Mclaren Greater Lansing

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36887 Based on record review and interview, the facility failed to monitor 3 (P-5, P-7, P-8) of 25 patients while waiting for evaluation and/or during their emergency care according to facility policy resulting in the potential for adverse patient outcomes. Findings include: Review of the medical record for P-5 revealed he was an 82-year-old male who presented to the Emergency Department (ED) 6/8/2026 at 1230 and was triaged at 1240 with a chief complaint of diarrhea. He was assigned an ESI (emergency severity index-standardized assessment tool used to determine the severity of patient condition) score of 3 - urgent. P-5 was placed in a room at 1421 and seen by the physician at 1504. Vital signs completed at 1242 during triage were as follows: Temperature (T)-36.3 degrees Celsius (97.3 Fahrenheit), Heart Rate (HR)-54, Respiratory Rate (RR)-16, Blood Pressure (BP)-136/73 and Oxygenation (SpO2)-96%. Vital signs were not re-evaluated during his ED visit. P-5 was discharged 6/8/2026 at 1908. His length of stay was 6 hours and 38 minutes. Review of the medical record for P-7 revealed he was a 33-year-old male who presented to the Emergency Department 12/30/2025 at 1710 with a chief complaint of anxiety. He was assigned an ESI level 4 - semi-urgent. P-7 was triaged at 1717 and roomed at 2156. Vital signs were completed at 1721 during triage as follows: T-36.9 Celsius (98.4 Fahrenheit), HR-93, RR-16, BP-147/90, SpO2-100%. During exam, P-7 admitted to not eating or drinking for the past week, medications were not helping, and he was tearful and had pressured speech. Following a psychiatric consult, P-7 was transferred to a psychiatric facility for inpatient admission on 12/31/2025 at 1407. His length of stay was 19 hours and 57 minutes. The only other vital signs obtained during P-7’s ED visit were on 12/31/2025 at 1240 as follows: HR-88, RR-16, BP-121/84. No vital signs were obtained during the whole 12-hour night shift from 12/30/2025 at 1900 to 12/31/2025 at 0700. On 6/9/2026 at 1515 during review of P-7’s medical record, ED Manager Staff A stated patients were monitored according to their ESI score and facility policy. Upon seeing the times vital signs were obtained for P-7, Staff A stated, “He should have had vitals sooner than that.” Review of the medical record for P-8 revealed she was a 21-year-old female who presented to the ED 5/6/2026 at 1723 with a chief complaint of being 33 weeks pregnant and having loose stool. She was triaged at 1728 and roomed at 1951. She was assigned and ESI score of 3 - urgent. Vital signs at 1730 during triage were as follows: T-36.7 Celsius (98.1 Fahrenheit), HR-89, RR-16, BP-129/80, SpO2-99%. Vital signs were not obtained again until 5/6/2026 at 2350 and were as follows: RR-16, BP-106/66. Additionally, it was noted that fetal heart tones were not obtained via doppler or ultrasound during her ED visit. She was transferred to the obstetrical unit on 5/7/2026 at 0002. Her length of stay was 6 hours and 34 minutes. On 6/9/2026 at 1336 during review of P-8’s medical record, ED Manager Staff A stated nursing clinical judgment should have gotten fetal heart tones. Facility policy #19694807 titled “Vital Signs in the Emergency Department” effective 6/2025 states, “ESI Level Upon Admission 1. Level 1: Vital signs should be taken every 5-15 minutes as needed based on clinical presentation and minimally every hour if clinically stable. 2. Level 2: Vital signs should be taken minimally every hour if clinically stable, or as needed based on clinical presentation. 3. Level 3: Vital signs should be taken every 4 hours if clinically stable or as needed based on clinical presentation. If abnormal, vital signs should be taken hourly until clinically stable. 4. Level 4: Vital signs should be taken every 4 hours or as needed based on clinical presentation. 5. Level 5: Vital signs should be reassessed as needed based on clinical presentation... Vital signs should be completed within 30 minutes of discharge or transfer... Behavioral Health 1. If medically stable, vital signs should be assessed minimally once a shift or sooner based on patients’ clinical presentation.” Facility policy #18951101 titled “Obstetrical Triage” effective 2/2022 states, “Electronic Fetal Monitor (EFM): Collection and assessment of FHR and uterine contraction (UC) data using an ultrasound transducer to monitor the FHR and a tocodynamometer to monitor UC... Patients who present to the Hospital with a non-OB-related condition and are at a gestational age of 20 weeks and 0 days or greater will be triaged in the ED with consult placed to the OB provider...” The procedure portion of the policy appeared to be for when the patient presented to the OB (obstetrical) department and included electronic fetal monitoring for a minimum of 20 minutes. The policy does not provide guidance for evaluation and/or monitoring of the mother and/or the fetus in the ED.”

