William Newton Hospital

“DISCHARGE PLANNING CFR(s): A Critical Access Hospital (CAH) must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from the CAH to post-discharge care, and reduce the factors leading to preventable CAH and hospital readmissions. This Condition is not met as evidenced by: 52950 Based on policy review, medical record review, and interview, the Critical Access Hospital (CAH) failed to ensure an effective discharge planning process that identified and arranged necessary post-hospital services prior to discharge. 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. On 03/09/26 at 4:20 PM, Surveyors notified hospital administration Staff A, Chief Nursing Officer that an IJ existed related to §485.642, Condition of Participation: Discharge Planning. On 03/10/26 at 10:06 AM, the hospital submitted a plan of removal (POR). On 03/10/26 at 10:52 AM the hospital was notified the written POR was accepted. The POR included the following: “Due to the lack of case management documentation for Patient #1, follow-through and verification of service setup with the Hospice company, and judicial authorization of a DNR, the patient was discharged to home without a DNR and without Hospice set up in the home. This has the potential to affect all patients who require post-hospital services. On 03/10/2026 Immediate implementation of the Patient Services Referral Verification Form for all discharges with post-hospital services needs. This form will be faxed to each referring services company, filled out by the referring company, and returned to Case Management and/or the nurse. The patient will not be discharged until receipt of the form and verification of post-discharge services. Post Hospital Services will be reviewed and checked off by the discharging RN on the discharge checklist. The Patient’s Referral Verification Form shall be uploaded into the patient’s medical record. Education implemented to nursing, case management on 3/10/2026.Completion date of 3/13/2026. Attestation will be signed after education has been completed and placed in the employee’s files. Patient Needs Prior to Discharge Form was created on 3/9/2026. This form will be placed in the patient’s chart. This discharge checklist will be completed by the primary nurse for all post-hospital care needs. Education implemented to nursing, case management on 3/10/2026. Completion date of 3/13/2026.Attestation will be signed after education has been completed and placed in the employee’s files. Case Management will coordinate Durable Medical Equipment, oxygen, for post-hospital care, which will be verified prior to discharge with the Respiratory Therapy Department or receiving facility to ensure all equipment is available upon the patient’s arrival to post-hospital services. This will also be verified by the discharging nurse per the patient’s needs checklist at discharge. Education to case management, nursing, and respiratory therapy was implemented on 3/10/2026. Completion date of 3/13/2026.will be signed after education has been completed and placed in the employee’s files. Immediate education/implementation for Judicial Authorization for Do Not Resuscitate processes to nursing/case management created on 3/9/2026. Patients who are deemed a current ward of the state will have their code status reviewed upon admission. If the patient declines in our care, the ward’s treating physician shall certify in writing to the guardian that the ward is in a persistent vegetative state or is suffering from an illness or other medical condition for which further treatment, other than for the relief of pain, would not likely prolong the life of the ward other than by artificial means, nor would be likely to restore to the ward any significant degree of capabilities beyond those the ward currently possesses, and which opinion is concurred in by either a second physician for the purposes of reviewing such circumstances and the appropriateness of any type of physician’s order which would have the effect of withholding or withdrawing life-saving or life-sustaining medical care, treatment, services or procedures. Such written certification shall be approved by an order issued by the court. Education implemented on 3/10/2026 and completion on 3/13/2026. Discharge Planning Policy was reviewed and revised on 3/9/2026. Pending approval through the Medical Executive Committee by 3/13/2026. Education/review to nursing, case management to be completed by 3/13/2026. Nursing and Case Management will be assigned this policy to review through Policy Tech. The Quality Director and or designee will conduct Post-Hospital Services Audits for 6 months of the corrective action put into place to prevent occurrence reoccurrence of a serious adverse outcome or event. Audit form developed 3/9/2026, education implemented on 3/10/2026. These results will be shared at the Quality / Risk Committee Meetings Quarterly. The Case Manager, Risk Manager, and Quality Director will receive education regarding appropriate documentation for each encounter on 3/10/2026 to be completed by 3/13/2026. “ The Critical Access Hospital’s plan of removal was validated on 03/16/26 at 2:43 PM. Findings Include: 1. The Critical Access Hospital (CAH) failed to ensure the patient’s discharge needs were evaluated for 1 of 21 sampled patients. (Refer tag C-1406) 2. The Critical Access Hospital (CAH) failed to ensure proper arrangements of post-hospital services for 1 of 21 sampled patients. (Refer tag C-1408) 3. The Critical Access Hospital (CAH) failed to ensure that the discharge plan was developed or implemented effectively for 1 of 21 sampled patients. (Refer tag C-1420) 4. The Critical Access Hospital (CAH) failed to ensure that all necessary medical information pertaining to the patient’s current course of illness and treatment was sent to the appropriate post-hospital provider for 1 of 21 sampled patients. (Refer tag C-1430)”

