St Bernard Hospital

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 34411 Based on document review and interview, for 1 of 11 (Pt #1) clinical records reviewed for patient rights, the Hospital failed to ensure that a patient’s guardian was involved in making informed decisions, for a patient who lacked decisional making capacity. Findings include: 1. The Hospital’s policy titled, “Informed Consent” (dated 4/25), was reviewed and required, “Responsibility for obtaining informed consent. The treating or supervising practitioner is ultimately responsible for discussing the proposed care with the patient, obtaining valid informed consent from the patient or their authorized surrogate decision-maker, and ensuring that valid consent or refusal of consent is documented in the medical record ...Process for obtaining informed consent ...General consent form. Upon registration for inpatient or outpatient care, [Hospital] shall require that the patient or their surrogate decision-maker execute [Hospital’s] general consent form ...Specific written consent. 1. All surgical cases. 2. Administration of anesthesia ...4. Procedure and otherwise covered in the surgical consent ...12. Paracentesis ...Adults who are not competent. If a patient lacks capacity to consent to their own care ...consent should be obtained from the patient’s authorized surrogate decision-maker in the following order of priority: 1. The patient’s guardian of the person; 2. The patient’s spouse; 3. Any adult son or daughter of the patient... Emergencies. In an emergency situation, practitioners may initiate appropriate care without obtaining prior informed consent if: i) the practitioner determines that there is a substantial likelihood that the patient’s life or health may be seriously endangered without immediate treatment; ii) the patient lacks capacity to consent, and an authorized surrogate decision-maker is not readily available to consent; and iii) the practitioner acts in good faith without knowledge of facts suggesting that the treatment would be contrary to the patient’s prior directives ...” 2. The clinical record for Pt #1 was reviewed on 6/1/2026. Pt #1 presented to the emergency department (ED) on 3/22/2026 at 3:15 PM, for hypotension (low blood pressure) and altered mental status. Pt #1 was admitted on 3/22/2026 at 9:09 PM. Pt #1 was discharged to a skilled nursing facility on 4/10/2026. The clinical record included: - Pt #1’s demographics face sheet listed a “Person to Notify”. The relationship to the patient was listed as, “Guardian of handicapped Pt.” (State-appointed guardian/Z #1). - Consents obtained upon admission from the patient access registrar in the ED, included the General Hospital Informed consent (for treatment and admission); “Advanced Directive for Health Care” (form indicating if patient has any living wills or power of attorney); “Notice of legal relationship between [Hospital] and the Physicians Providing Care at the Hospital” (indicating physicians are not employees of the hospital); and “Note of Understanding Valuables and No Smoking Policies”, all indicated that Pt #1 was unable to sign. There was no documentation indicating that Z #1 was notified to obtain informed consent. - ED Progress note (dated 3/22/2026 at 5:34 PM), included, “Chief complaint: Hypotension. Stated complaint: Altered mental status ...History of Present Illness: ...Alzheimer’s dementia ...BIBA [brought in by ambulance] from nursing home due to concern for hypotension. Upon evaluation, patient is A&O [alert and oriented] x1, oriented only to self. Patient’s [adult child/Z #2] is present and provided history ...Per [Z #2], patient has state guardian named [Z #1], contact information was provided ...Discharge Plan: Patient Disposition: Admitted as inpatient.” Pt #1’s physician orders included, in part, orders for procedures or treatments that required consent or notification: - 3/22/2026 at 8:30 PM: Right femoral, non-tunneled venous access catheter (centrally inserted intravenous/IV access). This was completed in the emergency department to obtain IV access. - 3/26/2026 at 1:47 PM: Insert PICC line (peripherally inserted central catheter). - 3/30/2026 at 6:32 PM: US (ultrasound) thoracentesis (medical procedure done to remove excess fluid or air from lungs). - 4/6/2026 at 12:58 PM: Esophagogastroduodenoscopy percutaneous endoscopic gastrostomy (g-tube) placement (EGD/visualization of gastrointestinal tract). The procedures and treatments were performed as ordered. Consents for surgical procedures and other treatments that require consents were reviewed and included: - Non-tunneled venous access catheter (dated 3/22/2026): Lacked consent from Z#1. Completed in the ED and consent was signed by the ED physician. There was no documentation that an attempt was made to contact Z #1 (or covering State Guardian) for notification and consent. - 3/26/2026 at 1:47 PM: Insert PICC line (peripherally inserted central catheter). Consent was obtained from Z #3 (covering State Guardian). - Thoracentesis (dated 4/2/2026): Included a phone consent from Z #2. However, there was no documentation that an attempt was made to contact Z #1 (or covering State Guardian) for notification and consent prior to obtaining consent from Z #2. - Percutaneous endoscopic gastrostomy tube insertion, surgical and anesthesia consent (dated 4/6/2026), included consent from Z #2. However, there was no documentation that an attempt was made to contact Z #1 (or covering State Guardian) for notification and consent prior to obtaining consent from Z #2. 