Sheridan County Hospital

“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 Critical Access Hospital (CAH) failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening exam (MSE) and failing to provide stabilizing treatment for 1 (Patient 1) of 20 patients who presented to the emergency department seeking emergency medical care. Failure to provide an appropriate MSE and appropriate stabilizing treatment places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death. Findings Include: Review of CAH policy titled “EMTALA GUIDELINES FOR EMERGENCY DEPARTMENT SERVICES” revised 05/20/2015 showed “ ...All patients shall receive a medical screening exam by an “on call provider” that includes providing all necessary testing and on-call services within the capability of the hospital to determine if an Emergency Medical Condition (EMC) exists. Federal law requires that all necessary definitive treatment be given to the patient and only when an EMC has been ruled out can care be referred to a physician office or clinic. ...An emergency medical condition is any condition that is a danger to the patient or unborn fetus or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. Emergency medical conditions include: Undiagnosed, acute pain which is sufficient to impair the normal functioning ...” Review of CAH document titled “Appendix A [Above Name Hospital] Medical Staff Rules and Regulations” reviewed and approved 11/23, showed, “ ...The federal laws establish a statutory requirement that hospitals with Emergency Departments (interpreted as the emergency function) will provide appropriate emergency treatment to all individuals with emergency medical conditions and all women in active labor. If it is determined an emergency medical condition exists as a result of a medical screening examination, the Emergency Department must provide treatment as required to stabilize the emergency medical condition within the capabilities of the organization, or arrange for a medically appropriate transfer to another facility ...Capabilities refers to the hospital’s physical space, equipment, and supplies, as well as services made available by the hospital such as trauma care, surgery, intensive care, pediatrics, obstetrics, or radiology. The capabilities of the hospital’s staff mean the level of care that the hospital’s personnel can provide within the training and scope of their professional licenses. The hospital’s capabilities to provide a medical screening examination and/or stabilizing treatment may be impacted by the availability of specialist and sub-specialists at any particular time ... Covered Persons means those persons to whom the hospital owes an obligation to provide a medical screening examination and, if appropriate, stabilizing treatment for an emergency medical condition ... Emergency Medical Condition is a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part ... Medical Screening Examination means the process that is required to reach the determination with a reasonable degree of clinical confidence, as to whether the patient has an emergency medical condition. A medical screening examination typically begins with a nursing assessment and is a spectrum ranging from a very simple to a more complex process. It may consist of as little as brief history and physical to the full use of ancillary services depending upon the situation. It is an ongoing process; not an isolated event. Triage is not a medical screening examination. This screening must be universally applied to all patients complaining of the same condition ... ...To Stabilize means a patient is either stable for transfer or stable for discharge. The duty to stabilize is required when the Physician has knowledge that the patient is suffering from an emergency medical condition. To stabilize is to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer ... Based upon this medical screening examination, if it is determined the patient has an emergency medical condition, the Hospital will provide treatment to stabilize the medical condition within the capacity and capabilities of the staff and facilities or will arrange for a certified transfer of the individual to an appropriate medical facility ...” Review of CAH policy titled “Scope of Service” revised 02/2021 showed “It is the policy of [Above Named Hospital] to provide emergency medical services to any patient presenting to the Emergency Room. The Emergency Room provides care 24 hours a day, 7 days a week. Scope and Complexity of Patient Care Needs; All patients that present to [Above Named Hospital] premises for non-scheduled visit in our seeking care, shall receive medical screening exam by Emergency Department “On Call Provider” or other qualified medical personnel as listed in the Medical Staff Bylaws. This includes providing all necessary testing and on-call services within the capability of [Above Named Hospital] to stabilize the emergent condition. These support services, clinical laboratory testing, respiratory therapy, and radiology services, will be provided to the patient in a timely manner. Patients’ response to treatment is evaluated. They are determined to be stable, stabilized, or unstable and a decision regarding disposition will be made ...” Review of CAH policy titled “Fundamental Standards of Care” effective 02/2006, showed, “ ... Fundamental Emergency Department nursing interventions include, but are not limited to the following ... vital signs will be repeated if not within normal limits, as follows: Adult ranges:.. BP: [Blood Pressure] 100/60-140/90 mm/Hg ... 