Memorial Healthcare

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48030 Based on document review and interview, the facility failed to provide the complainant with a written response following the facility’s investigation regarding a grievance for 2 (P-1, P-7) of 2 patient representatives filing a grievance with the facility, resulting in the potential for less-than-optimal outcomes. Findings include: On 9/10/2025 at 1105 review of the Complaint and Grievance log was conducted with the facility’s Patient Advocate (Staff Q). Staff Q reported she received a grievance for P-1 on 4/7/2025 by phone from his daughter. Staff Q reported she forwarded the grievance to the ED Manger, LTC Manager and alerted Risk Management on 4/7/2025 about the complaint. Staff Q explained the case was reviewed by the ED Medical Director on 4/7/2025 and interviews were completed with facility staff on 4/10/2025. Staff Q added that she called P-1’s daughter on 4/14/2025 and was met with voicemail and message was left requesting a return call. Staff Q explained P-1’s daughter called on 4/16/2025 asking why she had not gotten an update about the investigation and was given an update about the status of the investigation. On 4/21/2025 Staff Q called P-1’s daughter and wife and provided an update about the investigation findings and she revealed they were both expressing frustration about the opportunities for improvement/staff education and wanted more specific information about how the injury occurred and if the staff member was fired. Staff Q revealed when she attempted to explain that she was unable to provide that information, they notified her they would be contacting their lawyer and suing the facility and requested no further contact and “did not need” a letter. On 9/10/2025 at 1115 review of grievance #38494 for P-7 was conducted with Staff Q. Staff Q explained the facility received the complaint on 5/9/2025 from a primary care physician by phone that a pediatric patient he sent to the ED was required to wait in the lobby rather than being treated immediately for shortness of breath and that a staff member was rude. Staff Q stated she forwarded the complaint to the ED manager and ED assistant clinical manager. Staff Q revealed the employee involved with the complaint was forwarded to Talent Management for review and the ED leadership spoke with the employee. When queried if the complainant received a follow-up letter, Staff Q responded she did not send a letter because they did not file a complaint. When queried what her policy states about follow-up letters, Staff Q was uncertain that a follow-up letter was required and thought a follow-up by phone was permissible. Review of facility policy titled ‘Patient Complaint and Grievance”, policy #860.01D, date effective 1/1/2022, section #3 reveals “F. A written response to the patient/representative will be provided within seven (7) business days of receipt of the concern...NOTE: A written response is required even if the hospital has utilized other means, such meetings [sic] with the patient and/or representative, to resolve the grievance.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to provide a safe transfer from wheelchair to stretcher for 1 (P-1) of 10 patients reviewed resulting in injury, unmet patient needs and poor patient outcomes. Findings include: Review of record on 9/9/2025 at 1045 reveals P-1 was taken to the facilities ED on 3/31/2025 at 0539 for evaluation after an episode of seizure-like activity. Review of the Emergency Department Note reveals a chest x-ray was ordered by the ED provider and revealed P-1 had an “acute-subacute appearing mildly displaced right humeral head/neck fracture”. P-1 has been admitted to the facility Long-Term Care floor 4th floor since 4/30/2024. On 9/9/2025 at 1235 an interview with the ED physician (Staff L) was conducted and revealed he remembered P-1 and was not the primary ED provider but took over care from another provider when he started his shift. Staff L added he remembered that P-1’s wife was at the bedside while he was in the ED. Staff L explained that P-1 had an episode of seizure-like activity and was brought down to the ED from the LTC unit on the 4th floor, and a chest x-ray was ordered which found he had a humerus fracture. When queried if they were aware that P-1 had a humerus fracture prior to the x-ray, Staff L revealed they did not, and it was an incidental finding. Staff L explained the x-ray findings said “acute-subacute”, and it was unclear when or how the fracture occurred, but this type of fracture of the humerus typically occurs after a fall. Staff L explained the standard course of treatment for these injuries (humerus fractures) is pain management and 4mg Morphine was ordered and application of a sling. Staff L revealed he recommended follow-up with an orthopedic surgeon in one week at discharge and P-1 was taken back up to the LTC unit. When queried if any falls or injuries occurred while P-1 was in the ED, Staff L revealed he was not aware of any. During an interview with the Long-Term Care (LTC) technician (Staff M) on 9/10/2025 at 0910 it was revealed she remembered P-1 and that she was the one who transported him to the ED the on 3/31/2025 by wheelchair. Staff M recalled that a male staff member in the ED went to lift P-1 up from the wheelchair to the stretcher and she reminded him he was unable to bear weight and offered to help with the transfer, but