Syringa General Hospital

“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: 51906 Refer to A2405 as it relates to the failure of the hospital to ensure all patients presenting to the hosptial were recorded on a Cental Log. Failure to record every patient presenting to the hospital impacts the ability to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. Refer to A2406 as it relates to the failure of the hospital to ensure all patients presenting to the hospital for emergency services were provided an MSE. Failure to ensure all patients presenting to the ED were provided with an appropriate and complete MSE had the potential to negatively affect all patients presenting to the ED.”

“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: 51906 Based on review of incident reports and staff interviews, the hospital failed to maintain an accurate and complete Central Log for five (5) patients who presented to the Emergency Department (ED) requesting evaluation and treatment. This failure had the potential to impede the hospital’s ability to demonstrate compliance with EMTALA requirements and to ensure all individuals who presented to the ED received an appropriate medical screening examination. During review of the facility’s incident reports, one incident dated 9/24/25, it was identified that five (5) separate patients had presented to the Emergency Department requesting medical care but were not recorded in the hospital’s Central Log. The incident reports indicated that these individuals had arrived at the ED, had interacted with an RN, and were informed that the facility’s CT scanner was not operational. The RN directed the patients to travel to another hospital approximately 20 miles away for further evaluation. There was no documentation of these individuals in the Central Log, nor evidence of registration, triage, or a medical screening examination as required under EMTALA. During an interview conducted with the Director of Quality and Risk Management on 11/04/25 beginning at 12:45 PM, the Director stated that the RN who had interacted with the patients had failed to log them or provide a medical screening examination prior to advising transfer to another facility. The Director confirmed that the RN’s travel contract had been terminated following an internal review of the incidents. The facility failed to ensure that every patient that comes to the emergency department, seeking assistance was logged on a central 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: 51906 Based on medical record review, hospital policy, and staff interviews, the hospital failed to provide and document an appropriate Medical Screening Examination (MSE) 2 of 20 (Patient #1 and #3) patients who presented to the ED seeking medical treatment and whose records were reviewed. This failure put all patients at risk for lack of exam and treatment when presenting to the ED. Findings include: The hospital’s undated policy titled “Emergency Services Policy” states that an “Appropriate screening exam will include, but is not limited to: 1) full set of vital signs; 2) height/weight; 3) allergies ... 5) A brief history / physical assessment pertinent to the presenting complaint (e.g., auscultation of heart and lungs, inspection of wounds, injuries).” This policy was not followed. Examples include 1. Patient #1 arrived at the ED on 9/29/25 at 2:10 PM with a complaint of “rash.” The medical record included that the ED physician briefly spoke with the patient in the lobby but did not initiate a complete MSE. The medical record included “Patient presented [sic] the ER with her husband and one daughter due to concerns of scabies. Due to high ER volume and presenting concern, I went to the waiting room @ 1417 to evaluate them. Patient and her husband and daughter were non-toxic, alert and oriented. There was no discernable life or limb threatening condition, and so I recommend they be seen in the walk in clinic. Certainly, if they would rather be seen in the ER, I’d be happy to do so but it would take time given the low urgency of their conditions. Pt and her husband decided to go to the WIC.” Review of the medical record revealed no documentation of vital signs, height, weight, allergies, or any physical assessment. There was no evidence of auscultation, inspection, or any clinical evaluation related to the patient’s presenting complaint. The patient was discharged without receiving a documented medical screening exam. This failure to perform and document a complete MSE is inconsistent with both EMTALA requirements and the hospital’s Emergency Services Policy. The absence of clinical data and physical assessment prevents determination of whether an emergency medical condition existed and constitutes a violation of EMTALA. The ED physician who interacted with Patient #1 was interviewed on 11/05/25 beginning at 8:20 AM and Patient #1’s record was reviewed in his presence. When asked if he remembered Patient #1 he stated yes. When asked if he performed an MSE on Patient #1 he stated he did. He stated he performed a physical assessment of Patient #1. When asked where the assessment was documented he stated he did not document the assessment in the medical record. He stated he coordinated with the Nurse Practitioner in the RHC that was located in the same building. He stated he should have documented the assessment. The Director of Quality and Risk Management was interviewed on 11/04/25 beginning at 1:00 PM she confirmed there was no documented MSE or vital signs for Patient #1 in the hospital medical record. The hospital failed to comply with EMTALA requirements by not providing a complete and documented Medical Screening Examination for Patient #1. The patient was evaluated informally in the lobby without vital signs, history, or physical assessment, in direct violation of federal regulations and hospital policy. 2. Patient #3 arrived at the ED on 6/19/25 at 11:50 AM with complaints of right foot pain. Patient #3’s medical record included a progress note dated 6/19/2025 at 11:58 AM and signed by an RN on 06/20/25 at 7:35 AM. The note stated, “Pt in ER waiting room in wheelchair with visitor. Pt states he has a history of gout in his right foot, but comes to the ER today stating his right foot is swollen and it hurts to move. Pt does not feel like it is a gout flare up which is why he came in. Pt states pain is not the same as when he has a gout flare up. Pt A and O x4, no distress noted. Pt informed that the ER is busy at this time, and that it might be a while before they [sic] ER Nurse is able to take pt back to the ER to be seen. Pt informed that walk in clinic is open. Pt informed that he can wait and be seen in the ER if he wants, but if he would like to go to the walk in clinic he is more than welcome to. Re-iterated with pt that it is his choice and to not feel pressured to go to the walk in [sic]. RN informed pt that if the provider in the walk in clinic feels he needs x-rays, they can send pt up, so he would not be getting less care in the walk in clinic versus the ER. Pt expressed he was find with going to the walk in clinic if the ER nurse was busy at this time. Pt asked if he was able to get to the clinic in the wheelchair; instruction on how to get to the elevator given.” The Director of Quality and Risk Management was interviewed on 11/03/25 beginning at 1:30 PM. Patient #3’s medical record was reviewed in her presence. She stated that she had seen this patient encounter on the patient log and asked the RN about the encounter when she noted that there was no note or visit for the patient. She advised the RN to put a note in as to what the RN’s encounter was regarding the patient encounter. She acknowledged that the patient did not receive an MSE. The RN was interviewed on 11/05/2025 beginning at 11:30 AM. The RN was asked if she remembered Patient #3. After reviewing Patient #3’s chart she confirmed she remembered Patient #3. She was asked to describe her interaction with Patient #3. She stated that she is a Med-Surg nurse and she was contacted by the ER Nurse who asked her to go triage Patient #3 who was in the lobby. She stated she spoke with the patient, who was in a wheelchair and accompanied by someone unknown to the RN, and advised that the ER Nurse had no beds open and she let him know that he could wait but “it would be a while” and “he was fine with that.” Then she relayed that she told him “he could go down to the walk-in clinic and get seen faster.” She was asked if she spoke to the ER provider about her interaction with Patient #3 and she said she did not. She said that she did not take the patient’s vitals. She said the only question Patient #3 had “was if there was an elevator to get down to the walk-in clinic” and she informed him there was and Patient #3 went to the walk-in clinic via wheelchair. The hospital failed to comply with EMTALA requirements by not providing a complete and documented Medical Screening Examination for Patient #3. The patient was evaluated informally in the lobby without vital signs, history, or physical assessment, in direct violation of federal regulations and hospital policy.”

