West Jefferson Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48537 Based on record review and interview, 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 the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to examine 1 (#5) of 20 (#1 -#20) patients reviewed for medical screening exams (see findings tag A-2406).”

“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: 48537 Based on record review and interview, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the emergency department to determine whether or not an emergency medical condition existed. This deficient practice was made evident by failing to perform an appropriate history and physical examination for 1 (#5) of 20 (#1 - #20) patients reviewed for medical screening exams. Findings: Review of the hospital’s policy titled “Treatment in the Emergency Department” last revised on 07/23/2024, revealed the following in part: “Policy: 1. The Emergency Department within its capability provides for an appropriate medical screening examination of any individual, regardless of payer class, who presents himself or herself at the Emergency Department and requests (or has a request made on his or her behalf) either examination or treatment for a medical condition. Procedure: 1. Any hospital that has an emergency room is required to: a) provide an appropriate medical screening examination within the capability of the Emergency Department and any ancillary services “routinely” available to the Emergency Department for any individual (whether or not a Medicare beneficiary) who presents at the hospital, and for whom a request is made on the individual’s behalf, for examination or treatment to determine if the individual has an “emergency medical condition. b) if the individual has an “emergency medical condition”, the hospital must: i) provide for any further medical examination or treatment that may be necessary to stabilize the medical condition within the staff and facilities available at the hospital; or ii) provide for the transfer of the individual to another facility in accordance with the provisions of COBRA.” Review of Patient #5’s medical record from hospital “a” revealed she arrived to the ED (emergency department) on 06/14/2025 at 3:12 PM via personal vehicle with a chief complaint “other” and diagnoses of Reported Sexual Assault of Adult; Facial Laceration and Abrasion. Further review of the medical record revealed a documented triage note by S7RN stating “Patient reports being found by her godmother at 6:00 AM. Patient reports that she has a loss of time. She is concerned for possible S/A (sexual assault). She has bruising and abrasion under the right eye, left arm and the right hand.” Review of S7RN’s documented assessment of Patient #5 revealed the following in part: At 3:51 PM, HEENT (head, eyes, ears, nose and throat) - bruising under the right eye with swelling; Abdominal - nausea. Review of S4MD ED provider HPI (history of present illness) note revealed the following in part, “31 year old female arrives to the emergency department with concern about possible sexual assault, needs SANE (sexual assault nurse examiner) exam. Injuries sustained do not pose immediate life-threatening risk wound care can safely be delayed until evidence is collected by SANE.” The documentation by the physician did not contain any explaniaton as the the patinet’s “loss of time” or why the patient thought she might have been assaulted. There was no documentation the physician asked her about her bruising under the right eye and how it might have occurred or if she had pain in any other parts of the body. Review of S4MD’s documented physical exam revealed the following in part, “HEENT: Head - normocephalic and atraumatic; SKIN: General - Skin is warm and dry, Findings - Lesion (hemostatic laceration below right eye, abrasion to right hand and left elbow) present; NEUROLOGICAL: General - No focal deficit present, Mental Status - She is alert and oriented to person, place and time.” The physician failed to further document which nerves were tested for deficits as part of the neurologic examination and how those nerves were tested. Review of S4MD’s Medical Decision Making documentation revealed “31 year old needing sexual assault nurse examiner evaluation. Discussed that we would transfer to obtain this. She left AMA (against medical advice) and self-reported to facility we had discussed transferring her to. She may have misunderstood that private vehicle transfer is also an option.” Review of Patient #5’s provider orders revealed no labs and/or diagnostic imaging was ordered for Patient #5 while at hospital “a”. Review of Patient #5’s medical record revealed at 4:02 PM S4MD changed Patient #5’s disposition to “ED Disposition set to Transfer to Another Facility and Patient #5 was discharged from the EMR (electronic medical record) at 4:05 PM by S7RN. Further review of the medical record revealed at 4:10 PM S7RN documented “Patient declined transfer to hospital “b”, was offered by MD, she signed out AMA and was given hospital “b” telephone contact information.” Patient #5’s documented final diagnoses included Adult Sexual Abuse, Confirmed; Laceration without Foreign Body of Other Part of