Three Rivers Health

“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: 28042 Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a triage and medical screening exam (MSE) for 1 patient (P-1) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for all patients seeking emergent care. See tag 2406: Failure to provide MSE”

“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: 28042 Based on interview and record review the facility failed to ensure triage and medical screening exam were performed for one (P-1) of twenty (#20) patients reviewed for triage and medical screening exam from a total sample of 20, resulting in potential for less than optimal outcomes for all patients seeking emergent care. Findings include: Review of ED (Emergency Department) to OB (Obstetric) logbook revealed “OB triage ED” form with P-1 listed on 07/05/2024 at 1154, with symptoms documented as “lost mucus plug”, EDC (Estimated date of confinement - Due date) listed as 07/11/2024, disposition listed as “OB”, OB Doctor documented as “Muskegon” and ER Doctor information was left blank. Review of the OB log for the month of July 2024 revealed that P-1 was not on the OB department log. Review of the facility’s electronic medical record system with Staff A and Staff B on 08/27/2024 at 1345, did not reveal any visits or medical record for P-1 in the emergency department, OB department, or any other department in the facility at any time. The facility was unable to produce any documentation that P-1 was provided a medical screening exam by a qualified medical personnel. In an interview on 08/27/2024 at 1430, Staff A (Vice President of Nursing) stated she had verified that Staff G (ED RN) was the staff member who documented P-1’s visit on 07/05/2024 in the ED to OB logbook. In an interview on 08/28/2024 at 0955, Staff G confirmed she was the nurse working triage on the day P-1 presented to the facility. She vaguely recalled P-1 presenting to the facility. Staff G said P-1 had some concerns about losing her mucus plug but wasn’t in imminent labor. Staff G stated she did the initial interview with her and left her with registration staff to be sent to the OB department. Staff G said her job as ED triage is to respond when called by registration for patient presenting with an OB complaint and make sure they are appropriate to go to OB. Her process would be to interview the patient, put her on the OB/ED log, then let registration put her in the registration system and call OB. Staff G stated she was not aware if P-1 went to OB. In an interview on 08/28/2024 at 1120, Staff F confirmed she was working in the OB department as an RN on 07/05/2024. Staff F stated she did not recall P-1 coming to the department with complaints about losing her mucus plug. In an interview on 08/28/2024 at 1430, Staff C (Registration Staff) stated when someone presented to the registration desk with OB complaints, the first thing she does is ask how far along they are so she knows who to call OB or ED. Then Staff C said she gets name, date of birth and calls the ED triage nurse who will come and do a quick interview to make determine how urgent the situation is. Every patient who comes in is registered. If the patient goes to OB, they are fully registered, if they go to ED a quick registration is done. Reivew of facility, “Triage” policy dated 01/2024 revealed, A. All patients who present to the Emergency Department (ED) will be assessed and evaluated by an RN. ED triage will be notified of a patient via registration staff calling for a “Nurse Assessment”. 1. The most important key factors required to determine a patients’ disposition are: A. Chief complaint and signs/symptoms associated with complaint. B. General appearance. C. Vital signs. D. Allergies E. Patient history including medication. Review of facility, “EMTALA Compliance” policy dated 01/2024 revealed, Medical Screening Examination. If a person comes to the Hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person would believe that the person is in need of emergency care, then qualified medical personnel will, within the Hospital’s capability and capacity, conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition.”

“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: 36887 Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a medical screening exam, resulting in unidentified patient condition and poor patient outcomes. Findings include: See Specific Tag: A-2406 Failure to provide a medical screening exam”

