Heartland Regional Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39025 Based on document review and interview the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The hospital failed to ensure a patient on hold for psychiatric transfer was safe from elopement. The Immediate Jeopardy began on 06/13/26 due to the Hospital’s failure to ensure a patient on hold for psychiatric transfer was safe from elopement. While on psychiatric hold pending transfer for inpatient psychiatric placement, (Pt#1) eloped from the emergency department through a back hall, out the door. Pt #1 was ultimately found the next day with a fatal gunshot wound to the head in a nearby residence.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39025 Based on review of video footage, clinical record review, and staff interview for 1 (Pt#1) of 10 patient records reviewed, the Hospital failed to ensure a patient on hold for psychiatric transfer was safe from elopement. While on psychiatric hold pending transfer for inpatient psychiatric placement, (Pt#1) eloped from the emergency department through a back hall, out the door. Pt #1 was ultimately found the next day with a fatal gunshot wound to the head in a nearby residence. The Findings Include: 1. On 06/23/26 at approximately 10:30 AM, a review of video footage from 6/13/26 was conducted with Patient Safety Risk Manager (E#4). Video surveillance revealed the following: 1:23 PM - Pt#1 (confirmed by E #4) arrives via ambulance at ambulance bay. 7:30 PM - Pt#1 exits SW (southwest entrance). Pt#1 is alone and barefoot. 7:31 PM - Pt#1 walking across helipad then goes out of camera view. 7:32 PM - ED Charge Nurse (E#6) exits SW entrance. 7:33 PM - ED Charge Nurse (E #7) entered SW Entrance (confirmed with E #4 E #7 exited from a different door/camera view, and was only seen re-entering SW door). There is no video surveillance of interior of ED or patient rooms, only exits. 2. Pt#1’s record was reviewed throughout the survey. Pt#1 arrived to the ED on 6/13/26 at 1:38 PM via Emergency Medical Services (EMS). EMS report dated 6/13/26 at 1:23 PM stated, “Chief complaint ... combative aggressive with (family member) ADHD (attention deficit hyperactivity disorder), autism (neurodevelopmental condition affecting how a person perceives, communicates, and interacts with the world).” - ED Provider Notes dictated by Physician’s Assistant (PA - E#8) on 6/13/26 at 2:04 PM indicated, “Subjective: (Pt#1) is a 15-year-old ... male that presents to the ER (Emergency Room) via EMS for destructive and violent behavior at home. (family member) reported he was throwing things around the room breaking things. When (family member) confronted him about his behavior the child became more angry and picked up his TV and hit his (family member). He reports it in the past he has been sent to psychiatric hospitals for his behavior. He denies any suicidal or homicidal thoughts. ... Physical Exam: ...Psychiatric: Thought Content: ... Thought processes appears normal, patient is very flat affect ... 7:30 PM: This provider notified that the patient eloped from the ER. Security, House supervisor and (local police department) was notified. Medical Decision Making: .... Plan is for patient to be transferred for psychiatric treatment. Risk: Decision regarding hospitalization ... Final diagnosis: Behavior Disturbance ... ED Disposition: Eloped. - ED Notes dictated by ED RN (E#9) on 6/13/26 revealed the following: 1:45 PM - “Bed: ED06 ...” ED Notes dictated by ED RN (E#10) reviewed and stated: 7:41 PM - “7:20 PM pt out in hallway wanting to know where his boots are at, was told that they are in security possession, pt told that they would be checked on to be sure. Pt refused to go back to his room, states he is going to wait in the hall. Told pt that they would be checked on after I see a pt that needed something. Pt was not in room or hallway afterwards and other pt in ER states pt ran back through cp (cardiopulmonary) center.” ED Notes dictated by ED Charge RN (E#6) reviewed and stated: 7:55 PM - “Spoke with the father of pt and he (Pt #1) was seen leaving by another pt about 20 or so min (minutes) ago. 8:29 PM - “Pt was seen on camera leaving through the er/north hallway door that is badgeless