3. On 6/2/2026 at 8:52 AM, an interview was conducted with the Chief Medical Officer (MD #2). MD #2 stated that when an invasive procedure or surgical procedure is going to be performed, the provider explains the risks and obtains consent from the patient. MD #2 stated that if the patient is not decisional and has a guardian, the guardian should be notified to obtain consent. 4. On 6/2/2026 at 1:02 PM, an interview was conducted with a Gastroenterologist (MD #3). MD #3 stated that MD #3 performed the PEG (gastrostomy tube) placement for Pt #1. MD #3 stated that regarding obtaining informed consent, the person who is listed on face sheet, will be contacted to get the consent. MD #3 stated that the provider and the nurse will contact that listed person to obtain the consent. MD #3 stated that if the patient has a State guardian, we will contact that guardian to obtain consent. MD #3 stated that if there is difficulty getting in touch with the guardian, the team will reach out to the social worker for assistance. MD #3 stated that a surgical procedure will not be performed without a consent, unless it is an emergency situation.”

“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: 39802 Based on document review and interview, the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to ensure an appropriate medical screening examination (MSE) was completed, including an evaluation from on-call specialty physician when requested and results of ordered imaging was completed. (A-2406 A) 2. The hospital failed to ensure an appropriate medical screening exam was completed, in accordance with the hospital’s stroke (cerebral vascular accident - CVA) protocol, for a patient who presented to the emergency department with stroke symptoms. (A-2406 B)”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 39802 Based on document review and interview, for 1 of 3 ED (emergency department) clinical records (Pt. #1) reviewed for on-call requests, the Hospital failed to ensure that the on-call physician presented to the hospital to evaluate a patient when requested. Findings include: 1. Hospital A’s policy titled, “EMTALA” (dated 08/2025), was reviewed and required, “ ...On-call physicians. A. On-call list: The Hospital will maintain a list of on-call physicians who are available to assist the Hospital in providing emergency care as described above. If a medical screening examination indicates that a person has an emergency medical condition (EMC) requiring the services of an on-call physician, the Hospital shall, on recognition of the EMC contact the on-call physician to provide necessary consultation. The on-call physician shall respond in person, and be physically present at the hospital within ninety (90) minutes or less, unless circumstances prevent an earlier response. The physician may respond by telecommunication, and provide advice to the ER physicians, the physician must still present at the Hospital if requested by the emergency room physician or qualified medical personnel. B. On-call physician’s failure to respond. In an on-call physician fails or is unable to respond in a timely fashion, the Hospital will: (1) contact an alternative or back-up physician from the on-call list, if any; (2) if no alternative or backup physicians are available and the person needs emergency care that is not available at the Hospital, arrange for an appropriate transfer to another hospital or medical facility as described above ...” 2. Hospital A’s clinical record of Pt. #1’s ED visit on 07/30/2025 was reviewed on 09/08/2025. Pt. #1 presented to the ED on 07/30/2025 at 1:33 PM with a chief complaint of boil on genitals. The Medical Screening Examination/MSE completed by ED Physician (MD#3) on 07/30/2025 at 5:59 PM, included “ ...[Pt. #1] has past medical history of type 1 diabetes coming in for evaluation of 3 to 4 days of pain to the perineum. [Pt. #1] has also subsequently developed testicular swelling ... denies any fever, chills, nausea, vomiting ... has had some mild abdominal pain, denies any dysuria [pain on urination]. The patient reports had significantly worsening pain prior to arrival to the department for evaluation. The patient was initially seen in our fast-track department, but the practitioner who saw the patient immediately felt the patient should be seen in the main ER so was brought over here for further evaluation. Patient was noted to be hyperglycemic of 434 [normal range 74-110] Additional progress notes by MD#3 on 07/30/2025 included the following: - “@ 5:59 PM discussed with Hospital B. Called prior to having labs or CT performed as do not want to delay care if patient has true Fournier’s gangrene. Spoke to [urologist at Hospital B], would like me to discuss with general surgery and is happy to be on consult for urology. Spoke to [Z#1 - General Surgeon at Hospital B], would like me to discuss with general surgery here and request bedside evaluation, possible I&D [incision and drainage], but happy to accept transfer in the meantime. [Z#1] is aware that labs and CT are pending ...” - “@ 6:15 PM, discussed case with [On-call General Surgeon MD#4]. Discussed my concern for Fournier’s gangrene. Discussed the patient’s presentation. Discussed my plan to transfer patient to Hospital B where they have general surgery and urology