“The hospital is a Type V (111) two story structure with a partial basement and an upper non-patient level used for ancillary services. The original building was constructed in 1940 with subsequent remodeling, including a major renovation/addition completed in 1989, and a futher expansion of the Emergency/Radiology departments completed in 1999. The facility is protected throughout by a complete automatic fire extinguishing system, with an interconnected fire alarm/smoke detection system in common areas, and at some barrier partition door assemblies. Portable fire extinguishers are provided throughout, with an diesel-fired Emergency Power Supply System generator set. The hospital is currently licensed for 16 hospital beds. The following deficiencies were cited during the fire/life safety survey conducted on March 25, 2025. The facility was surveyed under the LIFE SAFETY CODE, 2012 Edition, Existing Health Care Occupancy, in accordance with 42 CFR 482.41.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 34125 Based on record review an interview, the facility failed to ensure fire alarm inspections were performed in accordance with NFPA 72. Failure to ensure completion of sensitivity testing, and that all installed initiating devices are identified for location, along with identifying those entities responsible for monitoring, has the potential to create confusion in staff response during a fire event. This deficient practice affected patients, staff and visitors on the date of the survey. Findings include: During review of provided fire alarm inspection records conducted on 3/25/25 from 9:00 - 11:00 AM, review of the provided annual fire alarm inspection report dated October 8, 2024, established the inspection failed to identify the location in the facility of all devices tested, the responsible party for monitoring of the system, or the last known documented sensitivity testing. Interview of the Director of Engineering at approximately 1:35 PM, established he was not aware of any sensitivity testing performed on the fire alarm system. Actual NFPA standard: NFPA 72 14.4.5% Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. 14.4.5.3% In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.3 After the second required calibration test, if sensitivity tests indicat”

“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: 34125 Based on record review and observation, the facility failed to ensure the fire suppression system was maintained in accordance with NFPA 25. Failure to ensure fire suppression system pendants are free of obstructions such as non-factory applied paint, and that at a minimum, semi-annual waterflow alarm testing is completed, has the potential to hinder system response during a fire event. This deficient practice affected patients, staff and visitors on the date of the survey. Findings include: 1) During review of provided fire suppression maintenance and inspection records conducted on 3/25/25 from 9:00 - 11:00 AM, records failed to indicate or establish any waterflow alarm testing had been conducted within the past twelve months. 2) During the facility tour conducted on 3/25/25 from 12:00 - 2:30 PM, observation of installed fire suppression system pendants located in the storage area at the rear of the Laundry, identified both pendants were coated with non-factory applied painting. Actual NFPA standard: 5.2% Inspection. 5.2.1 Sprinklers. 5.2.1.1% Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1% Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)%Loading (6) Painting unless painted by the sprinkler manufacturer 5.2.1.1.3% Any sprinkler that has been installed in the incorrect orientation shall be replaced. 13.2.6 Alarm Devices. 13.2.6.1 Mechanical waterflow device”

“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: 34125 Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 70, and approved, listed assemblies. Failure to enclose live electrical wiring and ensure use of relocatable power taps (RPTs) is not performed with non-approved appliances and installations, has the potential to increase the risk of electrical shock and arc fires. This deficient practice affected patients, staff, and visitors on the date of the survey. Findings include: During the facility tour conducted on 3/25/25 from 12:30 - 3:00 PM, observation of facility electrical installations identified the following: - An open 4-gang electrical junction box with exposed wiring in the housekeeping breakroom. - An RPT connected in series to another RPT (daisy-chained) in the housekeeping breakroom. - The Doctor’s “Nook” using a RPT to supply power to a portable heating unit. - Discharge Planning daisy-chained a RPT to a battery backup power supply. - Anesthesia/Surgery nursing office using a RPT daisy-chained into a battery backup power supply, to supply power to a microwave, mini fridge, and a coffee maker. Actual NFPA standard: NFPA 70 Chapter 1 General Article 110 110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved. Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved, Identified, Labeled, and Listed. 110.3 Examination, Identification, Installation, and Use of Equipment. (A) Examination. In judging equipment, considerations such as the following shall be evaluated: (1) Suitability for installation and use in conformity with th”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 34125 Based on record review and interview, the facility failed to ensure installed electrical receptacles were inspected and tested in accordance with NFPA 99. Failure to inspect and test receptacles in the patient care vicinity, based on type and documented performance data, has the potential to hinder reliability for continual use as designed. This deficient practice affected patients, staff, and visitors on the date of the survey. Findings include: During review of provided maintenance and inspection records conducted on 3/25/25 from 9:00 - 11:00 AM, no documentation was available demonstrating receptacles installed in patient bed locations had been tested at any duration. Interview of the Director of Engineering established he was unaware of the requirement for testing of outlets. Actual NFPA standard: 6.3.4% Administration of Electrical Systems 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.”

