Valor Health

“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 ED logs, medical record review, policy review, 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. Findings include: Refer to A2407 as it relates to the failure of the hospital to provide stabilizing treatment. Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the ED seeking emergency care.”

“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: 51906 1. Based on review of the Emergency Department (ED) central log, medical record review, facility census documentation, hospital policy, and staff interviews, the hospital failed to comply with the requirements of 42 CFR §489.24. Specifically, the hospital failed to provide necessary stabilizing treatment within its capability and capacity of the hospital and inappropriately transferred individuals with emergency medical conditions (EMCs) for non-medical reasons. This directly impacted 3 of 11 patients who were transferred to other facilities and whose records were reviewed (Patient #6, #9, and #11). These failures demonstrate systemic noncompliance with EMTALA obligations and affect the hospital ’ s ability to ensure all individuals presenting to the ED receive stabilizing treatment within the hospital ’ s capability and capacity. Findings include: A hospital policy titled, “Emergency Department (ED) Scope of Service” dated 05/13/2025 was reviewed. The policy stated, “All necessary definitive treatment will be given to the patient within the hospital ’ s capabilities.” Under the heading of “STAFFING” is listed “The ED maintains 1 staff RN (24 hours a day), 1 ED technician (24 hours a day) and 1 registration clerk (0730-0000) for patient care. Additional supplemental staff is provided based on the influx, acuity, and assessment of patient ’ s care needs.” A hospital policy titled, “EMTALA Guidelines” dated 12/26/2024 was reviewed. This policy stated, “This hospital shall not transfer patients who are potentially unstable if the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility shall only be for reason of medical necessity, unless the risks have been fully reviewed and the patient insists on leaving AMA.” This policy also stated, “Upon completion of the MSE: Provide any necessary stabilizing treatment for the EMCs and labor within the hospital ’ s capability and capacity.” A hospital policy titled, “Scope of Services - Medical-Surgical Unit” dated 01/26/2026 was reviewed. This policy stated, “The scope of services includes general medical nursing care, including cardiac monitoring via telemetry unit, the treatment of respiratory conditions requiring continuous oxygenation to the patient via mask or cannula; pre- and post-surgical care and monitoring, convalescence and health restoration.” The policy further stated, “The Medical-Surgical Unit maintains at 1 staff RN, 1 ward clerk as needed, and 1 patient care technician. The ratio of registered nurses to certified nurses aids shall be maintained 1:1. If patient ratio increases above max acuity of 16 than (sic) 2 staff RNs, 1 ward clerk as needed, and 1 patient care technician, CNA shall be staffed. The ratio of registered nurses to certified nurses aides shall be maintained at 2:1 for acuity above 16 .....The patient to nurse ratio shall not exceed 1:4-5, or an acuity of 16, assessed with the approved acuity tool (Kidd et al., 2014). On day/nights with one RN, if census or acuity exceeds limits another RN will be called in to work to provide safe care (Serratt et al., 2011). If there is a deficiency in the number of staff required to care for the patient, all attempts shall be made to replace the deficiency with a qualified staff member. The unit manager maintains the ultimate responsibility for providing adequate staffing and will provide patient care if a registered nurse is not available ...Patient acceptance decisions will be made only after evaluating current patient acuity, available night shift staffing resources, and the projected impact of next-day surgical admission to the MS unit ....All potential admission denials must be escalated through the Charge Nurse and the Department Manager or Administrator on Call. A denial determination will occur only after a structured assessment of current census, patient acuity, staffing levels, skill mix, and anticipated workload. This process ensures decisions are clinically justified, operationally appropriate, and aligned with patient safety standards and organizational accountability.” These policies were not followed. Examples included: Patient #6 was a 37 year old female who presented to the ED on 10/27/25 at 6:12 PM with a chief complaint of “Fever for last 12 hrs, pain level 8/10 on left side.” Patient #6 ’ s medical record was reviewed. The form “Emergency Department Reports” was reviewed. An entry under “Reexamination/Reevaluation” stated, “2114 hrs-workup results discussed patient notified of diagnosis of pyelonephritis. Will need to treat with antibiotics .... Consultation to urology to ensure no additional recommendations from their perspective ....2134-hrs.