coverage as I do feel the patient is going to need urologic intervention in addition to general surgery which Z#1 agrees with. I communicated the request from Z#1 that the general surgeon on-call at this hospital come bedside to evaluate the patient and perform an incision and drainage because if this is Fournier’s gangrene, early debridement is important. MD#4 states MD#4 will not come into the department to perform incision and drainage or bedside evaluation at this time, and prefers ER to ER transfer for the patient to go to a facility that has urology coverage along with general surgery. We had an extensive discussion regarding this and the request of Z#1 for MD#4 to come bedside and evaluate the patient and possibly perform I&D, but MD#4 declines.” - “@ 6:20 PM called back Hospital B to discuss. Z#1 accepts patient transfer. Discussed with Emergency Department Attending at Hospital B who accepts patient ...” - “@ 7:00 PM discussed case with Z#1, requesting I call another surgeon to evaluate the patient bedside.” - “@ 7:10 PM discussed case with MD#5 who is alternative general surgeon on call. States that MD#5 will not come bedside to evaluate the patient as it will take him 1.5 hours to drive here.” Nursing Notes on 07/30/2025 included the following: - 6:36 PM by ED Nurse (E#6): [Ambulance Company B] ACLS arrival 9:00 PM ETA [estimated time of arrival] for transport. - 6:46 PM by E#6: [Ambulance Company A] ACLS arrival 60-90 minutes for transport. The Transfer Form indicated that Pt. #1 was picked by Ambulance Company A with ALS (advanced life support) services to Hospital B on 07/30/2025 at 9:25 PM for a higher level of care. The Form indicated that Hospital’s B’s ED Physician was the accepting physician. 3. The ED Physician On-Call lists (3/2025-9/2025), were reviewed and included physician coverage, 24/7, 7 days a week, for all the required specialties. The July 2025 Surgery On-call schedule was reviewed and indicated that General Surgeon MD#4 was on-call on 07/30/2025. 4. A telephone interview was conducted with General Surgeon (MD#4) on 09/09/2025, at approximately 1:12 PM. MD#4 stated that there are two general surgeons including MD#4 and MD#5 that alternate being on-call. MD#4 stated that when scheduled to be on-call, they are required to be available for consultation or emergencies 24/7. MD#4 stated if called, MD#4 will come in depending on the urgency of the case or time of day. MD#4 stated that if the patient is stable, likely MD#4 will come in the next morning to do the surgery. MD#4 stated that in regard to Pt. #1, the ED physician already called a urologist for consult, who accepted the patient. MD#4 stated that the transfer process had already started and stated that this was not an emergency case. MD#4 stated that Hospital B’s surgeon asked MD#4 to see the patient; however, MD#4 stated that the patient was already going to Hospital B and that MD#4 didn’t need to see the patient. MD#4 stated that if MD#4 was going to come in and start a procedure, then MD#4 would just take the patient to the OR (operating room) and do the procedure. MD#4 stated that as a general surgeon, MD#4 can do debridement but due to the location of the necrotic tissue, it was best to have a urologist onboard as well. MD#4 stated that in Pt. #1’s case, it would just be a waste of time for MD#4 to come in and felt it was unnecessary for MD#4 to meddle in Pt. #1’s case when general surgery and urology were already onboard at Hospital B. 5. An interview was conducted with the ED Medical Director (MD#6) on 09/10/2025, at approximately 9:27 AM. MD#6 stated that when a specialty physician is on-call, and is requested to come in, the expectation is for them to come in within an hour and a half.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 39802 A. Based on document review and interview, the hospital failed to ensure an appropriate medical screening examination (MSE) was completed, including an evaluation from on-call specialty physician as requested and results of ordered imaging was completed, for 1 of 2 patients (Pt #1) for whom an evaluation from on-call specialty was requested. Findings include: 1. Hospital A’s policy titled, “EMTALA” (dated 08/2025), was reviewed and required, “...Medical Screening Examination (MSE). If a person comes to the Hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person sould believe that the person is in need of emergency care, then qualified medical personnel will, within the Hospital’s capability and capacity, conduct and document an appropriate medication screening examination reasonably calculated to identify an emergency medical condition...” 2. Hospital A’s clinical record of Pt. #1’s ED visit on 07/30/2025 was reviewed on 09/08/2025. Pt. #1 presented to the ED on 07/30/2025 at 1:33 PM with a chief complaint of boil on genitals. -The Triage Assessment, dated 07/30/2025 at 1:50 PM, indicated that Pt. #1 was assigned an acuity level of 4 [1= resuscitative; 2 =emergent; 3 = urgent; 4 = semi-urgent; and 5 =routine] and included the following vital signs: Heart Rate (HR) = 128 (normal 60-100); Respirations (RR) = 18 (normal 12-24); Blood Pressure (BP) = 124/77 (normal 90/60-120/90); Oxygen Saturation (O2Sat) = 99% on room air/RA (normal 94-100%); Temperature (Temp) = 98.4 Fahrenheit/F (normal 97-99). -The fast-track provider’s note, dated 7/30/2025 at 2:47 PM, included, “ ...presents to fast track for evaluation of 10/10 sharp pain in right testicle with swelling and perianal abscess for 2 days. Chaperoned genital exam performed. Pt tachycardic [elevated heart rate], hyperglycemic [elevated blood sugar] at 434 [normal range for diabetic = 70 to 130 mg/dL before meals, and less than 180 mg/dL after meals]. Pt upgraded to main ED, charge nurse aware, report given to [ED Physician - MD #3]. Pt being roomed in CC3A.” - The Medical Screening Examination/MSE completed by ED Physician (MD#3) on 07/30/2025 at 5:59 PM, included “ ...