University of KS Hlth System Great Bend Campus

“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: 47234 Based on document review, record review, policy review and interview the hospital failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to: 1. provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed for patients who presented to the obstetrics department seeking medical care; 2. provide stabilizing treatment for patients who presented to the emergency department seeking medical care; and 3. appropriately transfer patients who presented to the emergency department seeking emergency medical care for an emergency medical condition (EMC). Failure to perform an appropriate MSE, provide stabilizing treatment and appropriately transfer patients places patients at risk for unidentified emergency medical conditions and deterioration of their condition resulting harm and injury up to an including death. The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation. (Refer tag 2406) On 05/01/25 at 8:13 AM, surveyors notified Staff C1, Administrator, that an immediate jeopardy (IJ) existed related to A2406 §489.24(a); §489.24(c), Appropriate Medical Screening Examination. The hospital submitted a plan of removal (POR) on 05/01/25 at 8:55 AM. On 05/01/25 at 12:50 PM the hospital was notified the written POR was accepted. The POR included but was not limited to the following: May 1, 2025 Re: Immediate Jeopardy Removal Plan - EMTALA Medical Screening Exam [Above Named Hospital] has taken the following actions to remove the Immediate Jeopardy, effective immediately: Contacted the OB Medical Director, via phone, to notify him of the change in practice regarding OB-privileged providers providing on-site medical screening exams for OB patients presenting for emergent care. Notified OB-privileged providers of the need to provide an on-site assessment of OB patients presenting for emergent care. Educated OB nursing staff to the need to call the on-call OB-privileged provider to come in for an on-site assessment if an OB patient presents for emergent care. Clarification notification to OB nursing staff they are to continue their assessment processes. The change in practice is contacting the OB-privileged provider to come on-site to conduct a medical screening exam. The hospital’s plan of removal validated prior to survey exit on 05/01/25 at 12:52 PM. Findings Include: The hospital failed to provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 3 of 20 patients (Patient’s 1, 11 and 12) who presented to the hospital seeking medical care. (Refer to tag A2406) The hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. (Refer to tag A2407) The hospital failed to ensure an appropriate transfer of 6 of 6 patients (Patient’s 4, 5, 6, 13, 14 and 16) who transferred with an emergent medical condition (EMC). (Refer to 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: 47234 Based on record review, policy review, document review and interview the hospital failed to provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 3 of 20 patients (Patient’s 1, 11 and 12) who presented to the hospital seeking medical care. The hospital’s failure to provide an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which causes delays in necessary stabilizing treatment and may lead to deterioration of the person’s condition, including harm and death. Findings Include: Review of hospital policy titled “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” last revised 04/2025, showed, “ ...Qualified Medical Personnel (QMP): A physician, physician assistant, an Advance Practice Registered Nurse in the Emergency Department or a Certified Nurse Midwife in Obstetric Unit with demonstrated competency acting within the scope of his or her license under a medically approved protocol ...” Review of hospital document titled “Hypertension in pregnancy patient care,” dated 11/17/24 showed, “ ... Hypertension in pregnancy is defined as systolic blood pressure greater than or equal to 140 mm Hg, diastolic blood pressure greater than or equal to 90 mm Hg .... Notify the practitioner of a systolic reading of 140 mm Hg or greater, a diastolic reading of 90 mm Hg or greater, or for both for two measurements taken within 15 minutes as directed by your facility or the practitioner’s order. Patient with hypertension should be reassessed within 15 minutes. If the patient remains hypertensive, evaluation by a practitioner is needed ... continue to monitor the patient’s blood pressure at an interval determined by the practitioner’s order and the patient’s condition ... Obtain blood samples for diagnostic tests ...” Review