“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], for one (P-1) of twenty patients reviewed resulting in the delayed recognition and delayed treatment of an emergent medical condition. Findings include: See Specific Tags: A-2406: Failure to provide an appropriate 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: 29955 Based on an interview and record review, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 1 (P-1) of 20 patients reviewed, resulting in delayed recognition and delayed treatment of an emergent medical condition. Findings include: A review of P-1’s medical record occurred on 2/18/2026 at 1225. According to the medical record, P-1 was a 70-year-old female who presented to the ED via ambulance on 1/5/2026 at 2023 with complaints of chest pain, difficulty breathing, and shortness of breath. The record indicated that a code for cardiac arrest began at 2035 after P-1 became unconscious while being transferred from the EMS (Emergency Medical Services) stretcher to the ED bed. Advanced Cardiovascular Life Support (ACLS) was initiated and continued until 2116, when P-1 was pronounced deceased. Staff R, Registered Nurse (RN), entered a triage note on 1/5/2026 at 2321 documenting a tracking acuity of 1 - Resuscitation. According to the National Library of Medicine, “The ESI (Emergency Severity Index - tracking acuity) is a 5-level triage algorithm used to determine acuity level of patients presenting to the emergency department and prioritize resources. Triage providers assess the chief complaint and immediate needs, obtain vital signs, and then assign an ESI score of 1 to 5 as follows: ESI 1 (Immediate medical attention) ...” Description of the Emergency Severity Index. Available from: https://www.ncbi.nlm.nih.gov/books/NBK598804/table/ch4.tab3/ During an interview on 2/19/2026 at 0915 , Staff I, Director of the ED, stated that triage does not begin until a patient is in a room and report is handed off between the ambulance crew and the assigned nurse. During an interview on 2/19/2026 at 0935, Staff P, RN, stated she had been the charge nurse when P-1 arrived at the ED with the EMTs (Emergency Medical Technicians). Staff P stated that P-1 had been assigned a room that did not have an ED stretcher, and P-1 was kept “on the wall” until the stretcher returned from transporting another patient to admission. Staff P explained that “on the wall” refers to waiting with the ambulance crew across from the charge nurse ’ s station until a room is ready or when there is significant ambulance traffic entering the ED. Staff P further stated that one of the EMTs said P-1 needed to be placed into a room. The EMT then became firm and stated that P-1 needed to be put into a room “now,” as P-1 was beginning to deteriorate. The EMTs were then directed to the assigned room, and another nurse ran to get a stretcher from one of the trauma bays. Staff P stated that she grabbed Staff F, physician, who was the closest provider to the room. Staff P stated that P-1 lost consciousness during the transfer from the ambulance stretcher to the ED stretcher. Staff P further stated that Staff Q ran to get the crash cart, and a code blue was called overhead. Staff P stated P-1 was “stable” when she was brought in the ED and deteriorated quickly within the ten minutes waiting on a bed for the assigned room. Staff P further stated that when the ambulance crew called in to alert that P-1 was being brought to the ED that the crew stated P-1 was stable. The call on the hern radio from the ambulance occurred on 01/05/2026 at 2014, arrived at the hospital at 2023, and the code for P-1 was started at 2035. A review of the ambulance run sheet dated 1/5/2026 revealed arrival at the ED on 1/5/2026 as 2020 and transfer of care at 2032. The following was on the ambulance run sheet report, “At that time an emergent light & siren priority transport began and a high priority 2 radio report to (facility) ER was given with no further orders or directions given by (facility). During transport the patient (P-1) remained awake and alert to her baseline. Patient advised that her chest pain was constant at a 6/10 and still felt like lightheadedness/pressure. Upon arrival to the ER the patient’s blood pressure had improved to 119/90 but patient advised that her chest pain was getting worse and rated it at 8/10. She also began to advise that she was not feeling good and felt sick to her stomach as well. Upon entering inside the ER (facility) nursing staff advised M-12 crew to hold the wall while they waited for a bed and the room to be cleaned. During that time the patient