St Joseph Health System, LLC

“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: 32952 Based on document review, interview and observation the facility failed to ensure care in a safe environment for 1 out 20 medical records (MR) reviewed (Patient #1). Findings include: 1. Facility policy titled “(ACCESS.003 - CORP) Patient Rights and Responsibilities”, last revised on 2/29/24 indicated the following: The hospital protects the patient from harassment, neglect...and abuse that could occur while the patient is receiving care, treatment, and services. 2. Facility policy titled “(PCS.20.03.32) Reporting of Suspected Abuse or Neglect”, with a publish date of 7/2023 indicated the following: Patients have the right to be free from mental, physical...neglect...It is the policy...to protect patients from real or perceived abuse, neglect...from anyone, including family, acquaintances, staff, providers, students, volunteers, or other patients/visitors, etc. III. Definitions: D. Neglect: Failure to provide adequate physical protection. 3. Facility policy titled “(ED.03.11.02) Dismissing a Patient from the Emergency Department (ED)” with a publish date of 9/22/2025 indicated the following: II. PURPOSE: To facilitate safe discharge from the Emergency Department through: D. Coordinated ED care within the context of the healthcare system, including other referrals, social services, or other types of follow-up services. III. ACTIONS: A. Screening for issues of concern, behavior, learning, medical problems, or language barriers that may impact a safe discharge should be assessed throughout the ED visit (triage through discharge). 4. Review of Patient #1’s medical record indicated the following: Patient #1 had three separate Emergency Department visits at Facility #1 (Acute Care Facility) on 11/19/25 through 11/20/25. (a.) (Patient #1) arrived via EMS/ambulance from (Facility #2, Long-Term Care Facility) to the Emergency Department at (Facility #1) on 11/19/25 at 10:51 p.m. with a chief complaint of left eye pain after cataract surgery today. (b.) A nursing note by (N1, Registered Nurse/Emergency Department) dated (11/20/25 at 12:00 a.m.) indicated the following: (Patient #1) left AMA (Against Medical Advice) and was wheeled (outside) across the street by security. 5. (Patient #1) arrived via EMS/wheelchair to the Emergency Department at (Facility #1), a second time on 11/20/25 at 1:40 a.m. (a.) A triage note by (N1) for (Patient #1) dated 11/20/25 at 1:59 a.m. indicated the patient had a chief complaint of eye pain and now wants treated for (his/her) eye pain. (Patient #1) was discharged on 11/20/25 at 4:10 p.m. (b.) A nursing note by (N1) on 11/20/25 at 4:00 a.m. indicated the following: (Patient #1) then asked, “I know I am trying to get a hold of nursing home am I allowed to stay in the lobby?” (N1) stated, “You are allowed to stay in the lobby for approximately 30 minutes to an hour. If you get ahold of the nursing home and they pick you up, you can stay in the lobby until they pick you up and I will let security know. If you are not able to get a hold of them, again you can stay in the lobby for a little bit but then security will ask you to leave eventually because you cannot stay in our lobby all night.” (c.) (Patient #1) was wheeled outside across the street by staff to a park bench. 6. (Patient #1) arrived via EMS/ambulance to the Emergency Department at (Facility #1), a third time on 11/20/25 at 6:58 a.m. with a chief complaint of left eye pain post-surgery and panic attack. (a.) An Ambulance Run Report from Facility #1 indicated that EMS arrived on scene at (Facility #1) on 11/20/25 at 6:28 a.m. and left scene 11/20/25 at 6:50 a.m. to (Facility #1). Chief Complaint: Anxiety. Duration: 5 hours. EMS narrative history text indicated the following: (EMS) dispatched to the intersection of Van Buren Street and Main Street on a sick person. This is the parking lot of (Facility #1). The patient states the ER wheeled (him/her) to the parking lot and (he/she) sat on the (park) bench for several hours. Patient has an amputation on (his/her) right leg below the knee and is unable to walk. The outside temperature is 38 degrees (Fahrenheit). Patient states (he/she) is having a panic attack. 7. Observation of Facility #1’s Security Video Camera footage on 1/14/26 at approximately 2:00 p.m. related to Patient #1’s three ED visits on 11/19/25 and 11/20/25 indicated the following: (a.) ED Visit #1 - On 11/19/25 at 11:59 p.m., Patient #1 was escorted in a wheelchair by SO5 (Security Officer/Facility #1) from the facility lobby to the outside and was able to self-transfer (himself/herself) onto a park bench across from Facility #1. Patient #1 was observed to be wearing pants, t-shirt, light zip up sweatshirt jacket with a hood, a sock and a shoe on left foot. Patient #1 was observed to have a white bandage over (his/her) left eye, BKA (below the knee amputation) of the right leg, with a sock/dressing on the patient’s stump. SO5 was observed taking the facility wheelchair back into the building. Patient #1 was observed sitting on the park bench after SO5 went into the facility. (b.) ED Visit #2 - On 11/20/25 at 1:35 a.m., EMS staff walk to Facility #1 entrance, get a wheelchair and return to Patient #1 with the wheelchair. Patient #1 transfers self into the wheelchair from the park