Rumford Hospital

“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: 42601 Based on document reviews and interviews, the hospital failed to maintain an accurate and complete Emergency Department (“ED”) patient log. This was evidenced by failing to document patients who presented to the ED seeking medical attention for two (2) of twenty-two (22) patients reviewed (Patient #21 and #22). Findings: The hospital’s “Emergency Medical Treatment and Active Labor Act (EMTALA)” policy, last approved 02/14/2024, states in part, “The following guidelines apply to the care and treatment of: ... 2. An individual who presents to any location on the hospital’s main campus (including parking structures and other on-campus hospital buildings) and who: a. Requests care for a medical or surgical emergency ... . To the extent possible, the below-listed data should be collected for an individual who triggers the hospital’s EMTALA obligations: 1. the individual’s name and date of birth; 2. the date and time of the individual’s arrival; 3. the individual’s presenting complaint; and 4. the date, time and nature of the individual’s disposition (discharged home, admitted, transferred, left before conclusion of care, expired, etc.).These data should normally be collected in an electronic log of all individuals presenting to the emergency department of the maternity department that is initiated by registration staff and disposition by clinical staff.” On 06/03/2025, the hospital self-reported two (2) possible EMTALA violations, to the Division of Licensing and Certification, that occurred between 12:44 AM and 2:40 AM, where two (2) different patients arrived via ambulance and Medical Doctor (“MD”) #1 told the Emergency Medical Technicians (“EMTs”) that the hospital was on diversion and they needed to take the patients to another hospital. On 06/06/2025, an unannounced complaint survey was initiated. On 06/06/2025 at 10:05 AM, the Quality Accreditation Program Manager provided a patient log from 06/01/2025 through 06/06/2025. This log was reviewed and both Patient #21 and Patient #22 were not on the ED patient log. 1. Patient #21: - Patient #21 arrived in the ambulance bay of the hospital at approximately 12:00 AM; - Upon arrival, they were advised by MD #1 that the hospital was on diversion due to the Computed Tomography (“CT”) scan not being available; - They were advised to leave the hospital since the patient was not critical; and - Patient #21 left via ambulance and was not placed on the central log. 2. Patient #22: - Patient #22 arrived in the ambulance bay of the hospital at approximately 2:30 AM; - The ambulance called the ED five (5) minutes prior to arrival via telephone; - MD #1 went out to the ambulance entrance and informed the EMS staff that the hospital was currently unable to take the patient due to the lack of CT capabilities; - MD #1 reportedly stated, “Our doors are closed and we are not expecting the patient”; - Patient #22 left via ambulance and was not placed on the central log. On 06/06/2025 at 10:07 AM, an interview was conducted with the ED Medical Director, who stated the following; - On 06/03/2025 at 7:18 AM, I became aware of a possible EMTALA violation; - I was told it was a trauma patient who arrived on the hospital premises and was turned away without the Provider following the EMTALA requirements; - At 7:47 AM, I called the hospital and spoke with [MD #1], discussed the potential violation and provided re-education on the EMTALA requirements and that even if the hospital is on diversion, once the patient is seeking medical attention arrives at the hospital, normal protocols would need to be followed; - At 8:21 AM, I spoke with my leadership and made them aware of the possible violation and we planned immediate re-education to Providers and staff; - We did notify all Providers that any patient who arrives and is not being discharged home or transferred appropriately must be discussed with me until I am sure all staff and Providers are aware of the requirements [outlined in the policy]; and - At approximately 8:43 AM, I learned of another patient who arrived in the ambulance bay and was sent to another hospital. On 06/06/2025 at approximately 10:05 AM, the Quality Accreditation Program Manager verified that Patient #21 and Patient #22 were not on the patient log. She was able to provide evidence that since the incident, though they have kept a patient log that is accurate.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the facility failed to provide a Medical Screening Exam (“MSE”), as required by the Emergency Medical Treatment and Labor Act (“EMTALA”) regulations, for patients presenting via ambulance to the Emergency Department (“ED”) for treatment in two (2) of twenty-two (22) patients reviewed (Patient #21 and #22). Findings: The hospital’s “Emergency Medical Treatment and Active Labor Act (EMTALA)” policy, last approved 02/14/2024, states in part, “The following guidelines apply to the care and treatment of: ... 