“DISCHARGE PLANNING EVALUATION CFR(s): (1) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-CAH care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 52950 Based on policy review, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the discharge plan was implemented and that necessary services and information were arranged and communicated to the receiving provider prior to discharge for 1 of 21 (Patient 1) sampled patient records reviewed. This deficient practice has the potential to affect all patients receiving services at this CAH by placing them at risk for unsafe discharge, unmet medical needs, and lack of continuity of care, which could result in deterioration of the patient’s condition, preventable readmissions, or serious adverse outcomes. Findings Include: Review of undated CAH policy titled, “Department: Case Management Discharge Planning,” , showed” ...Case Management will contact chosen resources and assist patient and patient designee to know action they need to take to have the resources made available to the patient ...” Patient 1 Review of Patient 1’s medical record dated 09/11/25 showed that the patient presented to the emergency department by her group home for concerns of being sleepier and more lethargic recently, with low blood pressure. Initial case management assessment, evaluation, and discharge planning were completed on 09/12/25 at 1:34 PM by Staff D, Case Management. Review of Patient 1’s “Daily Progress Note” dated 09/16/25 showed “ ...Patient actively declining, poor quality of life, and likely to continually aspirate. Spoke with DPOA, who agreed to Hospice care, but cannot authorize DNR status without petitioning the court. Paperwork filled out and placed on chart to assist with court petition ...” Review of Patient 1’s “Physician Entered Orders,” dated 09/16/25 at 11:50 PM, showed “Consult Hospice.” Review of Patient 1’s “Progress Note” dated 09/19/25 at 9:58 AM showed “ ...given poor overall status, working on change in status to DNR through court, agreed upon guardian. Possible DC back to facility on hospice with case management helping coordinate ...” Review of Patient 1’s “Physician Entered Orders,” dated 09/19/25 at 11:39 AM, showed “Discharge to LTC (long term care) Facility, [Long Term Care Facility (LTCF) 1] with hospice.” Review of Patient 1’s “Case Management INPT Discharge Note” dated 09/19/25 at 11:33 AM showed home with Hospice 1. Choice form completed. LTCF to transport Patient 1 back to the group home. During an interview on 03/06/26 at 12:45 PM, Staff D, Case Management (CM), confirmed that there is no documentation in the medical record for sending documentation to Hospice 1 for Patient 1, nor for the patient’s oxygen needs.”

“DISCHARGE PLANNING EVALUATION CFR(s): (2) A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-CAH services, including, but not limited to, hospice care services, post- CAH extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 52950 Based on policy review, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the discharge plan was implemented and documented, including arranging necessary medical equipment prior to discharge, for 1 of 21 patient records reviewed (Patient 1). This failure has the potential to affect the patient’s health and safety following dismissal. Findings Include: Review of undated hospital policy titled, “Nursing Service Discharge of Patient,” showed “ ...12. If the patient has been on oxygen, notify respiratory of the discharge so that they may assess the patient for any need of home oxygen therapy ...” Patient 1 Review of Patient 1’s medical record showed that on the day of dismissal,09/19/25, the patient was on 7 liters per OxyMask. Respiratory therapist documentation dated 09/19/25 at 9:40 AM, showed “ ...oxy mask 7 L. pt has very dry mouth with lots of dried mucus on the tongue and oral cavity. used a green sponge soaked with water, cleaned inside of the mouth and areas around the lips for 5 mins. No suction needed at this time. Pt’s SPO2 dropped during the cleaning but recovered once oxy mask was back on.” The medical record did not contain documentation confirming that hospice had been notified of Patient 1’s discharge or that hospice had arranged oxygen services. During an interview on 03/09/26 at 9:32 AM, Staff R, Respiratory Therapist, explained that respiratory usually arranges for home oxygen, but was under the impression Patient 1 was under Hospice care when dismissed, so O2 was not arranged.”