bench and EMS staff at 1:39 a.m. assist Patient #1 in the wheelchair across the street to Facility #1’s entrance and take the patient inside to registration (c) ED Visit #2 - On 11/20/25 at 4:10 a.m., Patient #1 wheelchaired to the lobby. No behaviors were observed related to Patient #1 during this time. (d) ED Visit #2 - On 11/20/25 at 5:22 a.m., SO6 (Security Officer/Facility #1) was observed in the lobby walking over to where Patient #1 was located and appears to speak to the patient. No behaviors were observed related to Patient #1 during this time. (e.) ED Visit #2 - On 11/20/25 at 5:35 a.m., Patient #1 wheeled (himself/herself) outside in a wheelchair across the street from Facility #1 with SO6 walking behind the patient. Patient #1 transferred self onto a park bench and SO6 took the facility wheelchair back into Facility #1. Patient #1 remained sitting outside on a park bench with (his/her) hood over (his/her) head. No behaviors were observed related to Patient #1 during this time. (f.) ED Visit #3 - On 11/20/25 at 6:28 a.m., EMS arrived back to Patient #1 who was sitting on a park bench outside across from Facility #1. (g.) ED Visit #3 - On 11/20/25 at 6:33 a.m., Patient #1 was placed on a gurney by EMS staff at the park bench and loaded into the ambulance at 6:36 a.m. and left the area at 6:50 a.m. with Patient #1. (h.) ED Visit #3 - On 11/20/25 at 6:53 a.m., EMS arrived at Facility #1’s ED ambulance bay entrance with Patient #1 and 2 EMS staff. 8. During an interview with SO5 (Security Officer/Facility #1) on 1/14/26 at approximately 3:00 p.m., SO5 indicated that (he/she) was called to the ED related to Patient #1 by the nursing staff as the patient according to nursing staff was being very belligerent, yelling and wanting AMA (Against Medical Advice) but would not leave the ED room, so (he/she) escorted Patient #1 outside to a park bench across from Facility #1 to sit. SO5 indicated that there was a bus stop at that corner. SO5 indicated that (he/she) was told by nursing staff to get Patient #1 out of the facility, but does not recall the specific staff member who made the request. 9. During an interview with A1 (Chief Quality Officer), A2 (Quality Coordinator) and A5 (Compliance Officer/Facilities Director) on 1/14/26 at approximately 3:14 p.m., they verified the security camera video footage that was reviewed related to Patient #1 on 11/19/25 and 11/20/25. 10. During a phone interview with N1 (Registered Nurse/Emergency Department) on 1/14/26 at approximately 4:25 p.m., N1 indicated that Patient #1 was not transferred to (Facility #2) as there needs to be criteria met for an ambulance transport such as medical emergency/reasoning, not just because a patient wants to go to a different facility. N1 indicated that Patient #1 left AMA on (his/her) first visit to the ED on 11/19/25. N1 indicated that Patient #1 had called for an ambulance to attempt to go to (Facility #2). N1 indicated that Patient #1 came in multiple times to be seen in the ED from 11/19/25 to 11/20/25. 11. During a phone interview with PA3 (Physician Assistant) on 1/15/26 at 11:15 a.m., PA3 indicated that (he/she) was not aware that Patient #1 was escorted outside by security and/or that security came and got the patient. PA3 indicated that it was horrible and not acceptable that Patient #1 was placed outside of the facility with no means of mobility in the middle of the night in the cold elements. 12. A review of documents titled “November 19, 2025, Weather History at (Airport #18) provided by A5 on 1/15/26 indicated that on 11/19/25 at 11:54 p.m., the outside temperature was 42.1 degrees Fahrenheit. 13. A review of documents titled “November 20, 2025, Weather History at (Airport #18) provided by A5 on 1/15/26 indicated that on 11/20/25 at 12:54 a.m., 1:46 a.m., 1:54 a.m., 4:03 a.m., 4:54 a.m., 5:54 a.m. and 6:54 a.m. the outside temperature was 42.1 degrees Fahrenheit. 14. During an interview with A3 (Registered Nurse/Emergency Room Director) on 1/15/26 at 2:05 p.m., A3 indicated that there was nothing in place including a policy that (he/she) indicates to their nursing staff that a patient needs to leave the building within 30 minutes of discharge. A3 indicated that if a patient comes from a facility to the ED, a nurse contacts the facility to give them report and tells the facility staff that they are sending the patient back to them following discharge from the ED. 15. During an interview with A1 and A2 on 1/16/26 at approximately 3:30 p.m., they verified the medical record information for Patient #1. 16. During a phone interview with SO6 (Security Officer/Facility #1) on 1/16/26 at 5:00 p.m., SO6 verified that (he/she) escorted Patient #1 who was in a wheelchair, outside to a park bench across from (Facility #1), where Patient #1 transferred (himself/herself) to the park bench. SO6 indicated that (he/she) did take the facility wheelchair back into the facility and left Patient #1 on the park bench outside. SO6 indicated that (he/she) was instructed to escort the patient outside the building by another security officer as the patient had been in the lobby long enough and was time for (him/her) to leave. SO6 indicated that (he/she) escorted (Patient #1) to a park bench since the patient was unable to stand as (he/she) had a below the knee amputation on one of (his/her) legs.”

