Hillsdale Hospital

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to address a grievance for 2 (P-1, 26) of 3 patients in a timely manner and/or inform them of a lengthy investigation resulting in a loss of patient rights. Findings include: On 2/13/2024 at 1253, review of the medical record for P-1 revealed he was a 78-year-old male that had presented to the ED (emergency department) on 12/20/2023 at 1906 with a chief complaint of shortness of breath. He was discharged 12/20/2023 at 2035 with a diagnosis of stable COPD (chronic obstructive pulmonary disease). On 2/13/2024 at 1253, Risk Manager Staff B, who was also the patient advocate, stated she knew P-1’s daughter as she worked as a nurse practitioner in one of the clinics associated with the facility. Staff B stated she had been contacted by P-1’s daughter who was upset because the ED physician did not order anything other than a breathing treatment. The daughter informed Staff B her father had been admitted to the VA (veterans administration) hospital in septic shock and his kidneys had shut down. He went home on hospice about a week later, then died. The grievance documentation was again requested on 2/14/2023 at 0904. Staff B stated she didn’t “formalize” everything until the grievance was resolved; however, was able to provide the email that had been sent by P-1’s daughter. She stated she had spoke with ED Medical Director Staff H several times regarding this situation requesting a review and that he contact P-1’s daughter. Additionally, Staff B stated she had received a phone call “last week” from another family member of P-1 and had attempted to call her back; however, had not made contact and left a message. Staff B stated she had not heard back from them. Staff B was unable to provide documentation of when the phone contact was received or when she attempted to return the call. ED Manager Staff A, who was also present during the conversation with Risk Manager Staff B on 2/14/2024 at 0904 stated to Staff B, “I just remembered this morning (P-1’s daughter) had called and emailed me the day after he was here (12/21/2023).” On 2/13/2024 at 1630, review of the correspondence from P-1’s daughter to Risk Manager Staff B revealed she had sent an email on 1/18/2024 stating she wished to discuss her father’s ED visit and the ED physician that had provided care, Staff C. Staff B responded stating she was available any time and provided her phone number. P-1’s daughter sent another email 1/19/2024 requesting a time that would be good to call and then outlined the basics of her concerns in the email stating, “He was 78 years old. He was in a wheelchair. He was hallucinating. They put O2 (oxygen) on him, gave him neb (nebulizer breathing treatment) treatment, took off the O2 and sent him home. NOT one single test. Nothing... By the time he as (sic) admitted to ICU (intensive care unit) on life support he had CHF (congestive heart failure) and no kidneys... he was admitted in cardiogenic shock...” Further review of the correspondence revealed no reply to P-1’s daughter. The daughter’s email was forwarded to ED Medical Director Staff H on 1/19/2024 for review. On 2/5/2024, P-1’s daughter sent another email to Risk Manager Staff B stating she was “Unsure what I need to do next. Is there someone else you think I should talk to?” Again, Staff B did not respond to P-1’s daughter, but forwarded the email to Staff H stating, “I received this today, & she is wanting answers. Someone needs to call her please.” During an interview with Medical Director Staff H on 2/14/2024 at 1139, he stated he had been made aware of the family’s concerns with P-1’s care on 1/19/2024 from the risk manager. He stated he spoke with Physician Staff C about it and was aware he was supposed to have called the complainant. He stated there were “multi-factor reasons for delays in calling the family back.” Staff H stated he was going to call P-1’s daughter back “yesterday”; however, then “you showed up and I thought I should wait to see the outcome (of the survey).” ED Manager Staff A was interviewed on 2/14/2024 at 1157. She stated she had been called by P-1’s daughter on 12/21/2023 and asked to look into the medical record of P-1 because she felt the care of her father had been substandard. Staff A stated she had also received an email from P-1’s daughter on 12/22/2023 stating her father had been admitted to ICU with multilobular pneumonia and exacerbation of CHF. When queried what she had done with the information when she received it, Staff A stated she had informed ED Medical Director Staff H on 12/21/2023 via text to inform him of