West Calcasieu Cameron Hospital

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure all suspected abuse, neglect, and/or harassment were reported and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by failure to report suspected child abuse for 2 (#1, #2) of 20 sampled patients. Findings: Pursuant to Louisiana Children’s Code (Ch.C.), art 603(17)a (2025) “Mandatory reporter” includes in part, any of the following individuals: (a) “Health practitioner” is any individual who provides healthcare services, including a physician, surgeon, physical therapist, dentist, resident, intern, hospital staff member, an outpatient abortion facility staff member, podiatrist, chiropractor, licensed nurse, nursing aide, dental hygienist, any emergency medical technician, a paramedic, optometrist, medical examiner, or coroner, who diagnoses, examines, or treats a child or his family. Pursuant to Louisiana Children’s Code (Ch.C.), art, 610(A). Reporting procedure; reports to the legislature and the United States Department of Defense Family Advocacy Program, includes in part, A. A reporter shall immediately report suspected child abuse or neglect or that child abuse or neglect was a contributing factor in a child’s death in the following ways: (1) To the Department of Children and Family Services if the reporter has reason to believe that the perpetrator is any of the following: (a) A parent or caretaker as defined in Article 603. (b) A person who maintains an interpersonal dating or engagement relationship with the parent or caretaker. (c) A person living in the same residence as the parent or caretaker. (d) A person living in the same residence as the child, or any residence of the child, if the child has more than one residence. (e) An employee or an operator of an early learning center as defined in R.S. 17:407.33. (f) An operator or employee of a registered family child day care home. (g) Another child residing in the same residence for cases of suspected sexual abuse. (h) Indeterminable by the mandatory reporter, but the reporter suspects that the abuse occurred at the child’s residence. (2) To a local or state law enforcement agency if the reporter has reason to believe that the perpetrator is any of the following: (a) A person other than a person provided for in Subparagraph (1) of this Paragraph. (b) A teacher, instructor, administrator, staff person, school bus driver, teacher aide, paraprofessional, food service worker, or employee of any public or private elementary, secondary, vocational-technical training, special, or postsecondary school, city, parish, or other local public school board, if the abuse or neglect is perpetrated on a student. (c) Another child who does not reside in the same residence for cases of suspected sexual abuse. (3) Dual reporting to both the department and the local or state law enforcement agency is permitted. However, the agency who receives a report pursuant to Subparagraph (1) or (2) of this Paragraph shall be the agency responsible for accepting and acting on the report and shall ensure referral to other agencies as necessary. (4) Reports to the department shall be made as follows: (a) A mandatory reporter shall make a report of suspected abuse or neglect requiring immediate assistance via the designated state child protection reporting hotline telephone number. A report of suspected abuse or neglect which is of a nonemergency nature may be reported via the Louisiana Department of Children and Family Services Mandated Reporter Portal online. Reports may also be made in person at any child welfare office. (b) If a report involves alleged sex trafficking, all mandatory reporters shall report via the hotline telephone number to the department regardless of whether there is alleged parental or caretaker culpability. (c) A permitted reporter shall make a report through the designated state child protection reporting hotline telephone number or in person at any child welfare office. Review of the hospital’s policy titled “Abuse and Neglect Notification and Reporting”, reviewed 09/2025, revealed in part, “Policy: All suspected or alleged cases of abuse or neglect are to be reported as mandated by Louisiana State Law to the respective protective service agencies. Separate agencies are available for reporting of abuse or neglect in the following age categories: 1. Children (under eighteen years of age or an emancipated minor) 2. Adults 18-59 years of age who are “mentally or physically dysfunctional” 3. Elderly age 60 and over 4. Nursing home residents. Procedure: 2. Notify the Coroner’s Office and/or law enforcement agency as appropriate. 3. Reporting of suspicion of child abuse is required by law. 4. Notify the appropriate protective service agency: a. Child Protective Services Hotline: 337-491-2545 Daytime: 1-888-524-3578 Immediate Attention: 1-855-452-5437 b. Adult Protective Services: 1-800-898-4910 c. Elderly Protective Services: 337-491-2815 OR 1-833-577-6532 d. Ombudsman Program: 337-474-2585 (Nursing Home residents) OR 1-800-738-2256 5. Notify physician to examine patient and assist law enforcement and protective service agencies with appropriate reports. Fill out the Battered Child Act Form for report on a child”. In an interview on 01/13/2026 at 3:46 PM, S3AR confirmed that she remembered an extended family who presented to the emergency department on 12/04/2025 requesting an examination of two children for possible child abuse. S3AR confirmed the family spoke to the triage nurse and then left without an examination. In a phone interview on 01/14/2026 at 1:52 PM, S4RN stated the lady said she had already contacted CPS (Child Protective Services) previously and nothing had been done about the abuse. S4RN confirmed she did not contact CPS or law enforcement regarding the children (Patient #1 and Patient #2). S4RN stated the lady with the children told her she was taking the children to the police. 53243”

“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: 44763 Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1.) the hospital failed to maintain an accurate and complete emergency department (ED) central log on each individual who came to the emergency department as evidenced by failing to document in the central log patients who presented seeking medical attention for 2 (#1, #2) of 20 sampled patients (see findings tag A-2405); and 2.) the hospital failed to provide a medical screening examination on all patients who presented to the emergency department (ED) seeking treatment for 2 (#1, #2) of 20 sampled patients (see findings tag A-2406).”

