Benewah Community Hospital

“The hospital is a four story, Type II (222) structure, originally constructed in 1958. The most recent addition to the original structure was the east tower, completed in 2012. The addition is separated by two hour construction to the original single story hospital building and houses both administration and clinical/healthcare functions. The entire hospital is protected throughout by an automatic fire extinguishing system design/installed per NFPA Std 13 for light hazard occupancy and has a supervised manual fire alarm system with partial detection in corridors and common areas. The facility is located within a rural fire district, with both county and state EMS services available. The facility is equipped with piped-in medical gas in accordance with all applicable NFPA standards and emergency back-up power through and on-site, diesel-fired Emergency Power Supply System (EPSS) generator. The Critical Access Hospital (CAH) is currently licensed for 19 hospital beds and had a census of 1 on the date of the survey. The facility was found to be in substantial compliance during the Fire/Life Safety survey conducted on October 9, 2024. The facility was surveyed under the LIFE SAFETY CODE, 2012 Edition, Chapter 19, Existing Healthcare Occupancies, in accordance with 42 CFR 482.41.”

“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: 37689 . Based on interview and record review, the hospital failed to meet the regulatory requirements under the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by: 1. Three of 21 patients (Patient #3, Patient #17 and Patient #18) whose records were reviewed were not provided with an appropriate medical screening examination (MSE) to determine whether an emergency medical condition existed. Additionally, the patients did not receive the same MSE the hospital performed on other patients who came to the Emergency Department with similar signs and symptoms. (Cross refer to tag C2406). 2. Patient #18 was not provided with the necessary stabilizing treatment within the capabilities of the hospital (Cross refer to tag C2407). 3. The hospital failed to ensure an appropriate transfer when Patient #18, who was in labor, was transferred to a hospital about an hour away without fetal monitoring and with erroneous certification that her emergency medical condition was “stabilized” and not “in labor” (Cross refer to tag C2409).”

“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: 44100 . Based on medical record review, ED log review, transfer log review, policy review, and staff interviews, it was determined the hospital failed to provide an appropriate medical screening exam to 3 of 21 patients (Patients #3, #17, #18) who presented to the ED and whose medical records were reviewed. The MSEs provided to Patient #3 and Patient #17 were both inappropriate on their face and disparate from the MSE provided to three similarly situated patients identified upon record review (Patients #13, 19, and 21). This failed practice had the potential to put patients at risk of deterioration due to an unidentified EMC. Findings include: Review of a hospital policy titled “Medical Screening Exam”, dated 9/20/23, showed, “An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital must apply a screening process that is reasonably calculated to determine whether an emergency medical condition exists in a non-discriminatory manner.” Review of a hospital policy titled “Emergency Medical Treatment and Labor Act (EMTALA) Policy,” dated 10/20/2022, showed, in part: “If an individual comes to the Emergency Department the hospital will provide... an appropriate medical screening examination within the capability of the Hospital ’ s Dedicated Emergency Department, including ancillary services routinely available, to determine whether or not an emergency medical condition exists” and “The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department.” The policy required that “the medical screening examination is the examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist” and that the “medical screening examination is required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not.” Review of a hospital policy titled “Emergency Department - Labor (Obstetrical) Patient,” dated 2/03//2021, showed the policy ’ s stated “purpose” was to “establish guidelines for a laboring (obstetrical) patient that [sic] presents to the emergency department” and required that “If delivery does not appear to be imminent,” assessment is to include, among other things, “fetal heart tones via Doppler, ...Vaginal bleeding, ...Membrane status ...Intact, leaking, or ruptured, ...If ruptured: time, color, odor, [and] Contractions ...Frequency, duration, strength.” The policy required that “if delivery appears to be imminent or if unable to transfer patient: 1. Contact all staff listed on the attached Call List - Obstetric Patient in Labor. 