St Lukes Magic Valley Medical Center

“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: 49416 Based on record review, hospital policy review, and staff interviews, it was determined the hospital failed to ensure there was no delay in care for 2 of 10 Patients (Patient #5 and Patient #6) who were seen in the ED and whose records were reviewed. This had the potential to affect other patients seen in the ED. Findings include: A hospital policy titled: Emergency Department: Code Sepsis - Adult, revised dated 10/28/25, was reviewed. The policy documented, “An adult patient who screens positive for a known or suspected source of infection and has two or more of the following SIRS vital signs: · Temp over 38C or under 36C · Respiratory rate over 20/min · Heart rate over 90 bpm · Including early lab results showing WBC under 4k or over 12k or band neutrophils over 10% AND has one or more of the following: · Systolic Blood pressure under 90 mm Hg (or MAP under 65) · Capillary Refill 3 seconds or longer · Altered Mental Status (AMS) Initiate protocol to facilitate early treatment and decrease delays. “ This policy was not followed. An example included: Patient #5 was a 14-year-old male who presented to the ED on 4/16/26 at 10:55 AM with the chief complaint of chest pain. Patient #5 ’ s record was reviewed and included: HPI: “ Patient is a 14-year-old male presenting to the ED with right-sided chest pain and cough. History was obtained from the patient and his father, who is at bedside. Patient was involved in a motorcycle crash 2 weeks ago, during which a CT scan revealed a lung infection. He was prescribed antibiotics and has completed three courses, with the last dose taken 5 days ago. He denies any history of cystic fibrosis, blood clots, or recent hospitalizations other than a sleep study. He reports persistent right-sided chest pain that worsens with deep breaths and a non-productive cough. He denies hemoptysis. Last night, he experienced a fever of 104.2 deg F, which decreased to 102 deg F after taking ibuprofen at 0200. No further medication has been taken since. His pulmonologist, Dr. Tibbetts, advised him to visit the ER for further evaluation.” 11:00 AM: EKG completed 11:06 AM: ESI 2 Vitals of note: BP 96/61 Temp 36.3 [MAP 65] 11:17 AM: Patient roomed 11:20 AM: Vitals of note: BP 86/53 [MAP 62] 11:30 AM: Vitals of note: BP 80/55 [MAP 63] Resp:23 11:34 AM: Vitals of note: BP 74/48 [MAP 59] Resp:22 11:43 AM Labs drawn 11:45 AM: Vitals of note: BP 79/50 [MAP 59.6] 11:51 AM: “ Cardiac symptoms: Lightheaded; dizziness “ 12:00 PM: Vitals of note: BP 82/50 [MAP 61] Resp:20 12:05 PM: Provider at bedside (MSE) 12:15 PM: Vitals of note: BP 79/57 [MAP 64] Resp:19 12:33 PM: First medication provided lactated ringers bolus 1,000 ml given 12: 35 PM: Vitals of note: BP 79/49 [MAP 59] Resp:20 12:43 PM: New lactated ringers bolus 1,000 ml given 12:45 PM: Xray 12:45 PM: Vitals of note: BP 75/52 [MAP 60] Resp:20 12:55 PM: Vitals of note: BP 73/47[MAP 56] Resp:20 MAP: 56 1:05 PM: Vitals of note: BP 80/60 [MAP 67] 1:12 PM: New lactated ringers bolus 1,000 ml given 1:25 PM: Vitals of note: BP 79/53 [MAP 62] 1:30 PM: Vitals of note: BP 81/54 [MAP 63] 1:32 PM: New lactated ringers bolus 1,000 ml given as well as ceftriaxone 2.5 hours after arrival 1:38 PM: Sepsis huddle results: severe sepsis/septic shock 1:45 PM: Vitals of note: BP 82/57 [MAP 65.3] 1:48 PM: NORepinephrine given 1:50 PM: Vitals of note: BP 84/55 [MAP 64.7] Resp:21 1:55 PM: Vitals of note: BP 95/63 Resp:21 Heart rate: 58 2:05 PM: Vitals of note: BP 91/61 Resp:17 Heart rate: 53 2:10 PM: Vitals of note: BP 94/62 Resp:20 Heart rate: 59 2:15 PM: Vitals within normal limits 2:32 PM: Patient transferred to higher level of care via helicopter MAPs were not documented in all vital records but based on the available blood pressure the MAPs were calculated. Patient # 5’s medical record also included a provider note labeled “Discussion” (no time stamp): “ Patient was brought to his room in the emergency department where he was evaluated for his complaints. IV was established. He was resuscitated aggressively with a total of 3L of crystalloid, but after 2L he remained persistently hypotensive and so it was felt that initiation of vasopressors should not be delayed further. He was started on a norepinephrine infusion while he received 1/3 L of crystalloid. Laboratory testing was obtained reviewed as above. CBC showed a markedly elevated white blood cell count of 28,000 with a significant bandemia 29% bands. Initial lactate was elevated at 2.3. Comprehensive metabolic panel showed elevated creatinine of 1.55 the rest of the metabolic panel essentially unremarkable respiratory panel was negative for all viral components lipase was normal troponin was undetectable blood cultures were obtained and are pending. Ultimately given that the patient was requiring vasopressor support, it was felt he would need pediatric intensive care unit and that he would have to be transferred to St. Luke’s Boise for further management CONSULTATIONS: Case was discussed with the pediatric intensivist, Dr. Gardner who accepted the patient in transfer to the pediatric ICU for further management of septic shock due to pneumonia. “ An ED physician