-consultation with urology on-call (DR NAME). Reviewed patient ’ s history workup results and findings. He feels this is more of a hospitalist issue not requiring urology at this time.” Another entry noted, “2228 hrs. consultation with hospitalist on-call (DR. NAME) .... She recommends patient be admitted for IV antibiotics until cultures are available to determine her stability. Currently we have no capacity at this facility. Patient is unsure if she wants to be transferred if she is unable to find care for her children..” A form titled, “PHYSICIAN CERTIFICATION” dated 10/27/25 at 10:28 PM found in Patient #6 ’ s chart and reviewed. A box stating “Specialized equipment of (sic) services at the receiving hospital (describe):” is checked. There is no description of the specialized equipment or services were listed. Under “Risks of Transfer:” is listed with a check mark in the box next to the sentences, “Deterioration of medical condition during transfer” and “Delay in treatment due to transfer” indicating these are the risks of the transfer. Patient #9 was a 61 year old male who presented to the ED on 1/05/26 at 2:22 PM with the chief complaint of “Last seen 1/03/26 in ER for SOB, prescribed medication but has not picked it up and started it. No pain at this time.” Patient #9 ’ s medical record was reviewed. The form “Emergency Department Reports” was reviewed. An entry under “Reexamination/Reevaluation” stated, “1822 hrs-workup results discussed. Patient is agreeable to admission. Will try to admit to our facility. Consultation requested to (DR NAME). She is happy to admit the patient and feels comfortable with his admission to this facility however nursing reports that no bed availability.” A form titled, “PHYSICIAN CERTIFICATION” dated 1/05/26 at 6:59 PM found in Patient #9 ’ s chart and reviewed. A box stating “Specialized equipment of (sic) services at the receiving hospital (describe):” is checked. The description listed is “Bed Availability.” Under “Risks of Transfer:” is listed with a check mark in the box next to the sentences, “Deterioration of medical condition during transfer” and “Delay in treatment due to transfer” indicating these are the risks of the transfer. Patient #11 was a 75 year old female who presented to the ED on 1/25/26 at 9:31 PM with the chief complaint of “Altered mental status since 1700, per EMS stroke-like symptoms. Baseline reported dementia. Reported fevers and chills.” Patient #11 ’ s medical record was reviewed. The form “Emergency Department Reports” was reviewed. An entry under “Medical Decision Making” stated, “Urine strongly positive for infection. I suspect this is the source. Talked with husband about aggressiveness of care. Given confusion, vomiting, rigors, and tachycardia, sepsis is a reasonable likelihood. No beds available at this hospital.” A form titled, “PHYSICIAN CERTIFICATION” dated 1/26/26 at 12:03 AM was found in Patient #11 ’ s chart and reviewed. A box stating “Specialized equipment of (sic) services at the receiving hospital (describe):” is checked. The description listed is “Hospital Bed.” Under “Risks of Transfer:” is listed with a check mark in the box next to the sentences, “Deterioration of medical condition during transfer” indicating this is the risk of the transfer. Facility forms titled, “Staff Assignments & Acuity” was provided to the surveyors. These forms had a spot for a date, employee shifts and names, hospital room numbers from 101 to 106 and from 115 to 120, a space to write acuity, admit time, and discharge time. These forms were reviewed. A facility form titled, “Staff Assignments & Acuity” dated, “Monday October 27th” was reviewed. The form listed 2 RN ’ s for day shift, 2 CNA/TECHs for day shift. This form listed 2 RN ’ s for night shift and 2 staff for CNA/TECH. There are no acuities listed next to any of the room numbers. It is unclear what the acuity was for the patients, how many patients the hospital currently had, and why the hospital would not be able to admit additional patients. A facility form titled, “Staff Assignments & Acuity” dated, “Monday January 5th” was reviewed. The form listed 2 RN ’ s for day shift, 2 CNA/TECHs for day shift. This form listed 2 RN ’ s for night shift and 2 staff for CNA/TECH. There are acuities listed next to several rooms for the day shift. The acuities add up to 15. The section of the form for night shift includes patient acuity and rooms occupied was not filled out. It is unclear what the acuity