2. Contact Life Flight and request dispatch of the neonatal team, [and] prepare for delivery.” The policy then lists specific equipment and supplies to use, describes how to perform the delivery, and directs hospital staff to “Prepare mother and infant for transport to another facility” after delivery. Review of the “Emergency Department - Scope of Services” policy, dated 9/29/22, revealed that “Emergency Medicine Privileges” routinely include “delivery of newborn, emergency” and “resuscitation, all age.” Review of a hospital policy titled “Standing Order - Vaginal Bleeding,” dated 12/13/21, described the “scope/responsibility” of the policy to include “trained hospital nursing staff and ED providers” and the policy purpose “to provide expedited care to any patient presenting to the emergency department (ED) of ... with vaginal bleeding.” Among other items, the policy described the “procedure” for screening to include “Establish intravenous (IV) access to obtain blood for labs via purple, green, red, blue, and yellow tubes and order type and cross; ...Evaluate and quantify bleeding; ...Order qualitative/quantitative pregnancy test (Human Chorionic Gonadotropin [HCG]/âHCG); Set up for pelvic exam including the following: 1. Lighted speculum. 2. Lubricant. 3. Culture swabs. 4. Vaginal packing; ...Check for ultrasound availability and order if necessary.” Review of Patient #3 ’ s medical record showed Patient #3 presented to the hospital ED on 3/17/24 at 12:47 PM with a chief complaint of vaginal bleeding. Documentation by Physician A described that she was a 32-year-old female who reported “that she is approximately 6 weeks pregnant when she had heavy vaginal bleeding yesterday” and “had abdominal cramping yesterday but that has mostly resolved. She was on the phone with her midwife today who encouraged her to come to the [emergency] department.” The medical record did not contain documentation that Patient #3 had previously undergone an ultrasound examination during this pregnancy to confirm that the location of her pregnancy was intrauterine (inside the uterus), as opposed to potentially ectopic. Ectopic pregnancy occurs when a pregnancy implants outside the uterus and can be associated with life-threatening hemorrhage, loss of future fertility, infection, coagulopathy (dysfunction of the body ’ s blood clotting organs and system), and damage or dysfunction to the uterus, fallopian tubes, ovaries, and/or other abdominal and pelvic organs. The medical record also did not contain documentation that Patient #3 was evaluated for other causes of bleeding, such as traumatic injury, nor offered any laboratory testing (including quantitative human chorionic gonadotropin testing [measurement of pregnancy hormone levels]), pelvic examination, or consideration of ultrasound as part of her MSE, as required by hospital policy. The medical record did not contain evidence that Patient #3 refused any portion of her examination or treatment. Review of Patient #17 ’ s medical record showed that Patient #17 presented to the hospital ED on 9/29/23 at 4:44 PM with a chief complaint of vaginal bleeding while in custody of law enforcement. Documentation by Physician A described that she was a 22-year-old female who was 10 weeks, 5 days pregnant, and “She woke up from her nap and she had vaginal bleeding. She reports her underwear was covered in blood ...She has not had an ultrasound yet with this pregnancy.” Physician A documented the “physical exam” to include “Abdomen Mild tenderness to palpation in pelvic area,” but there was otherwise no documentation to suggest evaluation or quantification of bleeding or further pelvic examination. The medical record also did not contain documentation that Patient #17 was evaluated for other causes of bleeding, such as traumatic injury. The “Medical Decision Making” documented for Patient #17 by Physician A stated, “22-year-old female presents to the emergency department in law enforcement custody with complaint of vaginal bleeding. Patient is approximately 10 weeks pregnant. She had not had an ultrasound to demonstrate IUP [intrauterine pregnancy] yet. She does complain of pelvic pain. Concern for ectopic pregnancy persist.” Laboratory testing for quantitative human chorionic gonadotropin testing (measurement of pregnancy hormone levels) was