exit at 7:30 PM. (E#6) is seen walking about 1.5 minutes later. Did not see any sign of the child.” - ED orders on 6/13/26 at 2:04 PM by E#8 stated, “ ... Complete Columbia Suicide Severity Rating Scale: ...Frequency: Q (Every) shift 6/13/26 2:05 PM - Until Specified ... Educate Patient/Family on Suicide Prevention ...” - Pt #1’s Flowsheets indicated Pt #1 was placed on Suicide Precautions with Environmental Risk Assessment completed at 2:00 PM (completed by E #9) and again at 7:00 PM (completed by E #10). The flowsheets indicated, “ED Peds Psycho/Social - Sat (Saturday) June 13, 2026, 2:46 PM, completed by ED RN (E#9): ... Patient Behaviors: Flat affect ... ED Suicide Precautions and Environmental Risk Assessment: 2:00 PM Visual Appearance Flat; Behavior Defensive: Intervention - Fluids offered/accepted ... “ 3. On 06/24/26 at approximately 2:00 PM, a request was made to review policies on elopement risk assessment and managing psychiatric patients. The Regional Quality Director (E#11) stated, “We don’t have a specific policy on elopement or managing psychiatric patients in the ED.” 4. On 6/25/26 at 10:36 AM, an interview was conducted with ED RN (E#10). When asked about the incident, E#10 stated, “When I met (Pt#1), he was in the hallway looking for his boots. I did a quick assessment by asking if he was suicidal/homicidal and he said no. He was coherent and calm. While speaking to him in the hall outside his room, another patient began waving at me as she needed help returning to bed from going to the bathroom. I told (Pt#1) that I would be right back and to stay there. He said he would. When I returned, which was in about 1-2 minutes, (Pt#1) was gone. The shift report that I received from ED RN (E#9) was that (Pt#1) was autistic and had ADHD. Dad was out in the lobby. (Pt#1) was there for behavioral issues. The plan for the patient was placement at a facility.” 5. An interview was conducted on 06/24/26 at approximately 2:00 PM with Risk Manager/Patient Safety (E#4). E#4 reviewed and acknowledged Pt#1’s record documented the plan was for Pt#1 “to be transferred for psychiatric treatment.””

“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: 39025 Based on document review, video review and interview it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the Hospital failed to complete a comprehensive Medical Screening Exam (MSE) to include an assessment of patient’s complaint of right hip pain, following a fall in the lobby of the ED. Findings include: 1. The “Emergency Medical Treatment and Patient Transfer Policy (EMTALA)” revised 06/25 was reviewed. It stated, “ ... Comes to the emergency department with respect to an individual requesting examination and treatment means the individual is on the hospital property (including parking lot, campus, ambulance Bay, and other departments of the hospital) ... Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, ... ) such as the absence of immediate medical attention could reasonably be expected to result in: ... b. Serious impairment to bodily function, or c. Serious dysfunction of any bodily organ or part ... The medical screening examination is an ongoing process and the medical records must reflect continuing monitoring based on the patients need and continue until the patient is either stabilized ... Stabilized/Stabilization: ... 1. Stable for discharge: A patient is stable for discharge, when within reasonable clinical confidence, It is determined that the patient has reached the point where his/her continued care, including diagnostic workup and/or treatment could reasonably be performed as an outpatient provided the patient is given a plan for appropriate follow up with the discharge instructions; or, the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings...” 2. On 09/2/25 at 11:30 AM, the ED waiting room security video was reviewed with Supervisor of Security (E#7). The video captured (Pt#1) walking independently into the ED waiting room on 8/1/25 at 7:11 PM. As (Pt#1) walked across the waiting room towards the reception desk, (Pt#1’s) legs buckled and (Pt#1) fell to the floor, landing on his right side/hip at 7:11:53 PM. (Pt#1) was not observed breaking the fall before landing on the floor. While (Pt#1) lay