“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: 34125 Based on record review and interview, the facility failed to ensure Emergency Power Supply System (EPSS) generator sets were inspected, tested and maintained in accordance with NFPA 110. Failure to ensure inspection maintenance and testing of the EPSS generator is completed per the standard, has the potential to hinder facility response during a loss of power. This deficient practice affected patients, staff, and visitors on the date of the survey. Findings include: During review of provided inspection, maintenance and testing records conducted on 3/25/25 from 9:00 - 11:30 AM, no documentation was available for monthly load and battery conductivity testing within the past twelve months. Interview of the Director of Engineering at approximately 1:30 PM, established he was not aware of the requirement. Actual NFPA standard: NFPA 110 8.3 Maintenance and Operational Testing. 8.3.7% Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ’ s specifications. 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. 8.4 Operational Inspection and Testing. 8.4.1% EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 34125 Based on record review, observation, and interview, the facility failed to ensure Patient Care Related Electrical Equipment (PCREE) devices, including multiple outlet connections were inspected and tested in accordance with approved, listed assemblies, and NFPA 99. Failure to conduct testing and performance data for PCREE devices, and multiple outlet connections, has the potential to increase exposure to electrical shock and arc fires. This deficient practice affected patients, staff and visitors on the date of the survey. Findings include: 1) During record review conducted on 3/25/25 from 9:00 - 11:00 AM, no documentation was available demonstrating UL 1363A power strips used in patient care areas, had been tested, or undergone any performance rating analysis. 2) During the facility tour conducted on 3/25/25 from 12:00 - 2:30 PM, observation of installed PCREE devices, including, but not limited to UL 1363A multiple outlet connections, established the following: - A UL 1363A power strip located in the procedure room was in use on the floor, with three open and unsecured outlets exposed. - Both Labor and Delivery rooms (L/D) were using UL 1363A power strips at the patient beds, both located on the floor, and three open outlets for L/D 1; five open outlets for L/D 2. At approximately 2:15 PM, a interview of the staff responsible for documentation of biomed equipment determined she was not aware of the requirement for UL 1363A testing documentation. Further interview of Engineering staff at approximately 2:45 PM, established a testing program was in place at the facility, but the program was terminated. Actual NFPA standard: NFPA 99 Chapter 10 Electrical Equipment 10.2 Performance Criteria and Testing for Patient Care-Related Electrical Appliance”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 44100 Based on observation and staff interview, it was determined the CAH failed to ensure the emergency cart in the OR suite had medications that were current and ready for immediate use. This had the potential for the health and safety of patients in the OR suite to be compromised in the event of a medical emergency requiring immediate use of the emergency cart. Findings included: The OR emergency cart was opened and reviewed on 3/12/25 beginning at 1:30 PM in the presence of the OR RN manager and the pharmacist. The following medications were identified as expired: 1. Lidocaine 2%, 100mg/5ml vial, 2 vials, expired 1/25 2. Magnesium sulfate 2grams in 50 ml bottle, expired 2/25 3. Amiodarone 150mg/3ml vial, 3 vials, expired 2/25 The OR RN manager confirmed these medications were expired. The pharmacist confirmed these medications were expired. The CAH failed to ensure emergency medications in the OR suite were accessible and ready for use in the event of an emergency.”

“PERSONNEL CFR(s): (1) Except as specified in paragraph (d)(3) of this section, there must be a doctor of medicine or osteopathy, a physician assistant, a nurse practitioner or a clinical nurse specialist with training or experience in emergency care on call and immediately available by telephone or radio contact, and available on site within the following timeframes: (i) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area other than an area described in paragraph (d)(1)(ii) of this section; or (ii) Within 60 minutes, on a 24-hour a day basis, if all of the following requirements are met: (A) The CAH is located in an area designated as a frontier area (that is, an area with fewer than six residents per square mile based on the latest population data published by the Bureau of the Census) or in an area that meets criteria for a remote location adopted by the State in its rural health care plan, and approved by CMS, under section 1820(b) of the Act. (B) The State has determined under criteria in its rural health care plan, that allowing an emergency response time longer than 30 minutes is the only feasible method of providing emergency care to residents of the area served by the CAH. (C) The State maintains documentation showing that the response time of up to 60 minutes at a particular CAH it designates is justified because other available alternatives would increase the time needed to stabilize a patient in an emergency. (2) A registered nurse with training and experience in emergency care can be utilized to conduct specific medical screening examinations only if- (i) The registered nurse is on site and immediately available at the CAH when a patient requests medical care; and (ii) The nature of the patient’s request for medical care is within the scope of practice of a registered nurse and consistent with applicable State laws and the CAH’s bylaws or rules and regulations. (3) A registered nurse satisfies the personnel requirement specified in paragraph (d)(1) of this section for a temporary period if-- (i) The CAH has no greater than 10 beds; (ii) The CAH is located in an area designated as a frontier area or remote location as described in paragraph (d)(1)(ii)(A) of this section; (iii) The State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation on the issue of using RNs on a temporary basis as part of their State rural health care plan with the State Boards of Medicine and Nursing, and in accordance with State law, requesting that a registered nurse with training and experience in emergency care be included in the list of personnel specified in paragraph (d)(1) of this section. