Community Hospital of Anderson and Madison County

“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 a medical screening exam (MSE) for 1 of 20 medical records reviewed (patient #1). Findings include: 1. Facility policy titled “EMTALA: Emergency Medical Screening, Stabilization and Transfer” last revised on 5/2024, indicates on page 1 under policy statements that EMTALA requires hospitals that participate in Medicare to provide a medical screening examination to any person who comes to the emergency department, regardless of the individuals ability to pay. Page 2 indicates under 1. Medical Screening Examination: The Hospital must provide an appropriate medical screening examination (MSE). An “appropriate MSE” is: a. An exam performed within the capability of the Hospital’s emergency department, including any ancillary services routinely available to the ED (e.g. x-ray, lab services etc.), to determine if an emergency medical condition exists or not. 2. Review of patient #1’s medical record from Facility #1 (Critical Access Hospital) indicated the following: A review of Patient #1’s Emergency Department Summary Report for Facility #1 dated 10/15/24 indicated the patient arrived via walk in to the emergency department on 10/15/24 at 9:46 p.m. with an acuity level of 3. Patient #1’s chief complaint was a fall. Patient tripped on uneven ground and hit (his/her) left wrist. Family reports that (he/she) has passed out 4 times in the car ride over. ED vitals on 10/15/24 at 9:52 p.m. indicated the following: heart rate: 125 beats per minute, blood pressure: 168/98 mmHg (millimeter of mercury), ED Disposition: Left Without Being Seen after triage: States they cannot wait for a room and are going to call an ambulance. The MR for patient #1 lacked a MSE performed at facility #1. 3. Review of patient #1’s medical record from Facility #2 indicated the following: A review of Patient #1’s Emergency Department Summary from Facility #2 dated 10/15/24 indicated the following: Patient #1 was brought via EMS (Emergency Medical Services) to the Emergency Department at Facility #2 on 10/15/24 at 10:37 p.m. and was discharged on 10/16/24 at 1:00 a.m. with a diagnosis of a left radius fracture. Patient was given short-term pain medicine for home and plan to have (him/her) follow-up as an outpatient with orthopedics. 4. During an interview with Family Member #2 on 11/8/24 at 10:10 a.m., Family Member #2 indicated Patient #1 was registered and had an arm band at Facility #1 ED. Family Member #2 indicated that the nurse initially came out and took Patient #1’s blood pressure and stated that the rooms were full, and it would be a while, but if the patient loses consciousness again to have the receptionist let (him/her) know. Family Member #2 indicated that the receptionist would not go get the nurse when Patient #1 went unconscious again and indicated that they would need to go to Facility #2. Family Member #2 indicated that (he/she) told the receptionist that you cannot turn us away. So, the Family Member #2 called 911, while they were on the premises of Facility #1 and 911 said to go out on to the street and call 911 to get an ambulance transport to Facility #2. EMS transported Patient #1 to Facility #2. Family Member #2 indicated that Patient #1 had a fall that ended up with multiple fractures to left arm and was the reason for the cycling of (his/her) in/out of consciousness. 5. During an interview with N2 on 12/2/24 at 4:42 p.m., N2 indicated that they worked as Charge Nurse in the Emergency Department on 10/15/24 and only remember that Patient #1 had left the ED before being seen by a provider. 6. During an interview with N1 on 12/2/24 at 4:44 p.m., N1 indicated that they worked on 10/15/24 when Patient #1 had come into the ED. N1 indicated that Patient #1 had never lost consciousness when they were in the ED. N1 indicated that Patient #1 was complaining of pain in (his/her) left wrist, was sitting in a wheelchair and had (Family Member #2) with them. N1 indicated that Patient #1 had a sling/cloth wrapped around (his/her) left shoulder/elbow to support their arm when they came into the facility. N1 indicated that (Family Member #2) kept asking to have Patient #1 go back into an ED room before anyone else because Patient #1’s arm was broken. N1 indicated that (he/she) told them that they could not make an exception and that they go by the ESI (Emergency Severity Index) system. N1 indicated that they had a full waiting room/ED. N1 indicated that (Family Member #2) was observed to be on the phone when (Family Member #2) and Patient #1 left the facility. 7. During an interview with A2 on 12/3/24 at 9:49 a.m., A2 verified the medical record information for Patient #1. 8. During a phone interview with Patient #1 on 12/3/24 at 4:52 p.m., Patient #1 indicated that while (he/she) was in the ED waiting room of Facility #1, (he/she) kept going in and out of consciousness. Patient #1 indicated that Family Member #2 had went to the registration desk and told them that I kept going in and out of consciousness and that (he/she) was really worried about (him/her). Patient #1 indicated that they told Family Member #2 that if they wanted to be seen that Family Member #2 would need to take Patient #1 to another hospital, so Family Member #2 wheeled (him/her) out to the parking lot and started driving down the road and (he/she) stopped, called 911 because started having breathing problems. Patient #1 indicated that an ambulance came, gave (him/her) pain medications and it helped (him/her) from going in and out of consciousness as much.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 47186 Based on document review and interview, the facility failed to provide patient written notification of a grievance outcome and the date of completion in 1 of 10 medical records reviewed (patient 9). Findings Include: 1. Facility policy, Network Patient Feedback Management (Complaints & Grievances), PolicyStat ID 11749428, last revised 05/2022: indicated under Policy Statements H: Upon resolution of a grievance for a facility on a hospital license, a final written or electronic (email) communication will be sent to the patient (or when applicable the complaintant); under General Information: D. Grievances require written resolution to the patient, patient representative, or complainant and must contain the following: 1. the name of the contact person 2. the steps taken on behalf of the patient to investigate the grievance 3. the results of the grievance process 4. the date of completion. 2. The Incident/Grievance Log lacked documentation of written notification to P9, per policy, that the investigation of the Incident/Grievance reported was completed and of its outcome. 3. In interview on 11/14/24 at approximately 4:53 pm, A1 (Registered Nurse, Quality Director) and A2 (Registered Nurse, Director Acute Care) confirmed no written notification to P9 regarding the Complaint/Grievance investigation outcome was indicated in administrative documents, per policy.”

“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: 47186 Based on document review and interview nursing staff failed to document patient report of inappropriate touching by staff in patient’s electronic medical record in 1 of 10 medical records reviewed (patient 9). 1. Facility policy, Management of an Inpatient Report of Sexual Assault, Rape, or Other Sexual Nature Occurring on Community Health Network Property, PolicyStat ID 15186285, last revised 04/2024: indicated under Policy Statements: C. Caregiver is to document the facts of the event in the patients electronic medical record. 2. Review of P9’s MR lacked documentation of patient’s complaint of inappropriately touched by staff reported on 4/07/24. 3. In a telephone interview on 11/16/24 at approximately 6:41 am to 6:57 am, N7 (RN) confirmed worked dayshift (7 am - 7 pm) on 4/7/24 and indicated saw P9 that morning. N7 indicated P9 reported 2 staff made the patient feel uncomfortable when staff entered patient’s room to change a wet gown after patient spilled some juice in bed. N7 indicated he/she reported P9’s complaint in person to N10 (RN) and sent a message to A5 (Administrative Manager) regarding patients’ statement.”