Staff T declined and picked P-1 up himself and transferred him. Staff M explained she felt the ED nurse could have done a better job and should have had assistance with a Hoyer lift or other staff and reported her concerns to the nurse when returning to the LTC Unit. When queried if anyone from the facility has instructed her to do anything different next time, she transfers a patient to the ED, Staff M revealed, “no nothing has changed”. Review of the High-Quality Review meetings which the facility conducted on 4/7/2025 and 4/23/2025 with the ED Director, LTC Director, ED Manager, Quality Director, Chief Nursing Officer, LTC Administrator following P-1’s the fractured humerus. The High- Quality Review revealed the facility identified the following opportunities for improvement and findings: 1. PCT (patient care technician) transferred patient from LTC to ED. Ideally, patient should have been transferred to a stretcher to LTC prior to going to ED. - ACTION: LTC staff will be instructed to request stretcher from RN supervisors prior to transfer to ED. If RN supervisor is unavailable, then an ED staff member will assist with transfer. 2. Request that CMO review Chest Xray with Radiology group to determine if we can gain better understanding of the age of the fracture - ACTION: CMO reviewed with Radiology. It was determined that the fracture was likely recent but there is no way to determine when this happened (LTC vs. ED). During an interview on 9/10/2025 at 1134 with the former ED Manager (Staff R), who was involved in the High-Quality Review Meetings about P-1’s injury, it was revealed that following the meetings he followed up with the ED RN (Staff T) about transferring P-1 to the stretcher from the wheelchair. Staff R explained that he told Staff T that he should not transfer a patient by himself from a wheelchair to a stretcher and directed him to have additional staff help for safety. When queried when the conversation occurred, Staff R was unsure of the date. When queried if education was provided to ED staff about the changes in process for patients being transferred from the LTC Unit to the ED, Staff R revealed he discussed it at employee huddles, and sent and email out to staff, but was unable to provide which employees received the education or the dates of completion. On 9/10/2025 at 1347 an interview with the House Supervisor Manager (Staff U) was conducted. Staff U revealed she is no longer responsible for managing the house supervisors but did recall the incident involving P-1. When queried if she was responsible for updating/educating the House Supervisors at the facility about the change in process for transfers from the LTC Unit to the ED, Staff U revealed she was and that she sent an email out to the supervisors and spoke about it at daily huddles. When queried if she could provide a list of employees and the dates/times they were educated about the change in process, Staff U revealed she was unable to provide that information. On 9/10/2025 at 1400 an interview with the Chief Nursing Officer (Staff B) was conducted and when queried if the facility had additional education about safe patient transfers or updated facility policies, Staff B revealed they had not. The facility did not provide a policy regarding Abuse and Neglect when requested.”

“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 record review and interview, the facility failed to perform a medical screening exam for 1 (P-1) of 30 patients reviewed who received services in the emergency department resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: On 6/20/2024 at 1255, review of the discharge log for the past 6 months (12/2023-present) revealed one finding for a female patient that was transferred to Facility C as alleged in the complaint to the State Agency (SA); however, it did not have the same events. Multiple female patients from 6/7/2024 were selected for sample that were transferred; however, none matched the description of events as was recounted in the complaint to the SA. On 6/20/2024 at 1615, review of a list of facilities under the Facility A’s provider number was reviewed and it was noted there were several “outpatient clinics.” A request was made for the facility to determine if any of the outpatient clinics were urgent cares, and, if so, was there a transferred female patient that matched the events described in the complaint to the SA. On 6/21/2024 at 0920, Chief Nursing Officer (CNO) Staff A stated there was a dermatology office renting space in Facility A who had a patient (P-1) sent to the emergency department (ED) for an EKG (electrocardiogram); however, the patient did not want to be admitted to the ED. Following the EKG, the patient returned to the dermatology office. The dermatology office later called an ambulance to transport the patient to Facility B. Staff A stated there was no medical record and the patient was not in their system (had not been registered). The only thing present was an EKG with P-1’s name on it. On 6/21/2024 at 0925, CNO Staff A was queried as to her expectation of staff when a patient is taken to the ED for services to which she stated, “Anytime a patient goes to the ER (emergency room), receiving anything, they should be registered and seen.” On 6/21/2024 at 0947, Nurse Practitioner (NP) Staff J stated she worked both the dermatology clinic and the ED. She stated she saw P-1 in the dermatology office for a severe skin infection. As part of the evaluation, vital signs were obtained and P-1’s heart rate (HR) was 29 beats per minutes (bpm). “She had a history of A-fib (atrial fibrillation-irregular heart rate; heart’s upper chambers beat out of coordination with the lower chambers.)