was for the patients, how many patients the hospital currently had, and why the hospital would not be able to admit additional patients during the night shift. A facility form titled, “Staff Assignments & Acuity” dated, “Sunday January 25th” was reviewed. The form listed 2 RN ’ s for day shift, 2 CNA/TECHs for day shift. This form listed 2 RN ’ s for night shift and 2 staff for CNA/TECH. There are acuities listed next to several rooms for the day shift. The acuities add up to 15. The section of the form for night shift includes patient acuity and rooms occupied was not filled out. It is unclear what the acuity was for the patients during night shift, how many patients the hospital currently had, and why the hospital would not be able to admit additional patients during the night shift. A facility census log for the medical surgical floor was provided for the months of October 2025 and January 2026. The facility census for 10/27/2025 was reviewed. It shows there are 3 patients admitted to the medical surgical floor on 10/27/2025 with the admit dates of 10/11/2025, 10/23/2025, and 10/25/2025. Review of the facility census for 10/27/25 showed the RN to patient ratio was 1 RN for 3 patients. It is unclear why patients could not be admitted to the medical surgical floor on 10/27/25 with a ratio of 1 RN for 3 patients. The facility census for 1/05/26 was reviewed. It shows there were 3 patients admitted to the medical surgical floor on 1/25/26 with the admit dates of 12/31/25, 12/31/25, and 1/05/2026. Review of the facility census for 1/05/26 showed the RN to patient ratio was 1 RN for 3 patients. It is unclear why patients could not be admitted to the medical surgical floor on 1/05/26 with a ratio of 1 RN for 3 patients. The Medical Director of the Emergency Department was interviewed on 2/24/26 beginning at 1:38 PM. Patient #11 ’ s chart was reviewed in his presence. He stated he remembered the patient. He was asked if he remembered having a conversation with anyone about admitting this patient to this hospital. He explained, “there is always a conversation” and stated, “this is perfect for our hospital” and “they are local so would much prefer to be in here” in reference to Patient #11. He denied remembering having a conversation regarding this patient ’ s admission. He shared if there aren ’ t any beds there is usually one nurse who is supposed to be in charge of “do we have beds or not” and sometimes there is “an emphatic no and sometimes there ’ s let me call around.” He shared there are always physical beds, but staff may not be available to care for patients. He said the ability to admit a patient to this hospital depends on “how many people are there, how many techs can come in, how many surgeries or swing beds are they planning, how many discharges are they planning but I am not really involved in that process.” He shared, “I would have preferred to admit her here.” The Executive Director of Clinical Services was interviewed on 2/24/26 beginning at 11:22 AM. She explained an acuity tool is used to determine whether a patient should be admitted to this hospital or transferred. She explained the general guideline of the nurse to patient ratio on medical surgical floor is 1 nurse to 5 to 6 patients and the acuity should not be above 16. She explained acuity is based on patient need and swing bed patients are usually a 2 or 3, and new admits are automatically a 4 due to the number of tasks need to be performed on a new admit. The patient charts for Patient #6, Patient #9, and Patient #11 were reviewed in her presence at the time of interview. She was asked if she could speak to why these patients were transferred and not admitted to the hospital. She explained on 10/27/25 Patient #6 she did not know. She explained on 1/05/26 Patient #9 was transferred to keep two beds open for elective ortho surgeries scheduled on the next day 1/06/2026. She relayed for Patient #11 on 1/25/26 the patient was transferred due to having 4 patients on the floor and the acuity being 15. The Executive Director of Clinical Services was asked if staff were called in to attempt to meet the acuity needs of these patients needing admitting before the patients were transferred. She could not provide documentation of staff attempting to be called in to meet the staffing needs. She further shared she had PRN staff, but they have “day jobs” and do not usually come in when asked. She was asked how often PRN staff are required to work and she started “1 time every 6 weeks, sometimes we don ’ t need them.” The Acute Care Nurse Manager was interviewed on 2/24/26 beginning at 10:26 AM. She was asked what happens if a patient needs to be admitted but there are no beds available. She shared the nurses talk and the doctors do a doctor-to-doctor