of hospital document titled, “Rules & Regulations [Above Named Hospital],” dated 05/2022, showed, “ ... the Hospital shall provide for an appropriate medical screening examination within the capability of the hospital’s emergency department for any individual who comes to the hospital’s emergency department on whose behalf the request is made for examination or treatment for a medical condition as required by the Emergency Medical Treatment and Active Labor Act... A “medical screening examination” is the process required to determine, within a reasonable clinical competence, whether the patient has an emergency medical condition as defined under EMTALA and applicable hospital policies ... All medical screening examinations shall be performed by a qualified medical personnel in a manner consistent with Hospital policies. As determined by the Governing Body, “qualified medical personnel” shall include (i) members of the medical staff acting within the scope of their Privileges, and (ii) Advanced Practice Providers who have been approved to practice at the hospital’s acting within their scope of their approval ... Review of hospital document titled, “Obstetric triage of patients,” last reviewed on 02/23/25, showed “ ...Clinical Alert: If the patient’s systolic blood pressure exceeds 140 mm Hg or the diastolic blood pressure exceeds 90 mm Hg, notify the practitioner because these signs may indicate gestational hypertension [high blood pressure that develops after 20 weeks of pregnancy in woman with normal blood pressure]. Gestational hypertension is a blood pressure that exceeds these values on two separate occasions at least 4 hours apart after 20 weeks’ gestation ...” Review of Obstetrics Log (OB) [Obstetrics is medicine focused on the care of women during pregnancy] from 11/28/24 to 04/29/25 showed that 59 out of 82 patients were assessed by a registered nurse (RN) who according to interview and hospital policy are not a QMPs. Review of email dated 04/30/25 at 3:45 PM, showed that there are currently 10 RN’s working on obstetrical unit. During an interview on 04/30/25 at 3:38 PM, Staff E, Accreditation and Regulatory Compliance Manager, stated that no RNs in OB are QMPs to provide appropriate MSEs. During a review of the personnel files on 05/01/25 at 09:10 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that the following nursing staff employed on the OB unit; Staff U, RN, Staff V, RN, Staff W, RN, Staff H, RN, Staff Y, RN, Staff Z, RN, Staff T, RN, Staff X, RN, Staff A1, RN and Staff B1, RN, are not QMPs. Patient 1 Review of Patient 1’s medical record showed a 23-year-old female, who was approximately 31 weeks pregnant, presented to the OB Unit on 04/21/25 at 12:45 AM with complaint of “ ...Pain Itching; Location of Pain Hand radiating to other body parts, arms, legs, back, neck, and abd. [Abdomen] ...” Review of “Vital Signs” dated 04/21/25 at 1:01 AM, showed, “ ...Order comments: Notify provider and increase the frequency of vitals to q15 minutes for the parameter below: HR>120, SBP<80 or >140, DBP<50 or >90, RR >20, SpO2 <95% and temp >38 Celsius (recheck hourly) ...” Review of “Vitals,” dated 04/21/25 showed Patient 1’s blood pressure (BP) was 148/86 at 1:09 AM and 159/99 at 2:19 AM, prior to discharge. Her lowest BP was 141/82 at 1:31 AM. Review of “PT [Patient] Reported Data,” dated 04/21/25 at 1:15 AM, showed, “ ...Pregnancy induced hypertension - Preeclamptic Risk [pregnancy complication characterized by new onset of high blood pressure] - Headache; Hypertension...” Review of “Progress Notes” dated 04/21/25 showed, by Staff H, RN, “ ...0130 [1:30 AM] Notifiy (sic)[Staff G, MD], lab results, symptoms per patient, current fetal HR [heart rate] status, and ctx [contraction] status. Order received. 0145 [1:45 AM] Medication given per [Staff G, MD], provided water, ice packs, and fan for comfort ...” Patient 1’s medical record showed, “ ...Discharge Date and Time: 4/21/25 2:45 AM ...” Review of Patient 1’s [Hospital 2] medical record dated 04/21/25 at 12:42 PM, showed, “ ...here for c/o [complaint of] itching on hands, feet, abdomen and back. Informed dr [doctor] that pt [patient] also with elevated bp [blood pressure] on arrival 168/88 ...takes 100 mg labetalol [medication to treat high blood pressure] BID [twice a day] last took this morning ...dr [doctor] ...will send ursodol [Ursodeoxycholic acid is prescribed to pregnant women to treat intrahepatic cholestasis of pregnancy] to home pharmacy ...to increase labetalol to TID [three times a day] as well ...” During an interview on 04/29/25 at 10:30 AM, Patient 1 stated that on that same day of 04/21/25 after