Hiawatha Community Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 45841 Based on facility document review, interview, record review, and observation, the facility failed to ensure they provided emergency care necessary to meet the needs of patients. The failure occurred for 17 (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) of 17 patients reviewed for a medical screening exam (MSE) and 4 (Patients 2, 4, 5, and 12) of 7 patients reviewed for a safe setting. Specifically, the facility failed to ensure emergency services were organized under the direction of a qualified member of medical staff, failed to designate qualified medical personnel (QMP) to perform MSEs, and failed to ensure the emergent safety needs of psychiatric patients in the emergency department (ED) were met. The failure had the likelihood of resulting in patient harm due to the facility not being properly managed or equipped. The facility also failed to ensure that equipment used to treat emergency conditions was kept ready and available for 1 of 1 Vapotherm machine (a machine used to provide respiratory support) observed. (Refer to C-0884) Findings Include: 1. A facility document titled, “Medical Staff Bylaws,” approved by the Board of Trustees 08/27/24, indicated, “Medical Staff: shall mean practicing and appropriately licensed physicians and dentists formally appointed and privileged to attend patients of the Organization.” The document revealed, “Advanced Practice Provider: shall mean non-physician health care professionals qualified by licensure, certification or other approval to practice their respective profession in the State of Kansas, such as nurse practitioners, physician assistants, and nurse anesthetists.” The document revealed, “Allied Health Staff: shall mean non-physician health care professionals in a field allied to a physician or dentist qualified by licensure, certification or other approval to practice their respective profession in the State of Kansas and shall be categorized in accordance with Article VII of these Bylaws.” The bylaws also indicated, “1. Active Staff” included “a) The active staff shall consist of those physicians and dentists who agree to assume all the functions and responsibilities of membership on the Active Staff.” The bylaws also indicated, “Allied Health Staff are not members of the Medical Staff, but shall have the duties, responsibilities and prerogatives as may be specifically set forth throughout these Medical Staff Bylaws. Individuals in this category shall consist of non-physician health care professionals qualified by licensure, certification or other approval to practice their respective profession in the State of Kansas [sic] Allied Health Staff shall include nurse anesthetists, nurse practitioners, physician assistants, respiratory therapists, physical and occupational therapists, audiologists, chiropractors, clinical psychologists, podiatrists, and other such professionals.” A facility document titled, “Amended and Restated Bylaws of [Facility #1 name] Board of Directors,” dated 03/22/22, indicated, “The Governing Board delegates to the Chief Executive Officer the responsibility to choose clinical service leaders. The clinical service leaders will be responsible to the Chief Executive Officer in consultation with the Chief of the Medical Staff for the functioning of the clinical services, and will have general supervision over the clinical work falling within the clinical services.” During a telephone interview on 09/10/25 at 12:53 PM, the Chief Executive Officer (CEO) stated that the ED Medical Director was the title held by Advanced Practice Registered Nurse (APRN) #1. The CEO stated that he had been the CEO since 06/2024, and APRN #1 was in his role over the ED when he arrived. He stated that in the Spring of 2025, or maybe closer to January, the Medical Executive Committee (MEC) put forward recommended service line directors, and that was then sent to the board for approval. He said that when the facility was updating the medical staff bylaws, they wanted to include APRNs as medical staff members and allow them voting rights; that was the intent. He stated that how it was written, he could see how it would look like they were still Allied Health, but he thought they were being moved to be classified as medical staff. He stated that although APRNs no longer needed a collaborative agreement with a physician, they were still requiring them at the facility. He stated the APRN needed a collaborative agreement to be able to vote on the medical staff, but it was required regardless of if they wanted to vote. During a telephone interview on 