Highlands Arh Regional Medical Center

“EMERGENCY SERVICES READINESS CFR(s): Effective July 1, 2025, in accordance with the complexity and scope of services offered, there must be adequate provisions and protocols to meet the emergency needs of patients. This Standard is not met as evidenced by: 47852 Based on interviews, record review, and review of facility policies, it was determined the facility failed to provide adequate provisions and protocols to meet the emergency needs of patients for one (1) of 21 sampled patient (P), P1. P1 presented to the facility’s Emergency Department with complaints of pain eight (8) out of 10 following falls at home. The facility did not follow their policy for triage or care of P1 following P1’s complaint of eight (8) out of 10 pain or further complaints of pain 10 out of 10 with chest pain. The findings include: Review of the facility’s policy, “Pain Management,” revised 07/15/2025, revealed all patients would be evaluated for pain on initial presentation to the hospital. Further review revealed a numerical pain scale of zero (0) to 10 would be utilized with severe pain being seven (7) to 10. Review of the facility’s policy, “Triage Assessment and Reassessment,” adopted 10/2024, revealed the purpose of the policy was to ensure timely and accurate triage, assessment, and reassessment of patients to prioritize care and manage resources effectively. Further review revealed the policy aimed to standardize procedures for determining patient acuity and frequency of vital sign monitoring based on the Emergency Severity Index (ESI). Continued review revealed ESI Level 2 as a high-risk situation, confused, lethargic, disorientation, severe pain, severe distress or high-risk vital signs and ESI Level 4 was one (1) resource required. Additionally, the triage assessment procedure included determining the patient’s acuity level using the ESI system to identify life-threatening conditions and prioritize care and initiating treatment protocols relevant to the patient’s presenting condition if there was an anticipated delay in provider evaluation. Review revealed ESI Level 2 patients vital signs should be reassessed every one (1) hour or more frequently based on patient acuity and clinical presentation. Review of ESI Triage Algorithm, Version 5, revealed a patient with severe pain/distress was classified as an ESI Level 2. Review of the facility’s policy, “ED Nursing Chest Pain On Arrival Policy,” adopted 01/14/2023, revealed the facility defined chest pain as more than pain in the chest and pain in the chest, shoulders, and back should be considered equivalents. Further review revealed the ED Nursing Chest Pain on arrival order set would be implemented by the ED Registered Nurse (RN) after triage on all patients presenting to the ED complaining of chest pain or equivalent symptoms. Review of the facility’s policy, “ED Nursing Chest Pain On Arrival Protocol Orders,” adopted 01/14/2023, revealed all patient who arrived at the ED with chest pain should receive the following care: A. The treatment protocols would be implemented by the ED RN after triage or primary nursing assessment. The ED RN would initiate the order set within the Electronic Medical Record (EMR) system for ED Nursing Chest Pain On Arrival Protocol Orders. B. The ED Physician, Physician’s Assistant (PA), or Nurse Practitioner (APRN) would be notified of the protocol implementation. The provider would sign, time, and date the corresponding protocol order sheet in the EMR and make changes if applicable. Further review revealed the orders to be placed included an electrocardiogram (ECG) (a test to check heart rhythm) 12 lead once, an ECG 12 lead as needed every 15 to 30 minutes, a chest x-ray, cardiac monitoring, continuous pulse oximetry, oxygen as needed, immediate (STAT) labs, and a 324 milligram (mg) Aspirin. Review of the facility’s policy, “Trauma Activation Criteria-Level IV Trauma,” undated, revealed potential criteria for activation included older adults with low impact mechanisms (such as ground level falls) which might result in severe injury, anticoagulants (blood thinners), and ED Provider and nursing staff judgement. Review of P1’s Face Sheet revealed Facility 1 registered P1 in the Emergency Department (ED) on 05/15/2025 at 7:23 PM for a complaint of “fell times two (2) yesterday, hurt shoulder.” Review of P1’s Physician Orders, dated 05/15/2025, revealed ED Physician 1 ordered a chest x-ray and ribs x-ray at 10:04 PM which was taken at 11:43 PM and resulted on 05/16/2026 at 12:38 AM. However, there was no evidence that the chest pain or trauma protocols were ordered. Review of ED Physician 1’s note revealed the provider saw P1 on 05/15/2025 at 9:59 PM. Further review revealed P1 was brought into the ED after falling two (2) times the day before with complaints of head and neck pain over the right shoulder and right chest. Continued review revealed P1 had a history of atrial fibrillation (an irregular heart rhythm) with a pacemaker and took Eliquis (a blood thinning medication). Additionally, P1 