being dismissed from [Above Named Hospital], she sought care at another hospital where she received lab work and medications for the itching and blood pressure. During an interview on 04/30/25 at 1:04 PM, Staff H, RN, stated that Patient 1’s blood pressure was elevated at 159/99. She was already taking medication for high blood pressure. During an interview on 04/30/25 at 8:13 AM, Staff G, Obstetrician Gynecologist (OBGYN), MD, stated that she was unaware of the patient’s blood pressure of 159/99 and was reporting symptoms of headache. Given these findings, the patient should have been admitted for additional care. Since itching is sign of intrahepatic cholestasis [a liver condition that affects bile flow during pregnancy] the patient would require additional labs and medication. During an interview 04/30/25 at 9:24 AM, Staff T, OB RN, stated that we have always called it triage, but I guess it is like a Medical Screening Exam (MSE). The physician is called within an hour or earlier if there are contractions, bleeding or premature rupture of membranes and provide them with the triage information, such as telling them if vital signs are stable. During a review of the personnel files for Staff H, OB RN on 04/30/25 at 1:50 PM, revealed that Staff H was a traveling nurse, and was not a QMP as defined in the hospitals Rules & Regulations. During an interview on 04/30/25 at 1:50 PM, Staff C, DON, stated that Staff H, OB RN does not have any competencies to provide an MSE as a QMP. Patient 11 Review of Patient 11’s medical record showed a 31-year-old female, who was in her first trimester (1-13 weeks pregnant) of pregnancy presented to the OB Unit on 12/10/24. An MSE was provided by Staff V, RN, with a complaint “ ...comes in for not feeling infant move and headache and swelling ...”and a visit diagnosis of “ ...Supervision of normal intrauterine pregnancy in multigravida [a female who has been pregnant at least a second time], first trimester ...” During an interview on 05/01/25 at 9:10 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that Staff V, RN, does not have any competencies to provide an MSE as a QMP. Review of Patient 11’s medical record failed to show evidence that an MSE was provided by a QMP. Patient 12 Review of Patient 12’s medical record showed a 29-year-old female, who was approximately 35 weeks pregnant, presented to the OB Unit on 04/20/25. An MSE was provided by Staff X, RN, on 04/20/25 at 2:45 PM with a chief complaint of “ ...Rupture of Membrane [Leaking or bursting of the sac that protects the baby or fetus] ...” During an interview on 05/01/25 at 9:10 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that Staff X, RN, does not have any competencies to provide an MSE as a QMP. Review of Patient 12’s medical record failed to show evidence that an MSE was provided by a QMP.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47234 Based on record review, policy review, document review and interview the hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death. Findings Include: Review of hospital policy titled “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” Last Revised 04/2025, showed, “ ... Stabilize: with respect to an emergency medical condition as defined above, to provide treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration is likely to result from (or occur during) the transfer of an individual ...Stable for discharge: QMP has determined, within reasonable clinical confidence, that the patient has reached a point where his/her continued care, including diagnostic work-up and/ or treatment, could be reasonably performed as an outpatient or later as an inpatient with no material deterioration in condition, provided the patient has given a plan for appropriate follow up care with discharge instructions ...” Review of hospital document titled, “Hypertension in pregnancy patient care,” dated, 11/17/24 showed, “ ... Hypertension [high blood pressure] in pregnancy is defined as systolic blood pressure greater than or equal to 140mm Hg, diastolic blood pressure greater than or equal to 90mm Hg .... Notify the practitioner of a systolic reading of 140mm Hg or greater, a diastolic reading of 90mm Hg or greater, or for both for two measurements taken within 15 minutes as directed by your facility or the practitioner’s order. Patient with hypertension should be reassessed within 15 minutes. If the patient remains hypertensive, evaluation by a practitioner is needed ... continue to monitor the patient’s blood pressure at an interval determined by the practitioner’s order and the patient’s condition ... Obtain blood samples for diagnostic