09/10/25 at 2:11 PM, the CEO called back and stated that he did not speak clearly earlier, and he wanted to clarify. He stated that advanced practice providers (APPs) were a part of the allied health staff. He said they wanted to include them in the medical staff, but their counsel advised against that. He stated that instead, they had created a path where APPs could vote with the medical staff if they had a collaborative agreement with a physician. During an interview on 09/10/25 at 9:31 AM, Medical Doctor (MD) #2 stated that the previous year she was the Chief of Staff. She stated that MD #3 was the current Chief of Staff. She stated that all the service line director appointments were an administrative decision. She stated that APRN #1 was over the ED service line. A facility document titled, “[Facility #1] Medical Executive Committee Meeting Minutes,” dated 01/16/25, indicated that proposed medical staff assignments were discussed and assigned. An undated facility document titled, “[Facility #1] 2025 Medical Staff Assignments,” indicated that the medical staff service line chairperson for the emergency care service line was APRN #1. The document also indicated that APRN #1 was a member of the Allied Health Staff. A facility document titled, “Meeting Agenda,” dated 01/28/25, indicated that the Board of Directors meeting included the 01/2025 medical executive committee report. The facility’s undated organizational chart indicated that the Emergency Care Medical Director reported to the Chief of Staff, who then reported to the CEO. An e-mail dated 09/09/25 at 10:43 AM, the Chief Nursing Officer (CNO) indicated that APRN #1 was the ED medical director, and he reported to the Chief of Staff. During an interview on 09/10/25 at 2:19 PM, MD #3 stated that APRN #1 was the ED Medical Director and ran the ED service line. During an interview on 09/11/25 at 9:01 AM, APRN #1 stated that he had been the ED service line chair for about three to four years, since Facility #1 took over and created service-line set up. He stated that APPs were considered allied health, but they had voting rights for things at the medical staff meetings. He stated that the facility tried to allow the APPs to be involved since there were so many of them. 2. A facility document titled, “Medical Staff Bylaws,” approved 08/27/24, revealed it did not designate who was considered to be QMP to provide MSEs in the ED. An e-mail dated 09/08/25 at 4:21 PM from the Chief Nursing Officer (CNO) indicated that she did not see anything specific on who was considered a QMP to perform a MSE in the medical staff bylaws. Per the email, the CNO indicated that the facility had a policy previously that specified it, but the facility determined that registered nurses (RNs) could no longer perform MSEs with the addition of 24 hours, seven-days-a-week coverage of ED providers, and the policy was not current to reflect that. During an interview on 09/09/25 at 9:04 AM, the CNO stated that they found an old policy that included QMP. She stated that they stopped using it sometime in 2023 when they stopped using RNs as QMP. She stated that when they went through updating and revising policies, the policy that included QMPs was missed. She stated that while they were separate hospitals, Facility #4 and Facility #1 worked together and based policies and bylaws off each other. She stated that Facility #4’s updated medical staff bylaws included the QMP section, but Facility #1’s did not. She stated she was going to look back at the previous version of Facility #1’s medical staff bylaws to see if they were included then. Patient 1’s “Emergency Department Note,” dated 08/17/25, revealed the patient went to the ED after a violent episode where they tried to stab a child and their girlfriend and attempted to slit their own wrist. The note revealed they were seen by Advanced Practice Registered Nurse (APRN) #1. Patient 2’s “Emergency Department Note,” dated 08/07/25, revealed the patient went to the ED due to mental health and wellbeing concerns. The note revealed they were seen by APRN #1. Patient 3’s “Emergency Department Note,” dated 05/16/25, revealed the patient went to the ED after being unresponsive due to a possible overdose on insulin. The note revealed they were seen by APRN #7. Patient 4’s “Emergency Department Note,” dated 04/28/25, revealed the patient went to the ED due to a reported overdose. The note revealed they were seen by APRN #7. Patient 5’s “Emergency Department Note,” dated 03/17/25, revealed the patient went to the ED due to a reported overdose for a suicide attempt. The note revealed they were seen by APRN #8 and APRN #9. Patient 6’s “Emergency Department Note,” dated 08/13/25, revealed the patient had a history of factitious disorder, anger outburst, suicidal ideation, and intentional overdose. The note indicated they were taken to the ED after being found face down in a truck stop bathroom. The record revealed they were seen by APRN #1. Patient 7’s “Emergency Department Note,” dated 03/25/2025, revealed the patient went to the ED due to a sudden onset of left-sided weakness and a right upward gaze. The note revealed they were seen by APRN #1. Patient #8’s “Emergency Department Note,” dated 05/26/25, revealed the patient had a history of stroke, anxiety, depression, hypertension, and hyperlipidemia. The note indicated the patient went to the ED due to left-sided weakness and numbness and tingling in their arm and leg, vision changes in both eyes, and difficulty swallowing. The note revealed the patient was seen by APRN #7. Patient 9’s “Emergency Department Note,” dated 04/17/25, revealed the patient went to the ED due to chest discomfort and feeling like they could not get their breath. The note revealed the patient was seen by APRN #1. Patient 10’s “Emergency Department Note,” dated 05/25/25, revealed the patient went to the ED due to chest pain. The note revealed the patient was seen by APRN #1. Patient 11’s “Emergency Department Note,” dated 08/29/25 at 2:28 AM, revealed the patient went to the ED due to feeling cold. The note revealed the patient was seen by APRN #10. Patient 12’s “Emergency Department Note,” dated 03/21/25, revealed the patient went to the ED due to attempting to cut their neck. The note revealed the patient was seen by APRN #1. Patient 13’s “Emergency Department Note,” dated 04/18/25, revealed the patient went to the ED due to concerns of chest pain and pressure. The note revealed the patient was seen by APRN #9. Patient 14’s “Emergency Department Note,” dated 03/03/25, revealed the patient went to the ED due to abdominal pain. The note revealed they were seen by APRN #8. Patient 15’s “Emergency Department Note,” dated 03/03/25, revealed the patient went to the ED due to abdominal cramping at approximately nine weeks pregnant. The note revealed they were seen by APRN #9. Patient 16’s “Emergency Department Note,” dated 05/16/25, revealed the patient went to the ED due to abdominal pain at five weeks pregnant. The note revealed they were seen by APRN #7. Patient 17’s “Emergency Department Note,” dated 08/26/25, revealed the patient went to the ED due to vaginal bleeding. The note revealed they were seen by APRN #1. During an interview on 09/10/25 at 2:19 PM, Medical Doctor (MD) #3 stated it was his understanding that all the ED providers were considered QPMs to perform MSEs in the ED. He stated that physicians and APRNs were utilized as ED providers, but it was a rare occurrence for a physician to be in the ED. He stated that the ED transitioned to almost exclusively advanced practice providers (APPs) a few years prior. During an interview on 09/11/25 at 9:01 AM, APRN #1 stated that currently, QMPs in the ED were physicians, nurse practitioners, and physician assistants. He stated that in the distant past, the facility had used RNs as well, but now there was a provider staffed 24/7, which had been in place for about five years. He stated that at one time, QMPs were designated in the bylaws and ED policy, but about a year to a year and a half prior, those were updated, and he was currently unable to say for sure if it was included. 3. A facility document titled, “Crisis Services Outline for Emergency Departments,” dated 01/2024, indicated under collaboration with crisis services, “If inpatient treatment is recommended, it may take several hours to several days to obtain placement and coordinate transportation to the psychiatric hospital, and during this time the individual will need to remain at the safe location and will not be allowed to leave for safety purposes.” A facility document titled, “Mental Health Management in Emergency Care,” revealed, “3. Suicide Precautions” included “c. ALL mental health patients will have their room checked for ligature risks. It is not possible to eliminate all potential ligatures; however, the following items should be assessed,” which included “i. Loose cords or cables;” “ii. Sharp objects (scissors, glass, etc. [et cetera; and so forth]);” “iii. Furniture that can be used to hang or harm oneself (chairs, carts, etc.);” and “iv. Any other item that can pose a risk (belts, shoe laces, etc.).” The document continued, “d. The ED does not currently have a ‘Safe Room’ specific for mental health patients. For this reason, all mental