Bronson Battle Creek Hospital

“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: 29955 Based on 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] by failing to provide a medical screening exam (MSE) and failed to log arrival to the Emergency Department (ED) for 1 patient (P-1), who came to the emergency department requesting examination and/or treatment for a medical condition, out of 21 patients reviewed for EMTALA requirements. This failed practice resulted in the potential for the patient to experience deterioration from an unidentified emergency medical condition, which posed a risk to her health and safety. Findings include: See tags: A-2405 Failure to keep an Emergency Department log with names of all persons arriving to the Emergency Department seeking Emergency Services A-2406 Failure to complete a medical screening exam”

“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: 29955 Based on interview and record review, the facility failed to maintain a central log for 1 (P-1) of 21 patients coming to the hospital emergency department (ED) seeking emergency services resulting in inaccurate documentation of P-1’s arrival to the emergency department. Findings include: During an interview with the System Risk Manager (staff E) on 3/10/2025 at 1340, staff E said there was no documentation in the facility’s system regarding P-1’s arrival on hospital property on 2/21/2025. Staff E confirmed that P-1 had been brought to the ED on 2/21/2025 and provided security video documentation. On 3/10/2025 at 1355 record review occurred of security video footage from 2/21/2025. Video footage revealed a police car arriving at the ED parking lot at 1706. P-1 was observed outside of the police car with the police officer (staff K). An additional officer (staff L) was visualized walking to the police car and then entering the building at 1710. Staff L was seen walking to the triage nurse’s station and speaking with staff I, (registered nurse) at 1711. At 1716 staff L was visualized walking back to the police car where P-1 was located with staff K. At 1728 staff L walked back into the building to the security office. At 1732 the police car with P-1 left the facility’s property. On 3/17/2025 at 1230, an interview was conducted with staff L. Staff L was queried if she was at the facility on 2/21/2025 with staff K and P-1. Staff L stated she was at the facility with staff K and P-1 because staff K had transported P-1 to the hospital after a suicide attempt at his home. Staff L was then asked if she had spoken with the triage nurse (staff I) regarding P-1. Staff L stated she went in the building and spoke with staff I, and had informed her that there was a suicidal patient (P-1) outside with staff K. Staff L was asked if P-1 was registered as a patient. Staff L stated that P-1 was not registered. Staff L was queried if she was told not to bring the patient into the facility. Staff L stated, “No. I was told they (ED) were really swamped and stated it might be better to take him (P-1) to (facility B).” On 3/10/2025 at 1130, review of facility’s central log for a 6-month period (9/1/2024 - 3/9/2025) revealed no documented evidence that P-1 arrived at the facility and sought treatment on 2/21/2025. An interview with registered nurse, staff I, occurred on 3/10/2025 at approximately 1545. Staff I was queried if she remembered a conversation with staff L on 2/21/2025 at approximately 1710 where the officer indicated P-1 was located in the parking lot for a suicide attempt. Staff I responded, “I do not recall.” Staff I was asked if she could remember her shift on 2/21/2025 and if it was on diversion. Staff I stated she did not remember if the hospital was on diversion on 2/21/2025. Review occurred of the document titled, “EMTALA Essentials for the Emergency Department,” dated 07/22, reference number 9005056. The document read, “All persons presenting to the Emergency Department at (facility) requesting a medical evaluation will be registered and assessed...” Review occurred of the policy titled, “System ED-8 Triage Guidelines for the Emergency Department,” not dated. According to the policy the following is noted, “I) (Facility A) will provide hospital emergency care to all patients requesting emergency care who are on hospital property.””