“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: 44763 Based on record reviews and interviews, the hospital failed to maintain an accurate and complete emergency department (ED) central log on each individual who came to the emergency department as evidenced by failing to document in the central log patients who presented seeking medical attention for 2 (#1, #2) of 20 sampled patients. Findings: Review of the hospital’s policy titled “EMTALA Medical Screening Exam and Stabilization Policy” reviewed 09/2025, revealed in part, “Procedure: E. Record-Keeping: The hospital, whether transferring or receiving patients, must maintain for a minimum period of five (5) years the following: 3. A central log on each individual seeking emergency services and who come to the hospital, the emergency department, anywhere on the hospital campus of the hospital designated with CMS provider-based status. The log must include an indication whether the individual refused treatment or transfer, or was transferred, admitted and treated, stabilized and transferred, or discharged. Logs that are maintained in other departments that perform medical screening examinations shall be deemed a part of the central log and are subject to the same requirements as the central log”. Review of the ED central log for the dates of 12/01/2025 through 12/06/2025 failed to reveal documentation of 2 children brought to the emergency department for an examination for possible abuse as reported to the Louisiana Department of Health. In an interview on 01/13/2026 at 3:46 PM, S3AR stated she remembered 2 ladies and a man bringing a baby in a carrier (Patient #2) and one child walking who appeared to be 2-4 years old (Patient #1) to the ED on 12/04/2025. S3AR stated the ladies were family members to the children, but not their guardian. S3AR stated the lady told her the chief complaint of one of the children was the child being burned. S3AR stated the lady also told her the children needed to be seen because the parents were suspected. S3AR stated S4RN was working in the triage room that day. S3AR stated once S4RN told the lady the hospital would have to contact the parent for consent to treat, the lady became angry and said she would just leave and take the children to the police because she knew the mother would not give permission for the children to be seen. S3AR stated they were not turned away, they needed permission from the parent for the children to be seen. S3AR confirmed she did not enter Patient #1 and Patient #2 into the ED central log. 53243”

“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: 44763 Based on record reviews and interviews, the hospital failed to provide a medical screening examination on all patients who presented to the emergency department (ED) seeking treatment for 2 (#1, #2) of 20 sampled patients. Findings: Review of the hospital’s policy titled “EMTALA Medical Screening Exam and Stabilization Policy” reviewed 09/2025, revealed in part, “Procedure: A. Medical Screening Examination 1.) The hospital will provide a medical screening examination for every individual who comes to the emergency department seeking or appearing to need medical treatment, and shall also provide such an examination for every person who comes to another area of the hospital campus seeking or appearing to need treatment for an apparent emergency medical condition. Pregnant women who come to the emergency department or who come to another area of the hospital campus seeking unscheduled medical treatment related to pregnancy shall receive a medical screening exam, stabilizing treatment and appropriate transfer. 3.) A medical screening examination shall also be conducted when a request is made on behalf of the individual by someone other than the individual, even if the person requesting the examination is not the individual’s legally responsible person”. Review of the ED central log for the dates of 12/01/2025 through 12/06/2025 failed to reveal documentation of 2 children brought to the emergency department for an examination for possible abuse as reported to the Louisiana Department of Health. In an interview on 01/13/2026 at 3:46 PM, S3AR stated she remembered 2 ladies and a man bringing a baby in a carrier (Patient #2) and one child walking who appeared to be 2-4 years old (Patient #1) to the ED on 12/04/2025. S3AR stated the ladies were family members to the children, but not their guardian. S3AR stated the lady told her the chief complaint of one of the children was the child being burned. S3AR stated the lady also