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of emergency services in the States. The letter from the Governor must also describe the circumstances and duration of the temporary request to include the registered nurses on the list of personnel specified in paragraph (d)(1) of this section; (iv) Once a Governor submits a letter, as specified in paragraph (d)(3)(iii) of this section, a CAH must submit documentation to the State survey agency demonstrating that it has been unable, due to the shortage of such personnel in the area, to provide adequate coverage as specified in this paragraph (d). (4) The request, as specified in paragraph (d)(3)(iii) of this section, and the withdrawal of the request, may be submitted to us at any time, and are effective upon submission. This Standard is not met as evidenced by: 39430 Based on staff interviews, medical record review, and incident report review, the facility failed to ensure adequate staffing to provide safe and effective services in the Emergency Department (ED). This failure directly affected 2 of 20 patients (Patient #16 and Patient #17) whose records were reviewed. The lack of sufficient staffing caused delayed assessment and treatment for individuals seeking emergency care. Findings included: 1. Patient #16 was a 73-year-old female who presented to the ED on 6/24/24 at 10:46 AM with severe abdominal and back pain. She was discharged at 11:59 PM the same day. The patient’s ED record indicated triage at 11:01 AM. However, a subsequent clinic visit note from the RHC, documented by a PA at 11:05 AM (4 minutes after ED triage), stated, “Patient was triaged in the WIC [walk in clinic] with severe upper abdominal pain. The patient had a pulse of 40 bpm, was cold and clammy, with nausea and lightheadedness, unable to sit still or lie down. The patient was immediately transferred to the ED in a wheelchair.” This showed that after triage in the ED, Patient #16 was registered and seen at an attached RHC, examined by a PA, and then transferred back to the ED. Patient #16 received a Medical Screening Examination in the ED on 6/24/24 at 11:07 AM. The medical record confirmed the patient was admitted at 11:59 AM on 6/24/24 and underwent a cholecystectomy (surgery to remove gallbladder) at the facility. The Quality Director was interviewed on 3/12/25, beginning at 10:30 AM, and the medical record of Patient #16 was reviewed. The Quality Director confirmed the record indicated the patient was triaged in the ED and then sent to the RHC before receiving the MSE. The registration clerk was interviewed on 3/11/25, beginning at 3:48 PM. When asked whether a patient could be sent to the RHC upon presenting to the ED, the registration clerk confirmed, “It could happen, but not often,” though the clerk did not recall Patient #16. 2. Patient #17 was a 56-year-old female who presented to the ED on 7/23/24 at 4:01 PM and was transferred to another facility via Life Flight at 3:35 AM on 7/24/24. An incident report documented that registration had called back to the ED nurse several times over the course of an hour, expressing concern that the patient was decompensating and needed immediate attention. Patient #17’s medical record included a nursing note at 4:55 PM (54 minutes after the initial presentation), stating, “Patient in waiting area. Alert to self and date of birth, unable to recall the year. Significant others and friends with patient report that she is deteriorating. Patient recalls having a wound on the foot for 2 days. Awaiting ED bed.” At 5:01 PM (one hour after the initial presentation), a note by an ED provider, “At bedside, received orders.” The medical record further noted labs were drawn at 5:10 PM, followed by vitals and an X-ray at 5:30 PM on 7/23/24. A nursing note at 5:01 PM indicated, “Patient was seen in the Walk-In Clinic and advised to come to the ED. The patient has a foot wound and altered mental status.” The Quality Director was interviewed on 3/12/25, beginning at 10:30 AM, and the medical record of Patient #17 was reviewed. The Quality Director confirmed the record demonstrated the patient presented to registration at 4:01 PM and was triaged into the ED at 5:01 PM. The record also indicated the MSE was documented at 8:07 PM, four hours after the patient’s presentation to the ED. When asked about the timing of the MSE, the Quality Director stated, “There is no way to tell when the MSE was actually completed.” An ED RN was interviewed on 3/11/25, beginning at 3:15 PM. When asked whether there would ever be a situation in which a patient would wait an hour in the waiting area before being seen by an ED nurse, the RN responded, “I would lay eyes on them, especially if registration had called back.” The RN further confirmed, “I would document laying eyes on the patient.” It was unclear through documentation why Patient #17 had to wait for an hour before being seen by the ED nurse or ED provider and why four hours elapsed between registration and the documented MSE. An interview was conducted with an ED provider on 3/12/25, beginning at 3:30 PM. The provider explained that they were required to cover both the ED and several RHC visits during the same shift. The provider stated this workload was overwhelming and exceeded what could be managed effectively, particularly during times of increased patient volume. A Staff RN was interviewed on 3/13/25, beginning at 9:40 AM. When asked about staffing levels in the ED, the RN stated staffing was generally adequate, though there were occasions when additional help was needed. When asked about the challenges of having one provider cover both the ED and RHC during the same shift, the RN explained, “It’s frustrating waiting for the doctor to come up from the clinic, and patients in the ED must wait for the doctor to see them.” The hospital did not provide sufficient staffing coverage in the ED to ensure timely and effective patient care. Staff interviews revealed extended wait times for triage and treatment, delays in administering potentially critical interventions, and periods when the ED was left with insufficient personnel to handle patient volume safely. Furthermore, the hospital operated a RHC that provided both scheduled and walk-in care. The ED physician was expected to cover both the ED and the RHC during the same shift, further compromising the physician’s ability to provide continuous and immediate emergency medical care. This dual responsibility increased the risk of delayed treatment and patient safety concerns. The hospital failed to ensure adequate staffing in the ED.”