“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: 29955 Based on interview and record review, the facility failed to provide a medical screening exam (MSE) for 1 (P-1) of 21 patients reviewed resulting in the potential for an untreated emergency medical condition and poor outcomes. Findings include: On 3/10/2025 at 1100 review of the Emergency Department (ED) log from 9/10/2024 to 3/9/2024 revealed no evidence of P-1’s arrival to the facility. On 3/10/2025 at 1340 an interview was conducted with staff E, the System Risk Manager. According to staff E and review of video documentation, it was confirmed that P-1 was present at the facility on 2/21/2025. Staff E stated an investigation had been conducted when he was made aware of the patient (P-1) being brought to the facility. Staff E stated he was able to confirm a police car had brought an individual (P-1) to the facility for a suicide attempt but did not bring the patient into the ED. On 3/11/2025 at 1115 an interview was conducted with staff M, Medical Director of the ED. Staff M was queried if a medical screening exam is required for all patients presenting to the ED. Staff M stated, “Yes...All patients receive a MSE unless they leave without being seen.” Staff M was then queried if a MSE would be done on a patient in police custody in the parking lot area. Staff M stated, “Yes...It would not matter where, a MSE can be done anywhere on campus...” On 3/17/2025 at 1235 staff L, police officer, confirmed P-1 was brought to the facility on 2/21/2025. Staff L was queried if the facility was aware that P-1 was in the parking lot. Staff L stated, “yes...they were really swamped and stated it might be better to take him (P-1) to (facility B).” On 3/11/2025 at 1600 a review of the document titled, “EMTALA Essentials for the Emergency Department, dated 07/22, reference number 9005056.” According to the document it revealed, “A medical screening exam will be completed by a qualified provider and documented in the patient ’ s electronic health record. If an emergency medical condition exists or active labor is diagnosed, the patient will be provided with stabilizing care up to and including admission or transfer when appropriate...” On 3/11/2025 at 1630 a review of the policy titled, “System Administration A-11 Treatment and Active Labor Act Compliance - EMTALA,” policy code A-11, dated 06-07-02. According to the policy it revealed, “Any person who comes to the hospital ’ s dedicated Emergency Department (ED), Labor and Delivery Department, or arrives on hospital property requesting treatment for what may be an emergency medical condition will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 29955 Based on record review, interview, and observation, the facility failed to ensure nursing staff implemented fall safety interventions for fall prevention for 7 of 14 patients (P-1, P-5, P-6, P-7, P-8, P-9 and P-14) resulting in harm to 2 patients (P-1, and P-14) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include: See Specific Tag: A-0392”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 29955 Based on record review, interview, and observation, the facility failed to ensure nursing staff implemented fall safety interventions for fall prevention for 7 of 14 patients (P-1, P-5, P-6, P-7, P-8, P-9 and P-14) resulting in harm to 2 patients (P-1, and P-14) and the potential for harm for all patients at the facility who have a high risk for falls. Findings include: Documentation review of P-1 medical record occurred on 7/18/2024. According to documentation P-1 sustained a fall on 6/16/2024 at 2057 on the Ortho/Neuro unit (C-2). On 7/18/2024 at 1430, an interview was conducted with staff Q, registered nurse who cared for P-1 on 6/16/2024 at the time of the fall. Staff Q was asked if fall precautions for P-1 were in place. Staff Q stated “yes.” Staff Q stated she was not in the room at the time of the fall. Staff Q stated that P-1 was found on the ground. Staff Q also stated that P-1’s mother had left to go home, and that P-1 was in the room alone. Staff Q was then asked if P-1’s bed alarm was activated when P-1 fell. Staff Q stated that the bed alarm was not functioning at the time of the fall. Staff Q was then asked if the chair alarm was in the bed at the time of the fall. Staff Q stated that the chair alarm was put in P-1’s bed by the House Supervisor after P-1 fell. Staff Q was queried if it was known that the bed alarm was not working prior to P-1 falling. Staff Q stated, “No.” Staff Q was then asked who was notified post fall event. Staff Q stated that she had called the house supervisor, staff N, P-1 physician, staff V, and P-1 mother. Staff Q stated that P-1 underwent CT scans after the fall. A nursing note by staff Q on 6/16/2024 at 2100 revealed the following, “Patient had unwitnessed fall and was found on floor by this RN. Charge nurse notified. House supervisor notified. Vital signs checked. Vital signs stable. Skin check was done. Scattered abrasions noted and bump to right side head noted on assessment. MD notified of event. Mother (name) notified of event. Full head to toe assessment done on patient. Will notify MD with any changes.” Based on medical record review, on 6/16/2024 at 2123, CT of the cervical spine and brain were completed. The indication for the CT scans stated, “ground level fall from bed.” Findings resulted on 6/16/2024 at 2309. Findings were significant for “Intracranial Hemorrhage: Mild acute subarachnoid hemorrhage in the medial right parietal sulci.” A repeat CT of the brain was completed on 6/17/2024 at 0925. Findings were noted