collected 9/29/2023 at 5:50 PM, but the result was not available or reviewed prior to discharge. Physician A documented that the hospital did not have ultrasound capabilities at the time of Patient #17 ’ s visit and that she would be transferred to another facility with those capabilities. However, the medical record did not contain evidence that Patient #17 was offered other screening within the hospital ’ s capabilities prior to being transferred, including the procedure described by the hospital ’ s “Standing Order - Vaginal Bleeding” policy. Documentation by RN #1 reflected that Patient #17 was transferred to another facility by law enforcement 9/29/2023 at 6:15 PM. Review of comparator medical records from similarly situated patients included the following: Review of Patient #13 ’ s medical record showed she presented to the hospital ED on 1/15/2024 at 8:25 AM approximately seven weeks pregnant with a complaint of vaginal spotting and pelvic cramping. There was documentation that Patient #13 had previously undergone ultrasound evaluation to confirm intrauterine pregnancy. Patient #13 ’ s medical record contained evidence of pelvic examination, laboratory testing, blood bank evaluation, repeat point of care ultrasound, evaluation and quantification of bleeding, and other screening required by hospital policy as part of her MSE. Review of Patient #19 ’ s medical record showed she presented to the hospital ED on 11/14/2023 at 6:04 PM approximately 20 weeks pregnant with a complaint of vaginal bleeding. She was evaluated by Physician A, who quantified her bleeding on pelvic examination as “moderate.” Physician Assistant #1 ordered an ultrasound. Patient #19 ’ s medical record also contained evidence of laboratory testing, blood bank evaluation, and other screening required by hospital policy as part of her MSE, and she was subsequently transferred to another facility. Review of Patient #21 ’ s medical record showed she presented to the hospital ED on 11/22/2023 at 2:51 PM with a complaint of lower abdominal and pelvic cramping and described taking multiple home pregnancy tests, which were positive. Patient #21 ’ s medical record contained evidence of laboratory testing, including quantitative human chorionic gonadotropin testing (measurement of pregnancy hormone levels), ultrasound, and evaluation and quantification of bleeding as part of her MSE. Ultrasound was concerning for ectopic pregnancy, and Patient #21 was transferred to another facility for further treatment. Review of Patient #18 ’ s medical record showed that she presented to the hospital ED on 9/24/2023 at 3:30 AM with a chief complaint of “water broke 2 [hours] ago.” Under “History of Present Illness,” Physician B documented that Patient #18 was a “33-year-old G5 [number of times she has been pregnant], P2 [number of times she had given birth] at 36 weeks 2 days EGA [estimated gestational age] presenting via POV [privately operated vehicle] in labor. Patient felt a large gush of fluid and thinks her water broke approximately 2 hours prior to presentation. Some very minimal pink spotting, no frank vaginal bleeding. Active fetal movement. Reports contractions are just under 10 minutes apart. Patient presented [to] the emergency department as her last 2 children came very quickly when she went into labor, and she was worried she would not make it to [name of Hospital B, 52 miles away],” where she had planned to deliver her child. The “Physical Exam” documented by Physician B described Patient #18’s “cervix was dilated to 3 cm [centimeters], 50% effaced, [a measurement of thinning of the cervix prior to birth], -2 [station, location of the fetal head within the pelvis], soft.” “Medical Decision Making” documented by Physician B stated Patient #18 was “presenting in labor ...decision was made to transport patient via EMS to [Hospital B] for obstetric services.” Patient #18’s medical record did not contain evidence that her MSE included evaluation of fetal heart tones via Doppler, membrane status (intact, leaking, or ruptured and if ruptured, time, color, and odor), or frequency, duration, or strength of contractions, as required by hospital policy prior to transfer. During an interview on 7/25/24 at 12:30 PM, RN #1 confirmed the ED had two available dopplers for evaluation of fetal heart tones at the time of Patient #18 ’ s presentation. When asked about normal procedure for assessment of fetal heart tones for an ED patient in labor, she reported that nurses often take the fetal heart tones but that a doctor can also assess fetal heart tones. Cross-refer to tags C-2407 and C-2409.”