continued to complain of her worsening chest pain, dizziness, and nausea. (Facility) nursing staff was advised and was again told to hold the wall. The patient’s condition continued to worsen as they became very pale diaphoretic and stated having an altered mental status as facility nursing staff advised the patient could be taken to the room. Room 5. The patient was disconnected from the cardiac monitor and moved from the stretcher to the bed via she assisted transfer and the patient cell phone was left with the patient. A medic minute report was given to nursing staff with no doctor observed in the room and patient was turned over to facility nursing staff.” According to the policy titled “Triage of Patients in the Emergency Department,” policy number CP 0019, dated 07/17/2024, subsection “5. Procedure,” the following was noted: “5.1. Patients will be assessed by triage personnel upon arrival to the ED.” A review of the document titled, “ED Chest Pain Flowchart,” revision date 7/1/2025, revealed the following flow of a patient presenting with chest pain, “Via EMS => Possible Cardiac ACS (Acute Coronary Syndrome) Complaint* => Pt (patient) bedded, put on cardiac monitor => ECG Performed, interpreted by MD, DO, or APP < 10 minutes and ECG placed....” (*Possible cardiac = new onset chest pain, pressure, heaviness, or tightness w/ or w/o {with or without} radiating to upper extremities, neck, jaw, shoulders or back, SOB {shortness of breath}, diaphoresis, N/V {nausea/vomiting}, weakness, extreme fatigue, dizziness, syncope, LOC {loss of consciousness}, lower chest - upper abdominal pain, anxiety, absence of chest pain, neck/back pain, fatigue.””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 29955 Based on record review and interview, the facility failed to follow policy and provide a psychiatric evaluation by CMH (Community Mental Health) for 3 of 4 patients (P-2, P-8, P-9) reviewed for presentation to the Emergency Department (ED) with suicidal ideation, resulting in the potential for poor outcomes including death. Findings include: P-2: On 6/27/2024 at 1400 document review was conducted of P-2’s medical record. P-2 was described as, “Patient is a 23-year-old female with a past medical history significant for chronic nausea/vomiting, bipolar disorder, lupus, and RA (rhematoid arthritis) who presents to the emergency department with a chief complaint of shortness of breath... “Pt (P-2) was at a f/u (follow-up) appointment at (facility) and ended up making suicidal statements. Pt is currently not having suicidal thoughts. Is just frustrated. C/O (complains of) pain where pt had a chest tube placed.” P-2 arrived at the ED via ambulance on 6/4/2024 at 1239. Documentation by staff K included, “Today, she was seen her psychiatry NP (Nurse Practitioner). She was expressing to her nurse petitioner that she had worsening suicidal thoughts due to her ongoing shortness of breath and frustration.” On 6/27/2024 at 1100 an interview was conducted with staff K, ED Physician. Staff K was queried if he knew P-2 had presented to the ED with an existing petition. Staff K stated he was aware of the petition for P-2, but ED staff were unable to find the petition for P-2. Staff K was asked if a petition would have been sufficient for P-2 to stay under suicidal precautions. Staff K stated, “Yes, but I was under the impression that her medical status would have kept her and provided time to observe (P-2) for suicidal ideations ... I had no idea that the internal medicine group was not going to admit.” Staff K was then queried if any staff member made an attempt to re-petition the patient or reached out to the EMS (Emergency Medical Services) squad to inquire about the petition. Staff K stated he did not know if any staff member had tried to obtain the petition. On 6/27/2024 an interview was conducted with staff N, ED physician. Staff N was asked about his role in the care of P-2. Staff N stated that he had received report from staff K at the change of shift. Staff N was queried if he knew P-2 was brought to the facility as a petitioned patient. Staff N stated that he was aware of the patient being there as part of a petition, but the petition was not presented with the patient. Staff N was asked what the plan was when he received report from staff K. Staff N stated that staff K had ordered the patient (P-2) to be evaluated by the Internal Medicine hospitalist. Staff N stated that staff K had planned that P-2 would be admitted for low oxygenation levels. Staff N stated that staff K had stated he did not feel that the patient (P-2) was truly suicidal but