“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: 36887 Based on interview and document review the facility failed to initiate the triage process in a timely manner and/or failed to perform a timely medical screening examination to determine whether an emergency medical condition existed for 9 (P-1, 21, 22, 23, 24, 25, 26, 27, 28 ) of 28 patients reviewed who presented to the emergency department for evaluation resulting in the actual and potential poor patient outcomes up to and including death. Findings include: On 11/20/2023 at 1030, review of the medical record for P-1, the patient of concern, revealed there was only basic registration information, consent for treatment, and medication information that had been pulled in from previous visits. The documents showed an arrival of 9/25/2023 at 2113. The complaint was listed as “Suicidal-LWBS (left without being seen).” Discharge time was listed as “2220 approx.” (sic) On 11/21/2023 at 1430, review of the facility’s investigation included a statement written by Registration Clerk Staff P on 10/2/2023 (statement was not timed). She stated that the police officer came in with P-1 and “advised that (P-1) was talking about suicide and harming herself... Around 10:25 pm (22:25) (P-1’s) mother said she was missing, where did she go, call the Police. Mother left to go looking for (P-1). I said I was not aware of her leaving... (Staff L) came up front and I told her to contact (Staff N) for direction on contacting Police at 22:30. Around 22:40 someone said there was an accident on (the highway)...” Staff P was unavailable for interview. During an interview with Staff A on 11/20/2023 at 0958, she stated the facility investigation showed P-1 had been brought in through the ED lobby by a police officer for suicidal ideation. Shortly after arrival, P-1’s mother arrived. “Apparently, the patient and the mother had been fighting. The mom took a seat approximately 20 feet away from the girl in the lobby... ED was swamped. A patient with an allergic reaction and angioedema was being coded and a trach (tracheostomy-a hole placed through the neck into the trachea to help air and oxygen reach the lungs) was being placed. No call was made for nurse assessment.” Staff A explained the process had been for the registration staff to call for a nurse assessment for any emergent issue such as chest pain or stroke symptoms. All other patients, the registration person would call back on a radio that a patient was in the lobby awaiting triage. “The video shows the girl look at her mom and then walk out. After about 30 seconds, the mother notices she is gone and panics, running to the door and looking for her... (P-1) deliberately stepped in front of a car. She was dead at the scene and was not brought back to the hospital (for attempted resuscitation).” Staff A further stated P-1 had a history of suicidal ideation and “this was not the first time” P-1 had stepped out into traffic. On 11/20/2023 at 1437, review of video documentation from 9/25/2023 revealed P-1 had been sitting in the lobby waiting for triage for 70 minutes prior to leaving. On 11/21/2023 at 1149, Staff K, the charge nurse and triage nurse from 9/25/2023, stated the ED had been extremely busy. The police officer that had brought P-1 to the hospital had informed her P-1 “had assaulted her mother. I immediately asked if she was going to be arrested. He said no. He stated he was leaving, and her mother was with her in the lobby. Nothing was ever said about her being suicidal. I never laid eyes on her...There is not a nursing presence in the lobby at all times.” On 11/21/2023 at 1430, further review of the faclity investigation interviews from 10/2/2023 revealed an untimed statement from Physician Staff Q who was also unavailable for interview. He stated there was a critical patient and he “was getting airway secured (sic). After that he was told by an RN (registered nurse) that a 16 year old was hit on the highway and was coming in. A little later he was told that the patient was in the waiting room and then eloped and got hit.” He was queried during the facility interview as to if caring for the critical patient had delayed P-1 from coming back into the ED for a medical screening exam to which he stated it did delay someone from coming back; but was unsure it would have been P-1. He further stated suicidal patients were not prioritized and he felt the ED needed a dedicated triage nurse as well as a dedicated social worker for psychiatric consults/assessments. When interviewed on 11/20/2023 at 1308, Risk Manager Staff C stated she was called by VP Nursing Staff A within one hour of the event. “I knew right away we would need an RCA for this critical incident.” Staff C stated there were multiple “opportunities” identified for the facility to improve upon. “First, the patient was not triaged. This is the root of the situation. Had she been triaged correctly this could have potentially been avoided... There was a drift from normal practice. It is not the role of non-clinical people to determine acuity... There is not a good process in place for behavioral health patients. Somewhere, they forgot about being able to use sitters for behavioral health patients... While it was busy and a lot was going on, it doesn ’ t absolve us of our responsibility. Hospital work demands assessment of priorities. Suicidal ideation is a priority. There was no suicide screening being done. Review of the Action Plan on 11/21/2023 at 1030 revealed 14 of 20 items listed were still in progress or their stage had not been identified on the provided documentation as follows: 3. Send policy to QPCC (Quality Patient Care Committee) In progress. 4. Audit compliance - number of CSSRS vs number of patients with chief complaint of behavioral health concern. Audit weekly for 90 days. After first week, evaluate need for additional education. In progress. 5. Triage Update/Nurse Assessment - Nurse Assessment must be called on EVERY patient. In progress. 6. Find location for triage at the front desk. In progress. 9. Reiterate patients are 1:1 only if they are a high risk from CSSRS. In progress. 11. Update Elopement policy. Stage process is in is unidentified. 12. Educate staff on what to do when a patient elopes. In progress. 14. Evaluate security. In progress. 15. Track door to triage time. In progress. 16. Evaluate length of stay. Stage process is in is unidentified. 17. Re-educate on Policy Stat. Stage process is in is unidentified. 18. Send CBL (computer-based learning) for staff to complete? Update as needed. In progress. 19. Train team lead to complete Safe-T tool. In progress. 20. Re-educate staff on elopement policy. Stage process is in is unidentified. On 11/20/2023 at 1129, a targeted review of the 24-hour census from 9/25/2023 revealed other patients also left without being seen (LWBS) as follows: -P-21 An 8-year-old male who presented to the ED at 0847 for an upper extremity injury. Triage 0945. LWBS 1035. -P-22 A 7-year-old female who presented to the ED at 0914 for a cough. Triage 0950. LWBS 1250. -P-23 A 59-year-old male who presented to the ED at 0919 for a laceration. Traige 0955. LWBS 1236. -P-24 A 36-year-old male who presented to the ED at 0929 for abdominal pain. Triage 1000. LWBS 1302. -P-25 A 24-year-old female who presented to the ED at 1143 for a sore throat. Triage not done. LWBS 1250. -P-26 A 27-year-old male who presented to the ED at 1615 for generalized weakness. Triage not done. LWBS 1711. -P-27 A 19-year-old female who presented to the ED at 2015 for an upper extremity injury. Triage not done. LWBS 2300. Review of facility policy #9076427 titled “Triage” last revised 4/2015 states, “All patients who present to the Emergency Department will be classified by an RN. 1. The most important key factors required to determine a patients’ (sic) disposition are: a. Chief complaint and signs/symptoms associated with complaint b. General appearance c. Vital signs d. Allergies (for patient safety) e. Patient history including medication, (prescription, non-prescription and supplements. The above information will be required on all patients in Triage and may be collected in a room prior to entering ED or at the bedside.” The policy fails to include the triage process, such as timelines, how patients in the lobby are monitored, and what to do if a nurse is not present at the time the patient presents to the facility to be seen. Review of the facility “Medical Staff Bylaws” last revised 1/31/2019 failed to identify who could conduct a medical screening exam. Request was made for the medical staff “Rules and Regulations” but was not provided prior to end of survey.”