was interviewed on 4/28/26 beginning at 10:25 AM. The physician reported that, while there were standard protocols for adults, there were no protocols for children because of their complexity. A hospital policy titled, “ Policy: Pain management “, revised date 04/02/2026, was reviewed. The policy included, “INTERVENTIONS A. Non-pharmacological and/or pharmacological approaches/interventions will be considered for pain control. Pain interventions will be initiated and documented for any of the following: a. Patient reports pain PATIENT POPULATION PAIN SCALE PAIN SEVERITY Adult Patients (able to communicate) Scale: 0-10 0=no pain 1 to 3= mild pain 4 to 6 = moderate pain 7 to 10= severe pain “ A hospital policy titled, “Oxygen Therapy - Adult “ , revised date 2/13/26 was reviewed. Criteria for Intervention included.” For use on patients that are hypoxic on room air with SPO2 at or below 90% or signs and symptoms of respiratory distress: Initiate protocol to facilitate early treatment and decrease delays. BOLD indicates pre-checked order to be implemented. Unbolded orders require nursing judgement based on the patient presentation, complaint, or patient history. Orderable Medical 1. Initiate oxygen at 2 L or greater as clinical status dictates. Titrate oxygen to achieve sat at or greater than 90%. (bold in original policy)” These policies were not followed. An example included: Patient #6 was a 61 year old female who presented to the ED on 4/9/26 at 1:54 PM with back spasms and shoulder pain, catheter concerns and was 10 days post operative. Patient #6 ‘s record was reviewed and included: Patient #6’s medical record documented her past surgery, 3/30/26, included a radical hysterectomy and vaginectomy with bilateral salpingo oophorectomy, significant bilateral pelvic and aortic lymph node dissection with complicated bladder repair, placement of bilateral ureteral stents and radical tumor debulking and was found to have necrotic and infected top portion of her uterus. Patient #6 had vitals taken including a pain score of 8- severe at 2:00 PM and given an ESI of 3. Chief complaint updated to include that catheter had stopped working yesterday and that is when Patient #6 developed the right shoulder and side pain/spasms. Vitals were taken again at 2:40 PM and were within normal limits, pain was not assessed nor was Patient #6 provided pain medication. The patient was roomed at 2:59 and physician assigned at 3:23 PM. Patient #6 ’ s medical record additionally documented: 3:40 PM: Vitals update: 02 91%, no pain assessment 3:45 PM: Vitals update: 90% no pain assessment 3:53 PM: Hydromorphone and ondansetron ordered but not given, there was no documentation on why the ordered pain medications were not given. 4:15 PM: 02: 93% no pain assessment 4:16 PM Bladder irrigation, no pain medication provided since arrival 4:40 PM Vitals update: 91% no pain assessment 4:51 PM: Pain assessed at 9 Hydromorphone given, 2 hours and 51 min after last pain assessment and with no pain medication given 5:00 PM 16:40 Vitals update: 90% no pain assessment 5:10 PM: Pain assessment: 0 5:45 PM Vitals update: 90% no pain assessment 6:00 PM Vitals update: 88% no pain assessment and no oxygen intervention 6:15 PM Vitals update: 89% no pain assessment and no oxygen intervention No intervention for oxygen documented for Patient #5 during ED visit. Vitals taken at 18:30 ,18:45, 19:00, 19:15, 19:30 did not monitor 02 7:49 PM: Vitals update: 91% Pain: 6 8:01 PM: Patient transferred for higher level of care with diagnosis of: 1. Bladder leak 2. Postoperative surgical complication involving genitourinary system associated with genitourinary procedure, unspecified complication 3. Pleural effusion on right 4. Hydronephrosis, bilateral Discussion/decision making from the medical record (not time stamped): “ Patient’s laboratory evaluation was significant for significant increase in patient’s white blood cell count. White blood cell count was elevated at 22.44 today which is significantly increased from laboratory evaluation 2 days ago when her white count was 13. Hemoglobin and hematocrit are low at 9.9 and 32.6 but in review of past medical records this is at baseline for the patient. Patient had significant elevation in CRP at 298. Pro-Cal is slightly elevated as well. We were able to gently flush the patient’s catheter to determine that the catheter is patent and able to drain. I was able to aspirate some blood from the patient’s bladder. “ Patient #6 presented to the ED with severe pain (score of 8) 10 days after radical surgery, received bladder irrigation without pain medication, went to CT without pain medication. Pain medication was ordered at 3:53 PM and not provided until 4:51 PM, 2 hours 58 minutes after her arrival to the ED. The PA who was the provider for Patient #6 was interviewed beginning at 11:00 AM on 4/27/26. The PA reported that she would expect that the nursing protocol would begin oxygen if it went below 90%. The PA also reported that she thought she remembered the patient denied pain medicine but confirmed there was no documentation of pain medication refusal and pain score increased during that same period. Additionally, the PA confirmed that pain medication was ordered and there was a delay of an hour in administration. The facility failed to ensure there was no delay in care which placed patients at risk in receiving needed stabilizing treatment.