as, “Stable trace subarachnoid blood products within the medial left parietal sulci.” On 6/18/2024 at 1357 an X-ray of the right elbow was completed for right elbow swelling. Findings documented as, “no displaced fracture or dislocation ...there is soft tissue swelling.” On 6/18/2024 at 1356 an X-ray of the right shoulder was completed. Indication for the x-ray was “fall, right shoulder bruising.” Findings documented as, “No acute fracture or dislocation involving the right shoulder.” During the record review of P-1’s medical record, documentation revealed that on 6/14/2024 at 2327 the following was documented, “Universal Fall Risk interventions; Bed/Chair alarm (consider plugging chair alarm into call light system and volume on high) ...” On 7/18/2024 at 1300 an interview occurred with staff A, the Manager of Patient Safety and Quality. Staff A was queried about P-1’s fall on 6/16/2024. Staff A stated that during the investigation of P-1’s fall, it was revealed that P-1’s bed alarm did not work due to P-1’s weight not being heavy enough to trigger the bed alarm. Documentation of first use of chair alarm on bed was on 6/17/2024 at 0046 (after P-1’s fall) by staff N, house supervisor. During interview on 8/1/2024 at 1310 Staff A was queried why the Morse Fall assessments were only documented four times in P-1 medical record. Staff A stated that Morse Fall assessments are used initially on admission of a patient to the facility up to 24 hours. Staff A explained that the EMR (electronic medical record) gathers information from documentation during the course of the patient’s hospital stay and a Predictive Fall model score is assigned to the patient On 7/18/2024 a document review occurred of the policy titled, “System Nursing G-07 Fall Prevention and Management Policy & Procedure,” no date provided. According to the policy it states under, “Fall Prevention Standard Work, Assess patient: Complete and document a new Morse Fall Scale and Score: upon admission, during first 12 hours of admission, after treatment/procedure with sedation or anesthesia. Use Morse Fall Score to guide interventions: < 50: use Universal precautions interventions and any additional from moderate or high risk level as needed, = 50: use High Risk precautions interventions and consider Fall Watch level. Key Point: Why, Assessment with Morse Fall Scale at these required times supplements predictive model scoring during data generation upon arrival and recovery from anesthesia or sedation ...Patients post sedation are at risk due to lack of safety awareness and/or transitory deficits in sensation and ability to bear weight (altered mobility). The Morse Fall Scale is an evidence-based approach to help determine the risk for fall.” The Fall Prevention Flowchart describes “Low Risk” interventions as “Universal Interventions Includes all patients FPM (Fall Predictive Model) score 0 - 33 includes the following interventions, “orient to room / call light, call light in reach, bed low and locked, personal items in reach, adequate lighting, TEMP rounding, fall prevention screening, fall prevention education, call to stop a fall sign, room free form clutter, and Individualized interventions.” “Moderate Risk” includes FPM score 34 - 68 includes the following interventions, “All Universal interventions, yellow armband, fall precautions sign outside door, staff stay with patient during elimination, consider gait belt use.” “High Risk” includes FPM score >68 includes the following interventions, “All Universal and Moderate Fall Risk Interventions, Bed Alarm/Chair Alarm (consider plugging chair alarm into call light system and volume on high include signage as applicable, use gait belt for ambulation, assess need for video surveillance, assess need for Fall Watch Status.” According to the documentation for Fall Predictive Model, P-1 was not documented as a high risk fall although diagnoses included developmental delay of an 18-month-old, mental retardation, autism, and seizure disorder. According to the Morse Fall assessment P-1 was not considered high risk for falls. P-1 did not have a documented history of falling (score - 0), had a secondary diagnosis (score 15), intravenous therapy/saline lock (score 20), gait weak according to assessment and was receiving PT while hospitalized (score 10), Mental status - Overestimates / Forgets limitations as a bed/chair alarm was in use and P-1 has Developmental Delay, Mental Retardation, and Autism Diagnoses (score 15) - Total score 60. According to the Morse Fall assessment scale P-1 should have been a high risk for falls based upon the information in P-1 EMR. The following scoring is used to determine risk of falls: Score Risk 0 No risk for falls < 25 Low risk 25 - 45 Moderate risk >45 High risk “Morse Fall Risk Score table” - Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors. Content last reviewed July 2023. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html. The facility failed to provide interventions for P-1 based upon failure to accurately score the patient, and failure of the Fall Predictive Model to accurately score the P-1. On 7/18/2024 at 1110 during a tour of the CCU (Critical Care Unit) observation of P-5 with a fall risk sign outside of room. Record review of P-5 medical record occurred on 7/18/2024. P-5 was admitted to the hospital on 7/9/2024 for acute respiratory failure with hypoxia. According to P-5 first Morse Fall assessment on 7/9/2024 at 2141, P-5 was scored a 55, high risk for falls. On 7/10/2024 interventions noted a “yellow armband” as an intervention to alert staff of P-5 being a fall risk. P-5 failed to have an armband. On 7/18/2024 at 1118 during the tour of the CCU, observation of P-6 revealed a fall risk sign outside of the room. Record review of P-6 medical record occurred on 7/18/2024. P-6 was admitted to the facility on 7/13/2024 for blood in the urine. P-6 Morse Fall Risk score was 60 (high risk). P-6 was scored a “moderate” fall risk on 7/14/2024 at 1001. On 7/14/2024 at 1249 interventions included a fall risk “yellow armband” as an intervention to alert staff of P-6 being a fall risk. P-6 was observed and did not have a yellow armband. On 7/18/2024 at 1125 during the tour of the CCU, observation of P-7 with a fall risk sign outside of the room. Record review of P-7 medical record occurred on 7/18/2024. P-7 was admitted to the facility on 7/17/2024 for chest pain. P-7 predictive model for falls was scored at 58.1. On 7/18/2024 at 0016 P-7 was noted to be a “moderate” fall risk. Interventions listed included a fall risk “yellow armband” as an intervention to alert staff of P-7 being a fall risk. P-7 was observed and did not have a yellow armband. On 7/18/2024 at 1132 during the tour of the CCU, observation of P-8 with a fall risk sign outside of the room. Record review of P-8 medical record occurred on 7/18/2024. P-8 was admitted to the facility on 7/12/2024 with the chief complaint of “fall with injury.” P-8 was documented as having acute altered mental status, hyperglycemia, and hematuria. Further documentation included “patient confused and not making sense...unable to state date and month.” On 7/12/2024 at 1041, P-8 Morse Fall score documentation revealed P-8 was oriented to own ability, and not having a secondary diagnosis. P-8 initial Morse Fall Score on 7/12/2024 at 1041 was incorrect at 45. P-8 Morse Fall Score should have been 60 at his initial screening. P-8 presented to the facility related to a fall, had a secondary diagnosis, had an IV, and was not oriented to his own ability. On 7/12/2024 at 1041, “fall prevention/watch interventions” included yellow armband. P-8 failed to have a “yellow armband” as an intervention to alert staff of P-8 being a fall risk at the time of observation. On 7/18/2024 at 1140 during a tour of the CCU, P-9 room had a fall risk sign outside of the room. P-9 was not on the unit at the time of tour but was in dialysis. On 7/18/2024 at 1140 P-9 was observed in the dialysis treatment area while on C-2 (Ortho-Neuro Unit). Record review of P-9 medical record occurred on 7/18/2024. P-9 was admitted to the facility on 7/12/2024. P-9 chief complaint was fever. P-9 was diagnosed with cholecystitis, pericardial effusion, and sepsis. P-9 initial Morse Fall Risk score was 65 on 7/12/2024 at 1343. P-9 Predictive model score for risk for fall 6.95 on 7/12/2024 at 1401. On 7/13/2024 at 1127 fall risk interventions included “yellow armband” as an intervention to alert staff of P-9 being a fall risk. P-9 was noted not to have a yellow armband. On 7/19/2024 P-14 was identified as a moderate injury from a fall on 7/2/2024. Record review of P-14 medical record revealed P-14 was admitted to hospital on 7/2/2024 at 0602 for total knee replacement with a diagnosis of loosening of prosthesis. P-14 was transferred to unit C-2 on 7/2/2024 post surgery. P-14 first Morse fall assessment was completed on 7/2/2024 at 0609. P-14 score was 35. A second morse fall risk assessment was completed on 7/2/2024 1228. The second score was 60. A third morse fall risk was completed on 7/2/2024 at 1652 and P-14’s score was 75. On 7/2/2024 P-14’s fall risk intervention list included “Do not leave alone during elimination.” P-14’s medical record revealed on 7/2/2024 around 1500 P-14 fell in the bathroom while alone. P-14 fall caused dehiscence of the surgical wound requiring additional surgery and was transferred to surgery at 1641. P-14 underwent surgery for debridement and closure of the wound at 1708. P-14 was transferred back to C-2 at 1938. On 7/3/24 at 1254 Physician, staff X documented the following at 1257, “Patient with a complicated postop recovery, was originally going to be a same day surgery, had difficulty with buckling so was changed to stay overnight for more physical therapy before discharge. Patient was up into the bathroom (on Ortho/Neuro unit) when her surgical leg gave out and she fell to the floor causing her surgical incision to dehisce, patient was taken back to surgery for I&D and reclosure of wound. This morning patient doing well, discussed concerns for postoperative infection and the increased risks for it following the dehiscence.” On 7/19/2024 at 1010 an interview was conducted with staff L, Outcome Coordinator for Patient Safety and Quality. Staff L was asked what action plans were implemented to address falls in the facility. Staff L explained a “Kaiser” study had been completed at a system level. Staff L also stated that “TEMP” rounding had been implemented and started in May of 2024. Staff L explained “TEMP” rounding included rounding on patients to check for toileting, placing the call light within reach, placing necessary items within reach, check that the bed is in low position and locked, check bed/chair alarms are on, assess patient’s position in bed and comfort, ensure the patient is repositioned every two hours, and assessing patient’s pain level using a pain scale. Staff L further stated that two admission nurses had been hired to help with patient admissions as part of the Fall reduction project. Review of falls for the facility failed to show a decrease in falls since the implementation of “TEMP” rounding and the addition of admission nurses.”