at a potential risk for death. Findings include: 1. Review of policy “Emergency Medical Treatment and Labor Act (EMTALA)”, dated 10/2022, revealed in part “... Provide and appropriate MSE to any individual who comes to the emergency department; Provide necessary stabilizing treatment to an individual with an EMC or an individual in labor; Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC ... “ 2. Review of “Procedure MercyOne New Hampton Medical Center”, dated 10/2022, revealed in part “... A medical screening examination is conducted when a request is made on behalf of the individual by someone other than the individual, even if the person requesting the examination is not the individual’ s legally responsible person ... a log on each individual who comes to the ED will be maintained ... “ 3. Review of Patient #21’s medical chart from Hospital K revealed: a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner. b. (late entry; encounter time unknown) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient. c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). d. (late entry; encounter time unknown) On 1/4/24 at 6:05 PM ED MD A documented the following, “I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21’ s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG” ... “I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]” ... “I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment.” Patient #21 prepared the patient’s ride to Hospital L for evaluation and treatment. e. The medical record lacked documentation of the time when the patient left the ED. 4. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21’ s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level of 7.7 mmol/L which prompted order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with Patient #21’ s results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this was an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport. 5. On 1/4/24 at 6:05 PM ED MD A documented the following, “I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21 ’ s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG” ... “I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]” ... “I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment.” 6. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form. 7. See A 2405, 2406, 2407 and 2409 for further detailed 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: 48530 Based on medical record review of Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the critical access hospital’s administrative staff failed to ensure hospital emergency department (ED) staff maintained a complete ED log for 1 of 21 patients reviewed (Patient #21) who presented to the ED 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 hospital seeking care for a potential emergency medical condition (EMC). Findings include: 1. On 1/16/24 Hospital K provided a copy of their ED log dated 7/1/23 to 1/9/24. Review of the hospital’ s ED log for 1/4/24 revealed lack of an entry in the log for Patient #21. 2. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported waiting in the ED room until ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explaining treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged their own transportation to Dialysis Center R. 3. Patient #21’ s Nursing Home S record review revealed a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15. 4. During an interview on 1/17/24 at 3:15 PM, Hospital K ED Tech G reported Patient #21 was registered as an outpatient. 5. During an interview 1/17/24 at 10:45 AM Hospital K ED Clinical Lead explained when staff checked a patient into the ED, the patient information populated in the hospitals electronic tracking software and the ED log. The ED Clinical Lead confirmed that ED staff did not check Patient #21 into the ED; and therefore, Patient #21 did not show up on the ED log. 6. During an interview 1/17/24 at 10:30 AM, Hospital K Chief Nursing Officer explained when staff checked a patient into the ED, the patient information populated in the hospitals electronic tracking software and the ED log. The Chief Nursing Officer confirmed no policy for maintaining an ED log. 7. During an interview 1/17/24 at 1:56 PM Hospital K Registration Supervisor confirmed no policy for maintaining an ED log.”

“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: 48530 Based on medical record review from Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the Critical Access Hospital’s administrative staff failed to ensure the Emergency Department (ED) staff at Hospital K provided, within the hospital’s capabilities, an appropriate medical screening examination (MSE) to 1 of 21 emergency patients reviewed (Patient #21). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care places them at risk for an undetected emergency medical condition. Findings include: 1. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explained treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged for transportation to Dialysis Center R. 2. Patient #21’ s Nursing Home S record review revealed a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15. 3. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21’ s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level of 7.7 mmol/L which prompted an order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this was an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport. 4. Review of Patient #21’s medical chart from Hospital K revealed: a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner. b. (late entry; encounter time unknown) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient. c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level of 6.9 mmol/L. d. (late entry; encounter time unknown) On 1/4/24 at 6:05 PM ED MD A documented the following, “I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21’ s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG” ... “I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]” ... “I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment.” Patient #21 prepared patient’s own ride to Hospital L for evaluation and treatment. e. The medical record lacked documentation of the time when the patient left the ED. 5. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form. 6. Review of Patient #21’s medical chart from Hospital L revealed: a. On 1/4/24 at 1:59 PM, Patient #21 presented to Hospital L ED from Dialysis Center R with elevated potassium level, previously drawn on 1/4/24 at Hospital K. ED DO P was contacted by ARNP O and discussed evaluation, treatment, stabilization, and transfer to a higher level of care. ED DO P performed MSE, provided treatment and repeat potassium level decreased to 6.1 mmol/L. Hospital V accepted Patient #21 and transfer was made by ground ambulance. 7. During an interview 1/22/24 at 10:30 AM, Hospital L ED DO P recalled Patient #21 arrived to Hospital L ED from Dialysis Center R. ED DO P reported Patient #21 arrived to Dialysis Center R via taxi. ED DO P reported ARNP O called and discussed pending arrival of Patient #21 for further evaluation and treatment of critically elevated potassium level of 6.9 mmol/L hours earlier at Hospital K where no MSE, treatment or appropriate transfer was arranged. ED DO P reported Patient #21 should have had the potassium level decreased by Hospital K prior to transport in order to lower the risk for cardiac instability which could have led to cardiac arrest. ED DO P reported due to a critical potassium level, the expectation would be Hospital K completed an MSE, performed stabilizing treatment and transfered Patient #21 by ground ambulance. 8. During an interview 1/17/24 at 3:04 PM, Hospital K ED RN F reported Patient #21 was told that they could be registered for outpatient services at the ED desk. 9. During an interview on 1/17/24 at 3:15 PM, Hospital K ED Tech G reported Patient #21 was registered as an outpatient encounter. ED Tech G reported never witnessing ED MD A refusing to treat anyone that presented to the ED at Facility K. 10. During an interview on 1/23/24 at 1:00 PM Hospital K Laboratory Staff T reported receiving a lab order via fax on 1/4/24 at 11:34 AM from ARNP I. Laboratory Staff T reported performing a lab draw on Patient #21 in the ED on 1/4/24 at 11:42 AM. 11. During an interview on 1/17/24 at 10:45 AM Hospital K ED Clinical Lead confirmed that Patient #21 was not registered with an ED encounter and they did not sign an AMA form. ED Clinical Lead reported hospital staff complete education on EMTALA training at orientation, complete annual online competency modules, and have EMTALA reminders at monthly nursing meetings.”

“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: 48530 Based on medical record review from Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the Critical Access Hospital’s administrative staff failed to ensure the Emergency Department (ED) staff at Hospital K provided, within the hospital’s capabilities, an appropriate medical screening examination (MSE) to 1 of 21 emergency patients reviewed (Patient #21). Failure to provide all patients with appropriate stabilizing treatment placed (Patient #21) at risk for a worsening emergency medical condition and at a potential risk for death. Findings include: 1. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explained treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged for transportation to Dialysis Center R. 2. Patient #21’ s Nursing Home S record review revealed a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15. 3. During an interview 1/22/24 at 10:30 AM, Hospital L ED DO P recalled Patient #21 arrived to Hospital L ED from Dialysis Center R. ED DO P reported Patient #21 arrived to Dialysis Center R via taxi. ED DO P reported ARNP O called and discussed impending arrival of Patient #21 for further evaluation and treatment of critically elevated potassium level of 6.9 mmol/L hours earlier at Hospital K where no MSE, treatment or appropriate transfer was arranged. ED DO P reported Patient #21 should have had the potassium level decreased by Hospital K prior to transport in order to lower the risk for cardiac instability which could have led to cardiac arrest. ED DO P reported due to a critical potassium level, the expectation would be Hospital K completed an MSE, performed stabilizing treatment and transfered Patient #21 by ground ambulance. 4. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21’ s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level of 7.7 mmol/L which prompted order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this is an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport. 5. Review of Patient #21’s medical chart from Hospital K revealed: a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner. b. (late entry; unknown encounter time) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient. c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level of 6.9 mmol/L. d. (late entry; unknown encounter time) On 1/4/24 at 6:05 PM ED MD A documented the following, “I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21’ s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG” ... “I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]” ... “I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment.” Patient #21 prepared patient’s ride to Hospital L for evaluation and treatment. e. The medical record lacked documentation of the time when the patient left the ED. 6. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form. 7. Review of Patient #21’s medical chart from Hospital L revealed: a. On 1/4/24 at 1:59 PM, Patient #21 presented to Hospital L ED from Dialysis Center R with elevated potassium level, previously drawn on 1/4/24 at Hospital K. ED DO P was contacted by ARNP O and discussed evaluation, treatment, stabilization, and transfer to a higher level of care. ED DO P performed MSE, provided treatment and repeat potassium level decreased to 6.1 mmol/L. Hospital V accepted Patient #21 and transfer was made by ground ambulance. 8. 1/17/24 at 10:45 AM Hospital K ED Clinical Lead confirmed that Patient #21 was not registered with an ED encounter and they did not sign an AMA form. ED Clinical Lead reported hospital staff complete education on EMTALA training at orientation, complete annual online competency modules, and have EMTALA reminders at monthly nursing meetings.”

