Lasalle General Hospital

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 53491 Based on visual observation the facility failed to provide a fire alarm system that when activated properly provides positive alarm sequence, automatic occupant notification via audible and visual signals. When the building is equipped with life safety systems, that offer complete coverage, the occupants maintain a sense of security in an emergency. This deficiency has the potential to affect 18 of 18 residents. During the record review on May 12, 2026 it was observed that the speakers on Zone 9 of the fire alarm system were not sounding. It was also observed the fire alarm was in trouble for phone line 2. Interview with Hospital Administrator revealed the facility was not aware the speakers on Zone 9 of the fire alarm system were not sounding nor was the facility aware that the fire alarm was in trouble for phone line 2, which was acknowledged by the Administrator during the exit meeting.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 53491 Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 18 of 18 residents. During the facility tour on May 12, 2026 it was observed that the sprinkler system was passed due for its annual inspection. Interview with Hospital Administrator revealed the facility was not aware that the annual inspection had not been conducted on the automatic sprinkler system and this was acknowledged by the Administrator during the exit meeting.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 53491 Based on visual observation the facility failed to assure that the fire and/or smoke barrier doors in the facility were inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80). The deficient practice has the potential to affect 18 of 18 residents. During the facility tour on May 12, 2026 it was osberved that the fire and/or smoke doors have not been inspected and tested annually. Interview with Hospital Administrator revealed the facility was not aware that the fire and smoke doors shall be inspected and tested annually.”

“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: 50453 Based on observation, record review, and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) failure to ensure employees were trained in crisis intervention in 5 (S4CNA, S5SW, S6RT, S7RN, S8RN) of 5 personnel files reviewed; 2) failure to ensure the glucometer Quality Control Solutions were properly labeled upon opening with an open date or beyond use date; 3) failure to ensure employees have current resuscitative certifications for population served for 1 (S7RN) of 6 nursing personnel files reviewed; and 4) failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for psychiatric patients. Findings: 1) Failure to ensure employees were trained in crisis intervention in 5 (S4CNA, S5SW, S6RT, S7RN, S8RN) of 5 personnel files reviewed. A review of employee personnel records for S4CNA, S5SW, and S6RT failed to reveal current documented crisis intervention training. Review of the emergency room personnel records for S7RN and S8 RN failed to reveal documented evidence of crisis intervention training. In an interview on 05/13/2026 at 1:16 PM, S1DON confirmed that the emergency room staff did not have training in crisis intervention. In an interview on 05/13/2026 at 2:17 PM, S2PD confirmed that S4CNA, S5SW, and S6RT did not have documentation of current crisis intervention training in their employee files. S2PD also confirmed that all staff taking care of behavioral patients should have current crisis intervention training to provide a safe patient environment. 