tests ...” Review of hospital document titled, “Obstetric triage of patients[Obstetrics is medicine focused on the care of women during pregnancy],” last reviewed on 02/23/25, showed “ ...Clinical Alert: If the patient’s systolic blood pressure exceeds 140 mm Hg or the diastolic blood pressure exceeds 90 mm Hg, notify the practitioner because these signs may indicate gestational hypertension [high blood pressure that develops after 20 weeks of pregnancy in woman with normal blood pressure]. Gestational hypertension is a blood pressure that exceeds these values on two separate occasions at least 4 hours apart after 20 weeks’ gestation ...” Patient 1 Review of Patient 1’s medical record showed a 23-year-old female, who was approximately 31 weeks pregnant, presented to the Obstetric Unit (OB) on 04/21/25 at 12:45 AM with complaint of “ ...Pain Itching; Location of Pain Hand radiating to other body parts, arms, legs, back, neck, and abd. [Abdomen] ...” Review of “Vital Signs” dated 04/21/25 at 1:01 AM, showed, “ ...Order comments: Notify provider and increase the frequency of vitals to q15 minutes for the parameter below: HR>120, SBP<80 or >140, DBP<50 or >90, RR >20, SpO2 <95% and temp >38 Celsius (recheck hourly) ...” Review of “Vitals,” dated 04/21/25 showed Patient 1’s blood pressure (BP)was 148/86 at 1:09 AM and 159/99 at 2:19 AM, prior to discharge. Her lowest BP was 141/82 at 1:31 AM. Review of “PT [Patient] Reported Data,” dated 04/21/25 at 1:15 AM, showed, “ ...Pregnancy induced hypertension - Preeclamptic Risk [pregnancy complication characterized by new onset of high blood pressure] - Headache; Hypertension.” Review of “Progress Notes” dated 04/21/25 showed, by Staff H, RN, “ ...0130 [1:30 AM] Notifiy (sic)[Staff G, MD], lab results, symptoms per patient, current fetal HR [heart rate] status, and ctx [contraction] status. Order received. 0145 [1:45 AM] Medication [Benadryl 50mg oral] given per [Staff G, MD], provided water, ice packs, and fan for comfort. Patient 1’s medical record showed, “ ...Discharge Date and Time: 04/21/25 2:45 AM ...” Review of Patient 1’s [Hospital 2] medical record dated 04/21/25 at 12:42 PM, showed, “ ...here for c/o [complaint of] itching on hands, feet, abdomen and back. Informed dr [doctor] that pt [patient] also with elevated bp on arrival 168/88 ...takes 100mg labetalol [medication to treat high blood pressure] BID [twice a day] last took this morning ...dr [doctor] ...will send ursodol [Ursodeoxycholic acid is prescribed to pregnant women to treat intrahepatic cholestasis of pregnancy] to home pharmacy ...to increase labetalol to TID [three times a day] as well ...” During an interview on 04/29/25 at 10:30AM, Patient 1 stated that on that same day of 04/21/25 after being dismissed from [Above Named Hospital], she sought care at another hospital where she received lab work and medications for the itching and blood pressure. During an interview on 04/30/25 at 1:04 PM, Staff H, RN, stated that Patient 1’s stated that the patient presented with non-obstetric concern of itching, which is not considered a pregnancy related symptom. Her blood pressure was elevated at 159/99. She was already taking medication for high blood pressure. During an interview on 04/30/25 at 8:13 AM, Staff G, Obstetrician Gynecologist (OBGYN), MD, stated that she was unaware of the patient’s blood pressure of 159/99 and that the patient was reporting symptoms of headache. Given these findings, the patient should have been admitted for additional care. Since itching is sign of intrahepatic cholestasis [a liver condition that affects bile flow during pregnancy] the patient would require additional labs and started on a medication called Ursodeoxycholic acid. During an interview 04/30/25 at 9:24 AM, Staff T, OB RN, stated that that itching in pregnant woman could be a sign of intrahepatic cholestasis. That would need additional lab test and sign of possible early delivery. If pregnant patient has a headache and blood pressure of 159/99 it would need to be reported to the doctor. Review of the medical record showed the hospital failed to provided Patient 1 stabilizing treatment for signs and symptoms of intrahepatic cholestasis and gestational hypertension.”

