Norton-King’s Daughters’ Health

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49128 Based on document review and interview, nursing services failed to reassess pain level within 1 hour after pain medication administration on 1 of 2 pain medication administrations, for (patient # 7). Findings include: 1. Facility policy, titled Medication- Administration of Intermittent Pain and Comfort Medications, PolicyStat ID 14708950, last revised 11/23, indicated reassessment will take place within 60 minutes for oral controlled substance administration and will include: pain assessment rating using an appropriate scale if patient is awake, sedation level, and respiratory rate. 2. Patient # 7’s Medical Record (MR) Medication Administration Reconciliation (MAR) indicated Percocet 5/235 mg, 1 tablet, given on 2/24/24 at 3:04 am.; MR lacked documented reassessment of pain within 60 minutes. 3. In interview, on 3/27/24 at approximately 10:54 am, via phone call, A3 (Chief Nursing Officer [CNO]) verified patient # 7 received Percocet pain medication on 2/24/24 at 3:04 am, and pain was not reassessed until the same day at 6:00 am. A3 verified the reassessment was not done according to facility policy.”

“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: 49128 Based on document review and interview, it was determined that 1 of 20 (Patient #7 ) medical records 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 and appropriate transfer. Findings Include: 1. See findings cited at 42 CFR 489.24, A2406 and CFR 489.24 A2409.”

“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: 49128 Based on document review and interview, the facility failed to provide an appropriate medical screening exam for 1 of 1 of 22 patients (patient #7). Findings include; 1. Facility policy titled EMTALA Guidelines (Emergency Medical Treatment and Labor Act) last revised 2/21 indicates on page 2 of 5 under EMTALA requirements “Provide an appropriate MSE to any individual who comes to the emergency department.” 2. Facility policy titled Emergency Detention Order last revised 10/23 indicates on page 3 of 6 that the application for Emergency Detention of Mentally Ill and Dangerous or Gravely Disabled Person will be initialed by the Emergency Department or attending physician with the assistance of the APN, PA, Registered Nurse, or Social Services. The policy defines mental illness or mentally ill as a psychiatric disorder, which substantially disturbs an individual’s thinking, feeling, or behavior, and impairs the individual’s ability to function. Dangerous is defined as a condition in which an individual, as a result of mental illness, presents a substantial risk that the individual will harm the individual or others. Gravely disabled is defined as a condition in which an individual, as a result of mental illness, is in danger of coming to harm because the individual is unable to provide for his/her food, clothing, shelter, or other essential human needs; or has a substantial impairment or obvious deterioration of his/her judgement, reasoning or behavior that results in the individual’s inability to function independently. 3. Review of the closed MR for Patient # 7 indicated the patient arrived to F1’s ED on 2/23/24 at approximately 6:47 pm for bilateral knee and hip pain. Triage was documented at 7:58 pm. Triage assessment indicated patient arrived to the ED via wheelchair with complaints of having arthritis and severe pain, rating the pain at 10 out of 10 on zero to 10 pain scale. Triage document indicated FM1 (Significant Other of Patient # 7) would like a psychiatric consult prior to leaving. Patient did not indicate to be a suicide risk. MR indicated patient was seen by MD1 (F1 Medical Doctor [MD]) on 2/23/24 at 9:00 pm; at this date and time, MD1 indicated he/she would provide a dose of analgesia and get hip x-ray’s. On the same date, at 10:00 pm, MD1 indicated family was concerned that the patient was psychotic and hallucinating and requesting psychiatric workup. Orders (bilateral hip and pelvis x-ray and Percocet 5/325 milligram [mg] 1 tablet) placed 2/23/24 at 9:00 pm. MR indicated patient was given a Percocet 5/325 mg, 1 tablet, for pain on 2/23/24 at 9:22 pm, with a pain reassessment completed 2/23/24 at 10:22 pm and documented pain level as 3/10. Order for ED Mental Health Teleassessment entered on 2/23/24 at 9:27 pm. Nurse’s note entered 2/24/24 at 12:02 am, indicated patient was on the phone with F2 (Psychiatric Facility) for mental health teleassessment. MR indicated pain assessment completed 2/24/24 at 12:03 am, pain level documented as 5/10. Nurse’s note entered 2/24/24 at 12:18 am indicated patient ended the mental health teleassessment with F2, patient stating he/she “couldn’t do this” and he/she was “done”. Patient indicated he/she was in too much pain and did not know anyone at F1. The MR lacked documentation that the pain level that prevented the mental health assessment was addressed so that the patient could continue with the assessment. Nurse’s note entered 2/24/24 at 12:30 am indicated communication received from F2 indicating a need for inpatient admission at F2, however due to the incomplete mental health teleassessment, F2 desired an Emergency Detention Order (EDO). The MR lacked documentation that the attending MD completed a psychiatric assessment to determine if the EDO was actually required/needed. Nurse’s note entered 2/24/24 at 12:40 am indicated F2 would not allow patient to finish the assessment and MD2 (F2 MD) was firm on wanting an EDO, MD1 was made aware of this. An EDO was signed by a judicial officer on 2/24/24 at 1:39 am. Order for second Percocet 5/325 mg placed 2/24/24 at 2:58 am. MR indicated Percocet 5/235 mg, 1 tablet, given on 2/24/24 at 3:04 am. MR lacked pain reassessments from 2/24/24 at 3:05 am until 2/24/24 at 6:00 am; pain level reassessed and documented as 8/10. The MR lacked documentation that the pain level of 8/10 was treated prior to the patients transfer. The MR lacked evidence that the attending MD declared the patient as mentally Ill and dangerous or gravely disabled person prior to obtaining an EDO. The MR lacked documentation that F2 was informed of patients need for assist with ADL’s and need for use of a wheelchair. The patient was transferred to F2 and the patient was denied admission upon arrival due to need for assistance with ADL’s and a wheelchair. 4. In interview, on 3/27/24 at approximately 10:54 am, via phone call, A3 (CNO) verified patient # 7 received Percocet pain medication on 2/24/24 at 3:04 am, and pain was not reassessed until the same day at 6:00 am. A3 verified the reassessment was not completed according to facility policy.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49128 Based on document review, the facility failed to ensure appropriate transfer was completed for 1 of 22 patients (patient #7). Findings include; 1. Facility policy titled EMTALA Guidelines (Emergency Medical Treatment and Labor Act) last revised 2/21 indicates on page 2 of 5 under EMTALA requirements: Provide for an appropriate transfer of the individual if either the individual requests the transfer or the hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC (emergency medical condition) (or the capability or capacity to admit the individual). 2. Review of the closed MR for Patient # 7 indicated the patient arrived at the emergency department (ED) on 2/23/24 due to bilateral knee and hip pain at 10 out of 10 on a pain scale with 10 being the most severe. The patients significant other requested a psychiatric consult. The patient could not complete a mental health assessment via telehealth due to pain level. The increased pain at the time of the assessment was not addressed so that the patient could complete the telehealth psychiatric consult. The MR indicated that an Emergency Detention Order (EDO) was obtained and the patient was transferred to F2 (psychiatric facility). He/she was transported via the sheriffs department. 3. In interview, on 3/26/24 at approximately 3:10 pm, N2 (RN) verified he/she walked patient # 7 to the Sheriff’s Department van, through the ambulance doors. N2 verified it was the Sheriff’s Department’s policy to shackle and handcuff all EDO transfers.”