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 44100 Based on hospital policy review, medical record review, and staff interview, the hospital failed to ensure a Medical Screening Examination (MSE), stabilizing treatment, and diagnostic interventions were provided without delay for 2 of 24 sampled patients (Patient #22 and #24) whose records were reviewed. This resulted in a potential delay in treatment and diagnosis and treatment for affected patients and had the potential to impact all patients seeking care in the ED. Findings include: A hospital policy titled, “Emergency Department and Urgent Care Protocol: Cardian - Adult” dated 1/20/25, was reviewed and included: “ Adult patient presenting with complaints of atraumatic chest pain or shortness of breath, dusky skin, diaphoresis, dysrhythmias (known or suspected). Consider for patients with non-traumatic jaw, shoulder, arm, or upper back pain; weakness; upper abdominal pain, indigestion, nausea, or vomiting; light headedness and/or dizziness. SLHS goal is for ECG obtained within 5 minutes of ED arrival to identify patients with STEMI.” A hospital Policy Appendix titled, “Emergency Department Patient Care Guidelines,” dated 11/11/25, documented Primary Triage information including: “If triage queue exists, expedite triage for c/o time-sensitive emergencies ... Emergency Severity Index (ESI): Levels 1-5 “ ESI level 1 = requires ESl-defined life-saving intervention “ ESI level 2 - high risk patient “ ESI level 3 - care includes 2 or more ESI-defined resources “ ESI level 4 - care includes 1 (one) ESl-defined resources “ ESI level 5 - care includes NO ESl-defined resources “ These policies were not followed. Examples include: 1.Patient #22 was a 27-year-old male who presented to the ED with thermal and chemical burn to his face and left hand and reported he was also “hit in the left eye” on 10/27/25 at 3:48 PM. Patient #22’s medical record was reviewed and included: Patient #22’s medical record documented first set of vitals at 4:01 PM and the patient was triaged as a “4”. Patient #22 returned to the waiting room and was not assigned a provider until 4:56 PM, and did not receive stabilizing treatment until 5:26 PM, 98 minutes after ED arrival. Additionally, it was unclear why Patient #22 was triaged at a level 4 and not level 1 or 2 when he potentially needed eye saving interventions. The ED Provider note documented, “Initial assessment and differential diagnosis ... : Potential conditions that pose a threat to life or limb for this emergency department visit based on the history and risk factors available at this time are: Chemical exposure to the left eye, thermal burn to the face and hand...Risk for this patient is potentially quite high with hot chemical exposure to the left eye. A detailed and focused examination was required in this patient who presents with thermal burns to the face and hand and potential chemical irritation in the left eye and thermal burn in the left eye.” Patient #22’s medical record documented he received treatment to his eye and was discharged home that same day. The ED Assistant Nurse Manager was interviewed on 12/2/25 beginning at 11:45 AM and reviewed Patient #22’s medical record. The ED Assistant Nurse Manager confirmed that risk to “life or limb”, in this case an eye, should have been triaged as a 1 or 2 and the level 4 was inappropriate for this patient. The ED Assistant Nurse Manager further confirmed that a triage of a 1 or 2 would have supported a more prompt MSE and assessment by the provider. The facility failed to ensure an MSE, diagnostics, and treatment were not delayed for Patient #22. 2.Patient #24 was a 76-year-old female who presented to the SLMV ED with chief complaint of chest pain and nausea on 9/08/25 and registered at 4:25 PM. Patient #24’s medical record was reviewed and included: Patient #24’s triage was completed at 4:32 PM and she was given an ESI score of “3” and returned to the waiting room. Patient #24 had an ECG performed at 4:52 PM, 28 minutes after presenting to the ED. Patient #24’s medical record documented an IV was started at 5:02 PM and labs drawn. Nitroglycerin was given at 5:04 PM, vitals taken again and aspirin given at 5:05 PM, 40 minutes after Patient #24’s arrival to the ED. Patient #24’s medical record documented a “left heart catheterization” beginning at 5:43 PM. Patient #24’s medical record documented, “Successful PCI of 100% occluded late mid to distal LAD.”It was unclear why Patient #24 was triaged at a level 3 and not level 1 or 2 when she needed lifesaving interventions. Patient was discharged home on 9/10/25. The ED Assistant Nurse Manager was interviewed on 12/2/25 beginning at 11:45 AM and Patient #24’s medical record was reviewed. The ED Assistant Nurse Manager confirmed chest pains and nausea should be triaged as a 1 or 2. The ED Assistant Nurse Manager additionally confirmed the expectation would be an ECG within 5 minutes per facility policy. The facility failed to properly triage Patient #24 and provide timely MSE and stabilizing treatment.”