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 44100 Based on observation and staff interview, it was determined the CAH failed to ensure all medications used in the infusion unit were properly labeled and stored. This had the potential to cause harm to all patients using infusion and/or wound care services. Examples included: A tour of the infusion center and wound care center was conducted on 3/12/25 beginning at 1:30 PM with the Director of Quality. The wound care area contained the following on the counters and in the cabinets: 1. Anasept skin and wound cleanser, 12 ounce bottle, open, not dated or initialed 2. Ultrasound gel, 8.5 ounce bottle, open, not dated or initialed 3. Dakin solution, 16 ounce bottle, open, not dated or initialed 4. Deep Prep II, soft tissue massage cream, 15 ounce jar, open, not dated or initialed 5. Vaseline, 3.75 ounce jar, open, not dated or initialed 6. Medihoney gel, 1.5 ounce tube, open, dated 12-6 The wound care RN present at the time of the tour confirmed these listed items were not labeled appropriately. The Director of Quality was interviewed on 3/12/25 beginning at 1:45 PM. She confirmed the items listed above were not appropriately labeled or stored correctly. The CAH failed to ensure medications were stored and labeled properly.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 39430 Based on observation, a review of CDC, AORN, and FDA guidelines, and staff interviews, it was determined the hospital failed to maintain a sanitary environment. This failure had the potential to place all patients receiving care at the facility at an increased risk for infection. Findings included: 1. The facility failed to follow CDC and AORN guidelines for the storage of surgical attire and patient linens. The CDC Guidelines for Environmental Infection Control were reviewed at https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html. The guidelines stated clean and sterile textiles must be stored in a manner that minimized exposure to moisture, dust, and other contaminants. Additionally, the CDC guidelines specified: “Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items.” The AORN Guidelines for Perioperative Practice were reviewed. The guidelines stated, “Laundered scrub apparel in enclosed carts, cabinets, or dispensing machines that are cleaned and disinfected regularly.” The guidelines further specified that perioperative textiles, including surgical scrubs, must be stored in a controlled, clean environment to prevent microbial contamination and ensure patient and staff safety. These guidelines were not followed. Examples included: During an observation on 3/10/25, beginning at 3:15 PM, a tour of the facility’s clean linen storage was conducted. Patient gowns, sheets, towels, and OR surgical attire were stored in an unfinished basement with bare concrete walls and floors. Directly above patient clean linens, multiple pipes were covered in a thick layer of dust and debris. Additionally, an approximately 10-inch circular penetration in the wall allowed air to blow directly into the storage area, increasing the risk of contamination from dust, debris, and other airborne particles. Storing patient linens and surgical attire in an unfinished basement with exposed concrete surfaces and an open penetration allowing unfiltered air to enter the storage area which exposed them to potential contamination from dust, moisture, and environmental debris, did not comply with these infection control standards. On 3/11/25, beginning at 11:30 AM, the facility’s Quality Director and Environmental Services Supervisor were interviewed. The facilities Quality Director confirmed the facility followed CDC guidelines and AORN guidelines. During the interview, both confirmed the above observations and acknowledged patient linens and surgical attire were stored in an unfinished basement with a 10-inch circular wall penetration allowing unregulated airflow into the storage area. Additionally, they confirmed the room where hospital linens and clean OR scrubs were stored was not cleaned regularly. This failure to adhere to CDC and AORN guidelines placed patients and staff at risk for healthcare-associated infections due to potential contamination of linens and surgical attire. 2. Hospital staff failed to perform appropriate hand hygiene. CDC guidelines were reviewed at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. The CDC outlined hand hygiene for healthcare workers and recommended handwashing: - After touching a patient or the patient’s surroundings. - After contact with blood, body fluids, or contaminated surfaces. - Immediately after glove removal. This standard was not followed. Examples included: On 3/10/25 at 3:15 PM, during an observation of a blood draw on a patient, the phlebotomist failed to remove gloves and perform hand hygiene after the procedure. The phlebotomist continued wearing gloves while performing other laboratory tasks and touched multiple clean work surfaces before removing the dirty gloves. Upon glove removal, the phlebotomist did not perform hand hygiene. On 3/12/25 at 1:30 PM, the Quality Director was interviewed, and the above observations were reviewed with her. She confirmed the hospital followed CDC guidelines, and stated hand hygiene should be performed after removing gloves and before touching clean surfaces. The facility failed to provide a sanitary environment through proper hand hygiene practices as outlined by the CDC. 3. The hospital failed to ensure sharps containers were utilized appropriately. This placed patients and staff at risk for accidental needle sticks and potential exposure to blood and body fluids. FDA guidelines for sharps disposal containers were reviewed at https://www.fda.gov/medical-devices/safely-using-sharps-needles-and-syringes-home-work-and-travel/sharps-disposal-containers-health-care-facilities. The guidelines stated sharps disposal containers must have a “puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter.” This standard was not followed. Examples included: On 3/10/25 at 3:15 PM, during an observation of a blood draw on a patient, the phlebotomist disposed of a needle into a large sharps disposal container on the floor next to the patient chair. The lid of the sharps container was not secure, and half of the container was open. The unsecured lid created a wide enough opening for a hand to enter, increasing the risk of potential blood or other body fluid splashes. On 3/12/25 at 1:30 PM, the Quality Director was interviewed, and the above observations were reviewed with her. She confirmed that the sharps disposal container lid should have been secured. The facility failed to ensure appropriate sharps disposal practices, leading to an unsanitary environment and increased risk of exposure to bloodborne pathogens. 4. The hospital failed to ensure patient procedural areas were cleaned and disinfected between patients. CDC cleaning guidelines were reviewed at https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_3-4-2-general-patient-areas. The CDC recommended cleaning minor procedural areas in outpatient wards “before and after (i.e., between) each patient.” This standard was not followed. Examples included: On 3/10/25 at 3:15 PM, during an observation of two separate blood draws on two different patients, the phlebotomist failed to clean the patient chair used for venipuncture after the first patient and before the second patient. On 3/12/25 at 1:30 PM, the Quality Director was interviewed, and the above observations were reviewed with her. She confirmed the hospital followed CDC guidelines and the chair should have been cleaned prior to the second patient. The facility failed to adhere to CDC cleaning guidelines, placing patients at increased risk for healthcare-associated infections due to inadequate environmental sanitation.”