“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: 47234 Based on record review, policy review, document review and interview the hospital failed to ensure appropriate transfer of patients with an emergency medical condition (EMC) for 6 of 6 patients (Patients 4, 5, 6, 13, 14 and 16) reviewed for transfer. Failure to ensure an appropriate transfer place patients at risk for an unsafe transfer and deterioration person’s condition, including harm and death. Findings Include: Review of a hospital policy titled “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” last reviewed 04/2025, showed, “ ...If physician not physically present at the time of transfer, a designated QMP [Qualified Medical Professional] may sign the certificate. The determination to transfer the patient will be made by the physician in consultation with the signing QMP, and the physician will co-sign the certification within 24 hours of the transfer ...” Patient 4 Review of Patient 4’s medical record showed a 77-year-old the patient who presented to emergency department (ED) on 04/21/25 at 10:28 AM by private vehicle. Patient 4 was triage at 10:41 AM. Her chief complaint was chest pain. Patient 4 was seen and evaluated by Staff K, Advanced Practice Registered Nurse (APRN). Review of Patient 4’s medical record dated 04/21/25 at 3:10 PM showed Patient 4 was transferred by ALS (Advanced Life Support) air ambulance for diagnosis of non-ST elevation MI [Myocardial Infarction] (NSTEMI) (a type of heart attack). During an interview on 04/30/25 at 10:37 AM, Staff A, Emergency Department Manager, stated that there is no co-signature on Patient’s 4 medical record. Review of Patient 4’s certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” policy. Patient 5 Review of Patient 5’s medical record showed a 47-year-old the patient who presented to ED on 01/16/25 at 11:34 AM by private vehicle. Patient 5 was triage at 11:40 AM. Her chief complaint was rapid heart rate. Patient 5 was senn and evaluated by Staff M, APRN. Review of Patient 5’s medical record dated 01/16/25 at 6:30 PM showed Patient 5 was transferred by ALS (Advanced Life Support) ground ambulance for diagnosis of Atrial fibrillation with RVR (heart rhythm disorder where the atria beat irregularly and the ventricles beat too fast), Hyperthyroidism (overproduction of hormone by the gland in of the neck (thyroid), Hypomagnesemia (low magnesium levels in the blood). Review of Patient 5’s certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” policy. Patient 6 Review of Patient 6’s medical record showed a 22-year-old the patient who presented to ED on 03/23/25 at 4:11 PM by ambulance. Patient 6 was triage at 4:11 PM. His chief complaint was gunshot wound to head. Patient 6 was seen and evaluated by Staff M, APRN. Review of Patient 6’s medical record dated 03/23/25 at 4:42 PM showed Patient 6 was transferred by ALS (Advanced Life Support) air ambulance for diagnosis of gunshot wound of head. During an interview on 04/30/25 at 10:37 AM, Staff A, Emergency Department Manager, stated that there is no co-signature on Patient’s 6 medical record. Review of Patient 6’s certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” policy. Patient 13 Review of Patient 13’s medical record showed a 44-year-old male who presented to the ED on 03/10/25 at 11:07 AM by private vehicle. Patient 13 was triaged at 11:17 AM. His chief complaint was paranoid delusions with a diagnosis of psychosis. (state of mind that results in magical thinking, delusions, and/or hallucination. The inability to process stimuli properly.) Patient 13 was seen and evaluated by Staff Q, APRN. Review of Patient 13’s medical record dated 03/10/25 at 11:32 PM showed Patient 13 was accepted for transfer to a behavioral health hospital and transported via secured vehicle. During an interview on 04/29/25 at 3:15 PM, Staff Q, Advanced Practice Registered Nurse (APRN), stated that Patient 13 did not have a co-signature from a physician on the EMTALA plus transfer form. Review of Patient 13’s certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” policy. Patient 14 Review of Patient 14’s medical record showed a 67-year- old male who presented to the ED on 02/25/25 at 2:25 PM by private vehicle. Patient 14 was triaged at 2:27 PM. His chief complaint of chest pain resulted in diagnosis of Myocardial Infarction (often called a heart attack, in which blood cannot reach the organ of the heart properly, usually due to blood clots). Patient 14 was seen and evaluated by Staff Q, APRN. Review of Patient 14’s medical record dated 02/25/25 at 2:56 AM showed Patient 14 was transferred to an acute care hospital via air ambulance. During an interview on 04/29/25 at 3:15 PM, Staff Q, Advanced Practice Registered Nurse (APRN), stated that Patient 14 did not have a co-signature from a physician on the EMTALA plus transfer form. Review of Patient 14’s certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” policy. Patient 16 Review of Patient 16’s record showed a 44-year-old male who presented to the ED on 04/04/25 at 