“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: 48530 Based on medical record review from Hospital K and Hospital L, Nursing Home S record review, patient and staff interviews, the Critical Access Hospital’s administrative staff failed to ensure the Emergency Department (ED) staff at Hospital K provided, within the hospital’s capabilities, an appropriate medical screening examination (MSE) to 1 of 21 emergency patients reviewed (Patient #21). Failure to provide all patients with appropriate transfer placed Patient #21 at risk for a worsening emergency medical condition (EMS) and at a potential risk for death. Findings include: 1. During an interview on 1/22/24 at 6:23 PM, Patient #21 reported a history of dialysis (the process of removing excess water and waste products from the blood in people whose kidneys can no longer perform these functions naturally) treatment three times a week for three years at Dialysis Center R. Patient #21 reported an elevated potassium (an important electrolyte that helps control muscle and nerve activity; normal range 3.6 to 5.2 millimoles per liter) level at Dialysis Center R on 1/3/24 which prompted ARNP I to order a repeat potassium level blood draw on 1/4/24. Patient #21 was told by LPN H at Nursing Home S (place of residence), that transportation had been arranged for the repeat blood draw at Hospital L. Patient #21 reported they did not want to ride the 45 minute trip each way to Hospital L and called Dialysis Center R. RN N at Dialysis Center R talked with the ARNP I, who gave permission to Patient #21 to have blood drawn at Hospital K. Patient #21 arrived at the ED entrance of Hospital K and Patient #21 stated they needed a blood draw. ED RN F stated outpatient registration and blood draw could be performed in the ED. Patient #21 recalled being placed in an ED room and blood draw was performed there. Patient #21 reported ED MD A discussed laboratory blood draw resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 6.9 millimoles per liter (mmol/L). Patient #21 further reported ED MD A had spoken to ARNP O and gave Patient #21 the options of going to Hospital L or being transported to another higher level of care facility. Patient #21 did not recall ED MD A explained treatment was needed at Hospital K or the risk of leaving with a critical potassium level. Patient #21 reported they felt well at that time and promptly arranged for transportation to Dialysis Center R. 2. During an interview on 1/22/24 at 10:34 AM Director of Nursing at Nursing Home S explained Patient #21 was determined to be of sound mind after a Brief Interview for Mental Status (quick assessment of cognitive function; score of 15 indicates intact cognition) performed on 11/20/2023 resulted in a score of 15. 3. During an interview 1/22/24 at 10:30 AM, Hospital L ED DO P recalled Patient #21 arrived to Hospital L ED from Dialysis Center R. ED DO P reported Patient #21 arrived to Dialysis Center R via taxi. ED DO P reported ARNP O called and discussed impending arrival of Patient #21 for further evaluation and treatment of critically elevated potassium level of 6.9 mmol/L hours earlier at Hospital K where no MSE, treatment or appropriate transfer was arranged. ED DO P reported Patient #21 should have had the potassium level decreased by Hospital K prior to transport in order to lower the risk for cardiac instability which could have led to cardiac arrest. ED DO P reported due to a critical potassium level, the expectation would be Hospital K completed an MSE, performed stabilizing treatment and transfer of Patient #21 by ground ambulance. 4. During an interview on 1/22/24 at 11:00 AM, ARNP O reported Patient #21’ s routine monthly laboratory blood draw at Dialysis Center R on 1/3/24 resulted a critical potassium level (above 5.5 millimoles per liter is dangerously high needing emergency treatment) of 7.7 millimoles per liter (mmol/L) which prompted order sent to Hospital L for repeat potassium blood draw on 1/4/24. ARNP O recalled due to transportation issues Patient #21 presented to Hospital K and colleague ARNP I ordered repeat potassium blood draw on 1/4/24 at Hospital K. ARNP O reported Hospital K phoned with results of a critical potassium level of 6.9 mmol/L. ARNP O recalled telling ED MD A at Hospital K this is an emergency and advised to obtain EKG and lower the potassium level with insulin and glucose or albuterol. ARNP O reported with an untreated critical potassium level, Patient #21 could have had an arrhythmia resulting in a cardiac arrest in transport. 