Mclaren Port Huron

“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: 48772 Based on interview and record review, the facility failed to establish an individualized plan of care, failed to ensure nursing and support staff adhered to the policies and procedures of the facility, and failed to ensure that nursing documented fall risk assessments accurately. See tags: A0396 - Nursing Care Plan A0398 - Supervision of Nursing Personnel”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48772 Based on interview and record review, the facility failed to establish an individualized plan of care for 1 (P-1) of 10 patients reviewed, resulting in the potential for unmet care needs and negative outcomes for this patient. Findings include: P-1 is a 67-year-old male with a past medical history of cerebral vascular accident with residual left side weakness, coronary artery disease, chest pain/angina, diabetes mellitus, reflux, hyperlipidemia, hypertension, myocardial infarction, osteoarthritis, and prostate disorder. On 7/1/25, P-1 underwent ureteroscopy with kidney stone lithotripsy and bilateral renal stent placement. P-1 presented to the emergency center (EC) on 7/8/25 with sepsis with leukocytosis, fever, and possible urinary tract infection. On 7/9/25 at 1030, P-1 had an unwitnessed fall while in the EC, fracturing his left proximal humerus as well as an acute mildly displaced left proximal femur sub capital neck fracture. On 7/11/25, a left direct anterior hip hemiarthroplasty was performed. P-1 was transferred to an extended care facility on 7/17/25. During record review on 9/2/25, it was noted that the plan of care initiated on 7/8/25 included discharge planning, knowledge deficit, pain management, and safety/protection. The plan failed to include fall risk or sepsis. This finding was reviewed and acknowledged with the Director of Quality (Staff C) on 9/2/25 at 1300.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48772 Based on record review and interview, the facility failed to ensure nursing and support staff adhered to the policies and procedures of the facility and failed to ensure that nursing documented fall risk assessments accurately in 1 (P-1) of 10 records reviewed, resulting in an unwitnessed fall and the patient sustaining two fractures. Findings include: P-1 is a 67-year-old male with a past medical history of cerebral vascular accident with residual left side weakness, coronary artery disease, chest pain/angina, diabetes mellitus, reflux, hyperlipidemia, hypertension, myocardial infarction, osteoarthritis, and prostate disorder. On 7/1/25, P-1 underwent ureteroscopy with kidney stone lithotripsy and bilateral renal stent placement. P-1 presented to the emergency center (EC) on 7/8/25 with sepsis with leukocytosis, fever, and possible urinary tract infection. On 7/9/25 at 1030, P-1 had an unwitnessed fall while in the EC, fracturing his left proximal humerus as well as an acute mildly displaced left proximal femur sub capital neck fracture. On 7/11/25, a left direct anterior hip hemiarthroplasty was performed. P-1 was transferred to an extended care facility on 7/17/25. The fall risk assessment tool was completed on 7/8/25 at 1800 and evaluated the following: age (60-69; 1 point), fall history (N/A), elimination, bowel and urine (N/A), Medications (on 1 or more fall risk drug; 3 points), Patient Care Equipment (IV infusion; 1 point), Mobility (requires assistance or supervision for mobility, transfer, or ambulation; 2 points), and Cognition (N/A). P-1’s initial fall risk score was 7, which indicates a moderate fall risk (6-13 points). The chart review indicated that P-1 was incontinent of urine and presented to the EC with urinary tract infection symptoms. These findings were not included in the fall risk assessment and have the potential to add an additional 2 points for incontinence or 4 points for urgency/frequency and incontinence. Medication review indicates that P-1 was taking Trazadone 50mg at night, Neurontin 300mg at night, Ultram 50mg, four times a day as needed, and Dilaudid 0.5mg, that was given 7/8/25 at 1039, patients on 2 or more high fall risk drugs receive 5 points. The chart review also indicated the patient has left side weakness from prior stroke, ambulates with a walker and was brought to the EC with increased weakness. Unsteady gait would add 2 additional points, for a fall risk score of 13 to 15 points. Fall risk scores greater than 14 are high risk. Review of the Fall Prevention Guidelines indicate that patients with moderate and high-risk are identified with yellow armband and yellow socks, document risk on whiteboard, and include risk in handoff. Patients with moderate risk should be