7:29 PM by private vehicle. Patient 14 was triaged at 7:34 PM. His chief complaint was of right sided extremity weakness that led to the diagnosis of an Acute Ischemic Stroke (Blockage of blood to the brain, usually resulting from a blood clot. Leads to the gradual death of brain tissues). Patient 16 was seen and evaluated by Staff I, Physician Assistant-Certified (PA-C). Review of Patient 16’s medical record dated 04/04/25 at 9:10 PM, showed Patient 16 was transferred to an acute care hospital by fixed wing transport ambulance. During an interview on 04/29/25 at 2:28 PM, Staff M, Advanced Practice Registered Nurse (APRN), stated that Patient 16 did not have a co-signature from a physician on the EMTALA plus transfer form. Review of Patient 16’s certification of transfer failed to show an appropriate transfer countersignature or consultation from a physician within 24 hours specified by the hospital “Emergency Medical Treatment and Active Labor Act Compliance (EMTALA),” policy. During an interview on 04/29/25 at 2:51 PM, Staff I, Physician Assistant (PA), stated that the physician co-signature is signed after the patient has been transferred. During an interview on 04/29/25 at 3:05 PM, Staff Q, Advance Practice Registered Nurse (APRN), stated that a physician signature is required on the EMTALA Plus forms, not sure of the exact steps involved. During an interview on 04/29/25 at 4:11, PM, Staff K, Advance Practice Registered Nurse (APRN), stated that when a patient is transferred, the receiving facility’s physician is the cosigner and signs the EMTALA form. During an interview on 04/30/25 at 10:00 AM, Staff D1, Doctor of Osteopathic Medicine (DO), Emergency Department Director, stated that as the only physician, he personally has never co-signed the EMTALA Plus Transfer form.”

“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: 47234 Based on policy review, document review, record review, and interview, the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 7 of 20 emergency department (ED) patients reviewed when the nursing staff failed to: 1. Complete Electrocardiograms (EKG) per procedure for Patients 3, 4, 5 and 14; 2. Complete vital signs as required per policy for Patients 8 and 10; and, 3. Notify the provider of abnormal vital signs per procedure for Patient 1. This deficient practice has the potential to place patients at risk for harm and adverse outcomes. Findings Include: 1. Failed to complete an Electrocardiogram (EKG) as per hospital procedure. (Patients 3, 4, 5 and 14) Review of hospital document titled, “Assessment of the Acute Coronary Syndrome (ACS) Patient in ED...” last reviewed on 03/31/25, showed, “ ...Assessment is an ongoing process, documented in the medical record at intervals as described in this procedure. These assessment and documentation time frames represent the minimum requirements. ...Chest pain or severe epigastric pain (discomfort in the upper region of the abdomen), nontraumatic in origin, with components of myocardial ischemia (the heart muscle having insufficient blood flow leading to reduced supply of oxygen) or myocardial infarction (type of heart attack, blockage of blood flow to a heart muscle) (MI): 1. Central/substernal crushing chest pain, pressure, tightness, heaviness, cramping, burning or aching sensation. Patients may also describe as “chest discomfort ...Obtain (or delegate to an ED technician) a 12-lead ECG within 5 minutes of arrival ...” Patient 3 Review of Patient 3’s medical record showed a 14-year-old presented to the Emergency Department on 04/16/25 at 10:00 PM, with a chief complaint of chest pain. Patient 3 had a diagnosis of atypical chest pain (chest pain that doesn’t meet the criteria for typical or classic chest pain) and discharged home on 04/17/25 at 1:07 AM. Review of Patient 3’s medical record showed the first EKG was done at 10:55 PM, 54 minutes after arrival. During an interview on 04/29/25 at 3:05 PM, Staff Q, Advance Practice Registered Nurse (APRN), stated that patients with chief complaint of chest pain, the goal is to complete an EKG within 10 minutes of their arrival. At our facility, respiratory therapists (RTs) are responsible for performing EKGs. However, delays can occur, especially if the RT is already attending to another critical patient or performing another EKG. During an interview on 04/30/25 at 8:52 AM, Staff E, Accreditation and Regulatory Compliance Manager, stated that the hospital does not have an internal chest pain policy. Instead, we customize and follow [a publisher of professional health information company’s] as procedure and standing orders. The medical record failed to show