5. Review of Patient #21’s medical chart from Hospital K revealed: a. On 1/4/24 at approximately 11:29 AM, Patient #21 presented to Hospital K ED registration desk asking for outpatient lab work. Patient #21 presented without orders from a practitioner. b. (late entry; encounter time unknown) On 1/4/24 at 12:30 PM ED RN F documented they requested that Nursing Home S provide laboratory orders for the patient. c. On 1/4/24 at 11:42 AM lab work performed at Hospital K resulted abnormal potassium level of 6.9 mmol/L. d. (late entry; encounter time unknown) On 1/4/24 at 6:05 PM ED MD A documented the following, “I was first made aware of [Patient #21] when I was forwarded a call from an outside provider, [ARNP O] working with [Dialysis Center R]. [ARNP O] alerted me that [Patient #21] had an elevated potassium in our facility, and [ARNP O] requested that we treat [Patient #21 ’ s] urgent condition, and transfer for consideration of dialysis after stabilization and assessment, including an EKG” ... “I approached [Patient #21] and discussed the situation, and [Patient #21] declined being seen locally. [Patient #21] preferred to have all evaluation and treatment performed at [Hospital L]” ... “I then contacted [ARNP O], to inform them the decision that [Patient #21] made. I was informed at that time [Hospital L] does not have inpatient dialysis treatment, therefore [Facility L] was not an ideal option for the patient, I again communicated this to the [Patient #21], and despite this, [Patient #21] continued with the plan to go to [Hospital L] as opposed to local treatment.” Patient #21 prepared the patient’s ride to Hospital L for evaluation and treatment. e. The medical record lacked documentation of the time when the patient left the ED. 6. During an interview on 1/17/24 at 11:30 AM, Hospital K ED MD A explained when ED staff registered a patient for an ED encounter, the ED staff performed an appropriate MSE. ED MD A reported Patient #21 was not registered for an ED encounter and lab work was ordered by an outside provider. ED MD A reported receiving a phone call from ARNP O requesting Patient #21 be evaluated and treated at Facility K for critical lab results. ED MD A recalled asking Patient #21 to be evaluated and treated in the ED at Facility K and Patient #21 expressed the desire to travel to Facility L. ED MD A notified ARNP O that Patient #21 did not want to be seen at Facility K and was planning on going to Facility L. ARNP O again expressed they did not have the capability to treat Patient #21 at Facility L. ED MD A relayed the additional information to Patient #21 and again Patient #21 expressed the desire to travel to Facility L. ED MD A recalled a conversation with Taxi Driver J to confirm that they were agreeable to drive Patient #21 to Facility L. ED MD A confirmed that Patient #21 did not receive an MSE and did not sign an AMA form. 7. Review of Patient #21’s medical chart from Hospital L revealed: a. On 1/4/24 at 1:59 PM, Patient #21 presented to Hospital L ED from Dialysis Center R with elevated potassium level, previously drawn on 1/4/24 at Hospital K. ED DO P was contacted by ARNP O and discussed evaluation, treatment, stabilization, and transfer to a higher level of care. ED DO P performed MSE, provided treatment and repeat potassium level decreased to 6.1 mmol/L. Hospital V accepted Patient #21 and transfer was made by ground ambulance. 8. During an interview 1/17/24 at 3:04 PM, Hospital K ED RN F reported Patient #21 was told that they could be registered for outpatient services at the ED desk. 9. During an interview on 1/17/24 at 3:15 PM, Hospital K ED Tech G reported Patient #21 was registered as an outpatient encounter. ED Tech G reported never witnessing ED MD A refusing to treat anyone that presented to the ED at Facility K. 10. During an interview on 1/23/24 at 1:00 PM Hospital K Laboratory Staff T reported receiving a lab order via fax on 1/4/24 at 11:34 AM from ARNP I. Laboratory Staff T reported performing a lab draw on Patient #21 in the ED on 1/4/24 at 11:42 AM. 11. 1/17/24 at 10:45 AM Hospital K ED Clinical Lead confirmed that Patient #21 was not registered with an ED encounter and they did not sign an AMA form. ED Clinical Lead reported hospital staff complete education on EMTALA training at orientation, complete annual online competency modules, and have EMTALA reminders at monthly nursing meetings.”