“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: 44100 . Based on hospital policy review, staff interviews, and review of patient medical records and documents, it was determined the hospital failed to stabilize 1 of 21 patients (Patient #18) who presented to the ED seeking emergency care and whose records were reviewed. The hospital determined that Patient #18 was “in labor” but failed to provide stabilizing treatment outlined in its policies for imminent delivery, including assurance that Patient #18 delivered her fetus and placenta prior to discharge or transfer. This failed practice placed the patient at risk of precipitous out-of-hospital delivery and placed the health of the patient and her fetus in serious jeopardy, including complications of delivery such as shoulder dystocia, respiratory distress of the infant, and maternal hemorrhage, among others. Findings include: Review of a hospital policy titled “EMTALA Policy”, dated 12/04/2020, which defines “Labor” as “the process of childbirth, beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a provider, certified nurse-midwife or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and state law, certifies that, after a reasonable time of observation, the woman is in false labor.” The policy further requires that the hospital “1. Provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition; or 2. Arrange for transfer of the individual to another medical facility.” Review of a hospital policy titled “Emergency Department - Labor (Obstetrical) Patient,” dated 2/3/21, showed the policy ’ s stated “purpose” was to “establish guidelines for a laboring (obstetrical) patient that [sic] presents to imminent, staff shall prepare for a precipitous delivery in the ED. When mother and newborn are stable, they will be transferred to the nearest appropriate facility for postpartum care. Emergency Medical Treatment and Labor Act (EMTALA) guidelines shall be followed for all patient transfers.” The policy required that “if delivery appears to be imminent or if unable to transfer patient: 1. Contact all staff listed on the attached Call List - Obstetric Patient in Labor. 2. Contact Life Flight and request dispatch of the neonatal team, [and] prepare for delivery.” The policy then lists specific equipment and supplies to use, describes how to perform the delivery, and directs hospital staff to “Prepare mother and infant for transport to another facility” after delivery. The policy further requires that, “if delivery does not appear to be imminent,” various screening be performed (cross refer to tag C-2406) and “the provider will ...seek consultation from an OB provider regarding transfer to another facility or discharge to home.” Review of the “Emergency Department - Scope of Services” policy, dated 2/03/21, revealed that “Emergency Medicine Privileges” routinely include “delivery of newborn, emergency” and “resuscitation, all ages.” Review of Patient #18 ’ s medical record showed that she presented to the hospital ED on 9/24/2023 at 3:30 AM with a chief complaint of “water broke 2 [hours] ago.” Under “History of Present Illness,” Physician B documented that Patient #18 was a “33-year-old G5 [number of times she has been pregnant], P2 [number of times she had given birth] at 36 weeks 2 days EGA [estimated gestational age] presenting via POV [privately operated vehicle] in labor. Patient felt a large gush of fluid and thinks her water broke approximately 2 hours prior to presentation. Some very minimal pink spotting, no frank vaginal bleeding. Active fetal movement. Reports contractions are just under 10 minutes apart. Patient presented [to] the emergency department as her last 2 children came very quickly when she went into labor, and she was worried she would not make it to [ Hospital B, 52 miles away],” where she had planned to deliver her child.” “Medical Decision Making” documented by Physician B stated Patient #18 was “presenting in labor” and reflected that the hospital had knowledge of Patient #18 ’ s prior two precipitous deliveries and Patient #18 ’ s concern that there was inadequate time to effect a safe transfer to another hospital before delivery. Patient #18’s medical record contained an ED note from PA #1 which stated, “Patient presented the[sic] Emergency Department as her last 2 children came very quickly when she went into labor, and she was worried she would not make it to [Hospital B].” The medical record did not contain evidence that Patient #18 delivered her fetus and placenta prior to discharge or transfer, nor that the hospital determined her delivery was “not imminent,” as required by hospital policy. Review of collateral records also supported that the hospital had knowledge that Patient #18 was a pregnant woman having contractions such that there was inadequate time to effect a safe transfer to another hospital before delivery and/or that transfer may pose a threat to the health or safety of Patient #18 or her fetus. Physician B documented having spoken to Physician C, an OB/GYN physician at Hospital B, about Patient #18 ’ s presentation to arrange transfer to Hospital B. Review of transfer center records from Hospital B describe the call from Physician B as “looking to initiate transfer for this [patient] that [sic] is in active labor...” Subsequent transfer-related communication documentation attributed to Physician B further said, “Connected w/ [Physician C]; case and presentation reviewed, this is a 33F who is G5P3 who came into Benewah in active labor. She is currently 36 weeks and 2 days. Contractions 9 minutes apart, 3.5 cm dilated, water has broke.” Review of the emergency medical services (EMS) records for Patient #18 revealed that EMS personnel were called to the hospital to assist in transferring Patient #18 to Hospital B and “were informed by the MD on staff [Physician B] to make it to [Hospital B] as quickly as possible as she was progressing fairly rapidly. Patient stated that her water had broken approx. 2 hours prior and that she delivers quickly as her 2 previous deliveries had arrived approximately 2 hours after her water had broken as well” and that “patient has a history of hemorrhage following deliveries.” Staff documented that Patient #18 was transferred to Hospital B on 9/24/2023 at or about 4:00 AM via emergency medical services (EMS). Ambulance Transport Order marked “EMT transport only (routine emergency measures: follow BLS guidelines) Vital signs q [every]15 min.” Confirmed ambulance transfer was volunteer EMTs willing to transfer patient to [Hospital B], 52 miles away on a 2-lane winding rural mountain road. Physician B was interviewed on 7/25/24 at 10:15 AM. Physician B confirmed he thought Patient #18 was stable for transfer. Physician B reported Patient #18’s vitals were stable, and it seemed like “normal labor.” When asked if he assessed the stability of the fetus through fetal heart tones or other method, Physician B reported he believed that he had. Surveyors were unable to find a record of fetal heart tones or other monitoring of unborn child in Patient #18’s medical record. Review of hospital credentialing file for Physician B revealed that Physician B was credentialed to perform “delivery of newborn, emergency” and “resuscitation, all ages” as well as “attendance at delivery to assume care of normal newborns.” Cross-refer to tags C-2406 and C-2409.”