the phone call from P-1’s daughter and had forwarded the email on 12/22/2023. Review of the Complaint/Grievance Log from 8/2023-present on 2/14/2024 at 1200 revealed and entry for P-1. As a result of the above investigation, two other grievances were reviewed. Further review of the Grievance Log revealed an entry dated 1/18/2024 regarding P-26 who was evaluated in the ED on 3/1/2023. While in the ED, P-26 received a head CT (computerized tomography - “cat scan”) that was positive for a brain lesion; however, the patient and her husband were informed “it was fine.” P-26 found out in May of the CT and passed away in October. P-26’s husband questioned if earlier treatment of the lesion could have made a difference. Grievance documentation revealed the complaint was received 1/18/2024 and an email was sent the same day to ED Medical Director Staff H. On 2/1/2024, a phone call was made to the complainant from Staff H and a second follow-up phone call was made by Risk Manager Staff B. A closing letter was sent 2/6/2024. No other letters had been sent regarding the investigation taking longer than 7 days. Review of facility policy titled “Patient Family Complaint and Grievance” last revised 4/2021 states, “Patient Grievance: A formal written or verbal complaint made to the hospital by a patient or patient representative that is of serious nature or that cannot be resolved promptly by staff or department manager... The following issues are automatically considered patient grievances and the CEO, Patient Advocate, Risk Manager, Chief Nursing Officer should be notified as soon as possible whenever a complaint involves: The exercise of patient rights regarding his/her care; Premature discharge; Privacy and Safety of the patient; Confidentiality and access to patient records...Complaints otherwise serious in nature... Any complaint/grievance that is unable to be resolved ‘on the spot’ while in the hospital or is received after discharge will be forwarded to the Patient Advocate... The Patient Advocate is responsible for following up and resolving all patient complaints/grievances, including feedback to the patient, department head and President/CEO, Department manager will participate in the investigation and resolution process... All verbal or written grievances will be reviewed, investigated and resolved within seven days. If the grievance is not able to be resolved in this timeframe it will be communicated that the hospital is still working to resolve it and will follow-up with progress letters every 7-30 days (Time frames will be discussed with the complainant) until such time the grievance is resolved.””

“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 observation, interview, and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases] regarding 1) placement of signage for the rights of patients in respect to examination and treatment of emergent conditions and women in labor, providing an appropriate medical screening exam for 1 (P-1) of 1 patients, 2) meeting physician and nurse staffing requirements according to facility bylaws/policy and acceptable standards of practice, and 3) registration processes that do not discourage patients from remaining for treatment resulting for all patients served in the emergency department resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include: See Specific Tags: A-2402 Failure to have appropriate EMTALA (emergency medical treatment and labor act) signage A-2406 Failure to provide an appropriate medical screening exam; failure to provide appropriate physician staffing according to bylaws; failure to provide appropriate nurse staffing for triage according to facility policy and acceptable standards of practice A-2408 Failure to have registration practices that do not discourage patients remaining for further evaluation”

“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: 36887 Based on observation and interview, the facility failed to have emergency medical treatment and labor act (EMTALA) signage present in the emergency department waiting area resulting in the potential for all patients presenting through the main emergency department entrance to be uninformed of their rights. Findings include: During the initial tour of the emergency department (ED) on 2/13/2024 at 0833, the patient waiting area was entered and found to be lacking EMTALA signage. This was confirmed by Staff A at the time of discovery who stated, “They must have taken it down when they painted. I know it was right here.” Staff A was queried as to when the waiting area had been painted; however, she was unable to recall when it had been done.”