[Pt. #1] has past medical history of type 1 diabetes coming in for evaluation of 3 to 4 days of pain to the perineum. [Pt. #1] has also subsequently developed testicular swelling ... denies any fever, chills, nausea, vomiting ... has had some mild abdominal pain, denies any dysuria [pain on urination]. The patient reports had significantly worsening pain prior to arrival to the department for evaluation. The patient was initially seen in our fast-track department, but the practitioner who saw the patient immediately felt the patient should be seen in the main ER so was brought over here for further evaluation. Patient was noted to be hyperglycemic of 434 [normal range 74-110 ...” Additional progress notes by MD#3 on 07/30/2025 included the following: - “@ 5:59 PM discussed with Hospital B. Called prior to having labs or CT performed as do not want to delay care if patient has true Fournier’s gangrene. Spoke to [urologist at Hospital B], would like me to discuss with general surgery and is happy to be on consult for urology. Spoke to [Z#1 - General Surgeon at Hospital B], would like me to discuss with general surgery here and request bedside evaluation, possible I&D [incision and drainage], but happy to accept transfer in the meantime. [Z#1] is aware that labs and CT are pending ...” - “@ 6:15 PM, discussed case with [On-call General Surgeon MD#4]. Discussed my concern for Fournier’s gangrene. Discussed the patient’s presentation. Discussed my plan to transfer patient to Hospital B where they have general surgery and urology coverage as I do feel the patient is going to need urologic intervention in addition to general surgery which Z#1 agrees with. I communicated the request from Z#1 that the general surgeon on-call at this hospital come bedside to evaluate the patient and perform an incision and drainage because if this is Fournier’s gangrene, early debridement is important. MD#4 states MD#4 will not come into the department to perform incision and drainage or bedside evaluation at this time and prefers ER to ER transfer for the patient to go to a facility that has urology coverage along with general surgery. We had an extensive discussion regarding this and the request of Z#1 for MD#4 to come bedside and evaluate the patient and possibly perform I&D, but MD#4 declines.” - “@ 6:20 PM called back Hospital B to discuss. Z#1 accepts patient transfer. Discussed with Emergency Department Attending at Hospital B who accepts patient ... aware that labs and CT are pending, I communicated that we will send updated labs as they are available for the patient, and if we are able to get a CT in the meantime we will send a copy of the disc.” - “@ 6:57 PM WBC [white blood cell count] = 40.4 [indicating possible infection as normal range = 4.8-10.8] - “@ 7:00 PM discussed case with Z#1, requesting I call another surgeon to evaluate the patient bedside.” - “@ 7:10 PM discussed case with MD#5 who is alternative general surgeon on call. States that MD#5 will not come bedside to evaluate the patient as it will take him 1.5 hours to drive here.” - “@ 7:13 PM signed out to oncoming physician.” Physician orders were placed on 07/30/2025 as follows: - 1:57 PM: Motrin (pain medication) - 5:32 PM: Urinalysis and Chlamydia (sexually transmitted disease) Panel - 5:41 PM: Glucose POC (Point of Care) - 5:47 PM: CT abdomen pelvis with contrast STAT for testicular pain swelling - 5:49 PM: Clindamycin, Zosyn, and Vancomycin antibiotic infusions. - 5:58 PM: Morphine (narcotic pain medication) - 6:01 PM: Ultrasound scrotum STAT for scrotal pain. - 6:27 PM: Comprehensive Metabolic Panel (CMP), Lactic Acid, Blood cultures, CBC (complete blood count), and Hematology. - 7:02 PM: Glucose POC Bed - 7:59 PM: Humulin R (insulin) - 6 units IV The record indicated that comprehensive metabolic panel (includes kidney function labs) was collected on 07/30/2025 at 6:27 PM and send to the lab at 6:41 PM. The results of CMP were completed at 7:54 PM and indicated that Pt. #1 had normal kidney function. Blood Glucose Results on 07/30/2025 included: - 434 at 5:41 PM - 495 at 6:27 PM - 521 at 7:02 PM The medication administration record (MAR) indicated that the patient received motrin and morphine for pain and received all 3 ordered antibiotics on 07/30/2025 starting at 5:49 PM. The MAR also indicated that Pt. #1 received the ordered dose of regular insulin (Humulin R) on 07/30/2025 at 8:00 PM. The record lacked documentation that CT and ultrasound tests were completed as ordered. There was no documentation of blood glucose testing after Pt #1 received insulin. - Nursing Notes on 07/30/2025 indicated that they were some delays for transport to arrive, with an estimated arrival time of approximately 9:00 PM. - The Transfer Form indicated that patient was picked up by ambulance to transfer to Hospital B on 07/30/2025 at 9:25 PM (more than 3 hours after imaging orders were placed). 