“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: 49416 Based on medical record review, policy review, and patient and staff interview, it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24: Responsibilities of Medicare Participating Hospitals in Emergency Cases. Refer to A - 2406 as it relates to the facility’s failure to provide an appropriate MSE for 2 of 25 patients (Patient #11 and #24) whose records were reviewed. Refer to A - 2407 as it relates to the facility’s failure to provide an appropriate stabilizing treatment for 1 of 25 patients (Patients #11) whose record was reviewed. Refer to A - 2408 as it relates to the facility’s delay in providing approrpriate treatment for 2 of 25 patients (Patients #24 and #25) whose records were reviewed. Refer to A - 2409 as it relates to the facility’s failure to ensure an appropriate transfer for 5 of 6 patients (Patients #1, #2, #3, #4 and #5) who were transfered and whose records were reviewed. Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the ER seeking emergency care.”

“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: 49416 Based on policy review, record review, and staff interview, it was determined hospital staff failed to ensure the MSE was sufficient to determine whether an EMC existed for 2 of 25 patient (Patient #11 and #24) whose records were reviewed. This put all patients presenting to the ER for emergency medical care at risk for a negative outcome. Findings include: A facility policy titled “EMTALA MERICAL SCREENING” dated 9/19/23, stated “Every patient presenting to Syringa Hospital & Clinics (“SHC”) property requesting medical examination or treatment will receive an appropriate medical screening examination within the capability of the hospital, including ancillary services routinely available, to determine whether an emergency medical condition exists.” The policy also stated “LOCATIONS AND CIRCUMSTANCES THAT REQUIRE MEDICAL SCREENING: Medical Screenings are performed at...SCH Emergency Department for any patient who presents to the department requesting medical examination or treatment for any medical condition including a pregnant person with contractions, or if the patient is unable to speak, a condition that a prudent layperson would believe needs exam or treatment...” This policy was not followed. Examples include: 1. Patient #11 was a 38 year old male who presented to the ER with a chief complaint of “body aches, fever, HA, dizziness/lightheaded for ‘couple days.”” Patient #11’s medical record included a note titled “Emergency Documentation” dated 1/14/25 at 6:46 PM. It included Provider A attempted to take medical history and Patient #11 was “not forthcoming.” The note also included when Provider A asked the patient to speak up and Patient #11 responded with derogatory comments. Patient #11’s medical record documented Provider A “informed the pt he was no longer welcome on Syringa Premises given his comportment.” Provider A further documented “I am concerned as I do believe that the patient is legitimately ill. He meets sepsis criteria and may meet severe sepsis, but I was unable to ascertain prior to the pt leaving. His comportment, belligerence and volatility make it impossible for him to be safely treated here at this time, though.” A Nursing note in Patient #11’s medical record documented at 6:18 PM stated, “Pt holding head with rt [right] arm resting on side rail of gurney, mother on cell phone speaker. Difficult to understand pt’s speech. MD asking pt to speak up, conversation between [MD] and pt escalated. MD instructing pt to discharge out of ER. Pt voice not leaving. MD states will notify police for trespassing, MD requesting RN to notify police” An additional nursing note included in Patient #11’s medical record, dated 1/14/25 at 6:30PM documented, “Pt discharged ambulatory to private vehicle. ER tech followed pt out of building.” ER RN A and ER Technician were interviewed on 3/11/25 beginning at 3:15 PM. Both ER RN A and the ER Technician confirmed they were working in the ER when Patient #11 presented to the hospital. ER RN A remembered the referenced patient. She reported that Patient #11 appeared sick and had a high fever. ER RN A also reported that Patient #11 “was in a wheelchair, disoriented and withdrawn” and it took some discussion, but she was able to get a blood draw. ER RN A further reported the patient was difficult to interview when the doctor was present. ER RN A confirmed that the doctor told the Patient #11 he would have to leave the ER. The ER Technician confirmed that she watched Patient #11 leave the ER and confirmed that no information on where to receive additional medical services was provided. Provider A was interviewed on 3/12/25 beginning at 3:30 PM. Provider A was asked if in his opinion the patient received an MSE and he stated, “we took his vitals.” When asked if the patient received care elsewhere or if he knew the disposition of the patient Provider A stated, “he left, I don’t know.” 51906 2. Patient #24’s medical record was reviewed. Patient #24 was a 73 year old female who had an ER visit on 6/24/24 at 10:46 AM and was discharged at 11:59 PM with chief complaint of severe abdominal pain and back pain. Patient #24’s ED record documented ED triage at 11:01 AM. However, subsequent clinic note by PA at 11:05 AM stated “Pt was triaged in the WIC [walk in clinic] with severe upper abdominal pain ... Pt has a pulse of 40 bpm [beats per minute], was cold and clammy with nausea and lightheadness [sic] unable to sit still or lay down ... pt was immediately transferred to the ER in a wheelchair.” Patient #24 was provided an MSE in the ED on 6/24/24 at 11:07 AM. Registration Clerk A in the ED was interviewed on 3/11/25 beginning at 3:42 PM. She was asked what happens when someone comes to the ED and requests to be seen. She said she “generally encourages them to go to the ER.” She stated registration will say, “we also have a walk-in clinic.” Registration Clerk A did not remember Patient #24. The Quality Director was interviewed on 3/11/25 at 3:52 PM and was asked about the process of when a patient presents to the ED asking to be seen. She said if they come to the ED and say, “I need to be seen” the patient is then asked, “do you want to be seen in the ER versus the clinic?” She was asked if the ED desk was for the ED only and she shared that the desk was for the ED and hospital services and that the WIC had a registration desk downstairs through a different entrance. The Quality Director was interviewed 3/12/25 beginning at 10:30 AM and the medical record of Patient #24 was reviewed in her presence. The Quality Director confirmed that the record demonstrated the patient was triaged in the ED and sent to the clinic before receiving an MSE. The Quality Director confirmed that this did not follow the policy for ED visits. Registration Clerk B in the ED was interviewed on 3/12/25 beginning at 9:39 AM. She was asked how the registration process works if a patient presented saying they felt unwell and wanted to be seen. She stated she asks, “What’s going on?” and offers them the option of being seen in the ED or the WIC. She said she refuses to answer a patient if they inquire about cost or time to wait to be seen and has the patient decide on where they would like to be seen. It was unclear what procedure was followed when a patient presents to the ED desk and requested to be seen. The hospital failed to ensure all patients received an MSE.”