2. An individual who presents to any location on the hospital’s main campus (including parking structures and other on-campus hospital buildings) and who: a. Requests care for a medical or surgical emergency ... .” In addition, “A medical screening examination and any indicated stabilizing treatment should be provided to any individual who triggers the hospital’s EMTALA obligations as described ... . The complete medical screening exam, including tests and consults along with findings and the medical decision related to stabilizing treatment and the decision to discharge home, admit to the hospital, or transfer to another medical facility should be documented in the medical record by any physician, physician assistant, or nurse practitioner appropriately credentialed physician may conduct a medical screening to determine whether or not an emergency medical condition exists.” On 06/03/2025, the hospital self-reported two (2) possible EMTALA violations, to the Division of Licensing and Certification, that occurred between 12:44 AM and 2:40 AM, where two (2) different patients arrived via ambulance and Medical Doctor (“MD”) #1 told the Emergency Medical Technicians (“EMTs”) that the hospital was on diversion and they needed to take the patients to another hospital. On 06/06/2025, an unannounced complaint survey was initiated. On 06/06/2025 at 10:05 AM, the Quality Accreditation Program Manager provided a patient log from 06/01/2025 through 06/06/2025. This log was reviewed and both Patient #21 and Patient #22 were not identified as being on the ED patient log. 1. On 06/06/2025 at 1:42 PM, Patient #21’s ambulance run report was reviewed and this revealed the following: - The ambulance arrived in the ambulance bay of the hospital at approximately 12:00 AM; - Upon arrival, EMS staff were advised by MD #1 that the hospital was on diversion due to the Computed Tomography (“CT”) scan not being available; - EMS were advised to find another drop off point since the patient was not critical; - The ambulance then arrived at the receiving hospital, which is an additional thirty-three (33) miles away, at 12:55 AM. 2. On 06/10/2025 at 2:40 AM, Patient #22’s ambulance run report was reviewed and this revealed the following: - The ambulance team arrived in the ambulance bay of the hospital, due to the proximity of the hospital to the call location, at approximately 2:30 AM; - The ambulance called the ED five (5) minutes prior to arrival via telephone; - The ambulance staff were advised by a Registered Nurse (“RN”) taking the call that the hospital did not currently have CT capabilities; - Transport continued to the hospital ambulance bay; - MD #1 informed the ambulance satff that the hospital was currently unable to take the patient due to the lack of CT capabilities; - MD #1 would not accept the patient due to them being on diversion; - The EMT’s explained to MD #1 that until calling the RN, they were unaware of the diversion; - MD #1 reportedly stated, “Well we told you on the phone so why are you here”; - The ambulance crew explained to MD #1 that due to their proximity Rumford Hospital was the closest receiving hospital; - MD #1 reportedly stated, “Our doors are closed and we are not expecting the patient”; - The ambulance crews tried to explain that it was protocol to take the patient to closet receiving facility which was, in fact, Rumford Hospital; - The ambulance crew asked if MD #1 would like to lay eyes on the patient; - MD #1 asked, “Do I need too and why” and stated again we are on diversion and were not accepting the patient; On 06/06/2025 at 10:07 AM, an interview was conducted with the ED Medical Director, who stated the following; - On 06/03/2025 at 7:18 AM, I became aware of a possible EMTALA violation; - I was told it was a trauma patient who arrived on the hospital premises and was turned away without the Provider following the EMTALA requirements; - At 7:47 AM, I called the hospital and spoke with [MD #1], discussed the potential violation and provided re-education on the EMTALA requirements and that even if the hospital is on diversion, once the patient is seeking medical attention at the hospital, normal protocols would need to be followed; - At 8:21 AM, I spoke with my leadership and made them aware of the possible violation and we planned immediate re-education to Providers and staff; - We did notify all Providers that any patient who arrives and is not being discharged home or transferred appropriately