Head; and Abrasion of Right Hand and Left Elbow. Patient #5 signed the AMA form on 06/14/2025 at 4:04 PM with her reason for leaving AMA as “took too long, no testing on premises.” Review of Patient #5’s medical record from hospital “b” revealed she arrived on 06/14/2025 at 4:45 PM with a chief complaint of “Sexual Assault - Patient drank alcohol last night at work, a work friend brought her home. Her family member found her passed out in the driveway face down with her dress pulled over up with her buttocks showing. Patient has no memory of what happened, her family member told her she should have a rape kit done. Complains of pain and bruising/laceration to right cheek, feels nauseated, vomited and tasted medicine. Patient #5’s work up included imaging (chest x-ray, CT head, cervical spine and maxillofacial), labs (CBC, CMP and urine pregnancy) and the SANE nurse was notified. Hospital “b” ED RN documented in the triage assessment “Appearance: Awake and Alert. Patient looks worried. Neuro: Headache to right head side. Pain 10/10; Gastro: Nausea and vomiting; Skin: Bruise and abrasion above right eyebrow.” Patient #5 also received Toradol for pain, lactated ringer’s fluid bolus and Zofran for nausea and vomiting. Further review revealed Patient #5 ultimately decided against the forensic examination once in the SANE exam suite, but Patient #5 was given instructions, guidance and resources in case she changed her mine and wanted to have the forensic examination completed. Patient #5 was discharged from hospital “b” emergency department at 8:30 PM. On 09/30/2025 at 1:05 PM, an interview was conducted with S2CMO, who stated with minor facial trauma documented for Patient #5, she would not meet qualifications for CT imaging of the head. She had reports of memory loss, but that also does not meet the recommended standards for CT imaging. He further stated she would have needed to have had severe headaches and/or complaints of loss of consciousness. He stated based on what was documented by the S4MD in her note, he does not feel she would have qualified for any additional testing or workup outside of being transferred for assessment by the SANE nurse, which is a service hospital “a” does not provide, thus the reason behind the transfer disposition prior to Patient #5 leaving AMA.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the care of each patient. This deficient practice was evidenced by: 1. Failure to ensure wound care RN notified the physician after assessing a patient with deteriorating wound prior to patient discharge for 1 (#1) of 3 (#1-#3) patients sampled with wounds. 2. Failure to ensure the RN documented Braden score every shift, per hospital policy, for 1 (#3) of 3 (#1-#3) sampled patients with wounds. Findings: Review of the hospital policy titled “Wound Care: Assessment, Staging and Treatment of Pressure Injury” with an original creation date 03/1989 and next review date 05/2025 revealed, in part: “Policy: 1. Assess and document Braden score, skin integrity, and actual/suspected skin breakdown: b. Every shift and with acute changes by primary nurse. Document in EMR: 1. Skin assessment and Braden score with initial assessment and then every shift or for acute changes in condition or Braden Assessment.” 1. Review of Patient #1’s medical record revealed an admit date 11/22/2024. Patient #1 had the diagnoses of peripheral vascular disease, stroke, end stage renal disease, and coronary vascular disease. Review of Patient #1’s nurses’ notes revealed Patient #1 had wounds to buttocks. Further review of assessments of wounds revealed, in part: 12/12/2024, AM assessment: Drainage amount: small. Wound odor: none. 12/12/2024, PM assessment: Drainage amount: small. Wound odor: mild. 12/13/2024, AM assessment: Drainage amount: small. Wound odor: mild. 12/13/2024, PM assessment: Drainage amount: small. Wound odor: foul. 12/14/2024, AM assessment: Drainage amount: small. Wound odor: mild. 12/14/2024, PM assessment: Drainage amount: scant. Wound odor: foul. 12/15/2024, AM assessment: Wound bed progress: deteriorating. Drainage amount: moderate. Wound odor: foul. 12/15/2024, PM assessment: Wound bed progress: deteriorating. Drainage amount: moderate. Wound odor: foul. Review of Patient #1’s physician “Progress Notes” dated 12/15/2024 revealed, in part: “Nurses at bedside concerned that sacral wounds seem deeper. Wound care re-consulted.” Review of Patient #1’s wound care “Progress Notes” dated 12/16/2024 by S4RN, Wound Care, revealed, in part: “Assessed in room with S6RN, Wound Care. Sacrum extending to bilateral buttocks unstageable. Mild odor noted. As per (S5MD) recommendation will continue enzymatic debridement.” Review of Patient #1’s medical record revealed, in part, S5MD recommended enzymatic debridement on 12/10/2024. Further review of Patient #1’s medical record revealed no evidence RN wound care nurses contacted the physician after assessing the patient’s wounds on 12/16/2024. Review of Patient #1’s medical record revealed the patient discharged from the hospital 12/16/2024. In an interview on 02/11/2025 at 10:13 AM, S4RN, Wound Care confirmed Patient #1’s physician was not notified of buttock wound with odor after assessing the patient on 12/16/2024. S4RN, Wound Care confirmed S5MD’s recommendations from 12/10/204 were used to treat Patient #1’s sacrum to bilateral buttocks wound on 12/16/2024. In an interview on 02/11/2025 at 11:23 AM, S2Dir. PSQ confirmed Patient #1’s buttocks wound deteriorated from 12/12/2024 to 12/16/2024. S2Dir. PSQ confirmed there was no evidence wound care RNs notified the physician after assessing Patient #1 on 12/16/2024. S2Dir. PSQ confirmed Patient #1 was discharged from the hospital on 12/16/2024. 