on the floor, an emergency medical services (EMS) paramedic (E#21) already present in the waiting room was observed responding to (Pt#1). Another EMS paramedic (E#22) was observed coming out of the ED treatment room door and kneeling down beside (Pt#1), followed by the ED Charge Nurse (E#12). (E#12) was observed standing for a few seconds in front of (Pt#1) on the floor, then walking around the ED waiting room and retrieving a wheelchair which she rolled back over to (Pt#1). At that time, (E#21), (E#22), and one armed security guard (E#9) lifted (Pt#1) off the floor and into the wheelchair. At approximately 7:15 PM, (E#12) wheeled (Pt#1) back into the ED treatment area through the same door she came out of. (Pt#1) lay on the floor for a total of approximately 4 minutes and 7 seconds. On 08/02/25 at 2:21 AM, an unarmed security guard (E#10) was observed holding (Pt#1) under the left arm and assisting with walking from the ED waiting room out the door to the parking lot. (Pt#1) was observed holding his right hip area and walking with a limp. There was no further accessible video beyond the ED waiting room doors. 3. (Pt#1’s) medical records were reviewed throughout the survey. The Patient Care Timeline dated 08/01/25 at 7:18 PM to 08/02/25 at 2:25 AM) had no documentation regarding (Pt#1’s) fall in the ED lobby approximately 6 minutes and 7 seconds prior to 7:11:53 PM. The ED Provider Notes dated 8/1/25 at 8:29 PM, by ED physician (E#13), stated “Subjective: (Pt#1) presents to the ER (emergency room) via private vehicle with complaints of dizziness, lower abdominal pain and unable to urinate since 12:30 pm ... (Pt#1) was in our waiting room when he felt lightheaded and felt like he was going to pass out. He caught himself as he was falling. He did not lose total consciousness. He denies any injury to his head ... Review of Systems: ... Musculoskeletal: Negative for arthralgias (joint pain) and back pain ... Objective: ... Physical Exam: Vitals (Afebrile (without fever), vital signs stable) ... Constitutional: ...Comments: Small frail appearing ... Musculoskeletal: General: No swelling. Normal range of motion. Cervical back: Normal range of motion and neck supple ... . Final diagnoses: Dizziness (Primary). Hematuria (bleeding), unspecified type. Hydronephrosis (swollen kidney), unspecified hydronephrosis type ... ED Disposition: Discharge.” -Pt #1’s exam on 8/1/25 did not include assessment/evaluation of leg pain/injury after falling in the waiting room. - Pt#1 returned to the ED via EMS on 8/5/25 at 8:49 AM with a chief complaint of right hip pain. ED Provider Notes dated 8/5/25 at 8:55 AM by physician (E#14) stated, “Subjective: (Pt#1) with a history of prostate cancer comes into the emergency room because of right hip pain... Patient states that ever since then (8/1/25 - after fall) (Pt #1) has been having severe pain in the hip joint and has been unable to get up and walk...” An x-ray was completed and indicated, “Acute transverse avulsion fracture (when small piece of bone attached to ligament or tendon, breaks away from rest of bone) at the upper pole of the right greater trochanter with avulsion fracture along the superior rim of the left acetabulum laterally.” A MRI (magnetic resonance imaging - medical imaging that uses strong magnetic field and radio waves to create detailed images) of the right hip was completed and indicated, “Final result ... (8/5/25 3:59 PM) ...Impression: 1. Nondisplaced intertrochanteric fracture of the right proximal femur (break in the upper part of thigh bone, specifically in the region between upper parts of femur where bone fragments remain in alignment with fracture occurring on right side) with redemonstrated of avulsion fracture of the superior (upper) aspect of the greater trochanter (bony prominence located at the upper end of the thigh bone). 2. Intramuscular edema (excess fluid accumulates within the muscles) of the right hip, likely reactive muscle strain secondary to the fracture ... Pt #1 was admitted and had surgery (hip nailing) completed for the fracture. Pt #1 was discharged on 8/7/25 at 12:04 PM. Pt #1’s “Discharge Summary” dated 8/7/25 at 10:27 AM by hospitalist (E#18) stated, “ ... Hospital Course: (Pt#1) presented to our facility after suffering a ground level fall where he had a nondisplaced IT (intertrochanteric) fracture of the proximal femur. Orthopedics consulted. (Pt#1) underwent IM nailing (intramedullary nailing - rod inserted into hollow center of broken long bone)...” 