2) Failure to ensure the glucometer Quality Control Solutions were properly labeled upon opening with an open date or beyond use date. Review of the package insert for the Accu-Chek Controls revealed in part the following: “Note: Write discard date on the bottle label. The control solution is stable for 3 months after opening or until the expiration date on the bottle label, whichever comes first.” Observations during a tour on 05/11/2026 from 10:52 AM - 12:10 PM revealed the glucometer Quality Control Solutions currently being used on the inpatient unit were not labeled with an opening date or beyond use date. In an interview during the tour, S1DON confirmed the above-mentioned findings. S1DON also stated they only go by the expiration date on the vials and not by the manufacturer recommendations. Observations during a tour on 05/11/2026 from 12:52 PM - 1:10 PM revealed the glucometer Quality Control Solutions currently being used in the emergency department were not labeled with an opening date or beyond use date. In an interview during the tour, S7RN confirmed the above-mentioned findings. Observation of the behavioral health unit on 05/12/2026 at 3:22 p.m. revealed the glucometer Quality Control Solutions currently being used were not labeled with an opening date or beyond use date. In an interview at the time of discovery, S2PD confirmed the above-mentioned findings. 3) Failure to ensure employees have current resuscitative certifications for population served for 1 (S7RN) of 6 nursing personnel files reviewed. Review of S7RN’s personnel record revealed the following expired certifications: -Basic Life Support, expiration date of 03/31/2026; -Advanced Cardiac Life Support, expiration date of 3/31/2026; and -Pediatric Advanced Life Support, expiration date of 3/31/2026. In an interview on 05/13/2026 at 11:46 AM, S1DON confirmed the above-mentioned findings. 4) Failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for psychiatric patients. Tour of the behavioral health unit on 05/11/2026 from 10:54 a.m. to 11:05 a.m. revealed the nurses’ station doors were open to the geriatric hall and the adult hall and no staff were present. In an interview at the time of the observation, S1DON confirmed the above-mentioned observation and revealed the nurses’ station doors were to remain closed and locked to maintain a safe patient environment. Observation of the behavioral health unit on 05/12/2026 at 3:22 p.m. revealed the nurses’ station door was open to the geriatric hall and no staff were present. In an interview at the time of the observation, S2PD confirmed the above-mentioned observation and revealed the nurses’ station doors were to remain closed and locked to maintain a safe patient environment. 51596”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 51596 Based on record review and interview, the hospital failed to ensure orders for restraint or seclusion used for the management of violent behavior was written and renewed every 4 hours for 1 (#10) of 1 record reviewed for restraints or seclusion. Findings: Review of the hospital’s policy entitled “Behavioral Health Unit: Restraint” reviewed 02/27/2020, revealed in part, (2.0) If less restrictive patient management techniques have been tried unsuccessfully ... (2.2) In such an emergency, the Charge Nurse will report immediately to the treating Physician or other Licensed Independent Practitioner the condition of the patient, the situation requiring restraint and obtain an order for the intervention. (2.4) Written orders for the use of physical restraints shall be time limited, not to exceed 4 hours for adult patients. Review of Patient #10’s Nurse Note dated 04/17/2026 at 11:24 p.m., revealed in part, Patient pacing in hallway, kicking outside doors, and yelling at staff. Attempts to verbally de-escalate and educate patient were unsuccessful. Patient slammed elbow into window, window shattered. Sheriff’s Office called for assistance. Sheriff’s Officers x 3 assisted staff to get patient into seclusion. Review of Patient #10’s Nurse Note dated 04/18/2026, revealed in part, Patient observed in the seclusion room this morning and remains agitated. Medication was administered at 8:15 a.m., at which time patient was escorted to his room to lay down and rest. Further review of Patient #10’s medical record revealed a Restraint/Seclusion Flow Sheet initiated on 04/17/2026 at 11:15 p.m. and ending on 04/18/2026 at 7:00 a.m. Further review revealed no initial order for the initiation of restraints or seclusion or any renewal orders every four hours. In an interview on 05/12/2026 at 2:07 p.m., S2PD confirmed Patient #10 did not have any orders for restraints or seclusion on 04/17/2026 or renewal orders every 4 hours but should have.”