“DISCHARGE PLANNING CFR(s): (6) The CAH’s discharge planning process must require regular reevaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. This Standard is not met as evidenced by: 52950 Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the discharge planning process included regular re-evaluation of the patient’s condition to identify changes that required modification of the discharge plan for 1 of 21 (Patient 1) sampled patient records reviewed. The CAH’s failure to ensure ongoing and regular reevaluation of discharge planning needs has the potential to affect all patients receiving services at this facility for inappropriate or unsafe discharges, unmet post-hospital care needs, delay in necessary services or equipment, lack of coordination with post discharge providers, and increase risk for adverse outcomes, including readmission, deterioration of conditions or death. Findings Include: Review of undated critical access hospital policy titled “Department: Case Management Discharge Planning,” and undated hospital policy titled “ Nursing Service Discharge of Patient,” showed that the policies did not include ongoing or regular reevaluation of patients’ discharge needs. Patient 1 Review of Patient 1’s Case Management documentation showed that the initial assessment was done on 09/12/25 at 1:34 PM and then the discharge note on 09/19/25 at 11:33 AM. Review of Patient 1’s “Daily Progress Note” on 09/16/25 by Staff I, MD, showed “ ...Patient actively declining, poor quality of life, and likely to continually aspirate. Spoke with DPOA who agreed to Hospice cares, but cannot authorize DNR status without petitioning the court. Paperwork filled out and placed on chart to assist with court petition ...” Further review showed “ ... Patient with poor quality of life, overall poor prognosis, advanced age with cerebral palsy, repetitive aspirations with tube feeds, difficult to maintain IV access and unable to obtain Midline vs PICC. Currently decompensating despite antibiotic therapy, treatments for secretions, etc. Holding tube feeds at this time 2/2 aspirations, but nutritional status will eventually become problematic. Meds still being administered via G Tube, including potassium, which continues to be low despite adequate supplementation, indicating likely wasting vs poor absorption. Should she decompensate further, she is likely to require aggressive treatments up to and including intubation and/or compressions, which could prove devastating and result in vent dependence vs persistent vegetative state. Discussion with DPOA regarding pursuing hospice/palliative cares fruitful - agreed to pursue Hospice cares in outpatient, and will petition court for DNR status. Physician exam paperwork confirming the need to obtain a DNR status completed and witnessed, place on paper chart ...” The medical record did not contain documentation of judicial authorization for the Do Not Resuscitate (DNR) prior to discharge. During an interview on 03/05/26 at 4:04 PM, Staff Q, Licensed Practical Nurse (LPN), at Patient 1’s long-term care residential facility (LTCF) 1, stated that she was aware of Patient 1’s condition and had spoken to the Case Manager and nursing staff regarding transferring her back to LTCF 1. We weren’t comfortable taking her back until the DNR was in place and hospice had been arranged. The Case Manager notified Staff Q that Patient 1 was ready for discharge, and when the transport van arrived, they were told that Patient 1 was on 7 liters of oxygen. When they informed the nurse taking care of Patient 1, their regulator only went to 5 liters they were told it was okay to transport on 5 liters, as Patient 1 was going to “desat” (desaturation indicating a drop in blood oxygen levels below normal) anyways. Patient 1 was brought back to the LTCF 1, without a DNR in place, and stopped breathing when arrived. Cardiopulmonary resuscitation (CPR) was initiated, emergency medical service (EMS) called and Patient 1 returned to the hospital Emergency Department (ED) .”