health patients should be kept in close proximity to the Nurses Station for close monitoring.” An e-mail from the Chief Nursing Officer (CNO), dated 09/10/25 at 9:06 AM, indicated there was no specific policy for patient sitters. Per the email, the organization did not have patient sitters as a job role. Per the email, the ED utilized sitters from Facility #3 typically, and if a sitter was not provided, the ED nurse provided one-to-one supervision. An observation of the ED on 09/08/25 at 3:18 PM with the Director of Emergency Care (DEC), revealed three bays/rooms with two stretchers in each bay, separated by a curtain. One bay/room was considered the Procedure Room. During the tour at 3:19 PM, the Procedure Room was observed to have a large, rolled, draped supply cart that contained miscellaneous medical equipment on Side A of the room. Between Side A and Side B of the room, there was a sink with a cabinet above it with no lock on it. The cabinet held drawers that included scalpels, surgical blades, scissors, ring cutter, and suturing supplies. Below the sink was a drawer with no lock that included miscellaneous sterilized instruments, including a curette. During an interview on 09/08/25 at 3:19 PM, the DEC stated that the ED did not have a psychiatric safe room, so they utilized the procedure room, Side B, which was closest to the door, as the room. She stated that all the cords from the monitor would be removed, and the patient would be placed with a one-to-one sitter in the doorway looking at the patient, if the patient scored anything other than low risk on the suicide scoring tool. She stated that the large cart against the far wall near Side A was not removed from the room when a psychiatric patient was in the room, and they used Side B for the patient. She also stated that staff would do their best to remove any sharp items. When asked if the cabinets containing sharp items and a drawer containing miscellaneous sterilized instruments could lock, she stated that they could look into putting a lock on the cabinets. Patient 2’s “Emergency Department Note,” dated 08/07/25, revealed the patient went to the ED due to mental health and wellbeing concerns. Patient 4’s “Emergency Department Note,” dated 04/28/25, revealed the patient went to the ED due to a reported overdose. Patient 5’s “Emergency Department Note,” dated 03/17/25, revealed the patient went to the ED due to a reported overdose for a suicide attempt. Patient 12’s “Emergency Department Note,” dated 03/21/25, revealed the patient went to the ED due to attempting to cut their neck. An e-mail dated 09/11/25 at 11:11 AM, from the CNO, indicated that Patient 2 was in Procedure Room Bed “B” for their visit on 08/07/25; Patient 4 was in Procedure Room Bed “B” for their visit on 04/28/25; Patient 5 was in Procedure Room Bed “A” for their visit on 03/17/25; and Patient 12 was in Procedure Room Bed “B” for their visit on 03/21/25. During an interview on 09/11/25 at 9:01 AM, Advanced Practice Registered Nurse (APRN) #1 stated that for psychiatric patients, typically most of the equipment and supplies from the rooms would be moved out. He stated, “We do not have a good place for psychiatric patients in the emergency department.” He also stated that he honestly did not know what all the staff moved, just that it was the policy to remove anything that could be harmful, including the big cart and cords. During an interview on 09/11/25 at 1:58 PM, Registered Nurse (RN) #5 stated that it was absolutely the nurse’s responsibility to ensure that patients who required one-to-one staff observation received it. She stated they also removed anything from the rooms that patients could harm themselves with, such as cords and needles, and the patient would be placed in a gown and yellow socks. She stated that she started not long ago, so she stated she would also review the policy to ensure she had not missed anything. RN #5 stated she would have to check whether the items in the cabinet and drawers would be removed. She stated that she was unable to recall if there were locks on the cabinet, but she stated everything had to be removed. During an interview on 09/11/25 at 2:36 PM, RN #6 stated that when psychiatric patients were brought in, the nurse would bring them back to a room. She stated that psychiatric patients would go to the first available room to get the process started. She stated that the process included removing equipment and supplies out of the room and off the counters that patients could cut, poke, or hang themselves with. RN #6 stated there were locks on the suture cupboards and the drawer. She stated they did not always empty drawers.