“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 record review, the facility failed to 1) provide an appropriate medical screening exam for 1 (P-1) of 1 patients, failed to 2) follow facility bylaws as to who can provide a medical screening exam for 1 (P-9) of 27 patients reviewed and failed to 3) follow facility policy and professional standards of practice regarding staffing of triage for 2 (P-1, 17) of 27 patients reviewed resulting in the potential for poor patient outcomes. Findings include: 1) On 2/13/2024 at 1300, review of the medical record for P-1 revealed he was a 78-year-old male that presented to the emergency departement (ED) via private vehicle on 12/20/2023 at 1906 with a chief complaint of shortness of breath. His wife also reported he was having hallucinations. Past medical history included hypercholesterolemia (high cholesterol), hypertension (high blood pressure), and heart disease. Triage notes indicated he had a cough and wheezing. A triage note dated 12/20/2023 at 1914 stated, “O2 (oxygen) saturation (O2 sat): 76%. Additional comments: Patient brought to ER (emergency room) room; inaccurate reading in triage.” Triage nurse Staff G was queried on 2/14/2024 at 1129 as to why she thought the O2 sat was inaccurate to which she explained she was unable to get a good pleth (a graphical display of the pulse oximeter signal over time). On 12/20/2023 at 1918, the initial nursing assessment revealed P-1 was oriented with pink mucous membranes; however, a narrative note stated P-1 was in “Mild respiratory distress. The patient can speak a few words at a time. Bilateral rhonchi present anteriorly.” The O2 sat was 100% at that time. Review of the physician notes revealed P-1 was evaluated by the physician on 12/20/2023 at 1920. Physical exam was normal with the exception of lung sounds being decreased. The physician reviewed vital signs from 1926 and 1931 on 12/20/2023 with O2 sats being 95% both times. Further review of the medical record revealed P-1 was given an incentive spirometer (device used to measure the volume of the air inhaled into the lungs during inspiration) on 12/20/2023 at 1922, and received a breathing treatment on 12/20/2023 at 2000. Respiratory Therapist Staff D conducted an assessment pre-breathing treatment which indicated P-1 had an O2 sat of 93% on room air and had decreased breath sounds. Post treatment, no O2 sat was obtained and lung sounds remained decreased. P-1 was discharged on 12/20/2023 at 2035 with a diagnosis of stable COPD (chronic obstructive pulmonary disease). No vital signs were obtained on discharge. No chest x-ray or labs were obtained. There was no mention of P-1 having been placed on oxygen or having oxygen removed in the medical record; however, on 2/14/2024 at 1157, a reviewed text from ED Manager Staff A to ED Medical Director Staff H from 12/21/2023 revealed Staff A stated the patient had been placed on oxygen but her staff did not chart it. During an interview on 2/13/2024 at 1510, ED Physician Staff C stated P-1 had been quiet and did not talk much. “He didn’t want to be there... His wife gave us the medical history and stated he had been at the clinic where he was swabbed for infulenza which was negative... There was a congested cough, so I gave him a breathing treatment.” Staff C Stated no one told her P-1 had been experiencing hallucinations. Staff C was queried as to if being sent by a clinic for evaluation, the patient having a congested cough, and decreased breath sounds would prompt the need for an x-ray. She stated it would not prompt an x-ray if the patient had normal vital signs. “He was really so benign at the time. The patient had no complaints, and the vital signs were fine... I guess at that time he didn’t give me that vibe that something more should be checked... He was answering questions, he was A&Ox4 (alert and oriented to person, place, time, and situation), and he didn’t want to be here. I think that changes the picture a bit.” When interviewed on 2/14/2023 at 1157, ED Manager Staff A stated she received a call on 12/21/2023 from the daughter of P-1 who was a nurse practitioner in one of their clinics. The daughter requested the medical record be reviewed as she felt the care for her father had been substandard. Staff A stated she then received an email from P-1’s daughter on 12/22/2023 which stated her father had been admitted to a VA (veterans administration ) hospital, was in the intensive care unit (ICU), and had multi-lobular pneumonia and exacerbation of CHF (congestive heart failure.) Risk Manager Staff B stated on 2/13/2023 at 1300 she had also received an email grievance from P-1’s daughter on 1/19/2024 which outlined concerns with the care received. On 2/13/2024 at 1630, review of the email from P-1’s daughter dated 1/19/2024 revealed the following statement: “He had CHF and dry kidneys. By the time he as (sic) admitted to ICU on life support he had CHF and no kidneys... he was admitted in cardiogenic shock... He was also admitted with miltilobular pneumonia and sepsis.” On 2/14/2024 at 1139, ED Medical Director Staff H stated he was aware of the grievance regarding P-1’s care and stated he felt there “should have been more of a work-up... Any 78-year-old shows up with any complaint needs more of a work-up than just vital signs.” Review of P-17’s medical record revealed he was a 42-year-old male who came to the ED on 11/03/2023 at 1556 with complaint of cough (productive), and chest and nasal congestion. Vital signs obtained by a LPN were significant for heart rate of 115, oxygen saturation of 90%, and a temperature of 96.9 F. The next documentation was at 1912 (almost 4 hours later) indicating the patient had left the ED without being seen or notifiying anyone at 1738. There is no documentation noting if the patient was called to return to the ED for the MSE or if the emergency physician reviewed the chart and noted the abnormal vital signs. There was no physical exam and no examination by a qualified medical professional. 