“DISCHARGE PLANNING CFR(s): (b) Standard: Discharge of the patient and provision and transmission of the patient’s necessary medical information. The CAH must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, postdischarge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 52950 Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that necessary medical information was provided to the receiving post-hospital care provider for 1(Patient 1) of 21 sampled patients. Failure to provide necessary medical information to the receiving provider has the potential for gaps in care coordination and continuity of care following discharge. Findings Include: Patient 1 Review of Patient 1’s medical record showed that the patient was discharged on 09/19/25 at 12:36 PM. Discharge summary showed “ ...The patient is now cleared for discharge to home facility with hospice to continue care ...” The medical record did not contain documentation that discharge instructions, clinical information, medication list, or treatment orders were sent to the hospice agency. There was no evidence that the hospice provider received notification of the discharge or the patient’s current care needs, including the requirements for oxygen therapy. During an interview on 03/05/26 at 11:13 AM, Staff N, Hospice 1, , stated that the referral was received, but the discharge orders had not been received, and that Patient 1 died before admission. During an interview on 03/06/26 at 12:45 PM with Staff D, Case Management, confirmed that for Patient 1 there is no documentation in the medical record for sending documentation to, nor for the patient’s oxygen needs.”

“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: 52950 Based on record review, policy review, email review, staff interviews and observation the critical access hospital (CAH) failed to ensure the Emergency Medical Treatment and Labor Act (EMTALA) requirements were met by failing to ensure an appropriate medical screening exam (MSE) was provided by qualified medical personnel (QMP) and failed to ensure EMTALA signage was conspicuously posted in required locations, including emergency department triage and treatment areas and waiting area in Labor & Delivery area. Failure to ensure the MSE was performed by a QMP and EMTALA signage places patients at risk for unidentified emergency medical conditions (EMC) and for being unaware of their rights to MSE, stabilizing treatment, and medicaid participation. Findings Include: The CAH failed to have the required EMTALA signage posted in the treatment and triage areas of the emergency room and the waiting area in Labor and Delivery. (Refer to tag C-2402) The CAH failed to ensure an appropriate medical screening examination (MSE) was provided by a qualified medical personnel (QMP) for 3 (Patient 1, Patient 23 and 24) of 24 patients reviewed. (Refer to tag C-2406)”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 52950 Based on observations and staff interview, the critical access hospital failed (CAH) to ensure the Emergency Medical Treatment and Labor Act (EMTALA) signage was conspicuously posted in all required locations, including emergency department (ED) triage and treatment areas, and Obstetrical/Labor and Delivery waiting areas, resulting in the potential for patients to be unaware of their rights with respect to examination and treatment of emergency medical conditions (EMC) and women in labor, and whether or not the critical access hospital participates in the medicaid program. Finding Include: Observation on 12/15/25 at 10:32 AM revealed no EMTALA signage posted in the Obstetrical/ Labor and Delivery waiting area. In the triage area, the signage was not permanently posted, but instead hung on a ring that did not ensure it was continuously conspicuous to individuals presenting for evaluation of labor. Observation on 12/15/25 at 10:50 AM revealed no EMTALA signage posted in the ED triage area or ED treatment rooms. EMTALA signage was observed only at the ED registration desk and the nursing station, which is not consistently accessible or visible to patients once they enter triage or are placed in treatment rooms. During an interview on 12/15/25 at 2:00 PM with Staff C, Registered Nurse (RN), Labor and Delivery Manager, confirmed that the EMTALA signage was only displayed on a ring in the OB triage area, and there was no signage in the Obstetrics (OB) waiting area. During an interview on 12/16/25 at 3:20 PM with Staff B, Chief Nursing Officer (CNO) and Emergency Department (ED) Manager confirmed EMTALA signage was not posted in the ED triage or treatment areas.”