“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: 44100 . Based on hospital policy, staff interviews, and review of patient records and documents, the hospital failed to provide an appropriate transfer because it failed to minimize risk of the transfer, failed to assure the transfer was effected through qualified personnel and transportation equipment, and misrepresented patient condition for 1 of 21 patients (Patient #18) who presented to the ED for emergency care and whose record was reviewed. This failed practice placed the patient at risk of precipitous out-of-hospital delivery and placed the health of the patient and her fetus in serious jeopardy. Findings include: Review of a hospital policy titled “EMTALA Policy”, dated 12/04/2020, defines “Labor” as “the process of childbirth, beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a provider, certified nurse-midwife or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and state law, certifies that, after a reasonable time of observation, the woman is in false labor.” The policy further requires that the hospital “1. Provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition; or 2. Arrange for transfer of the individual to another medical facility.” “When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedure: a. The Hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual’s health and, in the case of a woman who is having contractions, the health of the unborn child.” The policy also stated “The transfer must be performed through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The provider is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer.” Review of a hospital policy titled “Emergency Department - Labor (Obstetrical) Patient,” dated 02/03/21, showed the policy ’ s stated “purpose” was to “establish guidelines for a laboring (obstetrical) patient that [sic] presents to the emergency department” and required that “If the ED provider determines that delivery is imminent, staff shall prepare for a precipitous delivery in the ED. When mother and newborn are stable, they will be transferred to the nearest appropriate facility for postpartum care. Emergency Medical Treatment and Labor Act (EMTALA) guidelines shall be followed for all patient transfers.” The policy required that “if delivery appears to be imminent or if unable to transfer patient: 1. Contact all staff listed on the attached Call List - Obstetric Patient in Labor. 2. Contact Life Flight and request dispatch of the neonatal team, [and] Prepare for delivery.” The policy then lists specific equipment and supplies to use, describes how to perform the delivery, and directs hospital staff to “Prepare mother and infant for transport to another facility” after delivery. Review of Patient #18 ’ s medical record showed that she presented to the hospital ED on 9/24/2023 at 3:30 AM with a chief complaint of “water broke 2 [hours] ago.” Under “History of Present Illness,” Physician B documented that Patient #18 was a “33-year-old G5 [number of times she has been pregnant], P2 [number of times a she had given birth] at 36 weeks 2 days EGA [estimated gestational age] presenting via POV [privately operated vehicle] in labor. Patient felt a large gush of fluid and thinks her water broke approximately 2 hours prior to presentation. Some very minimal pink spotting, no frank vaginal bleeding. Active fetal movement. Reports contractions are just under 10 minutes apart. Patient presented [to] the emergency department as her last 2 children came very quickly when she went into labor, and she was worried she would not make it to [Hospital B]” where she had planned to deliver her child. “Medical Decision Making” documented by Physician B stated Patient #18 was “presenting in labor” and reflected that the hospital had knowledge of Patient #18 ’ s prior two precipitous deliveries and Patient #18 ’ s concern that there was inadequate time to effect a safe transfer to another hospital before delivery. The medical record also did not contain evidence that Patient #18 delivered her fetus and placenta prior to discharge or transfer, nor that the hospital determined her delivery was “not imminent,” as required by hospital policy. Review of collateral records also supported that the hospital had knowledge that Patient #18 was a pregnant woman having contractions such that there was inadequate time to effect a safe transfer to another hospital before delivery and/or that transfer may pose a threat to the health or safety of the Patient #18 or her fetus. Physician B documented having spoken to Physician C, an OB/GYN physician at Hospital B, about Patient #18 ’ s presentation to arrange transfer to Hospital B. Review of transfer center records