had chest pain from the fall. Review revealed the provider assessed P1’s lungs to be clear with no rales, rhonchi or wheezing (abnormal lung sounds). Further review revealed ED Physician 1 next documented a chest tube insertion at 1:41 PM (later interviews revealed the time was 1:41 AM on 05/16/2025) for a hemothorax on P1’s right side with initial drainage of 1500 milliliters (ml). Continued review revealed P1 had multiple rib fractures (four (4) or more) with a pneumothorax and discharged to another facility. Review of the Transfer Center Summary (a system used by the facility to facilitate transfers to other facilities) revealed Facility 1 had requested an urgent transfer to Facility 2 for a “higher level of care” due to trauma initiated on 05/16/2025 at 12:20 AM. Further review revealed ED Physician 1 gave report on 05/16/2025 at 12:33 AM to Facility 2’s ED Physician that P1 had fallen and had a right hemopneumo (thorax) and fifth (5th) rib fracture and Facility 2’s ED physician advised ED Physician 1 to put in a chest tube before transporting P1. Review of P1’s Transfer Record revealed no documentation of why P1 was transferred to another facility or how P1 was transferred. Further review revealed ED Physician 1 signed both the section that P1 was stable and the section that P1 was unstable. Continued review revealed no risks and benefits of transfer documented. Review of Facility 1’s Discharge Summary revealed the facility triaged P1 on 05/15/2025 at 7:24 PM at an ESI Level 4 (less urgent) with complaints of pain eight (8) out of 10 with a frequency of re-assessment and vital signs every two (2) hours. Further review revealed the facility documented P1’s Pain Assessment on 05/15/2025 at 8:28 PM to be 10/10 in the right chest and back and vital signs to begin every one (1) hour frequency. During an interview, on 02/19/2026 at 12:38 PM, ED Physician 1 stated he was looking at P1’s chart remotely and stated the chest pain protocol was not initiated because P1 was a “trauma” patient and he would have immediately seen the patient once the patient registered as having a fall with pain eight (8) out of 10. He further stated he called for a portable chest x-ray and could see “on the screen” P1 had rib fractures and a hemopneumothorax in real time as the x-ray was being taken. He continued to state he placed a chest tube in P1, then notified the surgeon on call who stated he did not feel comfortable taking care of P1 secondary to P1 taking a blood thinning medication and requested P1 be sent to Facility 2 for evaluation by a thoracic surgeon. However, records indicate ED Physician 1 called for a transfer to Facility 2 prior to placing the chest tube and the ED Physician at Facility 2 recommended the chest tube. During an interview, on 02/19/2026 at 7:52 PM, Registered Nurse (RN) 1 stated he provided care to P1 on 05/15/2025 after the patient was triaged and placed in a bed. He further stated if he triaged a patient with chest pain, he would typically initiate the chest pain protocol and order an ECG. The triage nurse on 05/15/2025 night shift no longer worked at the facility and the facility was unable to provide a current phone number for the nurse. Numerous attempts were made to contact P1 and his family member without a return call.”

“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: 44370 Based on interviews, record review, video footage, EMS (Emergency Medical Services) Patient Care Report, Child Adult Domestic and Dating Abuse Standard Report, Kentucky Incident- Reporting System, and review of facility policies, it was determined the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) to determine whether or not an emergency medical condition existed for one (1) of nine-teen (19) sampled patients. Patient (P)1 presented to the Emergency Department (ED) on 07/08/2025 at 8:35 PM with complaints of sexual assault. The facility failed to provide P1 with an appropriate MSE, no pelvic examination was performed. The findings include: Cross Refer to A2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44370 Based on interviews, record review, video footage, EMS (Emergency Medical Services) Patient Care Report, Child Adult Domestic and Dating Abuse Standard Report, Kentucky Incident- Reporting System, and review of facility policies, it was determined the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s emergency department (ED) to determine whether or not an emergency medical condition existed for one (1) of nine-teen (19) sampled patients. Patient (P)1 presented to the Emergency Department (ED) on 07/08/2025 at 8:35 PM with complaints of sexual assault. The facility failed to provide P1 with an appropriate MSE, no pelvic examination was performed. The findings include: Review of the document titled, “Emergency Medical Services (EMS) Patient Care Report,” dated 07/08/2025, revealed EMS was dispatched to P1’s home at 7:21 PM, arrived on scene at 7:47 PM, and left the scene at 7:57 PM. EMS arrived with P1 at FAC 1 at 8:33 PM. Continued review of the EMS report of P1’s history