3. An interview was conducted with the ED Medical Director (MD#6) on 09/10/2025, at approximately 9:27 AM. MD#6 stated that ideally STAT imaging should be done within an hour. MD#6 stated that when a specialty physician is on-call, and is requested to come in, the expectation is for them to come in within an hour and a half to evaluate the patient. B. Based on document review and interview, the hospital failed to ensure an appropriate medical screening exam, in accordance with the hospital’s stroke (cerebral vascular accident - CVA) protocol, was completed for 1 of 2 patients (Pt #2) who presented to the emergency department with stroke symptoms. Findings include: 1. The Hospital’s “Code Stroke Alert Protocol Emergency Department” (dated 1/8/2025), was reviewed on 9/9/2025 and required, “The [City] Emergency Management System (EMS) standard operating procedures coordinate Stroke patients to be transported to designated Stroke Centers and/or Tertiary Care Center [complex medical care] however, there may be times where patients present to [Hospital] Emergency Department for management. This policy gives an overview of the Stroke Protocol guiding rapid response and treatment of stroke cases ...ED Nurse: Activate Code Stroke Alert (Time Goal Door/notification to page out <5 minutes). Take stretcher from planned exam room and move it to CT and wait for patient arrival if indicated. Document using Code Stroke Alert section on the ED narrator to include vital signs, abbreviated NIHSS [neurological assessment for stroke], pupil size and reaction, and dysphagia [difficulty swallowing] screening ...CT Tech: CT Technologist will clear CT scanner table immediately and proceeds with non-contrast head CT (Time Goal/CT head without contrast completed <20 minutes).” 2. The Hospital’s “Alteplase (Systemic) Administration Protocol for Stroke/STEMI/PE”, was reviewed, and included, “Alteplase (tPA is a powerful thrombolytic agent used for systemic administration in the treatment of acute thromboembolism [blood clot]. This protocol outlines the procedure associated with dosing, administration, and preparation of alteplase (Activase) for the following ...Acute ischemic stroke when administered within 3 to 4.5 hours of symptom onset ...” 3. The clinical record for Pt #2 was reviewed on 9/8/2025. Pt #2 presented to Hospital A’s ED (emergency department) on 7/11/2025 at 12:24 PM, with a chief complaint of left sided weakness. -ED Triage Assessment note (dated 7/11/25 at 12:24 PM), documented by the ED Triage RN (E #3/registered nurse), included, “Patient stated complaint: L [left] side weakness/can’t smile ...Pt arrived for complaint of left arm weakness and slurring since this morning when [Pt #2] woke up around 11 AM. Pt reports going to bed around 2 AM ...” The triage note lacked documentation of a “Code Stroke” being initiated. In addition, there was no NIHSS documentation as required by “Code Stroke” protocol. -ED Nursing Assessment note (dated 7/11/25 at 12:31 PM) documented by the ED RN (E #4) included, “Systems Assessment: Neurological: Within Defined Parameters “Yes” ...Vital signs: Blood pressure 150/95 [normal 120/80]; Heart rate 85 [normal adult 60-100 beats per min]; respiratory rate [normal adult 16-20]; oxygen saturation 100 percent [normal above 92 percent].” -A subsequent nursing note by E #4, (dated 7/11/25 at 12:46 PM), included, “Patient states that roughly an hour ago [Pt #2] was trying to grip the remote and noticed that grip to [Pt #2’s] left hand was weak. Patient reports no pain and is noted to have good strength to [Pt #2’s] [right] hand and to both lower extremities. Patient states [Pt #2] feel as though [Pt #2] has a very slight difference in [Pt #2’s] speech as well...” - HPI (history of present illness), dated 7/11/25 at 12:48 PM, documented by the ED Physician (MD #1), included, “ ...Exam: left grip strength is weaker than the right side ...Hospital course ... 4:45 PM-pt has [Pt #2] grip strength back to [Pt #2] normal baseline. Slight slurring of speech but clinically improving ...5:30 PM-case d/w [discussed with] [outside physician] rec [recommend] transfer for Neuro/MRI. 5:50 PM-case d/w [outside hospital - Hospital C]. Face sheet faxed. 6:15 PM-pt refused admission/transfer. Pt is of sound mind and capable of making sound medical decisions. I [MD #1] had a long d/w pt and [pt’s family member] at bedside regarding [Pt #2] concerning symptoms for a stroke and need for higher level of care. Pt wants to sign out. [Pt #2’s family member] was requesting d/c [discharge] paperwork as well. I [MD #1] had a long conv[ersation] w/ them regarding the possibility of death, perm pain/disability and other serious medical problems. Multiple alternatives were d/w pt in great detail. Pt verbalized understanding of the ama [against medical advice] process and risk of having stroke that could cause severe disability and/or death ...Discharge Plan: Patient Disposition: Left Against Medical Advice [AMA]. Clinical Impression: TIA (transient ischemic attack/temporary stroke like attack).” MD #1’s orders from included: - 7/11/2025 at 12:46 PM: CT Angio head (computed tomography angiography/imaging of the blood vessels in the head and neck) - stat (without delay) - 7/11/2025 at 12:49 PM: CT Angio neck, CT head/brain without contrast - stat -The CT scan reports included that there were no acute findings or brain bleeds on the CT scans. However, the CT reports indicated