told her the children needed to be seen because the parents were suspected. S3AR stated S4RN was working in the triage room that day. S3AR stated once S4RN told the lady the hospital would have to contact the parent for consent to treat, the lady became angry and said she would just leave and take the children to the police because she knew the mother would not give permission for the children to be seen. S3AR stated they were not turned away, they needed permission from the parent for the children to be seen. S3AR confirmed she did not enter Patient #1 and Patient #2 into the ED central log. In a phone interview on 01/13/2026 at 4:06 PM, S4RN stated she remembered sitting in triage on 12/04/2025 and saw people with babies enter the ED. S4RN stated the admit clerk asked for information and had the baby’s (Patient #2) name pulled up on the screen when she got involved. S4RN stated the lady was adamant on not giving the staff the guardian’s contact information. S4RN stated the lady told her this baby (Patient #2) was being abused and needed to be seen. S4RN stated when she explained the hospital’s registration process to the lady, she became angry and said she would just take the children (Patient #1 and Patient #2) to the police station. S4RN stated the lady got up and left the ED. S4RN confirmed the children (Patient #1 and Patient #2) were not provided a medical screening exam because the lady became frustrated and walked out before the medical screening exam could take place. Review of Patient #1’s emergency department record from hospital ‘A’ revealed in part, Patient #1 arrived on 12/05/2025 at 1:25 PM. Review of the provider note dated 12/05/2025 revealed in part, “[stated age] male with no chronic PMH [past medical history] presents with bruise on chest. Patient was brought in by his [family member #1] for concern of child abuse. They said they tried to go to another hospital yesterday but were told that they could not be evaluated because they did not have the right resources. [Family member #1] states that every time she picks up the kids, they are dirty and have not eaten in a few days because the [family member #2] sells food stamps for drugs and alcohol. They have tried to make multiple reports with DCFS [Department of Children and Family Services] but they have not looked into it yet. Children have been left home alone while the [family member #2] goes to the club. Says the patient is drinking but not eating very well. He previously has had a black eye. They noticed his chest was sore and they said that his [family member #2] kicked him when he was trying to crawl up into her lap.” Further review of the documented revealed in part, “SANE [Sexual Assault Nurse Examiner] RNs [registered nurses] performed initially a majority of interview and examinations. I did perform a medical exam and obtained screening chest and pelvic x-rays. X-rays were negative. Plan is for the patient’s onset [sic] to take him home with them and to continue trying to get DCFS involved to remove patient from parents’ custody.” “Diagnosis: Child abuse.” “Disposition and Plan: Discharge.” Review of Patient #2’s emergency department record from hospital ‘A’ revealed in part, Patient #2 arrived on 12/05/2025 at 1:24 PM. Review of the provider note dated 12/05/2025 revealed in part, “[stated age] male with no chronic PMH presents with leg burn. Patient was brought in by his [family members #1] who took the patient from the [family member #2]. They believe the burn is from a blunt being on the bed and the ashes getting onto the patient. They said they tried to go to another hospital yesterday but were told that they could not be evaluated because they did not have the right resources. [Family member #1] states that every time she picks up the kids, they are dirty and have not eaten in a few days because the [family member #2] sells food stamps for drugs and alcohol. They have tried to make multiple reports with DCFS but they have not looked into it yet. Children have been left home alone while the [family member #2] goes to the club.” Further review of the document revealed in part, “Patient has a diaper rash. I do not suspect an overlying candida infection currently. Will instruct for zinc oxide use and pediatrician followup. Skeletal survey performed given concern for child abuse, and it was negative. Sheriff’s office is aware and are trying to help get DCFS involved. Patient is going to go home with the [family members #1]. No medical indication for admission. Since patient does have a safe place to go home to with the [family member #1], they will be discharged.” “Diagnosis: Child abuse; diaper rash.” “Disposition and Plan: Discharge.” 53243”