call and then the administrator on call is called and a decision is made to admit or not. She was asked if an attempt is made to call people in to care for patients and she said there was. She was asked if this was documented anywhere and she said it was not. She was asked if she was ever called and asked to work due to the need for additional staffing and she said she was called often and works a lot. She was asked if she was ever called in to avoid a transfer due to not having enough staff and she said she was not aware of any transfers due to not having staff available. She shared she has not had to staff 2 nurses on her floor “for a long time.” She was asked if she felt the need for additional staff or nurses and she denied feeling the need for additional staff or nurses. She was asked what a reason would be to deny an admit to this hospital and transfer a patient instead and she said, “usually we have a surgery coming to the floor the next day when we refuse an admit.” An ER RN was interviewed on 2/24/26 at 9:00 AM. He shared sometimes the medical surgical RN will help in the ER if their patients are stable and there is a tech or CNA to watch their patients. He shared nurse managers can be called to help in the ER and on the medical surgical floor. He said if there are no patients in the ER the ER RN goes to the medical surgical floor and helps if needed and help with tasks and gave examples of giving medication and witnessing medication wastage. The hospital did not provide stabilizing treatment within its capability and capacity and inappropriately transferred patients with EMCs for non-medical, administrative reasons. This practice constitutes a violation of 42 CFR §489.24 and placed patients at risk for delay in definitive treatment. 2. Based on review of medical record review, hospital policy, and staff interviews, the hospital failed to comply with the requirements of 42 CFR §489.24. Specifically, the hospital failed to provide necessary stabilizing treatment within its capability. This directly impacted 1 of 21 patients who were seen and treated in the facility’s emergency room and records were reviewed (Patient #18). Findings Include: One patient (Patient #18) medical record was identified as not receiving stabilizing care and represented the potential to impact all patients seeking care in the ED. A hospital policy titled, “ Emergency Department (ED) Scope of Service” with an effective date of 07/21/25, was reviewed and included:” All necessary definitive treatment will be given to the patient within the hospital’s capabilities.” A hospital policy titled, “Emergency Department (ED) Scope of Service” dated 05/13/2025 was reviewed. The policy stated, “All necessary definitive treatment will be given to the patient within the hospital ’ s capabilities.” Under the heading of “STAFFING” is listed “The ED maintains 1 staff RN (24 hours a day), 1 ED technician (24 hours a day) and 1 registration clerk (0730-0000) for patient care. Additional supplemental staff is provided based on the influx, acuity, and assessment of patient ’ s care needs.” These policies were not followed. Example included: Patient #18 was an 83-year-old female who presented to the ED on 1/05/26 at 11:01 AM via private vehicle. Chief complaint was listed as “high heart rate”. Patient #18’s medical record was reviewed and included: 1. “1116 hrs.-patient seen evaluated. Patient is in obvious A-fib with RVR. Will bolus with liter of normal saline and provide dose of Cardizem 20 mg IV. ... 2. 1700 hrs.-oral Cardizem 120 mg long-acting and 5 mg Eliquis p.o. ordered. 3. 1856 hrs.-due to patient volume and acuity delay in administration of oral meds. Patient back in A-fib with RVR. Will administer additional dose of metoprolol.” Patient 18’s MAR documented the following: 1. Administration of the Cardizem and Eliquis at 7:19 PM not 5:00 PM as ordered. 2. A provider note at 6:56 PM, “due to patient volume and acuity delay in administration of oral meds. Patient back in A-fib with RVR.” 3. Patient #18 was discharged home on 1/05/26 at 9:40 PM. Based on the ED logs for 1/05/26, there were 6 patients in the ED (either roomed or in the waiting room) at 5:00 PM and it is unclear what the acuity were for the patients as there were no acuity logs for the ED. The RN on duty at the time of the order of Cardizem and Eliquis was interviewed on 2/24/26, beginning at 4:00 PM. The RN reported she did not know why the medication was not administered. The RN also confirmed her shift ended at 7:00 PM and she had left for the day before the medication was administered. Conclusion: A potential EMTALA violation of stabilizing care was identified for Patient #18. The facility failed to provide necessary medications in a timely fashion for Patient #18.”