that Pt #2’s CT scans were not performed until 2:45 PM (2 hours after being ordered). - According to the protocol, Pt #2 was outside of the window to initiate tPA (symptom onset was greater than 3-4.5 hours). -Discharge instructions included information on TIA; follow-up information with the primary care clinic; and prescriptions for aspirin 325 mg oral daily, were given and signed by Pt #2 on 7/11/1025 at 6:17 PM. 3. On 9/9/2025 at approximately 9:35 AM, a phone interview was conducted with the ED Triage RN (E #3/triaged Pt #2). E #3 stated that although the Hospital is not “Stroke-Certified”, there are still times when a patient presents to the ED, with stroke symptoms. E #3 stated that the triage nurse will let the nurse in back know about the patient, and then the doctor will put in orders right away. E #3 stated that also, if the patient does present with stroke symptoms, the patient will get a CT scan within 30 minutes to an hour. 4. On 9/9/2025 at 10:27 AM, an interview was conducted with the ED Manager (E #2). E #2 stated that when a patient presents with stroke-like symptoms, the triage nurse activates the stroke protocol based on assessment. E# 2 stated that nurses are expected to follow the stroke protocol. E #2 stated that the ED nurse does neuro checks, gets labs, and an EKG. E #2 stated that a CT scan should be done within 30 minutes of the patient arriving at the ED. 5. On 9/10/2025 at 9:28 AM, an interview was conducted with the ED Medical Director (MD #6). MD #6 stated that (Hospital A) is not a Stroke Center. MD #6 stated that, however if a patient presents to the ED, with stroke symptoms, a rapid assessment in triage should be done. MD #6 stated that the triage nurse should trigger and follow the Code Stroke protocol. MD #6 stated that a CT scan should ideally be done within 10 minutes of the patient’s arrival. MD #6 stated that the CT scan is important to know if the stroke is hemorrhagic (bleeding) or ischemic (blood clot), as this will determine the treatment course. 6. On 9/11/2025 at 9:45 AM, an interview was conducted with a CT Technologist (E #13). E #13 stated that when a patient comes to the ED, and a stroke needs to be ruled out, a CT scan is done STAT. E #13 stated that STAT means “right away”. E #13 stated that if there is more than one CT scan ordered at the same time (different patients), the CT techs have to prioritize the order of whose testing would be done first. E #13 stated that for example, a CT to rule stroke would “trump” a CT of the knee.”

“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: 50411 Based on document review, observation and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The hospital failed to ensure signage was posted conspicuously in places that are noticed by all individuals entering the Emergency Department and the wording was in languages of the population served by the hospital. (A- 2402) 2. The hospital failed to ensure that Pt. #1 was registered in the ED log. (A-2405) 3.The hospital failed to ensure a medical screening examination was conducted to determine if an emergency medical condition existed. (A-2406 A) 4. The hospital failed to provide a medical screening exam, including reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. (A-2406 B)”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 50411 Based on document review, observation, and interview, it was determined that the Hospital failed to ensure signage was posted conspicuously in places that are noticed by all individuals entering the emergency department and the wording was in languages of the population served by the hospital. Findings included: 1. The Hospital’s policy titled, “Emergency Medicine - General Patient Care Triage Policy (Revised 3/2022) was reviewed and did not included any provision regarding posting of EMTALA signage as required. 2. A tour of the emergency department (ED) was conducted with the Director of Nursing (E#11), Nurse Informatics Coordinator (E#10), and the Chief of Clinical, Quality and Patient Safety Officer (E#9) on 2/10/2025 from 10:30 AM - 11:50 AM. An EMTALA signage (in English) was located on the wall by the walk-in entrance to the ED, the signs were approximately 8 by 11 inches and blended in with other signage. No EMTALA signage was posted by the ambulance entrance. 3. During the tour, an interview was conducted with the ED Manager (E#5). E#5 stated that no EMTALA signage is posted by the ambulance entrance.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 20 patients’ (Pt. #1) clinical records reviewed who presented to Hospital A’s ED (emergency department), the Hospital failed to ensure that Pt. #1 was registered in the ED log. Findings include: 1. On 2/10/2025, the hospital’s policy titled, “ Registration Log - Emergency Department” (2023) was reviewed and included, “Policy: All patients will be registered by the Registrar after she/he has been triaged. All pertinent data will be obtained and entered into the computer where an account number is assigned. 1. The Log, a continuously maintained control register, provides a reference for treatment and disposition of patients presenting to the Emergency Department ...” 2. On 2/10/2025, Hospital A’s ED (Transferring Hospital) logs from October 21, 2024, through October 24, 2024, were reviewed. The logs did not indicate that Pt. #1 presented to Hospital A’s ED on 10/22/2024. 