“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: 44763 Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1.) the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice was evidenced by failure to provide an appropriate medical screening exam for 1 (#6) of 20 (#1 - #20) patients reviewed (see findings tag A-2406); and 2.) the hospital failed to ensure appropriate documentation of transfer for 1 (#4) of 20 (#1-#20) patients reviewed. This deficient practice was evidenced by failure of the physician to certify the risks and benefits of the transfer were discussed with the patient and/or their family prior to transfer (see findings tag A-2409).”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice was evidenced by failure to provide an appropriate medical screening exam for 1 (#6) of 20 (#1 - #20) patients reviewed. Findings: Review of the hospital’s policy titled “EMTALA Medical Screening Exam and Stabilization Policy”, revised 05/2021, revealed in part, “Purpose: To establish guidelines for providing appropriate medical screening examination (MSE) and any necessary stabilizing treatment or an appropriate transfer for the individual as required by The Emergency Medical Treatment and Labor Act (EMTALA) statute code. Policy: A. It is the policy of West Calcasieu Cameron Hospital: 1.) To provide a medical screening examination (MSE) by a physician or qualified medical person (QMP) to any individual who comes to the hospital or to a campus department of the hospital seeking an examination or medical treatment (whether eligible for insurance benefits and regardless of ability to pay) to determine if the individual has an emergency medical condition; and 2.) If the MSE reveals that an emergency medical condition exists, the hospital will provide the individual with further examination and treatment necessary to stabilize the individual’s emergency medical condition within the capability of the hospital, or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below.” Review of Patient #6’s ED record dated 05/10/2025 revealed Patient #6 presented at 12:51 PM with a chief complaint of abdominal pain. Review of the physician note by S1MD dated 05/10/2025 1:17 PM revealed in part, “Patient is a [stated age] with a history of polycystic ovarian syndrome she has had a hysterectomy with a right oophorectomy she still has her left ovary for the last week she has been having severe lower abdominal pain radiating to the left side she takes multiple medications she does have bipolar disease also she suffers with constipation and has been vomiting lately. The pain has been all week it got worse over the weekend she has never been here to the emergency department I think she gets all of her GYN [gynecology] care in [stated city]. Patient denies any fever her vital signs are stable she was given fentanyl and route but that is not controlling her pain she says. We will get a workup including a CT [computed tomography] of the abdomen pelvis and some IV [intravenous] fluids. She also denies any urinary symptoms. Patient keeps her eyes closed during the entire conversation and exam she does not look at you her belly exam is soft with positive bowel sounds she has tenderness in the lower abdomen but no guarding or rebound. The pain appears to come in waves and palpation of the abdomen does not set off the pain.” Review of the physician orders revealed Patient #6 was ordered the following medications in the ED: Promethazine IV 25mg [milligrams] IVPB [intravenous piggyback] once; Morphine Solution IV 4mg IV push once; Toradol IV 30mg IV push once; K-DUR (Potassium Chloride) extended tab 40mEq [milliequivalent] by mouth once; IV Bolus NS [normal saline] 1,000mL [milliliters] IV once; Flagyl IVPB Premix 500mg IVPB once; Morphine Solution IV 4mg IV push once; and “Additional Nursing Order: give the bomb orally”. Further review revealed “the bomb oral contains: magnesium citrate 30mL; mineral oil, heavy 30mL; and Docusate liquid (200mg) 20mL.” Review of the Comprehensive Metabolic Profile (CMP) results revealed in part, “K [potassium] 2.3 panic L [low]” “critical potassium result called to and read back by S2RN at 2:44 PM on 05/10/2025.” Further review of the results revealed “NA [sodium] 126 low”; “CL [chloride] 88 low”; “CA [calcium] 10.1 high.” Review of the CT Abdomen/Pelvis results revealed in part, “Impression: Large volume of stool within the level of the sigmoid