must be discussed with me until I am sure all staff and Providers are aware of the requirements [outlined in the policy]; and - At approximately 8:43 AM, I learned of another patient who arrived in the ambulance bay and was sent to another hospital. On 06/09/2025 at 9:02 AM, a phone interview was conducted with MD #1. She stated the following: - I am a locum, and before my shift, I was informed that the hospital was on diversion, had no CT, and limited x-ray availability; In regard to Patient #21 - - I just heard the nurses chatting, that the EMT is bringing a patient in and the nurses told them we were on diversion; - The nurses handled that patient themselves; - I was not a part of that; - The Nurses told me that the EMT said they didn’t know that we were on diversion, but again, I was just following what staff were saying; and - I am not sure if it was a direct diversion or if they were onsite. In regard to Patient #22 - - An ambulance called in and they said they had a trauma patient but he/she was stable; - They showed up and called in from their phone in the ambulance bay; - I went outside and verified with them that this was the patient they just spoke about; - The EMS stated yes it was and asked if I was refusing to take the patient; - I said no, and asked if the patient was unstable now, has there been a change; - He kept asking if I wanted to “Lay eyes on the patient”; - I stated no, do I need to; - I have never refused to see a patient; and - I understand EMTALA, I would never say you can’t bring them in [the hospital]. In addition, she stated that the [ED Medical Director] spoke with her and explained the 250-yard rule, and she stated she was aware of that. She said, “I never refused to see [Patient #22] but they kept saying [he/she] was stable. I know EMTALA very well but I have never been on this side of the fence. Maybe next time, I will quickly look in the back to check that the patient is stable.” On 06/09/2025 at approximately 9:00 AM, MD #1 confirmed that the patients were in the ambulance bay, but due to the hospital being on diversion, she decided to tell the ambulance to drive to another hospital and did not provide Patient #21 or Patient #22 with a Medical Screening Exam. On 06/10/2025 at 11:37 AM, an interview was conducted with the ED Medical Director. He stated the following: - He has provided education to the ED staff, reminding them it is not up to the RN to make the call for diversion, if they get a call from EMT, they will relay to the MD the condition ...and then the MD decides; - In addition, until I can be sure that diversions are being handled appropriately, the Providers need to call me if we divert a patient; - Leadership emailed all Providers and ED staff the EMTALA policy, as well as the EMTALA “tip sheet”; and - Staff were instructed to repsond to the email to ensure that it was received and reviewed, which was confirmed.”

“RESTRAINT AND SECLUSION CFR(s): All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure that restraint orders were renewed, or that restraints were removed upon the expiration of the restraint order for one (1) out of five (5) restrained patients reviewed (Patient #1R). Findings: 1. Patient #1R’s medical record was reviewed and revealed that Physician #1 ordered the patient be placed in soft restraints at 9:03 AM on 09/05/2023. The order reads in part: “ ...Order Details: Restraint Type: 4 Point Soft, Orders May NOT Exceed 4 Hours. MD Must see patient within 1 hour and minimally every 4 hours ...” 2. Patient #1R’s medical record contains an entry by RN #1 dated 09/05/2023 at 2:45 PM which stated that the physical restraints were discontinued at 14:45 (2:45 PM) on 09/05/2023. RN #1’s documentation reads in part: “ ...Restraint Activity Physical Restraint Discontinued Restraint Discontinue Time 9/5/2023 14:45 EDT ...” 3. At 9:06 AM on 02/07/2024 RN #2 reviewed Patient #1R’s medical record and provided the following information: RN #2 confirmed at 9:06 AM on 02/07/2024 that Patient #1R was placed in restraints on 09/05/2023. RN #2 confirmed that the restraints were ordered for a duration of 4 hours beginning at 9:03 AM. RN #2 confirmed that the restraint order was not renewed. RN #2 confirmed that either the restraints should have been discontinued at 1:03 PM on 09/05/2023 per the order, or the order should have been renewed. RN#2 confirmed that according to the medical record, the restraints were not removed until 2:45 PM on 09/05/2023. 4. At 10:32 AM on 02/07/2024 an in-person interview was conducted with Accreditation Coordinator which revealed the following information: Accreditation Coordinator confirmed at 10:33 AM on 02/07/2024, that the 09/05/2023 restraint order for Patient #1R should have been renewed.”