“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: 42316 Based on ED log review, medical record review, policy review, Mayo Clinic Reference review, observation, and staff and patient interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This had the potential for negative outcomes and life-threatening complications. Findings include: Refer to A2406 as it relates to the failure of the hospital to ensure a medical screening examinations were performed for all patients presenting to the ED and within the capability of the hospital. Refer to A2407 as it relates to the failure of the hospital to provide stabilizing treatment. The effects of these practices put all patients presenting to the ED for emergency medical treatment at risk of significant negative outcome.”

“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: 42316 44100 Based on ED log review, medical record review, policy review, observation, and staff and patient interview, it was determined the hospital failed to ensure an appropriate MSE was conducted for 2 of 3 patients (Patients #6 and #12) who presented to the ED with pregnancy related chief complaints and whose records were reviewed. Failure to conduct a complete MSE had the potential for significant harm to the patient and unborn child. Findings include: A facility policy titled, “EMTALA Guidelines,” revised 12/26/24 stated, “All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis ... Medical Screening Exams (MSEs) shall include at a minimum the following: ... physical exam of affected systems and potentially affected systems ... necessary testing to rule out emergency medical conditions.” A facility policy titled, “Medical Screening Examination (MSE),” revised 3/11/25, stated, “All patients presenting to ... and seeking care ... must be accepted and evaluated ... All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis.” A facility policy titled, “Medical Screening Exam - Pregnant Patient,” revised 8/01/25, draft copy, was provided to surveyors and was reviewed. This policy stated, “Medical Screening Exams (MSEs) for pregnant patients should include ... B. obtain clean catch urine sample, C. Fetal assessment: Fetal heart rate monitoring (Bedside ultrasound or Doppler, depending on gestational age and equipment). D. Perform sterile vaginal exam (SVE), if indicated.” The above policies were not followed. Examples include: 1. Patient #6 was a 34 year old female who presented to the ED on 4/16/25 at 12:34 AM with a chief complaint of 5 weeks pregnant via IVF with lower abdominal pain and bleeding. Patient #6 was registered and disposition was listed as LWBS. A phone interview was conducted on 8/19/25 beginning at 4:05 PM with the ED RN, RN A, who was on shift when Patient #6 presented. She was asked if she recalled Patient #6 and she stated she believed she did. She stated she brought her [Patient #6] to a room to triage. She stated, “I called [Physician A] in the room to say we had a patient here with abdominal bleeding and she wanted to see if she had an ectopic or if pregnancy was viable and [Physician A] said he would see her but to just let her know we don’t have ultrasound available in the middle of the night. I told the patient and husband and they were angry and left before [Physician A] could see them.” A phone interview was conducted with Patient #6 on 8/20/25 beginning at 9:30 AM. Patient #6 recounted her ED visit on 4/16/25 as follows, “I was brought back to a room ... The RN was on the phone with the doctor, I was in fear of an ectopic. The RN said to me and my husband there was nobody here who can do a scan but we can transfer you. My husband and I were upset and so we left, but if they had done an exam he would have found that I was miscarrying and there were retained parts and tissue in the cervix because that’s what they found at [other ED] within 45 minutes of being there. At [other ED] they used forceps and removed the tissue in the cervix and my pain stopped. Then I was transferred to [acute