of present illness revealed the primary complaint was, “Patient wants a rape kit done. Patient admits to alcohol use. Patient admits to drug use.” P1’s medical history included abuse, alcohol intoxication, alcohol dependence, anxiety disorder, bipolar disorder, PTSD (Post Traumatic Stress Disorder), borderline personality behavior, other personality disorder, and paranoid personality. Additional review of the EMS “Narrative” revealed, an emergency call in reference to a female at the scene of a domestic dispute. A Kentucky State Police (KSP) Trooper requested EMS, and EMS responded without delay. P1 admitted to alcohol use, methamphetamine (addictive stimulant drug) use and was requesting a rape kit to be done at the emergency department. An assessment was performed and determined that P1 was alert and oriented times four to person, place, and time. Upon arrival on scene, EMS took personal protective equipment precautions and proceeded on scene, finding a female patient (P1) with the KSP Trooper who advised that the female was stating that she was raped earlier in the day and was wanting to go have a rape kit done. The KSP Trooper informed EMS personnel that the patient had a history of mental health issues. EMS then assisted P1 to and into the unit where she stepped inside and sat on the stretcher. Once in the semi-fowler’s position, P1 was secured via straps and vitals were obtained, and transport began. During transport, P1 had no new onsets and no decline in her condition. P1 spoke constantly to herself but denied any visual or auditory hallucinations. Upon arrival to the facility, once P1 was retrieved from the unit and taken into the facility, P1 was directed to be taken to triage. Review of video surveillance recording for 07/08/2025 revealed EMS arrived at the hospital with P1 at 9:04 (8:33) PM. EMS was seen arriving to treatment room eight at 9:11 PM. Physician 1 was seen entering P1’s room at 9:17 PM and exited at 9:20 PM. A staff nurse entered P1’s room at 9:37 PM and exited at 9:42 PM with what appeared to be laboratory tubes. At 10:05 PM, the physician entered the room and exited at 10:06 PM. KSP Trooper 1 entered P1’s room at 10:15 PM and exited at 10:30 PM. The crisis advocate arrived while the KSP Trooper was in the room and waits in the hall. At 10:31 PM, Advocate 2 entered P1’s room and exited at 11:00 PM. P1 was observed to go out of the facility to “smoke” twice during the night. P1 was discharged on 07/09/2025 at 7:34 AM and was observed to leave treatment room eight at 8:08 AM. (According to an interview with Facility Security on 8/27/2025 at 1:09 P.M. he stated that he did know the time stamp was wrong sporadically, varied day to day, it was never correct and had been an hour off at times). Review of the Patient Demographics revealed Patient (P)1 presented to the Emergency Department (ED) on 07/08/2025 at 8:35 PM with complaints of sexual assault and was discharged on 07/09/2025 at 7:34 AM. Review of the ED note dated 07/08/2025 revealed P1 came to the facility with a complaint of sexual assault and was seen by the provider (Physician 1) at 8:44 PM. According to the ED note, Patient 1 was a 33-year-old female who presented with a complaint of sexual assault. Patient 1 had a long history of polysubstance abuse, alcohol abuse, drug abuse, and psych (Psychiatric) issues. P 1 stated that she was with her fiancé/boyfriend and over the day, he forcibly made her have sexual intercourse and ejaculated in her at least three times. P1 stated it was not consensual, and she was also choked. P1 admitted to being an alcoholic and drinks a 5th of vodka a day. P1 smelled of alcohol. At this time, P1 was requesting a sexual assault kit. Continued review revealed P1 had a history of bipolar affect, depression, post-traumatic stress disorder (PTSD-mental health condition that can develop after experiencing or witnessing a traumatic event or series of events), schizophrenia, schizoaffective disorder, substance abuse disorder, alcohol use disorder, traumatic brain injury, and seizure disorder. Review of the section of the medical record titled “Exam” (examination) revealed no documentation that a pelvic examination was performed on patient #1, when she presented to the facility’s ED for the evaluation of sexual assault. As this failure resulted in an inappropriate MSE for patient #1 on 7/8/2025. Review of laboratory values for serum alcohol revealed a reading of 240 (0.24%) with a normal range being 0-10 milligrams per deciliter. Review of ED note dated 07/08/2025 at 9:08 PM revealed, the Clinical Nurse Manager (CNM 1) spoke to the sexual assault advocate, who stated they would be in the ED shortly. Review of the physician’s note dated 07/08/2025 at 10:27 PM revealed the patient had been waiting for a Sexual Assault Nurse Examiner Examination (SANE) evaluation. Patient had decided not to wait any longer and wanted to go to the precinct to make a formal report. P1 understood that if she left and bathed, evidence will be difficult to obtain. Review of ED Note dated 07/09/2025 at 12:37 