“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: 32952 Based on document review and interview, it was determined that in 1 (Patient #1) of 20 medical records (MR) reviewed of patients who presented to the hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide an appropriate medical screening exam. Findings Include: 1. See findings cited at 42 CFR 489.24, A2406.”

“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: 32952 Based on document review and interview, the facility failed to provide an appropriate medical screening exam (MSE) in 2 instances for 1 of 20 patient (Patient #1) medical records reviewed. Findings include: 1. Facility policy titled “(COMP.004-MANDATORY) Emergency Medical Treatment and Active Labor Act (EMTALA)” with a publish date of 7/14/2022 indicated the following under B. Medial Screening: “When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED (including ancillary services routinely available to the ED), shall be provided to determine whether an emergency medial condition (EMC) exist...” 2. Review of Patient #1’s medical record for a second ED visit on 11/20/25 at 1:40 a.m. indicated the following: (Patient #1) arrived via EMS/wheelchair to the Emergency Department at (Facility #1) on 11/20/25 at 1:40 a.m. with an acuity of 3. A review of Patient #1’s vitals flowsheet indicated on 11/20/25 at 1:57 a.m., Patient #1 had a temperature of 98.2 degrees Fahrenheit, blood pressure of 162/113 mmHg (millimeters of mercury), respiratory rate of 16 (breaths per minute), pulse of 123 (beats per minute), oxygen saturation of 100%, left eye aching pain level of 7 out of 10. A triage note by (N1) for (Patient #1) dated 11/20/25 at 1:59 a.m. indicated the patient had a chief complaint of eye pain and now wants treated for (his/her) eye pain. A nursing note by (N1) on 11/20/25 at 4:10 a.m. indicated (Patient #1) was given discharge instructions and the patient was wheeled to the lobby. The MSE for patient lacked documentation and/or refusal of treatment for Patient #1’s blood pressure and increased heart rate. 3. Review of Patient #1’s medical record from the third ED visit indicated the following: Patient #1 arrived via EMS/ambulance to the Emergency Department at (Facility #1) on 11/20/25 at 6:58 a.m. with a chief complaint of left eye pain post-surgery and panic attack with an acuity of 5. An Ambulance Run Report from Facility #1 indicated that EMS arrived on scene at (Facility #1) on 11/20/25 at 6:28 a.m. and left scene 11/20/25 at 6:50 a.m. to (Facility #1). Chief Complaint: Anxiety. Duration: 5 hours. EMS assessment of (Patient #1’s) vital signs on 11/20/25 at 6:40 a.m. indicated the following: blood pressure: 172/109 mmHg, pulse: 118 beats per minute, respirations: 22 breaths per minute. EMS narrative history text indicated the following: (EMS) dispatched to the intersection of Van Buren Street and Main Street on a sick person. This is the parking lot of (Facility #1). (Patient #1) had a procedure on (his/her) eye at this (facility) the previous day. The patient states the ER wheeled (him/her) to the parking lot and (he/she) sat on the (park) bench for several hours. Patient has an amputation on (his/her) right leg below the knee and is unable to walk. The outside temperature is 38 degrees (Fahrenheit). Patient states (he/she) is having a panic attack. A triage note by (N3) for Patient #1 dated 11/20/25 at 7:06 a.m. indicated the patient was assigned an acuity level of 5, orientation: alert, oriented to person, place, time, situation affect/behavior: appropriate, calm and cooperative. (Patient #1’s) vital signs were assessed and indicated the following: blood pressure: 165/92 mmHg, pulse: 111 beats per minute, respiratory rate: 16 breaths per minute, Oxygen saturation: 100 percent on room air, temperature: 98.3 degrees Fahrenheit and pain to (his/her) left eye with a pain level of 10 out 10 = worst possible pain. An ED provider note by MD2 on 11/20/25 at 1:52 p.m. indicated the following: (Patient #1) was seen by (MD2) on 11/20/25 at 7:05 a.m. History of Present Illness: (Patient #1) with a history of insulin-dependent diabetes and most recently cataract surgery yesterday afternoon by (MD5). Presents to the ER for (his/her) third visit in the last 12 hours secondary to anxiety. A nursing flowsheet by N4 for Patient #1 dated 11/20/25 at 7:10 p.m. indicated (Patient #1’s) vital signs were reassessed and indicated the following: blood pressure: 114/82 mmHg, pulse: 108 beats per minute, respiratory rate: 16 breaths per minute, Oxygen saturation: 93 percent on room air and pain level of 0 out 10 indicating no pain. The medical record lacked documentation that the increased heartrate was addressed. A nursing note by (N4) on 11/20/25 at 7:15 p.m. indicated (Patient #1) waited for (his/her) ride and for (his/her) wheelchair provided by case manager. (His/Her) ride got here at 7:00 p.m. and the patient was discharged (to home). The MSE for patient lacked documentation that the patients anxiety or abnormal vital signs were addressed/treated.”