Bloomington Meadows Hospital

“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, observation, and interview, the facility failed to provide a medical screening examination for 1 of 20 patient medical records (MR) reviewed. (Patient [P]15) Findings include: 1. Facility policy titled, Emergency EMTALA/Assessment Process, PolicyStatID: 13792158, last revised 3/2012, indicated Under POLICY: 2. When a person presents for evaluation, or when a potential patient is seen at an offsite location by the mobile assessment team, an appropriate assessment will be completed. The assessment as described in the assessment policy will include: personal demographics, medical history/screening information psychiatric history/mental status exam, initial diagnostic impression. 2. P15 MR indicated the following: a. Facility consent for treatment forms completed and signed by FM1 (Guardian of P15). b. MR lacked documentation of a medical screening examination. c. MR indicated FM1 signed facility Refusal to Permit Medical Treatment or Transfer form on 5/1/24 at approximately 11:10, did not distinguish am or pm. 3. Facility document, untitled, dated 5/6/24 at 6:03 pm, indicated P15 was under the care of the Emergency Medical Services (EMS) while physically present at the facility, then at an undocumented time was signed in and under the care of the facility. 4. Observation of facility video surveillance completed 6/3/24 at approximately 3:30 pm, indicated on 5/1/24 at approximately 8:15 pm, P15 arrived to facility via Emergency Medical Services (EMS). On 5/1/24 at approximately 9:53 pm facility staff were observed signing an item held by EMS, then EMS exited building. On 5/1/25 at approximately 11:20 pm P15 left facility with family. 5. In interview, on 6/3/24 at approximately 4:10 pm, N2 (Intake Clinician) verified part of the intake process was a transfer of care from EMS to facility. When patients arrive at the facility via EMS there was a patient transfer of care from EMS to the facility and it would be documented by EMS, and signed by facility staff. This documentation was typically done on an electronic tablet. EMS does not give the facility a copy of the documentation. N2 verified once EMS exits the facility, the facility has accepted care of the patient. 6. In interview, on 6/3/24 at approximately 2:36 pm, A3 (Director of Risk Management, Performance Improvement, and Medical Records [DRM]) verified FM1 signed the facility Refusal to Permit Medical Treatment or Transfer form at 11:10 pm. 7. In interview, on 6/3/24 at approximately 4:20 pm, A2 (Interim Director of Intake) verified the nurse in the video surveillance signed EMS transportation document and EMS exited the facility at approximately 9:53 pm on 5/1/24. 8. In interview, on 6/4/24 at approximately 10:20 am, FM1 verified he/she signed the Refusal to Permit Medical Treatment or Transfer after suggestion by facility staff to come get P15.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 49128 Based on document review and interview, the facility failed to admit a patient they accepted for admission and which the facility had the capabilities of treating for 1 of 20 medical records (MR) reviewed. (Patient [P]15) Findings include: 1. Facility procedure titled, Facility - Red/Yellow/Green Admission Criteria, no approval date listed, indicated under Red Zone: EXCLUSIONARY/CANNOT BE TREATED AT OUR FACILITY: 1. suctioning/trach, 2. wounds requiring complicated dressings, 3. severe neurological deficits, 4. continuous oxygen, 5. difficulty swallowing, 6. indwelling catheters, 7. intravenous tubing, 8. uncontrolled seizure disorder, 9. infections disease requiring isolation, 10. unstable vital signs, 11. need for heparin, 12. total nursing care, 13. currently medically unstable, 14. enrolled in hospice or end of life care, 15. IQ less than 70, 16. PICC line. 2. Facility document, untitled, dated 5/6/24 at 6:03 pm, indicated P15 was under the care of the Emergency Medical Services (EMS) while physically present at the facility, then at an undocumented time was signed in and under the care of the facility. The document indicated F1 was unable to meet the care needs of P15. 3. P15 MR indicated the following: a. Facility consent for treatment forms completed and signed by FM1 (Guardian of P15). b. MR indicated FM1 signed facility Refusal to Permit Medical Treatment or Transfer form on 5/1/24 at approximately 11:10, did not distinguish am or pm. c. MR lacked documented attempts for placement or transfer to another facility. d. MR lacked documented phone calls between facility staff and FM1. 4. Observation of facility video surveillance completed 6/3/24 at approximately 3:30 pm, observed date 5/1/24 at approximately 8:15 pm to approximately 11:20 pm, indicated on 5/1/24 at approximately 8:15 pm P15 arrived to facility via Emergency Medical Services (EMS). On 5/1/24 at approximately 9:53 pm facility staff seen signing an item held by EMS, then EMS exited building. On 5/1/25 at approximately 11:20 pm P15 left facility with family. 5. In interview, on 6/3/24 at approximately 2:36 pm, A3 (Director of Risk Management, Performance Improvement, and Medical Records [DRM]) verified FM1 signed the facility Refusal to Permit Medical Treatment or Transfer form at 11:10 pm. 6. In interview, on 6/3/24 at approximately 2:37 pm, A2 (Interim Director of Intake) verified there were no facility policies related to insulin pumps and insulin pumps were not listed as exclusionary criteria. 7. In interview, on 6/3/24 at approximately 2:50 pm, MD1 (facility provider) verified he/she agreed to accept P15 as a patient at the facility and was aware of the existing insulin pump prior to acceptance of patient. 8. In interview, on 6/3/24 at approximately 4:10 pm, N2 (Intake Clinician) verified part of the intake process is to check with nursing units to verify adequate staff before accepting a patient. 9. In interview, on 6/4/24 at approximately 10:20 am, FM1 verified he/she signed the Refusal to Permit Medical Treatment or Transfer after suggestion by facility staff to come get P15.”