AM revealed CNM 1 spoke to the local crisis center to inquire about a SANE nurse arrival, the local crises center stated they would contact the SANE nurse and would call the hospital back. A call was returned by the crisis line and revealed they do not send any SANE nurses to hospitals, but they would contact the helpline and call back. A call was returned, and information was provided that there was not a SANE nurse on call. The Provider (physician 1) was made aware. Review of ED Note dated 07/09/2025 at 7:34 AM revealed that the patient was potentially going to a domestic violence shelter and staff spoke with P1 in the room. P1 notified the ED staff that she was going to be going home with a friend that would be picking her up from the hospital. ED staff confirmed that P1 did not wish to complete a sexual assault kit at that time. Information was provided for the healing program with the local crisis center, and their number was provided. additional review of the ED note indicated no other needs verbalized by P1 and staff would assist as needed. Review of the ED Note dated 07/09/2025 at 7:34 AM and added to the chart at 4:05 PM, revealed CNM 1 was contacted by the KSP trooper and confirmed that P1 declined a rape kit that morning and resources were provided. Review of document titled, “Child, Adult Domestic and Dating Abuse Standard Report”, dated 07/082025 at 6:26 PM, revealed Officer 1 responded to a domestic violence/abuse incident at the home of P1, who had reported an incident and the relationship to the perpetrator as a “dating relationship”. P1 was conscious and the report indicated P1 was injured with visible injuries that included a small scratch on the front of her neck. P1 was transported to FAC 1 due to sexual assault allegations. Review of the Kentucky Incident-Based Reporting System (KYIBRS) report, “Narrative,” dated 07/08/2025 at 6:27 PM, revealed that officers responded to P1’s residence on a complaint of domestic violence. Officer 1 spoke with P1, who reported being assaulted, choked, and raped by her boyfriend. Continued review of the “Investigation,” Officer 1 made contact with patient one outside the residence in the driveway. P1 stated her boyfriend choked her into a seizure, and she was not right mentally. P1 stated she brought food to her boyfriend, as he was not allowed to stay with her because he keeps hurting her. P1 told Officer 1 that she and her boyfriend (BF) had an argument. P1 stated she was an alcoholic and was taking suboxone (a medication used to treat opioid use disorder). P1 stated that the BF would not let her leave and that he choked her into a seizure, and she already has brain damage. P1 stated the BF put his arm around her neck, caused her to have a seizure, and when P1 woke, she did not know where she was and started screaming for help, and the BF choked her out again. P1 stated that when she woke, the BF raped her. P1 stated the BF put his penis in her, and she kept telling him to stop. P1 reported the BF took her clothes off, pulled up her shirt, pulled her pants down, and stopped when he “got off.” Officer 1 noted a smell of alcohol coming from P1, and P1 admitted to drinking and stated that she was an alcoholic. P1 was asked if she remembered telling Officer 1, she was raped by a “teddy bear,” and she said yes and that she was unconscious then and was conscious today. Review of facility policy titled, “EMTALA-Medical Screening”, dated 08/2005, revealed, “the purpose was to ensure that all patients requesting emergency services in an area of any facility meeting the definition of a dedicated emergency department received an appropriate medical screening examination as required by the emergency medical treatment and active labor act”. Continued review revealed, “the medical screening examination was an ongoing process, and the medical record must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred. Screening was to be conducted to the extent necessary to determine whether an emergency medical condition exists. A qualified medical person designated by established criteria must perform MSE. Review of facility policy titled, “Sexual Assault Forensic Medical Exam”, dated 02/09/2023, revealed, “every hospital in the state which offers emergency services shall provide that a physician, sexual assault nurse examiner or other qualified medical professional is available on call 24 hours each day for the examination of persons seeking treatment as victims of sexual offences.” The hospital was required to provide a sexual assault forensic medical examination to any victim who requested such treatment, regardless of whether the crime was reported to law enforcement. This examination would include, but not be limited to basic medical care, sample gathering services, and laboratory tests, as appropriate. During an interview with the KSP Trooper on 08/26/2025 at 1:58 PM, he stated he responded to Facility 1 with a report of sexual assault on 07/08/2025. The KSP Trooper stated when he arrived P1 had not been brought in yet and the ED seemed busy. The