supervised with bedside activities and those at high-risk interventions include supervising all ambulating, and 1:1 toileting. EC Tech (Staff M) was interviewed on 9/3/25 at 0937. Staff M stated that on 7/9/25, he was working as a float throughout the EC. He went into P-1’s treatment room to help him up to the commode. Staff M stated that when the patient was done, he stood him up and then sat him back down on the commode and went out of the room to find assistance to get him back into bed, and that is when he heard him fall. When queried about the fall risk precautions that were in place, Staff M stated that P-1 didn’t have a fall risk bracelet on at that time, and he couldn’t recall if he had yellow socks on or if fall risk was written on the whiteboard in the room. When queried about the handoff communication, Staff M stated, “I didn’t get a report on this patient.” Policy- Fall Prevention Guidelines (1.2.7, revised 10/22) states for moderate risk (score 6-13) : yellow armband and yellow socks are applied, document risk on whiteboard, include risk in handoff, remove clutter, ensure adequate lighting, keep clear path to bathroom, coil/secure excess cords, supervise bedside activities, orient patient to surroundings, education on fall risk, establish elimination schedule, encourage call light use, answer call light promptly, purposeful hourly rounds, activate bed and chair alarms, and consider adding Virtual Safety Companion. For high risk (scores above 14) includes moderate interventions and in addition includes supervise all ambulating, use gait belt during ambulation, and 1:1 toileting.”

“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: 38269 Based on interview and record review the facility failed to comply with the requirements of 42 CFR 489.24 by failing to provide a medical screening exam (MSE) and failing to log the arrival of a patient in the Emergency Department (ED) log for 1 patient (P-1) of 20 patients reviewed for Emergency Medical Treatment and Labor Act (EMTALA) requirements, resulting in the potential for an unidentified medical emergency. Findings include: See Tags: A-2405 Failure to maintain an Emergency Department Log including names of all patients presenting to the ED 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: 38269 Based on interview and record review the facility failed to maintain an emergency department log for 1 (P-1) of 20 patients reviewed for seeking emergency services, resulting in the omission of P-1’s arrival and request for emergency screening and or treatment. Finding include: On 04/30/2025 at 1017 a telephone interview was conducted with Triage RN (Staff U), she confirmed that she was the triage nurse on duty in the ED on 03/23-24/2025 from 2:00pm-2:00am. Staff U explained that (P-1) presented to the ED two times on 03/24/2025, (the initial presentation time was unknown, the second presentation was observed on a video recoding at 0128). During the interview Staff U shared that she informed P-1 that she would not be seen without parental or guardian consent, and P-1 exited the ED. The House Supervisor was then informed of the minor (P-1) presenting to the ED. Staff U stated, “The House supervisor confirmed that, parental consent was necessary to be seen.” When queried if Staff U placed P-1’s name into the ER log at anytime she stated no. On 04/30/2025 at 0840 an interview was conducted with the Patient Access Representative (PAR) that was on duty the night of the incident involving P-1. Staff O was queried regarding P-1’s arival being placed into the ED log. Staff O stated, “Yes I did place the name of (P-1) into the ED log when she arrived around 0300 with a parent.” Staff O denied logging P-1’s name into the ED log at any other time on 03/24/2025. Staff O also confirmed that he recalled P-1 presenting to the ED and being told by the triage nurse that P-1 would not be seen without the consent of a parent or guardian. When queried if Staff O had ever received EMTALA training or if he had ever turned a minor away from the ED. Staff O stated, “Yes I have had training, we have it every year. No, I have never turned a minor away before. I don’t meet the requirements to make that decision, that would be the triage nurse.” On 04/29/2025 at 1520, a review of security video footage dated 03/24/2025 was viewed with the Director of ED Staff E, the Manager of ED Staff F, and Security Supervisor Staff V. The video revealed the following: At 0128, P-1 enters the ED and is seen speaking with the Patient Access Rep, Staff O. Two (2) male security guards are also viewed behind the desk. At 0135, another patient access representative appeared at the desk, while Staff O walked to the triage room. Unable