“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: 51596 Based on record review and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. The deficient practice was evidenced by failure to: 1. monitor glucose as ordered for 1 (#5) of 1 medical record reviewed for glucose monitoring; and 2. monitor vital signs as ordered for 3 (#5, #6, and #10) of 30 sampled medical records reviewed. Findings: 1. Failed to monitor glucose as ordered. Review of Patient #5’s medical record revealed admission to the BHU on 04/28/2026 at 8:13 p.m. Further review revealed a physician’s order dated 04/19/2026 at 10:53 a.m. for Dextro Stick AC&HS. Review of Patient #5’s glucose record failed to reveal glucose monitoring on: 05/04/2026 before breakfast; 05/06/2026 before dinner; and 05/10/2026 before breakfast. In an interview on 05/12/2026 at 3:15 a.m., S2PD confirmed Patient #5 did not have glucose monitoring documented on the above dates but should have. 2. Failed to monitor vital signs as ordered. Patient #5 Review of Patient #5’s medical record revealed admission to the BHU on 04/28/2026 at 8:13 p.m. Further review revealed physician’s orders dated 04/28/2026 at 10:52 p.m. for Vital Signs (VS) Q4h Review of Patient #5’s VS documentation failed to reveal monitoring for a period of: 6 hours and 2 minutes on 04/29/2026 between 4:58 a.m. and 11:00 a.m. 7 hours and 24 minutes on 04/29/2026 between 11:00 a.m. and 6:24 p.m. 24 hours and 3 minutes from 04/29/2026 at 6:24 p.m. until 04/30/2026 at 6:27 p.m. Patient #6 Review of Patient #6’s medical record revealed admission to the BHU on 05/07/2026 at 9:50 a.m. Further review revealed a physician’s order dated 05/07/2026 at 10:45 a.m. for VS Q4h Review of Patient #6’s VS documentation failed to reveal monitoring for a period of: 4 hours and 49 minutes on 05/07/2026 between 9:50 a.m. and 3:39 p.m. 13 hours and 8 minutes from 05/07/2026 at 6:17 p.m. until 05/08/2026 at 7:25 a.m. 12 hours and 24 minutes from 05/08/2026 at 6:09 p.m. until 05/09/2026 at 6:33 a.m. Patient #10 Review of Patient #10’s medical record revealed admission to the BHU on 04/17/2026 at 2:41 a.m. Further review revealed an order dated 04/17/2026 at 2:58 a.m. for VS Q4h Review of Patient #10’s VS failed to reveal monitoring for a period of: 7 hours and 49 minutes on 04/17/2026 between 3:11 a.m. and 11:00 a.m. 9 hours and 43 minutes from 04/17/2026 at 5:47 p.m. until 04/18/2026 at 3:30 a.m. 7 hours and 30 minutes on 04/18/2026 between 3:30 a.m. and 11:00 a.m. Interview with S2PD on 05/12/2025 at 1:17 p.m. revealed vitals signs were supposed to be monitored every 4 hours (Q4h) x 48 hours following admission to the behavioral health unit (BHU). She verified the above mentioned findings were not documented as ordered.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 51596 Based on record review and interview, the hospital failed to ensure medical records were promptly completed. This deficient practice was evidenced by the hospital’s failure to maintain a system to accurately track and ensure completion of medical records. Findings: Review of the facility’s document titled “By-Laws and Rules and Regulations of the Medical Staff”, last reviewed 09/2025, revealed in part, medical records are to be completed within 30 days of discharge. Medical records not completed within 30 days of discharge are considered delinquent. Providers will receive written notification of delinquent medical records. Written notification of delinquent medical records results in automatic temporary suspension of the practitioner’s admitting privileges. Medical records not completed by the date specified on the written notification of delinquent medical records will result in suspension of the practitioner’s clinical privileges, including the right to admit patients, consult on patients, and voting and office holding prerogatives. Review of a spreadsheet identifying incomplete medical records for discharged patients on 05/11/2026 at 3:10 p.m. with S12HIM revealed the hospital currently had 517 delinquent medical records from 04/2023 through 04/11/2026. Interview with S12HIM on 05/12/2026 at 3:15 p.m. revealed medical records were to be completed within 30 days of patient discharge. S12HIM revealed she tracked delinquent medical records on a computer spreadsheet. Review of the spreadsheet with S12HIM revealed 517 delinquent medical records from 04/2023 through 04/11/2026. S12HIM revealed she did not know which of the 517 medical records had been completed or how many remained delinquent. S12HIM revealed “we just keep harassing” practitioners to complete medical records. S12HIM confirmed the hospital did not have a system to accurately track completion of medical records within 30 days of patient discharge. S12HIM confirmed practitioner’s privileges were not suspended when medical records were delinquent.