documented evidence that Patient 3’s EKG was completed within 5 minutes of arrival as required by hospital procedure. Patient 4 Review of Patient 4’s medical record showed a 77-year-old the patient who presented to emergency department (ED) on 04/21/25 at 10:28 AM by private vehicle. Patient 4 was triage at 10:41 AM. Her chief complaint was chest pain. Review of Patient 4’s medical record showed the first EKG was done at 11:16 AM, 48 minutes after arrival. Review of Patient 4’s medical record dated 04/21/25 at 3:10 PM showed Patient 4 was transferred by Advanced Life Support (ALS) air ambulance for diagnosis of non-ST elevation MI [Myocardial Infarction] (NSTEMI) (a type of heart attack). During an interview on 04/29/25 at 4:11, PM, Staff K, Advance Practice Registered Nurse (APRN), stated that patients who have chest complaints, an EKG should be performed within 15 minutes of arrival. There should never be a situation where an EKG is delayed, then stated “48 minutes it is unacceptable.” The medical record failed to show documented evidence that Patient 4’s EKG was completed within 5 minutes of arrival as required by hospital procedure. Patient 5 Review of Patient 5’s medical record showed a 47-year-old the patient who presented to ED on 01/16/25 at 11:34 AM by private vehicle. Patient 5 was triage at 11:40 AM. Her chief complaint was rapid heart rate. Review of Patient 5’s medical record showed the first EKG was done at 11:42 AM, 8 minutes after arrival. Review of Patient 5’s medical record dated 01/16/25 at 6:30 PM showed Patient 5 was transferred by ALS ground ambulance for diagnosis of Atrial fibrillation with RVR (heart rhythm disorder where the upper heart chambers for the atria beat irregularly and the lower heart chambers for ventricles beat too fast), Hyperthyroidism (overproduction of hormone by the gland in of the neck (thyroid), Hypomagnesemia (low magnesium levels in the blood). During an interview on 04/29/25 at 2:28 PM, Staff M, Advance Practice Registered Nurse (APRN), stated that the EKG timing starts from the moment of the patient’s first contact with a healthcare provider, not necessarily when they arrive in the ER. Not every patient presenting with chest pain is brought directly back, but the goal is always to perform the EKG as quickly as possible. During an interview on 04/30/25 at 10:00 AM, Staff D1, Doctor of Osteopathic Medicine (DO), Emergency Department Director, stated that any patient presenting with a primary complaint of chest pain, an EKG should be performed within the first 15 minutes. The medical record failed to show documented evidence that Patient 5’s EKG was completed within 5 minutes of arrival as required by hospital procedure. Patient 14 Review of Patient 14’s medical record showed a 67-year- old male who presented to the ED on 02/25/25 at 2:25 PM by private vehicle. Patient 14’s chief complaint of chest pain resulted in diagnosis of Myocardial Infarction, (a heart attack, in which blood cannot reach the organ of the heart properly, usually due to blood clots) STEMI [ST-Elevation Myocardial Infarction] (a type of heart attack). Review of Patient 14’s medical record showed the first EKG was done at 2:36 PM, 11 minutes after arrival. Review of Patient 14’s medical record dated 02/25/25 at 2:56 AM showed Patient 14 was transferred to an acute care hospital via air ambulance. During an interview on 04/29/25 at 4:33 PM, Staff L, RN, stated that an EKG should be performed immediately to rule out a STEMI, especially when the patient presents with chest pain. Typically, we aim to complete the EKG within the first 5 minutes of the patient’s arrival to the ER room. Patients who report chest pain are brought directly to a room. The medical record failed to show documented evidence that Patient 14’s EKG was completed within 5 minutes of arrival as required by hospital procedure. 2. Failed to complete vital signs as required by policy. (Patients 8 and 10) Review of hospital policy titled “Initial Patient Assessment,” dated 02/2024, showed, “ ...Emergency Department/OB Triage; Time Frame for Completion; Within 30 minutes of arrival ...Vital Signs ...” Patient 8 Review of Patient 8’s medical record showed Patient 8 presented to the Emergency Department on 02/27/25 at 7:05 PM, with a chief complaint of laceration of right thumb without foreign body without damage to nail, and pain of right clavicle (collarbone). The medical record failed to show documented evidence that Patient 8’s vital signs were done within 30 minutes upon arrival as required by policy. Patient 8’s medical record failed to show evidence vital signs were obtained. Patient 8 was