2) On 2/13/2024 at 1115, review of facility Bylaws, last revised 9/23/2023 revealed the following: “EMTALA - Emergency Medical Treatment or Active Labor Act - The person performing the medical screening examination is a qualified physician with hospital privileges.” On 2/132023 at 1342, review of the medical record for P-9 revealed she was a 75-year-old female evaluated on 8/23/2023 by a NP for shortness of breath and a cough. On 2/13/2023 at 1345, Risk Manager Staff B, who was present during the medical record review, was shown the bylaws. Staff B stated, “Okay. We can change that.” On 2/14/2023 at 1139, ED Medical Director Staff H confirmed both NPs and PAs (physician assistant) work in the ED. 3) On 2/13/2024 at 1435 review of the medical record for P-17 revealed no acuity had been assigned to the patient. On 2/14/2024 at 1129, an interview was conducted with LPN Staff G, who had triaged P-1 on 12/20/2023. Staff G was queried as to what information she obtained while working in triage to which she stated she obtained vital signs, chief complaint, medical history, medication list, and allergies. She further explained she could not do initial assessments, acuity, or GCS (glasgow coma scale-a scale used to determine level of consciousness following a brain injury) because it was not in her scope of practice. On 2/13/2024 at 1409, the ED Nurse Manager Staff A was queried as to why no acuity levels had been assigned to two patients that had been reviewed. She stated, “LPNs (licensed practical nurses) cannot give acuity but they can triage. The registered nurse (RN) is supposed to assign the acuity once the patient is roomed and they do their assessment... It’s hard. They (LPNs) are not doing assessments or acuities.” On 2/13/2024 at 1409, Risk Manager Staff B who was also present stated during COVID, the facility changed their triage process to direct bedding instead of a traditional triage. She explained they view it as a “gri-age” where the patient was greeted, a chief complaint and vital signs are obtained, and then the patient was taken directly back to a room. Review of the facility policy titled “Triage” dated 8/2021 states, “The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department... The initial evaluation at Triage will be documented in the EMR (electronic medical record) and shall include: Quick Registration; Date and Time of Initial Triage Evaluation; Chief Complaint and symptoms associated; Source of information; Onset of symptoms; Allergies, including allergies to latex; Acuity Level, Temperature; Level of Consiousness”. On 2/13/2024 at 1412, Staff B was shown the triage policy. She stated, “Not all policies got fixed after COVID while we have been experiencing this staffing shortage.” Review of the ED LPN job description on 2/14/2024 at 1030 states, “Provides quality, professional, and compassionate nursing care according to regulatory requirements and nursing standards of practice in a manner that meets the physical, psychosocial, and spiritual needs of patients and their families.” Review of the Emergency Nurses Association “Position Statement” from 2018 revealed the following: “It is the position of the Emergency Nurses Association (ENA) that: 1. Triage is a critical assessment process performed by a registered nurse or nurse practitioner with a minimum of one-year of emergency nursing experience, as well as appropriate additional credentials and education that may include certification in emergency nursing and continuing education in trauma, pediatrics, and cardiac care, with verification or certification in those subspecialties as appropriate.””

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to have a registration process that did not discourage the patient from staying in the facility to receive treatment resulting in the potential for all patients served by the facility to leave without being seen or leave prior to completion of evaluation to avoid payment for services. Findings include: During an interview with Registration Staff F on 2/14/2024 at 1121, she was queried as to if she requested co-pays when registering a patient. Staff F stated at the time of registration, the patient was informed of their co-pay amount and informed the co-pay would be collected at the time of discharge. Staff F was queried as to if she received training in EMTALA (emergency medical treatment and labor act) to which she stated she did not. On 2/14/2024 at 1320, review of staff files for Staff F, RN (registered nurse) Staff A, RN Staff E, and LPN (licensed practical nurse) Staff G revealed no competencies present for EMTALA. Risk Manager Staff B stated on 2/14/2024 at 1322 EMTALA competencies had not been required for the past 2 years. Review of provided facility registration policy titled “Patient Identification At Registration” last revised 10/2021 does not address the issue of asking or receiving co-pays from the patient or patient representative.”