1. The CAH failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking emergency medical care. (Refer to tag A2406) 2. The CAH failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking emergency medical care. (Refer to tag A2407)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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 Critical Access Hospital (CAH) failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 of 20 patients (Patient 1) who presented to the emergency department (ED) seeking emergency medical care. The hospital’s failure to ensure an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which delays necessary stabilizing treatment and may lead to deterioration of the person’s condition, including harm and death. Findings Include: Patient 1 Review of Patient 1’s medical record showed 31-year-old female presented to the ED on 06/16/24 at 9:00 AM via private vehicle and triaged Level 2 (Emergency/High risk). Patient 1’s chief complaint was Joint Pain, Confusion, and Malaise (general discomfort). Review of “Vital Signs” dated 06/16/24 at 9:06 AM showed “BP [Blood Pressure] 185/102 (normal less than 120/80) ...Pain Score 10 ...” Review of “Vital Signs Bar Graph” dated 06/16/24 showed the following: 10:30 AM: BP 170/110 11:25 AM: BP 195/122 (hypertensive crisis higher than 180 systolic or higher than 120 diastolic pressure is a sudden severe increase in blood pressure that can lead to a heart attack, stroke or other life threatening health problems) 12:07 PM: BP 187/126 12:51 PM: BP 231/153 Review of “Review of Systems” dated 06/16/24 at 12:45 PM showed “ ...Neurological:...Endorses headache ...” Review of Patient 1’s “Assessment” dated 06/16/24 at 12:45 PM showed “ ...Periodontal disease (gum infection that damages gums and can destroy the jawbone); patient presents with tooth pain and generalized malaise. This is most likely due to her underlying periodontal disease ...” Review of “Medical Decision Making” dated 06/16/24 at 12:45, PM showed “ ... Reexaminations: Patient is resting comfortably in bed. She declined any medication to control the pain at this time. Patient still declines pain medication on reexam. -Patient Response to Treatment: Patient responded well to 60 mg Toradol (non-steroidal anti-inflammatory drug to treat pain) IM [intramuscular]. Consultations: NONE-Level of Risk this Patient is Considered: Low; Plan: patient will be discharged home. “ Review of “Narrative Notes” dated 06/16/24 showed “12:38 PM- IM Toradol shot given ...12:45 PM -Nurse discussed education and discharge with the patient. Vital signs taken. Provider aware of vital signs ...” Review of Patient 1 medical record showed patient was discharged from Emergency Room on 06/16/24 at 12:51 PM. During an interview on 08/27/24 at 1:44 PM, Staff H, RN (Registered Nurse), stated that a blood pressure over 140/90 is consider high. Patient 1’s blood pressure was extremely elevated and the provider was told. The provider thought it was due to pain. Staff H stated that Patient 1’s blood pressure was very high and she was very concerned about why Patient 1 was being sent home with a BP that high since that is “something that shouldn’t have happened.” During an interview on 08/27/24 at 1:55 PM, Staff G, Physician Assistant (PA), stated that 220’s/150’s would be considered a high blood pressure for an adult patient. Staff G stated that depending on evidence of organ damage or lab findings he would go from there. Staff G stated that he attributed Patient 1’s high blood pressure to pain and sent her home with hydrocodone (pain medication). Staff G stated that they would have Patient 1 “follow up for blood pressure would be appropriate but is not documented ...” During an interview on 08/28/24 at 8:32 AM, Staff F, Director of Nursing, stated that she would be concerned with a blood pressure of 220/153, and that she didn’t know if that blood pressure was stable for dismissal ...” During an interview on 08/28/24 at 11:59 AM, Staff I, MD (Doctor of Medicine), Chief Medical Officer (CMO), stated that someone with a blood pressure of 220’s/150’s and a headache should not have been dismissed and that they would need to be given medications. He stated that the medical screening exam should address the blood pressure with a complaint of headache. Since there was no treatment provided for the blood pressure with headache, the patient was not stabilized before dismissal. Review of Patient 1’s medical record showed the CAH failed to address or further evaluate Patient 1’s elevate blood pressure of 231/153 as part of the medical screening exam and there was no documentation to indicate why the provider did not address or further evaluate Patient 1’s elevated blood pressure.”