“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 policy review, record review, ER log review, and staff interview, it was determined hospital staff failed to ensure the patient received stabilizing treatment prior to discharge or transfer for 1 of 25 patients (Patients #11) whose records were reviewed. This put all patients presenting to the ER for emergency medical care at risk for a negative outcome. Findings include: The facility had a EMTALA Medical Screening policy dated 9/19/23, that stated “Persons with emergency medical conditions will be treated and their condition stabilized without regard to ability to pay for services.” The policy defines stabilize as “providing medical treatment of the patient’s condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during a transfer of the individual from a facility.” This policy was not followed. An example includes: Patient #11 was a 38 year old male who presented to the ER with a chief complaint of “body aches, fever, HA, dizziness/lightheaded for ‘couple days.’” Patient #11’s medical record included a note titled “Emergency Documentation” dated 1/14/25 at 6:46 PM. It included Provider A attempted to take medical history and Patient #11 was “not forthcoming.” The note included that Patient #11 made “derogatory comments” to Provider A. The note also included when Provider A asked the patient to speak up, Patient #11 made further derogatory comments, and the note included Provider A “informed the pt he was no longer welcome on Syringa Premises given his comportment.” Provider A further documented, “I am concerned as I do believe that the patient is legitimately ill. He meets sepsis criteria and may meet severe sepsis, but I was unable to ascertain prior to the pt leaving. His comportment, belligerence and volatility make it impossible for him to be safely treated here at this time, though.” A nursing note in Patient #11’s medical record documented at 6:18 PM, “Pt holding head with rt arm resting on side rail of gurney, mother on cell phone speaker. Difficult to understand pt’s speech. MD asking pt to speak up, conversation between [MD] and pt escalated. MD instructing pt to discharge out of ER. Pt voiced not leaving. MD states will notify police for trespassing, MD requesting RN to notify police” An additional nursing note included in Patient #11’s medical record dated 1/14/25 at 6:30PM documented, “Pt discharged ambulatory to private vehicle. ER tech followed pt out of building.” Patient #11’s ER patient summary dated 1/14/25 at 7:16 PM, after the patient left the hospital, was included in Patient #11’s medical record and documented no follow up instructions or education. Additionally, there was no patient signature on the signature page indicating that the patient received the discharge information. ER RN A and ER Technician working with Patient #11 were interviewed on 3/11/25 beginning at 3:15 PM. The nurse remembered Patient #11. The nurse reported Patient #11 appeared sick and had a high fever. ER RN A also reported that Patient #11 “was in a wheelchair, disoriented and withdrawn” and it took some discussion, but she was able to get a blood draw. ER RN A further reported the patient was difficult to interview when the doctor entered. ER RN A confirmed the doctor told the patient he would have to leave the ER. The ER Technician confirmed that she watched the patient leave the ER and confirmed that information on other providers or where to receive medical services was not provided. Provider A was interviewed on 3/12/25 at 3:30 PM. Provider A was asked if in his opinion the patient received an MSE and he stated, “we took his vitals.” Provider A confirmed that Patient #11 did not receive treatment for his symptoms. When asked if the patient received care elsewhere or if he knew the disposition of the patient Provider A stated, “he left, I don’t know.” The facility failed to ensure all patients presenting to the ER were provided with 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: 49416 Based on policy review, record review, incident log review, and staff interview, it was determined hospital staff failed to provide an MSE and treatment in a timely manner for 2 of 25 patient (Patients #24 & #25) whose records were reviewed. This put all patients presenting to the ER for emergency medical care at risk for a negative outcome. Findings include: A facility policy titled, “EMTALA Medical Screening” dated 9/19/23 stated, “Every patient presenting to Syringa Hospital & Clinics (“SHC”) property requesting medical examination or treatment will receive an appropriate medical screening examination within the capability of the hospital, including ancillary services routinely available, to determine whether an emergency medical condition exists.” This policy was not followed. Examples include: 1. Patient #24 was a 73-year-old female who presented to the ER on 6/24/24 at 10:46 AM with severe abdominal and back pain. She was discharged at 11:59 PM the same day. The patient’s ER record indicated triage at 11:01 AM. However, a subsequent clinic visit note from the Rural Health Clinic, documented by a PA at 11:05 AM (4 minutes after ER triage), stated, “Patient was triaged in the WIC [walk in clinic] with severe upper abdominal pain. The patient had a pulse of 40 bpm, was cold and clammy, with nausea and lightheadedness, unable to sit still or lie down. The patient was immediately transferred to the ER in a wheelchair.” This showed that after triage in the ER, Patient #24 was registered and seen at an attached Rural Health Clinic, examined by a PA, and then transferred back to the ER. The incident report was reviewed, included an incident for Patient #24 reported on 6/28/24. The incident report documented “Pt came to ER, was down to clinic without medical screening. Pt ended being sent right back up for suspected triple A [abdominal aortic aneurysm]. At the time, ER was expecting a code and had two other pts. One receiving blood and going to obs. No documentation of provider being aware and doing a medical screening.” The Quality Director was interviewed 3/12/25 beginning at 10:30 AM and the medical record of Patient #24 was reviewed. The Quality Director confirmed the record demonstrated Patient #24 was triaged in the ED and sent to the clinic before receiving an MSE. The Quality Director confirmed that this did not follow the policy for ED visits. Registration Clerk A was interviewed on 3/11/25 beginning at 3:48 PM. Registration Clerk A was asked if a patient could be sent down to the Walk In Clinic when presenting to the ER. Registration Clerk A reported it “could happen, but not often.” Registration Clerk A did not specifically remember Patient #24. 