St Luke Hospital & Living Center

“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 record review, document review, policy review and interview, the Critical Access Hospital (CAH) failed to comply with 42 Code of Federal Regulations (CFR) 489.24 by failing to follow policy and include a patient on the central log and failing to provide a medical screening examination (MSE) for 1 (Patient 1) of 20 patient reviewed. This failure has the likelihood to negatively impact patient outcome due to delayed care. Findings Included: Review of a CAH policy titled, “EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening Examination (MSE), Stabilization and Transfer,” revised 01/2016, indicated, “An appropriate MSE will be provided to individuals on the Hospital’s Campus that request emergency medical services or on whose behalf such services are requested. The purpose of the MSE is to determine whether the Patient [sic] has an Emergency Medical Condition (EMC).” Review of a CAH policy titled, “EMTALA [Emergency Medical Treatment and Labor Act]: Medical Screening Examination (MSE), Stabilization and Transfer,” revised 01/2016, indicated, “Logs must be maintained and must reflect all Patients [sic] who present seeking Emergency Medical Services and whether each Patient [sic] refused treatment or was refused treatment, was transferred, was admitted and treated, was stabilized and Transferred [sic], or was discharged.” Review of a CAH policy titled, “Overview of Emergency Department [ED],” with an effective date of 04/25/23, indicated, “Every patient who presents himself for Emergency Room treatment will be entered in the ER [Emergency Room] log.” 1. The CAH failed to ensure its central log included each individual who came to the emergency department seeking emergency medical care. (Refer to C2405) 2. The CAH failed perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 (Patient 1) of 20 patient who presented to the emergency department (ED) seeking emergency medical care. (Refer to C2406)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45841 Based on record review, interview, document and policy review, the Critical Access Hospital (CAH) failed to ensure its central log included each individual who came to the emergency department (ED) seeking emergency medical care for 1 (Patient 1) of 20 patient. Failure to include individuals on the ED central log has the potential to affect all patients who present to the ED. Findings Included: Review of Patient 1’s “Health Status Note,” dated 05/08/24 at 8:40 AM, revealed that, at 6:00 AM on 05/08/24, a Licensed Practical Nurse (LPN) transported Patient 1 to the ED via wheelchair. Per the LPN’s note, Registered Nurse (RN) 2 told the LPN a physician’s order was required to bring Patient 1 to the ED. The LPN’s note identified that RN 2 stated, “We don’t even have a provider here at this time anyway.” Per the note, the LPN then transported Patient 1 back to the living center and, with other staff assistance, transferred Patient 1 to a recliner for monitoring and continual assessments. The LPN then documented that at 7:00 AM, ED RN 3 accompanied the LPN to the living center and received a report regarding Patient 1 from the LPN. The note identified that the LPN and RN 3 transported Patient 1 to the ED and transferred Patient 1 to an ED gurney. Review of the CAH’s “ER Log Report” for the timeframe from 12/01/23 to 05/19/24 revealed Patient 1 was on the log report with an “Admit Date/Time” of 05/08/24 at 7:20 AM. However, Patient 1’s earlier arrival to the ED, wherein the LPN sought assistance for Patient 1 at 6:00 AM on 05/08/24, was not logged in the report. During an interview on 05/21/24 at 1:31 PM, the Chief Nursing Officer (CNO) confirmed Patient 1 was refused treatment and not added to the ED log the first time Patient 1 presented to the ED on 05/08/24, noting that if a patient was not registered in the ED, they were not added to the ED log.”

“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: 45841 Based on record review and interview, the Critical Access Hospital (CAH) failed to perform an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) existed for 1 (Patient 1) of 20 patient who presented to the emergency department (ED) seeking emergency medical care. The failure to perform an appropriated MSE to determine if an EMC exist has the potential to negatively impact patient outcome due to a delayed care. Findings Included: Review of Patient 1’s “Health Status Note,” dated 05/08/24 at 8:40 AM, revealed that, at 6:00 AM on 05/08/24, a Licensed Practical Nurse (LPN) transported Patient 1 to the facility’s ED via wheelchair. Per the LPN’s note, Registered Nurse (RN) 2 told the LPN a physician’s order was required to bring Patient 1 to the ED. The LPN’s note identified that RN 2 stated, “We don’t even have a provider here at this time anyway.” Per the note, the LPN then transported Patient 1 back to the living center and, with other staff assistance, transferred Patient 1 to a recliner for monitoring and continual assessments. At 6:44 AM, a family member instructed the LPN to send Patient 1 to the ED. The LPN then documented that, at 7:00 AM, ED RN 3 accompanied the LPN to the living center and received a report regarding Patient 1 from the LPN. The note identified that the LPN and RN 3 transported Patient 1 to the ED and transferred Patient 1 to an ED gurney. During an interview on 05/21/24 at 10:30 AM, RN 2 stated that a nursing home employee brought Patient 1 to the ED in a wheelchair, noting the nursing home employee explained that Patient 1 had fallen and was not themselves. Per RN 2, Patient 1 fell earlier in the week and when staff called the family, the family wanted no treatment sought. Due to this, RN 2 stated that she asked the nursing home employee if Patient 1’s family should be called first, noting the nursing home employee denied having spoken to Patient 1’s family or physician. According to RN 2, the nursing home employee agreed and left with Patient 1. During an interview on 05/21/24 at 3:47 PM, Advanced Practice Registered Nurse (APRN) 5 stated that she was onsite in a provider lounge at the time of the incident in question, noting she was never awakened by staff and was not aware of the incident in question until shift change. Per APRN 5, the process called for staff to check in a patient, conduct triage, and then call the phone in the provider lounge to notify the provider that a patient needed to be seen. APRN 5 stated it was not uncommon for nursing home patients to be brought to the ED directly since the ED was onsite. During an interview on 05/21/24 at 3:51 PM, the Chief Nursing Officer (CNO) stated that Patient 1 did not receive an MSE when the patient first presented to the ED at 6:00 AM on 05/08/24 and confirmed that this delayed care of the patient.”