colon. No mass lesion is seen. Follow-up with endoscopy is recommended to exclude underlying mass or stricture. Mild wall thickening of the transverse colon concerning for colitis.” Further review of Patient #6’s ED record revealed “Diagnosis: colitis indeterminate; constipation, unspecified”. “Disposition: Instructions: return to ED for worse or new symptoms. Discharged with whom: spouse.” Patient #6 was given prescriptions for the following medications: “Ciprofloxacin 500mg/tablet 1 tablet by mouth every 12 hours for 10 days Indication: infection; Flagyl tablets 500mg/tablet 1 tablet by mouth 2 times a day for 10 days Indication: infection; and Norco tablets 325mg, 10mg 1 tablet by mouth every 8 hours as needed for pain (fifteen tablets).” Patient #6 was discharged home from the ED on 05/10/2025 at 5:32 PM. Review of Patient #6’s ED record dated 05/11/2025 revealed Patient #6 presented at 10:57 AM with a chief complaint of cardiac arrest. Review of the triage note revealed “05/11/2025 10:57 AM patient arrived by EMS [emergency medical services] with agonal respirations noted. Patient immediately directed to ED exam 5. Pulse lost at this time. CPR [cardiopulmonary resuscitation] started by EMS. Chief Complaint: EMS reports spouse called for increased abdominal pain and ‘breathing weird.’ EMS reports patient vomited en route then started to have agonal respirations upon arrival to ED and lost pulse in ER [emergency room]. Emesis noted at time of CPR.” Review of the physician note by S4MD revealed in part, “Chief Complaint: Patient was brought to the ER for hyperventilation in an extended patient came in with CPR going on patient was seen here and discharged home yesterday.” “MDM: course in hospital patient was evaluated in the ER and chest x-ray showed bilateral aspiration pneumonia acute renal insufficiency hypertension patient also had hypokalemia potassium IV was given potassium will be given by the NG [nasogastric] tube fluids were started patient was treated with IV cefepime and IV Zithromax patient be admitted with Dr. [stated name] and the critical care consult was obtained from the critical care on-call Dr. [stated name] consult placed in the chart.” Review of the Comprehensive Metabolic Profile (CMP) results revealed in part, “NA 124 low”; “K 2.3 panic L”; “CL 82 low”; “CO2 [carbon dioxide] 16.8 low”; “CA 14.3 panic H [high]”; “Albumin 3.3 low”; “Total Prot [protein] 5.4 low”; “ALT [alanine aminotransferase] 41 high”; “AST [aspartate aminotransferase] 70 high”; “CA corrected 14.8 panic H”; “eGFR [estimated glomerular filtration rate] 28 low”; “Anion Gap 25 high.” “Critical (K, CA, CA corrected) result called to and read back by S3RN at 11:52 AM on 05/11/2025.” Review of the CT Abdomen/Pelvis results dated 05/11/2025 at 1:28 PM revealed in part, “Comparison: 05/10/2025.” “Impression: 1. Persistent colonic distention to the level of the proximal sigmoid colon concerning for obstruction. Severe colonic distention and probable colonic pneumatosis. Pattern is concerning for toxic megacolon. 2. New severe bibasilar pulmonary airspace disease which can be seen with aspiration, ARDS [acute respiratory distress syndrome] or pneumonia. 3. Findings were discussed with Dr. [stated name] shortly after the examination was performed.” Patient #6 was admitted to ICU (intensive care unit) on 05/11/2025 at 2:42 PM. Review of the provider note by S5MD revealed in part, “date of service: 05/11/2025 at 9:00 PM” “Assessment and Plan of Treatment: workup in ICU was extensive and occurred over multiple hours. Patient coded on arrival to ICU and received 3 rounds of chest compressions with 2 amps of epi [epinephrine] and 1 dose of atropine. Spontaneous circulation returned, but patient required 30 mcg [microgram] levophed and 0.04 vasopressin. CT abd [abdomen] reviewed with radiologist and we were concerned for toxic megacolon with some areas of pneumatosis. Bedside bladder pressure measured a water column of 22-23cm [centimeters] H2O with respiratory variation. Decision to proceed with emergent ex [exploratory] lap [laparotomy] with ongoing fluid resuscitation and correction of severe acidosis in the face of refractory shock. Ultimately had total abdominal colectomy with resection of 150cm of ileum due to necrosis. Bronch [bronchoscopy] also revealed tracheobronchitis confirming aspiration pneumonitis. Resuscitation efforts continued on return to ICU from OR [operating room] with reduction in pressor needs.” In a phone interview on 08/07/2025 at 2:55 PM S1MD stated he did remember Patient #6. S1MD