“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: 52950 Based on document review, record review, policy review, and staff interviews, the critical access hospital (CAH) failed to ensure an appropriate medical screening examination (MSE) was provided by qualified medical personnel (QMP) for 3 (Patient 1, Patient 23 and 24) of 24 reviewed. Failure to ensure an appropriate MSE is provided has the potential to place patients at risk for unidentified emergency medical conditions (EMC). Finding Include: Review of the CAH policy titled, “EMTALA: Medical Screening Examination and Stabilization, Policy for Transfer, and Provision of on-call Coverage,” date created 10/29/25, showed, “ ... A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC, or a pregnant woman is in labor. An MSE is required when: a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual’s behalf for examination or treatment for a medical condition, including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition. ...The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. ...iii. Labor and Delivery QMP. QMPs in the labor and delivery DED [dedicated emergency department] may be appropriately approved RNs and must communicate their findings as to whether or not a woman is in labor to the obstetrician on call, the laborist, or the ED physician ...” Review of a CAH document titled, “Medical Staff Rules and Regulations,” date revised 11/25, showed, “ ...SECTION 4 - EMERGENCY ROOM ... 9. Every patient who presents at WNH for emergency care shall receive a Medical Screening Exam (MSE) to determine if a medical emergency exists. An MSE can only be completed by a licensed independent practitioner (LIP) in the Emergency Department. When an OP provider is not available, a qualified competent OB nurse may perform an OB MSE. MSE is not the same as triage. Patients will receive an MSE in compliance with EMTALA laws. The screeners must have privileges at WNH ...11. Labor screening - A woman who presents to the Hospital or has been admitted and is experiencing contractions is considered in true labor, unless a physician or certified nurse midwife certifies that, after a reasonable time of observation, the woman is in false labor. Such certification can be provided by telephone if labor screening is conducted by qualified screeners who have specific privileges or documented competencies in screening for labor. The Medical Staff will determine the minimum content of an obstetric screening examination ...” Patient 1 Review of patient 1’s medical record showed a 37-year-old male presented to the emergency room (ED) on 11/07/25 at 10:08 PM, with a complaint of abdominal pain. Patient 1 was triaged by Staff I, RN, and then returned to the waiting area, as no treatment rooms were immediately available. Staff I, RN, notified Staff O, Agency RN, who took Patient 1 back to triage for discussion regarding current diagnostic limitations (no CT scanner). Patient 1 was informed multiple times that they are willing and able to evaluate and treat him at this facility. However, Patient 1 was also informed that the facility’s CT scanner was currently out of operation. It was explained that, if the provider’s assessment determined a CT scan was necessary, the patient would likely require transfer to a nearby facility for imaging. Patient 1 was also informed that there were currently four pending transfers and that transport availability and wait times may be extended. Patient 1 was informed he had the right to remain and be evaluated there, or he could choose to leave and seek evaluation at another facility with a functioning CT scanner. Patient 1 declined further evaluation and elected to leave without being seen by a provider on 11/07/25 at 10:38 PM. There was no against medical advice/left without being seen (AMA/LWBS) form signed by Patient 1 During a phone interview on 12/18/25 at 2:36 PM with Patient 1, stated that when he went to the ED, he was told the CT scanner was not working. Was told by the nurse that, based on his symptoms, he would need a CT scan, and that one of his options would be to go to another facility to have it done. Patient 1 was never seen by the physician. Didn’t sign anything about leaving without being seen. Patient 1 was told that they recommended he not go home but go to another ER to get the scan done. He stated that he ended up being transferred to another acute care hospital after the scan was done. Patient 1 stated that he was at the acute care hospital for about 3 weeks and was