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use. Findings: Review of the hospital policy titled, Medication Administration Policies (undated) revealed in part that multi-dose vials should be dated at the time of first use and discarded after 28 days from this date or upon expiration marked on the container (whichever comes first). Review of the hospital policy titled, Medication Use-Crash Cart Medications dated 01/16/2019 revealed, in part, that the carts are opened, inventoried, checked for out-dated or unusable drugs and supplies, and relocked weekly. 1. On 05/11/2026 at 10:45 AM, observation of the medication room on the psychiatric unit with S10RN revealed the following expired or unlabeled medications: - (2) opened 10mL vials of sterile water with no open date - (1) opened bottle of 100mL normal saline with the date of 01/10/2026 written on a sticker on the bottle - (1) bottle of Valproic Acid liquid 250mg/5mL, with expiration date of 04/30/2026 - (1) opened vial of Lidocaine1% 500mg/50mL with the date of 12/2/25 written on a sticker on the vial. The expiration date of the vial was dated April 2026. - (1) opened 50 mL vial of Lidocaine 1% with the date of 01/12/2026 written on a sticker on the vial - (1) opened 100mL bottle of normal saline with no open date - (1) opened 1000mL bottle of sterile water with no open date At that time, interview with S10RN revealed all opened containers of medication should have a sticker indicating the open date. S10RN further stated that all opened vials should be used within 30 days of opening. S10RN confirmed the above medications were expired or unlabeled with first use date and should not have been available for patient use. 2. On 05/11/2026 at 11:25 AM, observation of the medication prep area in the ED with S11RN revealed the following expired medications in the drawers and the cabinets: - Nystatin cream with expiration date of January 2026 - (1) opened 20mL vial of Lidocaine 1% with no first puncture date - (1) opened 50mL vial of Lidocaine 1% with no first puncture date - (1) opened vial of Celestone 30mg/5mL with expiration date of 05/08/2026 At that time, interview with S11RN revealed that opened vials should be dated with first puncture date and used within 30 days of opening. S11RN confirmed the above medications were either expired or undated and should not have been available for patient use. 3. On 05/11/2026 at 11:30 AM, observation of the crash cart in the second floor nursing station with S1DON revealed the following expired medication: - (4) 10 mL vials of Sodium Bicarbonate 0.5mg/mL expired 03/2026. On 05/11/2026 at 11:35 AM, observation of the second floor nursing supply cabinet revealed a 1000mL botlle of Sodium Chloride for irrigation with expiration date 03/2026. An interview with S1DON at that time confirmed that the expired medication and biologicals should not be stored in the drawers and cabinets with other medications available for patient use. 20310”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure supplies and equipment were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by failing to ensure expired supplies were removed from the patient care area. Findings: Observations during a tour on 05/11/2026 from 10:52 AM - 12:10 PM revealed: Inpatient Unit: -Indwelling Catheter Tray, quantity 2, expiration date of 03/28/2026. -Indwelling Catheter Tray, quantity 1, expiration date of 02/28/2026. During the tour, S1DON confirmed the above-mentioned findings.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 20310 51596 Based on observation and interview, the hospital failed to ensure an effective surveillance program for the prevention of infections. The deficient practice is evidenced by 1) having surfaces in the facility which prevented proper disinfection, and 2) having patient nutrition items stored in a refrigerator with staff food items. Findings: 1) having surfaces in the facility which prevented proper disinfection A tour of the hospital’s laboratory on 05/11/2026 between 2:23 p.m. and 2:45 p.m. revealed the following: an upholstered chair in the phlebotomy area with a tear to the right arm; and a phlebotomy cart with multiple layers of tape to the surface. A tour of the psychiatric unit on 05/12/2026 between 10:36 a.m. and 10:51 a.m. revealed the following: a seat with an abraded upholstered surface in the Quiet Room; and a table with laminate missing from a portion of the surface in the Activity Group Room. In an interview on 05/11/2026 at 2:30 p.m., S13Lab confirmed there was a tear in the arm of the upholstered chair and tape on the surface of the phlebotomy cart. S13Lab confirmed the chair and phlebotomy cart could not be adequately cleaned and were an infection control issue. In an interview on 05/12/2026 at 10:50 a.m., S2PD confirmed the abraded upholstered seat surface and damaged table surface could not be adequately cleaned and were an infection control issue. 