verified he ordered oral potassium for Patient #6 for the critically low potassium level. S1MD stated the patient’s potassium would need to be really low for him to give IV potassium. S1MD stated for a potassium of 2.3, he usually gives oral potassium. S1MD stated oral potassium usually starts to absorb within 45 minutes or so, and the oral potassium given to Patient #6 should have brought Patient #6’s potassium up close to 3. S1MD stated normally he would send the patient home with a script of oral potassium and verified, after review of the record, that Patient #6 was not given a prescription for oral potassium. S1MD verified the potassium was not repeated prior to discharge. S1MD stated he doesn’t repeat the labs and usually it’s done by the patient’s primary a couple days later. S1MD verified Patient #6 came in with constipation and he prescribed “the bomb,” an oral laxative. S1MD stated he didn’t think it was an obstruction due to what the CT showed. S1MD stated Patient #6 wasn’t vomiting but verified Patient #6 was having a lot of pain. S1MD stated he thought the pain was from the colitis. S1MD stated he wasn’t concerned with using the laxative because you can get that over the counter.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure appropriate documentation of transfer for 1 (#4) of 20 (#1-#20) patients reviewed. This deficient practice was evidenced by failure of the physician to certify the risks and benefits of the transfer were discussed with the patient and/or their family prior to transfer. Findings: Review of the hospital’s policy titled “EMTALA Medical Screening Exam and Stabilization Policy”, revised 05/2021, revealed in part, “C. Individuals Who Have An Emergency Medical Condition: 1. When it is determined that the individual has an emergency medical condition, the hospital shall: a. Within the capability of the staff and facilities available at the hospital, stabilize the individual to the point where the individual is either ‘stable for discharge’ or ‘stable for transfer’, as defined; or b. Provide for an appropriate transfer of the unstable individual to another medical facility in accordance with these procedures. Transfers of unstable individuals are allowed only to pursuant to patient request or when a physician, or a QMP in consultation with a physician, certifies that the expected benefits to the patient from the transfer outweigh the risks of transfer. Review of Patient #4’s emergency department record (ED) dated 05/03/2025 revealed Patient #4 presented at 10:19 AM with a chief complaint of facial injury/head pain. Review of the physician note dated 05/03/2025 revealed in part, “Chief Complaint: Patient states got up Thursday night to use restroom and ran into the corner of the door. Bruising and swelling noted to right eye and right side of face. Denies loss of consciousness. States seen at Urgent Care and told to come to ER [emergency room] for CT [computed tomography]. Reports increased pain to head. ‘I’m hurting on both sides of my head now.’” Further review of the physician note revealed in part, “Spoke with neurosurgeon at hospital ‘A’ in [stated city] since that is where the patient wants to go to see a neurosurgeon. Dr. [stated name] face this appears most likely to be traumatic subarachnoid bleed which they were normally observed with no surgical intervention and he is willing to have patient come to hospital ‘A’ emergency department where they will consult the nearest surgeons there to see the patient and also take a look at the fractured maxilla however if patient wants to go to see her previous neurosurgeons at hospital ‘B’ we could also call The [sic]. After discussion with patient’s family they are willing to proceed with transfer to hospital ‘A’ in [stated city] for neurosurgical evaluation.” Further review of Patient #4’s ED record revealed in part, “Diagnosis: hemorrhage subarachnoid traumatic w/o [without] LOC [loss of consciousness]; Fx [fracture] R [right] maxilla, closed. Review of the Patient Transfer to an Outside Facility form dated 05/03/2025 revealed in part, Patient #4 was transferred to hospital ‘A’ for neurosurgery services. Further review of the form revealed Section 4: Patient Condition and Risk was not documented. Section 4 included patient condition and risks and benefits of the transfer and required the physician to complete. In an interview on 08/05/2025 at 2:06 PM, S6RN confirmed Section 4: Patient Condition and Risk section of the transfer form was not documented by the physician. S6RN confirmed the section was blank.”