4. On 09/02/25 at 2:50 PM, an interview was conducted with Risk Management (E#5). (E#5) stated, “I just became aware and began investigating (Pt#1’s) incident from a risk management standpoint this past Friday, 08/29/25. Our Chief Operational Officer (E#2) asked me to look into this after receiving a call from someone in the community who (Pt#1) had spoken to about the visit to the ED on 8/1/25. I also spoke with (Pt#1) on the phone who confirmed there had not been a fall at home, as documented in the ED notes on 08/05/25, but rather in the lobby of our ED on 08/01/25. (Pt#1) indicated to me the hip pain was self-reported to the ED staff several times during his visit and prior to discharge. I reviewed the video footage and saw the fall. I did not review the video footage of (Pt#1) leaving the ED upon discharge. I read in the ED notes (Pt#1’s) exam was unremarkable and there was no mention of hip pain. I’m in the beginning stages of speaking with the staff involved in (Pt#1’s) care. I can’t speak to why an x-ray was not done.” 5. On 09/03/25 at 11:55 AM, an interview with ED physician’s assistant (E#15) was conducted. (E#15) stated, “I cared for (Pt#1) until about 11:00 PM on 08/01/25 at which time the physician (E#13) took over. (Pt#1) had a near syncopal episode in the lobby which got him back to the ED quicker than normal. Whenever I questioned (Pt#1) about that, (Pt#1) said that (Pt#1) got dizzy and just fell.” 6. On 09/03/25 at 12:15 PM, an interview was conducted with ED physician (E#14). (E#14) stated, “I saw (Pt#1) on 08/05/25, (E#14) stated, “It is certainly a reasonable expectation to get an x-ray if a patient of that age took a fall and complains of pain.””

“Standard-level Tag for Pharmaceutical Service CFR(s): 482.25 Standard-level Tag for §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients... This Standard is not met as evidenced by: 51190 Based on interview and document review, it was determined that for 1 of 10 (Pt #1) patients, the Hospital failed to ensure safe and appropriate tracking and control of medications which led to the facility sending a controlled substance home with the wrong pt. Findings include: 1. Pt #1’s record was reviewed throughout the survey. Pt #1’s record indicated Pt #1 was admitted to Medical/Surgical unit on 1/7/25 for pneumonia. Pt #1 brought in a home medication, buprenorphine-naloxene (suboxone - a controlled substance for pain) to be administered because the Facility did not stock this medication. Pt #1 was admitted with an order for suboxone 8-2 mg sublingual tablet 1 tablet 2 times a day and then was changed on 1/8 at 6:25 PM to 1/2 tab 2 times a day. Per timeline notes from 1/10/2025, “(E#8), pharmacy manager, was notified that nursing had not located the medication and suspected it may have been sent home with the wrong patient. The RN contacted (wrong patient) and verified that (the wrong pt) had the medication. On 1/10/25, Med/Surg Director (E #14) was notified and went to pick up incorrect medication from the involved patient. (E #14) picked up medication and brought the medication to Pharmacy. (E #14) and (E #8) documented in the waste log and disposed medication in Rx (pharmaceutical) Destroyer Container. On 1/10/25, the Hospitalist (E#9) reordered medication.” Pt #1’s record indicated Pt #1 missed one dose of the prescribed suboxone on the evening of 1/9 due to “mishandling.” 2. A policy titled, “Administration of Drugs: Patient’s Personal Drugs” was reviewed on 3/3/25. It stated, “Discharged patients: Drugs belonging to discharged patients shall be returned to the patient, adult family member, or adult significant other upon the patient’s discharge ...” 3. On 3/4/25 at 1:00 PM , an interview was conducted with Registered Nurse (E #15). E#15 reviewed Pt#1’s record and confirmed that she failed to use correct patient identifiers when sending home medication to discharging patient and Pt #1’s suboxone was sent home with the wrong pt and should not have been.”