depressed because of ongoing complex medical issues. Staff N stated that after the Internal Medicine hospitalist team did not feel that the patient (P-2) met the need for hospitalization that he had to tell the patient that she would be discharged home. Staff N stated that P-2 became irrational and irate. Staff N stated, “F bombs were flying from the patient’s mouth ...she was irrational.” Staff N was asked if the behavior would have elicited a psychiatric evaluation. Staff N stated the patient was not approachable after she found out that she would not be admitted and discharged home. On 6/27/2024 the Patient Experience Advocate provided a copy of the grievance filed with the facility by P-2. The grievance had been filed on 6/18/2024. Documentation included in the grievance stated that she (P-2) should have been certified because a petition existed, and she was suicidal on 6/4/2024. On 6/27/2024 an interview was conducted with Staff J, the Medical Director of the ED. Staff J was queried if the original petition had not accompanied the patient (P-2) was it possible that another petition could be initiated in lieu of the original petition. Staff J stated, “yes.” Staff J stated she had spoken with staff K and questioned what had taken place. Staff J stated that staff K had assessed the patient and felt the patient was not suicidal but depressed because of her physical illnesses. Staff J further stated staff K felt the patient would be admitted for low oxygenation levels. Staff J was queried if a patient is known to have presented to the ED related to being petitioned what is the procedure for physicians. Staff J stated that all patients presenting with petition are evaluated by the community mental health (CMH) employees for a psychological evaluation. Staff J was queried if P-2 had a psychological evaluation. Staff J stated, “No.” Documentation in P-2 medical record failed to have documentation of a psychiatric evaluation by Community Mental Health (CMH). Staff C, the Director of Patient Care Services confirmed the lack of a psychiatric evaluation. P-8: On 6/27/2024 during record review of P-8 medical record it was revealed that P-8 presented to the ED for suicidal ideation. P-8 presented to the facility ED on 4/17/2024 at 1308 with the chief complaint of, “Pt (patient, P-8) states that he wants to end his life. Pt states that his plan is to either shoot himself or to jump off a building.” P-8 was triaged and assigned an ESI number 2 - emergent. P-8 diagnosis was documented as “Suicidal Ideation.” P-8 CSSR (Columbia Suicide Severity Rating - a screening scale assessment tool that evaluates suicidal ideation and behavior) screened risk was documented as, “high risk.” According to documentation P-8 Columbia Suicide Severity responses to screening were as follows, “Past Month Wish to be Dead - Yes, Past Month Suicidal Thoughts - Yes, Past Month Ideation with Method No Intent - Yes, Patient Month with Intent No Plan - Yes, Past Month with Intent and Plan - Yes, Columbia Screen Suicide Behavior - Yes, CSSRS Screen Suicide Behavior Timeline - Within the last 3 Months.” Further document review of P-8 medical record included the review of patient history documented by the ED physician, staff U revealed, “The patient is a 28-year-old male, past medical history significant for PTSD (post-traumatic stress disorder), anxiety, depression, presents to the ED for evaluation of suicidal ideation. He states that he has had difficulty with addiction and meth use. He has been in and out of rehabs and has had some relapses. He just left rehab 2 days ago and states that he left because he was being mistreated due to the fact he is gay. That has happened at other facilities as well and has caused him to leave other facilities. He has been having suicidal thoughts now for the past 4 days. He says that he has attempted to hurt himself in the past and feels that he may act on his feelings today and that has him concerned. He does have some low back pain and a headache. He denies any fever, chills, chest pain or SOB (shortness of breath). Further ROS (review of systems) unremarkable ... Physical exam is as documented otherwise. Will order medical screening labs. Pet/cert will likely be necessary given suicidal ideation with a plan and prior attempts. Past medical history significantly affecting the patient’s presenting condition: PTSD, anxiety, depression” P-8 was placed on “suicide precautions” on 4/17/2024 at 1311. P-8 medical record included under the subtitle, “Management, re-evaluation and ED course,” ED Physician staff U documented, “The patient was re-evaluated