2. Patient #25 was a 56-year-old female who presented to the ER on 7/23/24 at 4:01 PM and was transferred to another facility via Life Flight at 3:35 AM on 7/24/24. The incident report was reviewed, included an incident for Patient #25 reported on 7/23/24. Patient #25 incident report documented, “When the patient presented to me at I quick registered her and called the ER at 4:03 ... The ER had 2 beds full and took back a patient who needed a catheter check before laying on my patient ... At 4:31 I called the ER nurse phone to let them know the patient was getting worse. No one answer the phone. I then called EXT 127 and spoke with ER RN A. She said they needed to clean a bed and then would get her back to the ER. Floor nurse came up to the counter to give us an update on another patient and I mentioned to that I had a patient who I was concerned about that the ER had not taken back or lad eye on yet. She said she would try to find the clinical nurse manager and see what could do. At approximately 4:55 PM my gut was telling to get someone to at least lay eye on her. I walked down to the ER and asked ER RN A if she could please lay eyes on my patient. ER RN A came up to the waiting room with me and evaluated the patient.” Patient #25’s medical record included a nursing note at 4:55 PM (54 minutes after the initial presentation), stating, “Patient in waiting area. Alert to self and DOB [date of birth], unable to recall the year. Significant others and friends with patient report that she is deteriorating. Patient recalls having a wound on the foot for 2 days. Awaiting ED bed.” At 5:01 PM (one hour after the initial presentation), a nursing note stated “[Provider B] at bedside, received orders.” The medical record further noted that labs were drawn at 5:10 PM, followed by vitals and an X-ray at 5:30 PM on 7/23/24. A nursing note at 5:01 PM indicated, “Patient was seen in the Walk-In Clinic and advised to come to the ED. The patient has a foot wound and altered mental status.” Patient #25’s Emergency Documentation signed by Provider B on 7/23/24 at 8:07 PM documented “Upon arrival patient noted to be acutely confused and somewhat delirious.” The Quality Director was interviewed 3/12/25 beginning at 10:30 AM and the medical record of Patient #25 was reviewed. The Quality Director confirmed the record demonstrated the patient presented to registration at 4:01 PM was triaged into the ED at 5:01 PM. The Quality Director confirmed the record demonstrated the MSE was documented at 8:07 PM. When asked when the MSE was completed the Quality Director stated, “There is no way to tell when the MSE was completed.” The Quality Director confirmed this did not follow the policy for ER visits. ER RN B was interviewed 3/11/25 beginning at 3:15 pm. When asked if there would be a time a patient would be waiting in the waiting area for ER triage for an hour, ER RN B responded, “I would lay eyes on them especially if registration had called back.” ER RN B further stated, “I would document laying eyes on the patient.” It was unclear through documentation why Patient #25 had to wait for an hour before being seen by the ER nurse or ER provider and why four hours elapsed between registration and the documented MSE. The facility failed to ensure all patients presenting to the ER were provided with an appropriate triage assessment and MSE in a timely manner.”

“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: 49416 Based on review of hospital policy, patient record, and staff interview, the facility failed to obtain complete and documented consent for transfer for 5 of 6 patients (Patients #1, #2, #3, #4, #5) whose records were reviewed and who had been transferred. This failed practice placed patients at risk of unsafe or potentially inappropriate transfer. Findings include: A hospital policy titled “EMTALA MEDICAL SCREENING,” dated 9/19/23 was reviewed. The policy stated, “EMTALA transfers must meet certain conditions:” listed were several bullet points one of which was “SHC must complete a written transfer certification form that documents the reason for requested transfer, that the transfer benefits outweigh the risks, and that the patient is aware of risks and benefits of transfer.” This policy was not followed. Examples include the following incomplete transfer certification forms: 1. Patient #1’s medical record was reviewed. The medical record showed Patient #1 was a 57 year old male who presented to the hospital ER on 10/28/24 with “acute aphasia, paraplegia x 3 limbs.” Review of patient record showed the “EMTALA/TRANSFER CONSENT FORM” was not complete as it was not indicated on the form if the patient consented to the transfer or if the patient requested the transfer. 2. Patient #2 was a 64 year old male who presented to the ER on 11/19/2024 with right lower abdominal pain that radiates to the right flank and hip. Patient #2’s medical record was reviewed. The medical record contained a document titled, “EMTALA/TRANSFER CONSENT FORM.” This form was not complete as it did not indicate if the patient had an emergent condition or if the patient had been stabilized. 3. Patient #3 was a 73 year old male presented to the ER on 12/06/24 with “balance issues. Patient also reporting some right upper quadrant pain.” Patient #3’s medical record was reviewed. The medical record contained a document titled, “EMTALA/TRANSFER CONSENT FORM”. This form was not complete as it did not indicate if the patient had an emergent condition or if the patient had been stabilized or if the patient consented to the transfer or if the patient had requested the transfer. 4. Patient #4 was a 70 year old male who presented to the ER on 1/28/25 with complaints of wanting his catheter removed and on examination frostbite was discovered. Patient #4’s medical record was reviewed. The medical record contained a form titled, “EMTALA/TRANSFER CONSENT FORM”. This form was not complete as it did not indicate if the patient requested the transfer or consented to the transfer. 5. Patient #5 was a 84 year old male who presented to the ER on 3/12/25 with complaints of chest pain for 3 days that radiated to the left arm with numbness and nausea. Patient #23’s medical record was reviewed. The medical record contained a form titled, “EMTALA/TRANSFER CONSENT FORM.” This form was not complete as it did not indicate if the patient had an emergent condition or if the patient had been stabilized. Additionally, the form did not indicate if the patient consented to the transfer or if the patient requested the transfer. The Director of Quality was interviewed on 3/12/25 at 10:37 AM and the above patient charts were reviewed in her presence. She was asked if she would expect the transfer forms to be filled out completely and she stated that she would expect forms to be complete. She agreed that the records did not have complete transfer forms. The hospital failed to ensure complete and accurate transfer documentation was provided to the receiving facility. Failure to include essential documentation can lead to delays in treatment, medication errors and inadequate continuity of care, compromising patient safety and well-being. 51906”