care hospital].” It was unclear why Patient #6 was not provided an MSE. 2. Patient #12 was a 28 year old female who presented to the ED on 6/29/25 with a chief complaint of “vaginal bleeding 26 weeks pregnant.” The visit was cancelled and the only information in the medical record was a face sheet with patient information such as name, birthday, and insurer. Her disposition was LWBS. The registration clerk, Staff A, who was working when Patient #12 presented to the ED was interviewed on 8/19/25 beginning at 3:14 PM. She confirmed she remembered Patient #12. When asked what happened and why Patient #12 left, she stated the RN had a conversation with Patient #12 and told her they could see her, but had no ultrasound available, and that would be the quickest way to determine if she was having a miscarriage. She said Patient #12 then decided to seek care elsewhere. The RN who spoke with Patient #12, RN B, was no longer employed at the hospital at the time of survey. The DON was interviewed on 8/19/25 during medical record review. She stated OB ultrasound was available during the week from 8:00 AM to 5:00 PM. She stated there was a bedside ultrasound machine some physicians used after hours for OB, depending on their comfort level with it. She stated, “ED docs [sic] are not comfortable with OB.” The ED Medical Director, Physician A, was interviewed on 8/19/25 at 3:23 PM. When asked why some physicians do bedside OB ultrasound and some do not, he stated it depends on what they are comfortable with. He stated it can be comforting to the mother to see fetal movement. He stated on weekends if ultrasound is needed they schedule for the next available appointment or arrange for a transfer. He stated an OB ultrasound does not usually change management of the patient. He stated, “It’s completely informal and can show them the baby is alive.” During the same interview with the Physician A, Patient #12’s case was reviewed. Physician A confirmed he reviewed Patient #12’s case. He stated they tell patients with presenting with OB complaints after hours it is likely they would need an ultrasound and a formal transfer, and most people would rather not delay their care. When reviewing the scenario where Patient #12 decided to go to another facility based on lack of ultrasound capability at night, he stated, “I don’t think at nighttime it’s uncommon.” Physician B, an ED physician, was interviewed on 8/21/25 beginning at 9:46 AM. When asked if he did bedside OB ultrasounds at night, he stated he would if the patient had already had an initial ultrasound. When asked what the bedside OB ultrasound could show he said it could confirm the intrauterine pregnancy, detect fetal heart tones, detect placental hemorrhage, and do a mini anatomy scan. It was unclear why some physicians could do bedside OB ultrasound and some could not. It was unclear why Patient #12 was not provided an MSE within the capability of the hospital. The facility failed to ensure all patients presenting to the ED were provided an MSE within the capability of the hospital. This failure created potential for serious harm, serious impairment, serious injury, or death. Obstetric emergencies are time sensitive and delays could result in significant injury, up to and including, death of the obstetric patient or the fetus. Failure to provide an MSE also caused the potential for other disease processes to go undiagnosed and caused patients traveling significant distances with medical emergencies to go without appropriate monitoring. The facility was notified of the Immediate Jeopardy finding on 8/20/25 at 1:14 PM. A plan of correction was submitted and accepted on 8/20/25 at 3:54 PM which included updated policies and in services outlining that availability of services would not be discussed with the patient until an MSE was complete. Observations and interviews were conducted in the ED on 8/21/25 beginning at 9:46 AM. The facility was notified the Immediate Jeopardy was removed at 10:16 AM on 8/21/25.”