to visualize anyone in the triage room due to tinted windows. P-1 moves to a seat in the waiting area as another patient is seen entering the ED. At 0140, Staff O was visualized speaking with P-1 who appears to be on her cell phone and holds the phone up towards Staff O. At 0142, P-1 was seen exiting the ED. At 0304, P-1 was visualized on the video recording returning to the ED with another person and it appeared that P-1 was registered. Review of records confirmed the registration was completed at that time. Review of the “ER LOG” dated 11/01/2024 through 04/29/2025 revealed that P-1’s name was entered into the “ER LOG” on 03/24/2025 at 0305. Both the Director of ED, Staff E, and the Director of Quality Improvement Staff C, confirmed the above findings. P-1 presented to the ED two times on 03/24/2025 and was refused treatment without parental or guardian consent. After being refused an evaluation P-1 drove herself 30 minutes to retrieve a parent and drove 30 minutes back to the hospital with her mother to receive treatment. Review of policy titled: “Emergency Center Initial Medical Screening Evaluation”, effective 4/25 4.2. All persons will be triaged (completion of the patient profile) will be triaged in the Emergency Center treatment area. 4.3. Individuals who present at the Emergency Center will have quick registration completed. 4.5. The Emergency Center provider will perform the Medical Screening Exam and provide medical treatment including any necessary diagnostic procedures or test that reasonably ensures no material deterioration of the condition is likely to result. The physician may discharge, admit, or transfer the patient to another facility.”

“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: 38269 Based on interview and record review the facility failed to provide a Medical Screening Examination (MSE) for 1 (P-1) of 20 patients reviewed, resulting in the potential for an unrecognized medical emergency for patients seeking medical screening and/or treatment. Findings include: On 04/29/2025 at 1400 review of the ED log from 11/01/2024 to 04/29/2025 revealed P-1 presented to the ED on 03/24/2025 at 0305 with a parent. On 04/29/2025 at 1520 review of security video dated 03/24/2025, at 0128, P-1 presenting to the ED by herself. At 0128, P-1 is seen by herself approaching the Patient Access Representative (PAR). At 0135, P-1 is seen sitting in the waiting area. At 0141, P-1 is seen with a cell phone and holding the phone up to Staff O. At 0142, P-1 is seen leaving the ED. At 0304, P-1 is seen with another person approaching the PAR. On 04/30/2025, at 1017, during a telephone interview with triage nurse Staff U, it was confirmed that P-1 presented to the ED twice before the 0304 presentation. Staff U stated, “The initial presentation was a few minutes before the 0128 presentation, and [P-1] knew she couldn’t be seen without parental or guardian consent.” The patient left the ED at 0142 without an ESI, or an MSE being completed. On 04/30/2025 a review of records revealed that P-1 presented to the ED with her mother on 03/24/2025 at 0304, with a chief complaint of abdominal pain starting approximately 1500 on 03/23/2025. Staff E confirmed that P-1 presented to the ED by herself with complaint of abdominal pain requesting an evaluation. P-1 did not receive triage or a MSE, due to not having a parent or guardian consent. Attempts were made to contact P-1’s parents without success and P-1 was not evaluated/assessed until she returned with her parent at 0304. Review of policy titled: “Emergency Center Initial Medical Screening Evaluation”, effective 4/25 1. Purpose: To ensure that individuals are to be treated in a timely manner based upon the acuity of their illness or injury by an Emergency Center (EC) physician, regardless of their ability to pay. To make an initial determination within the resources of the medical center whether an emergency medical condition exists for all patients who come to the Emergency Center requesting an examination or treatment. 2. Scope: 4.1. The RN will sort each person who presents to the Emergency Center and assign an ESI acuity level (See EC 260). 4.2. All persons will be triaged (completion of the patient profile) will be triaged in the Emergency Center treatment area. 4.3. Individuals who present at the Emergency Center will have quick registration completed. 4.5. The Emergency Center provider will perform the Medical Screening Exam and provide medical treatment including any necessary diagnostic procedures or test that reasonably ensures no material deterioration of the condition is likely to result. The physician may discharge, admit, or transfer the patient to another facility.”