3. On 2/10/2025, Hospital A’s incident report for Pt. #1 was reviewed. The incident report indicated, “ ... Event Date: 10/22/2024 ... Time: 6:00 PM ... (Location): Emergency Department ... Entered by: (E #5/ED Manager) ... (Pt. #1) arrived by (Name of Ambulance Company). Per (Ambulance Company) EMS (emergency medical services), (Pt. #1) was discharged from (Hospital B) today. (Pt. #1) was supposed to have O2 (oxygen) delivered. When (Pt. #1) arrived home, there was no supplies... (Ambulance Company) EMS called their dispatch, reported to come to (Hospital A ED). When arrived, per (Hospital A’s) ER/emergency room MD (MD #2/ED Attending Physician), not appropriate. (MD #2) asked (E #5) to wait to put the patient on the tracker...” 4. On 2/10/2025 at approximately 11:45 AM, an attempt to review Pt. #1’s clinical record at Hospital A with E #13 (Nursing Informatics Coordinator). E #13 stated that Pt. #1 was not entered into the hospital’s ED log/ED tracker; therefore, no clinical record was created for Pt. #1. 5. On 2/10/2025 at approximately 1:40 PM, an interview with E #5 (ED Manager) was conducted. E #5 stated, “I wrote the incident report. According to (Name of Ambulance Company) EMS crew, (Pt. #1) was recently discharged from (Hospital B). When they arrived to (Pt. #1’s home), the mother refused to accept because there was no oxygen delivered. The crew was running out of oxygen. They called their EMS dispatch, and they were advised to take (Pt. #1) to (Hospital A) for proper care. It was a learning experience for us. We acknowledge that the patient should have been registered into the ED log.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 36774 A. Based on document review and interview, it was determined that for 1 of 20 patients’ (Pt #1) clinical records reviewed seeking care in the ED ((Emergency Department), Hospital A (Transferring Hospital) failed to ensure a medical screening examination was conducted to determine if an emergency medical condition existed. Findings include: 1. On 2/10/2025, the hospital’s Medical Staff Bylaws and Rules and Regulations (2024) indicated, “ ... Department of Emergency Medicine ... Medical Screening: 1. All patients who request care must be medically screened by a physician ... 2. The extent of treatment rendered will be based on the medical screening by the Emergency Department physician on duty ...” 2. On 2/10/2025, the hospital’s policy titled, “General Patient Care Triage Policy” (2022) indicated, “Policy: 1. Triage is the screening of patients to determine their relative priority treatment. 2. The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into Resuscitative (Level 1), Emergency (Level 2), Urgent (Level 3), Semi-urgent (Level 4) or Routine categories (Level 5). 3. All patients who request care must be medically screened by a physician...” 3. On 2/10/2025, Hospital A’s incident report for Pt. #1 was reviewed. The incident report indicated, “ ... Event Date: 10/22/2024 ... Time: 6:00 PM ... (Location): Emergency Department ... Entered by: (E #5/ED Manager) ... (Pt. #1) arrived by (Name of Ambulance Company). Per (Ambulance Company) EMS/emergency medical services, (Pt. #1) was discharged from (Hospital B) today. (Pt. #1) was supposed to have O2 (oxygen) delivered. ... When arrived, per (Hospital A’s) ER/emergency room MD (MD #2/ED Attending Physician), not appropriate...” 4. On 2/10/2025 at approximately 11:45 AM, a review of Pt. #1’s clinical record at Hospital A was attempted with E #13 (Nursing Informatics Coordinator). E #13 stated that Pt. #1 was not entered into the hospital’s ED log/ED tracker; therefore, no clinical record was created for Pt. #1. 5. On 2/10/2025, the clinical record for Pt. #1 from Hospital B (Receiving Hospital) was reviewed: - On 10/22/2025 at 6:55 PM, (Name of Ambulance Company) run sheet for Pt. #1 indicated, “ ... Incident Location: (Hospital A ED) ... (Blood Pressure) 168/94 (normal is 120/80), Heart Rate 93 (irregular), Respiratory rate 22 (Rapid) ... Confused conversation, but able to answer questions ... Narrative ... (Hospital A ED nurse and MD #2) stopped us from leaving the hospital property and demanded that we take (Pt. #1) back to (Hospital B) because they did not want to accept (Pt. #1). (MD #2) said that it was (Hospital B) and (Name of Ambulance Company’s) fault for not properly discharging (Pt. #1) back home ... Per (MD #2), we weren’t allowed to leave unless we transported (Pt. #1) back to (Hospital B) ... We went to (Pt. #1’s) bedroom to obtain a set of vital signs, (Pt. #1) was already connected on the hospital’s vital (signs) machine. Upon observation, (Pt. #1) was agitated and (Pt. #1’s) vital signs were high and abnormal ... (MD #2 and the charge nurse) came into (Pt. #1’s bedroom) and asked us why we were taking a long time to get the patient onto our stretcher ... We transferred (Pt. #1) onto our stretcher ... Upon arrival to (Hospital B’s ED), the staff were expecting us ...” - On 10/22/2024 at 7:42 PM, the ED nurse’s progress note indicated, “(Pt. #1) presents to (Hospital B’s) ED via (name of Ambulance Company) from (Hospital A). Per EMS, (Pt. #1) was admitted to (Hospital B) recently with (a diagnosis of) respiratory failure (status post) intubation ... (Pt. #1) normally on 6 (liters of oxygen) since discharge, but no equipment was available at home so (Pt. #1) was brought to closest hospital (Hospital A). (Hospital A) transferred (Pt. #1) to (Hospital B) since (Pt. #1) received care