... She stated she felt ‘off’ and ‘lightheaded’ with movement and was short of breath.” Staff J stated she had decided to call an ambulance, but P-1 refused. She wanted to drive home and have her daughter take her to Facility B where her cardiologist was. Staff J did not feel it was safe for P-1 to drive home and stated she was concerned P-1 was in complete heart block (also known as 3rd degree heart block - abnormal heart rhythm resulting from a defect in the cardiac conduction system in which there is no conduction through the atrioventricular node leading to complete dissociation of the p waves and the qrs waves; can be fatal if not treated right away). Staff J encouraged P-1 to go down to the ED in Facility A for an EKG, and P-1 agreed. “I looked at it as though they were doing me a favor since I work down there too... The EKG showed Wenckebach (2nd degree heart block Type I - progressive prolongation of the PR interval until eventually an atrial impulse is completely blocked)... The trip to the ED seemed to scare her heart rate up a little and it was normal there. So I took her back to the dermatology office.” Staff J stated upon return to the dermatology office, P-1’s HR dropped again and the patient was symptomatic, so they called an ambulance to transport P-1 to Facility B. Staff J further stated, “Incidentally, (P-1) called the dermatology office yesterday and stated she ended up going to (Facility C) instead of (Facility B) because they were on diversion.” On 6/21/2024 at 1006, Patient Care Technician (PCT) Staff K stated she was in the ED performing EKG’s on patients when she was stopped by NP Staff J who asked her to do an EKG for her (on P-1). Staff K “pulled” NP Staff J and P-1 into Triage 2 (an area where EKG’s can be done for triaged patients awaiting evaluation) to do the EKG. Staff K stated she asked the patient her name and date of birth because she was not “in the system.” Staff K stated, “During the EKG, (NP Staff J) and (P-1) were talking about checking in (to the ED).” Upon finishing the EKG, Staff K stated she handed it to NP Staff J and then left to continue performing EKG’s on other patients. On 6/21/2024 at 1023, ED Medical Director Staff L stated, “If bringing someone to the ED for a test, they (the patient) should be part of the ED system.” Staff L further stated there should be an easy way for a patient to obtain an EKG on an outpatient basis. On 6/21/2024 at 1035, CNO Staff A stated, “There are ways of doing an outpatient EKG, but not through the ED. If they are coming to the ED, they need to be registered as an ED patient.” Facility policy #501.021 titled “Emergency Medical Treatment and Active Labor Act” effective 12/20/2017 states, “Any individual who presents to Emergency Department of this hospital shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition... Potential emergencies presenting to outpatient locations other than the Emergency Department... On-campus outpatient departments and Provider Based Clinics. 1) Patient will be evaluated and stabilized within the capabilities of the department. 2) Physician or mid-level provider will discuss patient with Emergency Department. 3) Physician will order moving patient to Memorial Healthcare Emergency Department or transferring to another hospital within the requirements of this policy. 4) If no physician or mid-level provider is available, patient will be moved to Memorial Healthcare Emergency Department.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48030 Based on document review and interview, the facility failed to ensure the Important Message from Medicare (IMM) contained the required contact information for the Quality Improvement Organization (QIO) for twelve out of twelve (P-1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) medical records reviewed resulting in the potential for denying all discharged and current Medicare patients their right to report concerns to the QIO. Findings include: On 1/30/2024 and 1/31/2024 during medical record review, it was revealed that the IMM for 12 out of 12 records reviewed did not have the Quality Improvement Organization (QIO) information included. The area designated on the form under “Rights as a Hospital Inpatient” was not complete and had “(insert QIO name and toll-free number of QIO)” rather than the actual contact information for the QIO. During an interview with the Director of Revenue Cycle, Staff M on 1/30/2024 at 1451 the IMM was reviewed. Staff M agreed the IMM was incomplete and the QIO name and toll-free number were not provided as the form states and as required. Staff M stated she is responsible for making sure the information on the IMM is correct and would have the form revised immediately. An updated and corrected IMM was provided prior to departure from facility on 1/31/2024. It was also observed the new form was being utilized in the Emergency Department for patients and includes QIO address and phone number. On 1/31/2023 at 0900 review of policy titled Patient/Resident Bill of Rights, Policy #002.18J, effective May 26, 2021 states under Purpose, “...will inform patients, staff, and visitors of the rights of all patients who receive care at the organization.””