from Hospital B describe the call from Physician B as “looking to initiate transfer for this [patient] that [sic] is in active labor at Benewah.” Subsequent transfer-related communication documentation attributed to Physician B further said, “Connected w/ [Physician C]; case and presentation reviewed, this is a 33F who is G5P3 who came into Benewah in active labor. She is currently 36 weeks and 2 days. Contractions 9 minutes apart, 3.5 cm dilated, water ha broke.” Review of the emergency medical services (EMS) records for Patient #18 revealed that EMS personnel were called to the hospital to assist in transferring Patient #18 to Hospital B and “were informed by the MD on staff [Physician B] to make it to [Hospital B] as quickly as possible as she was progressing fairly rapidly. Patient stated that her water had broken approx. 2 hours prior and that she delivers quickly as her 2 previous deliveries had arrived approximately 2 hours after her water had broken as well” and that “patient has a history of hemorrhage following deliveries.” Patient #18’s record included a scanned image of an “Ambulance Transport Order” marked “EMT transport only (routine emergency measures: follow BLS guidelines) Vital signs q[every]15 min.” “IV fluids,” “Medications,” and “Other Orders” were left blank, and there were no further orders for personnel or transportation equipment or other necessary and medically appropriate life support measures during the transfer. Patient #18’s record included a scanned image of a “Provider’s Certification Statement” marked “Reason for Transport: Labor.” A handwritten checkmark appears next to “Needed treatment is available at Benewah Community Hospital but patient requested transfer to another facility.” A checkmark next to “Needed treatment is not available at Benewah Community Hospital” appears to have been crossed out and initialed. On a scanned image of an “Emergency department patient treatment or transfer consent/request/refusal” form, a handwritten checkmark appears next to “Consent to transfer (To be completed if the patient consents to a transfer recommended by a physician) I have been examined by a physician ...They have explained my condition to me and have recommended that I be transferred to ___,” followed by a blank line that does not contain an entry. No checkmark appears next to “Request for transfer ...I request a transfer or discharge for the following reasons ...” The form has a signature on the line for “patient or authorized representative” that corresponds to Patient #18 ’ s name. Patient #18 ’ s medical record also contains a scanned image of a “Provider’s Assessment and Certification” form marked “The patient has been stabilized such that within reasonable medical probability, no material deterioration of the patient’s condition or the condition of the unborn child(ren) is likely from transfer,” and no checkmark appears next to “The patient is in labor.” The medical record otherwise does not contain evidence of a discussion with Patient #18 regarding risks of transfer, nor does there appear to be a request made by Patient #18 in writing, indicating the reasons for the request as well as indicating that she is aware of the risks and benefits of the transfer. The medical record also does not contain a physician certification that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the risks to Patient #18 or her fetus. Review of Patient #18’s medical record indicated Patient #18 was transferred to Hospital B on 9/24/2023 at or about 4:00 AM via emergency medical services (EMS). Review of an emergency medical services (EMS) record reflected that Patient #18 continued having contractions every two to eight minutes during the transfer and described that Patient #18 “felt [a] need to push” enroute. The report “narrative” includes documentation of contractions at 4:04, 4:11, 4:19, 4:25, 4:28, 4:32, 4:35, 4:39, 4:43, 4:50, 4:53, 4:56 (“Contraction - Felt need to push”), and 4:58. Arrival at Hospital B is documented as 5:00 and “at arrival to [Hospital B], we were rushed back to OB and immediately got patient [transferred] to the OB bed. Gave report to nurse and patient [stated] that she needed to push. [Hospital B] staff immediately started the process for delivery and [EMS] exited the room.” Review of records from Hospital B revealed that Patient #18 arrived 9/24/2023 at 5:05 AM “in active labor” and delivered a viable neonate at 05:12 AM. Cross-refer to tags C-2406 and C-2407.