2) having patient nutrition items stored in a refrigerator with staff food items On 05/11/2026 at 10:45 a.m., a tour of the psychiatric unit revealed the patient nutrition refrigerator was empty, had several food spills in it, and appeared to be out of order. A review of the refrigerator’s temperature log revealed the temperature recorded on 04/11/2026 was 46.1 degrees fahrenheit. On 04/12/2026, the temperature was recorded as 69.9 degrees fahrenheit , and was noted as out of order. All days since 04/12/2026 were noted as out of order. When asked where the patient nutrition products were being stored, S1DON stated they were in the staff lounge refrigerator. Observation at that time of the staff lounge refrigerator confirmed that patient nutrition items were stored in the refrigerator alongside various food items that S1DON identified as staff foods. S1DON stated “I know they are not supposed to be stored together, but that’s what we are doing right now.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure all practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient’s condition were contained in patients’ medical records. This deficient practice was evidenced by failing to ensure all verbal orders were included in the medical record for 1 (#1) of 3 (#1, #2, #3) medical records reviewed from a total sample of 20. Findings: Review of Patient #1’s medical record revealed an admission date of 09/09/2024. Review of the nurse’s note dated 09/09/2024 at 11:30 a.m. by S4RN revealed in part, “patient left unit at this time via wheelchair accompanied by family. AMA (against medical advice) papers signed. Per statement from patient, family to transport patient to ‘Hospital D’ ER (emergency room). Chart and records sent with patient per instruction from S3MD. Per instruction from MD two IVs (intravenous) left in place and foley catheter left in place.” Review of the physician orders failed to reveal a physician order to leave in place two IV accesses and a foley catheter at discharge. In an interview on 10/15/2024 at 2:45 p.m. S1DON and S2RN verified there was no documentation of a physician order to leave in place two IVs and a foley catheter at discharge in Patient #1’s medical record. S1DON stated the two IVs and foley catheter should not have been left in place at discharge. In a phone interview on 10/15/2024 at 3:44 p.m. S4RN stated S3MD gave her a verbal order to leave in Patient #1’s IVs and foley catheter at discharge.”

“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 observations, 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 failing to post EMTALA signage within the emergency department. (See findings tag A-2402); 2.) the hospital failing to place a psychiatric patient under a Physician’s Emergency Certificate (PEC) and failing to have documented evidence of conducting safety rounds on a psychiatric patient for 1 of 1 (#8) patients who presented to the emergency department with a psychiatric condition from a total sample of 20 (See findings tag A-2407); and 3.) the hospital failing to have documented evidence of an accepting physician at the receiving hospital, failing to have documented evidence of a physician certificate of transfer, failing to have documented evidence of identifying the risks and benefits of the transfer, and failing to provide appropriate mode of transport to the receiving hospital (See findings tag A-2409).”

“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: 44763 Based on observation and interview, the hospital failed to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA), with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. This deficient practice was evidenced by failing to post EMTALA signage within the emergency department. Findings: In an observation on 10/16/2024 at 11:41 a.m. - 12:04 p.m. of the emergency department accompanied by S1DON revealed there was no EMTALA signage posted anywhere within the emergency department. In an interview on 10/16/2024 at 12:03 p.m. S1DON verified there was no EMTALA signage posted anywhere within the emergency department.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 44763 Based on record reviews and interview, the hospital failed to provide stabilizing treatment. This deficient practice was evidenced by: 1.) failing to place a psychiatric patient under a Physician’s Emergency Certificate (PEC) and 2.) failing to have documented evidence of conducting safety rounds on a psychiatric patient for 1 of 1 (#8) patients who presented to the emergency department with a psychiatric condition from a total sample of 20. Findings: Review of Patient #8’s ED visit record revealed Patient #8 presented to the emergency department on 09/21/2024 at 7:35 p.m. Review of the emergency department provider note dated 09/21/2024 revealed in part, Patient #8 was seen by S5MD at 7:50 