“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: 51906 Based on medical record review, staff interview, Mayo Clinic Reference, and policy review, it was determined the hospital failed to provide stabilizing treatment within the capability of the hospital for 1 of 22 patients (Patient # 20) whose medical records were reviewed. Failing to provide stabilizing medical treatment had the potential to allow a medical condition to progress up to and including death. Findings include: A hospital policy titled, “Emergency Department (ED) Scope of Service” revised date of 5/13/25, stated, “All necessary definitive treatment will be given to the patient within the hospital’s capabilities. ED patients are then evaluated for response to treatment. They are are then admitted, transferred for further treatment not provided by the hospital, or discharged with follow-up instructions as appropriate.” This policy was not followed. An example includes: Patient #20 was a 40 year old female who present to the ED on 7/23/25 with a chief complaint of “HIGH BLOOD GLUCOSE.” An ED triage note by the RN at 10:43 AM noted under the label “Chief Complaint” included the following: “fatigue, urinary frequency, increased thurst [sic]. has [sic] been out of metformin [sic] for over a month having issues with refills.” A note under a section titled “Medical Decision Making” stated, “1044 hrs.-patient seen evaluated ... No clinical evidence of DKA [diabetic ketoacidosis]. Patient’s mucous membranes are moist and pink. Will obtain labs to screen for other conditions. No overt evidence of sepsis toxicity or acute infectious process. Patient agreeable to workup treatment plan of care.” The Mayo Clinic website (https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551) was accessed 8/25/25. It stated: “Diabetic ketoacidosis is a serious health condition that can happen as a result of diabetes. It can be life threatening ... Diabetic ketoacidosis symptoms often come on quickly, sometimes within 24 hours ... Symptoms might include: · Being very thirsty. · Urinating often. · Feeling a need to throw up and throwing up. · Having belly pain. · Being weak or tired. · Being short of breath. · Having fruity-scented breath. · Being confused. More-certain signs of diabetic ketoacidosis show up in home blood and urine test kits. They include: · High blood sugar levels. · High ketone levels in urine. Seek emergency care if: · Your blood sugar level is higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L) for more than one test. · You have ketones in your urine and can’t reach your healthcare professional for advice. · You have many symptoms of diabetic ketoacidosis. These include being very thirsty, urinating often, feeling a need to throw up or throwing up, belly pain, weakness or tiredness, shortness of breath, fruity-scented breath, and confusion. It’s important to get care right away. If it’s not treated, diabetic ketoacidosis can lead to death.” It was unclear how the provider determined the patient had “no clinical evidence of DKA” as patient presented with complaints of high blood glucose, increased urination, increased thirst, and fatigue. Patient #20’s medical record included an entry under a heading titled, “Point of Care Testing” labeled “Blood Glucose, MAR” dated 7/23/25 timed 10:35 AM with the following information “(H) 500 mg/dL” Her medical record indicated that she received a “1,000 mL IV Bolus ONE TIME ... Infuse over 31 min” at 10:49 AM. A further review of her medical record revealed she had a blood glucose reading from the lab at 11:06 AM of 483 mg/dL with the indication next to the reading of “(High).” A note titled “Reexamination/Reevaluation” documented by Physician C stated “1137 hrs.- ... Workup results are reassuring. Patient does have elevated blood sugar but no evidence of DKA or an acute infectious process. Patient is notified of workup results. She is notified of her active prescription. Patient encouraged to take part of her health care and become an active participant in it. Patient encouraged to follow-up with a primary care provider of her choice. She agrees to call and schedule an appointment and follow-up with the appointment as scheduled. She is encouraged to return to emergency room for any problems as needed. She is discharged stable amatory [sic] improved.” It was unclear how Physician C determined Patient #20 was stable and improved as there was no documented follow up of the patient’s presenting symptoms of increased thirst, increased urination, and her last blood glucose was noted to be high per the lab at 483 mg/dL. There was no reassessment documented of her blood glucose before she was discharged at 11:52 AM. Additionally, there was no documentation Patient #20 received any medications to lower her blood glucose levels. Physician C was interviewed on 8/19/25 beginning at 2:37 PM. Patient #20’s medical record was reviewed in his presence. He stated he knew who the patient was as he had just reviewed her record. He was asked about her blood glucose being 483 and being discharged without a recheck of her blood glucose or verification of her response to treatment. He stated, “we asked the social worker to come in. Our social worker is a lot better sometimes at exploring people’s issues and she’s also able to provide resource offerings that she’s an expert on and I’m not. So, we brought the social worker in and the patient’s whole persona just changed. She was like get me out of here. I remember that. We offered more fluids. She didn’t want any further care and yes, a follow up blood sugar would have been done, should have been done but she wanted to leave right now. Now I know, because I just reviewed the chart, that that should have been documented a little bit better, but it was just like get me out of here I want to leave. She didn’t want to discuss it.” Physician C confirmed none of the above information was recorded in Patient #20’s record. Patient #20’s emergency room log entry included that she was discharged home and did not leave the emergency room AMA. The hospital failed to ensure that all patients presenting received stabilizing treatment before being discharged.”