2. Review of Patient #3’s medical record revealed an admit date 12/05/2024. Patient #3 had the diagnoses of chronic stage IV ulcers of the sacrum and both hips, chronic sacral and left ischial osteomyelitis, and quadriplegia. Review of Patient #3’s medical record revealed, in part, no evidence Braden score documented for PM shift on 12/09/2024. In an interview on 02/10/2025 at 2:18 PM, S2Dir. PSQ confirmed Patient #3 did not have Braden score documented for PM shift on 12/09/2024. S2Dir. PSQ confirmed hospital policy required RN to document Braden score every shift.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by the elopement of a patient admitted with a Corner’s Emergency Certificate to prevent self-harm.. Findings: Review of the medical record for Patient #3 revealed he was admitted on 07/18/2024 with a diagnosis of drug overdose/suicide attempt. The patient was placed under a Corner’s Emergency Certificate and one to one sitter was assigned to the patient. Further review of the medical record revealed the patient eloped on 07/20/2024. Review of the initial report sent to the licensing authority documented a review of the video surveillance was performed by the hospital and revealed the patient left the room in a purple hospital gown at 4:49 p.m. and the sitter followed him out the room 21 seconds later. The patient was seen on video exiting the floor via the “back stairwell,” and the sitter was seen entering the lobby elevator. In interview on 07/23/2024 at 10:56 a.m., S6RN verified that the investigation into the elopement was not complete. S6RN verified she had collected the statement of the sitter, but the sitter had not been interviewed yet. In her statement, the sitter indicated that Patient #3 had forced his way passed her. S6RN verified that the sitter was taken off the schedule until the investigation could be completed. In interview on 07/23/2024 at 12:20 p.m., S5DS verified he had not completed his investigation and had not interviewed the security officer. S5DS verified security officers were assigned to perform real-time video surveillance of the exits that did not have a security officer physically present and one of the security officers should have seen Patient #3 as he left the building. S5DS verified that when a Dr. Flight is called, the officers typically try to secure the doors that are likely sites of egress based on the last known position of the patient. S5DS verified either the security officer was not watching the monitor and missed seeing the patient leave through the physician’s office building door, or when the Dr. Flight was called, the security officer missed seeing Patient #3 exit the door because he was in route to help secure the door. S5DS verified there was a security lapse when Patient #3 eloped from the facility. In interview on 07/23/2024 at 12:37 p.m., S1CNO verified that the operator recieved the call for the Dr. Fight at 4:52 p.m. In interview on 07/23/2024 at 1:10 p.m., S1CNO verified the review of the video surveillance of the doors revealed the patient exited the building at 4:52 p.m. through an egress door in the physician’s office building adjacent to the hospital. S1CNO verified security missed seeing Patient #3 leave the facility in real-time and, if they had seen him exit the building they might have caught him before he left hospital property.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 44495 Based on record review and interview the director of nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. The deficient practice is evidenced by failure of the nursing staff to verify a means of transportation prior to release from the emergency department for 2 (#1, #2) of 2 reviewed records of discharged patients. Findings: Review of the hospital policy “Discharge from the Emergency Department,” last reviewed 01/18/24, revealed in part, “8. Proper means of transportation is verified prior to the patient’s discharge.” - Review of the medical record for Patient #1 revealed the patient arrived via police. Review of the record for the departure mode for Patient #1 revealed in part, “Departure Mode: By Self.” ’ Review of the medical record for Patient #2 revealed the patient arrived via police. Review of the record for the departure mode for Patient #2 revealed in part, “Departure Mode: By Self.” In interview on 07/22/2024 at 1:34 p.m., S3RN verified that the documented departure mode was how they left the department by self or with assistance. In interview on 07/22/2024 at 1:35 p.m., S4SRN verified that the emergency department record did not contain documentation that the staff verified Patient #1 and Patient #2 had a proper means of transportation to take them home after discharge.”