most recently here ... Patient Acuity (2/Need care within 15 minutes) ...” - On 10/22/2024 at 7:54 PM, the ED physician’s progress note indicated, “(Pt. #1) ... recent discharge from this facility earlier today after hospitalization secondary to pneumonia brought in by EMS (emergency medical services) for readmission to the hospital as (Pt. #1) did not have his available medical equipment at home upon discharge today.. Medical Decision Making ... past medical history ... including Trisomy 21 (chromosomal abnormality causing developmental/intellectual delay) ... (Pt. #1) is not able to fully participate in history given (Pt. #1’s) baseline mental status... Plan for admission to ... unit for social worker and case management to assist patient in obtaining ... needed home equipment ... Impression and Disposition: Encounter for Social Work Intervention ...” - On 10/22/2024 at 8:38 PM, Pt. #1 was admitted to the observation unit. - On 10/23/2024 at 11:29 AM, the physician’s discharge summary indicated, “ ... Principal Diagnosis: (Acute Hypoxemic Respiratory Failure) ... Brief Hospital Course ... (Pt. #1) presented in acute hypoxemic respiratory failure secondary to severe (obstructive sleep apnea) and not having home (oxygen). (Pt. #1) was admitted for social work to organize home (oxygen) delivery for this patient. Social work was consulted, home oxygen was arranged, and (Pt. #1) was discharged back home with oxygen. 6. On 2/10/2025 at 1:40 PM, an interview with E #5 (ED Manager) was conducted. E #5 stated, “I wrote the incident report. According to (Name of Ambulance Company) EMS crew, (Pt. #1) was recently discharged from (Hospital B). When they arrived to (Pt. #1’s home), the mother refused to accept because there was no oxygen delivered. The crew was running out of oxygen. They called their EMS dispatch, and they were advised to take (Pt. #1) to (Hospital A) for proper care. All patients in the ED should be seen by a physician to determine if an emergency medical condition exists. It was a learning experience for us. We acknowledge that the patient should have been registered into the ED log and should have been seen by a physician. There was no documentation to indicate that the patient was triaged and provided a medical screening examination.” 7. On 2/11/2025 at approximately 9:12 AM, an interview was conducted with MD #2 (ED Attending Physician). MD #2 stated, “(Pt, #1) was brought to our ED. We did not have an idea what happened at (Hospital B). There was no proper discharge. All patients in the ED should receive medical screening examination. Unfortunately, we do not have documentation that a medical screening examination was provided (for Pt. #1).” B. Based on document review and interview, it was determined that for 2 of 5 clinical records (Pt. #14 and Pt. #17) reviewed for patients leaving the ED (emergency department) without being seen (LWBS), the Hospital failed to provide a medical screening exam, including reassessment of patients while waiting for medical screening by a qualified practitioner, to determine if an emergency medical condition existed. Findings include: 1. On 2/10/2025, the hospital’s policy titled, “General Patient Care Triage Policy” (2022) indicated, “Policy: 1. Triage is the screening of patients to determine their relative priority treatment. 2. The Registered Nurse will evaluate and categorize each patient upon arrival to the Emergency Department into Resuscitative (Level 1), Emergency (Level 2), Urgent (Level 3), Semi-urgent (Level 4) or Routine categories (Level 5). 3. All patients who request care must be medically screened by a physician...” 2. On 2/13/2025, the hospital’s policy titled, “Pain Management” (2021) was reviewed and included, “... Assessment... 2. A pain assessment is done upon arrival to the ED... Pain Management Intervention: 1. Pain relief measures are implemented as needed to maintain patient comfort... 2. Offer non-pharmacologic intervention... 3. Consider the guide below for pharmacologic management of acute pain... Severe pain (7-10) (High dose opioid/type of pain medication, etc... )... Reassessment... The time frame for reassessment is based on type of intervention used. If pain medication is given, the patient will be re-assessed in an hour... If pain intervention is ineffective, other intervention should be taken...” 3. On 2/13/2025, the clinical record for Pt. #14 was reviewed. On 11/21/2024, Pt. #14 came to the ED due to nausea, vomiting, abdominal pain, and dark stool for 2 days. At 10:49 PM, Pt. #14 was triaged with an ESI (Emergency Severity Index) of 3 (needs urgent care). Pt. #14 had a pain rating of 10 (severe abdominal pain). There were no pain intervention or reassessment from 10:49 PM through 1:03 AM (2 hours and 14 minutes). Pt. #14 left the ED at 1:03 AM. 4. On 2/13/2025, the clinical record for Pt. #17 was reviewed. On 11/22/2024, Pt. #17 came to the ED due to right hip pain. At 4:52 AM, Pt. #17 was triaged with an ESI of 5 (needs routine care). Pt. #17 had a pain rating of 9 (severe hip pain). There were no pain intervention or reassessment from 4:52 AM through 8:26 AM (3 hours 34 minutes). Pt. #17 left the ED at 8:26 AM. 5. On 2/13/2025 at approximately 9:30 AM, findings were discussed with E #5 (ED Manager). E #5 stated that there should be documentation of intervention and reassessment of patients’ pain while waiting for the medical screening examination by a physician.”