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 42316 Based on policy review, personnel file review, and staff interview, it was determined the CAH failed to ensure services were provided in accordance with facility policy for 3 of 4 nursing staff whose personnel files were reviewed (Staff A, B, and C). This caused a lack of current competency assessment for the two staff reviewed. Findings included: A CAH policy titled, “Evaluation/Competency Assessment,” approved 5/31/23 was reviewed. It stated, “On-going evaluation and competency assessment will be conducted annually and coincide with an employee’s annual performance appraisal.” This policy was not followed. Examples included: 1. Staff A’s personnel file was reviewed. Staff A was a current RN at the time of survey. Staff A’s skills competencies included nursing tasks such as sterile technique, venipuncture, and managing intravenous lines. The most recent competencies were completed 1/29/22. 2. Staff B’s personnel filed was reviewed. Staff B was a current RN at the time of survey. Staff B’s skills competencies included nursing tasks such as sterile technique, venipuncture, and managing intravenous lines. The most recent competencies were completed 2/03/22. 3. Staff C’s personnel filed was reviewed. Staff C was a current CNA at the time of survey. Staff C’s skills competencies included nursing assistant tasks such as safe transfers, vital signs, and managing personal cares. The most recent competencies sheet was dated 2/05/22, however within the document, each skill was marked as “met” on 5/31/19. It was unclear when the competencies were completed. The Risk Manager was interviewed on 4/25/24 beginning at 10:58 AM. When asked if these were the most current competencies for Staff A, B, and C, she stated they were. She confirmed the competencies were overdue. The CAH failed to ensure nursing staff skills competencies were current.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 42316 Based on observation, CDC guidelines review, and staff interview, it was determined the CAH failed to prevent potential transmission of infectious waste in the SPD for 2 of 2 reprocessing rooms observed. This caused clean areas in the SPD to potentially become contaminated with waste product. Findings include: A CDC document titled “Reduce Risk from Water from Plumbing to Patients,” updated 9/11/19 and accessed 4/30/24, was reviewed. It stated, “Recent evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilities can become contaminated with multidrug-resistant organisms (MDROs) ... Splashes may occur when water flow hits the contaminated drain cover or when a toilet or hopper is flushed. Splashes can lead to dissemination of MDRO-containing droplets, which in turn may contaminate the local environment or the skin of nearby healthcare personnel and patients.” The document also stated, “Install and utilize hopper and toilet covers. These covers should be closed before flushing.” These guidelines were not followed. An example included: Observations of surgical reprocessing began on 4/25/24 at 9:20 AM in the SPD. The CST was observed pre-cleaning the surgical instruments in the reprocessing room. On the counter was a suction cannister with saline and blood from the finished case. At 9:30 AM the CST was observed to pour the fluid down the drain of the hopper (a large toilet like basin for flushing fluid). The hopper did not have a cover. Additionally, the endoscope reprocessing room contained another hopper which did not have a cover. The IC Manager was interviewed on 4/25/24 at 10:58 AM and the above observations were reviewed with her. She confirmed the 2 hoppers observed did not have covers to prevent spray when flushing. The CAH failed to ensure hoppers were covered to prevent spray of waste fluid and water.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 39430 Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure comprehensive assessments were completed for 1 of 1 swing bed patients (Patient #31) whose record was reviewed. Lack of a complete assessment had the potential for unmet patient needs. Findings included: The CAH’s policy, “Nursing Admission Assessment” dated 8/31/23, stated, “Each assessment shall include biophysical, psychosocial, environmental, self-care, educational, discharge planning and significant others when appropriate.” This policy was not followed. An example includes: Patient #31 was a 84 year old female admitted to swing bed on 9/8/2023 6/08/19 for a femur fracture. Patient #31’s medical record included an admission nursing assessment. There was no documentation of an assessment for Patient #31 psychosocial needs. The CAH’s DON was interviewed on 4/25/24 beginning at 11:00 AM, and Patient #31’s record was reviewed in her presence. She confirmed there was no documentation of an assessment of Patient #31’s psychosocial needs. The hospital failed to ensure swing bed admission assessments were complete to include psychosocial needs.”