KSP Trooper stated he was familiar with the victim as she had made allegations in the past regarding the perpetrator, who was her live-in boyfriend. The KSP Trooper stated the victim was intoxicated and that she had requested a rape kit. The KSP Trooper stated the victim had reported forceful nonconsensual sex twice and the third time was consensual. The KSP Trooper stated Facility 1 was not a SANE ready hospital but had 2 SANE nurses and it was his understanding the physician could do the exam. The KSP Trooper stated he was told a SANE nurse was enroute to the hospital and he made a call to his supervisor. The KSP Trooper stated he went back inside and was told the SANE nurse would not be coming but someone would be at the hospital at 7 AM so the rape kit would be completed at that time. The KSP Trooper stated he was at the facility until about 1:00 AM. The KSP Trooper stated he went to the facility around 2 PM the next day to retrieve the evidence and the RN Case Manager told him the patient did not wish to complete the exam. During an interview with Registered Nurse (RN 2) on 08/28/2025 at 8:09 AM, she stated she recalled P1 being upset when she arrived. RN2 stated that Physician 1 was made aware that a sexual assault exam was needed for P1, and Physician 1 did not want to perform it. RN2 stated it was up to the physician whether to perform the exam. RN2 stated the ED was not equipped with on call SANE nurses. The Triage Nurse stated in interview on 08/28/2025 at 8:22 AM, that she was familiar with P1 as P1 was a repeat visitor to the ED and at another hospital. The Triage Nurse stated P1 came by ambulance and was triaged with a complaint of sexual assault by her boyfriend, and P1 requested a rape kit be done. The Triage Nurse stated P1 did appear to be under the influence. The Triage Nurse stated Physician 1 did not perform the exam and wanted to wait until the SANE nurse came in the following morning. During an interview with Physician 1 on 08/28/2025 at 8:36 AM, she stated she recalled P1 came to the ED with a complaint of sexual assault by her boyfriend and was requesting a rape kit. Physician 1 stated she was new to the hospital, and the charge nurse told her the hospital’s process was to have a SANE nurse come in. Physician 1 stated the nurse attempted to get a SANE nurse, but one was not available. Physician 1 stated the facility had a SANE nurse who would be in the next morning. Physician 1 stated P1 was intoxicated but stable and was fine with waiting until the morning. Physician 1 stated she ordered labs and gave P1 IV fluids. Physician 1 stated P1’s blood alcohol level was 0.24 which indicated P1 was highly intoxicated. Physician 1 stated P1 also had mental health diagnoses such as PTSD, bipolar and schizophrenia and she always wanted to make sure the patients understand what the exam entails as it was very invasive. Physician 1 stated P1 did want the exam but was somewhat hesitant. Physician 1 stated as the exam was invasive, she preferred to assess the patient to see how far to go. Physician 1 stated if the patient wasn’t ready, she would not push it. During an interview with Clinical Nurse Manager (CNM) 1 on 08/28/2025 at 9:17 AM, she stated she was the charge nurse on night shift rotation and had been working the ED for 4 years. CNM 1 stated she was familiar with P1 and on 07/08/2025 she came to the ED with a report of sexual assault by her boyfriend. CNM 1 stated the facility had two SANE nurses on staff, but they did not take call. CNM 1 stated she attempted to find a SANE nurse using the “hotline,” but none was available. CNM 1 stated P1 received some IV fluids and refused the exam the next morning, so P1 was discharged. CNM 1 stated she informed Physician 1, and the physician chose to wait until a SANE nurse was available the next morning. CNM 1 stated P1 was clinically intoxicated but “she was still with it and able to make informed decisions”. During an interview with the Emergency Department (ED) Director, on 08/28/2025 at 3:11 PM she stated RN 4 made her aware that P1 had arrived the night before with a complaint of sexual assault. The ED Director stated RN 4 told her that Physician 1 had refused to complete the sexual assault exam on P1. The ED Director stated she did not speak to Physician 1 but reached out to her director. The ED Director stated she thought the local crisis center had a SANE nurse they could send to the hospital, but she learned they did not provide that service. The ED Director stated she was told by the case manager that P1 had refused to stay and do the exam the next morning and was discharged. The ED Director stated the physician could have completed the exam and that a SANE nurse was not required to be present. The ED Director stated she expected the ED physicians to follow hospital policies and procedures as well as EMTALA guidelines. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide P 1 an appropriate MSE to include a pelvic examination to the extent necessary to determine whether or not an emergency medical condition existed.”