“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, document review and interview the Critical Access Hospital (CAH) failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking emergency 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: Patient 1 Review of Patient 1’s ED record showed 31-year-old female presented to the ED on 06/16/24 at 9:00 AM via private vehicle and triaged Level 2. Patient 1’s chief complaint was Joint Pain, Confusion, Malaise (general discomfort). Review of “Vital Signs” dated 06/16/24 at 9:06 AM showed “BP [Blood Pressure] 185/102 (normal less than 120/80) ...Pain Score 10 ...” Review of “Vital Signs Bar Graph” dated 06/16/24 showed the following: 10:30 AM: BP 170/110 11:25 AM: BP 195/122 (hypertensive crisis higher than 180 systolic or higher than 120 diastolic pressure is a sudden severe increase in blood pressure that can lead to a heart attack, stroke or other life threatening health problems) 12:07 PM: BP 187/126 12:51 PM: BP 231/153 Review of “Review of Systems” dated 06/16/24 at 12:45 PM showed “ ...Neurological:...Endorses headache ...” Review of Patient 1’s “Assessment” dated 06/16/24 at 12:45 PM showed “ ...Periodontal disease (gum infection that damages gums and can destroy the jawbone); patient presents with tooth pain and generalized malaise. This is most likely due to her underlying periodontal disease ...” Review of “Medical Decision Making” dated 06/16/24 at 12:45, PM showed “ ... Reexaminations: Patient is resting comfortably in bed. She declined any medication to control the pain at this time. Patient still declines pain medication on reexam. -Patient Response to Treatment: Patient responded well to 60 mg Toradol (non-steroidal anti-inflammatory drug to treat pain) IM [intramuscular]. Consultations: NONE-Level of Risk this Patient is Considered: Low; Plan: patient will be discharged home. Review of “Narrative Notes” dated 06/16/24 showed “12:38 PM- IM Toradol shot given ...12:45 PM -Nurse discussed education and discharge with the patient. Vital signs taken. Provider aware of vital signs ...” Review of Patient 1 medical record showed patient was discharged from Emergency Room on 06/16/24 at 12:51 PM. During an interview on 08/27/24 at 1:44 PM, Staff H, RN (Registered Nurse), stated that a blood pressure over 140/90 is consider high. Patient 1’s blood pressure was extremely elevated and the provider was told. The provider thought it was due to pain. Staff H stated that Patient 1’s blood pressure was very high and she was very concerned about why Patient 1 was being sent home with a BP that high since that is “something that shouldn’t have happened.” During an interview on 08/27/24 at 1:55 PM, Staff G, Physician Assistant (PA), stated that 220’s/150’s would be considered a high blood pressure for an adult patient. Staff G stated that depending on evidence of organ damage or lab findings he would go from there. Staff G stated that he attributed Patient 1’s high blood pressure to pain and sent her home with hydrocodone (pain medication). Staff G stated that they would have Patient 1 “follow up for blood pressure would be appropriate but is not documented ...” During an interview on 08/28/24 at 8:32 AM, Staff F, Director of Nursing, stated that she would be concerned with a blood pressure of 220/153, and that she didn’t know if that blood pressure was stable for dismissal ...” During an interview on 08/28/24 at 11:59 AM, Staff I, MD (Doctor of Medicine), Chief Medical Officer (CMO), stated that someone with a blood pressure of 220’s/150’s and a headache should not have been dismissed and that they would need to be given medications. He stated that the medical screening exam should address the blood pressure with a complaint of headache. Since there was no treatment provided for the blood pressure with headache, the patient was not stabilized before dismissal. During an interview on 08/28/24 at 11:59 AM, Staff I, MD (Doctor of Medicine), Chief Medical Officer (CMO), stated, “Should not have dismissed someone with a blood pressure of 220’s/150’s with a headache, they needed to be given medications. The medical screening exam should address the blood pressure with a complaint of headache. Review of Patient 1’s medical record showed the CAH failed to provide stabilizing treatment or interventions within their capability for Patient 1’s elevated blood pressure of 231/153 and there was no documentation in medical record to indicate why Patient 1’s blood pressure was not addressed or treated prior to discharge. Review of Patient 1’s medical record from Hospital B dated 06/16/24 at 6:16 PM showed “ ...Chief Complaint; headache and malaise ...initial vital signs: ...BP 165/114 ...administer Labetalol 10 mg IV for severe hypertension ...” Patient 1 was admitted from Emergency Room on 06/16/24 and discharged from Hospital B on 06/18/24 with diagnosis of Hypertensive Urgency (marked elevation in blood pressure without evidence of organ damage).”