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 45841 Based on observation and interview, the facility failed to ensure that equipment used to treat emergency conditions was kept ready and available for 1 of 1 Vapotherm machine (a machine used to provide respiratory support) observed. Specifically, the facility failed to store a Vapotherm machine in a secure manner that ensured its readiness for use. The failure had the likelihood of resulting in patient harm due to not being prepared for an emergent respiratory situation. Findings Include: A concurrent observation and interview on 09/08/25 at 3:29 PM, with the Director of Emergency Care (DEC), revealed a Vapotherm machine in the corner of the waiting room. The machine was draped and unsecured. The DEC stated that the Vapotherm machine was stored in the ED waiting room because respiratory staff wanted to have a Vapotherm machine near the ED and the respiratory supply room was too full for the machine to fit in there. She stated the registration area was staffed 24 hours a day, seven days a week, and they monitored the ED waiting room. She stated that registration staff could not see the Vapotherm machine from the registration desk, but they could see if someone went in its direction. During an interview on 09/11/25 at 12:40 PM, Respiratory Therapist (RT) #11 stated that she wanted a Vapotherm machine near the ED and had not considered that someone might contaminate or tamper with it while it was in the waiting room, as there were cameras and someone at the registration desk. She stated she had not considered it to be less patient-ready if it had been tampered with versus being down the hall in a storage room.”

“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: 45841 Based on facility policy review, record review, and interview, the facility failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to ensure appropriate transfer for 1 (Patient #1) of 3 patients reviewed for transfer requirements. Findings included: The facility failed to properly execute a transfer for 1 (Patient #1) of 3 patients reviewed for transfer requirements. (Refer to A2407 for details.)”

“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: 45841 Based on facility policy review, record review, and interview, the facility failed to properly conduct a transfer for 1 (Patient #1) of 3 patients reviewed for transfer requirements. Findings Include: An undated facility policy titled, “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines for the Emergency Department” indicated, “Transfers or Discharges: A patient must be stabilized prior to transfer and may not be transferred if at risk of deterioration, unless,” which included, “The hospital lacks the capability to treat the condition.” The policy also indicated, “All transfers must meet the following conditions,” which included, “Receiving hospital must accept the patient in advance, and the acceptance must be documented.” Patient 1’s “Emergency Department Note” revealed that the facility admitted the patient on 08/17/25 for suicidal ideation and revealed that the patient would need to be screened by Facility #3. The record included a note at 4:15 PM that indicated the patient had been cleared by Facility #3, and a safety plan was provided by them. The record indicated the patient’s mentation was at baseline. Per the record, the patient’s discharge disposition was “Home,” and the additional discharge instructions included instructions to follow the safety plan provided by Facility #3. Patient 1’s “Summary and Resolution” from Facility #3, dated 08/17/25, revealed that the patient wanted to self-admit to the emergency department (ED) at Facility #2. The record indicated that the patient’s family member agreed to transport them, and a safety plan was created for the drive to Facility #2. Per the record, the patient and their family member agreed that the patient could be safely transported by the family member to Facility #2. Patient 1’s “Crisis Safety Plan” from Facility #3, dated 08/17/25, revealed that the patient’s next outpatient appointment plan was at Facility #2, and the patient’s family member would transport them for inpatient treatment. Patient 1’s record revealed no documented evidence of Facility #2 accepting the patient in advance. During an interview on 09/11/25 at 9:01 AM, Advanced Practice Registered Nurse (APRN) #1 stated that he did not fully remember Patient 1 from 08/17/25. He stated he recalled something about Facility #3 seeing the patient and creating a safety plan about the patient admitting to an outpatient treatment center the following day.”