diagnosed with severe diverticulitis requiring a colostomy bag. During a phone interview on 12/19/25 at 9:57 AM with Staff I, RN, stated that she was orienting with Staff O, Agency RN, and had triaged Patient 1, who was having abdominal pain. Informed Staff O, Agency RN that she had returned Patient 1 to the waiting room, and he was likely going to need a CT scan. Patient 1 was brought back into the room, and Staff O discussed with Patient 1 the situation at the hospital, explaining that he would have to wait a while if the doctor felt he needed a CT scan. He told him we would be happy to see him but wanted to give him full disclosure of the possible wait times. Patient 1 asked him what his options were, and Staff O informed him there were other facilities in the area he could go to. Patient 1 decided to leave without being seen. Staff I also stated she brought him in the AMA form to sign but was told that was not needed because he had not been seen by a provider. Corrective action, related to Patient 1, taken prior to survey entrance included the following: Review of a message sent through Paylocity from Department Nurse Manager dated 11/8/25, “Just in Time Training: EMTALA [Emergency Medical Treatment and Labor Act],” stated, “With the CT [Computed Tomography] system down I know it feels like we should be telling people in the triage process that the CT is down. However, if we do this before a MSE (Medical Screening Exam) is completed it is considered an EMTALA violation because the patient has not had a complete MSE. We CAN NOT tell people to go to another facility, it has to be an intependant [sic] choice of the patient to leave. I know that a previous CEO stated that the MSE started in triage, as the nurse or medic is doing an initial assessment to see if there is a need for life saving treatment to be started immediately. However, the MSE to be fully completed must be done by a licensed independent provider-an MD [Doctor of Medicine], DO [Doctor of Osteopathic Medicine], PA [Physician Assistance], or APRN [Advanced Practice Registered Nurse]. I know that this situation has been challening [sic]and I appreciate all you have done to work through this challening [sic]time. I need you to type “I understand” below to acknowledge so I know that you have seen this.” Review of “The Exchange” bi-weekly employee newsletter, dated 11/13/25, to all staff, from Risk Management, “ ...Patient Screening & Triage Reminders stated, “Please review these guidelines and ensure you are strictly adhering to the requirements for both Medical Screening Examinations (MSE) by a provider and patient triage for all patients requesting evaluation. Your attention to these details helps us maintain compliance and deliver appropriate care. SCREEN ALL PATIENTS: If a person comes to the hospital requesting an evaluation for a medical condition, they must receive a medical screening examination (MSE) to determine if an emergency medical condition exists, this must be done by the provider. ALL patient must also have a triage completed - this is NOT the same as a MSE.” During an interview on 12/19/25 at 9:35 AM, with Staff B, CNO, stated that Staff O, Agency RN was placed on suspension until the investigation was completed and was later terminated. She stated that the ED did receive extra EMTALA education in addition to their annual training and “Just in Time Training” and in the newsletter Exchange. Patient 23 Review of Patient 23’s medical record showed a 20-year-old female, 38 weeks and 3 days gestation age (38.3 GA), presented to Labor and Delivery on 10/29/25 at 10:22 PM, with a complaint of lower back pain, increased urination, and was unsure if it was fluid or urine. Patient 23 was triaged by Staff L, Agency RN, and plan for random urinalysis, rapid point of care immunoassay rupture of membrane test (ROM plus) [test to detect premature rupture of fetal membranes in pregnant women], and sterile vaginal exam (SVE). Electronic fetal monitoring (EFM) and tocodynamometer (TOCO) [pressure-sensitive device placed on the upper part of the mother’s abdomen to measure changes in abdominal tension caused by uterine contractions] were applied. Vital signs documented; ROM was negative. Patient 23’s medical record revealed Staff L, Agency RN, updated Staff F, Doctor of Osteopathic Medicine (DO), Service Chief of Obstetrics (OB) at 11:13 PM of patient’s arrival and results of exam and testing, as well as fetal status. Review of Patient 23’s physician orders dated 10/29/25 at 10:28 PM revealed