and is clinically stable. He denies any further suicidal ideation. He states that he was just having a hard time facing having to go to a shelter, return to rehab in a few days and upcoming court cases. He is displaying good insight. He states that he wants to continue to live and take care of all the things that he needs to take care of. He agrees to follow up with CMH (Community Mental Health) and return to the ED if he begins to have thoughts of self-harm. Will provide resources for outpatient psychiatric follow up.” P-8 documented disposition was documented as, “Safe for discharge home to follow up with the PCP (primary care provider) in the next 5-7 days. The patient was informed of reasons to return to the ED. Vitals stable.” The patient (P-8) received patient education for “Suicidal Feelings: How to Help Yourself” and “Managing Depression, Adult,” prior to discharge. P-8 also received contact information for CMH (Community Mental Health). P-8 was discharged from the facility on 4/17/2024 at 1837. Documentation in P-8 medical record failed to have documentation of a psychiatric evaluation by CMH. Staff C, the Director of Patient Care Services confirmed the lack of a psychiatric evaluation. P-9: On 6/27/2024 during record review of P-9 medical record it was revealed P-9 presented to the ED on 5/5/2024 at 0717. Documentation included the diagnosis of “suicidal ideation.” P-9 was assigned an ESI number of 4 - semi-urgent. P-9 CSSRS screen was as follows: “Past Month Wish to be Dead - Yes, Past Month Suicidal Thoughts - No, Columbia Screen Suicide Behavior - No, CSSRS Screened Risk: Low Risk. According to the History of Present Illness the following was documented, “The patient is a 25-year-old with history of developmental delay who presented with suicidal ideation. The patient states that she has had a new AFC (adult foster care) home for the past month. She states that since she has been at the AFC home, she has not been allowed to eat what she wants. The patient endorses suicidal ideation, but she denies any plan. The patient states that she is depressed as she does not like her AFC home. She states that she was evicted from her other AFC home.” Documentation on 5/5/2024 in the medical record by staff V, ED physician continued, “On presentation in the emergency department, the patient’s vitals were notable for the patient being afebrile, normotensive and saturating well on room air. Physical exam was remarkable for endorsement of suicidal ideation. She denies any plan to harm herself. She states that if she is discharged she will not harm herself. She denies any homicidal ideation. She denies any hallucinations. She states that she would like to be moved to a new group home and is requesting to talk with CMH. CMH was not present in the emergency department at the time of presentation but will be here in a couple of hours. The patient states that she will wait to speak with them further. No workup is indicated as the patient denies any plan to harm herself. The patient was provided with food...On re-evaluation, the patient was hemodynamically stable. She states that she no longer wishes to wait to speak with CMH. She wishes to be discharged back to her group home. She denies any suicidal ideation at this time. Return precautions were discussed with the patient, who voiced understanding. The patient was advised to follow-up with their primary care provider and mental health provider. All questions were answered. The patient was discharged home.” Documentation in P-9 medical record failed to have documentation of a psychiatric evaluation by CMH. Staff C, the Director of Patient Care Services confirmed the lack of a psychiatric evaluation. On 6/27/2024 document review of the policy titled, , “Admission of Involuntary Patients,” policy number BH 105, revision date 10/23. Under the subtitle, “2.3. Petition,” it states, “2.3.1. A petition may be filed by any person 18 years of age or older and is filed with the court which asserts that an individual is a person requiring treatment as defined in the criteria listed below. A petition is filed when the person is not in the custody of the hospital.” Further review of the policy states under the subtitle, “2.4. Procedure for petition as follows: 2.4.1. When the petition is filed with the Probate Court it should be accompanied by the certificate of physician unless after reasonable effort the patient could not be secured for examination. If no certificate accompanies the petition, an affidavit setting forth the reasons an examination could not be secured should also be filed with the court.””