p.m. “HPI (history of present illness): 13 year old female brought by mother for voicing suicidal ideations.” “She has been dealing with bullying in school, and has made several voiced threats to hurt herself. She has been cutting herself on the hands recently. She threatened to jump off a 2 story building tonight.” Further review revealed “Clinical Impression: Other: MDD (major depressive disorder) with SI (suicidal ideation).” “Disposition: Other: sent via private auto to ‘Hospital C’. Disposition Notes: I called ‘Hospital C’, verified they have a bed. Spoke with patient’s mother, who agrees to take her there voluntarily, as she did not want to do a PEC since her kids have been through a lot as adopted foster kids. I agreed with her as long as she takes her there directly. Mom agrees. Nurse called ‘Hospital C’ to verify and reserve bed.” Review of the nurse’s notes dated 09/21/2024 revealed in part, “7:50 p.m. S5MD reports he spoke with ‘Hospital C’, they have a bed available, he reports mom agrees to take her for inpatient treatment.” “9:00 p.m. Spoke with intake at ‘Hospital C’ notified patient has just left and is on her way transported per mother.” Further review of the record failed to reveal Patient #8 being placed under a PEC. In a phone interview on 10/16/2024 at 11:33 a.m. S5MD stated he considered doing a PEC for Patient #8. He stated he discussed the situation with Patient #8’s mother and decided not to PEC Patient #8. He stated she was a minor. He stated Patient #8’s mother was willing to take Patient #8 to the psychiatric hospital. Further review of the record failed to reveal documented evidence of conducting safety rounds on Patient #8 while in the ED. Review of Patient #8’s medical record from ‘Hospital C’ revealed an admission date of 09/21/2024 at 11:13 p.m. Review of the psychiatric evaluation dated 09/22/2024 at 10:07 a.m. revealed in part, Patient #8 was admitted to ‘Hospital C’ under a formal voluntary admission with a psychiatric diagnosis of major depressive disorder, single episode, severe without psychotic features.”

“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, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#8) of 20 (#1-#20) patients who presented to the hospital’s emergency department (ED) with an emergency medical condition. This deficient practice was evidenced by: 1.) failing to have documented evidence of an accepting physician at the receiving hospital; 2.) failing to have documented evidence of a physician certificate of transfer; 3.) failing to have documented evidence of identifying the risks and benefits of the transfer; and 4.) failing to provide appropriate mode of transport to the receiving hospital. Findings: Review of Patient #8’s ED visit record revealed Patient #8 presented to the emergency department on 09/21/2024 at 7:35 p.m. Review of the emergency department provider note dated 09/21/2024 revealed in part, Patient #8 was seen by S5MD at 7:50 p.m. “HPI (history of present illness): 13 year old female brought by mother for voicing suicidal ideations.” “She has been dealing with bullying in school, and has made several voiced threats to hurt herself. She has been cutting herself on the hands recently. She threatened to jump off a 2 story building tonight.” Further review revealed “Clinical Impression: Other: MDD (major depressive disorder) with SI (suicidal ideation).” “Disposition: Other: sent via private auto to ‘Hospital C’. Disposition Notes: I called ‘Hospital C’, verified they have a bed. Spoke with patient’s mother, who agrees to take her there voluntarily, as she did not want to do a PEC (Physician’s Emergency Certificate) since her kids have been through a lot as adopted foster kids. I agreed with her as long as she takes her there directly. Mom agrees. Nurse called ‘Hospital C’ to verify and reserve bed.” Review of the nurse’s notes dated 09/21/2024 revealed in part, “7:50 p.m. S5MD reports he spoke with ‘Hospital C’, they have a bed available, he reports mom agrees to take her for inpatient treatment.” “9:00 p.m. Spoke with intake at ‘Hospital C’ notified patient has just left and is on her way transported per mother.” Further review of the record failed to reveal documented evidence of an accepting physician at the receiving hospital, documented evidence of a physician certificate of transfer, documented evidence of identifying the risks and benefits of the transfer, and failing to provide appropriate mode of transport to the receiving hospital. Review of Patient #8’s medical record from ‘Hospital C’ revealed an admission date of 09/21/2024 at 11:13 p.m. Review of the psychiatric evaluation dated 09/22/2024 at 10:07 a.m. revealed in part, Patient #8 was admitted to ‘Hospital C’ under a formal voluntary admission with a psychiatric diagnosis of major depressive disorder, single episode, severe without psychotic features.”