Sarah D Culbertson Memorial Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 49555 A) Based on document review and interview it was determined for 4 of 4 employee records reviewed, the CAH failed to staff the emergency department with staff who possess the education and specialized training to respond to the emergency medical needs and care of the patient population being served. Findings include: 1 . The employee files for E #2, E #5, E #7, and E #8 were reviewed on 2/19/25 at approximately 12:00 PM. All employee files lacked documentation of training related to the care of mental health patients such as elopement prevention, de-escalation training, and patient one-on-one education/training. 2. An interview was conducted with Quality Improvement (E #1) on 2/19/25 at approximately 2:30 PM. While discussing documentation of employee training related to elopement prevention, de-escalation training, and patient one-to-one sitter training, E #1 stated, “I will not be able to provide any documentation of staff completing those trainings. I am a CPI (Crisis Prevention Intervention) instructor. The facility does not hold CPI classes for the staff and we do not have a training program that covers those topics.” B) Based on document review and interview it was determined for 1 of 5 (Pt #7) patients records reviewed, the CAH failed to monitor the patient appropriately which allowed Pt #7 to elope twice. Findings include: 1. The policy titled “Sitters” (effective 7/2019) was reviewed on 2/18/25 at approximately 11:00 AM. The policy states, “ ...Keep the patient in view at all times ...” 2. Pt #7’s medical record was reviewed throughout the survey. The medical record noted Pt #7 presented to the Emergency Department (ED) on 1/9/25 at 6:21 AM for a psych evaluation. Pt #7 eloped from the ED at 10:06 AM. Pt #7 was brought back to the ED by police at 10:20 AM. Pt #7 assaulted staff, eloped from the ED a second time, and stole and wrecked an ambulance. The record lacked documentation of the time of the second elopement. 3. An interview was conducted with RN ED Manager (E #4) on 2/18/25 at approximately 12:00 PM. While discussing the 1:1 supervision for Pt #7 on 1/9/25, E #4 stated, “The first time, (E #8) was across the hall watching (Pt #7) through the door. The second time, (E #8) was right outside the door.””

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 34824 Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to provide safe care and services. Therefore the Condition of Participation 42 CFR 485.635, Provision of Services, was not met. Findings include: 1. The hospital failed to develop policies and procedures for providing emergency services to patients experiencing a mental health crisis (suicidal). 2. The Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (ii) Policies and procedures for emergency medical services. This Standard is not met as evidenced by: 49555 A. Based on document review, and interview, it was determined the critical access hospital failed to develop policies and procedures for providing emergency services to patients experiencing a mental health crisis (suicidal). Findings Include: 1. The policy titled “Self Harm (Suicide Precautions)” (revised 5/28/2024) was reviewed on 2/19/2025 at 3:00 PM and indicated, “ ...The nursing staff shall implement the Psychiatry Observation Sheet and suicide precautions while awaiting Physician/Provider order and remain 1:1 with the patient until provider assessment ...” 2. An interview was conducted on 2/19/2025 at 2:30 PM with Quality Improvement (E # 1). While discussing suicide precautions, E #1 stated, “We can spell it out for you, but we don’t have a policy or procedure in writing that describes what is included with suicide precautions.” B. Based on document review and interview, it was determined for 1 of 1 (Pt #7) patient records reviewed, who required the use of violent restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints. Findings include: 1. The Policy titled “Restraint and Seclusion Use (revised 7/2019)” was reviewed on 2/20/2025 at approximately 1:00 PM. The policy noted, “Restraint Or Seclusion Orders: “ ... Each episode of restraint use must be initiated in accordance with the order of an MD (Medical Doctor)/ DO (Doctor of Osteopathic Medicine) or other LIP (licensed Independent Practitioner) ... The attending physician shall be consulted as soon as possible if the attending physician did not order the restraint or seclusion.” “Procedure: ...Verify that the order for restraint or seclusion includes rationale for restraint, length of time and type of restraints to be used, and the extremity or body part(s) to be restrained.” 2. The clinical record of Pt #7 was reviewed on 2/19/2025 at approximately 11:00 AM. Pt #7 was placed in 4-point leather restraints on 1/9/2025 at 2:00 PM. Pt #7’s record lacked an order for restraints. 3. An interview was conducted on 2/20/2025 at approximately 10:30 AM with Quality Improvement (E #1). E #1 reviewed Pt #7’s record and stated, “There is no order for restraint placement. The nurses received a verbal order, but due to the craziness of the day it was likely missed. It should have been placed in the system and was not.””

“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: 49555 Based on document review it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination. (A-2406) An Emergency Medical Treatment and Active Labor Act (EMTALA) investigation was conducted on 8/13/24 through 8/14/2024 for complaint #IL00174764/241850. The EMTALA violation began on 6/22/24, due to Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE).”

“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: 49555 Based on document review and staff interview, it was determined that in 1 of 20 (Pt #10) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination (MSE). Findings include: 1. Pt #10’s medical record was reviewed throughout the survey (8/13/24 through 8/14/24). Pt #10 presented to the Emergency Department (ED) on 6/22/24 at 3:21 PM. Pt #10’s chief complaint was shoulder pain. The Chronological View log dated 6/22/24 noted the following: 3:22PM: Triage (Request) 3:26PM: Reg Complete (Request) 4:16PM: Patient Checked Out The record lacked evidence that the Triage Request for Pt #10 was completed and that a MSE was completed per policy. 2. On 8/14/24 at approximately 10:00 AM the policy, “Triage (revised 2/2015)” was reviewed. The policy stated “ ...A date and time of triage will also be obtained and the information entered on the ER Triage Record. This record will be kept on a clipboard in the ER office and the patients will be called to the ER as rooms become available and according to condition. Should the patient leave the triage area, the triage record will be kept in the ER Left Without Being Seen Binder ...Procedure: The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories ...Until the patient is triaged by the Triage RN and deemed to have a non-life-threatening condition, the Emergency Department Registration Clerk is not to obtain or request any financial information or demographic information.” 3. On 8/14/24 at approximately 10:30 AM, the policy, “EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES (revised 2/2019)” was reviewed. The policy stated, “All patient shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services with the capability of the hospital to reach a diagnosis.” 4. On 8/14/234 at approximately 11:00 AM, an interview was conducted with the Chief Nursing Officer (E#1). E #2 verbally agreed the clinical record lacked documentation that Pt #10 was triaged and did not receive a MSE.”