a phone order to discharge Patient 23 home when criteria met was received from Staff F, DO and documented by Staff L, Agency RN. The record showed Patient 23 was dismissed at 11:38 PM. Further review of Patient 23’s medical record revealed Staff F, DO, documented, “Reactive Non-Stress test on 10/29/25”, on date of service 10/29/25 and electronically signed on 11/05/25 at 9:11 PM by Staff F. Patient 23’s medical record failed to show documented evidence that Staff F, DO presented to the CAH to examine Patient 23 or that an appropriate MSE was provided by a QMP. Patient 24 Review of Patient 24’s medical record showed a 24-year-old female arrived on the OB floor on 11/24/25 at 6:17 PM, complaining of leaking of clear fluid. She reports decreased fetal movements (DFM) and denies vaginal bleeding (VB) or contractions (Ctx). The record showed Staff M, OB, RN, documented ROM obtained. Monitoring with external ultrasound (US), and TOCO. The record showed Staff N, OB, RN notified Staff F, DO, at 7:20 PM, that Patient 24 was 29 weeks of gestation age, a gentle SVE was done by Staff M, OB, RN, and “was closed.” No contractions noted on the monitor, ROM plus negative, fetal heart tones (FHTs) reactive 140’s. Review of the physician orders dated 11/24/25 at 6:25 PM revealed a phone order to discharge Patient 24 home when criteria met was received from Staff F, DO, and documented by Staff M, OB, RN. The record showed Patient 24 was dismissed at 7:35 PM. Further review of Patient 24’s medical record revealed Staff F, DO, documented, “Reassuring Non-Stress test for a 29 wk [week] gestation” on date of service 11/24/25, and electronically signed on 12/03/25 at 8:56 AM by Staff F. Patient 24’s medical record failed to show documented evidence that Staff F, DO presented to the CAH to examine Patient 24 or that an appropriate MSE was provided by a QMP. Review of personnel files on 12/18/25 at 2:15 PM with Staff B, Chief Nursing Officer (CNO), and Staff J, Human Resources Director (HRD), showed that Staff L, RN Agency, did not have EMTALA or triage education on file, or that she was qualified to perform an MSE. Staff B, CNO, stated that there are 13 Labor and Delivery (L&D) RNs, and all can perform MSE. Obstetrical registered nurses (RN) were identified by CAH policy as QMP; however, the hospital failed to demonstrate that these obstetrical RNs had documented training and competency to perform MSE. During an interview on 12/16/25 at 2:30 PM with Staff C, Registered Nurse (RN), Labor and Delivery Manager, stated that there is no formal ongoing competency process regarding OB nurses as QMP, and doing screening exams. “They have always done it. Had a meeting in October to discuss this. Review of the CAH meeting minutes, “EMTALA Policy Review” dated 10/07/25, showed, “ ...Discussions was held to complete OB competencies specific to the MSE. Discussed whether Dr. Miller could check off the nursing staff to prove competency ...” During a phone interview on 12/18/25 at 3:15 PM, Staff F, Doctor of Osteopathic Medicine (DO), Service Chief of Obstetrics (OB), stated that, they should have their training documented and maintain their qualifications. There are observation orders for the Labor and Delivery nurses to utilize for walk-ins. The OB nurses will notify him or the on-call OB doctor of the patient’s arrival and their assessment. I will review the non-stress test (NST) afterwards and dictate the results, not necessarily the same day. The Director of Nursing has emailed the MSE OB competency checklist, which will be initiated and maintained on an ongoing basis. During an interview on 12/19/25 at 9:20 AM with Staff H, OB RN, stated that anyone coming to labor and delivery will be triaged. When asked to describe the difference between triage and a medical screening exam, she was unable to provide a clear distinction. During an interview on 12/19/25 at 10:48 AM with Staff A, Interim Chief Executive Officer (CEO), stated that she questioned the lack of EMTALA signage in the ED and Labor and Delivery. She stated that, they had a meeting in October regarding EMTALA policy review and the gaps in the policies. She also stated that, the Medical Staff Rules and Regulations need to be updated/revised regarding OB nurses as QMPs, vague use of wording as qualified screeners will need to be defined. Will need to clearly define in the Rules and Regulations qualifications and competency requirements for OB QMP. A checklist has been drafted for competency validation for labor specific EMTALA.”