discharged on 02/27/25 at 8:10 PM, 61 minutes after arrival. During an interview on 04/30/25 at 10:00 AM, Staff D1, Doctor of Osteopathic Medicine (DO), Emergency Department Director, stated that every patient should have a full set of vital signs. During an interview on 04/30/25 at 10:00 AM, Staff A, Emergency Department Manager, stated that that there are no vital signs documented in Patient’s 8 medical record. Patient 10 Review of Patient 10’s medical record showed Patient 10 presented to the Emergency Department on 03/26/25 at 7:39 PM, with a chief complaint of a suture removal . The medical record failed to show documented evidence that Patient 10’s vital signs were done within 30 minutes upon arrival as required by policy. Patient 10’s medical record failed to show evidence vital signs were obtained. Patient 10 was discharged on 03/26/25 at 8:05 PM, 6 minutes after arrival. During an interview on 04/29/25 at 3:47 PM, Staff N, RN stated that every patient who presents to the emergency department regardless of their chief complaint should have a full set of vital signs. During an interview on 04/30/25 at 10:00 AM, Staff A, Emergency Department Manager, stated that that there are no vital signs documented in Patient’s 10 medical record. 3. Failed to notify the provider of abnormal vital signs (Patient 1). Review of hospital document titled, “Obstetric triage of patients,” dated 02/23/25, showed, “ ...Clinical Alert: If the patient’s systolic blood pressure exceeds 140 mm Hg or the diastolic blood pressure exceeds 90 mm Hg, notify the practitioner because these signs may indicate gestational hypertension. Gestational hypertension is a blood pressure that exceeds these values on two separate occasions at least 4 hours apart after 20 weeks’ gestation ...” Review of hospital document titled, “Hypertension in pregnancy patient care,” dated, 11/17/24 showed, “ ... Hypertension [high blood pressure] in pregnancy is defined as systolic blood pressure greater than or equal to 140 mm Hg, diastolic blood pressure greater than or equal to 90 mm Hg .... Notify the practitioner of a systolic reading of 140 mm Hg or greater, a diastolic reading of 90 mm Hg or greater, or for both for two measurements taken within 15 minutes as directed by your facility or the practitioner’s order. Patient with hypertension should be reassessed within 15 minutes. If the patient remains hypertensive, evaluation by a practitioner is needed ... continue to monitor the patient’s blood pressure at an interval determined by the practitioner’s order and the patient’s condition ...” Patient 1 Review of Patient 1’s medical record showed 23-year-old female, was seen in the Obstetric Unit (OB) on 04/21/25 at 12:45 AM with complaint of “ ...Pain Itching; Location of Pain Hand radiating to other body parts, arms, legs, back, neck, and abd. [Abdomen] ...” Review of “Vital Signs” dated 04/21/25 at 1:01 AM, showed, “ ...Order comments: Notify provider and increase the frequency of vitals to q15 minutes for the parameter: ...SBP (Systolic Blood Pressure is pressure exerted when blood in ejected into arteries)<80 or >140, DBP (Diastolic Blood Pressure is pressure blood exerts within the arteries between heartbeats)<50 or >90 ... (recheck hourly) ...” Review of “Vitals,” dated 04/21/25 showed Patient 1’s blood pressure (BP)was 148/86 at 1:09 AM and 159/99 at 2:19 AM, prior to discharge. Her lowest BP was 141/82 at 1:31 AM. Patient 1’s medical record showed, “ ...Discharge Date and Time: 4/21/2025 2:45 AM ...” Patient 1’s medical record failed to show evidence the nurse notified the provider of an elevated blood pressure in obstetrical triage. Review of Patient 1’s [Hospital 2] medical record dated 04/21/25 at 12:42 PM, showed, “ ...here for c/o [complaint of] itching on hands, feet, abdomen and back. Informed dr [doctor] that pt [patient] also with elevated bp [blood pressure] on arrival 168/88 ...takes 100 mg labetalol [medication to treat high blood pressure] BID [twice a day] last took this morning ...dr [doctor] ...to increase labetalol to TID [three times a day] ...” During an interview on 04/29/25 at 10:30 AM, Patient 1 stated that on that same day of 04/21/25 after being dismissed from this hospital she sought care at another hospital where she received medications and labs for her blood pressure. During an interview on 04/30/25 at 8:13 AM, Staff G, Obstetrician Gynecologist (OBGYN), MD, stated that she was unaware of the Patient 1’s blood pressure of 159/99 and that the patient was reporting symptoms of headache. Staff G stated that given these findings, the patient should have been admitted for additional care.”